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1: Lancet. 1999 Nov 20;354(9192):1776-81.
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Comment in:
Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh.

Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Peeling RW, Mabey D.

International Centre for Diarrhoeal Disease Research, and Centre for Health and Population Research, Bangladesh. s.hawkes@lshtm.ac.uk

BACKGROUND: In the control of reproductive-tract infections, including sexually transmitted infections (STIs), in low-income and middle-income countries, WHO recommends syndromic management for individuals with symptoms. This intervention was initially developed in areas where prevalence of such infections is high. We investigated the clinical effectiveness and cost of this approach among a group of women with a low prevalence of infection. METHODS: During a 5-month period, we investigated all women complaining of abnormal vaginal discharge and seeking care at maternal and child health/family-planning centres in Matlab, Bangladesh, for the presence of laboratory-diagnosed reproductive-tract infections and STIs. Syndromic diagnoses made by trained health-care workers were compared with laboratory diagnosis of infection. We then calculated the costs of treating women by means of the recommended WHO algorithm and an adapted algorithm incorporating use of a speculum and simple diagnostic tests. FINDINGS: The prevalence of endogenous infections among 320 women seen was 30%. Cervical infections (Neisseria gonorrhoeae and Chlamydia trachomatis) were found in only three women. The WHO algorithm had a high sensitivity (100%) but a low specificity (zero for bacterial vaginosis, candida, and Trichomonas vaginalis). The speculum-based algorithm had a low sensitivity (between zero and 59%) but a higher specificity (79-97%). Between 36% and 87% of costs would have been spent on uninfected women. INTERPRETATION: The high rate of overtreatment in the population studied carries both financial and social costs--the latter in potentially exposing women misdiagnosed as having an STI to threats of domestic disruption or even violence. We make recommendations for management programmes in areas of low STI prevalence and low income.

PIP: This paper presents a study on the syndromic management of reproductive tract infections among women in low-income and low-prevalence situations. Women complaining of abnormal vaginal discharge and seeking care at health centers in Matlab, Bangladesh, were examined for the presence of laboratory-diagnosed reproductive tract infections and sexually transmitted infections. In the results, 30% of 320 women were diagnosed as having endogenous infections. Overall result of the study revealed a low prevalence of sexually transmitted infections among these women. The WHO algorithm had 100% sensitivity but a low specificity, while the speculum-based algorithm had a low sensitivity (0-59%) but a higher specificity (79-97%). Cost analysis indicated that 87% of expenditure was wasted on overtreatment under the WHO algorithm, while only 36% of expenditure was wasted on overtreatment using the speculum-based algorithm. In conclusion, the development of simple, affordable and effective diagnostic tests should be prioritized by policymakers and public health specialists to ensure the provision of adequate services among the higher risk groups in society.

Publication Types:
PMID: 10577639 [PubMed - indexed for MEDLINE]