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Optimising the management of vaginal discharge syndrome in Bulgaria: cost effectiveness of four clinical algorithms with risk assessment
  1. Nadine Cornier1,2,
  2. Elena Petrova3,
  3. Philippe Cavailler4,
  4. Rossitza Dentcheva1,
  5. Fern Terris-Prestholt5,
  6. Arnaud Janin2,
  7. Béatrice Ninet6,
  8. Jean-Luc Anguenot6,
  9. Pierre Vassilakos7,
  10. Antonio Gerbase8,
  11. Philippe Mayaud5
  1. 1Médecins Sans Frontières, Sofia, Bulgaria
  2. 2Médecins Sans Frontières, Geneva, Switzerland
  3. 3Department of Dermato-Venereology, Sofia, Bulgaria
  4. 4Epicentre, Paris, France
  5. 5London School of Hygiene and Tropical Medicine, London, UK
  6. 6Hôpital Universitaire de Genève, Geneva, Switzerland
  7. 7Institut de Pathologie, Geneva, Switzerland
  8. 8World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Philippe Mayaud, Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; philippe.mayaud{at}


Objectives To evaluate the performance and cost effectiveness of the WHO recommendations of incorporating risk-assessment scores and population prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) into vaginal discharge syndrome (VDS) algorithms.

Methods Non-pregnant women presenting with VDS were recruited at a non-governmental sexual health clinic in Sofia, Bulgaria. NG and CT were diagnosed by PCR and vaginal infections by microscopy. Risk factors for NG/CT were identified in multivariable analysis. Four algorithms based on different combinations of behavioural factors, clinical findings and vaginal microscopy were developed. Performance of each algorithm was evaluated for detecting vaginal and cervical infections separately. Cost effectiveness was based on cost per patient treated and cost per case correctly treated. Sensitivity analysis explored the influence of NG/CT prevalence on cost effectiveness.

Results 60% (252/420) of women had genital infections, with 9.5% (40/423) having NG/CT. Factors associated with NG/CT included new and multiple sexual partners in the past 3 months, symptomatic partner, childlessness and ≥10 polymorphonuclear cells per field on vaginal microscopy. For NG/CT detection, the algorithm that relied solely on behavioural risk factors was less sensitive but more specific than those that included speculum examination or microscopy but had higher correct-treatment rate and lower over-treatment rates. The cost per true case treated using a combination of risk factors, speculum examination and microscopy was €24.08. A halving and tripling of NG/CT prevalence would have approximately the inverse impact on the cost-effectiveness estimates.

Conclusions Management of NG/CT in Bulgaria was improved by the use of a syndromic approach that included risk scores. Approaches that did not rely on microscopy lost sensitivity but were more cost effective.

  • Sexually transmitted infections (STI)
  • syndromic management
  • cervical infections
  • N gonorrhoeae (NG)
  • C trachomatis (CT)
  • cost effectiveness
  • Bulgaria
  • Eastern Europe
  • cervicitis
  • risk profiles
  • vaginal discharge
  • vaginal infections
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  • Funding This study was supported by a grant from the Swiss Agency for Development and Cooperation. PM and FT-P were supported by the UK Department for International Development (DFID) Knowledge Programme on HIV/AIDS and STI of the London School of Hygiene and Tropical Medicine. The views expressed in this article do not necessarily represent those of DFID.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Permission to carry out the study was given by Ministry of Health of Bulgaria. Ethical clearance was obtained from the Geneva University Hospital Ethical Committee and from the Commission of Professional Ethics of the Bulgarian Medical Board. The economic study was later approved by the Ethics Committee of the London School of Hygiene and Tropical Medicine.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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