GHENT UNIVERSITY Karoline FONCK - International Centre for ...

We evaluated the validity of different algorithms for the diagnosis of gonococcal and
chlamydial infections among 621 pregnant and non-pregnant women consulting for
complaints of vaginal discharge in 3 City Council clinics. The mean age was 24 years and
334 (54%) were pregnant. The overall prevalence rates were: 50% candidiasis, 23%
trichomoniasis, 9% bacterial vaginosis, 7% gonorrhoea, 9% chlamydia, 7% syphilis and 22%
HIV. In non pregnant women, gonococcal and chlamydial infection was significantly
associated with 1) demographic and behavioral risk markers such as being single, younger
than 20 years, multiple sex partners in the previous 3 months; 2) symptom fever; and 3)
signs including presence of yellow or bloody vaginal discharge, cervical mucopus, cervical
erythema and friability. Among pregnant women only young age, dysuria and fever were
significantly associated with cervical infection. However, none of these variables on itself was
both sensitive and specific enough for the diagnosis of cervical infection. Several algorithms
were generated and applied to the study data. The algorithm including risk markers
performed slightly better than the current Kenyan algorithm. We concluded that STIs form a
major problem in the Nairobi area and should be addressed accordingly. None of the tested
algorithms for the treatment of vaginal discharge would constitute a marked improvement of
the existing flowchart. Hence better detection tools for the specific etiology of vaginal
discharge are urgently needed.
An analysis of data collected through routine program monitoring indicates that syphilis
serology in pregnant women has declined in Nairobi from 7.3% to 3.8% between 1993 and
1997. We analyzed routinely collected data of 1998 to describe the performance and costs of
a decentralized syphilis-screening program in pregnant women. RPR seroprevalence was
3.4%. The program succeeded in screening and treating women and partners properly, but
failed in performing reliable RPR tests. The cost per averted case was calculated between
$95 and $112. The sustainability of this labor-intensive program is threatened by costs and
logistic constraints. Alternative strategies, such as mass epidemiological treatment of
pregnant women should be considered.
As part of a larger study on neonatal outcome of syphilis during pregnancy, we examined the
determinants of partner notification among pregnant syphilitic women. Of the 12,414 women
tested for syphilis at delivery, 377 (3%) were RPR reactive. Only 53% of those women
informed their partner and 36% of the partners were treated. Adverse pregnancy outcome
was related to lack of treatment of the partner during pregnancy (2% versus 15%, OR 6.1,
95% CI 0.8-45). This study shows lower partner notification/treatment rates in syphilisinfected
women identified at delivery than during pregnancy. These findings suggest that
messages focusing on the health of the unborn child have a positive effect on partner
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