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gonorrhea&#44; and syphilis has continued to rise&#46; In 2019&#44; the incidence of these 3 diseases was 44&#46;18&#44; 28&#46;88&#44; and 13&#46;29 per 100<span class="elsevierStyleHsp" style=""></span>000 persons&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> The incidence rates of gonorrhea and syphilis are higher in men than in women&#46; Those of chlamydia&#44; on the other hand&#44; are higher in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The last few years have been characterized by the pandemic caused by the respiratory virus SARS-CoV-2&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> the incidence of which has varied from month to month&#46; During those months when the incidence was high&#44; the Spanish government was obliged to declare a state of alarm with social restriction measures to control the spread of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Given that these measures were intended to reduce contact between persons who did not live together&#44; with the subsequent reduction in activities associated with nightlife&#44; we considered whether social restriction measures were also effective for reducing the frequency of the main bacterial venereal diseases and evaluated progress over the last 2 years&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">We aimed to study the incidence of bacterial STIs &#40;chlamydia&#44; gonorrhea&#44; and syphilis&#41; and the characteristics of patients diagnosed with these venereal diseases between January 2020 and December 2021 &#40;pandemic&#41; and to compare our findings with those recorded between January 2018 and December 2019 &#40;prepandemic&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We also studied the effect of the number of positive cases of SARS-CoV-2 infection on the number of positive cases of STI during the pandemic&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Using the database of the microbiology department&#44; we collected samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed by means of multiplex polymerase chain reaction &#40;PCR&#41; between January 2018 and December 2021 from throughout our health department&#46; We also collected SARS-CoV-2 samples from the microbiology department for patients from our health district&#44; independently of the patient&#39;s clinical condition&#44; between January 2020 and December 2021&#44; again using the database of the microbiology department&#46; The incidence of STI was calculated by counting the number of positive STI samples from patients in our health district and dividing the result by the catchment population&#46; The rate of positive results was determined by dividing the number of positive samples by the number of samples analyzed&#46; We recorded the age and sex of patients with positive STI samples from the different years of the study and analyzed the data using SPSS &#40;IBM Corp&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We found 692 cases of chlamydia&#44; 441 cases of gonorrhea&#44; and 101 cases of syphilis between January 2018 and December 2021&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The incidence rates of the 3 STIs were calculated for the years assessed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We observed a decrease in the incidence of chlamydia&#44; gonorrhea&#44; and syphilis in 2020 compared with 2019 &#40;7&#46;76 &#91;95&#37; CI&#44; 2&#46;9&#8211;14&#46;93&#93;&#44; 1&#46;11 &#91;95&#37; CI&#44; 0&#46;02&#8211;5&#46;57&#93;&#44; and 2&#46;29 &#91;95&#37; CI&#44; 0&#46;24&#8211;7&#46;22&#93; cases per 100<span class="elsevierStyleHsp" style=""></span>000 persons&#44; respectively&#41;&#46; In contrast&#44; in the year 2021&#44; the incidence rates for chlamydia and gonorrhea were the highest reported in recent years&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The number of samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed during 2018&#8211;2019 &#40;prepandemic&#41; were 4050&#44; 3406&#44; and 245&#44; with positive results detected for 331&#44; 188&#44; and 51&#44; respectively&#46; In comparison&#44; the number of samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed in 2020&#8211;2021 &#40;pandemic&#41; was 4741&#44; 4676&#44; and 272&#44; with positive results in 361&#44; 253&#44; and 50&#44; respectively&#46; These data were used to calculate the rate of positive results&#59; the findings were similar for all 3 infections during the years of the pandemic and previous years&#44; namely&#44; 8&#46;17&#37;&#44; 5&#46;51&#37;&#44; and 20&#46;81&#37; in 2018&#8211;2019 and 7&#46;61&#37;&#44; 5&#46;41&#37;&#44; and 18&#46;38&#37; in 2020&#8211;2021&#44; with no statistically significant differences&#46; We obtained more positive samples of chlamydia and gonorrhea during the years of the pandemic than previously and found similar figures for syphilis in both periods &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; with