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In Paraguay, incomplete surveillance data resulted in the burden of congenital syphilis being underestimated, which, in turn, led to missed opportunities for infant diagnosis and treatment.The prevalence of congenital syphilis, as defined by the World Health Organization (WHO), was estimated for Paraguay using the WHO congenital syphilis estimation tool. This tool was also used to monitor progress towards the elimination of mother-to-child transmission of syphilis.The burden of syphilis in Paraguay has historically been high: its prevalence in pregnant women was estimated to be 3% in 2018.The incidence rate of congenital syphilis estimated using the WHO tool was around nine times the reported prevalence. Subsequently, Paraguay: (i) provided training to improve diagnosis and case reporting; (ii) strengthened information systems for case monitoring and reporting; and (iii) procured additional rapid dual HIV-syphilis and rapid plasma reagin tests to increase syphilis testing capacity. In addition, the Ministry of Health prepared a new national plan for eliminating mother-to-child transmission of syphilis, with clear monitoring milestones.Health-care providers' reporting and surveillance procedures for congenital syphilis may not adequately reflect national and international case definitions. Use of the WHO congenital syphilis estimation tool in Paraguay drew attention to congenital syphilis as a national public health problem and highlighted the importance of comprehensive national surveillance systems and accurate data. Ongoing use of the WHO tool can track progress towards the elimination of mother-to-child transmission of syphilis by helping improve syphilis service coverage and national surveillance.Au Paraguay, l'insuffisance de données de surveillance entraîne une sous-estimation du fardeau causé par la syphilis congénitale, ce qui aboutit à des occasions manquées de diagnostiquer et traiter les nourrissons.Le taux d'incidence de la syphilis congénitale, telle que définie par l'Organisation mondiale de la Santé (OMS), a été calculée au Paraguay à l'aide de l'outil d'évaluation de l'OMS. Cet outil a également servi à suivre les progrès dans l'élimination de la transmission de la syphilis de la mère à l'enfant.Le fardeau de la syphilis au Paraguay a toujours été lourd: la prévalence de la maladie chez les femmes enceintes était estimée à 3% en 2018.Le taux de prévalence de la syphilis congénitale calculé avec l'outil de l'OMS était environ neuf fois plus élevé que celui enregistré. Par conséquent, le Paraguay a: (i) proposé des formations afin d'améliorer le diagnostic et le signalement des cas; (ii) renforcé les systèmes d'information pour le suivi et la notification des cas; et enfin, (iii) fourni des doubles tests rapides VIH/syphilis et des tests rapides de la réagine plasmatique supplémentaires en vue d'accroître les capacités de dépistage de la syphilis. En outre, le ministère de la Santé a élaboré un nouveau plan national destiné à éliminer la transmission de la syphilis de la mère à l'enfant, comprenant une série d'étapes de suivi.Les procédures des prestataires de soins de santé en matière de notification et de surveillance de la syphilis congénitale pourraient différer de la définition des cas aux niveaux national et international. L'utilisation de l'outil d'évaluation mis au point par l'OMS pour la syphilis congénitale au Paraguay a attiré l'attention sur cette maladie qui représente un problème de santé publique nationale, et souligné l'importance des systèmes de surveillance complets et des données précises. Continuer à employer cet outil peut permettre de mesurer les progrès accomplis dans l'élimination de la transmission de la syphilis de la mère à l'enfant, en contribuant à améliorer la couverture des services et la surveillance nationale.En Paraguay, los datos de vigilancia incompletos ocasionaron que se subestimara la carga de sífilis congénita, lo que, a su vez, hizo que se perdieran las oportunidades de diagnóstico y tratamiento de los lactantes.La prevalencia de la sífilis congénita, según la definición de la Organización Mundial de la Salud (OMS), se estimó para Paraguay utilizando la herramienta de estimación de la sífilis congénita de la OMS. Esta herramienta también se utilizó para monitorear el progreso hacia la eliminación de la transmisión maternofilial de la sífilis.La carga de sífilis en Paraguay ha sido históricamente alta: su prevalencia en embarazadas se estimó en un 3 % en 2018.La tasa de incidencia de sífilis congénita estimada con la herramienta de la OMS era aproximadamente nueve veces superior a la notificada. En consecuencia, Paraguay: i) impartió formación para mejorar el diagnóstico y la notificación de los casos; ii) reforzó los sistemas de información para el monitoreo y la notificación de los casos; y iii) adquirió más pruebas rápidas duales de VIH-sífilis y de inmunoglobulina E plasmática rápida para aumentar la capacidad de realizar pruebas de sífilis. Además, el Ministerio de Salud Pública preparó un nuevo plan nacional para eliminar la transmisión maternofilial de la sífilis, con claros hitos de monitoreo.Es posible que los procedimientos de notificación y vigilancia de la sífilis congénita que aplican los profesionales sanitarios no reflejen de manera adecuada las definiciones nacionales e internacionales de los casos. El uso de la herramienta de estimación de la sífilis congénita de la OMS en Paraguay llamó la atención sobre la sífilis congénita como un problema nacional de salud pública y destacó la importancia de contar con sistemas nacionales de vigilancia integrales y datos precisos. El uso constante de la herramienta de la OMS puede hacer un seguimiento de los avances hacia la eliminación de la transmisión maternofilial de la sífilis al ayudar a mejorar la cobertura de los servicios relacionados con la sífilis y la vigilancia nacional.أدت بيانات المراقبة غير المكتملة في باراغواي إلى الحد من عبء تقييم الزهري الخلقي، مما أدى بدوره إلى ضياع فرص تشخيص الرضع وعلاجهم.تم تقييم انتشار مرض الزهري الخلقي، وفقًا لتعريف منظمة الصحة العالمية (WHO)، في باراغواي باستخدام أداة تقييم الزهري الخلقي التابعة لمنظمة الصحة العالمية. تم استخدام هذه الأداة أيضًا لرصد التقدم نحو القضاء على انتقال مرض الزهري من الأم إلى الطفل.كان عبء مرض الزهري في باراغواي مرتفعًا على مدى تاريخها، فقد تم تقدير انتشاره بين النساء الحوامل بنسبة 3% في عام 2018.在巴拉圭，不完整的监测数据导致先天性梅毒的负担被低估，由此导致错过婴儿诊断和治疗的机会。.根据世界卫生组织的 (WHO) 定义，采用世界卫生组织先天性梅毒评估工具来估算先天性梅毒的患病率。该工具还可用来监测梅毒母婴传播评估领域的进展情况。.巴拉圭的梅毒负担历来很高：2018 年的孕妇患病率估计占到 3%。.使用世界卫生组织工具评估的先天性梅毒患病率大约是所报告的患病率的九倍。随后，巴拉圭：(I) 开展了培训以提升诊断和病例报告；(ii) 加强了病例监测和报告的信息系统，并且 (iii) 采购了额外的快速双重 HIV-梅毒检测和快速血浆反应素试验以增强梅毒检测能力。除此以外，卫生部还制定了一项新的全国性计划，通过明确的监测里程碑来评估梅毒的母婴传播。.医疗护理机构的先天性梅毒报告和监测程序可能无法充分反映全国性和国际性的病例定义。在巴拉圭采用世界卫生组织先天性梅毒评估工具提高了对先天性梅毒作为全国性公共卫生问题的关注度，强调了综合的全国性监测系统和准确数据的重要性。持续使用世界卫生组织工具可以有助于提高梅毒卫生服务覆盖面和全国性监测的普及，从而追赶梅毒母婴传播评估领域的进展。.В Парагвае неполные данные наблюдений привели к недооценке бремени врожденного сифилиса, что в свою очередь привело к упущенным возможностям в диагностике и лечении младенцев.В Парагвае распространенность врожденного сифилиса, по определению Всемирной организации здравоохранения (ВОЗ), оценивалась с использованием инструмента ВОЗ для оценки врожденного сифилиса. Этот инструмент также использовали для мониторинга прогресса в борьбе с передачей сифилиса от матери к ребенку.В Парагвае бремя сифилиса достигло рекордных показателей: его распространенность среди беременных женщин в 2018 году составила 3%.Распространенность врожденного сифилиса, оцененная с помощью инструмента ВОЗ, примерно в девять раз превышала зарегистрированную распространенность. В результате Парагвай: (i) организовал обучение для улучшения диагностики и отчетности о случаях заболевания; (ii) укрепил информационные системы для мониторинга случаев заболевания и отчетности; (iii) закупил дополнительные двойные экспресс-тесты на ВИЧ/сифилис и реакцию быстрого определения реагинов плазмы, чтобы расширить возможности тестирования на сифилис. Кроме того, Министерство здравоохранения подготовило новый национальный план по борьбе с передачей сифилиса от матери к ребенку с четкими этапами мониторинга.Процедуры отчетности и наблюдения медицинских работников за врожденным сифилисом могут неадекватно отражать определения случаев заболевания на национальном и международном уровне. Использование инструмента ВОЗ для оценки врожденного сифилиса в Парагвае привлекло внимание к врожденному сифилису как национальной проблеме в сфере общественного здравоохранения и подчеркнуло важность комплексных национальных систем наблюдения и точных данных. Постоянное использование инструмента ВОЗ поможет отслеживать прогресс в борьбе с передачей сифилиса от матери к ребенку, способствуя большему охвату услугами по борьбе с сифилисом и наблюдению на национальном уровне.

