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Bulletin of the World Health Organization logoLink to Bulletin of the World Health Organization
. 2019 Jun 6;97(8):548–562P. doi: 10.2471/BLT.18.228486

Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016

Chlamydiose, gonorrhée, trichomonase et syphilis: estimations de la prévalence et de l'incidence mondiales, 2016

Clamidia, gonorrea, tricomoniasis y sífilis: estimaciones de prevalencia e incidencia mundiales, 2016

الكلاميديا، والسيلان، وداء المشعرات، والزهري: تقديرات الانتشار والإصابة العالمية، 2016

衣原体病、淋病、滴虫病和梅毒:2016 年全球患病率和发病率估计

Хламидии, гонорея, трихомониаз и сифилис: распространенность в мире и оценка частоты заболеваний в 2016 году

Jane Rowley a, Stephen Vander Hoorn b, Eline Korenromp c, Nicola Low d, Magnus Unemo e, Laith J Abu-Raddad f, R Matthew Chico g, Alex Smolak f, Lori Newman h, Sami Gottlieb a, Soe Soe Thwin a, Nathalie Broutet a, Melanie M Taylor a,✉
PMCID: PMC6653813  PMID: 31384073

Abstract

Objective

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.

Methods

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.

Findings

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.

Conclusion

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 the World Health Organization global health sector strategy on sexually transmitted infections 2016–2021.

Introduction

Sexually transmitted infections are among the most common communicable conditions and affect the health and lives of people worldwide. The World Health Organization (WHO) periodically generates estimates to gauge the global burden of four of the most common curable sexually transmitted infections: chlamydia (etiological agent: Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae), trichomoniasis (Trichomonas vaginalis) and syphilis (Treponema pallidum).1–6 The estimates provide evidence for programme improvement, monitoring and evaluation.

These sexually transmitted infections cause acute urogenital conditions such as cervicitis, urethritis, vaginitis and genital ulceration, and some of the etiological agents also infect the rectum and pharynx. Chlamydia and gonorrhoea can cause serious short- and long-term complications, including pelvic inflammatory disease, ectopic pregnancy, infertility, chronic pelvic pain and arthritis, and they can be transmitted during pregnancy or delivery. Syphilis can cause neurological, cardiovascular and dermatological disease in adults, and stillbirth, neonatal death, premature delivery or severe disability in infants. All four infections are implicated in increasing the risk of human immunodeficiency virus (HIV) acquisition and transmission.7 Moreover, people with sexually transmitted infections often experience stigma, stereotyping, vulnerability, shame and gender-based violence.8

In May 2016, the World Health Assembly adopted the Global health sector strategy on sexually transmitted infections, 2016–2021.9 This strategy includes rapid scale-up of evidence-based interventions and services to end sexually transmitted infections as public health concerns by 2030. The strategy sets targets for reductions in gonorrhoea and syphilis incidence in adults and recommends the establishment of global baseline incidences of sexually transmitted infections by 2018. The primary objectives of this study were to estimate the 2016 global and regional prevalence and incidence of chlamydia, gonorrhoea, trichomoniasis and syphilis in adult women and men.

Methods

Prevalence estimation

Chlamydia, gonorrhoea and trichomoniasis

We generated estimates for these three infections through systematic reviews using the same methods as for the 2012 estimates.6

We searched for articles published between 1 January 2009 and 29 July 2018 in PubMed® without language restrictions. We used PubMed Medical subject heading (MeSH) terms for individual country names combined with: “chlamydia”[MeSH Terms] OR “chlamydia”[All Fields], “gonorrhoea”[All Fields] OR “gonorrhea”[MeSH Terms] OR “gonorrhea”[All Fields], “trichomonas infections”[MeSH Terms] OR (“trichomonas”[All Fields] AND “infections”[All Fields]) OR “trichomonas infections”[All Fields] OR “trichomoniasis”[All Fields]). We also asked WHO regional sexually transmitted infection advisors and other leading experts in the field for additional published and unpublished data.

To be eligible, studies had to collect most specimens between 2009 and 2016 or be published in 2010 or later if specimen collection dates were not available. Other study inclusion criteria were: sample size of at least 100 individuals; general population (e.g. pregnant women, women at delivery, women attending family planning clinics, men and women selected for participation in demographic and health surveys); and use of an internationally recognized diagnostic test with demonstrated precision using urine, urethral, cervical or vaginal specimens.

To reduce bias in the estimation of general population prevalence, we excluded studies conducted among the following groups: patients seeking care for sexually transmitted infection or urogenital symptoms, women presenting at gynaecology or sexual health clinics with sexually transmitted infection related issues, studies restricted to women with abnormal Papanicolaou test results, remote or indigenous populations, recent immigrant or migrant populations, men who have sex with men and commercial sex workers.

Two investigators independently reviewed all identified studies to verify eligibility. When more than one publication reported on the same population, we retained the publication with the most detailed information. For each included study, we calculated prevalence as the number of individuals with a positive test result divided by the total number tested. We then standardized these values by applying adjustment factors for the accuracy of the laboratory diagnostic test, study location (rural versus urban) and the age of the study population. If the adjustments resulted in a negative value, we replaced the value with 0.1% when doing the meta-analysis. The methods and adjustment factors were identical to those used to generate the 2012 estimates.6

We obtained estimates for 10 geographical areas (referred to as estimation regions).6 Estimates for high-income North America (Canada and United States of America), were based on the latest published United States estimates that used data from multiple sources.10,11 For the other nine estimation regions, we calculated a summary prevalence estimate by meta-analysis if there were three or more data points.12 There were sufficient data to generate an estimate for chlamydia in women in all regions, but not for gonorrhoea or trichomoniasis. For regions with insufficient data for gonorrhoea and trichomoniasis, we assumed that prevalence was a multiple of the prevalence of chlamydia. The infection specific multiples were based on those studies that met the 2016 inclusion criteria (available from the data repository).13 For men, when there were insufficient data for meta-analysis, the prevalence of an infection was assumed to be proportional to the prevalence in women. The male-to-female ratios were infection-specific and were set at the same values as in 2012 estimates.6

To reflect the contribution of populations at higher risk of infection (e.g. men who have sex with men and commercial sex workers), who are likely to be under-represented in general population samples, we increased prevalence estimates by 10%, as in the 2012 estimates,6 for each estimation region, apart from high-income North America.

We performed the meta-analyses using a Bayesian approach with a Markov Chain Monte Carlo algorithm implemented with the software BRrugs in R package (R foundation, Vienna, Austria).14 For each infection, the software generated 10 000 samples from the posterior distribution for the expected mean prevalence in each estimation region based on the β-binomial model, and used these to calculate the 2.5 and 97.5 uncertainty percentiles.15 We calculated global and regional prevalence estimates for each infection by weighting each of the 10 000 samples from estimation regions according to population size, using United Nations population data for women and men aged 15–49 years.16 We present results by WHO region, 2016 World Bank income classification17 and 2017 sustainable development goal (SDG) region.18 All analyses were carried out using R statistical software (R foundation).

Syphilis

We based syphilis estimates on the WHO’s published 2016 maternal prevalence estimates.19 These estimates were generated by using Spectrum-STI, a statistical trend-fitting model in the publicly available Spectrum suite of health policy planning tools20 and country specific data from the global Spectrum-STI syphilis database (available from the corresponding author). As in the 2012 estimation,6 we assumed that the prevalence of syphilis in all women 15–49 years of age in each country was the same as in pregnant women. We then increased the estimate by 10% to reflect the contribution of populations at higher risk. The men to women prevalence ratio of syphilis was set at 1.0 and assumed to have a uniform distribution ± 33% around this value, in agreement with data from a recent global meta-analysis of syphilis.21

We generated regional and global estimates by weighting the contribution of each country by the number of women and men aged 15–49 years. Regional and global 95% uncertainty intervals (UIs) were generated using the delta method;22 uncertainties were assumed to be independent across countries.

Incidence estimation

We calculated incidence estimates for each infection by dividing prevalence by the average duration of infection for all estimation regions except high-income North America where published estimates were used.10,11 Estimates of the average duration of infection were those used in the 2012 estimation6 and assumed to have a uniform distribution of ± 33.3% around the average duration. We calculated uncertainty in incidence for a given region, sex and infection at the national level using the delta method;22 uncertainty in the prevalence estimate was multiplied by uncertainty in the estimated duration of infection. Regional and global uncertainty intervals were generated assuming uncertainties were independent across countries.

Results

Data availability

Chlamydia, gonorrhoea and trichomoniasis

Of the 7244 articles screened, 112 studies met the inclusion criteria for one or more of the three infections (Fig. 1). We identified an additional 18 studies through expert consultations and reviewing reference lists (Nguyen M et al., Hanoi Medical University, Viet Nam, personal communication, 23 March 2018; El Kettani A et al., National Institute of Hygiene, Morocco, personal communication, 2 May 2016; Galdavadze K et al., Disease Control and Public Health, Republic of Georgia; personal communication, 22 August 2017).23–150 Of these 130 studies, 111 reported data for women only (Table 1; available at: http://www.who.int/bulletin/volumes/96/8/18-228486), three reported data for men only (Table 2; available at: http://www.who.int/bulletin/volumes/96/8/18-228486) and 16 reported data for both women and men (Table 1 and Table 2). Only 34 studies in women and four studies in men provided information on all three infections. The included studies contained 100 data points in women for chlamydia, 64 for gonorrhoea and 69 for trichomoniasis. In men, there were 16 data points for chlamydia, 11 for gonorrhoea and seven for trichomoniasis (Table 3).

Fig. 1.

Flowchart of the selection of studies for estimating the prevalence and incidence of chlamydia, gonorrhoea and trichomoniasis, 2016

WHO: World Health Organization.

Note: This figure does not include studies from North America; the North American estimates were based on published estimates.10,11

