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Am J Public Health. 2007 June; 97(6): 1118–1125.
PMCID: PMC1874220

Mycoplasma genitalium Among Young Adults in the United States: An Emerging Sexually Transmitted Infection

Abstract

Objectives. We sought to determine the prevalence of and risk factors associated with Mycoplasma genitalium infection in a nationally representative sample of young adults in the United States.

Methods. Urine specimens from 1714 women and 1218 men who participated in Wave III of the National Longitudinal Study of Adolescent Health (N=14322) were tested for M genitalium. Poststratification sampling weights were used to generate nationally representative estimates.

Results. The prevalence of M genitalium was 1.0% compared with 0.4%, 4.2%, and 2.3% for gonococcal, chlamydial, and trichomonal infections, respectively. No M genitalium–positive individuals reported symptoms of discharge. M genitalium prevalence among those who reported vaginal intercourse was 1.1% compared with 0.05% among those who did not. In multivariate analyses, M genitalium prevalence was 11 times higher among respondents who reported living with a sexual partner, 7 times higher among Blacks, and 4 times higher among those who used condoms during their last vaginal intercourse. Prevalence of M genitalium increased by 10% for each additional sexual partner.

Conclusions. M genitalium was more prevalent than Neisseria gonorrhoeae but less prevalent than Chlamydia trachomatis, and it was strongly associated with sexual activity.

Adolescents and young adults are disproportionately affected by sexually transmitted infections (STIs) and have the highest rates of Chlamydia trachomatis and Neisseria gonorrhoeae infections.1 Urethritis among men and endocervicitis among women are typically attributed to infection with either of these 2 bacterial STIs and sometimes with Trichomonas vaginalis.2,3 Infection with these organisms can lead to serious sequelae, such as chronic pelvic pain, ectopic pregnancy, infertility, and increased risk for HIV transmission.37 In many studies, however, only 30% to 40% of cervicitis cases have been associated with known pathogens,810 and etiology could not be identified in up to 50% of urethritis cases,2 which suggests the existence of other pathogenic organisms. Mycoplasma genitalium, a recently identified bacterium, is receiving increased attention as a potential cause of both these STI syndromes, yet it is still relatively understudied, and no population-level data on prevalence or risk factors exist.

M genitalium was first cultured in the early 1980s from the urethral exudates of 2 men with nongonococcal urethritis.11 Despite this initial isolation, the fastidious nature of M genitalium makes culture extremely difficult, and it was not until the development of DNA amplification assays12,13 that epidemiological studies of the association between M genitalium and disease syndromes could be undertaken. Since that time, all but 114 of the studies that used polymerase chain reaction (PCR) testing to detect M genitalium among men have reported a strong and significant association with non-gonococcal urethritis.1524 The data available from fewer studies of women suggest that M genitalium also is associated with cervicitis,2529 endometritis,30 pelvic inflammatory disease (PID),31 and tubal factor infertility.32

Most studies of M genitalium have been conducted in specialized populations (usually sexually transmitted disease [STD] clinics) and, although these groups are ideal for studying potentially new sexually transmitted organisms, they likely overestimate the prevalence in the general population. Furthermore, the high background level of many risk behaviors among STD clinic patients may mask or diminish the association of such factors with organisms identified in these individuals.33 Finally, most STD clinic attendees are sexually active, which makes it virtually impossible to determine whether, and to what extent, sexual activity is associated with newly identified potential pathogens. Thus, we tested young adults who participated in Wave III of the National Longitudinal Study of Adolescent Health (Add Health) for M genitalium to (1) generate population prevalence estimates of M genitalium among young adults aged 18 to 27 years in the United States, (2) identify sociobehavioral correlates of infection in the general population, and (3) confirm that M genitalium is sexually transmitted.

