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Characterization and Trend of Co-Infection with Neisseria Gonorrhoeae and Chlamydia Trachomatis from the Korean National Infectious Diseases Surveillance Database

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Characterization and Trend of Co-Infection with Neisseria Gonorrhoeae and Chlamydia Trachomatis from the Korean National Infectious Diseases Surveillance Database Original Article Health promotion, disease prevention, and lifestyle pISSN: 2287-4208 / eISSN: 2287-4690 World J Mens Health 2021 Jan 39(1): 107-115 https://doi.org/10.5534/wjmh.190116 Characterization and Trend of Co-Infection with Neisseria gonorrhoeae and Chlamydia trachomatis from the Korean National Infectious Diseases Surveillance Database Yumi Seo1 , Kyung-Hwa Choi2 , Gilho Lee1 Departments of 1Urology and 2Preventive Medicine, Dankook University College of Medicine, Cheonan, Korea Purpose: We analyzed the database from the Korean National Infectious Diseases Surveillance to reveal clinical characteris- tics of co-infection with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). Materials and Methods: Eligible cases included a single NG infection (male/female) for 6,421 (4,975/1,446), a single CT in- fection for 20,436 (6,107/14,329), and co-infection for 498 (233/265) between 2011 and 2015. Results: Cases of NG and CT have increased for 5 years; the proportion of co-infected male has increased continuously and was positively correlated with that of CT infections. But the proportion of co-infected female was positively correlated with that of NG infections, following an expanded wavelike-pattern. Generally, people with co-infection was younger than either infection alone (p=0.001). But the characteristics of co-infection revealed sex-specific differences. While the co-infected fe- males were younger than females in NG (p=0.001) or CT group (p=0.001), the co-infected males were younger than males in CT (p=0.001) only, not males in the NG group (p=0.394). Amongst males, 4.47% with NG had CT infection, while in female 15.49% with NG had CT (p=0.001). In contrast, in male 3.68% with CT infection had NG infection and in female 1.82% of CT had NG (p=0.001). Young people in both sexes have increased risks of co-infection bi-directionally (all p=0.001), except males with NG that were also co-infected with CT (p=0.642). Conclusions: The sex-specific findings in co-infection may improve understanding of gender-specific characteristics in NG and CT infections. Co-infected people are increasing for 5 years. Therefore, we must consider long-term complication of the co-infected people. Keywords: Big data; Chlamydia trachomatis; Coinfection; Neisseria gonorrhoeae This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION (CT) induce genito-urinary infections [1,2]. To control spreading of NG and CT infections, unbiased studies in Sexually transmitted infections (STIs) have serious epidemiology and clinical characteristics must be ap- impacts on quality of human life. Of many STIs, Neis- propriately conducted [3]. seria gonorrhoeae (NG) and Chlamydia trachomatis Previous epidemiology studies on NG and CT infec- Received: Sep 3, 2019 Revised: Nov 7, 2019 Accepted: Nov 27, 2019 Published online Dec 27, 2019 Correspondence to: Gilho Lee https://orcid.org/0000-0002-9253-6245 Department of Urology, Dankook University College of Medicine, 119 Dandae-ro, Dongnam-gu, Cheonan 31116, Korea. Tel: +82-41-550-6630, Fax: +82-41-550-3905, E-mail: [email protected] Copyright © 2021 Korean Society for Sexual Medicine and Andrology https://doi.org/10.5534/wjmh.190116 tions reported a wide range of results from different health centers (PHC) in Korea were appointed as senti- clinical settings and patient groups [1,2]. In addition, nel sites for STIs surveillance. The number of sentinel as most clinical studies for co-infection, either NG co- sites depended on the size of regional population, but infected with CT or CT co-infected with NG, are usu- regions with less than 100,000 people have at least one ally performed in selected patient groups, many biases sentinel site as an integral post for STI surveillance in are to be generalized. Indeed, the proportion of NG co- the lower population density areas. infection with CT in the literature varies considerably, The medical providers in the sentinel sites were to from less than 4% up to more than 60% [4-8]. report cases of NG and CT within 7 days after the di- Characteristics of co-infection have been mostly agnosis. In these reports, information such as patient’s studied in cases of NG co-infected CT [4,5,7]. In con- sex, age, day of diagnosis, name of STIs, whether NG trast, studies for CT co-infected with NG or bilateral were confirmed with guaranteed laboratory tests or co-infected cases are rarely reported to characterize symptomatic diagnosis, and the names of co-infection their bi-directional clinical significance [6]. As far as were also