Fig. 1

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Table 1. Included studies on chlamydia, gonorrhoea and trichomoniasis prevalence in women, 2009–2016.
Study, by WHO region Country or territory and location Date of study Population and age, years Chlamydia
 Gonorrhoea
 Trichomoniasis
Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, test Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, %
African Region
Wynn et al., 201823 Botswana, Gaborone Jul 2015–May 2016 ANC clinic attendees, > 18 Genital fluid, amplification test 400 7.8 Genital fluid, amplification test 400 1.3 Genital fluid, amplification test 400 5.3
Ginindza et al., 201743 Eswatini, nationalb Jun–Jul 2015 Outpatient clinic attendees, 15–49 Genital fluid, amplification test 655 5.8 Genital fluid, amplification test 655 5.3 Genital fluid, amplification test 655 7.8
Eshete et al., 201324 Ethiopia, Jimma Town Dec 2011–May 2012 ANC clinic attendees, 15–36 NR NR NR NR NR NR Genital fluid, culture 361 5.0
Mulu et al., 201525 Ethiopia, Bahir Dar May–Nov 2013 ANC clinic attendees, 15–49 NR NR NR Genital fluid, culture and Gram staina 214 0.9 Genital fluid, microscopy 214 1.4
Schönfeld et al., 201826 Ethiopia, Asella May 2014–Sep 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, point-of-care testb 580 5.3
Volker et al., 201727 Ghana, Western region Oct 2011–Jan 2012 Attendees at a hospital maternity clinic, 14–48 Genital fluid, amplification test 177 1.7 Genital fluid, culture 180 0.0 NR NR NR
Jespers et al., 201428 Kenya, Mombasa 2010–2011 Participants in a community survey, 18–35 Genital fluid, amplification test 110 3.6 Genital fluid, amplification test 110 0.9 Genital fluid, culture 110 2.7
Kinuthia et al., 201529 Kenya, Ahero and Bondo districts May 2011–Jun 2013 ANC clinic attendees, ≥ 14 Genital fluid, amplification test 1276 5.5 Genital fluid, amplification test 1276 2.5 Genital fluid, microscopy 1278 6.3
Drake et al., 201330 Kenya, Western Kenya Pre-2013 ANC clinic attendees, 14–21 Genital fluid, amplification test 537 4.7 Genital fluid, amplification test 537 1.7 Genital fluid, microscopy 537 5.6
Masese et al., 201731 Kenya, Mombasa Aug 2014–Mar 2015 Students, 15–24 Urine, amplification test 451 3.5 Urine, amplification test 451 1.6 Urine, amplification test 451 0.7
Masha et al., 201732 Kenya, Kilifi Jul–Sep 2015 ANC clinic attendees, 18–45 Urine, amplification test 202 14.9 Urine, amplification test 202 1.0 Genital fluid, culture 202 7.4
Nkhoma et al., 201733 Malawi, Mangochi District Feb 2011–Aug 2012 ANC clinic attendees, ≥ 15 NR NR NR NR NR NR Genital fluid, microscopy 1210 10.5
Olowe et al., 201434 Nigeria, Osogba Jul–Apr 2012 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, microscopy 100 2.0
Etuketu et al., 201535 Nigeria, Abeokutu Jun–Jul 2013 ANC clinic attendees, 15–44 NR NR NR NR NR NR Genital fluid, microscopy 300 10.3
Muvunyi et al., 201136 Rwanda, Kigali Nov 2007–Mar 2010 Controls for infertility study, adults Genital fluid, amplification test 312 3.8 NR NR NR NR NR NR
Franceschi et al., 201637 Rwanda, Kigali Apr 2013–May 2014 Students, 18–20 Urine, amplification test 912 2.2 NR NR NR NR NR NR
Vieira-Baptista et al., 201738 Sao Tome and Principe, Principe 2015 Attendees at a primary health-care clinic, 21–60 Genital fluid, amplification test 100 3.0 Genital fluid, amplification test 100 2.0 Genital fluid, amplification test 100 8.0
Moodley et al., 201539 South Africa, Durban May 2008–Jun 2010 ANC clinic attendees, adults Genital fluid, amplification test 1459 17.8 Genital fluid, amplification test 1459 6.4 Genital fluid, amplification test 1459 15.3
Jespers et al., 201428 South Africa, Johannesburg 2010–2011 ANC clinic attendees, adults Genital fluid, amplification test 109 16.5 Genital fluid, amplification test 109 0.9 Genital fluid, culture 109 4.6
Peters et al., 201440 South Africa, Mopani District Nov 2011–Feb 2012 Attendees at a primary health-care clinic, 18–49 Genital fluid, amplification test 603 16.1 Genital, amplification test 603 10.1 NR NR NR
de Waaij et al., 201741 South Africa, Mopani District Nov 2011–Feb 2012 Attendees at a primary health-care clinic, 18–49 NR NR NR NR NR NR Genital fluid, amplification test 575 19.7
Francis et al., 201842 South Africa, KwaZulu-Natal Oct 2016–Jan 2017 Youth people, 15–24 Genital, amplification test 259 11.2 Genital fluid, amplification test 259 1.9 Genital fluid, amplification test 259 4.6
Tchelougou et al., 201344 Togo, Sokodé Jun 2010–Aug 2011 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, microscopy 302 3.6
Donders et al., 201645 Uganda, Kampala Pre-2015 Outpatient clinic attendees, adult Genital fluid, amplification test 360 1.4 Genital fluid, amplification test 360 1.7 Genital fluid, amplification test 360 6.7
Rutherford et al., 201446 Uganda, Kampala Sep 2008–Apr 2009 Students, 19–25 Genital fluid, amplification test 280 2.5 Genital fluid, amplification test 280 1.1 Genital fluid, culture 247 0.8
de Walque et al., 201247 United Republic of Tanzania, Kilombero and Ulanga Districts Feb–Apr 2009 Participants in HIV prevention trial, 18–30 Genital fluid, amplification test 1204 2.7 Genital fluid, amplification test 1204 1.4 Genital fluid, amplification test 1204 16.2
Chiduo et al., 201248 United Republic of Tanzania, Tanga May 2009–Oct 2010 ANC clinic attendees, 18–44 Genital fluid, amplification test 185 1.6 Genital fluid, culture and Gram stain 185 1.6 Genital fluid, microscopy 185 11.4
Hokororo et al., 201549 United Republic of Tanzania, Mwanza Apr–Dec 2012 ANC clinic attendees, 14–20 Urine, amplification test 403 11.4 Urine, amplification test 403 6.7 Genital fluid, microscopy 403 13.4
Lazenby et al., 201450 United Republic of Tanzania, Arusha District Pre-2014 Participants for cervical cancer screening, 30–60 Genital fluid, amplification test 324 0.0 Genital fluid, amplification test 324 0.0 Genital fluid, amplification test 297 10.4
Maufi et al., 201851 United Republic of Tanzania, Mwanza Nov 2014–Apr 2015 ANC clinic attendees, 17–46 NR NR NR NR NR NR Genital fluid, microscopy 365 10.4
Chaponda et al., 201652 Zambia, Nchelenge District Nov 2013–Apr 2014 ANC clinic attendees, adults Genital fluid, amplification test 1083 5.2 Genital fluid, amplification test 1083 3.1 Genital fluid, amplification test 1083 24.8
Stephen et al., 201753 Zimbabwe, Harare Jan 2012–Apr 2012 ANC clinic attendees, > 18 Genital fluid, amplification test 242 5.8 NR NR NR NR NR NR
Region of the Americas
Touzon et al., 201454 Argentina, Buenos Aires Jan 2010–Dec 2012 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 1238 1.8
Testardini et al., 201655 Argentina, Buenos Aires Apr 2010–Aug 2011 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 386 5.2
Mucci et al., 201656 Argentina, Buenos Aires Aug 2012–Jan 2013 ANC clinic attendees, 10–42 NR NR NR Genital fluid, culture 210 0.5 Genital fluid, microscopy 210 1.4
Department of Public Health 201857 Bahamas, national 2016 ANC clinic attendees, adults Urine, amplification test 2504 12.0 Urine, amplification test 2504 2.0 NR NR NR
Magalhaes et al., 201558 Brazil, Rio Grande do Norte State 2008–2012 Participants for cervical cancer screening, 25–60 Genital fluid, amplification test 1134 10.9 NR NR NR NR NR NR
Miranda et al., 201459 Brazil, national Mar–Nov 2009 ANC clinic attendees, 15–24 NR NR NR NR NR NR Genital fluid, amplification test 299 7.7
Pinto et al., 201160 Brazil, national Mar–Nov 2009 ANC clinic attendees, 15–24 Urine, amplification test 2071 9.8 Urine, amplification test 2071 1.0 NR NR NR
Ferreira et al., 201561 Brazil, Belem and Para 2009–2011 ANC clinic attendees, < 19 Genital fluid, amplification test 168 16.7 NR NR NR Genital fluid, culture 168 3.0
Piazzetta et al., 201162 Brazil, Curitiba Pre-2011 Sexually active youth people, 16–23 Urine, amplification test 335 10.7 Urine, amplification test 335 1.5 NR NR NR
Silveira MF et al., 201763 Brazil, Pelotas Dec 2011–May 2013 Attendees at a hospital maternity clinic, 18–24 Genital fluid, amplification test 562 12.3 NR NR NR NR NR NR
Mesenburg et al., 201364 Brazil, Pelotas Dec 2011–Jan 2013 ANC clinic attendees, < 30 Genital fluid, amplification test 361 15.0 NR NR NR NR NR NR
Gatti et al., 201765 Brazil, Rio Grande Jan 2012–Jan 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 204 5.9
Marconi et al., 201566 Brazil, Botucatu Sep 2012–Jan 2013 Participants for cervical cancer screening, 14–54 NR NR NR NR NR NR Genital fluid, microscopy 1519 1.4
Neves et al., 201667 Brazil, Manaus Oct 2012–Dec 2013 Attendees at a primary health-care clinic, 14–25 Genital fluid, amplification test 1169 13.1 NR NR NR NR NR NR
Zamboni et al., 201668 Brazil, Santiago Mar 2013–Mar 2014 Outpatient clinic attendees, 15–24 Genital fluid, amplification test 181 5.5 NR NR NR NR NR NR
Melo et al., 201669 Brazil, Region of La Araucanía 2013–2014 Participants for cervical cancer screening, 18–24 Genital fluid, amplification test 151 11.3 NR NR NR NR NR NR
Glehn et al., 201670 Brazil, Federal District Nov 2014–Mar 2015 Attendees at a primary health-care clinic, 18–49 NR NR NR NR NR NR Genital fluid, culture 193 15.5
Ovalle et al., 201271 Chile, Santiago Apr 2010–Oct 2010 ANC clinic attendees, adults Genital fluid, amplification test 255 5.9 Genital fluid, culture 255 0.0 Genital fluid, culture 255 2.4
Huneeus et al., 201872 Chile, Santiago 2012–2014 Sexually active youth people, < 25 Genital fluid, amplification test 171 8.8 Genital fluid, amplification test 171 0.6 Genital fluid, amplification test 171 0.0
Villaseca et al., 201573 Chile, Santiago Jun 2013–Dec 2013 Attendees at a family health clinic, 15–54 NR NR NR NR NR NR Genital fluid, amplification test 101 3.0
Stella et al., 201174 Colombia, rural Medellin 2009–2010 Students, 15–18 NR NR NR Genital fluid, culture 262 0.0 NR NR NR
Paredes et al., 201575 Colombia, Sabana Centro province 2011 Students, 14–19 Urine, amplification test 436 3.2 Urine, amplification test 436 0.2 NR NR NR
Giraldo-Ospina et al., 201576 Colombia, Dosquebradas Jun 2012–Aug 2013 ANC clinic attendees, 15–47 Genital fluid, amplification test 101 0.0 Genital fluid, culture 101 2.0 NR NR NR
Ceron et al., 201477 Colombia, Bogota Aug–Dec. 2013 ANC clinic attendees, 15–40 Genital fluid, amplification test 226 5.3 Genital fluid, amplification test 226 0.0 NR NR NR
Jobe et al., 201478 Haiti, Jérémie Oct 2012 Attendees at a primary health-care clinic, 16–75 Genital fluid, amplification test 199 11.6 Genital fluid, amplification test 199 4.0 Genital fluid, amplification test 199 19.6
Jobe et al., 201478 Haiti, Jérémie Oct 2012 Attendees at a primary health-care clinic, 19–78 Genital fluid, amplification test 104 1.9 Genital fluid, amplification test 104 1.0 Genital fluid, amplification test 104 13.5
Scheildell et al., 201879 Haiti, Gressier Aug–Oct 2013 ANC clinic attendees, adults Urine, amplification test 200 8.0 Urine, amplification test 200 3.0 Urine, amplification test 200 20.5
Bristow et al., 201780 Haiti, Port-au-Prince Oct 2015–Jan 2016 ANC clinic attendees, > 18 Genital fluid, amplification test 300 14.0 Genital fluid, amplification test 300 2.7 Genital fluid, amplification test 300 27.7
Conde-Ferráez et al., 201781 Mexico, Merida Aug 2010–Jan 2011 ANC clinic attendees, adults Genital fluid, amplification test 121 8.3 NR NR NR NR NR NR
López-Monteon et al., 201382 Mexico, central Veracruz Jun–Jul 2012 Attendees at a primary health-care clinic, 14–50 NR NR NR NR NR NR Urine, amplification test 158 19.0
Magana-Contreras et al., 201583 Mexico, Villahermosa Jan 2013–Nov 2014 Participants for cervical cancer screening, 16–74 Genital fluid, amplification test 201 1.5 NR NR NR NR NR NR
Casillas-Vega et al., 201784 Mexico, Jalisco Sep 2013–Aug 2014 ANC clinic attendees, adults Genital fluid, amplification test 287 10.8 NR NR NR NR NR NR
Cabeza et al., 201585 Peru, Lima Dec 2012–Jan 2013 ANC clinic attendees, ≥ 16 Genital fluid, amplification test 600 10.0 NR NR NR NR NR NR
van der Helm et al., 201386 Suriname, Paramaribo Mar 2008–Jul 2010 Attendees at a family planning clinic, adults Genital fluid, amplification test 819 9.5 NR NR NR NR NR NR
