SYNDROMIC MANAGEMENT

Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda

C J Tann¹, H Mpairwe², L Morison¹, K Nassimu², P Hughes³, M Omara⁴, D Mabey¹, M Muwanga⁴, H Grosskurth³ and A M Elliott²

¹ London School of Hygiene and Tropical Medicine, London, UK
² Uganda Virus Research Institute (UVRI), Entebbe, Uganda
³ Medical Research Council (MRC)/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
⁴ Entebbe Hospitals, Entebbe Uganda

Correspondence to:
Correspondence to:
Dr Carolyn Tann
London School of Hygiene and Tropical Medicine, London, UK; carolyn.tann{at}lshtm.ac.uk

Objectives: To measure the prevalence of reproductive tract infections (RTIs) during pregnancy in Entebbe, Uganda, and to evaluate the current syndromic diagnosis and management approach in effectively targeting infections, such as bacterial vaginosis (BV) and trichomoniasis, that are associated with low birth weight and prematurity among newborns.

Methods: We enrolled 250 antenatal clinic attenders. Vaginal swabs and diagnostic tests were performed for BV, Trichomonas vaginalis (TV), candida, Neisseria gonorrhoeae, Chlamydia trachomatis and for HIV-1 and active (TPHA+/RPR+) syphilis infection. Same day treatment was offered for symptoms according to syndromic management guidelines. The treatment actually provided by healthcare workers was documented. Sensitivity, specificity, positive and negative predictive values were used to assess the effectiveness of syndromic management guidelines and practice.

Results: The prevalence of infections were: BV 47.7%, TV 17.3%, candida 60.6%, gonorrhoea 4.3%, chlamydia 5.9%, syphilis 1.6%, and HIV 13.1%. In total, 39.7% of women with BV and 30.2% of those with TV were asymptomatic. The sensitivity of syndromic management as applied by health workers in targeting BV and TV was 50.0% and 66.7%, respectively. This would have increased to 60.3% (BV) and 69.8% (TV) had the algorithm been followed exactly.

Conclusions: The prevalence of BV and TV seen in this and other African populations is high. High rates of asymptomatic infection and a tendency of healthcare workers to deviate from management guidelines by following their own personal clinical judgment imply that many vaginal infections remain untreated. Alternative strategies, such as presumptive treatment of BV and TV in pregnancy, should be considered.

Abbreviations: BV, bacterial vaginosis; PCR, polymerase chain reaction; RPR, rapid plasma reagin; RR, relative risk; RTIs, reproductive tract infections; TPHA, Treponema pallidum haemagglutination assay; TV, Trichomonas vaginalis; UVRI, Uganda Virus Research Institute; VDS, vaginal discharge syndrome

Keywords: bacterial vaginosis; trichomoniasis; pregnancy; syndromic management

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