Recent eLetters
Displaying 1-10 letters out of 138 published
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Other enemy that besieges us
Submit responseLymphogranuloma venereum was described first by Wallace in 1833 and again for Durand, Nicolas, and Favre in 1913. Climatic bubo is an infection of sexual transmission caused by the bacterium Chlamydia trachomatis. The first symptoms begin to appear from 3 to 12 days after the contagion and they appear like a painless blister, that becomes an ulcer, that can happen inadvertent and they can be confused with syphilis. The lymph nodes of the groin increase in size and they is sensitized by touch. Ulcers are coming along to destroy the internal and external tissue, with loss of pus and blood. The destructive nature of the lymphogranuloma also increments the risk of secondary infection for other pathogenic microbes. Our society knows a lot about the HIV, but many times we neglected other diseases than although they are not so dangerous like the HIV, they cause damage and affect our young people. If we know our enemies we will be able to combat them better.
Conflict of Interest:
None declared
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Treatment of ocular syphilis in patients infected with HIV / AIDS.
Submit responseOcular syphilis is very rare, equivalent to 1-2% of uveitis, however, is a simulator disease that can be confused, especially in immunocompetent individuals, as HIV-positive patients are more likely to acquire it. HIV co-infection with syphilis increases the risk of central nervous system disease, patients with AIDS who do not receive antiretroviral therapy, have bilateral disease and the posterior segment. There are many ways to manifest eye level, most of the publications mentioned isolated cases of secondary syphilis in stage chronic phase, and the majority in the neurosyphilis. In the cornea is suspected when there is a bilateral stromal keratitis, which may be associated with closed- angle glaucoma. In the iris can be expressed as granulomatous uveitis. In a series of cases of Barile was shown 9% of posterior uveitis and 27 % of panuveitis. Chao JR and colleagues reported four patients with neurosyphilis by positive VDRL and increasing of leukocytes in the cerebrospinal fluid. Two patients had placoid chorioretinitis, a homosexual patient presented bilateral papilledema and a heterosexual man presented anterior uveitis and bilateral papilledema. The condition of the posterior pole can vary as much as vasculitis, macular edema, neuroretinitis and even retinal necrosis. Neuro-ophthalmological manifestations of syphilis include Argyll-Robertson pupil, oculomotor nerve palsy and optic neuritis. Treatment of ocular syphilis should be as neurosyphilis, recommended 12 MU of penicillin G intravenously daily for 10-14 days or 2.4 MU procaine penicillin intramuscularly daily with oral probenecid for two weeks. Penicillin G benzathine can be applied after the treatment of penicillin G or procaine, It should not be applied as a first option, since it does not reach sufficient levels in the cerebrospinal fluid. In case of resistance, can be applied ceftriaxone, 1 g 2 times a day for seven days. We present two cases treated in our services in Cuba. Case 1. This 31 years old male patient referred to the Service of Infectious Diseases for being HIV positive and probable neurosyphilis by bilateral papilledema, was under medical treatment with penicillin G procaine. The reason for the consultation is low vision in Right eye (RE) since two weeks ago. Physical examination: AV 20/80 in RE and 20/25 in LE (Left Eye). IOP of 10 mm Hg in both eyes. RE with fine keratic precipitates, cells in CA 1 +, there are no changes in anterior segment of the LE. In the fundus papilledema is observed in RE and peripheral posterior vitreous detachment in LE. The retinal fluorangiography (FAG) shows active lesions of peripheral vasculitis and bilateral papilledema. Report is sent to the Service of Infectious Diseases where a antiretroviral therapy is indicated, in addition to completing his studies, resulting positive FTA-abs test. Returns three months later his vision improved to 20/25 in both eyes, in the fund of the eye is not observed the edema of the optic nerve previously affected. Case 2. Male patient, 32 years old, referred to the Service of Infectious Diseases for diagnosis of neurosyphilis in HIV-positive FTA-abs test positive. During his hospital stay was diagnosed with bilateral papilledema and paralysis of the fourth right nerve. Admitted by the presence of headache and diplopia of two months before to the first review. Visual acuity is 20/30 right eye and 20/25 left eye. His refraction is -0.75 sphere RE and -0.25 to - 0.75X 0 ° LE, improved to 20/20 RE and 20/15 LE. On examination of ocular motility is observed hiperhipotropia with limitation to the depression of RE and Bielchowski test positive. Conjunctive, cornea and lens of the normal