GHENT UNIVERSITY Karoline FONCK - International Centre for ...
GHENT UNIVERSITY Karoline FONCK - International Centre for ... GHENT UNIVERSITY Karoline FONCK - International Centre for ...
Table 3: Association between risk factors, symptoms and signs and gonococcal (NG) or chlamydial (CT) infection among 287 nonpregnant women and 334 pregnant women, consulting for vaginal discharge*. Non-pregnant women (n=287) Pregnant women (n=334) RISK DETERMINANTS SYMPTOMS SIGNS NG/CT - NG/CT NG/CT - NG /CT +ve ve Odds +ve ve Odds (n=53) (n=234) ratio (n=44) (n=290) ratio n (%) n (%) (95% CI) P n (%) n (%) (95% CI) Single 27 (51) 87 (37) 1.7 0.05 10 (23) 59 (20) 1.2 (1.0-3.2) (0.5-2.5) Age < 20 15 (28) 40 (17) 1.9 (1.0-3.8) Condom use 22 (42) 106 (46) 0.8 (0.5-1.5) >1 sex partner 14 (26) 18 (8) 4.3 (2.0-9.4) 1 or more new partners 12 (23) 26 (11) 2.3 (1.1-5.0) Pruritus 23 (43) 161 (69) 0.3 (0.2-0.6) Sore vulva 9 (17) 74 (32) 0.4 (0.2-0.9) Dysuria 15 (29) 57 (25) 1.2 (0.6-2.5) Dyspareunia 13 (25) 74 (33) 0.7 (0.3-1.4) Abdominal pain 28 (53) 112 (48) 1.2 (0.7-2.2) Fever 9 (17) 15 (7) 3.0 (1.2-7.2) Scratch marks 12 (23) 82 (35) 0.5 (0.3-1.1) Vulvitis 8 (15) 53 (23) 0.6 (0.3-1.4) Malodorous discharge 12 (23) 40 (17) 1.4 (0.7-3.0) Moderate/copious discharge 40 (77) 144 (64) 1.9 (0.9-3.8) Yellow/bloody discharge 28 (55) 66 (29) 3.0 (1.6-5.5) Purulent or bloody endocervical mucopus 23 (43) 55 (24) 2.5 (1.3-4.6) Cervix erythema 20 (38) 47 (20) 2.4 (1.3-4.5) Cervix friability 23 (43) 61 (27) 2.1 (1.1-4.0) Painful adnexa 19 (36) 56 (24) 1.8 (0.9-3.4) Motion tenderness 12 (23) 33 (14) 1.8 (0.9-3.7) 0.05 20 (46) 52 (18) 3.8 (2.0-7.5) 0.3 12 (27) 100 (35) 0.7 (0.4-1.4) DIAGNOSIS AND MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS 63
Evaluation of Algorithms The results of the validation of the different algorithms for pregnant and non-pregnant women are presented in Table 4. Table 4: Sensitivity, specificity and positive predictive value (PPV) for gonococcal and chlamydial infections for different diagnostic algorithms for vaginal discharge, among 621 women, and comparing pregnant with non-pregnant women. Total (n=621) Non-pregnant (n=287) Pregnant (n=334) Sensitivity Specificity PPV Sensitivity Specificity PPV Sensitivity Specificity PPV Algorithm (%) (%) (%) (%) (%) (%) (%) (%) (%) A 42 63 18 47 57 20 36 69 15 B 50 58 18 53 52 20 45 63 16 C 59 61 22 66 54 24 50 67 18 D 45 68 21 55 71 30 33 66 13 E 42 73 22 43 76 29 41 70 17 F 78 42 20 85 38 24 70 46 16 All the above algorithms require the presence of vaginal discharge and: A: Algorithm as in use in Kenya (complaint of abdominal pain and abdominal tenderness on examination); B : Modified Kenyan algorithm (complaint of abdominal discharge and no examination performed); C : WHO algorithm (risk score except for symptoms in partner); D: Yellow or bloody discharge visible on examination of vagina; E: Endocervical mucopus on speculum examination; F: Risk score positive and/or yellow or bloody vaginal discharge visible. Applying the Kenyan national policy algorithm resulted in a sensitivity of 42% and a specificity of 63% for gonococcal or chlamydial cervicitis, with a PPV of 18% (algorithm A). The Kenyan algorithm but without an abdominal examination, hence relying on the complaint of abdominal pain alone (B), resulted in a higher sensitivity and somewhat lower specificity. The