a total increase of 94 positive samples corresponding to an increase in the incidence rate of 26&#46;03 cases per 100<span class="elsevierStyleHsp" style=""></span>000 persons between 2018&#8211;2019 and 2020&#8211;2021&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cases of the 3 STIs from 2020&#8211;2021 were studied chronologically &#40;month by month&#41;&#46; The 3 diseases progressed in parallel during this period&#44; with increases and decreases in chlamydia&#44; gonorrhea&#44; and syphilis at the same time points&#46; We also analyzed PCR-positive SARS-CoV-2 samples from patients in our health district during January 2020 and December 2021&#46; The chronological &#40;monthly&#41; data of the positive SARS-CoV-2 and STI samples were compared&#46; The curves generated progressed in opposite directions&#44; with increases in the number of positive SARS-CoV-2 samples occurring in parallel to marked decreases in the number of positive STI samples and&#44; similarly&#44; sharp decreases in the number of positive SARS-CoV-2 samples coinciding with rapid increases in the number of positive STI samples&#44; with figures approaching those of the prepandemic period &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We observed no differences in the age of patients diagnosed with STIs during the pandemic compared with the previous years&#46; The mean age at diagnosis of chlamydia&#44; gonorrhea&#44; and syphilis throughout the study period was 29&#46;64 &#40;95&#37; CI&#44; 19&#46;33&#8211;41&#46;14&#41;&#44; 30&#46;86 &#40;95&#37; CI&#44; 20&#46;24&#8211;42&#46;45&#41;&#44; and 37&#46;04 &#40;95&#37; CI&#44; 26&#46;01&#8211;51&#46;00&#41; years&#44; respectively&#46; Significant differences were recorded in the percentage of males diagnosed with chlamydia during the pandemic compared to the prepandemic period &#40;55&#46;55&#37; vs 41&#46;7&#37;&#41;&#44; i&#46;e&#46;&#44; 13&#46;83&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; more diagnoses in males during the pandemic&#46; No further significant differences by sex were recorded for the other STIs &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">We collected a total of 1068 positive STI samples between 2018 and 2021 with the aim of evaluating possible changes in the behavior of these infections during the SARS-CoV-2 pandemic&#46; We observed a decrease in the number of positive STI samples during 2020 compared with 2019&#46; This decrease runs against the continuous upward trend for cases of STI that has been observed since the start of the 21st century&#46; The decrease in cases of STI in 2020 could be due to the effect of the social restriction measures implemented to control the spread of SARS-CoV-2&#44; together with the fear of infection by the virus among the public&#46; During the first stages of the pandemic&#44; the normal functioning of our STI clinic was affected&#44; with a decrease in the number of regular appointments and in the number of urgent appointments&#46; The reduced frequency of face-to-face visits led to fewer analyses being performed for the diagnosis of venereal disease&#46; These behaviors were reversed when the social restriction measures were relaxed&#44; with an increase in the number of regular visits and urgent appointments for a suspected STI&#46; These data agree with those reported in other studies&#44; which show a decrease in cases of STI during the months when the incidence of SARS-CoV-2 infection was high&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In order to analyze whether a greater or lesser number of tests for diagnosis of STI were performed and thus interpret our results&#44; we recorded the rates of positive results during and before the pandemic&#46; Positive results stabilized over the 4-year study period&#44; with even lower values in 2020&#8211;2021&#44; although no significant differences were recorded&#46; This finding would contradict the possibility of having analyzed a lower number of STI samples owing to a reduction in the number of visits because of the SARS-CoV-2 pandemic&#44; since in that case&#44; the positive results rate would have been higher during the years of the pandemic&#46; Similarly&#44; by observing the absolute number of samples analyzed for the different venereal diseases during both periods&#44; we can see that a greater number of STI samples were analyzed in 2020&#8211;2021 than in 2018&#8211;2019&#46; These results enable us to compare the incidence rates for both periods&#44; assuming the absence of bias owing to the epidemiological situation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">One notable finding of our study was that after analyzing the positive STI samples from before and during the pandemic&#44; we observe higher figures both for the absolute number of positive samples and for incidence rates during the pandemic &#40;2020&#8211;2021&#41; than before the pandemic &#40;2018&#8211;2019&#41;&#46; Consequently&#44; despite the