性傳播疾病暴發和基因組監測
資料來源：www.thelancet.com/infection 2022年7月6日在線發布/ https://doi.org/10.1016/S1473-3099(22)00361-9/財團法人台灣紅絲帶基金會
在過去的十年中，我們看到了病毒和細菌的重大國際爆發——這些通常透過非性的人與人之間的接觸而傳播——結果卻由性傳播引起並透過性網絡傳播。這包括在男男性行為者中全球傳播的A型肝炎和耐藥志賀氏菌。這些暴發是在許多國家和已確定的性傳播感染（如梅毒和淋病）持續的傳播和日益盛行的背景下發生的，這導致了廣泛的發病率。這些性傳播病原體的基因組定序，豐富了我們對這些流行病隨時間和跨人群的動態演變以及抗生素耐藥性的生物學機制的理解。
在《剌胳針傳染病》中，Hannah Charles 及其同事描述了在英國男男性行為者中傳播的廣泛耐藥 (XDR) 宋內志賀氏菌 (Shigella sonnei) 的爆發，特別是在接受 HIV 暴露前預防 (PrEP) 的男性中。一些病例臨床嚴重，導致住院，對多種抗生素的耐藥性嚴重限制了治療選擇。 XDR S Sonnei 病例也已在歐洲和全球範圍內報告。這項研究應用全基因組定序來彰顯最近在英國爆發的 XDR 志賀氏菌疫情，強調了幾點。
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首先，性傳播病原體的大規模爆發繼續對全球公共衛生構成嚴重威脅，包括新病原體的出現。最近國際爆發的猴痘主要影響男男性行為者，這突顯地提醒人們，新興病原體可以透過高風險的性網絡和國際旅行迅速傳播。儘管查爾斯和他的同事沒有包括已公開可獲得的國際基因組數據，以便將英國的疫情置於全球範圍內。但之前的工作已經證明性傳播病原體在全球範圍內迅速傳播，包括抗生素抗藥之志賀氏菌。基因組定序與來自受影響個體的人口統計和行為訊息相結合，使我們能夠生成有關病原體如何在不同高危人群（例如，僅與男性發生性關係的男性、僅與女性發生性關係、與女性和男性發生性關係的男性、女性、性工作者、旅行者和 PrEP 使用者）。這種方法可以優先考慮公共衛生介入措施，更有針對性，更有效地使用有限資源，儘管它依賴於衛生服務、公共衛生當局和實驗室之間的有效夥伴關係，這些實驗室可以隨時獲得基因組技術。然而，同樣重要的是讓受影響的社區群體參與基因組分析的訊息之生成和訊息之傳播，特別是如果這些訊息可能會給感染者個人帶來污名恥辱。
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其次，抗生素耐藥性增加是幾種性傳播病原體的緊迫問題。與 XDR 志賀氏菌一樣，由於對多種抗生素的耐藥性，淋病奈瑟菌和生殖器黴漿菌的治療選擇變得越來越有限，這些病原體有朝一日可能變得無法治癒。為了解決這個問題，迫切需要在性傳播感染的管理中進行抗生素管理，以減少抗生素耐藥性的發展，必須開發新的有效抗生素，並應考慮回收在面對多重耐藥性時仍然有效的舊抗生素。
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第三，靈活的公共衛生應對措施以迅速識別和遏制性傳播感染爆發仍然是實施的關鍵。其中包括及時檢測和治療（或隔離）病例、優化性接觸管理（識別、檢測和治療或隔離）、監測以及提高衛生提供者和受影響社區的知識和意識。更深入地去了解有利於病原體傳播的特定性行為和影響傳染性的生物學上之變數，可能有助於為減少傳染性和傳播的新策略提供訊息。在感染發生率特別高的人群中，這些介入措施的組合和強度需要更大。
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最後，儘管 COVID-19 大流行導致社會流動性受到限制，這可能減少了性傳播感染的傳播，但取消限制和恢復國際旅行意味著我們可能會看到這些疾病在本地和全球傳播的反彈性感染。在 COVID-19 時代，許多國家將面臨更大的衛生服務資金限制。查爾斯及其同事的這項研究，加上最近透過性接觸傳播的猴痘，及時提醒人們需要高度和可及的性健康服務和有效的公共衛生應對措施。
我們聲明沒有利益衝突。 MC 由國家健康和醫學研究委員會 (NHMRC) 合作計畫贈款 APP2003399 資助。 DAW 由 NHMRC Investigator Grant APP1174555 資助。
* Marcus Y Chen, Deborah A Williamson mchen@mshc.org.au
(MYC) 澳大利亞維多利亞州，阿爾弗雷德衛生系統，墨爾本性健康中心；以及澳大利亞維多利亞州墨爾本莫納什大學醫學、護理與健康科學學院中央臨床學院 。
(DAW)澳大利亞維多利亞州墨爾本大學，彼得多爾蒂感染與免疫研究所，傳染病學系；澳大利亞維多利亞州墨爾本皇家墨爾本醫院維多利亞傳染病參考實驗室；以及澳大利亞維多利亞州墨爾本 Walter and Eliza Hall 醫學研究所
Sexually transmitted outbreaks and genomic surveillance
資料來源：www.thelancet.com/infection Published online July 6, 2022 / https://doi.org/10.1016/S1473-3099(22)00361-9 / 財團法人台灣紅絲帶基金會編譯
Over the past decade, we have seen major international outbreaks of viruses and bacteria—that are usually transmitted through non-sexual person-to-person contact—resulting from sexual transmission and spread through sexual networks. This includes the global dissemination of hepatitis A and antimicrobial resistant Shigella among men who have sex with men. These outbreaks have occurred against a backdrop of sustained transmission and increasing prevalence of established sexually transmitted infections such as syphilis and gonorrhoea in many countries, which have resulted in widespread morbidity. Genome sequencing of these sexually transmitted pathogens has enriched our understanding of the dynamic evolution of these epidemics over time and across populations, as well as the biological mechanisms underlying antimicrobial resistance.
