Urogenital Chlamydia trachomatis Infections among Ethnic Groups in Paramaribo, Suriname; Determinants and Ethnic Sexual Mixing Patterns

Determinants and Ethnic Sexual Mixing Patterns. PLoS ONE 8(7): e68698. doi:10.1371/journal.pone.0068698 Urogenital Chlamydia trachomatis Infections among Ethnic Groups in Paramaribo, Suriname; Determinants and Ethnic Sexual Mixing Patterns Jannie J. van der Helm 0 Reinier J. M. Bom 0 Antoon W. Gru nberg 0 Sylvia M. Bruisten 0 Maarten F. Schim van der Loeff 0 Leslie O. A. Sabajo 0 Henry J. C. de Vries 0 0 1 STI Outpatient Clinic, Public Health Service Amsterdam , Amsterdam , The Netherlands , 2 Department of Research, Public Health Service Amsterdam , Amsterdam , The Netherlands , 3 Public Health Laboratory, Public Health Service Amsterdam , Amsterdam , The Netherlands, 4 Lobi Foundation, Paramaribo , Suriname , 5 Department of Experimental Virology, Academic Medical Center (AMC), University of Amsterdam , Amsterdam , The Netherlands, 6 Center for Infection and Immunity Amsterdam (CINIMA) , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands , 7 Dermatological Service, Ministry of Health , Paramaribo , Suriname , 8 Department of Dermatology, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands , 9 Center for Infectious Disease Control, National Institute of Public Health and the Environment , Bilthoven , The Netherlands Background: Little is known about the epidemiology of urogenital Chlamydia trachomatis infection (chlamydia) in Suriname. Suriname is a society composed of many ethnic groups, such as Creoles, Maroons, Hindustani, Javanese, Chinese, Caucasians, and indigenous Amerindians. We estimated determinants for chlamydia, including the role of ethnicity, and identified transmission patterns and ethnic sexual networks among clients of two clinics in Paramaribo, Suriname. Methods: Participants were recruited at two sites a sexually transmitted infections (STI) clinic and a family planning (FP) clinic in Paramaribo. Urine samples from men and nurse-collected vaginal swabs were obtained for nucleic acid amplification testing. Logistic regression analysis was used to identify determinants of chlamydia. Multilocus sequence typing (MLST) was performed to genotype C. trachomatis. To identify transmission patterns and sexual networks, a minimum spanning tree was created, using full MLST profiles. Clusters in the minimum spanning tree were compared for ethnic composition. Results: Between March 2008 and July 2010, 415 men and 274 women were included at the STI clinic and 819 women at the FP clinic. Overall chlamydia prevalence was 15% (224/1508). Age, ethnicity, and recruitment site were significantly associated with chlamydia in multivariable analysis. Participants of Creole and Javanese ethnicity were more frequently infected with urogenital chlamydia. Although sexual mixing with other ethnic groups did differ significantly per ethnicity, this mixing was not independently significantly associated with chlamydia. We typed 170 C. trachomatis-positive samples (76%) and identified three large C. trachomatis clusters. Although the proportion from various ethnic groups differed significantly between the clusters (P = 0.003), all five major ethnic groups were represented in all three clusters. Conclusion: Chlamydia prevalence in Suriname is high and targeted prevention measures are required. Although ethnic sexual mixing differed between ethnic groups, differences in prevalence between ethnic groups could not be explained by sexual mixing. - Funding: This work was supported by the Research and Development fund of the Public Health Service of Amsterdam (project no 2369 and 2371) and AGIS healthcare insurance (RVVZ no 1417000). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors declare that AGIS healthcare insurance is a commercial funder. This does not alter the authors adherence to all the PLOS ONE policies on data sharing and materials. Urogenital Chlamydia trachomatis infection, or chlamydia, is the most prevalent bacterial sexually transmitted infection (STI) worldwide [1]. Left untreated, chlamydia can lead to complications like pelvic inflammatory disease, ectopic pregnancy, and infertility. To reduce complications and transmission of chlamydia, active case finding and early treatment are critical strategies [2,3]. Suriname is on the South American continent, but as a consequence of a shared colonial past it is more socio-culturally connected to the Caribbean region. The prevalence of chlamydia in the general population in many countries of the Caribbean is unknown because testing facilities are lacking and routine screening is not available. A study in Guadeloupe among patients who were referred for a genital infection, showed a prevalence of 17% among men and 10% among women [4]. A study in Barbados among the general population showed a prevalence of 11% [5] and a study in Trinidad and Tobago among pregnant women showed a prevalence of 21% [6]. We previously found a prevalence of 21% among high-risk women and 9% among lowrisk women in Suriname [7]. The variety of ethnicities is distinctive for Surinamese society. The Surinamese population consists of Creoles and Maroons (both descendants of African diaspora due to the slave trade), Hindustani, Javanese, and Chinese (all descendants of labor immigrants from the former British Indies, Dutch Indies, and China, respectively), Caucasians (descendants of European colonialists), indigenous Amerindians, and people of mixed race. The five major groups are Hindustani (27.4%), Creole (17.7%), Maroon (14.7%), Javanese (14.6%), and mixed race (12.5%). These groups cannot be considered a minority since they are comparable in size and integrated parts of the total population [8]. Previous Surinamese studies on sexuality, however, have mainly focused on the Creoles, and rarely on other ethnicities [9,10]. The structure of sexual networks is important for STI transmission, but elucidating these transmission networks based on epidemiological and behavioral data alone is challenging. Combining epidemiological and behavioral data with molecular microbial genotyping techniques can provide more insight into the transmission patterns of C. trachomatis. Molecular typing can reveal the relatedness of bacterial strains that circulate among the population and may identify transmission networks at the pathogen level. Because of the low genetic variability of C. trachomatis, a typing tool with a high discriminatory resolution between strains is necessary to reveal network associations of C. trachomatis. Whereas suitable molecular techniques for Neisseria gonorrhoeae have been available for some time [11], high-resolution typing methods for C. trachomatis, such as multilocus sequence typing (MLST), have only been developed recently [12,13]. Studies using high-resolution typing of C. trachomatis strains have examined the relation between clinical symptoms [14], geographic locati (...truncated)