characteristics. Fundus in both eyes and optic disc with excavation 1 / 10, hyperemia and Raised edges, tortuous vessels since the emergency. FAG requested and quoted with results, the patient does not return. The importance of health officials from a country to insist on control of sexually transmitted diseases stems from the increased incidence of these kind of diseases such as syphilis, considered as a "great imitator" of many other infectious diseases and some autoimmune diseases. Dermatological tests are insensitive in the primary or secondary syphilis, because it has reduced levels of normal lymphocyte blastogenesis. In the case of HIV, it can cause a polyclonal expansion of inmunoglobuline IgG, resulting in activation of B cells with a side effect of CD8, complicating HIV infection. Opposite can also happen: there is a decrease of B cells, giving false positive serological tests. T. pallidum increases HIV replication and may also damage the mucosa by increasing the number of cells receptive to HIV. Patients with genital ulcers have an increased excretion of HIV RNA in seminal fluid. In conclusion, ocular syphilis remains a cause of diverse and complex eye conditions. We should suspect this diagnosis in patients without other infectious cause or autoimmune feature. Do not forget the background of sexual transmission risk that patients often deny.
Conflict of Interest:
None declared
Patient Consent - There is no identifiable information presented so patient consent is not needed. -
To prevent is better that to cure
Submit responseSexually transmitted diseases constitute a great group of diseases produced by different etiological agents, that they have in common that sexual relations are their principal line of transmission. This fact confers them the special connotation for their control we need to know and acting upon relations and sexual conducts of people. In the last 20 years, in our country has taken place a situation that complicates still more the actions of health about these diseases. While the liberalization in sexual relations becomes evident, with frequent changes of couples, the risk between the population is biggest, mainly between the young, in addition prejudices and limitations keep in the moments in which it proves to be necessary to talk about them. Possibly for these same circumstances, Sexually Transmitted Diseases constitute a serious problem of health all over the world. We have a program that tries to combine the real existent possibilities in the country, as of the present moment, as to diagnosis, treatment and epidemiologic handling of the cases, taking into account the most frequent diseases and the fact that they can produce bigger complications, but mainly those about which we consider more important in our area of health, specifically Syphilis and Blennorrhagia.
Conflict of Interest:
None declared
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What we will do when we will have the vaccine against the HIV?
Submit responseAIDS collects every day more human lives, the sexual irresponsibility, poorness, the economic crises, they have converted in allies of the mortal pandemic. But I wonder: When we find the vaccine to combat this virus, would have we the possibility of putting it at the disposal of the million sick persons around the world and whose economic condition is very bad? The distribution of the antiviral medications at present is limited, the economic restrict the possibilities for poor people, then when we will have the vaccine, the international organizations of health will have to make a great effort to achieve that the vaccine against the HIV is the solution of disease really, and no the agony of other ones that they will not be able to come over the vaccine.
Conflict of Interest:
None declared
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PREVENTION AND CONTROL OF SEXUALLY TRANSMITTED DISEASES IN CUBA.
Submit responseOn Cuba we notify between 40 and 50 thousand cases annually only of Sifilis, Blenorragia and Condylomatum Acuminatum, with tendencies to the increment for years. In order to get modification of the tendencies and reduction of the transmission of these diseases, we take promotional actions of health directed to establish habits and sexual safe or minor- risk conducts, but that only we have impact in the long term, because it is well known that it does not prove to be easy to modify these behavioral aspects of the life of people. These educational and promotional actions from health are common for all the Sexually Transmitted Diseases, including the HIV for that reason the actions played inside a specific program benefit the prevention in the group. With this method we exercise a better control and we raise knowledge and we supply of tools that they avoid the propagation of these diseases.
Conflict of Interest:
None declared
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Sex and Relationship Education - Did you get it?
