Elsevier

The Lancet

Volume 354, Issue 9192, 20 November 1999, Pages 1776-1781
The Lancet

Articles
Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

https://doi.org/10.1016/S0140-6736(99)02463-0Get rights and content

Summary

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.

Introduction

In many low-income countries, concerted efforts are being made to establish programmes for the control of reproductive-tract infections, including sexually transmitted infections (STIs). Antecedents for such a policy have arisen from several directions, including reports that associate STI control with a decrease in HIV incidence,1, 2 a 1993 World Bank report that showed that the burden of STIs in many urban populations in less developed countries makes up a substantial proportion of the entire disease burden of those populations,3 and recommendations from the 1994 United Nations International Conference on Population and Development (ICPD).4

Despite worldwide acknowledgment that control of STIs is a worthwhile target,3, 4, 5 the tools available for achieving this goal in low-income countries are limited. However, accurate management of infected individuals is a key component of most STI-control programmes. In the absence of cheap, simple, and accurate diagnostic tests, or comprehensive laboratory services for microbiological diagnosis, WHO has developed a set of syndromic-management guidelines for the treatment of men and women with symptoms presenting to basic health-care services in less developed countries.6 These clinical algorithms recognise that there are several possible causes of common clinical syndromes, and recommend treatment based on the most common causative organisms.7

Vaginal discharge is one of the most common clinical complaints among women of reproductive age in many parts of the world,8 and campaigns to broaden reproductive health-care services, for example through expansion of service provision in family-planning clinics, may result in more women having access to and receiving care. The effectiveness of treatment therefore carries both clinical and economic implications for many less developed countries. We studied the prevalence of reproductive-tract infections in women complaining of abnormal vaginal discharge who reported to maternal and child health/family-planning centres in one area of rural Bangladesh. We compared “gold standard” laboratory diagnostic tests with two management algorithms: the currently recommended WHO clinical algorithm for primary health-care workers, and the diagnoses made by trained health-workers by means of a speculum and simple bedside diagnostic tests. We also estimated the costs associated with the two management algorithms.

Section snippets

Patients

The International Centre for Diarrhoeal Disease Research, Bangladesh, provides clinical services, and carries out demographic surveillance in Matlab—a rural area of Bangladesh with a population of about 105000 people. Free clinical and contraceptive services are provided to married women of reproductive age through a series of village-based community health workers and centres for maternal health-care and child health-care (including family planning). All women who attended the centres during a

Presenting characteristics

All 465 women attending the centres with symptoms related to the genital tract during the study period agreed to take part in the survey. Their median age was 30·2 years (range 15·9–62·3). 451 women (97%) were married, three (0·6%) had never been married, and 11 (2·4%) were widowed or divorced. Most women reported an abnormal vaginal discharge (439 [94%]). Other common symptoms were genital itching (254 [55%]) and lower abdominal pain (186 [40%]). A smaller number of women complained of

Discussion

In this study of symptomatic women attending maternal and child health/family-planning centres in Matlab, Bangladesh, we found a low STI prevalence and a moderate prevalence of endogenous infections. The prevalence of STIs was much lower than in many studies in Africa,8 possibly because, in general, such centres in Bangladesh see only married women of reproductive age. In many societies, younger (unmarried) adolescents and divorced or abandoned women are at higher risk of STIs.17 As a result of

References (31)

  • AlderMW

    Sexually transmitted diseases control in developing countries

    Genitourin Med

    (1996)
  • WasserheitJN

    The significance and scope of reproductive tract infections among third world women

    Suppl Int J Gynaecol Obstet

    (1989)
  • VuylstekeB et al.

    Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire

    Clin Infect Dis

    (1993)
  • MayaudP et al.

    Risk assessment and other screening options for gonorrhoea and chlamydia in women attending rural Tanzanian antenatal clinics

    Bull World Health Organ

    (1995)
  • WHO

    STD case management workbooks: modules 1–7

    (1995)
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