METHODS

Add Health Study Design and Sample

Add Health was designed to explore causes of health-related behaviors among adolescents in grades 7 through 12 and the associated outcomes in young adulthood, with a focus on social contextual influences on health and risk behaviors.34 This school-based study used a stratified random sample of all US high schools and junior high “feeder” schools to identify participants. In 1994, approximately 90000 adolescents participated in the Wave I school-based survey. Subsequently, an in-home sample was drawn that comprised a core sample from each community plus selected special oversamples; 20748 of those respondents completed a more detailed questionnaire. Wave III of Add Health enrolled participants from July 2001 to April 2002. All Wave I in-home respondents who could be located were visited at home by Add Health Study personnel and received a request for informed consent. Respondents who agreed to participate in the probability sample (N=14322) completed a computer-assisted survey instrument that collected extensive data on demographic, social, and behavioral characteristics. Of those, 13192 (92.1%) respondents provided 15 mL to 20 mL of first-void urine for STI testing.

We selected a subsample of Wave III Add Health respondents that would provide 80% power for detecting prevalence ratios of approximately 2.0. We used quota sampling to randomly flag 7000 women in the Wave III Add Health sampling frame for recruitment to human papillomavirus (HPV) or M genitalium testing (to ensure 3500 sexually active women for HPV testing in separate analyses); 2000 men were randomly flagged for recruitment to M genitalium testing. Urine specimens were immediately placed on cold packs and shipped to the University of North Carolina within 96 hours of collection, where they were placed in 5 mL aliquots and frozen at −70°C until shipment on dry ice to the University of Washington. Some unflagged urine specimens also were received, which resulted in 3725 flagged and 353 unflagged urine specimens from women and 1048 flagged and 239 unflagged urine specimens from men. From the respondents with sampling weights, we selected all men with valid questionnaire information (n=1218) and a random sample of women (n=1714) for M genitalium testing.

Statistical Analyses

We performed a stratified weighted analysis, which took into account Add Health’s cluster sampling design, to generate nationally representative estimates. These cross-sectional analyses incorporated the school as the primary sampling unit, region of the United States as the stratification variable, and poststratification sampling weights. The poststratification sampling weights were specially designed for the M genitalium subsample and accounted for the Add Health master sampling design and overall survey nonresponse as well as the quota-sampling method used to select the M genitalium subsample (including the receipt and testing of unflagged specimens). Respondents without sampling weights (n=171) were excluded. We used a design-based Pearson χ2 test for comparisons of categorical characteristics and an adjusted Wald test for comparisons of continuous characteristics (weighted proportions are presented).

We conducted sensitivity analyses with methods described by Brookmeyer and Gail35 to estimate the effect of imperfect test performance characteristics, differential questionnaire nonresponse, and refusal to provide a urine specimen. Although true sensitivity and specificity of the PCR assay in this population are unknown, sensitivity of women’s urine was 68% and specificity was 99.6% compared with an infected patient standard in a separate population.36 As with other STIs, sensitivity was likely higher in men’s urine compared with women’s urine. The sensitivity analyses were performed under 4 assumptions for sensitivity and specificity (sensitivity and specificity=1.0, sensitivity=0.7 and specificity=0.995, sensitivity=0.85 and specificity=0.995, and sensitivity=0.7 and specificity=0.999) and 3 assumptions for prevalence of M genitalium among nonresponders (missing randomly: prevmiss is half that of responders; prevmiss is twice that of responders). We used weighted multivariate Poisson regression analyses to estimate prevalence ratios and to identify characteristics independently associated with M genitalium infection with Stata software, version 8.0 (Stata Corp, College Station, Tex). Because of the hypothesis-generating nature of these analyses, we did not make adjustments for multiple comparisons.

Laboratory Methods

Upon arrival at the University of Washington, specimens for M genitalium testing were thawed, aliquoted, and refrozen at −80°C. At the time of testing, specimens were thawed and processed using the AMPLICOR® CT/NG specimen preparation kit (Roche Diagnostics Corp, Indianapolis, Ind) in accordance with the manufacturer’s directions. A M genitalium–specific PCR assay with a microwell plate-based detection system was used for specimen testing.37 Initially positive and equivocal specimens were confirmed as positive if repeated duplicate tests resulted in at least 1 positive (n = 36) or 2 equivocal results (n = 0); 17 initially positive specimens (9 of which were equivocal) did not repeat as positive and were scored as negative. Thirty-one (89%) of 35 specimens with optical density values greater than 1.0 were repeatable compared with 5 (26%) of 19 specimens with values less than 1.0, which was consistent either with contamination or with lower genome copies in the latter specimens (7 of these had no sampling weights and were excluded from further analyses). Negative specimens were not retested.