Submit responseGaydos1 highlights the barriers to discussing sexual health issues openly and teenagers' lack of awareness of the high prevalence of STIs and potential adverse reproductive sequelae. Addressing these barriers is one solution to the 'Hidden Epidemic' of STIs. In the UK as in the USA, STI rates remain highest among sexually active teenagers, particularly those from deprived inner city areas and black ethnic minority groups.2 Ensuring a high standard of Sex and Relationships Education (SRE) may contribute to reducing risky sexual behaviour.3
During December 2010 for a medical student research project, we conducted a cross-sectional questionnaire survey to investigate high-risk teenagers' experience of SRE. Consecutive male and female patients aged 14-19 years attending Adolescent Genito-Urinary Medicine Clinics in Wandsworth, South London were asked to complete a questionnaire survey on their experience of SRE at school. The questionnaire asked if they had received SRE, the topics covered, timings, perceptions of SRE and where sexual health information was accessed. Data were entered and analysed using SPSS.
The response rate was 94% (97/103). The mean age of responders was 16 years (range 14-19), and 69% were female. Of 97 responders, 41% described their ethnicity as white, 49% black and 10% as other ethnic group. Although 99% had received SRE at school, 69% said the quality of SRE was average or poor. Median age at first SRE in school was 11 years (range 5- 16). Teenagers reported a desire to be taught earlier (by aged 12) about menstruation, teenage pregnancy, STIs, HIV and relationships. The biological topics, menstruation, contraception and STIs were found the most useful at school, but 30% said they were not taught about emergency contraception. Sexual health clinics, school lessons and friends were the main sources of sexual health information (91%, 77% and 74%, respectively). Only 30% felt comfortable accessing information from school. Over half the respondents accessed the media and internet which may not be reliable.
This survey found that most of these high risk, sexually active teenagers had received some SRE, but the standard was inconsistent and often too late. It suggests that in the UK, SRE should be taught as a statutory part of the national curriculum. We agree with Gaydos that special education tools such as effective SRE are needed to tackle the epidemic of STIs. In Holland SRE starts at the age of five and the country has the lowest teenage pregnancy rate in Europe.4 Providing SRE earlier at school backed up by easily accessible information from sexual health clinics might help to decrease STI rates among teenagers in the UK, North America and elsewhere.
Aneeta Kaneshanathan, Katia Prime, Phillip E Hay and Pippa Oakeshott
ACKNOWLEDGEMENTS We thank staff at Courtyard Clinic, St George's Hospital London - Wendy Majewska and Charlotte Jackson for their help with this project.
Population Health Sciences and Education, St George's University of London, London, SW17 ORE, UK Correspondence to: A Kaneshanathan Email: m0700538@sgul.ac.uk
REFERENCES
1. Gaydos. STI management and control in North America IUSTI region. Sex Transm Infect 2011;87:ii2-ii6.
2. Health Protection Agency. Acute STI diagnoses by PCT of residence, 2009 (England). Health Protection Report Vol 4 No. 34 - 27 August 2010.
3. Wellings K, Nanchahal K, Macdowall W, McManus S, Erens B, Mercer C, Johnson A, Copas A, Korovessis C, Fenton K, Field J. Sexual behaviour in Britain: early heterosexual experience. Lancet 2001; 358, 1843-1850.
4. UK Youth Parliament. SRE - Are you getting it? London; June 2007
Conflict of Interest:
None declared
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Sexual Transmited Diseases
Submit responseSTDs were commonly known as venereal diseases : Veneris is the Latin genitive form of the name Venus , the Roman goddess of love. Social disease was another euphemism. Public health officials originally introduced the term sexually transmitted infection , which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former. According to Ethiopian AIDS Resource Center FAQ - Are sexually transmitted infections (STIs) different from sexually transmitted diseases (STDs)? , "Sometimes the terms STI and STD are used interchangeably. This can be confusing and not always accurate, so it helps first to understand the difference between infection and disease. Infection simply means that a germ, virus , bacteria , or parasite that can cause disease or sickness if present inside a person's body. An infected person does not necessarily have any symptoms or signs that the virus or bacteria is actually hurting his or her body; they do not necessarily feel sick. A disease means that the infection is actually causing the infected person to feel sick, or to notice something is wrong. For this reason, the term STI which refers to infection with any germ that can cause an STD, even if the infected person has no symptoms is a much broader term than STD. " The distinction being made, however, is closer to that between a colonization and an infection , rather than between an infection and a disease . Specifically, the term STD refers only to infections that are causing symptoms . Because most of the time people do not know that they are infected with an STD until they start showing symptoms of disease , most people use the term STD, even though the term STI is also appropriate in many cases. Moreover, the term Sexually Transmissible Disease is sometimes used since it is less restrictive in consideration of other factors or means of transmission. For instance, meningitis is transmissible by means of sexual contact but is not labeled as an STI because sexual contact is not the primary vector for the pathogens that cause meningitis. This discrepancy is addressed by the probability of infection by means other than sexual contact . In general, an STI is an infection that has a negligible probability of transmission by means other than sexual contact, but has a realistic means of transmission by sexual contact (more sophisticated means blood transfusion , sharing of hypodermic needles are not taken into account). Thus, one may presume that, if a person is infected with an STI, e.g., chlamydia , gonorrhea , genital herpes , it was transmitted to him/her by means of sexual contact. The English language has short words for two of the most common: "pox" ( syphilis ) and "the clap" ( gonorrhea ).
