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Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda
  1. C J Tann1,
  2. H Mpairwe2,
  3. L Morison1,
  4. K Nassimu2,
  5. P Hughes3,
  6. M Omara4,
  7. D Mabey1,
  8. M Muwanga4,
  9. H Grosskurth3,
  10. A M Elliott2
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2Uganda Virus Research Institute (UVRI), Entebbe, Uganda
  3. 3Medical Research Council (MRC)/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
  4. 4Entebbe Hospitals, Entebbe Uganda
  1. Correspondence to:
 Dr Carolyn Tann
 London School of Hygiene and Tropical Medicine, London, UK; carolyn.tann{at}lshtm.ac.uk

Abstract

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.

  • 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
  • bacterial vaginosis
  • trichomoniasis
  • pregnancy
  • syndromic management

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Footnotes

  • Contributors

    CT contributed to the design of the study, data analysis and interpretation and drafted the manuscript; HM and MO contributed to acquisition of study data and to care of the participants; LM performed data analysis and interpretation and assisted in the drafting of the manuscript; KN was the technician responsible for processing microbiological samples; PH supervised the laboratory aspects of the study and contributed to the study design;. MM contributed to study design and organisation; DM, HG, AME contributed to the study design, organisation, interpretation of the data and the writing of the report. All authors have reviewed and approved the final version of the paper.

  • Competing interests: none declared.

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