Positive and negative controls for the whole procedure, including sample preparation (M genitalium whole cells and sample preparation reagents alone) and the PCR assay (M genitalium genomic DNA and sterile water), were included in every batch. Separate aliquots were assayed at the University of North Carolina for N gonorrhoeae and C trachomatis with Ligase Chain Reaction (Abbott LCx Probe System, Abbott Park, Ill)38,39 and for T vaginalis with a research-only PCR enzyme-linked immunosorbent assay.40,41 A third aliquot of women’s urine was assayed for HPV at the University of Washington with a PCR/dot-blot hybridization assay.42

RESULTS

Prevalence of M genitalium

M genitalium was detected in 33 of the individuals in our Add Health subsample, which resulted in a weighted prevalence of 1.0% (95% confidence interval [CI]=0.45, 1.46) (Table 1 [triangle]). The prevalence of M genitalium among men (1.1%; 95% CI=0.49, 2.44) and among women (0.8%; 95% CI=0.42, 1.57) was not significantly different (P=.57). Despite some trends, overall there was no significant difference in M genitalium prevalence by age or geographic region, but prevalence varied by race/ethnicity: it was highest among Blacks (4.0%; 95% CI=0.20, 6.63) and was somewhat higher among Latinos (0.8%; 95% CI=0.14, 4.08) compared with Whites (0.4%; 95% CI=0.19, 0.89; P<.001). The organism was not detected in anyone of American Indian or Asian descent.

TABLE 1
Prevalence of Mycoplasma genitalium Among Those Tested (N = 2932): Wave III of the National Longitudinal Study of Adolescent Health, 2003

Demographics, Sexual Behavior, and History Associated With M genitalium

M genitalium prevalence was significantly higher among Blacks compared with Whites (prevalence ratio [PR] = 8.9; 95% CI = 3.34, 23.81). It also was significantly higher among those who had ever lived with a sexual partner (PR = 12.4; 95% CI = 3.57, 42.86; Table 1 [triangle]). Among sexually active individuals (those who reported ever having engaged in vaginal intercourse), M genitalium prevalence was 1.1% compared with 0.05% among those who did not report vaginal intercourse (PR = 22.5; 95% CI = 4.35, 116.59). The few M genitalium–infected persons who did not report vaginal intercourse had either exclusively same-sex partners or provided no data on other types of sexual activity that may have resulted in exposure to M genitalium. Although M genitalium prevalence rose with increased numbers of sexual partners (lifetime and past year), M genitalium–positive respondents reported fewer mean episodes of vaginal intercourse during the past year compared with M genitalium–negative respondents (21.9 vs 69.4; P < .001). M genitalium infection was not significantly associated with age at sexual debut or with correct and consistent condom use (condom use during every episode of vaginal intercourse without any breakage or slippage) within the past 12 months, but it was more often detected among those who had used condoms during their last vaginal intercourse (PR = 4.1; 95% CI = 1.21, 13.50).

Contraception, Concurrent Infection, and Symptoms

M genitalium prevalence was significantly higher among women who used depo provera during the past year (PR=4.5; 95% CI=1.46, 13.65), but prevalence was not associated with use of other hormonal contraceptives in general. Consistent with high-risk sexual activity, M genitalium prevalence was significantly higher among respondents who believed they might currently be infected with N gonorrhoeae or C trachomatis (PR=3.4; 95% CI=1.09, 10.42), among respondents who tested positive for C trachomatis (PR=5.4; 95% CI=1.42, 20.75), and among women infected with HPV (PR=12.7; 95% CI=3.29, 48.78). None of the persons infected with M genitalium reported symptoms of urethral or vaginal discharge either within in the previous 24 hours or during the previous 12 months (including those who were coinfected with other STI pathogens), but 2.2% reported dysuria in the past 24 hours (data not shown). Similarly, none of the M genitalium–positive individuals reported diagnoses of nongonococcal urethritis, mucopurulent cervicitis, or vaginitis during the past 12 months.