Objectives Papua New Guinea (PNG) has among the highest rates of sexually transmitted infections (STIs) globally and is committed to reducing their incidence. The Syphilis Interventions Towards Elimination (SITE) model was used to explore the expected impact and cost of alternative syphilis intervention scale-up scenarios. Methods SITE is a dynamical model of syphilis transmission among adults 15–49 years. Individuals are divided into nine groups based on sexual behaviour and into six stages of infection. The model was calibrated to PNG using data from routine surveillance, bio-behavioural surveys, research studies and program records. Inputs included syphilis prevalence, risk behaviours, intervention coverage and service delivery unit costs. Scenarios compared different interventions (clinical treatment, contact tracing, syphilis screening, and condom promotion) for incidence and cost per infection averted over 2021–2030. Results Increasing treatment coverage of symptomatic primary/secondary-stage syphilis cases from 25 to 35% in 2020 to 60% from 2023 onwards reduced estimated incidence over 2021–2030 by 55%, compared to a scenario assuming constant coverage at 2019–2020 levels. The introduction of contact tracing in 2020, assuming 0.4 contacts per symptomatic person treated, reduced incidence over 2021–2030 by 10%. Increasing screening coverage by 20–30 percentage points from the 2019–2020 level reduced incidence over 2021–2030 by 3–16% depending on the target population. Scaling-up clinical, symptom-driven treatment and contact tracing had the lowest cost per infection averted, followed by condom promotion and periodic screening of female sex workers and men who have sex with men. Conclusions PNG could considerably reduce its syphilis burden by scaling-up clinical treatment and contact tracing alongside targeted behavioural risk reduction interventions. SITE is a useful tool countries can apply to inform national STI programming and resource allocation.

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people’s lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both ‘Others’ those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.

Summary Background The WHO Global Health Sector Strategy aims to reduce worldwide syphilis incidence by 90% between 2018 and 2030. If this goal is to be achieved, interventions that target high-burden groups, including men who have sex with men (MSM), will be required. However, there are no global prevalence estimates of syphilis among MSM to serve as a baseline for monitoring or modelling disease burden. We aimed to assess the global prevalence of syphilis among MSM using the available literature. Methods In this global systematic review and meta-analysis, we searched MEDLINE, Embase, LILACS, and AIM databases, and Integrated Bio-Behavioral Surveillance (IBBS) reports between April 23, 2019, and Feb 1, 2020, to identify studies done between Jan 1, 2000, and Feb 1, 2020, with syphilis point prevalence data measured by biological assay among MSM (defined as people who were assigned as male at birth and had oral or anal sex with at least one other man in their lifetime). Studies were excluded if participants were exclusively HIV-infected MSM, injection-drug users, only seeking care for sexually transmitted infections (STIs) or genital symptoms, or routine STI clinic attendees. Data were extracted onto standardised forms and cross-checked for accuracy and validity. We used random-effects models to generate pooled prevalence estimates across the eight regions of the Sustainable Development Goals. We calculated risk of study bias based on the Appraisal tool for Cross-Sectional Studies, and stratified results based on low versus high risk of bias. This systematic review and meta-analysis was registered with PROSPERO, CRD42019144594. Findings We reviewed 4339 records, 228 IBBS reports, and ten articles from other sources. Of these, 1301 duplicate records were excluded, 2467 records were excluded after title and abstract screening, and 534 articles were excluded after full-text analysis. We identified 345 prevalence data points from 275 studies across 77 countries, with a total of 606 232 participants. Global pooled prevalence from 2000–20 was 7·5% (95% CI 7·0–8·0%), ranging from 1·9% (1·0–3·1%) in Australia and New Zealand to 10·6% (8·5–12·9%) in Latin America and the Caribbean. Interpretation Unacceptably high syphilis prevalence among MSM warrants urgent action. Funding Wellcome Trust.

Objective: To estimate Mongolia’s prevalence and incidence trends of gonorrhea and chlamydia in women and men 15-49 years-old, to inform control of STIs and HIV, a national health sector priority. Methods: We applied the Spectrum-STI estimation model, fitting data from two national population surveys (2001 and 2008) and from routine gonorrhea screening of pregnant women in antenatal care (1997-2016), adjusted for diagnostic test performance, male/female differences and missing high-risk populations. Prevalence and incidence estimates were then used to assess completeness of national case reporting. Results: Gonorrhea prevalence was estimated at 3.3% (95% confidence interval, 1.6-3.9%) in women and 2.9% (1.3-3.4%) in men in 2016; chlamydia prevalences were 19.5% (17.3-21.9%) and 15.6% (13.8-17.5%). Corresponding new incident cases in women and men in 2016 totaled 60,334 (36,147-121,933) and 76,893 (40,428-267,884) for gonorrhea, and 131,306 (84,232-254,316) and 148,162 (72,145-444,110) for chlamydia. Gonorrhea and chlamydia prevalence declined by an estimated 33% and 11%, respectively, over 2001-2016. Comparing numbers of symptomatic and treated cases estimated by Spectrum with gonorrhea case reports suggests that 15% of symptomatic treated gonorrhea cases were reported in 2016; only a minority of chlamydia episodes were reported as urethral discharge cases. Discussion: Gonorrhea and chlamydia prevalence are estimated to have declined in Mongolia during the early 2000s, possibly associated with syndromic management in primary care facilities and improving treatment coverage since 2001, and scale-up of (Global Fund-supported) HIV/STI prevention interventions since 2003. However, prevalence remain high, with most gonorrhea and chlamydia cases not treated or recorded in the public health system.

