Sunil Sethi, Professor, STD division, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh,India

1. Mycoplasma genitalium :“Status in South Asia”
Sunil Sethi
Vice Chair , IUSTI AP South Asia Subregion,
Professor, STD division
Department of Medical Microbiology, Postgraduate
Institute of Medical Education and Research,
Chandigarh,India

2. PGIMER, Chandigarh

3. Chandigarh

4. Rock garden (Chandigarh)

6. Mycoplasma genitalium
 1980: Mycoplasma genitalium isolated from 2 of 13 men
with NGU (nongonoccocal urethritis)
 Sexually transmitted bacterium, lacks a cell wall
 1990’s: development of PCR assays, allowed study of disease
association
 1995: smallest genome known (580 kbp, ≈ 480 genes)

7.  M. genitalium contributes to pathogenesis
of several urogenital diseases

8. Jensen and Unemo. WHO Manual. 2013
Urogenital mycoplasmas

9. Worldwide prevalence
EUROPE
Denmark-1.1-2.3 %
Sweden-2.3-7.7 %
Norway-4.47 %
UK-4.5-6.6 %
CENTRAL &
SOUTH AMERICA
Brazil-5.8%
Honduras-7.1%
NORTH AMERICA
USA-5.4-22.4%
AFRICA
Tanzania-3.2-5%
Kenya-16%
Australia-1.3-11%
New Zealand-10%
Middle East
Iran-7.2%
Jordan-9%
Russia-26%
Sex Health. 2011 Jun;8(2):143-58. doi: 10.1071/SH10065

10. China & Japan
Jpn. J. Infect. Dis., 67, 17-21, 2014

11. South Korea

12. South Asia prevalence- Underdiagnosed
Bangladesh- 0.8%
India (Chandigarh 2009)- 6% NGU &
15 % in Infertility and 6% in
cervicitis
N=399
Random sampling of women
at PHC with vaginal disharge
(Rahman et al, 2008)
N=100
Men with NGU at STD/HIV
clinics
(Manhas et al, 2009)
Sex Health. 2011 Jun;8(2):143-58. doi: 10.1071/SH10065
Widely varying prevalence estimates of studies probably reflect
multi-factorial variables among populations tested (e.g. patient
health status and age, assay methods, specimen types)
No studies

13. Epidemiology in South Asia ?
 How much ? Prevalence and incidence
 Who ? Risk factors

14. Underdiagnosed infection in South Asia?
 M. genitalium prevalence among various populations
received relatively little attention
 Why?
 Lack of standardised testing
 Under-reported infections
 Lack of awareness
 Syndromic approach

15. Risk factor
Asymptomatic carrier state- serious epidemiological problem
Indian J Med Res. 2012 Dec;136(6):942-55

16.  While C. trachomatis - universally accepted as
an STI,
 pathogen status of M. genitalium is not so
prominent
 M. genitalium to be regarded more seriously
and to be recognized as a significant STI with
associated morbidity.

17. Association of Mycoplasma genitalium in HIV
positive men with NGU attending HIV and STD
clinics in Northern India
Sunil Sethi, Ashwini Manahas ,Ajay Wanchu*, Kanwar mohan**
and Meera Sharma
Department of Medical Microbiology and Dermatology
**, Internal Medicine* PGIMER, Chandigarh, India
Indian J Med Res 129, March 2009,
pp 305-310

18. Patient population
100 patients (Uretheritis) HIV clinic
HIV negative
(n=30)
•Urethral swabs(n=3) and FVU taken
•Informed consent,detailed clinical history
HIV positive
(n=70)

20. Conclusions of the study
 Chlamydia trachomatis (21%) and Ureaplasma
urealyticum (13%) were the most frequently
associated with NGU.
 M. genitalium was detected in 6%
 HIV positive individuals -7.1%,
 HIV negative individuals -3.3% (P>0.05)
 Not significantly associated with NGU in either
HIV positive or HIV negative men.

