Syndromic Management Protocols Research Articles

Diagnosis of female genital schistosomiasis and other genital infections in young South African women: challenges in the syndromic approach

IntroductionFemale genital schistosomiasis is a common but neglected disease, which results in symptoms similar to sexually transmitted infections in Schistosoma haematobium-endemic areas of Africa and Middle East. In primary healthcare of low-income countries, healthcare professionals use syndromic management protocols for guidance when treating symptoms of genital infection, due to lack of laboratory resources. These protocols do not include treatment for female genital schistosomiasis, despite the overlap of symptoms. Women are at risk of not receiving the appropriate treatment. The aim of this study was to investigate challenges and missed opportunities when using syndromic management protocols for sexually transmitted infections in female genital schistosomiasis-endemic areas.MethodsThis is a secondary analysis of data from a large cross-sectional prevalence study conducted in 2011 in KwaZulu-Natal, South Africa. Young women in schistosomiasis-endemic areas were asked about genital symptoms and underwent laboratory testing and gynecological examinations to look for common genital infections including female genital schistosomiasis. We used the current South African syndromic management protocols as the basis and analyzed the associations between the reported genital symptoms and the differential diagnoses with logistic regression.ResultsBy use of the syndromic approach the conditions gonorrhea, trichomoniasis and herpes could be identified. The symptom “lower abdominal pain” was significantly associated with documented female genital schistosomiasis. However, the same association was not found with gonorrhea or chlamydia. We found no significant association between reported vaginal discharge syndrome and female genital schistosomiasis or between genital ulcer syndrome and female genital schistosomiasis.DiscussionFemale genital schistosomiasis frequently co-exists with, and mimics other genital infections in rural areas of Sub-Saharan Africa. The management protocols in schistosomiasis endemic countries should include advice on how to diagnose and manage this chronic, waterborne genital condition. There is an urgent need to upscale laboratory and diagnostic resources in low-and middle-income countries and specifically schistosomiasis-endemic areas, to diagnose these common genital infections more accurately and to treat affected women accordingly.

Aetiological Pattern of Vulvovaginal Infections in Asymptomatic and Symptomatic HIV Seropositive Women on Antiretroviral Therapy

Introduction: Human Immunodeficiency Virus (HIV) causes severe public health problems. Despite the use of Highly Active Antiretroviral Therapy (HAART), opportunistic infections remain a serious problem in HIV infection. HIV seropositive women are at a higher risk of acquiring Vulvovaginal Infections (VVI), compared to their HIV seronegative counterparts. Also, the large untreated asymptomatic populations remain a source for transmitting agent. Aim: To identify the occurrence of vaginitis in symptomatic and asymptomatic HIV seropositive women. Materials and Methods: HIV seropositive female patients (60 symptomatic and 60 asymptomatic for vulvovaginitis) in the reproductive age group of 18-60 years were screened for their vaginal flora in a tertiary care hospital in East Delhi, India. Wet mount, Gram stain, and culture were performed to screen the samples for vaginitis. Asymptomatic samples were processed to check for asymptomatic VVI. Nugent and Amsel’s score were calculated for Bacterial Vaginitis (BV), and Donders classification was used for Aerobic Vaginitis (AV). Sabouraud’s Dextrose Agar (SDA) was used for fungal cultures, and Fluconazole and Voriconazole sensitivity was tested. The descriptive analysis of compiled data with Chi-square tests where applicable to compare differences between proportions was done. Results: As per the Nugent's score, 90% of symptomatic and 86.66% asymptomatic HIV reactive females had BV. Nugent scoring was found to be a better diagnostic criterion for BV. AV was observed in 33.33% asymptomatic patients. Candida albicans (C.albicans)was the most common agent isolated from 68.75% of Vulvovaginal Candidiasis (VVC) cases. Dual infection of BV and Candidiasis was reported to be 18.33% in symptomatic and 15% in asymptomatic HIV seropositive females. Conclusion: In the present study, despite Antiretroviral Therapy (ART), attendees manifested significantly with BV infection in both groups. VVC due to C. albicans was also predominant in both groups. Co-infection with BV and VVC was the highlight of this study as dual infections of BV and AV remain under-diagnosed as per Sexually Transmitted Infection (STI) syndromic management protocols. The clinicians need to identify AV as a separate entity as treatment modalities are essentially different.