Syphilis prevalence has been declining in every region by several percentage points per year. Nevertheless, the prevalence by region continued to vary, from as little as 0.1% in the European Region to as high as 3% in the African Region., Background This study assessed levels, trends, and associations of observed syphilis prevalence in the general adult population using global pooled analyses. Methods A standardized database of syphilis prevalence was compiled by pooling systematically gathered data. Random-effects meta-analyses and meta-regressions were conducted using data from the period 1990–2016 to estimate pooled measures and assess predictors and trends. Countries were classified by World Health Organization region. Sensitivity analyses were conducted. Results The database included 1103 prevalence measures from 136 million syphilis tests across 154 countries (85% from women in antenatal care). Global pooled mean prevalence (weighted by region population size) was 1.11% (95% confidence interval [CI], .99–1.22). Prevalence predictors were region, diagnostic assay, sample size, and calendar year interacting with region. Compared to the African Region, the adjusted odds ratio (AOR) was 0.42 (95% CI, .33–.54) for the Region of the Americas, 0.13 (95% CI, .09–.19) for the Eastern Mediterranean Region, 0.05 (95% CI, .03–.07) for the European Region, 0.21 (95% CI, .16–.28) for the South-East Asia Region, and 0.41 (95% CI, .32–.53) for the Western Pacific Region. Treponema pallidum hemagglutination assay (TPHA) only or rapid plasma reagin (RPR) only, compared with dual RPR/TPHA diagnosis, produced higher prevalence (AOR >1.26), as did smaller sample-size studies (2.16). Prevalence declined in all regions; the annual AORs ranged from 0.84 (95% CI, .79–.90) in the Eastern Mediterranean to 0.97 (95% CI, .97–1.01) in the Western Pacific. The pooled mean male-to-female prevalence ratio was 1.00 (95% CI, .89–1.13). Sensitivity analyses confirmed robustness of results. Conclusions Syphilis prevalence has declined globally over the past 3 decades. Large differences in prevalence persist among regions, with the African Region consistently the most affected.

Objective To develop a tool for estimating national trends in adult prevalence of sexually transmitted infections by low- and middle-income countries, using standardised, routinely collected programme indicator data. Methods The Spectrum-STI model fits time trends in the prevalence of active syphilis through logistic regression on prevalence data from antenatal clinic-based surveys, routine antenatal screening and general population surveys where available, weighting data by their national coverage and representativeness. Gonorrhoea prevalence was fitted as a moving average on population surveys (from the country, neighbouring countries and historic regional estimates), with trends informed additionally by urethral discharge case reports, where these were considered to have reasonably stable completeness. Prevalence data were adjusted for diagnostic test performance, high-risk populations not sampled, urban/rural and male/female prevalence ratios, using WHO9s assumptions from latest global and regional-level estimations. Uncertainty intervals were obtained by bootstrap resampling. Results Estimated syphilis prevalence (in men and women) declined from 1.9% (95% CI 1.1% to 3.4%) in 2000 to 1.5% (1.3% to 1.8%) in 2016 in Zimbabwe, and from 1.5% (0.76% to 1.9%) to 0.55% (0.30% to 0.93%) in Morocco. At these time points, gonorrhoea estimates for women aged 15–49 years were 2.5% (95% CI 1.1% to 4.6%) and 3.8% (1.8% to 6.7%) in Zimbabwe; and 0.6% (0.3% to 1.1%) and 0.36% (0.1% to 1.0%) in Morocco, with male gonorrhoea prevalences 14% lower than female prevalence. Conclusions This epidemiological framework facilitates data review, validation and strategic analysis, prioritisation of data collection needs and surveillance strengthening by national experts. We estimated ongoing syphilis declines in both Zimbabwe and Morocco. For gonorrhoea, time trends were less certain, lacking recent population-based surveys.

The Spectrum-STI model, structured by sub-groups within a population, was used in a workshop in Yunnan, China, to estimate provincial trends in active syphilis in 15 to 49-year-old adults. Syphilis prevalence data from female sex workers (FSW), men who have sex with men (MSM), and lower-risk women and men in Yunnan were identified through literature searches and local experts. Sources included antenatal care clinic screening, blood donor screening, HIV/STI bio-behavioural surveys, sentinel surveillance, and epidemiology studies. The 2017 provincial syphilis prevalence estimates were 0.26% (95% confidence interval 0.17–0.34%) in women and 0.28% (0.20–0.36%) in men. Estimated prevalence was 6.8-fold higher in FSW (1.69% (0.68–3.97%) than in lower-risk women (0.25% (0.18–0.35%)), and 22.7-fold higher in MSM (5.35% (2.74–12.47%) than in lower-risk men (0.24% (0.17–0.31%). For all populations, the 2017 estimates were below the 2005 estimates, but differences were not significant. In 2017 FSW and MSM together accounted for 9.3% of prevalent cases. These estimates suggest Yunnan’s STI programs have kept the overall prevalence of syphilis low, but prevalence remains high in FSW and MSM. Strengthening efforts targeting FSW and MSM, and identification of other risk populations e.g. among heterosexual men, are critical to reduce syphilis.

Summary Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. Funding Bill & Melinda Gates Foundation. BACKGROUND: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. METHODS: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. FINDINGS: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. INTERPRETATION: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition-in which increasing sociodemographic status brings structured change in disease burden-is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. FUNDING: Bill & Melinda Gates Foundation.