Partnership Characteristics

Of the 2932 respondents with sampling weights, 2303 (79.9%) provided data on their most recent sexual partnership (Table 2 [triangle]). M genitalium prevalence was significantly higher among individuals who had a non-White partner (PR = 11.0–62.4) or a partner whose race/ethnicity was different from their own (PR = 8.4; 95% CI = 2.51, 27.86). Compared to the prevalence of M genitalium among the respondents who believed their most recent partner had other concurrent partners, the prevalence of M genitalium among those who believed their partner was faithful was lower (PR = 0.1; 95% CI = 0.03, 0.61). Sexual behaviors such as time between meeting and first vaginal intercourse, frequency of vaginal intercourse, and oral or receptive anal sexual relations were not significantly associated with M genitalium infection.

TABLE 2
Partnership Characteristics for Most Recent Partnership Among Those Tested for Mycoplasma genitalium (n=2303): Wave III of the National Longitudinal Study of Adolescent Health, 2003

Of the 629 individuals who were missing data on partnership characteristics, only 55 (17.5%) reported no vaginal intercourse partners during the previous year. Thus, the majority (82.5%) of individuals who did not answer the detailed questions about romantic and sexual relationships during the previous 6 years reported at least 1 vaginal intercourse partner during the past 12 months. Among those who were missing data on partnership characteristics, M genitalium prevalence was 1.8%, and among those who provided data, prevalence was only 0.7% (PR=2.6; 95% CI=0.79, 8.78).

Sensitivity Analyses

Overall, 23.96% of Add Health participants in the Wave I probability sample did not participate in Wave III. Nonresponse was slightly higher in the Northeast (32%) compared with the West (25%), Midwest (21%), and South (24%), and the poststratification sampling weights adjusted for this differential nonresponse. An additional 7.89% of Wave III respondents refused to provide a urine specimen.43 We performed sensitivity analyses to assess the total effect of nonresponse combined with imperfect sensitivity and specificity of the PCR assay (Table 3 [triangle]). If non-response was random, a modest drop in specificity (specificity = 0.995) would lead to a sizeable reduction in prevalence (corrected PR = 0.6%; 95% CI = 0, 1.07). When specificity was set at 0.99 or higher, prevalence among all subgroups, except Blacks, was 0% (data not shown). If nonresponders had a lower prevalence of M genitalium compared with respondents (prevmiss = 0.5), overall prevalence would be somewhat lower than the 1.0% we observed. However, if M genitalium prevalence was higher among nonresponders (prevmiss = 2.0), prevalence estimates would be higher than what we observed. These general trends held for subgroup analyses by gender and race/ethnicity.

TABLE 3
Sensitivity Analyses Estimating the Potential Effect of Differential Nonresponse and Imperfect Urine Test Performance Characteristics on Prevalence Estimates of Mycoplasma genitalium: Wave III of the National Longitudinal Study of Adolescent Health, 2003 ...

Multivariate Analyses

After adjustment for other factors in the model, the prevalence of M genitalium was 11 times higher among individuals who had ever lived with a sexual partner (PR=11.2; 95% CI=3.17, 39.50) and 7 times higher among Blacks (PR=7.2; 95% CI=2.87, 17.92), and prevalence increased by 10% with each additional vaginal intercourse partner during the past year (PR=1.1 per partner; 95% CI=1.01, 1.18). Despite no association with correct and consistent condom use during the previous 12 months, M genitalium prevalence was 4 times higher among those who reported use of a condom during their last vaginal intercourse compared with those who did not (PR=3.9; 95% CI=1.33, 11.46). Because of the substantial proportion of missing data for partnership characteristics, and because the data were likely not missing at random (≥ 30% among M genitalium–positive persons compared with 20% among the subsample overall), partnership characteristics were not considered in the multivariate analyses.