van der Helm et al., 201287 Suriname, Paramaribo Jul 2009–Feb 2010 Attendees at a family planning clinic, > 18 Genital fluid, amplification test 753 9.2 NR NR NR NR NR NR
South-East Asia Region
Franceschi et al., 201637 Bhutan, Thimpu and Paro Sep 2013 Students in an HPV vaccination study, 18–20 Urine, amplification test 973 3.4 NR NR NR NR NR NR
Vidwan et al., 201288 India, Vellore Apr 2009–Jan 2010 ANC clinic attendees, 18–45 Genital fluid, amplification test 784 0.1 NR NR NR NR NR NR
Vijaya Mn et al., 201389 India, rural Bangalore Oct 2010–Sep 2012 Attendees at an obstetrics and gynaecology clinic, 25–46 NR NR NR NR NR NR Genital fluid, culture 750 2.1
Kojima et al., 201890 India, Mysore district May 2011–Jun 2014 ANC clinic attendees, young women Genital fluid, amplification test 213 0.5 Genital fluid, amplification test 213 0.9 Genital fluid, amplification test 213 6.1
Shah et al., 201491 India, Baroda May 2011–Aug 2012 ANC clinic attendees, 20–35 NR NR NR NR NR NR Genital fluid, microscopy 233 3.4
Krishnan et al., 201892 India, Udupi district Aug 2013–May 2015 Community members, 18–65 Urine, amplification test 811 0.2 Urine, amplification test 811 0.0 NR NR NR
Ani & Darmayani 201793 Indonesia, Bali Apr 2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 376 7.4
Banneheke et al., 201394 Sri Lanka, Colombo district 2007–2009 Participants in diagnostic test study, 16–45 NR NR NR NR NR NR Genital fluid, microscopy 601 2.8
European Region
Farr et al., 201695 Austria, Vienna Jan 2005–Jan 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, DNA probe-based assayc 3763 0.8
Ljubin-Sternak et al., 201796 Croatia, Zagreb Mar 2014–Feb 2015 Attendees at an obstetrics and gynaecology clinic, adults Genital fluid, amplification test 8665 1.7 NR NR NR NR NR NR
Peuchant et al., 201597 France, Bordeaux Jan–Jun 2011 ANC clinic attendees, 18–44 Genital fluid, amplification test 1004 2.5 Genital fluid, amplification test 1004 0.0 NR NR NR
Peuchant et al., 201597 France, Bordeaux Sep 2012–Feb 2013 ANC clinic attendees, < 25 Genital fluid, amplification test 112 7.1 Genital fluid, amplification test 112 1.8 NR NR NR
Galdavadze et al., personal communication 2012 Georgia, Tbilisi Jul 2011–Mar 2012 ANC clinic attendees, 14–44 Urine, amplification test 300 5.0 Urine, amplification test 300 0.3 NR NR NR
Ikonomidis et al., 201598 Greece, Thessaly state Feb 2012–Nov 2015 Attendees at a urology and gynaecology clinic, adults Genital fluid, amplification test 130 0.8 NR NR NR NR NR NR
O'Higgins et al., 201799 Ireland, Dublin Dec 2011–Dec 2013 ANC clinic attendees, 16–25 Genital fluid, amplification test 2687 4.9 NR NR NR NR NR NR
Hassan et al., 2016100 Ireland, Dublin Jul 2014–Jan 2015 Participants for cervical cancer screening, 25–40 Genital fluid, amplification test 236 3.0 Genital fluid, amplification test 236 0.0 NR NR NR
Bianchi et al., 2016101 Italy, Milan Dec 2008–Dec 2012 HPV vaccinated young women, 18–23 Genital fluid, amplification test 591 4.9 NR NR NR NR NR NR
Seraceni et al., 2016102 Italy, north-eastern Jan 2009–Dec 2014 Participants for cervical cancer screening, adults Genital fluid, amplification test 921 0.0 NR NR NR NR NR NR
Panatto et al., 2015103 Italy, Turin, Milan and Genoa Jan–Jun 2010 Women attending gynaecologic routine check-ups, 16–26 Genital fluid, amplification test 566 5.8 NR NR NR NR NR NR
Foschi et al., 2016104 Italy, Bologna Jan 2011–May 2014 Attendees at an obstetrics and gynaecology clinic, routine, > 14 Genital fluid, amplification test 3072 3.4 NR NR NR NR NR NR
Matteelli et al., 2016105 Italy, Brescia Nov 2012–Mar 2013 Sexually active students, ≥ 18 Urine, amplification test 1297 1.9 Urine, amplification test 1297 0.0 NR NR NR
Camporiondo et al., 2016106 Italy, Rome Mar 2013 Healthy women attending screening, 34–60 Genital fluid, amplification test 309 0.0 Genital fluid, amplification test 309 0.0 Genital fluid, amplification test 309 1.3
Leli et al., 2016107 Italy, Perugia Jan–Oct 2015 Outpatient clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 1487 1.3
Gravningen et al., 2013108 Norway, Finnmark 2009 Sexually active students, 15–20 Urine, amplification test 607 6.8 NR NR NR NR NR NR
Silva et al., 2013109 Portugal, Porto Pre-2013 Students, 14–30 Genital fluid, amplification test 432 6.9 NR NR NR NR NR NR
Babinská et al., 2017110 Slovakia, eastern parts 2011 Community members, adults Urine, amplification test 511 3.5 NR NR NR NR NR NR
Fernández-Benítez et al., 2013111 Spain, Laviana and Asturias Nov 2010–Dec 2011 Sexually active youth people, 15–24 Urine, amplification test 277 4.0 NR NR NR NR NR NR
Pineiro et al., 2016112 Spain, Basque Autonomous Community Jan 2011–Dec 2014 Attendees at a hospital maternity clinic, 14–54 Urine, amplification test 11 687 1.0 Urine, amplification test 11 687 0.0 NR NR NR
Field et al., 2018113 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 NR NR NR NR NR NR Urine, amplification test 2559 0.3
Sonnenberg et al., 2013114 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 Urine, amplification test 2665 2.3 Urine, amplification test 2665 0.1 NR NR NR
Eastern Mediterranean Region
Nada et al., 2015115 Egypt, Cairo Jan–Nov 2014 Controls for infertility study, adult Genital fluid, amplification test 100 2.0 NR NR NR NR NR NR
Hassanzadeh et al., 2013116 Iran (Islamic Republic of), Shiraz 2009–2011 ANC clinic attendees, adults NR NR NR Genital fluid, amplification test 1100 1.2 NR NR NR
Hamid et al., 2011117 Iran (Islamic Republic of), Zanjan province Apr 2009 Attendees at an obstetrics and gynaecology clinic, 15–45 NR NR NR Genital fluid, culture 328 0.9 NR NR NR
Nourian et al., 2013118 Iran (Islamic Republic of), Zanjan Jul 2009–Jun 2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 1000 3.3
Rasti et al., 2011119 Iran (Islamic Republic of), Kashan Pre-2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 450 0.4
Dehgan Marvast et al., 2017120 Iran (Islamic Republic of), Yazd May–Sep 2010 ANC clinic attendees, 16–39 Urine, amplification test 250 0.0 NR NR NR NR NR NR
Ahmadi et al., 2016121 Iran (Islamic Republic of), Sanandaj Aug 2012–Jan 2013 Controls for spontaneous abortion study, 19–42 Genital fluid, amplification test 109 11.9 NR NR NR NR NR NR
Arbabi et al., 2014122 Iran (Islamic Republic of), Kashan Oct 2012–Aug 2013 Attendees at a public health unit, 16–60 NR NR NR NR NR NR Genital fluid, culture 970 2.3
Hasanabad et al., 2013123 Iran (Islamic Republic of), Sabzevar Pre-2013 ANC clinic attendees, adolescents Urine, amplification test 399 12.3 Urine, amplification test 399 1.3 NR NR NR
Mousavi et al., 2014124 Iran (Islamic Republic of), Sanandai Feb–May 2013 Controls for infertility study, 14–40 Genital fluid, amplification test 104 5.8 NR NR NR NR NR NR
Nateghi Rostami et al., 2016125 Iran (Islamic Republic of), Qom May 2013–Apr 2014 Attendees at an obstetrics and gynaecology clinic, 18–50 Genital fluid, amplification test 518 7.1 NR NR NR NR NR NR
Marashi et al., 2014126 Iran (Islamic Republic of), not specified Pre-2014 Controls for infertility study, 20–40 Genital fluid, amplification test 200 6.5 NR NR NR NR NR NR
Joolayi et al., 2017127 Iran (Islamic Republic of), Ahvaz Aug 2016–Jan 2017 Controls for infertility study, 18–49 Genital fluid, amplification test 125 1.6 NR NR NR NR NR NR
El Kettani et al., personal communication, 2016 Morocco, Rabat, Salé, Agadir and Fes Oct 2011–Dec 2011 Attendees at a family planning clinic, 18–49 Genital fluid, amplification test 537 3.0 Genital fluid, amplification test 537 0.4 Genital, culture 537 5.6
El Kettani et al., personal communication, 2016 Morocco, Rabat, Salé, Agadir and Fes Dec 2011–Jan 2012 ANC clinic attendees, 18–49 Genital fluid, amplification test 252 3.6 Genital fluid, amplification test 252 0.8 Genital fluid, culture 252 5.2
Kamel 2013128 Saudi Arabia, Jazan Jul 2011–Jun 2012 Controls for infertility study, 18–40 Genital fluid, culture 100 4.0 NR NR NR NR NR NR
Western Pacific Region
Wen 2013129 China, Wuhu 2010 Sexually active adults, adults NR NR NR NR NR NR Genital fluid, microscopy 2010 6.6
Lu et al., 2013130 China, Shenzhen 2011–2012 Attendees at an obstetrics and gynaecology clinic, adults Genital fluid, amplification test 7892 5.4 NR NR NR NR NR NR
Xia et al., 2015131 China, east, 16 cities Jan–Dec 2011 Attendees at an hospital maternity clinic, adults Genital fluid, culture 108 268 1.5 NR NR NR NR NR NR
Zhang et al., 2017132 China, Shaanxi province Jun 2012–Jan 2013 ANC clinic attendees, adults Genital fluid, amplification test 500 3.4 NR NR NR NR NR NR
Zhang et al., 2017133 China, Beijing Mar–Oct 2014 Attendees at an obstetrics and gynaecology clinic, 20–70 Genital fluid, amplification test 953 2.2 Genital fluid, amplification test 953 0.0 Genital fluid, microscopy 953 1.7
Imai et al., 2015134 Japan, Miyazaki Oct 2011–Feb 2012 Students, > 18 Urine, amplification test 1183 3.7 NR NR NR NR NR NR
Suzuki et al., 2015135 Japan, national Oct 2013–Mar 2014 ANC clinic attendees, adults Genital fluid, amplification test 250 571 2.3 NR NR NR NR NR NR
Ministry of Health 2017136 Mongolia, national 2016 ANC clinic attendees, adults NR NR NR Genital fluid, culture 69 278 0.5 NR NR NR
Corsenac et al., 2015137 New Caledonia, national Aug–Dec 2012 Attendees at a primary health-care clinic, 18–49 Urine, amplification test 376 10.1 Urine, amplification test 376 3.5 NR NR NR
Unger et al., 2015138 Papua New Guinea, Madang Nov 2009–Aug 2012 ANC clinic attendees, ≥ 16 Genital fluid, amplification test 674 4.5 Genital fluid, amplification test 674 8.2 Genital fluid, amplification test 674 21.8
Wangnapi et al., 2015139 Papua New Guinea, Madang Feb 2011–Apr 2012 ANC clinic attendees, 16–39 Genital fluid, amplification test 362 11.0 Genital fluid, amplification test 362 9.7 Genital fluid, amplification test 362 21.3
Vallely et al., 2017140 Papua New Guinea, four provinces Dec 2011–Jan 2015 ANC clinic attendees, 18–59 Genital fluid, amplification test 765 22.9 Genital fluid, amplification test 765 14.2 Genital fluid, amplification test 765 22.4
Vallely et al., 2017140 Papua New Guinea, four provinces Dec 2011–Jan 2015 Participants for cervical cancer screening, 18–59 Genital fluid, amplification test 614 7.5 Genital fluid, amplification test 614 8.0 Genital fluid, amplification test 614 15.0
Badman et al., 2016141 Papua New Guinea, Milne Bay Aug–Dec 2014 ANC clinic attendees, > 18 Genital fluid, amplification test 125 20.0 Genital fluid, amplification test 125 11.2 Genital fluid, amplification test 125 37.6
Hahn et al., 2014142 Republic of Korea, Seoul Mar 2010–Apr 2011 ANC clinic attendees, adults Genital fluid, amplification test 455 2.2 Genital fluid, amplification test 455 0.4 Genital fluid, amplification test 455 0.0
Choe et al., 2012143 Republic of Korea, Seoul Mar–Dec 2010 Attendees at a health examination clinic, 20–59 Urine, amplification test 805 3.2 Urine, amplification test 805 0.2 NR NR NR
Kim et al., 2011144 Republic of Korea, Uijeongbu Jul–Dec 2010 Attendees at a check-up clinic, 20–60 Genital fluid, amplification test 279 3.9 Genital fluid, amplification test 279 0.4 Genital fluid, amplification test 279 2.5
Kim et al., 2014145 Republic of Korea, Seoul Jan–Oct 2012 Attendees at a health examination clinic, 25–81 Genital fluid, amplification test 405 1.2 Genital fluid, amplification test 405 0.0 Genital fluid, amplification test 405 0.2
Marks et al., 2015146 Solomon Islands, Honiara Aug 2014 Attendees at a primary health-care clinic, 16–49 Genital fluid, amplification test 296 20.3 Genital fluid, amplification test 296 5.1 NR NR NR
Ton Nu et al., 2015147 Viet Nam, Hue Sep 2010–Jun 2012 Attendees at a family planning clinic, adults NR NR NR NR NR NR Genital fluid, microscopy 534 0.7
Nguyen et al., personal communication, 2017 Viet Nam, Hanoi 2016–2017 ANC clinic attendees, > 18 Genital fluid, amplification test 490 6.9 Genital fluid, amplification test 490 0.0 Genital fluid, amplification test 490 0.8
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ANC: antenatal care; DNA: deoxyribonucleic acid; HIV: human immunodeficiency virus; NR: not reported; WHO: World Health Organization.

