Epidemiology of gonorrhea in countries of the Middle East and North Africa: systematic review, meta analyses, and meta regressions

Abstract

Abstract Background The epidemiology of Neisseria gonorrhoeae (NG) infection in the Middle East and North Africa (MENA) region remains poorly understood, despite the global recognition of its disease burden and the growing concern regarding antimicrobial resistance. This study aimed to systematically review the evidence on NG prevalence in MENA, estimate the pooled mean prevalence across different populations, and explore population-level associations with prevalence as well as sources of between-study heterogeneity. Methods The study conducted a systematic review, risk of bias assessment, meta-analyses, and meta-regressions, utilizing both published and unpublished evidence sourced from international, regional, and national databases, in adherence to PRISMA guidelines. Random-effects meta-analyses and meta-regressions were employed to analyze the data. Results The study identified 341 NG prevalence measures from 21 countries in MENA. The pooled mean prevalence of current urogenital infection was 1.9% (95% confidence interval (CI) 1.1–2.8%) in the general population, with a higher pooled prevalence in studies with sample sizes < 200 (3.1%; 95% CI 1.5–5.0%) compared to those with sample sizes ≥ 200 (1.1%; 95% CI 0.5–1.9%). Among specific populations, the pooled prevalence was 6.5% (95% CI 4.4–9.0%) in female sex workers, 7.5% (95% CI 2.8–14.0%) in attendees of infertility clinics, 3.0% (95% CI 0.4–7.0%) in women with miscarriage or ectopic pregnancy, 3.9% (95% CI 2.7–5.3%) in symptomatic women, and 41.4% (95% CI 34.9–48.1%) in symptomatic men. For male sex workers and men who have sex with men, the pooled prevalence of current urogenital infection was 1.6% (95% CI 0.4–3.4%), while the prevalence of current anorectal infection was 10.4% (95% CI 4.6–18.0%). Through multivariable meta-regressions, 64% of the prevalence variation was explained, revealing a hierarchical pattern in prevalence by population type and sex, and a prevalence decline at a rate of 1% per year. Conclusions NG prevalence in MENA is comparable to the global prevalence, underscoring a neglected and underrecognized disease burden, with social and economic consequences. Persistent transmission of NG among key populations and other populations at risk increases the potential for the emergence of new drug-resistant strains. MENA is far from achieving the World Health Organization’s target of reducing NG incidence by 90% by 2030.