Conflict of Interest:
None declared
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Response to Comparative performance of culture using swabs transported in Amies medium and the Aptima Combo2 nucleic acid amplification test in detection of Neisseria gonorrhoeae from genital and extra-genital sites: a retrospective study
Submit responseYour recent major article by Harryman et al 1 assessed the performance of Aptima Combo 2 (AC2) confirmed by Aptima GC (AGC) versus culture and concluded that AC2 with AGC confirmation performed well at genital and extra-genital sites for detection of GC. Culture with transport swabs was found to perform poorly for asymptomatic men, symptomatic and asymptomatic women and at extra-genital sites. The authors conclude that consideration should be given into how best to optimise GC culture in settings where direct plating is not feasible.
We strongly agree with them and are pleased to find the accumulating evidence for the performance benefits of AC2 confirmed with AGC. They mentioned that studies by Moss et al and Lavelle et al concluded that AC2 GC positives were likely to be true positives based on culture and partner data, but point out that both studies confirmed their positives only by repeating the same assay. However we in our later study confirmed all GC positives by AC2 by retesting residual sample in the AGC assay 2.
In our study we looked retrospectively at laboratory dual testing data between August 2006 and April 2008 and reviewed case-notes of all patients with a positive result for GC (culture or AC2 confirmed by AGC ). Testing was at Macclesfield genitourinary medicine (GUM) clinic (3589 dual NAATS samples from 1930 females and 2470 dual NAATS sample from 1867 males) and in the corresponding community served by the 'Team Chlamydia' office of the National Chlamydia Screening Programme (1549 male and 7934 female samples). Of the total of 15, 542 tests performed only one was positive for GC by AC2 but unconfirmed by AGC. There was no culture positive but AC2 negative result in any of our patients tested by both methods. At the GUM clinic, 6 (19%) male cases and 4 (25%) female cases would have been missed if tested only by culture. Of the 6 males, 3 were positive at extra-genital sites (pharyngeal swabs) only. In the community 23 young females would have gone undiagnosed and untreated for GC infection if tested only for chlamydia infection.
The overall positivity for GC in the GUM clinic was 1.3%, the true prevalence being 0.9% (after excluding already diagnosed cases referred from the community and those presenting as contacts) and that in the community was 0.4%.
Culture alone must now be considered unfit for testing asymptomatic patients and inadequate to meet the challenge of detecting and managing the large number of cases that are to be found outside of GUM settings 3. Following the recent Guideline 4- that GC should always be treated with a two antibiotic combination - GC culture may retain its importance for survey and monitoring of changes in antibiotic-susceptibility patterns but becomes less essential as a test for every individual patient.
Moncado et al 5 evaluated 3 of the CDC approaches for confirming GC positive NAAT results and concluded that confirmatory testing was not warranted for genital specimens. With our results and those of Harryman et al and as more evidence accumulates confidence may grow that, for AC2 at least, confirmation is unnecessary.