a Studies that reported using both culture and Gram stain were assumed to have the same sensitivity and specificity values as culture.

b The study used an immunochromatographic capillary-flow enzyme immunoassay and we assumed a sensitivity of 50% and specificity of 99%.

c The study used a nonamplified, nucleic acid probe-based test system and we assumed the same specific and sensitivity values as for a nucleic acid amplification test.

Table 2. Included studies on chlamydia, gonorrhoea and trichomoniasis prevalence in men, 2009–2016.
Study, by WHO region Country or territory and location Date of study Population and age, years Chlamydia
 Gonorrhoea
 Trichomoniasis
Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, %
African Region
Francis et al., 201842 South Africa, KwaZulu-Natal Oct 2016–Jan 2017 Community members, 15–24 Urine, amplification test 188 5.3 Urine, amplification test 188 1.6 Urine, amplification test 188 0.5
Rutherford et al., 201446 Uganda, Kampala Sep 2008–Apr 2009 Students, 19–25 Urine, amplification test 360 0.8 Urine, amplification test 360 0.0 NR NR NR
de Walque et al., 201247 United Republic of Tanzania, Kilombero and Ulanga districts Feb–April 2009 Participants in HIV prevention trial, 18–30 Urine, amplification test 1195 1.7 Urine: amplification test 1195 0.4 Urine, amplification test 1195 8.5
Region of the Americas
Huneeus et al., 201872 Chile, Santiago 2012–2014 Sexually active students, ≤ 24 Urine, amplification test 115 8.7 Urine, amplification test 115 0.0 Urine, amplification test 115 0.0
Paredes et al., 201575 Colombia, Sabana Centro province 2011 Students, 14–19 Urine, amplification test 536 1.1 Urine, amplification test 536 0.0 NR NR NR
South-East Asia Region
Jatapai et al., 2013148 Thailand, national Nov 2008–May 2009 Military recruits, 17–29 Urine, amplification test 2123 7.9 Urine, amplification test 2123 0.9 NR NR NR
European Region
Sviben et al., 2015149 Croatia, Zagreb Pre-2014 Controls in case-control study, 18–66 NR NR NR NR NR NR Urine, amplification test 200 2.0
Ikonomidis et al., 201598 Greece, Thessaly State Feb 2012–Nov 2015 Attendees at urology and gynaecology clinic, adult Genital, amplification test 171 0.6 NR NR NR NR NR NR
Matteelli et al., 2016105 Italy, Brescia Nov 2012–Mar 2013 Sexually active students, > 18 Urine, amplification test 762 1.4 Urine, amplification test 762 0.0 NR NR NR
Gravningen et al., 2013108 Norway, Finnmark 2009 Sexually active youth, 15–20 Urine, amplification test 505 3.4 NR NR NR NR NR NR
Babinská et al., 2017110 Slovakia, eastern parts 2011 Community members, adult Urine, amplification test 344 2.0 NR NR NR NR NR NR
Fernández-Benítez et al., 2013111 Spain, Laviana and Asturias Nov 2010–Dec 2011 Sexually active youth, 15–24 Urine, amplification test 210 4.3 NR NR NR NR NR NR
Field et al., 2018113 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 NR NR NR NR NR NR Urine, amplification test 1827 0.0
Sonnenberg et al., 2013114 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 Urine, amplification test 1885 1.9 Urine, amplification test 1885 0.1 NR NR NR
Eastern Mediterranean Region
Arbabi et al., 2014122 Iran (Islamic Republic of), Kashan Oct 2012–Aug 2013 Attendees at a public health unit, 16–60 NR NR NR NR NR NR Genital fluid, culture 233 0.9
Yeganeh et al., 2013150 Iran (Islamic Republic of), Tehran Pre-2013 Urology clinic attendees, 18–50 Urine, amplification test 100 4.0 NR NR NR NR NR NR
Western Pacific Region
Corsenac et al., 2015137 New Caledonia, national Aug–Dec 2012 Attendees at a primary health-care clinic, 18–49 Urine, amplification test 232 7.8 Urine, amplification test 232 3.4 NR NR NR
Choe et al., 2012143 Republic of Korea, Seoul Mar–Dec 2010 Attendees at a health examination clinic, 20–59 Urine, amplification test 807 7.9 Urine, amplification test 807 0.6 NR NR NR
Kim et al., 2011144 Republic of Korea, Uijeongbu Jul–Dec 2010 Attendees at a check-up clinic, 20–60 Urine, amplification test 430 6.7 Urine, amplification test 430 0.5 Urine, amplification test 430 0.2
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HIV: human immunodeficiency virus; NR: not reported; WHO: World Health Organization.

a Tests were either nucleic acid amplification test or culture.

Table 3. Number of data points that met the study inclusion criteria for the WHO 2016 prevalence estimates of chlamydia, gonorrhoea and trichomoniasis.
Estimation region No. of countries, territories and areas Chlamydia
 Gonorrhoea
 Trichomoniasis
Women
 Men
 Women
 Men
 Women
 Men
No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries
Central, eastern and western sub-Saharan Africa 41 16 7 2 2 15 7 2 2 21 9 1 1
Southern sub-Saharan Africa 6 7 4 1 1 6 3 1 1 6 3 1 1
Andean, central, southern and tropical Latin America and Caribbean 42 25 8 2 2 14 6 2 2 16 5 1 1
High-income North America 2 NA NA NA NA NA NA NA NA NA NA NA NA
North Africa and Middle East 20 11 4 1 1 5 2 0 0 5 2 1 1
Australasia and high-income Asia Pacific 6 6 2 2 1 4 1 2 1 3 1 1 1
Western, central and eastern Europe and central Asia 54 19 11 6 6 9 7 2 2 4 3 2 2
Oceania 14 7 3 1 1 7 3 1 1 5 1 0 0
South Asia 5 4 2 0 0 2 1 0 0 3 1 0 0
East Asia and south-east Asia 15 5 2 1 1 2 2 1 1 6 4 0 0
Total 205 100 43 16 15 64 32 11 10 69 29 7 7
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NA: not applicable; WHO: World Health Organization.

Note: Eight of the 112 studies with data for women had two separate data points (e.g. for different population groups).

For women, a total of 43 (21.0%) of 205 countries, territories and areas had one or more data points for chlamydia, 32 (15.6%) for gonorrhoea and 29 (14.1%) for trichomoniasis. For men, only 15 (7.3%) countries, territories and areas had one or more data points for chlamydia, 10 (4.9%) for gonorrhoea and 7 (3.4%) for trichomoniasis. For women there were sufficient data to generate summary estimates for chlamydia for the nine estimation regions, but not for gonorrhoea or trichomoniasis (Table 4).

Table 4. Approach used to generate 2016 regional estimates for chlamydia, gonorrhoea and trichomoniasis.
Estimation region Women
 Men
Chlamydia Gonorrhoea Trichomoniasis Chlamydia Gonorrhoea Trichomoniasis
Central, eastern and western sub-Saharan Africa Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Southern sub-Saharan Africa Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Andean, central, southern and tropical Latin America and Caribbean Meta-analysis Meta-analysis Meta-analysis Special casea Global male-to-female ratio Global male-to-female ratio
High-income North Americab United States estimate for 2012 United States estimate for 2008 United States estimate for 2008 United States estimate for 2012 United States estimate for 2008 United States estimate for 2008
North Africa and Middle East Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Australasia and high-income Asia Pacific Meta-analysis Gonorrhoea to chlamydia ratio Trichomoniasis to chlamydia ratio Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Western, central and eastern Europe and central Asia Meta-analysis Meta-analysis Trichomoniasis to chlamydia ratio Meta-Analysis Global male-to-female ratio Global male-to-female ratio
Oceania Meta-analysis Meta-analysis Meta-Analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
South Asia Meta-analysis Gonorrhoea to chlamydia ratio Trichomoniasis to chlamydia ratioc Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
East Asia and south-east Asia Meta-analysis Gonorrhoea to chlamydia ratiod Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
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a In consultation with advisors on sexual transmitted infections for the World Health Organization (WHO) Region of the Americas, we decided to use the midpoint between the 2016 estimate generated by applying the global male-to-female ratio (7.5%) and the 2012 estimate for the region (2.1%). We deemed the former to be too high and the latter too low.

b Following discussions with the United States Centers for Disease Control and Prevention, we based our estimates on the latest published United States national estimates21,22 and assumed they remained constant over time and that estimates for 15–39-year-old people could be extrapolated to the 15–49-year age range. We did not apply the adjustments used for other Regions in the WHO estimates process. The figures for the United States were also applied to Canada.

c The estimate based on the three available data points was over 4%, considerably higher than the 2012 estimate. Following discussions with regional experts we decided not to use this estimate, but instead to use the trichomoniasis to chlamydia ratio for low and lower middle-income countries, territories and areas.

d This estimation region is made up of countries from East Asia and South East Asia. We used the higher and upper-middle income gonorrhoea to chlamydia ratio for East Asia and the low and lower-middle income ratio for South East Asia.”

Syphilis

As of 2 May 2018, the Spectrum-STI Database contained 1576 data points from surveys conducted since 1990, including 978 from January 2009 to December 2016.151 In total, 181 (88.3%) of 205 countries, territories and areas had sufficient data to generate a Spectrum STI estimate for 2016. For the remaining 24 countries, territories and areas, we used the median value of the countries with data for the relevant WHO region as the 2016 estimate.

Prevalence and incidence estimates

Table 5 shows prevalence estimates for the WHO regions for 2016. Based on prevalence data from 2009 to 2016, the estimated pooled global prevalence of chlamydia in 15–49-year-old women was 3.8% (95% UI: 3.3–4.5) and in men 2.7% (95% UI: 1.9–3.7), with regional values ranging from 1.5 to 7.0% in women and 1.2 to 4.0% in men. For gonorrhoea, the global estimate was 0.9% (95% UI: 0.7–1.1) in women and 0.7% (95% UI: 0.5–1.1) in men, with regional values in women ranging from 0.3 to 1.9% and from 0.3 to 1.6% in men. The estimates for trichomoniasis were 5.3% (95% UI: 4.0–7.2) in women and 0.6% (95% UI: 0.4–0.9) in men, with regional values ranging from 1.6 to 11.7% in women and from 0.2 to 1.3% in men. For syphilis, the global estimate in both men and women was 0.5% (95% UI: 0.4–0.6) with regional values ranging from 0.1 to 1.6%. The WHO African Region had the highest prevalence for chlamydia in men, gonorrhoea in women and men, trichomoniasis in women and syphilis in men and women. The WHO Region of the Americas had the highest prevalence of chlamydia in women and of trichomoniasis in men.

Table 5. Comparison of 2012 and 2016 WHO regional prevalence estimates of chlamydia, gonorrhoea, trichomoniasis and syphilis.

