Immunofluorescence staining of human gastric cells grown in a microplate and infected with Chlamydia trachomatis. Blue: cell nuclei, green: C. trachomatis, grey: actin. (Image: Pargev Hovhannisyan / Universität Würzburg)
A phenomenon is known from everyday clinical practice that can occur after successful antibiotic treatment: when people who have already been treated come to the doctor with a new chlamydia infection, they are often infected with exactly the same strains of bacteria as the previous infection.
“It is therefore reasonable to assume that the bacteria find a niche in the body where they are not yet vulnerable, that they form a permanent reservoir there and can become active again later,” says Professor Thomas Rudel, chlamydia expert and Head of the Chair of Microbiology at the Biocentre of Julius-Maximilians-Universität (JMU) Würzburg in Germany. This phenomenon is known as persistence. It is problematic because the chlamydia that persist in the body become increasingly resistant to antibiotics over time.
Intestinal Organoids Experimentally Infected with Chlamydia
Experiments on mouse models have shown that chlamydia can persist in the intestines of animals. In humans the bacteria also seem to make themselves at home there. This is reported by the research groups of Thomas Rudel and Sina Bartfeld in the journal PLOS Pathogens. Professor Bartfeld worked at JMU until 2021; she now heads the Department of Medical Biotechnology at Technische Universität Berlin.
The researchers identified the intestine as a niche with the help of artificial organs in miniature format, so-called organoids. These are structures produced in the laboratory from human intestinal cells that are very similar in structure and function to the model organ.
The teams from Würzburg and Berlin tried to infect the intestinal organoids with chlamydia. They discovered that the inner cell layer of the organoids is very resistant to the bacteria: the pathogens could only penetrate there if the cell epithelium was damaged. From the blood side, however, the chlamydia were able to infect very efficiently. “In this case, we repeatedly found the persistent forms of the bacteria, which can be clearly identified with their typical shape under the electron microscope,” says JMU researcher Pargev Hovhannisyan, first author of the publication.
Clinical Studies and Further Experiments Must Follow
Transferred to the human organism, this would mean that chlamydia infection with subsequent persistence can only occur with difficulty via the inner side of the intestine, but very easily via the blood. However, whether this actually happens in the human body has yet to be confirmed in clinical studies, says Thomas Rudel.
The next step for Thomas Rudel and Sina Bartfeld is to to find out whether the chlamydia select certain cell types for their persistence – no easy task, as the intestine consists of hundreds of different cell types. But perhaps it is also factors from the surrounding tissue that trigger persistence. These and other details are now to be investigated.
Myths are widely held beliefs about various issues, including illness and disease. They come about through frequent storytelling and retelling. Dr Themba Hadebe, Clinical Executive at Bonitas Medical Fund, helps debunks myths about monkeypox (mpox).
Myth 1: Mpox (formerly monkeypox) is a new disease created in a lab
Fact: The mpox virus was discovered in Denmark (1958) in a colony of monkeys at a laboratory kept for research. The first reported human case was in 1970 in the DRC. Mpox is a zoonotic disease, meaning it can be spread between animals and people. It is found regularly in parts of Central and West Africa and can spread from person to person or occasionally from animals to people.
Myth 2: Mpox comes from monkeys
Fact: Despite its name, monkeypox does not come from monkeys. The disease earned the name when the ‘pox like’ outbreaks happened in the research monkeys. While monkeys can get mpox, they are not the reservoir (where a disease typically grows and multiplies). The reservoir appears to be rodents.
Myth 3: Only a handful of people have contracted mpox
Fact: Globally, more than 97 000 cases and 186 deaths were reported across 117 countries in the first four months of 2024. South Africa is among the countries currently experiencing an outbreak. On the 5 July, it was reported that the number of mpox cases in the country has risen to 20. This after four more cases have been confirmed in Gauteng and KwaZulu-Natal in the last few days.
15 patients have, however been given a clean bill of health.
Myth 4: It is easy to diagnose mpox
Fact: It is easy to mistake mpox for something else. While the rash can be mistaken for chickenpox, shingles or herpes, there are differences between these rashes. Symptoms of mpox include fever, sore throat, headache, muscle aches, back pain, low energy and swollen lymph nodes. Fever, muscle aches and a sore throat appear first. The rash begins on the face and spreads over the body, extending to the palms of the hands and soles of the feet and develops over 2-4 weeks in stages. The ‘pox’ dip in the centre before crusting over.
Laboratory confirmation is required. A sample of one of the sores is diagnosed by a PCR test for the virus (MPXV).