To estimate adult (15-49 years old) prevalence and incidence of active syphilis, gonorrhea, and chlamydia, and incidence of congenital syphilis (CS) and adverse birth outcomes (ABOs) in Colombia, over 1995-2016.The Spectrum-STI epidemiological model tool estimated gonorrhea and chlamydia prevalences as moving averages across prevalences observed in representative general population surveys. For adult syphilis, Spectrum-STI applied segmented polynomial regression through prevalence data from antenatal care (ANC) surveys, routine ANC-based screening, and general population surveys. CS cases and ABOs were estimated from Spectrum's maternal syphilis estimates and proportions of women screened and treated for syphilis, applying World Health Organization case definitions and risk probabilities.The Spectrum model estimated prevalences in 2016 of 0.70% (95% confidence interval (CI): 0.15%-1.9%) in women and 0.60% (0.1%-1.9%) in men for gonorrhea and of 9.2% (4.4%-15.4%) in women and 7.4% (3.5%-14.7%) in men for chlamydia, without evidence for trends over 1995-2016. The prevalence of active syphilis in 2016 was 1.25% (1.22-1.29%) in women and 1.25% (1.1%-1.4%) in men, decreasing from 2.6% (2.1%-3.2%) in women in 1995. Corresponding CS cases in 2016 (including cases without clinical symptoms) totaled 3 851, of which 2 245 were ABOs. Annual CS and ABO estimates decreased over 2008-2016, reflecting decreasing maternal prevalence and increasing cases averted through ANC-based screening and treatment.The available surveillance and monitoring data synthesized in Spectrum-STI- and the resulting first-ever national STI estimates for Colombia-highlighted Colombia's persistently high STI burden. Adult syphilis and congenital syphilis are estimated to be falling, reflecting improving screening efforts. Strengthened surveillance, including with periodic screening in low-risk populations and future refined Spectrum estimations, should support planning and implementation of STI prevention and control, including CS elimination.Estimar la prevalencia e incidencia en los adultos (de 15 a 49 años de edad) de sífilis activa, gonorrea y clamidiasis, así como la incidencia de sífilis congénita y resultados adversos del embarazo en Colombia durante el período de 1995 al 2016.Usando las herramientas del modelo epidemiológico Spectrum-STI se estimó la prevalencia de gonorrea y clamidiasis como promedios móviles entre las distintas prevalencias observadas en encuestas representativas de la población general. En cuanto a la sífilis en los adultos, Spectrum-STI aplicó la regresión polinomial segmentada a los datos sobre prevalencia recopilados en encuestas de atención prenatal, el tamizaje sistemático en la atención prenatal y encuestas a la población general. Los casos de sífilis congénita y de resultados adversos del embarazo se estimaron a partir de las cifras de Spectrum sobre sífilis materna y proporciones de mujeres examinadas y tratadas por sífilis, aplicando las definiciones de casos y probabilidades de riesgo de la Organización Mundial de la Salud.El modelo Spectrum estimó que en el 2016 la prevalencia de la gonorrea fue de 0,70% (intervalo de confianza de 95% [IC]: 0,15%-1,9%) en las mujeres y de 0,60% (0,1%-1,9%) en los hombres, y que la prevalencia de la clamidiasis fue de 9,2% (4,4%-15,4%) en las mujeres y de 7,4% (3,5%-14,7%) en los hombres, sin datos científicos acerca de las tendencias durante el período 1995-2016. La prevalencia de la sífilis activa en el 2016 fue de 1,25% (1,22-1,29%) en las mujeres y de 1,25% (1,1%-1,4%) en los hombres, con una reducción de 2,6% (2,1%-3,2%) en las mujeres con respecto a 1995. Los casos correspondientes de sífilis congénita en el 2016 (incluidos los asintomáticos) sumaron en total 3 851, de los cuales 2 245 fueron resultados adversos del embarazo. Las cifras anuales estimadas de sífilis congénita y resultados adversos del embarazo disminuyeron entre el 2008 y el 2016, lo que reflejó un descenso en la prevalencia materna y un aumento de casos evitados mediante el tamizaje y el tratamiento durante la atención prenatal.Los datos disponibles sobre vigilancia y seguimiento sintetizados en Spectrum-STI, así como los consiguientes estimados nacionales de infecciones de transmisión sexual (ITS) hechos por primera vez en Colombia, pusieron de relieve la carga de morbilidad por ITS persistentemente alta en ese país. Se estima que la sífilis en los adultos y la sífilis congénita van en descenso, lo que refleja mejoras en las actividades de tamizaje. Un fortalecimiento de la vigilancia, incluso con tamizaje periódico en las poblaciones de bajo riesgo, y estimaciones más refinadas con Spectrum en el futuro deberían brindar apoyo a la planificación y la ejecución de medidas para la prevención y el control de las infecciones de transmisión sexual, incluida la eliminación de la sífilis congénita.Estimar a incidência e a prevalência na população adulta (com idade de 15–49 anos) de sífilis ativa, gonorreia e clamídia e a incidência de sífilis congênita (SC) e desfechos adversos congênitos na Colômbia no período de 1995 a 2016.O modelo epidemiológico Spectrum-STI foi o instrumento usado para estimar a prevalência de gonorreia e clamídia como médias móveis nas prevalências observadas em pesquisas representativas da população geral. A sífilis em adultos foi estimada com a regressão polinomial segmentada aplicada ao modelo Spectrum-STI com dados de prevalência obtidos de pesquisas da atenção pré-natal, exames pré-natais de rotina de detecção precoce e pesquisas da população geral. Casos de SC e desfechos adversos congênitos foram estimados a partir das estimativas de sífilis materna do modelo Spectrum e percentuais de mulheres que fizeram testes de detecção e foram tratadas para sífilis, segundo as definições de casos da Organização Mundial da Saúde (OMS) e probabilidades de risco.O modelo Spectrum estimou, para 2016, uma prevalência de gonorreia de 0,70% (intervalo de confiança de 95% [IC 95%] 0,15%–1,9%) no sexo feminino e 0,60% (0,1%–1,9%) no sexo masculino e uma prevalência de clamídia de 9,2% (4,4%–15,4%) no sexo feminino e 7,4% (3,5%–14.7%) no sexo masculino, sem evidência de tendências no período 1995–2016. A prevalência de sífilis ativa em 2016 foi de 1,25% (1,22–1,29%) no sexo feminino e 1,25% (1,1%–1,4%) no sexo masculino, demonstrando um declínio da prevalência de 2,6% (2,1%–3,2%) observada em 1995 para o sexo feminino. Houve, ao todo, 3.851 casos correspondentes de SC em 2016 (incluindo casos assintomáticos), dos quais 2.245 foram desfechos adversos congênitos. Observou-se uma redução nas estimativas anuais de SC e desfechos adversos congênitos em 2008–2016, refletindo a diminuição da prevalência materna e o número crescente de casos evitados com exames pré-natais de detecção e tratamento.Os dados disponíveis de vigilância e monitoramento condensados no modelo Spectrum-STI, e as resultantes estimativas nacionais de infeções sexualmente transmissíveis (IST) obtidas pela primeira vez na Colômbia, evidenciam a alta carga persistente de IST no país. Estima-se que a ocorrência de sífilis do adulto e sífilis congênita esteja diminuindo em decorrência da melhoria nos esforços de detecção precoce. A vigilância reforçada, consistindo também de exames periódicos de detecção precoce nas populações de baixo risco e estimavas futuras aprimoradas do instrumento Spectrum, deve sustentar o planejamento e a implementação de controle e prevenção de IST e a eliminação da SC.

Objectives To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa. Methods The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome. Results In 2017 adult (15–49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32–0.80%) and 0.97% (0.19–2.28%), for gonorrhea 6.6% (3.8–10.8%) and 3.5% (1.7–6.1%), and for chlamydia 14.7% (9.9–21%) and 6.0% (3.8–10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases − reflecting population growth − the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10–28% in 2017. Conclusion South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections.

Background Evolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. We applied the Spectrum STI estimation tool to estimate the prevalence and incidence of active syphilis in adult women in Morocco over 1995 to 2016. The results from the analysis are being used to inform Morocco's national HIV/STI strategy, target setting and program evaluation. Methods Syphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics, women attending family planning clinics and other general adult populations, as available post-1995. Prevalence data were adjusted for diagnostic test performance, and for the contribution of higher-risk populations not sampled in surveys. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis. Results In 2016, active syphilis prevalence was estimated to be 0.56% in women 15 to 49 years of age (95% confidence interval, CI: 0.3%-1.0%), and around 21,675 (10,612-37,198) new syphilis infections have occurred. The analysis shows a steady decline in prevalence from 1995, when the prevalence was estimated to be 1.8% (1.0-3.5%). The decline was consistent with decreasing prevalences observed in TB patients, fishermen and prisoners followed over 2000-2012 through sentinel surveillance, and with a decline since 2003 in national HIV incidence estimated earlier through independent modelling. Conclusions Periodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. This first-ever undertaking engaged and focused national stakeholders, and confirmed the still considerable syphilis burden. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012. From 2017 Morocco plans to implement a system to record data from routine antenatal programmatic screening, which should help update and re-calibrate next trend estimations.