decrease in venereal diseases in 2020&#44; the year 2021 saw an increase in STIs&#44; with higher figures than in previous years and a return to the upward trend we observed before the pandemic&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The analysis of STI data chronologically and comparison with data for positive SARS-CoV-2 samples during the pandemic in patients from our health district yielded 2 graphs illustrating contrasting behavior&#58; STIs decreased considerably during the first wave of SARS-CoV-2 in March 2020 and&#44; as the number of cases of SARS-CoV-2 decreased&#44; the number of cases of STI increased sharply&#46; This behavior was cyclic throughout 2020 and in 2021&#44; albeit with gradually less marked decreases in the number of STIs&#46; The number of positive STI samples at the end of 2021 returned to values similar to those recorded before the pandemic&#46; Therefore&#44; we observed a pronounced effect of the number of positive SARS-CoV-2 cases on the appearance of positive STI cases during the pandemic&#46; This effect gradually diminished as the pandemic continued over time&#46; Our data are very similar to those reported elsewhere&#44; that is&#44; sudden decreases in cases of venereal diseases during the months when the incidence of SARS-CoV-2 was highest&#44; with sharp increases also during the months when incidence was lower and even&#44; as we observed&#44; exceeding figures recorded before the beginning of the pandemic&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Chlamydia inflection is more prevalent in women throughout the world&#44; as seen in our results from before the pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In contrast&#44; we found a significant 13&#46;83&#37; more cases of chlamydia infection among men during the pandemic than before&#46; Values for the other STIs did not differ by sex&#46; We have not seen this finding reported in other&#44; similar studies&#46; We are unable to account for this epidemiological change&#44; although it could be due in part to a reduction in scheduled visits to the gynecologist and a decrease in STI screening tests in women owing to the pandemic&#44; more frequent symptoms of chlamydial urethritis in men&#44; and possible coinfection in men&#46; However&#44; the similarity in the rates of positive results for chlamydia infection before and during the pandemic would contradict part of this theory&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Social restriction measures and fear of contracting SARS-CoV-2 infection led to an initial decrease in the frequency of STIs&#44; with a clearly negative correlation between positive cases of SARS-CoV-2 infection and positive cases of STI&#46; However&#44; this change in the behavior of venereal diseases did not persist during subsequent months&#44; and the year 2021 finished with the highest STI figures recorded to date&#46; Similarly&#44; we found an increase in cases of chlamydia infection among men during the pandemic compared with before the pandemic&#46; However&#44; we are unable to account for this difference&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Therefore&#44; STIs are currently one of the main health problems in young persons and adults&#46; Prevention and information campaigns should be implemented&#44; as should measures to raise awareness&#44; once the alarm generated by SARS-CoV-2 has subsided&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Material y m&#233;todos"
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    "fechaRecibido" => "2022-04-10"
    "fechaAceptado" => "2022-07-08"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Sexually transmitted infections"
            1 => "Chlamydia"
            2 => "Gonorrhea"
            3 => "Syphilis"
            4 => "SARS-CoV-2"
          ]
        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Infecciones de transmisi&#243;n sexual"
            1 => "Clamidia"
            2 => "Gonorrea"
            3 => "S&#237;filis"
            4 => "SARS-CoV-2"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 pandemic brought about social changes in 2020 and 2021&#46; The aim of this study was to evaluate the epidemiologic profiles of the main sexually transmitted infections &#40;STIs&#41; of bacterial origin &#40;chlamydia&#44; gonorrhea&#44; and syphilis&#41; diagnosed during this period and compare them to findings from previous years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Drawing on data from Hospital General Universitario in Valencia&#44; Spain&#44; we recorded the number of chlamydia&#44; gonorrhea&#44; and syphilis cases diagnosed monthly by multiplex polymerase chain reaction &#40;PCR&#41; in 2018&#8211;2021 and the number of PCR-confirmed SARS-CoV-2 cases diagnosed monthly in 2020&#8211;2021&#46; We also collected clinical and demographic information on all patients diagnosed with STIs during the years studied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The