Aetiology of sexually transmitted infections in Maputo, Mozambique

The study sought to ascertain the prevalence of the aetiological agents of genital discharge and genital ulcer diseases in Maputo, Mozambique. Consecutive consenting patients presenting to the Centro de Saúde do Porto in Maputo between March and April 2005 with genital discharge syndrome and/or genital ulcer diseases were recruited. Specimens were collected for the identification of STI pathogens. Of 346 recruited patients, 164 were male and 182 female. The prevalence of confirmed single aetiological agents for male urethritis was as follows: N. gonorrhoeae, 35%; C. trachomatis, 10%; and M. genitalium 4%. For vaginal discharge, N. gonorrhoeae was found in 11% of the women tested, followed by C. trachomatis (6.5%), bacterial vaginosis (34%), and T. vaginalis (2%). The prevalence of genital ulcers was as follows: Herpes simplex virus type 2, 62%; H. ducreyi 4 %; and C. trachomatis biovar LGV, 4%. Five percent of patients with genital ulcers had a positive syphilis serology (RPR ≥ 1:8 and confirmed by TPHA) and 35% of all tested patients were HIV-1/2 infected. Cases of mixed infections were present in 5%, 11% and 3% of patients with male urethritis, vaginal discharge, and genital ulcers respectively. The classic sexually transmitted infection aetiologies are still prevalent in Maputo. The study highlights the need for a periodic surveillance to inform syndromic management protocols.

The effect of syndromic management interventions on the prevalence of sexually transmitted infections in South Africa

Objectives Few studies have assessed the effect of syndromic management interventions on the prevalence of sexually transmitted infections (STIs) at a population level. This study aims to determine the effect of syndromic management protocols that have been introduced in South Africa since 1994. Study design A mathematical model of sexual behaviour patterns in South Africa was used to model the incidence of HIV, genital herpes, syphilis, chancroid, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis and vaginal candidiasis. Assumptions about health seeking behaviour and treatment effectiveness were based on South African survey data. The model was fitted to available STI prevalence data. Main outcome measures Reductions in STI prevalence due to syndromic management. Results Between 1995 and 2005, there were significant reductions in the prevalence of syphilis, chancroid, gonorrhoea, trichomoniasis and chlamydial infection. In women aged between 15 and 49, syndromic management resulted in a 33% (95% CI: 23–43%) decline in syphilis prevalence, a 6% (95% CI: 3–11%) reduction in gonorrhoea prevalence, a 5% (95% CI: 1–13%) reduction in the prevalence of bacterial vaginosis and a substantial decline in chancroid. However, syndromic management did not significantly reduce the prevalence of other STIs. For all STIs, much of the modelled reduction in STI prevalence between 1995 and 2005 can be attributed to either increased condom usage or AIDS mortality. Conclusions Syndromic management of STIs can be expected to decrease the prevalence of curable STIs that tend to become symptomatic, but has little effect on the prevalence of STIs that are mostly asymptomatic.

A Bayesian approach to uncertainty analysis of sexually transmitted infection models

ObjectivesTo propose a Bayesian approach to uncertainty analysis of sexually transmitted infection (STI) models, which can be used to quantify uncertainty in model assessments of policy options, estimate regional STI...

