Academic journal article Bulletin of the World Health Organization

A Flowchart for Managing Sexually Transmitted Infections among Nigerian Adolescent Females

Academic journal article Bulletin of the World Health Organization

A Flowchart for Managing Sexually Transmitted Infections among Nigerian Adolescent Females

Article excerpt

Voir page 304 le resume en francais. En la pagina 305 figura un resumen en espanol.


Sexually transmitted infections (STIs) constitute a major health problem for women worldwide, especially adolescents, among whom Chlamydia trachomatis and Trichomonas vaginalis infections are prevalent (1). Both of these infections present with mild or no symptoms, particularly chlamydial infection, and their management among this age group presents a difficult problem. In developed countries trichomoniasis is uncommon, but screening for C. trachomatis using deoxyribonucleic acid (DNA) amplification techniques has been recommended (2) and screening programmes for young women have been introduced (3, 4). In developing countries, screening for chlamydial infection is not yet feasible, both because of high costs and the difficulty of reaching the target population.

Traditionally, adolescents have had limited access to sexual health services in developing countries (5), although this situation is changing. The number of clinics catering for adolescents is growing, but it is still critical that diagnosis and treatment of chlamydial infection, gonorrhoea, and trichomoniasis be improved in such clinics (6). The strategy currently recommended for these infections by WHO for women of all ages is syndromic management (7). This approach minimizes the use of laboratory tests and enables health providers to treat all infections commonly associated with a given STI syndrome. However, syndromic management of vaginal discharge does not perform well in women of any age (8-15). It is likely to do worse among adolescents who not only are frequently asymptomatic, but who are inexperienced in distinguishing a normal from an abnormal discharge (1). This paper describes a flowchart for management of chlamydial infection, gonorrhoea, and trichomonlasis, which is better suited for adolescents, many of whom present at clinics for reasons other than a suspected STI. In such cases it is useful for health professionals to have a flowchart to establish risk of STI exposure in girls who may or may not have symptoms.


Cross-sectional surveys using cluster sampling techniques were used to recruit girls aged 14-19 years who were attending five secondary schools in Port Harcourt, Rivers State, Nigeria, or who lived in the same community. The girls were contacted through house-to-house visits and were carefully questioned on their sexual history, and if they were sexually experienced were asked to make a clinic appointment for later screening for STIs. Clinics were held in the schools or in a local health centre, where a "drop-in" centre for young people had been established. Sexually experienced girls were regarded as being sexually active if they reported having had a sexual partner within the previous three months. This was also regarded as evidence of "recent sexual activity". This definition differs from the WHO risk-screening criteria, which refer to a new partner within the previous three months (7).

We have previously described the methods used for specimen collection and laboratory analyses to determine the presence of C. trachomatis, N. gonorrhoeae and T. vaginalis (16), except that, in addition, the leukocyte esterase (LE) urine test was used in this study. This non-specific screening test has previously been incorporated into management protocols (17-20). Briefly, for trichomonal infection, wet-mount microscopy of high vaginal swabs was performed immediately the specimens arrived at the laboratory (within 4-6 h of collection). Gonococcal culture specimens were incubated at 35-37 [degrees] C for up to 48 h. The sugar-use test was performed on all oxidase-positive Gram-negative diplococci using Flynn & Waitkin slopes, and antimicrobial sensitivity was performed on gonococcal isolates. Chlamydia antigens were detected by enzyme-linked immunosorbent assay (ELISA) (Mastazyme, Mast Laboratories, Bootle, England). …

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