total number of STIs diagnosed increased from 570 in 2018&#8211;2019 to 664 in 2020&#8211;2021&#46; PCR positivity rates were similar in the 2 periods&#44; but the incidence rates were higher during the pandemic&#46; The chronologic correlation between SARS-CoV-2 and STI positivity was negative&#46; Mean age at diagnosis was 29&#46;64 years &#40;95&#37; CI&#44; 19&#46;33&#8211;41&#46;14 years&#41; for chlamydia&#44; 30&#46;86 years &#40;95&#37; CI&#44; 20&#46;24&#8211;42&#46;45 years&#41; for gonorrhea&#44; and 37&#46;04 years &#40;95&#37; CI&#44; 26&#46;01&#8211;51&#46;00 years&#41; for syphilis&#46; The number of men diagnosed with chlamydia increased by 13&#46;85&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; during the pandemic&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We observed a negative correlation between SARS-CoV2 infections and STIs during the pandemic and an increase in chlamydia cases among men&#46; STI cases rose during 2020&#8211;2021&#44; indicating that they remain a significant problem that needs to be addressed in young and adult populations&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
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          1 => array:2 [
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            "titulo" => "Material and methods"
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Entre 2020-2021 hemos sufrido una pandemia por el virus SARS-CoV-2&#46; Debido a los cambios sociales por la pandemia&#44; nos hemos propuesto estudiar el comportamiento epidemiol&#243;gico de las principales infecciones de transmisi&#243;n sexual &#40;ITS&#41; bacterianas &#40;clamidia&#44; gonorrea y s&#237;filis&#41; durante este periodo y compararlo con periodos previos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se recogieron las muestras mensuales de clamidia&#44; gonorrea y s&#237;filis entre los a&#241;os 2018-2021 y las muestras positivas mensuales de SARS-CoV-2 entre los a&#241;os 2020-2021 del Hospital General Universitario de Valencia&#44; analizadas por t&#233;cnica PCR Multiplex&#46; Se recogieron datos cl&#237;nicos y demogr&#225;ficos de los pacientes con ITS&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante los a&#241;os 2020-2021 &#40;pandemia&#41; se diagnosticaron m&#225;s casos de ITS total &#40;664&#41; que durante los a&#241;os 2018-2019 &#40;prepandemia&#41; &#40;570&#41;&#44; con tasas de incidencia superiores y tasas de positividad similares&#46; Se ha observado una correlaci&#243;n cronol&#243;gica negativa entre las muestras positivas de SARS-CoV-2 y las muestras positivas de ITS&#46; La edad media de los pacientes con diagn&#243;stico de clamidia&#44; gonorrea y s&#237;filis fue de 29&#44;64 &#40;IC 95&#37; 19&#44;33-41&#44;14&#41;&#44; 30&#44;86 &#40;IC 95&#37; 20&#44;24-42&#44;45&#41; y 37&#44;04 &#40;IC 95&#37; 26&#44;01-51&#44;00&#41; a&#241;os&#44; respectivamente&#46; El n&#250;mero de casos de clamidia en varones ha aumentado 13&#44;85&#37; &#40;IC 95&#37; 6&#44;39-21&#44;08&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#41; en los a&#241;os de pandemia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Durante los a&#241;os de pandemia ha existido una correlaci&#243;n negativa entre los casos de SARS-CoV-2 y los casos de ITS&#44; con m&#225;s casos de clamidia en varones&#46; Las ITS han aumentado en los dos &#250;ltimos a&#241;os&#44; por lo que son un importante problema de salud en la poblaci&#243;n joven y adulta que merece especial atenci&#243;n&#46;</p></span>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Number of positive COVID-19 samples &#40;blue line&#41; and number of positive STI samples &#40;orange line&#41; by month during 2020&#8211;2021&#46; STI indicates sexually transmitted infection&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differences in the percentage of men and women for the 3 STIs both before and during the pandemic&#46; A significant difference of 13&#46;83&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; more diagnoses of chlamydia infection among men was observed during the pandemic&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive samples&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Samples analyzed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive results&#44; &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chlamydia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">331&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">245&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">570&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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Original Article
Epidemiologic Profile of the Main Bacterial Sexually Transmitted Infections During the SARS-CoV-2 Pandemic
Comportamiento de las principales infecciones de transmisión sexual bacterianas durante la pandemia por SARS-CoV-2
A. Casanova-Esquembrea,
Corresponding author
avonasac.94@hotmail.com

Corresponding author.