Genital Ulcers in Men in Hong Kong

Treatment Guidelines (STG) and the provision of effective drugs. The syndromic case management strategy aims to reduce the load of STI in facilities. However in South Africa evidence still suggest that in many regions management of STI remain inadequate, more so in rural regions were accessibility of STI services is a challenge. The goal of the study was to assess the accessibility of STI services to clients, in terms of utilisation of STI services, partner notification rates, and clinicians’ knowledge about STI syndromic treatment and drug supplies. Methods: Interviews were conducted with nurses from 19 rural clinics and 8 mobile clinics in one district in Limpopo province South Africa. Observations for STIs consultations and record review were also conducted and scored using the District STI Quality of Care Assessment (DISCA) tool. Results: Facilities reported adequate drug supply, but only 39% of facilities offer after-hours services; there was lack of training in syndromic management with only 29% of clinicians trained. Though syndromic management protocols were available in all facilities, 50% of clinicians failed to cite the correct treatment for STI syndromes. Contact-slips for partner notification was provided in 41% of facilities but only 48% of sexual partners were treated; condoms were out of stock in 89% in the past month and in 11% of facilities during the survey. Conclusion: Majority of facilities does not offer afterhours services and client load was considered to be very low suggesting poor access of STI services. There is a need to train all clinicians and extend services to after hours to improve STI services including partner notification and treatment.

Access to Sexually Transmitted Infections Services in Rural South Africa: An Evaluation of the Implementation of the National Treatment Guidelines

Treatment of sexually transmitted infections (STI) is a major public health priority for South Africa. In 1996, the Department of Health adopted the syndromic case management to improve STI treatment by establishing the National Treatment Guidelines (STG) and the provision of effective drugs. The syndromic case management strategy aims to reduce the load of STI in facilities. However in South Africa evidence still suggest that in many regions management of STI remain inadequate, more so in rural regions were accessibility of STI services is a challenge. The goal of the study was to assess the accessibility of STI services to clients, in terms of utilisation of STI services, partner notification rates, and clinicians’ knowledge about STI syndromic treatment and drug supplies. Methods: Interviews were conducted with nurses from 19 rural clinics and 8 mobile clinics in one district in Limpopo province South Africa. Observations for STIs consultations and record review were also conducted and scored using the District STI Quality of Care Assessment (DISCA) tool. Results: Facilities reported adequate drug supply, but only 39% of facilities offer after-hours services; there was lack of training in syndromic management with only 29% of clinicians trained. Though syndromic management protocols were available in all facilities, 50% of clinicians failed to cite the correct treatment for STI syndromes. Contact-slips for partner notification was provided in 41% of facilities but only 48% of sexual partners were treated; condoms were out of stock in 89% in the past month and in 11% of facilities during the survey. Conclusion: Majority of facilities does not offer after-hours services and client load was considered to be very low suggesting poor access of STI services. There is a need to train all clinicians and extend services to after hours to improve STI services including partner notification and treatment.

The Costs of Treating Curable Sexually Transmitted Infections in Low- and Middle-Income Countries: A Systematic Review

Calls for increased investment in sexually transmitted infection (STI) treatment across the developing world have been made to address the high disease burden and the association with HIV transmission. The goals of this study were to systematically review evidence on the cost of treating curable STIs and to explore its key determinants. A search of published literature was conducted in PubMed and supplemented by reviews of gray literature. Studies were analyzed by broad focus. Regression analysis explored how intervention characteristics affect unit costs, accounting for differences in costing methods. Fifty-three primary studies were identified, of which 62% used empirical data, 35% presented economic costs, and 22% presented full costs. The median STI treatment cost was US dollars 17.80. Clinics serving symptomatic patients were consistently cheaper than outreach services, services using syndromic management protocols had lower costs, and unit costs decreased with scale. The compiled cost data provide an evidence base that can be used to help inform resource planning.

Strategies for diagnosis of bacterial vaginosis in a resource-poor setting

This study evaluated Amsel's criteria, the FemExam card and pH plus amine methods for the diagnosis of bacterial vaginosis (BV) in a resource-poor setting. Two hundred Azerbaijani women participated in a study about reproductive health that included a gynaecological examination and an interviewer-administered survey. Using the WHO syndromic diagnosis algorithm, nearly all women (99%) had abnormal vaginal discharge. The prevalence of BV by Gram stain was 35%; using pH plus amine, the FemExam card and Amsel's criteria, prevalence ranged from 29% to 49%. No behavioural or demographic characteristics were associated with BV as diagnosed by Gram stain. The sensitivity ranged from 0.59 to 0.74 and specificity from 0.65 to 0.92 using the three methods. The pH plus amine test is better than syndromic management protocols, and although it is not the most sensitive or specific of the three methods it will be easiest to implement in resource-poor settings.

