Bacterial vaginosis, vaginal flora patterns and vaginal hygiene practices in patients presenting with vaginal discharge syndrome in The Gambia, West Africa

Edward Demba,Maarten Schim Van Der Loeff,Linda Morison,Akum A Awasana,Robin Bailey,Philippe Mayaud,Beryl West,Euphemia Gooding

doi:10.1186/1471-2334-5-12

Edward Demba, Maarten Schim Van Der Loeff + Show 6 more

Open Access

https://doi.org/10.1186/1471-2334-5-12

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Abstract

BackgroundBacterial vaginosis (BV) – a syndrome characterised by a shift in vaginal flora – appears to be particularly common in sub-Saharan Africa, but little is known of the pattern of vaginal flora associated with BV in Africa. We conducted a study aimed at determining the prevalence of BV and patterns of BV-associated vaginal micro-flora among women with vaginal discharge syndrome (VDS) in The Gambia, West Africa.MethodsWe enrolled 227 women with VDS from a large genito-urinary medicine clinic in Fajara, The Gambia. BV was diagnosed by the Nugent's score and Amsel's clinical criteria. Vaginal swabs were collected for T vaginalis and vaginal flora microscopy, and for Lactobacillus spp, aerobic organisms, Candida spp and BV-associated bacteria (Gardnerella vaginalis, anaerobic bacteria, and Mycoplasma spp) cultures; and cervical swabs were collected for N gonorrhoeae culture and C trachomatis PCR. Sera were tested for HIV-1 and HIV-2 antibodies. Sexual health history including details on sexual hygiene were obtained by standardised questionnaire.ResultsBV prevalence was 47.6% by Nugent's score and 30.8% by Amsel's clinical criteria. Lactobacillus spp were isolated in 37.8% of women, and 70% of the isolates were hydrogen-peroxide (H202)-producing strains. Prevalence of BV-associated bacteria were: G vaginalis 44.4%; Bacteroides 16.7%; Prevotella 15.2%; Peptostretococcus 1.5%; Mobiluncus 0%; other anaerobes 3.1%; and Mycoplasma hominis 21.4%. BV was positively associated with isolation of G vaginalis (odds-ratio [OR] 19.42, 95%CI 7.91 – 47.6) and anaerobes (P = 0.001 [OR] could not be calculated), but not with M hominis. BV was negatively associated with presence of Lactobacillus (OR 0.07, 95%CI 0.03 – 0.15), and H2O2-producing lactobacilli (OR 0.12, 95% CI 0.05 – 0.28). Presence of H2O2-producing lactobacilli was associated with significantly lower prevalence of G vaginalis, anaerobes and C trachomatis. HIV prevalence was 12.8%. Overall, there was no association between BV and HIV, and among micro-organisms associated with BV, only Bacteroides spp. and Prevotella spp. were associated with HIV. BV or vaginal flora patterns were not associated with any of the factors relating to sexual hygiene practices (vaginal douching, menstrual hygiene, female genital cutting).ConclusionIn this population, BV prevalence was higher than in corresponding populations in industrialised countries, but the pattern of vaginal micro-flora associated with BV was similar. BV or vaginal flora patterns were not associated with HIV nor with any of the vaginal hygiene characteristics.

Highlights

Bacterial vaginosis (BV) – a syndrome characterised by a shift in vaginal flora – appears to be common in sub-Saharan Africa, but little is known of the pattern of vaginal flora associated with BV in Africa
The first vaginal swab was used for aerobic and anaerobic cultures; the second swab was used for direct wet mount microscopy, detection of fishy amine odour ("whiff" test) when mixed with 10% potassium hydroxide (KOH) preparation, and vaginal pH determination; the third swab was rolled onto a slide for Gram staining; two cervical swabs were collected for Neisseria gonorrhoeae culture on modified Thayer-Martin media, and for Chlamydia trachomatis polymerase chain reaction (PCR) testing using an in-house method [22]
Sera were screened by the ICEHIV1.O.2 (Murex Diagnostics Ltd, Dartford, UK) and reactive samples were retested by type-specific ELISAs: Wellcozyme HIV recombinant -1 (Murex) for HIV-1, and ICEHIV-2 test (Murex) for HIV-2

Summary

Introduction

Bacterial vaginosis (BV) – a syndrome characterised by a shift in vaginal flora – appears to be common in sub-Saharan Africa, but little is known of the pattern of vaginal flora associated with BV in Africa. BV appears to be common in sub-Saharan Africa where several studies have reported high prevalence rates, ranging from 20–49% among women presenting to STD clinics with vaginal discharge [6,7,8], from 21–52% among pregnant women attending antenatal clinics [9,10,11], and from 37–51% in community-based studies [3,12] These are very much higher than the rates reported from industrialised countries, 13% in GUM clinic attenders in the UK [13], 11% in gynaecology clinic attendees in London [14], and 15% to 30% in studies of non-pregnant women in USA [15]. Behavioural factors such as vaginal douching or menstrual hygiene practices have been suggested as important factors that might influence vaginal flora composition [18], but little data is available from African populations[19,20]

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