, B. Fuster Escriváb, J. Lorca Spröhnlea, C. Labrandero-Hoyosa, R. Peñuelas-Leala, C. Gimeno Cardonab, A. Pérez-Ferriolsa, P. Hernández-Bela
a Servicio de Dermatología, Hospital General Universitario de Valencia, Spain
b Servicio de Microbiología, Hospital General Universitario de Valencia, Spain
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence per 100<span class="elsevierStyleHsp" style=""></span>000 persons of the 3 sexually transmitted infections during 2018&#8211;2021&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sexually transmitted infections &#40;STIs&#41; comprise a heterogeneous group of infections that are transmitted from person to person through sexual contact &#40;vaginal&#44; anal&#44; oral&#41; and through nonsexual contact&#44; for example&#44; blood transfusions or contamination with body fluids&#46; The most prevalent bacterial infections are chlamydia&#44; gonorrhea&#44; and syphilis&#44; all of which are notifiable diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The latest epidemiological surveillance data on STIs in Spain&#44; published in 2019&#44; show that since the year 2001&#44; the incidence of chlamydia&#44; gonorrhea&#44; and syphilis has continued to rise&#46; In 2019&#44; the incidence of these 3 diseases was 44&#46;18&#44; 28&#46;88&#44; and 13&#46;29 per 100<span class="elsevierStyleHsp" style=""></span>000 persons&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> The incidence rates of gonorrhea and syphilis are higher in men than in women&#46; Those of chlamydia&#44; on the other hand&#44; are higher in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The last few years have been characterized by the pandemic caused by the respiratory virus SARS-CoV-2&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> the incidence of which has varied from month to month&#46; During those months when the incidence was high&#44; the Spanish government was obliged to declare a state of alarm with social restriction measures to control the spread of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Given that these measures were intended to reduce contact between persons who did not live together&#44; with the subsequent reduction in activities associated with nightlife&#44; we considered whether social restriction measures were also effective for reducing the frequency of the main bacterial venereal diseases and evaluated progress over the last 2 years&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">We aimed to study the incidence of bacterial STIs &#40;chlamydia&#44; gonorrhea&#44; and syphilis&#41; and the characteristics of patients diagnosed with these venereal diseases between January 2020 and December 2021 &#40;pandemic&#41; and to compare our findings with those recorded between January 2018 and December 2019 &#40;prepandemic&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We also studied the effect of the number of positive cases of SARS-CoV-2 infection on the number of positive cases of STI during the pandemic&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Using the database of the microbiology department&#44; we collected samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed by means of multiplex polymerase chain reaction &#40;PCR&#41; between January 2018 and December 2021 from throughout our health department&#46; We also collected SARS-CoV-2 samples from the microbiology department for patients from our health district&#44; independently of the patient&#39;s clinical condition&#44; between January 2020 and December 2021&#44; again using the database of the microbiology department&#46; The incidence of STI was calculated by counting the number of positive STI samples from patients in our health district and dividing the result by the catchment population&#46; The rate of positive results was determined by dividing the number of positive samples by the number of samples analyzed&#46; We recorded the age and sex of patients with positive STI samples from the different years of the study and analyzed the data using SPSS &#40;IBM Corp&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">We found 692 cases of chlamydia&#44; 441 cases of gonorrhea&#44; and 101 cases of syphilis between January 2018 and December 2021&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The incidence rates of the 3 STIs were calculated for the years assessed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We observed a decrease in the incidence of chlamydia&#44; gonorrhea&#44; and syphilis in 2020 compared with 2019 &#40;7&#46;76 &#91;95&#37; CI&#44; 2&#46;9&#8211;14&#46;93&#93;&#44; 1&#46;11 &#91;95&#37; CI&#44; 0&#46;02&#8211;5&#46;57&#93;&#44; and 2&#46;29 &#91;95&#37; CI&#44; 0&#46;24&#8211;7&#46;22&#93; cases per 100<span class="elsevierStyleHsp" style=""></span>000 persons&#44; respectively&#41;&#46; In contrast&#44; in the year 2021&#44; the incidence rates for chlamydia and gonorrhea were the highest reported in recent years&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The number of samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed during 2018&#8211;2019 &#40;prepandemic&#41; were 4050&#44; 3406&#44; and 245&#44; with positive results detected for 331&#44; 188&#44; and 51&#44; respectively&#46; In comparison&#44; the number of samples of chlamydia&#44; gonorrhea&#44; and syphilis analyzed in 2020&#8211;2021 &#40;pandemic&#41; was 4741&#44; 4676&#44; and 272&#44; with positive results in 361&#44; 253&#44; and 50&#44; respectively&#46; These data were used to calculate the rate of positive results&#59; the