WHO Region, by sex Estimated prevalence, % (95% UI)
Chlamydia
 Gonorrhoea
 Trichomoniasis
 Syphilis
2012 2016 2012 2016 2012 2016 2012 2012 (updated) 2016
Women
African Region 3.7 (2.7–5.2) 5.0 (3.8–6.6) 1.7 (1.2–2.6) 1.9 (1.3–2.7) 11.5 (9.0–14.6) 11.7 (8.6–15.6) 1.8 (1.4–2.5) 1.7 (1.5–1.9) 1.6 (1.2–2.0)
Region of the Americas 7.6 (6.7–8.7) 7.0 (5.8–8.3) 0.8 (0.5–1.1) 0.9 (0.6–1.5) 7.7 (4.3–13.1) 7.7 (5.1–11.5) 0.4 (0.4–0.5) 0.7 (0.6–0.7) 0.9 (0.7–1.1)
South-East Asia Region 1.8 (1.4–2.2) 1.5 (1.0–2.5) 0.4 (0.2–0.5) 0.7 (0.4–1.2) 1.8 (1.1–2.7) 2.5 (1.3–4.9) 0.4 (0.3–0.4) 0.4 (0.2–0.5) 0.2 (0.1–0.4)
European Region 2.2 (1.6–2.9) 3.2 (2.5–4.2) 0.3 (0.2–0.5) 0.3 (0.1–0.6) 1.0 (0.8–1.3) 1.6 (1.1–2.3) 0.2 (0.1–0.4) 0.1 (0.1–0.1) 0.1 (0.0–0.4)
Eastern Mediterranean Region 3.5 (2.4–5.0) 3.8 (2.6–5.4) 0.5 (0.3–0.7) 0.7 (0.5–1.1) 5.9 (4.5–8.0) 4.7 (3.3–6.7) 0.5 (0.4–0.9) 0.6 (0.5–0.8) 0.7 (0.4–1.0)
Western Pacific Region 6.2 (5.1–7.5) 4.3 (3.0–5.9) 1.2 (0.8–1.7) 0.9 (0.5–1.3) 5.5 (3.3–8.9) 5.6 (2.7–10.8) 0.2 (0.2–0.3) 0.3 (0.2–0.4) 0.2 (0.1–0.4)
Global total 4.2 (3.7–4.7) 3.8 (3.3–4.5) 0.8 (0.6–1.0) 0.9 (0.7–1.1) 5.0 (4.0–6.4) 5.3 (4.0–7.2) 0.4 (0.4–0.6) 0.5 (0.5–0.6) 0.5 (0.5–0.6)
Men
African Region 2.5 (1.7–3.6) 4.0 (2.4–6.1) 0.5 (0.3–0.9) 1.6 (0.9–2.6) 1.2 (0.7–1.7) 1.2 (0.7–1.8) 1.8 (1.1–2.8) 1.7 (1.4–2.0) 1.6 (1.2–2.0)
Region of the Americas 1.8 (1.3–2.6) 3.7 (2.1–5.5) 0.7 (0.4–1.0) 0.8 (0.4–1.3) 1.3 (0.9–2.0) 1.3 (0.9–1.8) 0.4 (0.3–0.6) 0.7 (0.5–0.8) 0.9 (0.7–1.2)
South-East Asia Region 1.3 (0.9–1.8) 1.2 (0.6–2.1) 0.5 (0.3–0.8) 0.6 (0.3–1.1) 0.2 (0.1–0.3) 0.2 (0.1–0.5) 0.4 (0.2–0.5) 0.4 (0.2–0.5) 0.2 (0.2–0.4)
European Region 1.5 (0.9–2.6) 2.2 (1.5–3.0) 0.3 (0.2–0.5) 0.3 (0.1–0.5) 0.1 (0.1–0.2) 0.2 (0.1–0.3) 0.2 (0.1–0.4) 0.1 (0.1–0.2) 0.1 (0.0–0.3)
Eastern Mediterranean Region 2.7 (1.6–4.3) 3.0 (1.7–4.8) 0.4 (0.2–0.6) 0.6 (0.3–1.0) 0.6 (0.4–0.9) 0.5 (0.3–0.7) 0.5 (0.3–0.9) 0.6 (0.5–0.8) 0.7 (0.4–1.0)
Western Pacific Region 5.2 (3.4–7.2) 3.4 (2.0–5.3) 1.0 (0.6–1.7) 0.7 (0.4–1.2) 0.6 (0.3–1.0) 0.6 (0.2–1.1) 0.2 (0.2–0.3) 0.3 (0.2–0.4) 0.2 (0.1–0.4)
Global total 2.7 (2.0–3.6) 2.7 (1.9–3.7) 0.6 (0.4–0.9) 0.7 (0.5–1.1) 0.6 (0.4–0.8) 0.6 (0.4–0.9) 0.5 (0.3–0.7) 0.5 (0.5–0.6) 0.5 (0.4–0.6)
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UI: uncertainty interval; WHO: World Health Organization.

Notes: The 2012 estimates are from Newman et al., 2015.6 For syphilis both the WHO estimate for 2012 and the 2018 updated 2012 estimate using Spectrum STI are shown.19 For chlamydia, gonorrhoea and trichomoniasis, the study inclusion window for 2016 was samples collected between 2009 and 2016, and for 2012, between 2005 and 2012.

These prevalence estimates correspond to the totals of 124.3 million cases of chlamydia, 30.6 million cases of gonorrhoea, 110.4 million cases of trichomoniasis and 19.9 million cases of syphilis (available from the data repository).13

Using the World Bank classification, high-income countries, territories and areas had the lowest estimated prevalence, and low-income countries, territories and areas had the highest prevalence of gonorrhoea, trichomoniasis and syphilis. For chlamydia, estimated prevalence was highest in upper-middle income countries, territories and areas (Fig. 2). The SDG grouping showed the highest prevalence of all four sexually transmitted infections in Oceania region, that is, Pacific island nations excluding Australia and New Zealand (available from the data repository).13

Fig. 2.

Prevalence estimates of chlamydia, gonorrhoea, trichomoniasis and syphilis in adults, by World Bank classification, 2016

UI: uncertainty interval.

Notes: We defined adults as 15–49 years of age and used year 2016 income classification from the World Bank.17

Fig. 2

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We estimated the global incidence rate for chlamydia in 2016 to be 34 cases per 1000 women (95% UI: 25–45) and 33 per 1000 men (95% UI: 21–48); for gonorrhoea 20 per 1000 women (95% UI: 14–28) and 26 per 1000 men (95% UI: 15–41); for trichomoniasis 40 per 1000 women (95% UI: 27–58) and 42 per 1000 men (95% UI: 23–69); and for syphilis 1.7 per 1000 women (95% UI: 1.4–2.0) and 1.6 per 1000 men (95% UI: 1.3–1.9; Fig. 3). The WHO Region of the Americas had the highest incidence rate for chlamydia and syphilis in both women and men, while the WHO African Region had the highest incidence rates for gonorrhoea and trichomoniasis in women and men. Incidence rates by income category and SDG regions are available from the data repository.13

Fig. 3.

Incidence rate estimates for chlamydia, gonorrhoea, trichomoniasis and syphilis in adults, by WHO Region, 2016

UI: uncertainty interval, WHO: World Health Organization.

Note: We defined adults as 15–49 years of age.

Fig. 3

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These incidence rates translate globally into 127.2 million (95% UI: 95.1–165.9) new 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 in women and men aged 15–49 years in 2016. Together, the four infections accounted for 376.4 million new infections in 15–49-year-old people in 2016. Approximately 13.5% (50.8 million) of these infections occurred in low-income countries, territories and areas, 31.4% (118.1 million) in lower middle income, 47.1% (177.3 million) in upper-middle income and 8.0% (30.1 million) in high-income (available from the data repository).13

Comparison of estimates

Comparing the 2012 estimates with the estimates presented here shows that more data points were available in women for the 2016 estimates. The number increased from 69 to 100 for chlamydia, 50 to 64 for gonorrhoea and 44 to 69 for trichomoniasis. For men, the number of data points fell from 21 to 16 for chlamydia and from 12 to 11 for gonorrhoea, but increased from one to seven for trichomoniasis. The period of eligibility for both estimates was eight years with an overlap of four years (2009 to 2012); in women 27 data points were included in both estimates for chlamydia, 18 for gonorrhoea and 20 for trichomoniasis. In men, these overlaps were six, five and one, respectively.

Table 5 compares the 2012 and 2016 prevalence estimates for the four infections. For syphilis, two estimates are presented for 2012, the published estimate6 and the 2012 estimate generated using Spectrum STI and the latest Spectrum data set.19 For all infections in both women and men, the 2016 global prevalence estimate was within the 95% UI for 2012. At the regional level, the 95% UIs for prevalence overlapped for all four infections in both men and women, apart from gonorrhoea in men in the WHO African Region which was higher in 2016 than in 2012.

Discussion

We estimated a global total of 376.4 million new curable urogenital infections with chlamydia, gonorrhoea, trichomoniasis and syphilis in 15–49-year-old women and men in 2016. This estimate corresponds to an average of just over 1 million new infections each day. The number of individuals infected, however, is smaller as repeat infections and co-infections are common.152

The estimates of prevalence and incidence in 2016 were similar to those in 2012, both globally and by region, showing that sexually transmitted infections are persistently endemic worldwide. Grouping countries, territories and areas according to SDG regions revealed that the prevalence and incidence of all four sexually transmitted infections, in both women and men, were highest in the Oceania Region. The small island states in this SDG region are part of the WHO Western Pacific Region, which is dominated by China (owing to its population size). Therefore, the levels of sexually transmitted infections and need for infection control in these island states are masked when viewing the estimates only by WHO Region. When using the World Bank classification of countries, the prevalence of gonorrhoea, trichomoniasis and syphilis were highest in low-income countries, territories and areas. The prevalence of chlamydia was highest in the upper middle-income countries, territories and areas, partly due to high estimates in some Latin American countries. Further research is needed to determine whether these estimates reflect methodological factors or differences in C. trachomatis transmission.

The 2016 estimates for chlamydia, gonorrhoea and trichomoniasis were based on a systematic review of the literature complemented by outreach to experts using the same methods as in 2012. The aim was to reduce bias and insure comprehensiveness in the search for data.19 For syphilis, the use of national estimates generated by a statistical model improves on the 2012 method by making use of historical trend data. The similarity between the published 2012 syphilis estimates and Spectrum STI generated estimates for 2012 provides reassurance about the validity of comparing the 2016 and 2012 estimates.

The study has limitations. First, limited prevalence data were available, despite an eight-year time window for data inclusion. Estimates for a given infection and region are therefore extrapolated from a small number of data points and ratios were used to generate estimates for some regions. For men, the lack of data was particularly striking. For syphilis, most data were from pregnant women, which might not reflect all women aged 15–49 years, or men. Second, the source studies include people in different age groups and used a range of diagnostic tests, so adjustment factors were applied to standardize measures across studies. Third, owing to the absence of empirical studies, incidence estimates were derived from the relationship between prevalence and duration of infection, and data on the average duration of infection for each of the four infections are also limited. Finally, because only studies among the general population were used, the prevalence and incidence in areas where key populations contribute disproportionately to sexually transmitted infection epidemics may have been underestimated despite the applied correction factor. These limitations have been discussed previously in detail.6

This study has implications for sexually transmitted infection programming and research. The quantity and quality of prevalence and incidence studies for sexually transmitted infections in representative samples of the general population, for both women and men, need improvement. Identifying opportunities to integrate data collection with clinical care platforms, such as HIV, adolescent, maternal, family planning and immunization is crucial. The recently developed WHO protocol for assessing the prevalence of sexually transmitted infections in antenatal care settings153 provides a framework and consistent methods that can be adapted for women and men. Comparing data across studies requires better understanding of the performance characteristics of diagnostic tests, and implications for estimates of the average duration of infection for each infection. The processes for producing future prevalence estimates could be made timelier and more efficient through continually updated systematic reviews,154 as well as technological solutions that automate searching of databases and facilitate high quality updates of reviews.

The global estimates of prevalence and incidence of four curable sexually transmitted infections are important in the broader global context, highlighting a continuing public health challenge. Prevalence and incidence data play an important role in the design and evaluation of programmes and interventions for sexually transmitted infections and in interpreting changes in HIV epidemiology. The global threat of antimicrobial resistance, particularly the emergence of N. gonorrhoeae resistance to the few remaining antimicrobials recommended for treatment, further highlights the importance of investing in monitoring prevalence and incidence.155 Estimates of prevalence and incidence are essential for calculations of the burden of disease due to sexually transmitted infections, which are needed to advocate for funding to support sexually transmitted infection programmes. These burden estimates can also be used to promote innovation for point-of-care diagnostics, new therapeutics, vaccines and microbicides. The WHO Global Health Sector Strategy on Sexually Transmitted Infections sets a target of 90% reductions in the incidence of gonorrhoea and of syphilis, globally, between 2018 and 2030.9 Major scale-ups of prevention, testing, treatment and partner services will be required to achieve these goals. The estimates generated in this paper, despite their limitations, provide an initial baseline for monitoring progress towards these ambitious targets.

Acknowledgements

We thank the WHO regional advisors and technical experts: Monica Alonso, Maeve Brito de Mello, Massimo Ghidinelli, Joumana Hermez, Naoko Ishikawa, Linh-Vi Le, Morkor Newman, Takeshi Nishijiima, Innocent Nuwagira, Leopold Ouedraogo, Bharat Rewari, Ahmed Sabry, Sanni Saliyou, Annemarie Stengaard, Ellen Thom and Motoyuki Tsuboi. We also thank Mary Kamb, S. Guy Mahiané, Otilia Mardh, Nico Nagelkerke, Gianfranco Spiteri, Igor Toskin, Teodora Wi, Nalinka Saman Wijesooriya and Rebecca Williams.

Funding:

This work was supported by the U.S. Centers for Disease Control and Prevention, the United Kingdom Department for International Development, and the World Health Organization Human Reproduction Programme. LJA and AS acknowledge support of Qatar National Research Fund (NPRP 9-040-3-008) that provided funding for collating data provided to this study.

Competing interests:

None declared.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Chlamydia, gonorrhoea and trichomoniasis

Of the 7244 articles screened, 112 studies met the inclusion criteria for one or more of the three infections (Fig. 1). We identified an additional 18 studies through expert consultations and reviewing reference lists (Nguyen M et al., Hanoi Medical University, Viet Nam, personal communication, 23 March 2018; El Kettani A et al., National Institute of Hygiene, Morocco, personal communication, 2 May 2016; Galdavadze K et al., Disease Control and Public Health, Republic of Georgia; personal communication, 22 August 2017).23–150 Of these 130 studies, 111 reported data for women only (Table 1; available at: http://www.who.int/bulletin/volumes/96/8/18-228486), three reported data for men only (Table 2; available at: http://www.who.int/bulletin/volumes/96/8/18-228486) and 16 reported data for both women and men (Table 1 and Table 2). Only 34 studies in women and four studies in men provided information on all three infections. The included studies contained 100 data points in women for chlamydia, 64 for gonorrhoea and 69 for trichomoniasis. In men, there were 16 data points for chlamydia, 11 for gonorrhoea and seven for trichomoniasis (Table 3).

Fig. 1.

