Management of Vaginal Discharge in Women Treated at a Jamaican Sexually Transmitted Disease Clinic: Use of Diagnostic Algorithms Versus Laboratory Testing

Abstract

The management of cervical infections is difficult in developing countries because laboratory facilities for diagnosing these infections are seldom available; therefore, syndrome-based management has been recommended by the World Health Organization (WHO). However, such alternative approaches need to be evaluated in real field settings. We used algorithms (flowcharts) for syndromic management of abnormal vaginal discharge to treat 752 women who presented at a Jamaican sexually transmitted disease (STD) clinic. Laboratory testing revealed cervical infection (gonococcal and/or chlamydial) in 34% of these women; trichomoniasis was documented for 25%; and at least one STD was documented for 54% of the women. Use of a clinical algorithm for diagnosing cervical infection was 73% sensitive (95% CI, 67-78) and 55% specific (95% CI, 49-62) when compared with laboratory testing. The risk-assessment-inclusive flowchart developed by WHO was 84% sensitive (95% CI, 80-89) and 40% specific (95% CI, 34-46) for diagnosing cervical infection. Positive predictive values for diagnosing cervical infection with use of the algorithms ranged from 42% to 43%, and negative predictive values ranged from 78% to 81%. The sensitivity of the algorithms for diagnosing trichomoniasis ranged from 85% to 88%. To treat as many infected women as possible, the most sensitive algorithm was selected for routine use in Jamaican STD clinics.

Genital syndromes and syndromic management of vaginal discharge in a community setting

“…However, it is evident that STDs are not a major cause of vaginal discharge and treatment of all symptomatic women for these diseases would, therefore, be a waste of scanty resources. This is in contrast to the STD clinic setting where the World Health Organization recommended algorithm was found to have a sensitivity of 85%, speci city of 40% and a positive predictive value (PPV) of 43% due to a higher prevalence of disease in a hospital setting 8 . Another disadvantage of the syndromic approach is that it does not address the issue of sub-clinical and asymptomatic infections 9 .…”

Economic hardship and sexually transmitted diseases in Haiti's rural Artibonite Valley.

“…A number of clinical algorithms have been developed for the diagnosis of gonorrhea and chlamydia that rely upon historical risk factors and clinical exam. [36][37][38] However, most of these algorithms are too insensitive or too cumbersome for application in the field. This study and others have shown that the urine LED is too insensitive and non-specific for use as an independent screening tool for cervical infection.…”

Screening and Syndromic Approaches to Identify Gonorrhea and Chlamydial Infection among Women

“…Development of simple, inexpensive, valid field diagnostics is a top priority for identifying and treating women with gonorrhea and chlamydial infection (Wasserheit 1989;Behets et al 1995;Ryan et al 1995;Mayaud et al 1995;Vuylsteke et al 1993;van Dam et al 1998). Whether family planning and other health-care services will be able to afford even inexpensive diagnostic tests and appropriate treatment is unknown.…”