Introduction In 2016, the World Health Assembly adopted the global strategy 2016–2021 for STI control through the health sector, with as impact target to reduce syphilis incidence by 90% from 2018 to 2030. We applied the Spectrum STI estimation tool to estimate national adult prevalence and incidence of active syphilis in Morocco currently and over 1995–2015, to inform its national HIV/STI strategy, target setting and program evaluation. Methods Syphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics conducted during 1996–2012, and among women attending family planning clinics. Prevalence data were adjusted for diagnostic test performance. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis. Rates estimated for ANC women were assumed to apply to the overall female adult (15–49 years) population. Results In 2016, syphilis prevalence was estimated to be 0.56% (95% confidence interval, CI: 0.3%–1.0%). Around 21,675 (10,612–37,198) new syphilis infections were estimated to have occurred in adult women in 2016. This is a decline from the prevalence estimate for 2000 of 1.38% (0.87%–2.1%). Conclusion Periodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012, when no new surveys were conducted. Planned recording of results from routine antenatal programmatic screening, being rolled out from 2017, should soon allow updating and re-calibration of future estimations.

Introduction Evolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. Methods The Spectrum modelling tool estimated prevalence and incidence of gonorrhoea and chlamydia in Morocco’s 15–49 year-old population, based on prevalence data adjusted for diagnostic test performance, urban/rural and male/female differences, and missing high-risk populations, and weighted by coverage and representativeness. Results Gonorrhoea prevalence was estimated at 0.37% (95% confidence interval, 0.14%–1.0%) in women and 0.32% (0.12%–0.87%) in men in 2015; chlamydia prevalences were 3.8% (2.1%–6.4%) and 3.0% (1.7%–5.1%). Corresponding numbers of new cases in 15–49 year-old women and men in 2015 were 79,598 (23,918–256,206) and 112,013 (28,700–307,433) for gonorrhoea, and 291,908 (161,064–524,270) and 314,032 (186,076–559,133) for chlamydia. Gonorrhoea and chlamydia prevalence had declined by 41% and 27%, respectively, over 1995–2015. Prevalence declines probably related to improved STI treatment coverage, and decreasing risk behaviours. Reporting completeness among treated urethral discharge (UD) cases was estimated at 46%–77% in 2015. Clinically reported UD cases corresponded to 13% of all (symptomatic and asymptomatic) gonorrhoea and chlamydia cases. Conclusion STI declines and improvements in treatment coverage are consistent with Morocco’s introduction of syndromic management in 2000, scale-up of prevention interventions, and declining HIV incidence after 2003. While gonorrhoea is four-fold more common as cause of clinical UD cases than chlamydia, Morocco continues to suffer a large, untreated burden of chlamydia. Reliable monitoring of both STIs requires new periodic surveys and/or novel forms of affordable surveillance beyond high-risk populations.

Introduction The World Health Organisation and many countries have set targets to reduce rates of syphilis and eliminate congenital syphilis. National trends in syphilis prevalence and incidence, however, are uncertain. We used the Spectrum-STI model to estimate prevalence trends of active syphilis in adult women, for countries with ≥3 data points post-1999 including ≥1 from year 2009 or later. Methods Prevalence data were adjusted for diagnostic test performance, and for the contribution of high-risk populations under-represented in surveys. National trends were estimated by logistic regression, weighting each data point by its national coverage. Estimates for 117 countries were aggregated to regional totals, weighting each country by adult population size, and imputing for countries without a trend estimate using regional averages. Results At January 2017, 1056 data points had been identified, between 1977–2016 (median 2009), covering 137 million tests (132 million in routine ANC screening, 5.3 million in ANC surveys; 0.79 million from non-ANC general adult population surveys), of which 1.36 million found active infection. In provisional estimates, prevalence was highest in sub-Saharan Africa and lowest in Europe and the Middle East and North Africa (MENA). Prevalence declined over 2002–2012 in all regions, with strongest proportional decline in MENA (≥1% to Conclusion Spectrum-STI is a useful tool to interpret syphilis data in a systematic manner, and evaluate time trends in national adult syphilis prevalence; however some high-STI countries lack recent data from ANC or any other general populations. These first standardised country estimates suggests that syphilis declines need to accelerate in most countries, if by 2021 they are to meet impact targets of the global STI control strategy and eliminate congenital syphilis.