Flowchart of the selection of studies for estimating the prevalence and incidence of chlamydia, gonorrhoea and trichomoniasis, 2016

WHO: World Health Organization.

Note: This figure does not include studies from North America; the North American estimates were based on published estimates.10,11

Fig. 1

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Table 1. Included studies on chlamydia, gonorrhoea and trichomoniasis prevalence in women, 2009–2016.

Study, by WHO region Country or territory and location Date of study Population and age, years Chlamydia
 Gonorrhoea
 Trichomoniasis
Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, test Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, %
African Region
Wynn et al., 201823 Botswana, Gaborone Jul 2015–May 2016 ANC clinic attendees, > 18 Genital fluid, amplification test 400 7.8 Genital fluid, amplification test 400 1.3 Genital fluid, amplification test 400 5.3
Ginindza et al., 201743 Eswatini, nationalb Jun–Jul 2015 Outpatient clinic attendees, 15–49 Genital fluid, amplification test 655 5.8 Genital fluid, amplification test 655 5.3 Genital fluid, amplification test 655 7.8
Eshete et al., 201324 Ethiopia, Jimma Town Dec 2011–May 2012 ANC clinic attendees, 15–36 NR NR NR NR NR NR Genital fluid, culture 361 5.0
Mulu et al., 201525 Ethiopia, Bahir Dar May–Nov 2013 ANC clinic attendees, 15–49 NR NR NR Genital fluid, culture and Gram staina 214 0.9 Genital fluid, microscopy 214 1.4
Schönfeld et al., 201826 Ethiopia, Asella May 2014–Sep 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, point-of-care testb 580 5.3
Volker et al., 201727 Ghana, Western region Oct 2011–Jan 2012 Attendees at a hospital maternity clinic, 14–48 Genital fluid, amplification test 177 1.7 Genital fluid, culture 180 0.0 NR NR NR
Jespers et al., 201428 Kenya, Mombasa 2010–2011 Participants in a community survey, 18–35 Genital fluid, amplification test 110 3.6 Genital fluid, amplification test 110 0.9 Genital fluid, culture 110 2.7
Kinuthia et al., 201529 Kenya, Ahero and Bondo districts May 2011–Jun 2013 ANC clinic attendees, ≥ 14 Genital fluid, amplification test 1276 5.5 Genital fluid, amplification test 1276 2.5 Genital fluid, microscopy 1278 6.3
Drake et al., 201330 Kenya, Western Kenya Pre-2013 ANC clinic attendees, 14–21 Genital fluid, amplification test 537 4.7 Genital fluid, amplification test 537 1.7 Genital fluid, microscopy 537 5.6
Masese et al., 201731 Kenya, Mombasa Aug 2014–Mar 2015 Students, 15–24 Urine, amplification test 451 3.5 Urine, amplification test 451 1.6 Urine, amplification test 451 0.7
Masha et al., 201732 Kenya, Kilifi Jul–Sep 2015 ANC clinic attendees, 18–45 Urine, amplification test 202 14.9 Urine, amplification test 202 1.0 Genital fluid, culture 202 7.4
Nkhoma et al., 201733 Malawi, Mangochi District Feb 2011–Aug 2012 ANC clinic attendees, ≥ 15 NR NR NR NR NR NR Genital fluid, microscopy 1210 10.5
Olowe et al., 201434 Nigeria, Osogba Jul–Apr 2012 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, microscopy 100 2.0
Etuketu et al., 201535 Nigeria, Abeokutu Jun–Jul 2013 ANC clinic attendees, 15–44 NR NR NR NR NR NR Genital fluid, microscopy 300 10.3
Muvunyi et al., 201136 Rwanda, Kigali Nov 2007–Mar 2010 Controls for infertility study, adults Genital fluid, amplification test 312 3.8 NR NR NR NR NR NR
Franceschi et al., 201637 Rwanda, Kigali Apr 2013–May 2014 Students, 18–20 Urine, amplification test 912 2.2 NR NR NR NR NR NR
Vieira-Baptista et al., 201738 Sao Tome and Principe, Principe 2015 Attendees at a primary health-care clinic, 21–60 Genital fluid, amplification test 100 3.0 Genital fluid, amplification test 100 2.0 Genital fluid, amplification test 100 8.0
Moodley et al., 201539 South Africa, Durban May 2008–Jun 2010 ANC clinic attendees, adults Genital fluid, amplification test 1459 17.8 Genital fluid, amplification test 1459 6.4 Genital fluid, amplification test 1459 15.3
Jespers et al., 201428 South Africa, Johannesburg 2010–2011 ANC clinic attendees, adults Genital fluid, amplification test 109 16.5 Genital fluid, amplification test 109 0.9 Genital fluid, culture 109 4.6
Peters et al., 201440 South Africa, Mopani District Nov 2011–Feb 2012 Attendees at a primary health-care clinic, 18–49 Genital fluid, amplification test 603 16.1 Genital, amplification test 603 10.1 NR NR NR
de Waaij et al., 201741 South Africa, Mopani District Nov 2011–Feb 2012 Attendees at a primary health-care clinic, 18–49 NR NR NR NR NR NR Genital fluid, amplification test 575 19.7
Francis et al., 201842 South Africa, KwaZulu-Natal Oct 2016–Jan 2017 Youth people, 15–24 Genital, amplification test 259 11.2 Genital fluid, amplification test 259 1.9 Genital fluid, amplification test 259 4.6
Tchelougou et al., 201344 Togo, Sokodé Jun 2010–Aug 2011 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, microscopy 302 3.6
Donders et al., 201645 Uganda, Kampala Pre-2015 Outpatient clinic attendees, adult Genital fluid, amplification test 360 1.4 Genital fluid, amplification test 360 1.7 Genital fluid, amplification test 360 6.7
Rutherford et al., 201446 Uganda, Kampala Sep 2008–Apr 2009 Students, 19–25 Genital fluid, amplification test 280 2.5 Genital fluid, amplification test 280 1.1 Genital fluid, culture 247 0.8
de Walque et al., 201247 United Republic of Tanzania, Kilombero and Ulanga Districts Feb–Apr 2009 Participants in HIV prevention trial, 18–30 Genital fluid, amplification test 1204 2.7 Genital fluid, amplification test 1204 1.4 Genital fluid, amplification test 1204 16.2
Chiduo et al., 201248 United Republic of Tanzania, Tanga May 2009–Oct 2010 ANC clinic attendees, 18–44 Genital fluid, amplification test 185 1.6 Genital fluid, culture and Gram stain 185 1.6 Genital fluid, microscopy 185 11.4
Hokororo et al., 201549 United Republic of Tanzania, Mwanza Apr–Dec 2012 ANC clinic attendees, 14–20 Urine, amplification test 403 11.4 Urine, amplification test 403 6.7 Genital fluid, microscopy 403 13.4
Lazenby et al., 201450 United Republic of Tanzania, Arusha District Pre-2014 Participants for cervical cancer screening, 30–60 Genital fluid, amplification test 324 0.0 Genital fluid, amplification test 324 0.0 Genital fluid, amplification test 297 10.4
Maufi et al., 201851 United Republic of Tanzania, Mwanza Nov 2014–Apr 2015 ANC clinic attendees, 17–46 NR NR NR NR NR NR Genital fluid, microscopy 365 10.4
Chaponda et al., 201652 Zambia, Nchelenge District Nov 2013–Apr 2014 ANC clinic attendees, adults Genital fluid, amplification test 1083 5.2 Genital fluid, amplification test 1083 3.1 Genital fluid, amplification test 1083 24.8
Stephen et al., 201753 Zimbabwe, Harare Jan 2012–Apr 2012 ANC clinic attendees, > 18 Genital fluid, amplification test 242 5.8 NR NR NR NR NR NR
Region of the Americas
Touzon et al., 201454 Argentina, Buenos Aires Jan 2010–Dec 2012 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 1238 1.8
Testardini et al., 201655 Argentina, Buenos Aires Apr 2010–Aug 2011 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 386 5.2
Mucci et al., 201656 Argentina, Buenos Aires Aug 2012–Jan 2013 ANC clinic attendees, 10–42 NR NR NR Genital fluid, culture 210 0.5 Genital fluid, microscopy 210 1.4
Department of Public Health 201857 Bahamas, national 2016 ANC clinic attendees, adults Urine, amplification test 2504 12.0 Urine, amplification test 2504 2.0 NR NR NR
Magalhaes et al., 201558 Brazil, Rio Grande do Norte State 2008–2012 Participants for cervical cancer screening, 25–60 Genital fluid, amplification test 1134 10.9 NR NR NR NR NR NR
Miranda et al., 201459 Brazil, national Mar–Nov 2009 ANC clinic attendees, 15–24 NR NR NR NR NR NR Genital fluid, amplification test 299 7.7
Pinto et al., 201160 Brazil, national Mar–Nov 2009 ANC clinic attendees, 15–24 Urine, amplification test 2071 9.8 Urine, amplification test 2071 1.0 NR NR NR
Ferreira et al., 201561 Brazil, Belem and Para 2009–2011 ANC clinic attendees, < 19 Genital fluid, amplification test 168 16.7 NR NR NR Genital fluid, culture 168 3.0
Piazzetta et al., 201162 Brazil, Curitiba Pre-2011 Sexually active youth people, 16–23 Urine, amplification test 335 10.7 Urine, amplification test 335 1.5 NR NR NR
Silveira MF et al., 201763 Brazil, Pelotas Dec 2011–May 2013 Attendees at a hospital maternity clinic, 18–24 Genital fluid, amplification test 562 12.3 NR NR NR NR NR NR
Mesenburg et al., 201364 Brazil, Pelotas Dec 2011–Jan 2013 ANC clinic attendees, < 30 Genital fluid, amplification test 361 15.0 NR NR NR NR NR NR
Gatti et al., 201765 Brazil, Rio Grande Jan 2012–Jan 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 204 5.9
Marconi et al., 201566 Brazil, Botucatu Sep 2012–Jan 2013 Participants for cervical cancer screening, 14–54 NR NR NR NR NR NR Genital fluid, microscopy 1519 1.4
Neves et al., 201667 Brazil, Manaus Oct 2012–Dec 2013 Attendees at a primary health-care clinic, 14–25 Genital fluid, amplification test 1169 13.1 NR NR NR NR NR NR
Zamboni et al., 201668 Brazil, Santiago Mar 2013–Mar 2014 Outpatient clinic attendees, 15–24 Genital fluid, amplification test 181 5.5 NR NR NR NR NR NR
Melo et al., 201669 Brazil, Region of La Araucanía 2013–2014 Participants for cervical cancer screening, 18–24 Genital fluid, amplification test 151 11.3 NR NR NR NR NR NR
Glehn et al., 201670 Brazil, Federal District Nov 2014–Mar 2015 Attendees at a primary health-care clinic, 18–49 NR NR NR NR NR NR Genital fluid, culture 193 15.5
Ovalle et al., 201271 Chile, Santiago Apr 2010–Oct 2010 ANC clinic attendees, adults Genital fluid, amplification test 255 5.9 Genital fluid, culture 255 0.0 Genital fluid, culture 255 2.4
Huneeus et al., 201872 Chile, Santiago 2012–2014 Sexually active youth people, < 25 Genital fluid, amplification test 171 8.8 Genital fluid, amplification test 171 0.6 Genital fluid, amplification test 171 0.0
Villaseca et al., 201573 Chile, Santiago Jun 2013–Dec 2013 Attendees at a family health clinic, 15–54 NR NR NR NR NR NR Genital fluid, amplification test 101 3.0
Stella et al., 201174 Colombia, rural Medellin 2009–2010 Students, 15–18 NR NR NR Genital fluid, culture 262 0.0 NR NR NR
Paredes et al., 201575 Colombia, Sabana Centro province 2011 Students, 14–19 Urine, amplification test 436 3.2 Urine, amplification test 436 0.2 NR NR NR
Giraldo-Ospina et al., 201576 Colombia, Dosquebradas Jun 2012–Aug 2013 ANC clinic attendees, 15–47 Genital fluid, amplification test 101 0.0 Genital fluid, culture 101 2.0 NR NR NR
Ceron et al., 201477 Colombia, Bogota Aug–Dec. 2013 ANC clinic attendees, 15–40 Genital fluid, amplification test 226 5.3 Genital fluid, amplification test 226 0.0 NR NR NR
Jobe et al., 201478 Haiti, Jérémie Oct 2012 Attendees at a primary health-care clinic, 16–75 Genital fluid, amplification test 199 11.6 Genital fluid, amplification test 199 4.0 Genital fluid, amplification test 199 19.6
Jobe et al., 201478 Haiti, Jérémie Oct 2012 Attendees at a primary health-care clinic, 19–78 Genital fluid, amplification test 104 1.9 Genital fluid, amplification test 104 1.0 Genital fluid, amplification test 104 13.5
Scheildell et al., 201879 Haiti, Gressier Aug–Oct 2013 ANC clinic attendees, adults Urine, amplification test 200 8.0 Urine, amplification test 200 3.0 Urine, amplification test 200 20.5
Bristow et al., 201780 Haiti, Port-au-Prince Oct 2015–Jan 2016 ANC clinic attendees, > 18 Genital fluid, amplification test 300 14.0 Genital fluid, amplification test 300 2.7 Genital fluid, amplification test 300 27.7
Conde-Ferráez et al., 201781 Mexico, Merida Aug 2010–Jan 2011 ANC clinic attendees, adults Genital fluid, amplification test 121 8.3 NR NR NR NR NR NR
López-Monteon et al., 201382 Mexico, central Veracruz Jun–Jul 2012 Attendees at a primary health-care clinic, 14–50 NR NR NR NR NR NR Urine, amplification test 158 19.0
Magana-Contreras et al., 201583 Mexico, Villahermosa Jan 2013–Nov 2014 Participants for cervical cancer screening, 16–74 Genital fluid, amplification test 201 1.5 NR NR NR NR NR NR
Casillas-Vega et al., 201784 Mexico, Jalisco Sep 2013–Aug 2014 ANC clinic attendees, adults Genital fluid, amplification test 287 10.8 NR NR NR NR NR NR
Cabeza et al., 201585 Peru, Lima Dec 2012–Jan 2013 ANC clinic attendees, ≥ 16 Genital fluid, amplification test 600 10.0 NR NR NR NR NR NR