algorithm with risk score C gave a sensitivity of 59% and a specificity of 61% with a PPV of 22%. Algorithm D relies on the inspection of the color of the vaginal discharge and does not necessarily require a speculum examination. Algorithm E requires inspection of the cervix by speculum examination. Both algorithms D and E result in a sensitivity and a specificity similar to algorithm A but with marginal higher PPV. Algorithm F, a combination of risk score and presence of yellow or bloody vaginal discharge, resulted in the highest sensitivity but had low specificity. Among non-pregnant women, all algorithms produced a higher sensitivity. Among pregnant women, however, the different algorithms had a lower sensitivity. The overall correct treatment rate of the different flow charts varied and was in general higher among non-pregnant women, except for flow charts D and E. The cost per case varied from US$ 0.5 to US$ 0.9. The cost per true cervical infection treated varied from US$ 6.7 for the risk score algorithm to US$ 8.3 for the Kenyan algorithm. Algorithm F identified more true cervical infections than the other flow charts but the overall cost was substantially higher (table not presented here). DIAGNOSIS AND MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS 64
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Table 3: Association between risk factors, symptoms and signs and gonococcal (NG) or chlamydial (CT) infection among 287 nonpregnant<br />
women and 334 pregnant women, consulting <strong>for</strong> vaginal discharge*.<br />
Non-pregnant women (n=287) Pregnant women (n=334)<br />
RISK DETERMINANTS<br />
SYMPTOMS<br />
SIGNS<br />
NG/CT -<br />
NG/CT<br />
NG/CT -<br />
NG /CT +ve ve Odds<br />
+ve ve Odds<br />
(n=53) (n=234) ratio<br />
(n=44) (n=290) ratio<br />
n (%) n (%) (95% CI) P n (%) n (%) (95% CI)<br />
Single 27 (51) 87 (37) 1.7 0.05 10 (23) 59 (20) 1.2<br />
(1.0-3.2)<br />
(0.5-2.5)<br />
Age < 20 15 (28) 40 (17) 1.9<br />
(1.0-3.8)<br />
Condom use 22 (42) 106 (46) 0.8<br />
(0.5-1.5)<br />
>1 sex partner 14 (26) 18 (8) 4.3<br />
(2.0-9.4)<br />
1 or more new partners 12 (23) 26 (11) 2.3<br />
(1.1-5.0)<br />
Pruritus 23 (43) 161 (69) 0.3<br />
(0.2-0.6)<br />
Sore vulva 9 (17) 74 (32) 0.4<br />
(0.2-0.9)<br />
Dysuria 15 (29) 57 (25) 1.2<br />
(0.6-2.5)<br />
Dyspareunia 13 (25) 74 (33) 0.7<br />
(0.3-1.4)<br />
Abdominal pain 28 (53) 112 (48) 1.2<br />
(0.7-2.2)<br />
Fever 9 (17) 15 (7) 3.0<br />
(1.2-7.2)<br />
Scratch marks 12 (23) 82 (35) 0.5<br />
(0.3-1.1)<br />
Vulvitis 8 (15) 53 (23) 0.6<br />
(0.3-1.4)<br />
Malodorous discharge 12 (23) 40 (17) 1.4<br />
(0.7-3.0)<br />
Moderate/copious discharge 40 (77) 144 (64) 1.9<br />
(0.9-3.8)<br />
Yellow/bloody discharge 28 (55) 66 (29) 3.0<br />
(1.6-5.5)<br />
Purulent or bloody endocervical<br />
mucopus<br />
23 (43) 55 (24) 2.5<br />
(1.3-4.6)<br />
Cervix erythema 20 (38) 47 (20) 2.4<br />
(1.3-4.5)<br />
Cervix friability 23 (43) 61 (27) 2.1<br />
(1.1-4.0)<br />
Painful adnexa 19 (36) 56 (24) 1.8<br />
(0.9-3.4)<br />
Motion tenderness 12 (23) 33 (14) 1.8<br />
(0.9-3.7)<br />
0.05 20 (46) 52 (18) 3.8<br />
(2.0-7.5)<br />
0.3 12 (27) 100 (35) 0.7<br />
(0.4-1.4)<br />
DIAGNOSIS AND MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS 63<br />
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