REFERENCES
1. Harryman L, Scofield S, Macleod J, et al. Comparative performance of culture using swabs transported in Amies medium and the Aptima Combo2 nucleic acid amplification test in detection of Neisseria gonorrhoeae from genital and extra-genital sites: a retrospective study. Sex Transm Infect 2011; doi;10.1136/sextrans-2011-050075
2. Mahto M, Zia S, Ritchie D, et al. Diagnosis, management and prevalence estimation of gonorrhoea: influences of Aptima Combo 2 assay with alternative target confirmation. International Journal of STD & AIDS 2009;20:315-319
3. Skidmore S, Copley S, Cordwell D et al. Positive nucleic acid amplification tests for Neisseria gonorrhoeae in young people tested as part of the National Chlamydia Screening Programme. International Journal of STD & AIDS 2011; 22: 398-399
4. Bignell C, FitzGerald M. UK national guideline for the management of gonorrhoea in adults, 2011. International Journal of STD & AIDS 2011;22:541-547
5. Moncada J, Donegan E, Schachter J. Evaluation of CDC- Recommended approaches for confirmatory testing of positive Neisseria gonorrhoeae nucleic acid amplification test results. J Clin Microbiol 2008;46:1614- 1619.
Conflict of Interest:
None declared
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High rates of syphilis among antenatal clients observed in Rarieda District, western Kenya
Submit responseStephanie Dellicour 1,2,3 , Florence Diemo4, Kayla Laserson2,3, Feiko ter Kuile1, Meghna Desai2,3 1. Child and Reproductive Health, Liverpool School of Tropical Medicine, UK 2. Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya 3. Centers for Disease Control and Prevention (CDC), Atlanta, USA 4. Rarieda District Medical Officer for Health (DMOH), Nyanza Province, Kenya
We read with great interest the article by Otieno-Nyunya and colleagues1. The authors report low prevalence of syphilis 1.8% (95% CI 1.5% to 2.1%) as detected through the Kenya AIDS Indicator Survey (KAIS) for 2007. The authors suggest these findings indicate that elimination of syphilis is a possibility in Kenya. They also show that syphilis testing is common among women attending antenatal care (ANC) clinics and that recent estimates suggest that prevalence of syphilis among pregnant women has declined to less than 1%. Despite this success, we wish to highlight that there may still be pockets of high syphilis prevalence in Kenya.
As part of an ongoing observational study among pregnant women attending ANC in Asembo, Rarieda District, western Kenya, we observed an unexpected high prevalence of syphilis of 11.5% (32/282). The study participants are women living in 33 villages within a 5km radius of the study health facility coming for routine antenatal care, representing the general population in this area (i.e. not selected according to any health related criteria). Antenatal profile laboratory tests are performed by the facility laboratory (supplied by the Kenya Medical Supplies Agency (KEMSA) or Mission for Essential Drugs and Supplies (MEDS)) and are available free of charge for study participants. Overall 282 first ANC clients have been tested for syphilis during the period between February and September 2011. Different tests have been used during that period depending on the supplies provided as follows: VDRL (from Euromedi Equipment LTD, UK) was used from February to beginning of May 2011 with an associated syphilis prevalence of 8% (11/143), treponemal only rapid test (Eurostrip from Euromedi Equipment LTD, UK) from May to July 2011 with a prevalence of 17% (17/101) and another treponemal only rapid test (from Acon Laboratories, USA) from August to September 2011 with a prevalence of 11% (4/38). Note that the latter two treponemal rapid tests show higher prevalence as these reflect both past and current infections. The prevalence of HIV infection in this population of pregnant women is 28% by rapid test (Determine from Alere Medical Company, Japan and Bioline Standard Diagnostics Inc., South Korea, with Uni-Gold Trinity Biotech PLC, Ireland as the tie-breaker).
All the 32 women testing positive for syphilis were asymptomatic and many did not get the prescribed treatment due to costs (one dose of Benzathine Penicillin and Erythromycin cost Ksh 300 equivalent to ~USD 3); 13 reported no treatment and 11 reported incomplete treatment out of 27 with follow up data. Untreated pregnancies can result in adverse outcomes due to syphilis, such as spontaneous abortion or stillbirth, neonatal death, low birth weight/premature birth or congenital infection of the newborn in up to 80% of cases.23 Furthermore due to the stigma associated with sexually transmitted infections (STIs), even if pregnant women get treated, their partners most often will not.