To generate estimates of the global prevalence and incidence of urogenital infection with chlamydia, gonorrhoea, trichomoniasis and syphilis in women and men, aged 15-49 years, in 2016.For chlamydia, gonorrhoea and trichomoniasis, we systematically searched for studies conducted between 2009 and 2016 reporting prevalence. We also consulted regional experts. To generate estimates, we used Bayesian meta-analysis. For syphilis, we aggregated the national estimates generated by using Spectrum-STI.For chlamydia, gonorrhoea and/or trichomoniasis, 130 studies were eligible. For syphilis, the Spectrum-STI database contained 978 data points for the same period. The 2016 global prevalence estimates in women were: chlamydia 3.8% (95% uncertainty interval, UI: 3.3-4.5); gonorrhoea 0.9% (95% UI: 0.7-1.1); trichomoniasis 5.3% (95% UI:4.0-7.2); and syphilis 0.5% (95% UI: 0.4-0.6). In men prevalence estimates were: chlamydia 2.7% (95% UI: 1.9-3.7); gonorrhoea 0.7% (95% UI: 0.5-1.1); trichomoniasis 0.6% (95% UI: 0.4-0.9); and syphilis 0.5% (95% UI: 0.4-0.6). Total estimated incident cases were 376.4 million: 127.2 million (95% UI: 95.1-165.9 million) chlamydia cases; 86.9 million (95% UI: 58.6-123.4 million) gonorrhoea cases; 156.0 million (95% UI: 103.4-231.2 million) trichomoniasis cases; and 6.3 million (95% UI: 5.5-7.1 million) syphilis cases.Global estimates of prevalence and incidence of these four curable sexually transmitted infections remain high. The study highlights the need to expand data collection efforts at country level and provides an initial baseline for monitoring progress of theProduire des estimations de la prévalence et de l'incidence mondiales des infections urogénitales dues à la chlamydiose, à la gonorrhée, à la trichomonase et à la syphilis chez les femmes et les hommes de 15 à 49 ans, en 2016.Pour la chlamydiose, la gonorrhée et la trichomonase, nous avons systématiquement recherché les études menées entre 2009 et 2016 qui s’intéressaient à la prévalence. Nous avons également consulté des experts régionaux. Pour produire des estimations, nous avons eu recours à une méta-analyse bayésienne. Pour la syphilis, nous avons regroupé les estimations nationales obtenues à l'aide de Spectrum-STI.Pour la chlamydiose, la gonorrhée et/ou la trichomonase, 130 études étaient éligibles. Pour la syphilis, la base de données de Spectrum-STI contenait 978 points de données pour la période considérée. Les estimations de la prévalence mondiale en 2016 chez les femmes étaient les suivantes: chlamydiose 3,8% (intervalle d'incertitude de 95%, II: 3,3–4,5); gonorrhée 0,9% (II 95%: 0,7–1,1); trichomonase 5,3% (II 95%: 4,0–7,2); et syphilis 0,5% (II 95%: 0,4–0,6). Chez les hommes, les estimations de la prévalence étaient les suivantes: chlamydiose 2,7% (II 95%: 1,9-3,7); gonorrhée 0,7% (II 95%: 0,5-1,1); trichomonase 0,6% (II 95%: 0,4-0,9); et syphilis 0,5% (II 95%: 0,4–0,6). L'incidence totale estimée était de 376,4 millions de cas: 127,2 millions (II 95%: 95,1–165,9 millions) de cas de chlamydiose; 86,9 millions (II 95%: 58,6-123,4 millions) de cas de gonorrhée; 156,0 millions (II 95%: 103,4-231,2 millions) de cas de trichomonase; et 6,3 millions (II 95%: 5,5–7,1 millions) de cas de syphilis.Les estimations mondiales de la prévalence et de l'incidence de ces quatre infections sexuellement transmissibles guérissables restent élevées. Cette étude souligne la nécessité d'amplifier les efforts de collecte de données au niveau des pays et offre un point de référence pour suivre la progression de laGenerar estimaciones de la prevalencia y la incidencia mundiales de la infección urogenital por clamidia, gonorrea, tricomoniasis y sífilis en mujeres y hombres de 15 a 49 años de edad en 2016.Para la clamidia, la gonorrea y la tricomoniasis, se realizaron búsquedas sistemáticas de estudios realizados entre 2009 y 2016 que registrasen la prevalencia. También se consultó a expertos regionales. Para generar estimaciones, se utilizó el metanálisis bayesiano. Para la sífilis, se añadieron las estimaciones nacionales generadas por el uso de Spectrum-STI.Para la clamidia, la gonorrea y/o la tricomoniasis, hubo 130 estudios que cumplían los criterios. Para la sífilis, la base de datos Spectrum-STI contenía 978 puntos de datos para el mismo periodo. Las estimaciones de prevalencia mundial en mujeres en 2016 fueron: clamidia 3,8 % (intervalo de incertidumbre, II, del 95 %: 3,3-4,5); gonorrea 0,9 % (II del 95 %: 0,7-1,1); tricomoniasis 5,3 % (II del 95 %: 4,0-7,2); y sífilis 0,5 % (II del 95 %: 0,4-0,6). Las estimaciones de prevalencia en hombres fueron: clamidia 2,7 % (intervalo de incertidumbre, II, del 95 %: 1,9-3,7); gonorrea 0,7 % (II del 95 %: 0,5-1,1); tricomoniasis 0,6 % (II del 95 %: 0,4-0,9); y sífilis 0,5 % (II del 95 %: 0,4-0,6). El total estimado de casos incidentes fue de 376,4 millones: 127,2 millones (II del 95 %: 95,1-165,9 millones) de casos de clamidia; 86,9 millones (II del 95 %: 58,6-123,4 millones) de casos de gonorrea; 156,0 millones (II del 95 %: 103,4-231,2 millones) de casos de tricomoniasis; y 6,3 millones (II del 95 %: 5,5-7,1 millones) de casos de sífilis.Las estimaciones mundiales de la prevalencia y la incidencia de estas cuatro enfermedades de transmisión sexual curables siguen siendo elevadas. El estudio destaca la necesidad de ampliar los esfuerzos de recopilación de datos a nivel nacional y proporciona una base inicial para el seguimiento de los progresos de laوضع تقديرات للانتشار والإصابة العالمية لعدوى الجهاز البولي التناسلي، وأمراض الكلاميديا، والسيلان، وداء المشعرات، والزهري لدى النساء والرجال، الذين تتراوح أعمارهم بين 15 و49 سنة، في عام 2016.بالنسبة للكلاميديا، والسيلان، وداء المشعرات، فقد قمنا بالبحث بشكل منهجي عن الدراسات التي تمت خلال الفترة من 2009 إلى 2016 والتي توضح مدى الانتشار. كما قمنا باستشارة خبراء إقليميين. ولوضع التقديرات، قمنا باستخدام التحليل التلوي Bayesian. بالنسبة لمرض الزهري، قمنا بتجميع التقديرات الوطنية الناتجة عن استخدام Spectrum-STI.بالنسبة لأمراض الكلاميديا، والسيلان، وداء المشعرات، كانت هناك 130 دراسة مؤهلة. وبالنسبة لمرض الزهري، احتوت قادة بيانات Spectrum-STI على 978 نقطة بيانات لنفس الفترة. كانت تقديرات الانتشار العالمي في عام 2016 في النساء: الكلاميديا 3.8% (فاصل عدم الثقة 95%: 3.3 إلى 4.5)، والسيلان 0.9% (فاصل عدم الثقة 95%: 0.7 إلى 1.1)، وداء المشعرات 5.3% (فاصل عدم الثقة 95%: 4.0 إلى 7.2)؛ والزهري 0.5% (فاصل عدم الثقة 95%: 0.4 إلى 0.6). كانت تقديرات الانتشار في عام 2016 في الرجال: الكلاميديا 2.7% (فاصل عدم الثقة 95%: 1.9 إلى 3.7)، والسيلان 0.7% (فاصل عدم الثقة 95%: 0.5 إلى 1.1)، وداء المشعرات 0.6% (فاصل عدم الثقة 95%: 0.4 إلى 0.9)، والزهري 0.5% (فاصل عدم الثقة 95%: 0.4–0.6). بلغ مجموع حالات الإصابة التقديري 376.4 مليون حالة: 127.2 مليون (فاصل عدم الثقة 95%: 95.1 إلى 165.9 مليون) حالات الكلاميديا؛ 86.9 مليون (فاصل عدم الثقة 95%: 58.6 إلى 123.4 مليون) حالات السيلان؛ 156.0 مليون (فاصل عدم الثقة 95%: 103.4 إلى 231.2 مليون) حالات داء المشعرات؛ 6.3 مليون (فاصل عدم الثقة 95%: 5.5 إلى 7.1 مليون) حالات الزهري.لا تزال التقديرات العالمية عالية لانتشار والإصابة بهذه الأمراض الأربعة المنقولة جنسياً والعلاج منها. تسلط الدراسة الضوء على الحاجة إلى توسيع جهود جمع البيانات على مستوى الدول، وتوفر خط أساس أولي لمراقبة التقدم المحرز في إستراتيجية قطاع الصحة العالمية التابع لمنظمة الصحة العالمية بشأن الأمراض المنقولة جنسياً خلال الفترة من 2016 إلى 2021.旨在估计 2016 年 15-49 岁男女泌尿生殖系统感染衣原体病、淋病、滴虫病和梅毒的全球患病率和发病率。.对于衣原体病、淋病和滴虫病,我们系统搜索了 2009 年至 2016 年间的患病率报告研究。我们还咨询了区域专家。为了生成估计值,我们使用了贝叶斯荟萃分析。对于梅毒,我们汇总分析了使用 Spectrum-STI 生成的全国估计值。.对于衣原体病、淋病和/或滴虫病,符合要求的有 130 项研究。对于梅毒, Spectrum-STI 数据库包含了同一时期的 978 个数据点。2016 年,全球女性患病率估计值为:衣原体病 3.8%(95% 不确定区间,UI:3.3-4.5);淋病 0.9%(95% UI:0.7–1.1);滴虫病 5.3%(95% UI:4.0–7.2)和梅毒 0.5%(95% UI:0.4-0.6)。全球男性患病率估计值为:衣原体病 2.7%(95% UI:1.9-3.7);淋病 0.7%(95% UI:0.5-1.1);滴虫病 0.6%(95% UI:0.4-0.9);梅毒 0.5%(95% UI:0.4-0.6)。预计病例总数为 3.764 亿:1.272 亿(95% UI:9510-16590 万)衣原体病病例;8690 万(95% UI:5860-12340 万)淋病病例;15600 万(95% UI:10340-23120 万)滴虫病病例;630 万(95% UI:550-710 万)梅毒病例。.对这四种可治愈的性传播疾病的患病率和发病率的全球估计值仍然很高。该研究强调了扩大国家级数据收集工作的必要性,并为监测 2016 至 2021 年世卫组织全球卫生部门性传播疾病战略的进展提供了初始基线。.Оценить распространенность в мировом масштабе и частоту урогенитальных инфекций, вызываемых хламидией, а также гонореи, трихомониаза и сифилиса у мужчин и женщин в возрасте от 15 до 49 лет по состоянию на 2016 год.Для хламидиоза, гонореи и трихомониаза авторы провели систематический поиск исследований, выполненных в период с 2009 по 2016 год, в которых приводились данные по распространенности заболеваний. Авторы также консультировались с международными специалистами. Для оценки использовался байесовский метаанализ. Для исследования сифилиса нами были объединены национальные оценки, созданные с использованием методики Spectrum-STI.Было обнаружено 130 исследований на тему хламидийной инфекции, гонореи и (или) трихомониаза. Что касается сифилиса, база данных Spectrum-STI за тот же период содержала 978 источников данных. По состоянию на 2016 год распространенность изучаемых заболеваний в мире среди женщин составляла: хламидиоз 3,8% (95%-й интервал неопределенности, ИН: 3,3–4,5), гонорея 0,9% (95%-й ИН: 0,7–1,1), трихомониаз 5,3% (95%-й ИН: 4,0–7,2) и сифилис 0,5% (95%-й ИН: 0,4–0,6). У мужчин распространенность хламидиоза составила 2,7% (95%-й ИН: 1,9–3,7), гонореи 0,7% (95%-й ИН: 0,5–1,1), трихомониаза 0,6% (95%-й ИН: 0,4–0,9) и сифилиса 0,5% (95%-й ИН: 0,4–0,6). Общее приблизительное количество случаев заболевания составило 376,4 млн человек: 127,2 млн (95 %-й ИН: 95,1–165,9 млн) случаев хламидийной инфекции, 86,9 млн (95%-й ИН: 58,6–123,4 млн) случаев гонореи, 156,0 млн (95%-й ИН: 103,4–231,2 млн) случаев трихомониаза и 6,3 млн (95%-й ИН: 5,5–7,1 млн) случаев сифилиса.Оценки мировой распространенности и частоты этих четырех излечимых инфекций, передаваемых половым путем (ИППП), остаются высокими. Исследование показывает необходимость предпринимать дальнейшие усилия по сбору данных на уровне каждой страны и может служить источником базовых значений для мониторинга прогресса в исполнении глобальных стратегий ВОЗ в секторе здравоохранения относительно ИППП на период 2016–2021 гг.