Myth 5: Mpox is easily treated
Fact: ‘Currently,’ says the National Institute for Communicable Diseases (NICD), ‘there is no registered treatment for mpox in South Africa. However, the World Health Organization (WHO) recommends the use of TPOXX for treatment of severe cases, in immunocompromised people’. However, the Department of Health (DoH) has only obtained this treatment, with approval on a compassionate use basis, for the five known patients with severe disease.
There is no mpox vaccine currently available in South Africa.
Myth 6: You can get mpox from being in a crowd or from a public toilet seat
Fact: Mpox is not like Covid-19 which is highly contagious. It spreads through direct contact via blood, bodily fluid, skin or mucous lesions or respiratory droplets.
It can also spread though bites and scratches. Studies have shown that the virus can stay on surfaces but it is not spreading in that way or in a public setting. The risk of airborne transmission appears low.
Myth 7: Mpox is deadly
Fact: While mpox lesions can look similar to smallpox lesions, mpox infections are much milder and are rarely fatal. That said, symptoms can be severe in some patients, needing hospitalisation and, in rare cases, result in death. It is, however, painful and very unpleasant. So, it is important to avoid infection.
Myth 8: Mpox is sexually transmitted
Fact: You can become infected though close, direct contact with the lesions, rash, scabs or certain bodily fluids of someone who has mpox. Even though this could imply transmission though sexual activity, it is not limited to that. You can also be exposed if you are in close physical proximity to infected people, such as spouses or young children who sleep in the same bed.
Myth 9: I can’t protect myself from getting Mpox
Fact: You can take precautions: Avoid handling clothes, sheets, blankets or other materials that have been in contact with an infected animal or person. Wash your hands well with soap and water after any contact with an infected person or animal and clean and disinfect surfaces. Practice safe sex and use personal protective equipment (PPE) when caring for someone infected with the virus.
Myth 10: You can’t stop other people being infected by you
Fact: You may not protect them by 100% but you can isolate. Also, alert people who have had recent contact with you. Wash your hands regularly with soap and water or use hand sanitiser, especially before or after touching sore and disinfected shared spaces. Cover lesions when around other people, keep skin dry and uncovered (unless in a room with someone else).
Mpox is a notifiable medical condition but is treatable, if you are concerned, call the DoH toll free number of 0800 029 999 but remember, your GP is your first port of call for all your healthcare needs.
There’s a comeback of sexually transmitted infections (STIs) in South Africa and around the world. The Gauteng Department of Health recently reported an increase of newly acquired STIs, in particular gonorrhoea and chlamydia. This spike in cases call for management guidelines and awareness programmes to be reviewed, reports Ufrieda Ho.
A rise in reported cases of sexually transmitted infections in Gauteng in 2023 is a wake-up call that control and management strategies are not keeping pace with the growing disease burden in South Africa’s most populous province.
“The Gauteng information confirms the rise in STIs that we are seeing in South Africa and across the world, including in the United States and Canada,” said Dr Nomathemba Chandiwana, a director and principal scientist at Ezintsha Research Centre at Wits University. She is also a co-author of the 2022 guidelines on the management of sexually transmitted infections produced by the Southern Africa HIV Clinicians Society.
Chandiwana said any increase in STIs should raise alarms because it means “we simply don’t have control over the things we thought we had under control”.
The World Health Organization (WHO) in 2022 noted that countries reported low coverage for preventive, testing and treatment services related to STIs, because of Covid-19 lockdown restrictions. The WHO confirmed that this had led to a “resurgence of STIs and the emergence of non-classical STIs [such as Shigella sonnei, hepatitis A, Neisseria meningitidis, Zika and Ebola] globally”. It also reported that currently more than 1 million new STIs are acquired around the world each day “posing a significant global health challenge”.
Since the middle of 2023, the WHO has pushed for low-cost point of care tests to be more readily available in low and middle income countries, saying this would improve screening and diagnosis, data collection and make STI services more effective. South Africa has not made such tests accessible, still relying on a syndromic approach, which is clinical diagnosis made by assessing a patient’s symptoms and other visible signs.
New public health threats
Chandiwana said a review of STI treatment and management guidelines is necessary because the rising numbers pose significant new public health threats. Of particular concern, she said, is that having STIs pushes up a person’s risk to contract HIV, which is “a chronic and serious disease” as well as developing other long term or irreversible medical risks, including reproductive complications.
Earlier in February, the Gauteng Department of Health reported that the incidence of Male Urethritis Syndrome (MUS) in men aged 15 to 49 in the province had increased from 12% in 2020 to 15% in 2023. The department did not provide actual figures for the comparison, which is also somewhat complicated by the fact that in 2020 there were strict COVID-19 lockdowns and restrictions in place.
The department’s information from 2023 showed that 167 109 males aged 15 to 49 visited health facilities across the province from April to December. Of these patients, 67 400 (40% of the 167 109) were treated for MUS.
