Academic journal article Bulletin of the World Health Organization

Screening for Sexually Transmitted Diseases in Rural Women in Papua New Guinea: Are WHO Therapeutic Algorithms Appropriate for Case Detection?(*)

Academic journal article Bulletin of the World Health Organization

Screening for Sexually Transmitted Diseases in Rural Women in Papua New Guinea: Are WHO Therapeutic Algorithms Appropriate for Case Detection?(*)

Article excerpt


Sexually transmitted diseases (STDs) are an important cause of morbidity and mortality worldwide, particularly in resource-poor settings. High rates of STDs have been documented among apparently low-risk women, with reported prevalences in antenatal clinics, family planning clinics and rural community-based surveys in the range 1-29% for Chlamydia trachomatis, 3-49% for Trichomonas vaginalis, 0.3-22% for Neisseria gonorrhoeae, and 0.3-18% for syphilis (1-3). The complications and sequelae of these infections affect women more than men, and include ectopic pregnancies, infertility, chronic pelvic pain, postpartum endometritis, cervical cancer, fetal wastage, low birth weight, and congenital or perinatal infections (1-4). More recently there has been increasing evidence that STDs increase sexual transmission of human immunodeficiency virus (HIV) (1, 5-7).

Although early detection and treatment of STDs can prevent complications and minimize the severity of long-term sequelae, many infections go untreated. Utilization of specialized services for the management of STDs is often low, in part because infections are frequently asymptomatic or produce vague, nonspecific symptoms, particularly among women. Cultural barriers, as well as poor understanding of the significance of symptoms may also reduce care-seeking by women. In order to make services more widely available, it has been suggested that STD screening and management should be incorporated into other primary health services, including family planning, antenatal, and maternal and child health (MCH) clinics (1-4, 8-14). Training staff and providing the necessary resources for appropriate management of symptomatic patients presenting for treatment at every level of the health system is clearly better than not having these services available. However, the vast majority of infected women (and possibly men) appear not to present for treatment at all, and there is thus a need for active case detection if infected people are to be identified and treated.

A further constraint is that laboratory diagnosis for STDs, even for syphilis or trichomonal infection, is frequently unavailable in peripheral health facilities in developing countries. In such settings, techniques for detection of chlamydial and gonococcal infection are prohibitively expensive and technically demanding (14). In response to the limited availability of laboratory tests, MHO has developed algorithms for the syndromic management of patients presenting for STD treatment (15). These algorithms are presented as flow charts (see Figs. 1 and 2), which indicate appropriate management based on the patient's symptoms, signs and risk assessment, and have been developed for various levels of clinical and microscopic capacity. A standard risk assessment has been developed, but it is recommended that this should be tailored to local risk factors if the information is available. However, these algorithms are intended for case management of people specifically presenting for treatment, and were not developed as a screening tool for case detection.


For case detection, screening based on risk assessment (with or without clinical information), followed by presumptive treatment, has been suggested (1, 9, 10, 12, 16). Several studies have appeared in which risk scores for the detection of chlamydial and gonococcal infection in various clinical settings in Africa have been developed and evaluated (9, 10, 12, 17). It has also been suggested that the MHO algorithms could be used as a screening tool in family planning, antenatal, and MCH clinics (18). This approach has the advantage that training health staff to use the MHO algorithms as a screening tool could be readily combined with training them in their use for symptomatic patients, and would avoid the potential confusion that might arise if different risk assessment tools are used for different purposes. …

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