21. Role of Mycoplasma genitalium in Infertility and
Cervicitis in north Indian Women- A pilot Study
Indian J Sex Transm Dis. 2015 Jul-Dec;36(2):144-8. doi:
Sethi S¹,Rajkumari N , Dhaliwal LK², Gupta N³,Yadav R¹,
Banga SS¹, Sharma M¹
¹Department of Medical Microbiology, ²Obstetrics and
Gynaecology, ³Cytology and Gynaecology Pathology,
PGIMER, Chandigarh

22. M.genitalium PCR(Biopsy)
281bp
7654321
1 2 3 4 5
In House
SORPOline M. genitalium
End-point PCR Kit,
Germany

23. M.genitalium PCR (Endocervical Swab)
In house Kit
281bp
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8

24. Conclusions of the study
• Significantly association of M.genitalium with
Infertility and cervicitis
– Infertility -15%(PI-8%, SI-7 %)
– Cervicitis – 6%
• Not much significant findings in HPE(Bx) in
both PI & SI 1.1%, 2.1%)
• However, PAP smear shows significant findings
when correlated(PI-4.3%,SI-8.5%,Cervicitis-
3.2%)

25. Duplex PCR
CT &MG CT &NG

26. Real time Multiplex PCR
C. trachomatis, N. gonorrhoeae and M. genitalium

27. Multiplex real-time PCR compared with three
monoplex real-time PCR assay in cervicitis patients
Organisms % Sensitivity % Specificity PPV NPV
C. trachomatis 100 (20/20) 100 (378/378) 100 (20/20) 100 (378/378)
N. gonorrhoeae 100 (18/18) 100 (380/380) 100 (18/18) 100 (380/380)
M. genitalium 90.91 (63/70) 100 (328/328) 100 (63/70) 97.91 (328/335)

28. Commercial assays available but not
used
Kit Principle
MycoSEQ™
Mycoplasma
Detection Assay
Sequencing
AmpliSens®
Mycoplasma
genitalium FRT
Fluorescence real
time
FTD Urethritits
basic
Taqman Chemistry

29. Challenges for diagnosis in South Asian countries
 Aymptomatic cases- reservoir of organism
 Culture insensitive & extremely slow
 NAAT
 In house Conventional PCRs – MgPa , 16S rRNA
 In house real-time PCR- MgPa, 16S rRNA
 In house multiplex PCRs – CT, MG, NG, UU
 No commericial assay being used –?cost
 Important to validate and quality assure in-house assays
 No rapid POC, no serology commercialized

30. Diagnosis of drug resistant Mycoplasma genitalium in South
Asia
 lack of data on prevalence of macrolide resistance-associated
mutations among the M. genitalium
 Syndromic management for STI control- No diagnostic assay
 Role M. genitalium plays reproductive tract morbidity in
resource-poor settings
 ?what extent M. genitalium strains have acquired
resistance mutations.
 No studies reporting macrolide-associated mutations

31. What is required for M.genitalium in South Asian
countries ?
 Development and validation of a commercial
multiplex assay M. genitalium - key resistance
mutations-
 Automated assays like Genexpert
 Systematic screening HRG- MSM for rectal infection
 Establishment of local and regional surveillance
networks -prevalence of infection and AMR
 Awareness and WHO active participation

32. Summary
 M. genitalium- emerging sexually transmitted infections
 Established cause of non gonococcal uretheritis (NGU)-Men
 Association with mucopurulent cervicitis, infertility quite
convincing
 No screening programmes -Largely underdiagnosed infection
in South Asia
 Lack of awareness among clinicians
 Need of laboratories to perform Quality assured In house
NAAT
 No data on drug resistance – emerging

34. Acknowledgements
 Dr.J.S Jensen, Staten serum Institute,
Denmark
 Margaretha jurstrand, orebro university
hospital, orebro, Sweden

35. 38th National Conference of IASSTD
&AIDSThank YOU