Syndromic management of vaginal discharge among women in a reproductive health clinic in India
Vishwanath,Sneh; Talwar,Vibha; Prasad,Rajendra; Coyaji,Kurus; Elias,Christopher J.; De Zoysa,Isabelle
Sexually Transmitted Infections 76(4): 303-306
Publication date: 2000
To examine the performance of the syndromic approachin the management of vaginal discharge among women attendinga reproductive health clinic in New Delhi, India.
Women who sought services from the clinic and who hada complaint of vaginal discharge were interviewed, underwenta pelvic examination, and provided samples for laboratory investigationsof bacterial vaginosis, candidiasis, syphilis, trichomoniasis,and Chlamydia trachomatis and Neisseria gonorrhoeae infections.Data analysis focused on the prevalence of infection and onthe performance of the algorithm recommended by the nationalauthorities for the management of vaginal discharge.
The most common infection among 319 women was bacterialvaginosis (26%). At least one sexually transmitted infectionwas detected in 21.9% of women. The prevalence of C trachomatisinfection was 12.2%; trichomoniasis 10%; syphilis 2.2%; N gonorrhoeaewas not isolated. An algorithm based on risk assessment andspeculum assisted clinical evaluation was not helpful in predictingcervical infections associated with C trachomatis (sensitivity5% and PPV 9%). This algorithm was sensitive (95%) though notspecific (22%) in selecting women for metronidazole therapyeffective against bacterial vaginosis or trichomoniasis, andovertreatment was a problem (PPV 38%). The sensitivity, specificity,and PPV of this algorithm for the treatment of candidiasis were46%, 98%, and 88% respectively. The cost per case assessed usingthe algorithm was $2 and the cost per infection correctly treatedwas $4.25.
The prevalence of cervical infection associatedwith C trachomatis was high among these "low risk" women. Thesyndromic approach is not an efficient tool for detecting thiscondition, and alternative approaches to evaluation and interventionare required. The syndromic management of vaginal dischargeamong women seeking family planning and other reproductive healthservices should focus on vaginal infections, thus enhancingquality of care and addressing women's concerns about theirhealth.