DISCUSSION

In this first-ever population-based prevalence estimate, M genitalium was detected among 1.0% of young adults aged 18 to 27 years. This figure was substantially higher than the prevalence of N gonorrhoeae (0.4%) but somewhat lower than that of C trachomatis (4.2%)39 and T vaginalis (2.2%).44 Although adjustment for less-than-perfect test performance characteristics in the sensitivity analyses reduced the prevalence estimates among all subgroups except Blacks, the overall prevalence of M genitalium still remained higher than that of N gonorrhoeae. Similar to many other sexually transmitted organisms, prevalence of M genitalium was highest among Blacks, yet unlike other STIs, prevalence was not significantly associated with gender, age, or geographic region. M genitalium infection was strongly associated with having engaged in vaginal intercourse, yet almost all M genitalium infections were asymptomatic. This organism has been presumed to be sexually transmitted,45 a conclusion made on the basis of studies of sexually active individuals that assessed either concordant rates of infection among small numbers of sexual partnerships16,46 or the association of sexual behaviors with M genitalium.18,21,26,47 None of these previous studies incorporated comparison groups of nonsexually active persons to show the absence of infection among such people. By contrast, our general population sample included both sexually experienced and inexperienced individuals, which permitted us to show the significant association of sexual activity with M genitalium detection and further strengthen the case for sexual transmission of this organism.

Although M genitalium infection was not associated with reported symptoms of vaginal or urethral discharge, these symptoms were not associated with detection of N gonorrhoeae or T vaginalis either. By contrast, these symptoms were inversely associated with C trachomatis (data not shown). This suggests that either the majority of reproductive tract infections in the general population are asymptomatic48 or that information on such symptoms was not accurately elicited in this survey. The prevalence of M genitalium detected by urine testing among these asymptomatic young adults (1.0%) was remarkably similar to the prevalence found by Uno et al. among asymptomatic Japanese men (1.1%),49 but it was somewhat lower than the 2.3% identified by Chandeying et al. among asymptomatic young men who were vocational college students in southern Thailand.50

Implications

The evidence for a pathogenic role of M genitalium among men is strong; the evidence for pathogenicity among women is suggestive but inconclusive. Detection of M genitalium in the lower genital tract has been associated with inflammation in the upper genital tract in the form of histologically diagnosed endometritis30 and clinically diagnosed PID.31 The organism also has been detected in the fallopian tube of a woman with laparascopically diagnosed salpingitis.51 Nevertheless, the proportion of lower–reproductive tract M genitalium infections (symptomatic or asymptomatic) that may cause upper tract inflammation and tissue damage remains unknown. Further studies of the natural history and pathogenesis of M genitalium infections among women are required to answer this question. Although several clinical studies have shown a strong association between M genitalium and urethritis among men,1524 no data yet exist on further associations between M genitalium infection of the urethra and complications of urethritis, such as urethral stricture or epididymitis.2 However, even asymptomatic infections are important, because they presumably serve as a reservoir for maintaining transmission within a population. Whether M genitalium–infected persons require or benefit from treatment—and if so, what antimicrobial therapy should be recommended—remains undefined. Open trials suggest that of the 2 antibiotics most commonly prescribed for nongonococcal urethritis or cervicitis—azithromycin and doxycycline—the former may be effective at treating symptomatic M genitalium infections,47,5257 but randomized blinded trials and further experience will be necessary to definitively identify the most appropriate antimicrobial therapy.