The diagnosis of MUS is an indicator of newly acquired STIs, in particular gonorrhoea and chlamydia, which according to the Gauteng Department of Health are the most prevalent STIs in South Africa.
Chandiwana said diagnosis of MUS in men and pelvic inflammatory disease (PID) among women, are made by assessing symptoms of pain, discomfort and genital discharge and sores. Conventionally, it’s treated with broad range antibiotics.
She explained South Africa’s guidelines to treatment and management is to make clinical decisions based on a patient’s symptoms and signs. “While this standard approach has worked, we are calling for a move to targeted diagnosis and targeted treatment. It’s because you want to know which STI someone has and to treat them for that particular disease,” said Chandiwana.
Different STIs can also result in different complications. Syphilis for instance, she said, can result in women giving birth to children who are deaf or blind or raises the risks for infertility. (Spotlight previously reported on congenital syphilis in South Africa in more depth here.)
“We also have STIs that are present but not visible, so asymptomatic STIs, including HPV (human papillomavirus), which is the leading cause of cervical cancer in black women in South Africa,” Chandiwana said.
“Of course it’s complicated in a public healthcare system where we might not have lab services everywhere, and where there may be lab testing there is a long turnaround for results,” she added.
What to do
It means a multi-pronged approach is still necessary. This she said, has to include a shift from blaming and policing people’s sexual behaviour. Her comments are in response to Gauteng MEC for health and wellness Nomantu Nkomo-Ralehoko’s remarks in the same Gauteng Department of Health press release in which the MEC drew a link between a higher number of women coming forward to be initiated on Pre-Exposure Prophylaxis (PrEP) – an antiretroviral drug prescribed for HIV-negative people to stop HIV infection – and the higher recorded number of STIs. The MEC is quoted saying: “We believe that the high uptake of PrEP among women has led this group to having unprotected sex resulting in high incidence of MUS. The studies have reported that STI incidence is also high among young women receiving PrEP.”
Chandiwana dismissed the conclusion of a causal relationship. “PrEP is a very important tool because it’s something people can take to prevent HIV. But before we had PrEP it was not like people were using condoms – people were using nothing. So I disagree, the uptake of PrEP is not directly involved with the increase of STIs,” she said.
What’s needed instead, she said, is to ask why people are not using condoms more often and why South Africa is not creating STI friendly services that include differentiated care for key populations such as sex workers, men who have sex with men, or people who inject drugs. There should also be more peer navigators, services that are quick, efficient and confidential as well as investment and development of rapid testing kits, she added.
Preliminary findings from the Sixth South African National HIV Prevalence, Incidence, and Behaviour survey released by the Human Sciences Research Council in November indicated that condom use had dropped substantially among young people from 2017 to 2022. It did prompt MEC Nkomo-Ralehoko to call for more uptake of PrEP. “We would like to encourage more males to get initiated on PrEP to protect themselves against STI. Additionally, both men and women who are on PrEP should use condoms to protect themselves against STIs, HIV and unwanted pregnancies,” she was quoted in the press release.
Role of medical male circumcision
Meanwhile, the NGO Right to Care is promoting voluntary medical male circumcision as another strategy to combat the rise in STI cases. “Uncircumcised men are more susceptible to STIs than men who are circumcised, especially STIs that cause ulcers or wounds,” said Dr Nelson Igaba, senior technical specialist for voluntary medical male circumcision at the NGO.
He described the Gauteng statistics as “worrying” and said it should be read as a prompt for more men to opt for circumcision. The NGO will connect men to their nearest public facility to have the procedure done for free. (They can be contacted at 082 808 6152.)
Dr Tendesayi Kufa-Chakezha, a senior epidemiologist at the Centre for HIV and STIs at the National Institute of Communicable Diseases (NICD), also homes in on the need for more awareness building.
“As a country we are not talking about STIs enough, among ourselves or with our children. More healthcare workers are needed and more training can be made available. We also need a massive campaign to educate communities on the causes of STI syndromes, symptoms, where to get treatment, types of treatments, complications and to go back to facilities if they don’t get better.”
Kufa-Chakezha said South Africa’s STI treatment guidelines do conform with existing WHO guidelines. She said the NICD regularly collects information and specimens from health facilities, which allows them to determine the most common causes associated with the symptoms that are most commonly seen. The NICD uses these findings to inform the country’s STI management and treatment strategies that are based on diagnosis and treatment of the most prevalent STIs.
“If as a country we are not able to get more people with or without STI symptoms screened and treated, we will continue to have people acquiring STIs, developing symptoms associated with them, becoming ill and developing complications from them,” she added.