Similar high prevalence has since been reported at the district level. Collated data from monthly health facility reports in the district show 23% prevalence of syphilis for 2009/2010 and 12% for 2010/2011 (DMOH personal communication). These high rates remained unreported as syphilis is no longer a notifiable disease in Kenya since 2009. Furthermore, the prominence of HIV indicators at district and provincial level reporting may also be partly responsible for other STIs being under-reported and overlooked. The prevalence of syphilis, and of STIs in general, is higher in antenatal clients compared to the general population as these represent the sexually active group. Whereas, a few previous studies have shown the prevalence of syphilis among pregnant women in Kenya to range from 3% to 4%,3 4 Otieno-Nyunya et al report a syphilis prevalence of less than 1% in recently pregnant women from the KAIS survey and noted the limitation from this small sub-sample (which included only 1 positive pregnant woman).
The high rate observed in Rarieda district highlights the fact that there might be hot spots which will need to be managed in order to achieve elimination. Screening pregnant women for syphilis provides an important means to monitor population prevalence and of identifying pockets of high syphilis prevalence. In 1940s, western European countries introduced antenatal syphilis screening and management programmes as part of the strategy for syphilis elimination.5 However implementation of antenatal screening for syphilis in low income countries is often poor due to irregular procurement of tests and the additional cost of the syphilis test incurred by ANC clients. Otieno-Nyunya et al report that antenatal syphilis screening is common in Kenya. However, there is considerable variation in the uptake of syphilis testing. In Rarieda district, less than 10% of first ANC clients are tested for syphilis as reported by the health facilities in 2009 and 2010. New simple and user-friendly, point-of -care rapid diagnostic tests for syphilis provide an opportunity to scale- up antenatal syphilis screening even in facilities without laboratory capacity.
The low country-wide population prevalence detected by KAIS is encouraging, but should be interpreted carefully. It will be important to enhance antenatal syphilis screening both for sentinel surveillance and to reduce the incidence of adverse pregnancy outcomes attributable to syphilis as well as congenital syphilis. Maternal syphilis screening and treatment is among the most cost-effective public health interventions. 6 The effect of the antenatal syphilis screening program could be improved through earlier antenatal attendance, as well as expansion to cover free syphilis treatment and explicit efforts to encourage partner notification and treatment. Operational barriers including procurement inconsistencies with syphilis test types and stock outs of both tests and treatment should be addressed. Additionally, more efforts are needed to increase public and health professional awareness of the potential serious consequences of syphilis. All these efforts will be required for disease control and eventually elimination. More emphasis should also be given to HIV uninfected ANC clients who don't currently benefit from free care and treatment. As argued previously, there should be stronger integration between syphilis screening and HIV-PMTCT programmes which have higher level of funding and political commitment. 7 The Kenyan Division of Reproductive Health would benefit from additional support to strengthen national STI program and policies for the antenatal population.
References 1. Otieno-Nyunya B, Bennett E, Bunnell R, Dadabhai S, Gichangi AA, Mugo N, et al. Epidemiology of syphilis in Kenya: results from a nationally representative serological survey. Sex Transm Infect 2011;87(6):521-25. 2. Kamb ML, Newman LM, Riley PL, Mark J, Hawkes SJ, Malik T, et al. A road map for the global elimination of congenital syphilis. Obstet Gynecol Int 2010;2010. 3. Temmerman M, Gichangi P, Fonck K, Apers L, Claeys P, Van Renterghem L, et al. Effect of a syphilis control programme on pregnancy outcome in Nairobi, Kenya. Sex Transm Infect 2000;76(2):117-21. 4. Buve A, Weiss HA, Laga M, Van Dyck E, Musonda R, Zekeng L, et al. The epidemiology of gonorrhoea, chlamydial infection and syphilis in four African cities. AIDS 2001;15 Suppl 4:S79-88. 5. Deperthes BD, Meheus A, O'Reilly K, Broutet N. Maternal and congenital syphilis programmes: case studies in Bolivia, Kenya and South Africa. Bull World Health Organ 2004;82(6):410-6. 6. Vickerman P, Peeling RW, Terris-Prestholt F, Changalucha J, Mabey D, Watson-Jones D, et al. Modelling the cost-effectiveness of introducing rapid syphilis tests into an antenatal syphilis screening programme in Mwanza, Tanzania. Sex Transm Infect 2006;82 Suppl 5:v38-43. 7. Watson-Jones D, Oliff M, Terris-Prestholt F, Changalucha J, Gumodoka B, Mayaud P, et al. Antenatal syphilis screening in sub-Saharan Africa: lessons learned from Tanzania. Trop Med Int Health 2005;10(9):934-43.