Risk factors for M genitalium infection were consistent with risk factors for other STIs. The strong association with ever having lived with a sexual partner was likely driven by the association with sexual activity, but it also suggests that transmission may require repeated exposure to an infected partner, which would be facilitated by the longer-term partnerships that are characteristic of individuals who live together. Similarly, the increased risk for M genitalium with increased number of vaginal sexual partners is likely a marker for greater exposure to the organism. The elevated risk among Blacks may be the result of disassortative mixing with respect to sexual activity class (e.g., persons who have had many lifetime partners mixing with persons who have had few lifetime partners) combined with assortative partner choice with respect to race/ethnicity,58 or it may be the result of higher rates of concurrency that are driven by a perceived shortage of Black men.59,60 At first glance, the increased prevalence of M genitalium among those who used condoms during their most recent vaginal intercourse seems paradoxical, but others have reported increased odds for STIs among condom users.61 This may be explained by social desirability bias, preferential (and possibly incorrect) use of condoms with high-risk partners, or lack of information on temporal sequence or infection status of the partner rather than inherent ineffectiveness of condoms.

Limitations and Conclusions

Factors that were independently associated with M genitalium infection represent characteristics of individuals. The associations between M genitalium and partnership characteristics were unadjusted and should be interpreted with caution. The substantial number of Add Health participants (22%) who did not provide partnership data for their most recent sexual partner despite having reported sexual activity during the previous year, and the higher prevalence of M genitalium among those who were missing data on these factors, suggests that the bivariate analyses of partnership characteristics may be biased. Because the questions were prefaced by the phrase “The next part of the interview is concerned with any romantic relationships and sexual relationships you have had at any time since the summer of 1995,” those who believed short-term sexual encounters were not relationships may have skipped the questions.

A major strength of our study was the large sample size and the representative sampling of young adults in the US population that was afforded by the Add Health study design. However, results should not be extrapolated to individuals outside the sample age range. The true sensitivity and specificity of the M genitalium PCR assay is unknown, so the sensitivity analysis was intended to provide outer limits of the prevalence estimates for a reasonable range of test performance. Although the use of specimens obtained using noninvasive methods, such as urine, allows us to obtain genital tract specimens in household surveys, detection of M genitalium in women’s urine specimens is less sensitive than is detection using swab specimens.36 The sensitivity of the testing may have been further reduced by the freeze-thaw cycles that the specimens underwent before testing. Decreased sensitivity for detecting C trachomatis and N gonorrhoeae in women’s urine specimens compared with swab specimens has been previously reported,62,63 and self-obtained vaginal swabs, which are widely accepted by women in the United States,64,65 may provide more sensitive detection of infection among women.

M genitalium was more prevalent than N gonorrhoeae in this general population sample, and characteristics associated with the infection strongly suggest that the organism is sexually transmitted. M genitalium infections were not associated with symptoms in these healthy young adults.

TABLE 4
Factors Independently Associated With Mycoplasma genitalium Infection Among Men and Women Aged 18 to 27 Years: Wave III of the National Longitudinal Study of Adolescent Health, 2003

Acknowledgments

This study was supported in part by the University of Washington STD Cooperative Research Center, funded by the National Institutes of Health (AI/MH34118), and a University of Washington Royalty Research Foundation grant (2533). L.E. Manhart was partially supported by a training grant from the National Institute of Allergy and Infectious Diseases (NIAID 5T32 A107140).

This research used data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris and was funded by a grant from the National Institute of Child Health and Human Development (P01-HD31921), with cooperative funding from 17 other agencies. Special acknowledgment is given to Ronald R. Rindfuss and Barbara Entwisle for assistance with the original design.

The authors would like to thank the Schmitz Laboratory at University of North Carolina for selecting, aliquoting, and shipping the specimens tested in our analyses.

Human Participant Protection
Study procedures were approved by institutional review boards at the University of North Carolina and the University of Washington.

Notes

Peer Reviewed

Contributors
L.E. Manhart coordinated study activities, completed and synthesized the analyses, and led the writing. K.K. Holmes originated the study and assisted with the writing. P.A. Totten directed the laboratory work and assisted with the writing. J.P. Hughes oversaw the statistical analyses. L.S. Houston performed the M genitalium testing. All authors assisted with originating ideas, interpreting findings, and reviewing drafts of the article.

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