A flowchart for managing sexually transmitted infections among Nigerian adolescent females.

To devise a flowchart suitable for assessing risk of trichomoniasis, chlamydia and gonorrhoea in an adolescent population, not all of whom will be sexually experienced or currently in a relationship. The data used to derive the flowchart were generated from cross-sectional microbiological surveys of girls aged 14-19 years in Port Harcourt, Nigeria. The flowchart screened on the basis of: (i) sexual experience; (ii) recent sexual activity; (iii) a positive urine leukocyte esterase (LE) test; and (iv) among LE negatives, a history of malodorous/pruritic discharge. Using this flowchart, we found that 26.2% of all adolescents screened would receive treatment for cervicitis and vaginitis. Chlamydial, gonococcal, and trichomonal infections were correctly diagnosed in 37.5%, 66.7%, and 50% of the cases, respectively. Although the flowchart is more suitable for an adolescent population than the vaginal discharge algorithm used in syndromic management protocols, it still lacks precision and needs adapting to local settings.

A Comparison of Cost-Effectiveness of Three Protocols for Diagnosis and Treatment of Gonococcal and Chlamydial Infections in Women in Africa

The cost-effectiveness of different STD diagnosis and treatment approaches has not been evaluated previously. The goals of the study were to compare the cost-effectiveness of "gold standard" care (GS), syndromic management (SM), and mass treatment (MT) protocols for the treatment of cervical gonococcal and chlamydial infections in a hypothetical model of 1 million women in Africa. A decision tree model was constructed for each of the protocols. Sensitivity analyses were conducted and 10,000 Monte Carlo simulations were run to test the robustness of the cost-effectiveness estimates to changes in underlying assumptions. MT with doxycycline for chlamydia was the most cost-effective protocol in terms of cost per cure. SM protocol had the lowest total programmatic costs. For the GS protocol, using azithromycin for chlamydial infections was found to be more cost-effective than using doxycycline. For both the GS and SM protocols, the total cost of the program was most sensitive to the percentage of women seeking STD treatment and the prevalence of non-STD vaginal discharge, whereas the cost of MT was almost exclusively determined by coverage rates. No single protocol carries with it all the desired conditions of an optimal cost-effective program. The treatment-seeking behavior, STD prevalence, and coverage of each locale must be evaluated to determine the most cost-effective and highest impact program. MT was found to be the most cost-effective protocol in terms of cost per woman treated when compared with the SM and GS protocols for STDs in women.

High occurrence of HBV among STD clinic attenders in Bombay, India.

The pattern of sexually transmitted disease (STD) is the basis for designing surveillance of specific STD, their trends and syndromic management protocols. Two hundred and fifteen consecutive first-time STD clinic attenders at a teaching hospital in Bombay were recruited for the study in October 1995. Thorough clinical examination and the following investigations were done: wet mount, Gram stain, Giemsa stain, modified Thayer-Martin (MTM) medium culture, Fontana stain, Venereal Disease Research Laboratory (VDRL), Treponema pallidium haemagglutination test (TPHA), HBsAg and HIV. Ulcerative STD constituted 73.5% of total STD while 15.8% were discharges and 10.2% were genital growths. Ulcers in decreasing order of frequency were chancroid (51.9%), genital herpes (29.1%) and syphilis (14.5). 76.5% of genital discharges were due to gonococcal infection. The high rate of ulcerative STD is possibly an important co-factor for the high HIV prevalence of 31.2% in Bombay. Of 182 patients tested for HBV, 16 (8.8%) were reactive for HBsAg, revealing a high prevalence among STD attenders. A high co-relation of HBsAg positive with either HIV or VDRL requires urgent attention for HBV intervention strategies in this population.