Teaching and learning space

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Collected vaginal specimens are smeared on a glass slide at the study site, a drop of normal saline is added to each slide and slide is then covered with a cover slip and transported individually in petri dishes to the laboratory. They are examined microscopically at x100 and x400 magnification. T. vaginalis is usually recognized by the typical jerky motility³⁷ but morphological details may be enhanced by staining the wet mount with very dilute solution of buffered methylene blue- clear, pear-shaped organism with four anterior flagellae and an axo style that traverses the body to end in a spine, are visualized.

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trichomonads, candida and clue cells while endocervical specimens underwent gonococcal culture and PCR for chlamydia. Cervical agents were detected in 37.5% of the women while vaginal agents were detected in 30.2%. The sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) for the diagnosis of gonorrhoea and/or chlamydia using a syndromic diagnosis were 90.8%, 46.9%, 50.9% and 89.3% respectively. These values were not calculated for vaginal infections and their conclusion was that the performance of the algorithm for detection of cervical infections was favorable in this study because of the high prevalence of cervical infections in the study group.

Vishwanath et al⁴¹ evaluated the performance of the syndromic approach in the management of vaginal discharge among women attending a reproductive health clinic in New Delhi, India. Women who sought services from the clinic and who had vaginal discharge were interviewed and 319 were recruited. Among these, prevalence of bacterial vaginosis was 20%, Chlamydia trachomatis 12.2%, Trichomonas vaginalis 10%, and syphilis 2.2%. N. gonorrhoea was not isolated.

An algorithm based on risk assessment and speculum assisted

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clinical evaluation was not helpful in predicting cervical infections associated with C. trachomatis (sensitivity 5% and PPV 9%).

Sensitivity, specificity and PPV for bacterial vaginosis/trichomoniasis were 95%, 22% and 38% while those for candidiasis were 40%, 98% and 88%. They concluded that the syndromic management of vaginal discharge among women seeking family planning and other reproductive health services should focus only on vaginal infections.

In Nairobi, Kenya, flowchart evaluation was conducted for cervicitis in STI clinics in both pregnant and non-pregnant women. The background prevalence of cervicitis due to STI was 13% and 19%

respectively⁴². It was observed that risk markers, symptoms, signs associated with cervicitis due to STIs were very different in the two sub-populations and none of the variables (risk, symptoms, signs), was both sensitive (>60%) and specific (>60%) for diagnosis of cervicitis. Following this evaluation, the conclusion of the researchers was that no flowchart is highly valid and that patient management should be based on knowledge of vaginitis and cervicitis due to STI prevalence in target population.

In a multi-center study conducted in Brazil by Moherdaui et al³⁵ to

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validate STD flow charts for the management of genital discharge and genital ulcer, 607 men and 348 women participated in the study. Among the women with vaginal discharge, a cervical infection was detected in 17%, a vaginal infection in 74% and mixed infection in 9%. The sensitivity of the diagnosis for cervical infection increased from 16% (clinical aetiologic diagnosis) to 54%

(when adding a syndromic approach) and to 68% when adding a risk assessment as in the national flow charts. Addition of a laboratory examination for the diagnosis of vaginal infection decreased the sensitivity (from 94% to 45% and from 90% to 66%, for trichomoniasis/bacterial vaginosis and candidiasis respectively) but increased the specificity (from 18% to 100% and from 15% to 90%, for trichomoniasis/bacterial vaginosis and candidiasis respectively).

Researchers evaluating clinical algorithms for the diagnosis of gonococcal and chlamydial infections among men with urethral discharge or dysuria and women with vaginal discharge in Benin Republic recruited 192 women presenting consecutively.⁴³ The reference test for gonorrhoea was a combination of results from culture and PCR and chlamydia infection was ascertained by

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enzyme linked immunosorbent assay and PCR. Two algorithms were evaluated. One based on symptoms and risk assessment (algorithm A), the other relying on speculum examination (algorithm B). The prevalence of gonococcal and chlamydial infections was 5.7% and 2.1% respectively. The sensitivity, specificity, positive and negative predictive values of algorithm A (algorithm B) were respectively 86.7% (93.3%), 41.8% (34.5%), 11.2% (10.8%), and 97.4% (98.4%). They therefore concluded that diagnosis of gonococcal and chlamydial infections without specific laboratory tests are problematic especially in a setting of low prevalence of cervical infections.

In Abidjan, flowcharts were evaluated for screening for cervicitis due to STI in sex workers⁴⁴. Conclusions from this study were that flowcharts need to be modified for screening and that the WHO simple flowcharts are not for screening/case-finding but for self-referred symptomatic women.

In a study questioning the efficacy of Syndromic approach in management of reproductive tract infections (RTIs) in a rural area of Chandigarh, India^, Thakwi et al⁴⁵ examined 138 cases of RTIs and concluded that besides financial constraints, social and

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educational barriers were among the deterrents of effective prevention and treatment of RTIs in rural areas and that concerted efforts with regular monitoring are requested to overcome barriers to proper use of syndromic approach.

In a similar study by Ranjan et al⁴⁶ evaluating reproductive tract infections among married women, prevalence of reproductive tract infections (RTIs) was 37.0% by syndromic approach, 51.7% by clinical examination and 36.7% by microbiological laboratory investigations^. Sensitivity, specificity of syndromic approach to diagnose any RTI was 53.6% and 72.6% respectively while clinical examination had 68.2% sensitivity and 60.5% specificity. The WHO syndromic approach based on symptoms had a low sensitivity in diagnosing RTIs among these women and sensitivity increased when clinical examination was used to diagnose these infections.

Cuccizza⁴⁷ reviewed some literature on vaginal discharge syndromic management of STIs. The author found that the syndromic approach is not a cost-effective tool for cervical infections and may be appropriate for vaginal infections, as it tended to produce higher sensitivity, specificity and positive predictive values for Trichomonas vaginalis, Bacterial vaginosis and Chlamydia trachomatis. The

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recommendation following the review was increased emphasis on condom use and distribution, as well as focusing on syndromic management of men’s STIs, and treatment of patients and their partners as an effective way to find and manage cervical infections among family planning clients.