van der Helm et al., 201386 Suriname, Paramaribo Mar 2008–Jul 2010 Attendees at a family planning clinic, adults Genital fluid, amplification test 819 9.5 NR NR NR NR NR NR
van der Helm et al., 201287 Suriname, Paramaribo Jul 2009–Feb 2010 Attendees at a family planning clinic, > 18 Genital fluid, amplification test 753 9.2 NR NR NR NR NR NR
South-East Asia Region
Franceschi et al., 201637 Bhutan, Thimpu and Paro Sep 2013 Students in an HPV vaccination study, 18–20 Urine, amplification test 973 3.4 NR NR NR NR NR NR
Vidwan et al., 201288 India, Vellore Apr 2009–Jan 2010 ANC clinic attendees, 18–45 Genital fluid, amplification test 784 0.1 NR NR NR NR NR NR
Vijaya Mn et al., 201389 India, rural Bangalore Oct 2010–Sep 2012 Attendees at an obstetrics and gynaecology clinic, 25–46 NR NR NR NR NR NR Genital fluid, culture 750 2.1
Kojima et al., 201890 India, Mysore district May 2011–Jun 2014 ANC clinic attendees, young women Genital fluid, amplification test 213 0.5 Genital fluid, amplification test 213 0.9 Genital fluid, amplification test 213 6.1
Shah et al., 201491 India, Baroda May 2011–Aug 2012 ANC clinic attendees, 20–35 NR NR NR NR NR NR Genital fluid, microscopy 233 3.4
Krishnan et al., 201892 India, Udupi district Aug 2013–May 2015 Community members, 18–65 Urine, amplification test 811 0.2 Urine, amplification test 811 0.0 NR NR NR
Ani & Darmayani 201793 Indonesia, Bali Apr 2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 376 7.4
Banneheke et al., 201394 Sri Lanka, Colombo district 2007–2009 Participants in diagnostic test study, 16–45 NR NR NR NR NR NR Genital fluid, microscopy 601 2.8
European Region
Farr et al., 201695 Austria, Vienna Jan 2005–Jan 2015 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, DNA probe-based assayc 3763 0.8
Ljubin-Sternak et al., 201796 Croatia, Zagreb Mar 2014–Feb 2015 Attendees at an obstetrics and gynaecology clinic, adults Genital fluid, amplification test 8665 1.7 NR NR NR NR NR NR
Peuchant et al., 201597 France, Bordeaux Jan–Jun 2011 ANC clinic attendees, 18–44 Genital fluid, amplification test 1004 2.5 Genital fluid, amplification test 1004 0.0 NR NR NR
Peuchant et al., 201597 France, Bordeaux Sep 2012–Feb 2013 ANC clinic attendees, < 25 Genital fluid, amplification test 112 7.1 Genital fluid, amplification test 112 1.8 NR NR NR
Galdavadze et al., personal communication 2012 Georgia, Tbilisi Jul 2011–Mar 2012 ANC clinic attendees, 14–44 Urine, amplification test 300 5.0 Urine, amplification test 300 0.3 NR NR NR
Ikonomidis et al., 201598 Greece, Thessaly state Feb 2012–Nov 2015 Attendees at a urology and gynaecology clinic, adults Genital fluid, amplification test 130 0.8 NR NR NR NR NR NR
O'Higgins et al., 201799 Ireland, Dublin Dec 2011–Dec 2013 ANC clinic attendees, 16–25 Genital fluid, amplification test 2687 4.9 NR NR NR NR NR NR
Hassan et al., 2016100 Ireland, Dublin Jul 2014–Jan 2015 Participants for cervical cancer screening, 25–40 Genital fluid, amplification test 236 3.0 Genital fluid, amplification test 236 0.0 NR NR NR
Bianchi et al., 2016101 Italy, Milan Dec 2008–Dec 2012 HPV vaccinated young women, 18–23 Genital fluid, amplification test 591 4.9 NR NR NR NR NR NR
Seraceni et al., 2016102 Italy, north-eastern Jan 2009–Dec 2014 Participants for cervical cancer screening, adults Genital fluid, amplification test 921 0.0 NR NR NR NR NR NR
Panatto et al., 2015103 Italy, Turin, Milan and Genoa Jan–Jun 2010 Women attending gynaecologic routine check-ups, 16–26 Genital fluid, amplification test 566 5.8 NR NR NR NR NR NR
Foschi et al., 2016104 Italy, Bologna Jan 2011–May 2014 Attendees at an obstetrics and gynaecology clinic, routine, > 14 Genital fluid, amplification test 3072 3.4 NR NR NR NR NR NR
Matteelli et al., 2016105 Italy, Brescia Nov 2012–Mar 2013 Sexually active students, ≥ 18 Urine, amplification test 1297 1.9 Urine, amplification test 1297 0.0 NR NR NR
Camporiondo et al., 2016106 Italy, Rome Mar 2013 Healthy women attending screening, 34–60 Genital fluid, amplification test 309 0.0 Genital fluid, amplification test 309 0.0 Genital fluid, amplification test 309 1.3
Leli et al., 2016107 Italy, Perugia Jan–Oct 2015 Outpatient clinic attendees, adults NR NR NR NR NR NR Genital fluid, amplification test 1487 1.3
Gravningen et al., 2013108 Norway, Finnmark 2009 Sexually active students, 15–20 Urine, amplification test 607 6.8 NR NR NR NR NR NR
Silva et al., 2013109 Portugal, Porto Pre-2013 Students, 14–30 Genital fluid, amplification test 432 6.9 NR NR NR NR NR NR
Babinská et al., 2017110 Slovakia, eastern parts 2011 Community members, adults Urine, amplification test 511 3.5 NR NR NR NR NR NR
Fernández-Benítez et al., 2013111 Spain, Laviana and Asturias Nov 2010–Dec 2011 Sexually active youth people, 15–24 Urine, amplification test 277 4.0 NR NR NR NR NR NR
Pineiro et al., 2016112 Spain, Basque Autonomous Community Jan 2011–Dec 2014 Attendees at a hospital maternity clinic, 14–54 Urine, amplification test 11 687 1.0 Urine, amplification test 11 687 0.0 NR NR NR
Field et al., 2018113 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 NR NR NR NR NR NR Urine, amplification test 2559 0.3
Sonnenberg et al., 2013114 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 Urine, amplification test 2665 2.3 Urine, amplification test 2665 0.1 NR NR NR
Eastern Mediterranean Region
Nada et al., 2015115 Egypt, Cairo Jan–Nov 2014 Controls for infertility study, adult Genital fluid, amplification test 100 2.0 NR NR NR NR NR NR
Hassanzadeh et al., 2013116 Iran (Islamic Republic of), Shiraz 2009–2011 ANC clinic attendees, adults NR NR NR Genital fluid, amplification test 1100 1.2 NR NR NR
Hamid et al., 2011117 Iran (Islamic Republic of), Zanjan province Apr 2009 Attendees at an obstetrics and gynaecology clinic, 15–45 NR NR NR Genital fluid, culture 328 0.9 NR NR NR
Nourian et al., 2013118 Iran (Islamic Republic of), Zanjan Jul 2009–Jun 2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 1000 3.3
Rasti et al., 2011119 Iran (Islamic Republic of), Kashan Pre-2010 ANC clinic attendees, adults NR NR NR NR NR NR Genital fluid, culture 450 0.4
Dehgan Marvast et al., 2017120 Iran (Islamic Republic of), Yazd May–Sep 2010 ANC clinic attendees, 16–39 Urine, amplification test 250 0.0 NR NR NR NR NR NR
Ahmadi et al., 2016121 Iran (Islamic Republic of), Sanandaj Aug 2012–Jan 2013 Controls for spontaneous abortion study, 19–42 Genital fluid, amplification test 109 11.9 NR NR NR NR NR NR
Arbabi et al., 2014122 Iran (Islamic Republic of), Kashan Oct 2012–Aug 2013 Attendees at a public health unit, 16–60 NR NR NR NR NR NR Genital fluid, culture 970 2.3
Hasanabad et al., 2013123 Iran (Islamic Republic of), Sabzevar Pre-2013 ANC clinic attendees, adolescents Urine, amplification test 399 12.3 Urine, amplification test 399 1.3 NR NR NR
Mousavi et al., 2014124 Iran (Islamic Republic of), Sanandai Feb–May 2013 Controls for infertility study, 14–40 Genital fluid, amplification test 104 5.8 NR NR NR NR NR NR
Nateghi Rostami et al., 2016125 Iran (Islamic Republic of), Qom May 2013–Apr 2014 Attendees at an obstetrics and gynaecology clinic, 18–50 Genital fluid, amplification test 518 7.1 NR NR NR NR NR NR
Marashi et al., 2014126 Iran (Islamic Republic of), not specified Pre-2014 Controls for infertility study, 20–40 Genital fluid, amplification test 200 6.5 NR NR NR NR NR NR
Joolayi et al., 2017127 Iran (Islamic Republic of), Ahvaz Aug 2016–Jan 2017 Controls for infertility study, 18–49 Genital fluid, amplification test 125 1.6 NR NR NR NR NR NR
El Kettani et al., personal communication, 2016 Morocco, Rabat, Salé, Agadir and Fes Oct 2011–Dec 2011 Attendees at a family planning clinic, 18–49 Genital fluid, amplification test 537 3.0 Genital fluid, amplification test 537 0.4 Genital, culture 537 5.6
El Kettani et al., personal communication, 2016 Morocco, Rabat, Salé, Agadir and Fes Dec 2011–Jan 2012 ANC clinic attendees, 18–49 Genital fluid, amplification test 252 3.6 Genital fluid, amplification test 252 0.8 Genital fluid, culture 252 5.2
Kamel 2013128 Saudi Arabia, Jazan Jul 2011–Jun 2012 Controls for infertility study, 18–40 Genital fluid, culture 100 4.0 NR NR NR NR NR NR
Western Pacific Region
Wen 2013129 China, Wuhu 2010 Sexually active adults, adults NR NR NR NR NR NR Genital fluid, microscopy 2010 6.6
Lu et al., 2013130 China, Shenzhen 2011–2012 Attendees at an obstetrics and gynaecology clinic, adults Genital fluid, amplification test 7892 5.4 NR NR NR NR NR NR
Xia et al., 2015131 China, east, 16 cities Jan–Dec 2011 Attendees at an hospital maternity clinic, adults Genital fluid, culture 108 268 1.5 NR NR NR NR NR NR
Zhang et al., 2017132 China, Shaanxi province Jun 2012–Jan 2013 ANC clinic attendees, adults Genital fluid, amplification test 500 3.4 NR NR NR NR NR NR
Zhang et al., 2017133 China, Beijing Mar–Oct 2014 Attendees at an obstetrics and gynaecology clinic, 20–70 Genital fluid, amplification test 953 2.2 Genital fluid, amplification test 953 0.0 Genital fluid, microscopy 953 1.7
Imai et al., 2015134 Japan, Miyazaki Oct 2011–Feb 2012 Students, > 18 Urine, amplification test 1183 3.7 NR NR NR NR NR NR
Suzuki et al., 2015135 Japan, national Oct 2013–Mar 2014 ANC clinic attendees, adults Genital fluid, amplification test 250 571 2.3 NR NR NR NR NR NR
Ministry of Health 2017136 Mongolia, national 2016 ANC clinic attendees, adults NR NR NR Genital fluid, culture 69 278 0.5 NR NR NR
Corsenac et al., 2015137 New Caledonia, national Aug–Dec 2012 Attendees at a primary health-care clinic, 18–49 Urine, amplification test 376 10.1 Urine, amplification test 376 3.5 NR NR NR
Unger et al., 2015138 Papua New Guinea, Madang Nov 2009–Aug 2012 ANC clinic attendees, ≥ 16 Genital fluid, amplification test 674 4.5 Genital fluid, amplification test 674 8.2 Genital fluid, amplification test 674 21.8
Wangnapi et al., 2015139 Papua New Guinea, Madang Feb 2011–Apr 2012 ANC clinic attendees, 16–39 Genital fluid, amplification test 362 11.0 Genital fluid, amplification test 362 9.7 Genital fluid, amplification test 362 21.3
Vallely et al., 2017140 Papua New Guinea, four provinces Dec 2011–Jan 2015 ANC clinic attendees, 18–59 Genital fluid, amplification test 765 22.9 Genital fluid, amplification test 765 14.2 Genital fluid, amplification test 765 22.4
Vallely et al., 2017140 Papua New Guinea, four provinces Dec 2011–Jan 2015 Participants for cervical cancer screening, 18–59 Genital fluid, amplification test 614 7.5 Genital fluid, amplification test 614 8.0 Genital fluid, amplification test 614 15.0
Badman et al., 2016141 Papua New Guinea, Milne Bay Aug–Dec 2014 ANC clinic attendees, > 18 Genital fluid, amplification test 125 20.0 Genital fluid, amplification test 125 11.2 Genital fluid, amplification test 125 37.6
Hahn et al., 2014142 Republic of Korea, Seoul Mar 2010–Apr 2011 ANC clinic attendees, adults Genital fluid, amplification test 455 2.2 Genital fluid, amplification test 455 0.4 Genital fluid, amplification test 455 0.0
Choe et al., 2012143 Republic of Korea, Seoul Mar–Dec 2010 Attendees at a health examination clinic, 20–59 Urine, amplification test 805 3.2 Urine, amplification test 805 0.2 NR NR NR
Kim et al., 2011144 Republic of Korea, Uijeongbu Jul–Dec 2010 Attendees at a check-up clinic, 20–60 Genital fluid, amplification test 279 3.9 Genital fluid, amplification test 279 0.4 Genital fluid, amplification test 279 2.5
Kim et al., 2014145 Republic of Korea, Seoul Jan–Oct 2012 Attendees at a health examination clinic, 25–81 Genital fluid, amplification test 405 1.2 Genital fluid, amplification test 405 0.0 Genital fluid, amplification test 405 0.2
Marks et al., 2015146 Solomon Islands, Honiara Aug 2014 Attendees at a primary health-care clinic, 16–49 Genital fluid, amplification test 296 20.3 Genital fluid, amplification test 296 5.1 NR NR NR
Ton Nu et al., 2015147 Viet Nam, Hue Sep 2010–Jun 2012 Attendees at a family planning clinic, adults NR NR NR NR NR NR Genital fluid, microscopy 534 0.7
Nguyen et al., personal communication, 2017 Viet Nam, Hanoi 2016–2017 ANC clinic attendees, > 18 Genital fluid, amplification test 490 6.9 Genital fluid, amplification test 490 0.0 Genital fluid, amplification test 490 0.8
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ANC: antenatal care; DNA: deoxyribonucleic acid; HIV: human immunodeficiency virus; NR: not reported; WHO: World Health Organization.