included (Supplement 1) [13-15]. Confirmed we understand, no data have been published about the diagnostic methods for NG infections included culture, epidemiology of NG, CT, and bilateral co-infections in a antigen detection, gram staining, and nucleic acid am- large Korean population database. plification test (NAAT), while methods for CT infec- Such combination of STIs may increase the suscep- tions included culture, antigen detection, and NAAT. tibility to long-term complications and transmissibility than each individual case. Stupiansky et al [9] revealed 2. Definition of co-infection from the National that NG shedding was higher in women with con- Infectious Diseases Surveillance of Korea current CT infection than in those infected with NG dataset alone. Nsuami et al [10] reported that symptoms related We obtained the reported cases of NG and CT from to STIs are reported more frequently by co-infected the NIDS dataset of Korea (http://www.cdc.go.kr/npt/ students than those with a single infection case. In ad- biz/npp/iss/stisStatisticsMain.do) between January 1, dition, concurrent NG infection may reactivate latent 2011 and December 31, 2015. If the individual cases of CT infections [11]. These reports are also supported by NG or CT with identical sex and age were coincidently Vonck et al [12], who showed that NG colonization was diagnosed on the same day at the same clinic, reported significantly higher in infected female mice with pre- both infections to regional PHCs for review on a single existing infection of Chlamydia muridarum, the mu- day, and also deposited the reviewed data in the Kore- rine strain of chlamydia. an NIDS database on a single day, such case of NG and This study aims to characterize the co-infection of CT was assumed to be from a single person, suggesting NG and CT from the database of the National Infec- co-infection. tious Diseases Surveillance of Korea (NIDS) of the The reported cases of NG and CT in the NIDS data- Korea Centers for Disease Control and Prevention (K- base of the K-CDC during the five years were primar- CDC). In order to do this, we categorized a single NG, a ily categorized by the day of diagnosis, followed by the single CT, and their co-infection from the NIDS data- age parameter, and lastly by the sex parameter in a base from 2011 to 2015, and examined their trends dur- single clinic. Finally, we merged the datasets of NG ing the periods. Finally, we calculated the proportions and CT infections. Between these periods, 9,064 cases of either NG co-infected with CT or CT co-infected were reported as NG infection, and 20,954 cases as CT with NG, and estimated specific subpopulations at the infection. We removed 2,125 NG cases because they risk of co-infection. were reported as suspected NG patients based on their clinical symptoms, not by the specified diagnostic tests MATERALS AND METHODS mentioned previously. We also removed 20 cases from each NG and CT infection group that overlap in age 1. Sentinel sites and their reports to the and sex on the same day of diagnosis in the same clinic Korean National Infectious Diseases (Fig. 1, Supplement 2). Surveillance of Korea Approximately 500 medical facilities and public 108 www.wjmh.org Yumi Seo, et al: Co-Infection with Gonococcus and Chlamydia 3. Statistical analysis no difference were rejected if p-values were less than We used analysis of variance (ANOVA) to evaluate 0.05. All analyses were performed using IBM SPSS for the difference in the ordinal scores among the NG, CT, Windows ver. 23 (IBM Corp., Armonk, NY, USA). and co-infection. The Tukey’s test was used as a post- hoc test. Pearson chi-square test was used to evaluate 4. Ethics statement the difference in categorical data. Odds ratios (OR) and This study did not require approval from the Institution- 95% confidence intervals (CI) were estimated with lo- al Review Board because the dataset did not contain any gistic regression analysis. Two-sided null hypotheses of personal information that may discern personal identity. Symptomatical diagnosis a Overlapping in age and sex on the same diagnostic day of NG infection (suspected cases) b ; 2,125 cases of NG CT infection ;20 cases of NG Reported cases of NG Confirmed cases of NG infection NG, CT and co-infected cases Only NG infection; 9,064 NG infection: 6,939 6,919 cases Male: 4,975 cases by sentinel health facilities infection; Female: 1,446 cases for STI surveillance in Korea 6,421 cases Primary clinics; 13,288 cases NG CT Male: 9,928/Female: 3,360 combined Male: 233 cases Hospitals; 4,528 cases infection; Female: 265 cases Male: 571/Female: 3,957 498 cases Regional health centers; 9,539 cases Only CT Male: 816/Female: 8,723 Reported cases of CT CT infection Male: 6,107cases infection; infection; 20,954 20,934 cases Female: 14,329 cases 20,436 cases Overlapping in age and sex on the same diagnostic day of NG CT infectionb;20 cases of CT Fig.
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