findings were similar for all 3 infections during the years of the pandemic and previous years&#44; namely&#44; 8&#46;17&#37;&#44; 5&#46;51&#37;&#44; and 20&#46;81&#37; in 2018&#8211;2019 and 7&#46;61&#37;&#44; 5&#46;41&#37;&#44; and 18&#46;38&#37; in 2020&#8211;2021&#44; with no statistically significant differences&#46; We obtained more positive samples of chlamydia and gonorrhea during the years of the pandemic than previously and found similar figures for syphilis in both periods &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; with a total increase of 94 positive samples corresponding to an increase in the incidence rate of 26&#46;03 cases per 100<span class="elsevierStyleHsp" style=""></span>000 persons between 2018&#8211;2019 and 2020&#8211;2021&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cases of the 3 STIs from 2020&#8211;2021 were studied chronologically &#40;month by month&#41;&#46; The 3 diseases progressed in parallel during this period&#44; with increases and decreases in chlamydia&#44; gonorrhea&#44; and syphilis at the same time points&#46; We also analyzed PCR-positive SARS-CoV-2 samples from patients in our health district during January 2020 and December 2021&#46; The chronological &#40;monthly&#41; data of the positive SARS-CoV-2 and STI samples were compared&#46; The curves generated progressed in opposite directions&#44; with increases in the number of positive SARS-CoV-2 samples occurring in parallel to marked decreases in the number of positive STI samples and&#44; similarly&#44; sharp decreases in the number of positive SARS-CoV-2 samples coinciding with rapid increases in the number of positive STI samples&#44; with figures approaching those of the prepandemic period &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">We observed no differences in the age of patients diagnosed with STIs during the pandemic compared with the previous years&#46; The mean age at diagnosis of chlamydia&#44; gonorrhea&#44; and syphilis throughout the study period was 29&#46;64 &#40;95&#37; CI&#44; 19&#46;33&#8211;41&#46;14&#41;&#44; 30&#46;86 &#40;95&#37; CI&#44; 20&#46;24&#8211;42&#46;45&#41;&#44; and 37&#46;04 &#40;95&#37; CI&#44; 26&#46;01&#8211;51&#46;00&#41; years&#44; respectively&#46; Significant differences were recorded in the percentage of males diagnosed with chlamydia during the pandemic compared to the prepandemic period &#40;55&#46;55&#37; vs 41&#46;7&#37;&#41;&#44; i&#46;e&#46;&#44; 13&#46;83&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; more diagnoses in males during the pandemic&#46; No further significant differences by sex were recorded for the other STIs &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">We collected a total of 1068 positive STI samples between 2018 and 2021 with the aim of evaluating possible changes in the behavior of these infections during the SARS-CoV-2 pandemic&#46; We observed a decrease in the number of positive STI samples during 2020 compared with 2019&#46; This decrease runs against the continuous upward trend for cases of STI that has been observed since the start of the 21st century&#46; The decrease in cases of STI in 2020 could be due to the effect of the social restriction measures implemented to control the spread of SARS-CoV-2&#44; together with the fear of infection by the virus among the public&#46; During the first stages of the pandemic&#44; the normal functioning of our STI clinic was affected&#44; with a decrease in the number of regular appointments and in the number of urgent appointments&#46; The reduced frequency of face-to-face visits led to fewer analyses being performed for the diagnosis of venereal disease&#46; These behaviors were reversed when the social restriction measures were relaxed&#44; with an increase in the number of regular visits and urgent appointments for a suspected STI&#46; These data agree with those reported in other studies&#44; which show a decrease in cases of STI during the months when the incidence of SARS-CoV-2 infection was high&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In order to analyze whether a greater or lesser number of tests for diagnosis of STI were performed and thus interpret our results&#44; we recorded the rates of positive results during and before the pandemic&#46; Positive results stabilized over the 4-year study period&#44; with even lower values in 2020&#8211;2021&#44; although no significant differences were recorded&#46; This finding would contradict the possibility of having analyzed a lower number of STI samples owing to a reduction in the number of visits because of the SARS-CoV-2 pandemic&#44; since in that case&#44; the positive results rate would have been higher during the years of the pandemic&#46; Similarly&#44; by observing the absolute number of samples analyzed for the different venereal diseases during both periods&#44; we can see that a greater number of STI samples were analyzed in 2020&#8211;2021 than in 2018&#8211;2019&#46; These results enable us to compare the incidence rates for both periods&#44; assuming the absence of bias owing to the epidemiological situation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">One notable finding of our study was that after analyzing the positive STI samples from before and during the pandemic&#44; we observe higher figures both for the absolute number of positive samples and for incidence rates during the pandemic &#40;2020&#8211;2021&#41; than before the pandemic &#40;2018&#8211;2019&#41;&#46; Consequently&#44; despite the decrease in venereal diseases in 2020&#44; the