BackgroundQuantifying sexually transmitted infection (STI) prevalence and incidence is important for planning interventions and advocating for resources. The World Health Organization (WHO) periodically estimates global and regional prevalence and incidence of four curable STIs: chlamydia, gonorrhoea, trichomoniasis and syphilis.Methods and findingsWHO's 2012 estimates were based upon literature reviews of prevalence data from 2005 through 2012 among general populations for genitourinary infection with chlamydia, gonorrhoea, and trichomoniasis, and nationally reported data on syphilis seroprevalence among antenatal care attendees. Data were standardized for laboratory test type, geography, age, and high risk subpopulations, and combined using a Bayesian meta-analytic approach. Regional incidence estimates were generated from prevalence estimates by adjusting for average duration of infection. In 2012, among women aged 15-49 years, the estimated global prevalence of chlamydia was 4.2% (95% uncertainty interval (UI): 3.7-4.7%), gonorrhoea 0.8% (0.6-1.0%), trichomoniasis 5.0% (4.0-6.4%), and syphilis 0.5% (0.4-0.6%); among men, estimated chlamydia prevalence was 2.7% (2.0-3.6%), gonorrhoea 0.6% (0.4-0.9%), trichomoniasis 0.6% (0.4-0.8%), and syphilis 0.48% (0.3-0.7%). These figures correspond to an estimated 131 million new cases of chlamydia (100-166 million), 78 million of gonorrhoea (53-110 million), 143 million of trichomoniasis (98-202 million), and 6 million of syphilis (4-8 million). Prevalence and incidence estimates varied by region and sex.ConclusionsEstimates of the global prevalence and incidence of chlamydia, gonorrhoea, trichomoniasis, and syphilis in adult women and men remain high, with nearly one million new infections with curable STI each day. The estimates highlight the urgent need for the public health community to ensure that well-recognized effective interventions for STI prevention, screening, diagnosis, and treatment are made more widely available. Improved estimation methods are needed to allow use of more varied data and generation of estimates at the national level.

Surgery for trachomatous trichiasis prevents blindness and is advocated by the WHO as part of the Surgery Antibiotic therapy Facial cleanliness and Environmental improvement (SAFE) strategy for the global elimination of trachoma. The authors conducted a randomized community trial to investigate the effect of providing surgery in villages on surgical uptake in The Gambia. 56 villages from two divisions were assigned to eight pairs of clusters matched by geographical division and proximity. One cluster from each pair was randomly assigned to receive village-based surgery and the other cluster health center-based surgery. Outcome measures were uptake rates and surgical results after 1 week and 3 months. The paired t-test was used to analyze the results. Overall uptake was 66% in the village-based clusters and 44% in the health-center-based clusters. Subjects in the village-based surgery arm had significantly shorter journey times (P = 0.01) and lower costs (P = 0.002). The mean difference in absolute acceptance rates of surgery was 20% better in village-based clusters (95% confidence interval [CI] –9% to +49%; P = 0.15) which would equate to an improvement of 45% (95% CI -20% to 120%) on the average acceptance rates of 44% in the health center-based group. These results strongly suggest better surgical uptake when surgery is provided in patients villages due to lower cost to the patient time saved and less fear of operation. (authors)

Summarybackground With increasing urbanization and westernization, rates of diabetes in sub-Saharan Africa (sSA) are likely to rise. Early detection and intervention plays an important role in delaying development of complications. In sSA in particular there is need for an affordable, reliable, safe, feasible test to avert human suffering and exhausting already stressed health facilities. methods Data from two large community-based studies were used to assess the value of glycosuria testing in the detection of diabetes in adults in a sub-Saharan country. A first study (A) tested participants for glycosuria by dipstick; if positive, fasting capillary glucose was measured. A later study (B) measured glucose concentration in venous blood 2 h after a 75-g glucose load; if glycaemia was ≥ 10 mmol/l, urine was tested for glycosuria. results The positive predictive value of glycosuria for a diagnosis of diabetes (fasting glucose ≥ 6.7 mmol/l) was 48%. Sensitivity was 64% (57% if a 2-h-value ≥ 10 mmol/l was used as gold standard). Sensitivity was higher among overweight and/or hypertensive subjects, among elderly people in the urban area, and among subjects with higher blood glucose levels. Extrapolated specificity was 99.7%, and the likelihood ratio 190. conclusions Glycosuria testing can identify a considerable number of undiagnosed diabetic patients when specially targeted at high-risk groups (obese, hypertensive, or elderly people). Dipstick glycosuria testing is an appropriate, safe, feasible test for sSA, where the prevalence of diabetes is expected to increase considerably in the near future.