In The Lancet Infectious Diseases, Hannah Charles and colleagues describe an outbreak of extensively drugresistant (XDR) Shigella sonnei transmitted among men who have sex with men in the UK, particularly among men taking HIV pre-exposure prophylaxis (PrEP). Several cases were clinically severe, resulting in hospitalisation, with resistance to multiple antibiotic classes severely limiting treatment options. Cases of XDR S sonnei have also been reported across Europe and globally. This study, which applied whole-genome sequencing to characterise a recent XDR Shigella outbreak in the UK, highlights several points.
First, major outbreaks of sexually transmissible pathogens continue to pose a serious threat to global public health, including the emergence of new pathogens. The recent international outbreak of monkeypox, which has predominantly affected men who have sex with men, is a salient reminder of how rapidly dissemination of emergent pathogens can occur through high-risk sexual networks and international travel. Although Charles and colleagues did not include publicly available international genomic data to place the UK outbreak within a global context, previous work has demonstrated the rapid global spread of sexually transmitted pathogens, including antimicrobial-resistant Shigella. Genome sequencing, when combined with demographic and behavioural information from affected individuals, allows us to generate high-definition pictures of how pathogens are transmitted between individuals within and across different at-risk populations (eg, men who have sex with men only, men who have sex with women only, men who have sex with both women and men, women, sex workers, travellers, and PrEP users).1–4 This approach might allow public health interventions to be prioritised and better targeted, with more efficient use of limited resources, although it is dependent on effective partnerships between health services, public health authorities, and laboratories with ready access to genomic technology. Equally important, however, is the inclusion of affected community groups in generating and disseminating information from genomic analyses, particularly if this information is potentially stigmatising for individuals who are infected.
Second, increasing antimicrobial resistance is a pressing concern with several sexually transmitted pathogens. As with XDR Shigella, treatment options for Neisseria gonorrhoeae and Mycoplasma genitalium are becoming increasingly limited due to resistance to multiple antibiotic classes, with the prospect that these pathogens might one day become untreatable. To address this, antimicrobial stewardship in the management of sexually transmitted infections is urgently needed to reduce the development of antimicrobial resistance, new and effective antimicrobials must be developed, and recycling of old antibiotics that remain effective in the face of multidrug resistance should be considered.
Third, nimble public health responses that swiftly identify and contain outbreaks of sexually transmitted infections remain critical to implement. These include timely testing and treatment (or isolation) of cases, optimal management of sexual contacts (identification, testing, and treatment or isolation), surveillance, and raising knowledge and awareness among health providers and affected communities. A better understanding of the specific sexual behaviours that favour the transmission of pathogens and the biological variables that affect infectiousness might help to inform novel strategies to reduce contagiousness and transmission. In populations where the incidence of infection is especially high, the combination and intensity of these component interventions need to be even greater.
Finally, although the COVID-19 pandemic led to restrictions on social mobility that might have curtailed the spread of sexually transmissible infections, the lifting of restrictions and resumption of international travel mean we are likely to see a rebound in the local and global transmission of these infections. In the COVID-19 era, many countries will face even greater constraints on funding for health services. The study by Charles and colleagues, coupled with the recent spread of monkeypox through sexual contact, are timely reminders of the need for highly accessible sexual health services and effective public health responses.
We declare no competing interests. MC is funded by the National Health and Medical Research Council (NHMRC) Partnership Project Grant APP2003399. DAW is funded by NHMRC Investigator Grant APP1174555.
*Marcus Y Chen, Deborah A Williamson mchen@mshc.org.au
Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC 3053, Australia (MYC); Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia (MYC) 。
Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia (DAW); Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia (DAW); Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia (DAW)