Conflict of Interest:
None declared
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In a recent letter Oakeshott 1 cited the lack of data on the prevalence of Trichomonas vaginalis (TV) in young women in the UK...
Submit responseIn a recent letter Oakeshott 1 cited the lack of data on the prevalence of Trichomonas vaginalis (TV) in young women in the UK. In their own pilot study of 183 stored self -taken vaginal samples from multi-ethnic London female students in age group of 16-27, 2 (1.1%, 95% CI 0.1%-3.9%) were positive by an in house multiplex real-time PCR test. We in Macclesfield, UK, recently conducted a prospective pilot study to gain female positivity data with the use of a Nucleic acid amplification test (NAAT), the Gen-Probe Aptima TV assay (ATV) in three different clinical settings - community clinics, genitourinary (GU) medicine clinic and its satellite prison GU medicine service2. All women at the three different settings were offered an ATV test on the residual portions of the Aptima transport medium from any vulvovaginal swabs or first catch urine samples that had been collected for a routine Aptima Combo 2 Chlamydia/Gonorrhoea test. Women below the age of 16 were excluded. Positivity rates at community clinics and GU medicine, were respectively 0/382 (0%) and 3/358 (0.8%, CI 0% - 1.7%). Positivity was significantly higher, 29/269 (10.8%, CI 7.1% - 14.5%) - Odds Ratio 14.3 (4.11 < OR < 59.55) - in those tested at the prison. This compares to overall chlamydia positivity rates of 4.6% in the community, 6.3% in GU medicine and 5.3% in the prison and overall gonorrhoea positivity rates of 0.09%, 0.2% and 0.2% respectively.
For the 32 ATV positive women, the mean age was 30.6 (range 19 to 48) years, 27 were White British/Irish, 2 Chinese and 3 were of Black African origin, 9 (28%) were symptomatic and 3/32 (9.4%) had concomitant chlamydia. No woman had concomitant gonorrhoea. We also conducted a questionnaire survey of English GU medicine clinics and obtained data from the United Kingdom Health Protection agency (HPA) for England. Both demonstrated the large variation in case rates by region and testing methods employed. Higher rates were seen in women, in prison GUM services and in London GUM clinics. Perry et al3 in a recent ongoing study in a London GUM clinic using the ATV assay on residual routine samples taken for CT /GC in women found a positivity rate of 11.8% (36/305, age range for both men and women 24-39 years ), 81% of whom were symptomatic. They concluded that ATV improved clinical detection by 33% over wet mount microscopy and did not reveal as many missed diagnoses as predicted. They speculated that this was because the majority were symptomatic and that the ATV assay may have more important role in community based screening of asymptomatic women or men.
Consideration of current standards of care may mean more tests should be offered to a wider population. Monitoring positivity in defined patient groups where the test might be introduced should lead to cost- effective application and also help to clarify the levels of asymptomatic carriage. Use of the new CE marked ATV assay in some populations is warranted so as to lead to proper detection and treatment of TV and also possibly the prevention of other co-transmitted infections, such as HIV. REFERENCES 1. Oakeshott P, Ahmed J, Hay PE et al. Trichomonas vaginalis among multi- ethnic female UK students. Sex Trans Infect 2011;doi:10.2236/sextrans-2011 -050061 2. Mahto M, Evans-Jones J, Zia S et al Finding cases of Trichomonas vaginalis infection in England. International Journal of STD and AIDS 2011;22:471-473 3. Perry M, Benzie A, Erasmus K et al Clinical utility of a nucleic acid amplification test for Trichomonas vaginalis in a targeted urban genitourinary medicine clinic population. Oral Presentation, British Association for Sexual Health and HIV (BASHH) Spring Meeting, Gateshead, 11th-13th May 2011.
Conflict of Interest:
None declared
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