Home treatment with antimalarials is a common practice in many countries, and may save lives by ensuring that more malaria cases receive prompt treatment. Through retrospective surveys we found that home treatment of young children with antimalarials was uncommon in rural Gambia. Few families kept medicines in the home in case of illness, 28% kept paracetamol and only 8% kept chloroquine. Less than 10% of cases of childhood 'malaria' had been treated with chloroquine at home, and 69% of those giving home medication did not know the correct dosage for a child. The most common course of treatment was the use of paracetamol and/or tepid sponging to reduce fever, before the child was taken to a government health facility. Treating a child with antimalarials at home was more costly than other forms of treatment. The low cost associated with the use of health services for children and the limited availability of antimalarials outside major towns contribute to the high use of government health services. This shows that that home treatment cannot be assumed to be the predominant mode of malaria treatment throughout Africa, and highlights the need for country-specific policies based on accurate local knowledge of treatment practices in both rural and urban areas.

The study aim was to compare three formulations, tablet deltamethrin, liquid deltamethrin and liquid permethrin, for their impact on vector behaviour and persistence. Product acceptance, perceived side-effects and user's perceptions of effectiveness were also investigated. At the beginning of the 1998 rainy season, 255 nets in a Gambian village were dipped in one of the three insecticides. Chemical residue analysis immediately after dipping showed that the target doses were reached for the liquid insecticides, but tablet deltamethrin deposited significantly less. Insecticide persistence at 5 months, however, was highest for the tablet formulation. Susceptibility tests established that Anophelines in this area were sensitive to both insecticides. All three formulations appeared effective as very few live Anophelines, or other mosquitoes, were caught under the treated nets. This conclusion was supported by the bioassay data with both deltamethrin formulations giving over 90% mortality soon after dipping and at 3 months, and at 5 months 70.8 and 79.6% were obtained for deltametrin liquid and tablet, respectively. Permethrin appeared less effective at all times (72.4, 86.8, 59.0%). There were no serious side-effects reported by the villagers following dipping. All three treatments were perceived as effective by the majority (92%) of users and most (93%) wanted to use the insecticide again. Deltamethrin tablets thus appear as good as permethrin for treating bednets in The Gambia. In addition, a tablet formulation is considerable easier to pack and distribute.

Hypertension is emerging as an important public health problem in sub-Saharan Africa. We studied blood pressure (BP) patterns, hypertension and other cardiovascular risk factors in a rural and an urban area of The Gambia. A total of 5389 adults (> or =15 years) were selected by cluster sampling in the capital Banjul and a rural area around Farafenni. A questionnaire was completed, BP, pulse rate, height and weight were recorded. Glucose was measured 2 h after a 75 g glucose load among participants > or =35 years (n = 2301); total cholesterol, triglycerides, creatinine and uric acid were measured among a stratified subsample (n = 1075). A total of 7.1% of the study participants had a BP > or =160/95 mm Hg; 18.4% of them had a BP > or =140/90 mm Hg. BP was significantly higher in the urban area. BP increased with age in both sexes in both areas. Increasing age was the major independent risk factor for hypertension. Related cardiovascular risk factors (obesity, diabetes and hyperlipidaemia) were significantly more prevalent in the urban area and among hypertensives; 17% of measured hypertensives were aware of this, 73% of people who reported to have been diagnosed as hypertensive before had discontinued treatment; 56% of those who reported being on treatment were normotensive. We conclude that hypertension is no longer rare in either urban or rural Gambians. In the urban site hypertension and related cardiovascular risk factors were more prevalent. Compliance with treatment was low. Interventions aimed at modifying risk factors at the population level, and at improving control of diagnosed hypertension are essential to prevent future increases of cardiovascular morbidity and mortality. In view of limited resources and feasibility of intervention in rural Gambia, these could initially be directed towards urbanised populations.

There is little doubt that the various reproductive tract infections (RTIs) and their complications and sequelae are a significant public health problem in terms of morbidity and, common opinion among the medical profession notwithstanding, mortality.1–6 This paper reviews the economic burden of RTIs in the developing world, as well as resources available and needed for their prevention and control. Since data on these topics are scarce to nonexistent, we are by necessity quite vague in many sections of this paper, and we do not quantify resources needed to control RTIs.

Over the last two decades, the maternal mortality ratio appears to have fallen by up to 50% in the Farafenni, a rural area of The Gambia. This reduction almost certainly reflects improvements in access to essential obstetric services. The ratio, however, is still 50 times higher than in Western and Northern Europe or North America. This paper provides information from a community-based study of 623 women who had recently given birth in the Farafenni area. Information on how, when, and why care was accessed, and what type of care and information were provided were obtained from traditional and western methods of health care were during visits. Women were asked about their experiences during prenatal, delivery and postpartum periods. Results from this study highlight a number of opportunities for improving the quality of maternal health services that could be implemented relatively easily with existing resources. Résumé Les Expériences des Mères face aux Besoins Prénatals à l\'Accouchement et aux Soins Postpartum en Gambie Rurale. Au cours de ces deux dernières décennies, le rapport de la mortalité semble avoir baissé de jusqu\'à 50% dans la Farafenni, une région rurale en Gambie. Cette baisse, si l\'on veut, reflète certainement des améliorations par rapport à l\'accès aux services obstétriques. Le rapport néanmoins est cinquante fois plus élevé qu\'en Europe occidentale et l\'Europe du Nord ou en Amérique du nord. Cet article fournit l\'information recueillies d\'une communauté dans le cadre d\'une étude faite sur 623 femmes qui venaient récemment d\'accoucher dans la région de la Farafenni. Nous avons pu obtenir des renseignements sur le comment, le quand et le pourquoi l\'on a recherché le soin, ainsi que sur le type du soin assuré à travers les méthodes traditionnelles et occidentales de services de santé. On a posé des questions aux femmes sur leurs expériences pendant les périodes prénatales, de l\'accouchement et du postpartum. Les résultats émanant de cette étude indiquent un certain nombre d\'opportunités pour améliorer la qualité de service de maternité qu\'on peut relativement mettre en oeuvre avec les ressources disponsibles. (Af. J. Of Reproductive Health: 2002 6(1): 74-83)

For the in vivo evaluation of hip joint prostheses that are developed for man, the suitability of the pony as an animal model has been studied. Human and custom made prostheses were implanted into 1 femur in each of 7 ponies to replace the femoral head. The surgical approach was through a caudolateral incision. The prosthesis was fixed in the femur with bone cement. Because of errors in the implantation technique and resulting lack of sufficient fixation 2 ponies as well as 1 control animal with an excision arthroplasty were unwilling or unable to stand. Rigid fixation of the implant was achieved in 3 ponies. They were returned to pasture after 8 days. A full return to a normal gait did not occur within an observation period of up to 3 months. All 3 ponies developed a dorsolateral coxofemoral luxation and pseudarthrosis within the first 10 days. A mismatch between the equine anatomy and human prosthesis geometry was thought to be the cause. We, therefore, believe that the pony does not provide a suitable model for the testing of human femoral joint implants. The results, however, indicate that coxofemoral surgery can be performed in the adult pony. For clinical reconstruction of joint function, a custom made total artificial hip joint might provide better results.