year 2021 saw an increase in STIs&#44; with higher figures than in previous years and a return to the upward trend we observed before the pandemic&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The analysis of STI data chronologically and comparison with data for positive SARS-CoV-2 samples during the pandemic in patients from our health district yielded 2 graphs illustrating contrasting behavior&#58; STIs decreased considerably during the first wave of SARS-CoV-2 in March 2020 and&#44; as the number of cases of SARS-CoV-2 decreased&#44; the number of cases of STI increased sharply&#46; This behavior was cyclic throughout 2020 and in 2021&#44; albeit with gradually less marked decreases in the number of STIs&#46; The number of positive STI samples at the end of 2021 returned to values similar to those recorded before the pandemic&#46; Therefore&#44; we observed a pronounced effect of the number of positive SARS-CoV-2 cases on the appearance of positive STI cases during the pandemic&#46; This effect gradually diminished as the pandemic continued over time&#46; Our data are very similar to those reported elsewhere&#44; that is&#44; sudden decreases in cases of venereal diseases during the months when the incidence of SARS-CoV-2 was highest&#44; with sharp increases also during the months when incidence was lower and even&#44; as we observed&#44; exceeding figures recorded before the beginning of the pandemic&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Chlamydia inflection is more prevalent in women throughout the world&#44; as seen in our results from before the pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> In contrast&#44; we found a significant 13&#46;83&#37; more cases of chlamydia infection among men during the pandemic than before&#46; Values for the other STIs did not differ by sex&#46; We have not seen this finding reported in other&#44; similar studies&#46; We are unable to account for this epidemiological change&#44; although it could be due in part to a reduction in scheduled visits to the gynecologist and a decrease in STI screening tests in women owing to the pandemic&#44; more frequent symptoms of chlamydial urethritis in men&#44; and possible coinfection in men&#46; However&#44; the similarity in the rates of positive results for chlamydia infection before and during the pandemic would contradict part of this theory&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Social restriction measures and fear of contracting SARS-CoV-2 infection led to an initial decrease in the frequency of STIs&#44; with a clearly negative correlation between positive cases of SARS-CoV-2 infection and positive cases of STI&#46; However&#44; this change in the behavior of venereal diseases did not persist during subsequent months&#44; and the year 2021 finished with the highest STI figures recorded to date&#46; Similarly&#44; we found an increase in cases of chlamydia infection among men during the pandemic compared with before the pandemic&#46; However&#44; we are unable to account for this difference&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Therefore&#44; STIs are currently one of the main health problems in young persons and adults&#46; Prevention and information campaigns should be implemented&#44; as should measures to raise awareness&#44; once the alarm generated by SARS-CoV-2 has subsided&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 pandemic brought about social changes in 2020 and 2021&#46; The aim of this study was to evaluate the epidemiologic profiles of the main sexually transmitted infections &#40;STIs&#41; of bacterial origin &#40;chlamydia&#44; gonorrhea&#44; and syphilis&#41; diagnosed during this period and compare them to findings from previous years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Drawing on data from Hospital General Universitario in Valencia&#44; Spain&#44; we recorded the number of chlamydia&#44; gonorrhea&#44; and syphilis cases diagnosed monthly by multiplex polymerase chain reaction &#40;PCR&#41; in 2018&#8211;2021 and the number of PCR-confirmed SARS-CoV-2 cases diagnosed monthly in 2020&#8211;2021&#46; We also collected clinical and demographic information on all patients diagnosed with STIs during the years studied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The total number of STIs diagnosed increased from 570 in 2018&#8211;2019 to 664 in 2020&#8211;2021&#46; PCR positivity rates were similar in the 2 periods&#44; but the incidence rates were higher during the pandemic&#46; The chronologic correlation between SARS-CoV-2 and STI positivity was negative&#46; Mean age at diagnosis was 29&#46;64 years &#40;95&#37; CI&#44; 19&#46;33&#8211;41&#46;14 years&#41; for chlamydia&#44; 30&#46;86 years &#40;95&#37; CI&#44; 20&#46;24&#8211;42&#46;45 years&#41; for gonorrhea&#44; and 37&#46;04 years &#40;95&#37; CI&#44; 26&#46;01&#8211;51&#46;00 years&#41; for syphilis&#46; The number of men diagnosed with chlamydia increased by 13&#46;85&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; during the pandemic&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We observed a negative correlation between SARS-CoV2 infections and STIs during the pandemic and an increase in chlamydia cases among men&#46; STI cases rose during 2020&#8211;2021&#44; indicating that they remain a significant problem that needs to be addressed in young and adult populations&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Entre 2020-2021 hemos sufrido una pandemia por el virus SARS-CoV-2&#46; Debido a los cambios sociales por la