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Public health issues

Syndromic management of infection

In low and middle -income countries, the World Health Organisation recommends syndromic (symptoms and sign-based) management of individuals with symptomatic chlamydial infection. The cost and clinical effectiveness of this strategy in different settings has been investigated by a number of authors.

There have been a number of African-based studies. In Benin, 481 female sex workers were screened for sexually transmitted infections using laboratory tests. They were asked to return to the clinic within 10 days for laboratory test results and appropriate treatment when necessary. The prevalence of cervical infections was 24.5%. In comparison to the gold standard, the sensitivity of syndromic diagnosis for N. gonorrhoeae or C. trachomatis infections was 48.3% compared with 74.6% for the locally performed laboratory tests. However, the real sensitivity of the laboratory tests dropped to 28.8% since 57.6% of the infected women did not return to the clinic within 10 days. The poor return rate emphasized the need for presumptive treatment on the basis of symptoms on initial attendance at the clinic [Mukenge-Tshibaka et al., 2002].  In the Central African Republic, 481 women visiting the antenatal services of the 3 major governmental health centres in the capital city were tested for sexually transmitted infections and they underwent gynaecological examination. 34% of the women were diagnosed as having at least one sexually transmitted infection. Self-reported and health worker-recognized symptoms and signs manifested only low sensitivities, specificities, and positive predictive values [Blankhart et al., 1999]. The effectiveness of syndromic treatment as a control strategy depends on the proportion of episodes which become symptomatic. In Uganda, Korenromp et al., 2002 estimated that the proportions of episodes becoming symptomatic were 45% and 11% for males with N. gonorrhoeae or  C. trachomatis respectively; corresponding figures for women were 14% and 6%. It was considered that in populations with low treatment rates like Uganda the probability of recognizing and treating symptoms was low and that health education should be an important priority of control programmes.

In Asia, in Bangladesh, Hawkes et al., 1999 investigated all women complaining of abnormal vaginal discharge and seeking care at maternal and child health/family-planning centres for the presence of laboratory-diagnosed reproductive-tract infections. Syndromic diagnoses made by trained health-care workers were compared with the laboratory diagnosis of infection. The prevalence of endogenous infections among the 320 women seen was 30% but cervical gonococcal or chlamydial infections were found in only 3 of these women [an unusually low prevalence of infection compared with other settings]. The WHO algorithm had a high sensitivity (100%) but a low specificity. An alternative speculum-based algorithm had a low sensitivity (between zero and 59%) but  higher specificity (79-97%).  Cost analysis indicated that 87% of expenditure was wasted on overtreatment under the WHO algorithm, while only 36% of expenditure was wasted on overtreatment using the speculum-based algorithm [Hawkes et al., 1999]. In India, Vishwanath et al., 2000 assessed the usefulness of the syndromic approach in the management of vaginal discharge among women attending a reproductive health clinic in New Delhi, India. Women who sought services from the clinic and who had a complaint of vaginal discharge were interviewed, underwent a pelvic examination, and provided samples for laboratory investigations of bacterial vaginosis, candidiasis, syphilis, trichomoniasis, and Chlamydia trachomatis and Neisseria gonorrhoeae infections. Data analysis focused on the prevalence of infection and on the performance of the algorithm recommended by the national authorities for the management of vaginal discharge. The most common infection among 319 women was bacterial vaginosis (26%) and at least one sexually transmitted infection was detected in 21.9% of women. It was concluded that the syndromic approach is not an efficient tool for detecting chlamydial infection in women [Vishwanath et al., 2000]. In China, Hong et al., 2002 reported that the WHO syndromic algorithm for the management of pelvic inflammatory disease in women was useful, leading to effective reduction of symptoms following treatment. In men in S. Thailand, a study was performed to determine whether the conventional urine two-glass test or a leucocyte esterase test of first-void urine  could improve the sensitivity or specificity of the World Health Organization (WHO) algorithm for the syndromic management of men with urethritis [Chandeying et al., 2000]. Neither the two-glass test nor the leukocyte esterase test of first void urine were considered useful in improving on the WHO algorithm for management of men with urethritis. It was recommended that in this area, men with symptoms of urethritis in whom a urethral discharge is present on examination should be offered immediate treatment for presumptive N. gonorrhoeae and C. trachomatis infections as per the WHO algorithm. As far as treatment in a resource-poor setting is concerned, Rustomjee et al., 2002 performed a small, randomised controlled trial to assess the effectiveness of azithromycin versus a standard regimen with doxycycline/ciprofloxacin in the treatment of sexually transmitted infection. Infection with Chlamydia trachomatis was cured in 23/24 (95.8%) of women with azithromycin versus 19/21 (90.5%) in the doxycycline arm (P = 0.6), resulting in three treatment failures. Gonorrhoea was cured in 55/56 (98.2%) women, with one treatment failure in a patient with concomitant C. trachomatis infection. Although this trial lacks adequate power, the results indicate that a single oral dose of azithromycin may prove to be an effective and convenient treatment for sexually transmitted infections in women in a resource-poor environment.

[MEW] July 2004

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References

Blankhart, D., Muller, O., Gresenguet, G. & Weis, P. (1999). Sexually transmitted infections in young pregnant women in Bangui, Central African Republic. International Journal of STD and AIDS. 10, 609 - 614.

Chandeying, V., Skov, S., Tabrizi, S. N., Kemapunmanus, M. & Garland, S. (2000).  Can a two-glass urine test or leucocyte esterase test of first-void urine improve syndromic management of male urethritis in southern Thailand? International Journal of STD and AIDS. 11, :235 - 240.

Hawkes, S., Morison, L., Foster, S., Gausia, K., Chakraborty, J., Peeling, R. W,  & Mabey, D. (1999).  Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet. 1999 Nov 20;354(9192):1776-81.

Hong, S., Xin, C., Qianhong, Y., Yanan, W., Wenyan, X., Peeling, R. W. & Mabey, D. (2002). Pelvic inflammatory disease in the People's Republic of China: aetiology and management. International Journal of STD and AIDS 13, 568 - 572.

Korenromp, E. L., Sudaryo, M. K., de Vlas, S. J., Gray, R. H., Sewankambo, N. K., Serwadda, D., Wawer, M. J. & Habbema, J. D. (2002). What proportion of episodes of gonorrhoea and chlamydia becomes symptomatic? International Journal of STD and AIDS. 13,  91 - 101.

Mukenge-Tshibaka, L., Alary, M., Lowndes, C. M., van Dyck, E., Guedou, A., Geraldo, N., Anagonou, S., Lafia, E. & Joly, J. R. (2002). Syndromic versus laboratory-based diagnosis of cervical infections among female sex workers in Benin: implications of nonattendance for return visits. Sexually Transmitted Diseases 29, 324 - 330.

Rustomjee, R., Kharsany, A. B., Connolly, C. A. & Karim, S. S. (2002). A randomized controlled trial of azithromycin versus doxycycline/ciprofloxacin for the syndromic management of sexually transmitted infections in a resource-poor setting. Journal of Antimicrobial Chemotherapy 49, 875 - 878.

Trollope-Kumar, K. (1999). Symptoms of reproductive-tract infection: not all that they seem to be. Lancet 354, 1745 - 1746.

Vishwanath, S., Talwar, V., Prasad, R., Coyaji, K., Elias, C. J. & de Zoysa, I. (2000). Syndromic management of vaginal discharge among women in a reproductive health clinic in India. Sexually Transmitted Infections 76, 303 - 306.