a Studies that reported using both culture and Gram stain were assumed to have the same sensitivity and specificity values as culture.

b The study used an immunochromatographic capillary-flow enzyme immunoassay and we assumed a sensitivity of 50% and specificity of 99%.

c The study used a nonamplified, nucleic acid probe-based test system and we assumed the same specific and sensitivity values as for a nucleic acid amplification test.

Table 2. Included studies on chlamydia, gonorrhoea and trichomoniasis prevalence in men, 2009–2016.

Study, by WHO region Country or territory and location Date of study Population and age, years Chlamydia
 Gonorrhoea
 Trichomoniasis
Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, % Clinical specimen, testa Sample size Study prevalence, %
African Region
Francis et al., 201842 South Africa, KwaZulu-Natal Oct 2016–Jan 2017 Community members, 15–24 Urine, amplification test 188 5.3 Urine, amplification test 188 1.6 Urine, amplification test 188 0.5
Rutherford et al., 201446 Uganda, Kampala Sep 2008–Apr 2009 Students, 19–25 Urine, amplification test 360 0.8 Urine, amplification test 360 0.0 NR NR NR
de Walque et al., 201247 United Republic of Tanzania, Kilombero and Ulanga districts Feb–April 2009 Participants in HIV prevention trial, 18–30 Urine, amplification test 1195 1.7 Urine: amplification test 1195 0.4 Urine, amplification test 1195 8.5
Region of the Americas
Huneeus et al., 201872 Chile, Santiago 2012–2014 Sexually active students, ≤ 24 Urine, amplification test 115 8.7 Urine, amplification test 115 0.0 Urine, amplification test 115 0.0
Paredes et al., 201575 Colombia, Sabana Centro province 2011 Students, 14–19 Urine, amplification test 536 1.1 Urine, amplification test 536 0.0 NR NR NR
South-East Asia Region
Jatapai et al., 2013148 Thailand, national Nov 2008–May 2009 Military recruits, 17–29 Urine, amplification test 2123 7.9 Urine, amplification test 2123 0.9 NR NR NR
European Region
Sviben et al., 2015149 Croatia, Zagreb Pre-2014 Controls in case-control study, 18–66 NR NR NR NR NR NR Urine, amplification test 200 2.0
Ikonomidis et al., 201598 Greece, Thessaly State Feb 2012–Nov 2015 Attendees at urology and gynaecology clinic, adult Genital, amplification test 171 0.6 NR NR NR NR NR NR
Matteelli et al., 2016105 Italy, Brescia Nov 2012–Mar 2013 Sexually active students, > 18 Urine, amplification test 762 1.4 Urine, amplification test 762 0.0 NR NR NR
Gravningen et al., 2013108 Norway, Finnmark 2009 Sexually active youth, 15–20 Urine, amplification test 505 3.4 NR NR NR NR NR NR
Babinská et al., 2017110 Slovakia, eastern parts 2011 Community members, adult Urine, amplification test 344 2.0 NR NR NR NR NR NR
Fernández-Benítez et al., 2013111 Spain, Laviana and Asturias Nov 2010–Dec 2011 Sexually active youth, 15–24 Urine, amplification test 210 4.3 NR NR NR NR NR NR
Field et al., 2018113 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 NR NR NR NR NR NR Urine, amplification test 1827 0.0
Sonnenberg et al., 2013114 United Kingdom, national Sep 2010–Aug 2012 Sexually active adults, 16–44 Urine, amplification test 1885 1.9 Urine, amplification test 1885 0.1 NR NR NR
Eastern Mediterranean Region
Arbabi et al., 2014122 Iran (Islamic Republic of), Kashan Oct 2012–Aug 2013 Attendees at a public health unit, 16–60 NR NR NR NR NR NR Genital fluid, culture 233 0.9
Yeganeh et al., 2013150 Iran (Islamic Republic of), Tehran Pre-2013 Urology clinic attendees, 18–50 Urine, amplification test 100 4.0 NR NR NR NR NR NR
Western Pacific Region
Corsenac et al., 2015137 New Caledonia, national Aug–Dec 2012 Attendees at a primary health-care clinic, 18–49 Urine, amplification test 232 7.8 Urine, amplification test 232 3.4 NR NR NR
Choe et al., 2012143 Republic of Korea, Seoul Mar–Dec 2010 Attendees at a health examination clinic, 20–59 Urine, amplification test 807 7.9 Urine, amplification test 807 0.6 NR NR NR
Kim et al., 2011144 Republic of Korea, Uijeongbu Jul–Dec 2010 Attendees at a check-up clinic, 20–60 Urine, amplification test 430 6.7 Urine, amplification test 430 0.5 Urine, amplification test 430 0.2
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HIV: human immunodeficiency virus; NR: not reported; WHO: World Health Organization.

a Tests were either nucleic acid amplification test or culture.

Table 3. Number of data points that met the study inclusion criteria for the WHO 2016 prevalence estimates of chlamydia, gonorrhoea and trichomoniasis.

Estimation region No. of countries, territories and areas Chlamydia
 Gonorrhoea
 Trichomoniasis
Women
 Men
 Women
 Men
 Women
 Men
No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries No. of data points No. of countries
Central, eastern and western sub-Saharan Africa 41 16 7 2 2 15 7 2 2 21 9 1 1
Southern sub-Saharan Africa 6 7 4 1 1 6 3 1 1 6 3 1 1
Andean, central, southern and tropical Latin America and Caribbean 42 25 8 2 2 14 6 2 2 16 5 1 1
High-income North America 2 NA NA NA NA NA NA NA NA NA NA NA NA
North Africa and Middle East 20 11 4 1 1 5 2 0 0 5 2 1 1
Australasia and high-income Asia Pacific 6 6 2 2 1 4 1 2 1 3 1 1 1
Western, central and eastern Europe and central Asia 54 19 11 6 6 9 7 2 2 4 3 2 2
Oceania 14 7 3 1 1 7 3 1 1 5 1 0 0
South Asia 5 4 2 0 0 2 1 0 0 3 1 0 0
East Asia and south-east Asia 15 5 2 1 1 2 2 1 1 6 4 0 0
Total 205 100 43 16 15 64 32 11 10 69 29 7 7
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NA: not applicable; WHO: World Health Organization.

Note: Eight of the 112 studies with data for women had two separate data points (e.g. for different population groups).

For women, a total of 43 (21.0%) of 205 countries, territories and areas had one or more data points for chlamydia, 32 (15.6%) for gonorrhoea and 29 (14.1%) for trichomoniasis. For men, only 15 (7.3%) countries, territories and areas had one or more data points for chlamydia, 10 (4.9%) for gonorrhoea and 7 (3.4%) for trichomoniasis. For women there were sufficient data to generate summary estimates for chlamydia for the nine estimation regions, but not for gonorrhoea or trichomoniasis (Table 4).

Table 4. Approach used to generate 2016 regional estimates for chlamydia, gonorrhoea and trichomoniasis.

Estimation region Women
 Men
Chlamydia Gonorrhoea Trichomoniasis Chlamydia Gonorrhoea Trichomoniasis
Central, eastern and western sub-Saharan Africa Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Southern sub-Saharan Africa Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Andean, central, southern and tropical Latin America and Caribbean Meta-analysis Meta-analysis Meta-analysis Special casea Global male-to-female ratio Global male-to-female ratio
High-income North Americab United States estimate for 2012 United States estimate for 2008 United States estimate for 2008 United States estimate for 2012 United States estimate for 2008 United States estimate for 2008
North Africa and Middle East Meta-analysis Meta-analysis Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Australasia and high-income Asia Pacific Meta-analysis Gonorrhoea to chlamydia ratio Trichomoniasis to chlamydia ratio Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
Western, central and eastern Europe and central Asia Meta-analysis Meta-analysis Trichomoniasis to chlamydia ratio Meta-Analysis Global male-to-female ratio Global male-to-female ratio
Oceania Meta-analysis Meta-analysis Meta-Analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
South Asia Meta-analysis Gonorrhoea to chlamydia ratio Trichomoniasis to chlamydia ratioc Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
East Asia and south-east Asia Meta-analysis Gonorrhoea to chlamydia ratiod Meta-analysis Global male-to-female ratio Global male-to-female ratio Global male-to-female ratio
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a In consultation with advisors on sexual transmitted infections for the World Health Organization (WHO) Region of the Americas, we decided to use the midpoint between the 2016 estimate generated by applying the global male-to-female ratio (7.5%) and the 2012 estimate for the region (2.1%). We deemed the former to be too high and the latter too low.

b Following discussions with the United States Centers for Disease Control and Prevention, we based our estimates on the latest published United States national estimates21,22 and assumed they remained constant over time and that estimates for 15–39-year-old people could be extrapolated to the 15–49-year age range. We did not apply the adjustments used for other Regions in the WHO estimates process. The figures for the United States were also applied to Canada.

c The estimate based on the three available data points was over 4%, considerably higher than the 2012 estimate. Following discussions with regional experts we decided not to use this estimate, but instead to use the trichomoniasis to chlamydia ratio for low and lower middle-income countries, territories and areas.

d This estimation region is made up of countries from East Asia and South East Asia. We used the higher and upper-middle income gonorrhoea to chlamydia ratio for East Asia and the low and lower-middle income ratio for South East Asia.”

Syphilis

As of 2 May 2018, the Spectrum-STI Database contained 1576 data points from surveys conducted since 1990, including 978 from January 2009 to December 2016.151 In total, 181 (88.3%) of 205 countries, territories and areas had sufficient data to generate a Spectrum STI estimate for 2016. For the remaining 24 countries, territories and areas, we used the median value of the countries with data for the relevant WHO region as the 2016 estimate.

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