pandemia&#44; nos hemos propuesto estudiar el comportamiento epidemiol&#243;gico de las principales infecciones de transmisi&#243;n sexual &#40;ITS&#41; bacterianas &#40;clamidia&#44; gonorrea y s&#237;filis&#41; durante este periodo y compararlo con periodos previos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se recogieron las muestras mensuales de clamidia&#44; gonorrea y s&#237;filis entre los a&#241;os 2018-2021 y las muestras positivas mensuales de SARS-CoV-2 entre los a&#241;os 2020-2021 del Hospital General Universitario de Valencia&#44; analizadas por t&#233;cnica PCR Multiplex&#46; Se recogieron datos cl&#237;nicos y demogr&#225;ficos de los pacientes con ITS&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante los a&#241;os 2020-2021 &#40;pandemia&#41; se diagnosticaron m&#225;s casos de ITS total &#40;664&#41; que durante los a&#241;os 2018-2019 &#40;prepandemia&#41; &#40;570&#41;&#44; con tasas de incidencia superiores y tasas de positividad similares&#46; Se ha observado una correlaci&#243;n cronol&#243;gica negativa entre las muestras positivas de SARS-CoV-2 y las muestras positivas de ITS&#46; La edad media de los pacientes con diagn&#243;stico de clamidia&#44; gonorrea y s&#237;filis fue de 29&#44;64 &#40;IC 95&#37; 19&#44;33-41&#44;14&#41;&#44; 30&#44;86 &#40;IC 95&#37; 20&#44;24-42&#44;45&#41; y 37&#44;04 &#40;IC 95&#37; 26&#44;01-51&#44;00&#41; a&#241;os&#44; respectivamente&#46; El n&#250;mero de casos de clamidia en varones ha aumentado 13&#44;85&#37; &#40;IC 95&#37; 6&#44;39-21&#44;08&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0003&#41; en los a&#241;os de pandemia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Durante los a&#241;os de pandemia ha existido una correlaci&#243;n negativa entre los casos de SARS-CoV-2 y los casos de ITS&#44; con m&#225;s casos de clamidia en varones&#46; Las ITS han aumentado en los dos &#250;ltimos a&#241;os&#44; por lo que son un importante problema de salud en la poblaci&#243;n joven y adulta que merece especial atenci&#243;n&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence per 100<span class="elsevierStyleHsp" style=""></span>000 persons of the 3 sexually transmitted infections during 2018&#8211;2021&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Number of positive COVID-19 samples &#40;blue line&#41; and number of positive STI samples &#40;orange line&#41; by month during 2020&#8211;2021&#46; STI indicates sexually transmitted infection&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differences in the percentage of men and women for the 3 STIs both before and during the pandemic&#46; A significant difference of 13&#46;83&#37; &#40;95&#37; CI&#44; 6&#46;39&#8211;21&#46;08&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0003&#41; more diagnoses of chlamydia infection among men was observed during the pandemic&#46;</p>"
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                  \t\t\t\t">331&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gonorrhea&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">188&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3406&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">245&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#46;81&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7701&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Number of Positive Samples&#44; Samples Analyzed&#44; and Positive Result Rates for the 3 Sexually Transmitted Infection Before and During the Pandemic&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Factores de riesgo para infecciones de trasmisi&#243;n sexual en adolescentes de un colegio de educaci&#243;n secundaria"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46;F&#46; Cifuentes-Z&#250;&#241;iga"
                            1 => "G&#46;A&#46; Gaete-Villegas"
                            2 => "I&#46;A&#46; Morales-Ojeda"
                            3 => "C&#46;M&#46; Sp&#250;lveda Saldias"
                            4 => "D&#46;A&#46; Parada Jim&#233;nez"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Horiz Med"
                        "fecha" => "2020"
                        "volumen" => "21"
                        "paginaInicial" => "e1125"
                      ]
                    ]
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              "identificador" => "bib0085"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                          "autores" => array:1 [
                            0 => "World Health Organization &#91;Internet&#93;"
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                        "fecha" => "2021"
                        "editorial" => "WHO"
                        "editorialLocalizacion" => "Geneva"
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              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "El resurgir de las infecciones de transmisi&#243;n sexual&#46; &#191;Una nueva epidemia en nuestra sociedad&#63;"
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                        0 => array:2 [
                          "etal" => false
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Actas Dermosifiliogr&#46;"
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                        "volumen" => "107"
                        "paginaInicial" => "175"
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                0 => array:2 [
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ISSN: 00017310
Original language: English
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