Sexual Health Sexual Health Society
Publishing on sexual health from the widest perspective
RESEARCH ARTICLE

Syndromic management of sexually transmissible infections in resource-poor settings: a systematic review with meta-analysis of the abnormal vaginal discharge flowchart for Neisseria gonorrhoea and Chlamydia trachomatis

Caroline van Gemert A B H , Margaret Hellard A B , Catriona S. Bradshaw C D , Freya J. I. Fowkes A B E F , Paul A. Agius A B , Mark Stoove A B and Catherine M. Bennett G
+ Author Affiliations
- Author Affiliations

A Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia.

B Department of Epidemiology and Preventative Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia.

C Central Clinical School, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia.

D Melbourne Sexual Health Clinic, 580 Swanston Street, Carlton, Vic. 3053, Australia.

E Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic. 3010, Australia.

F Department of Infectious Diseases, Central Clinical School, Monash University, Level 2, The Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia.

G Centre for Population Health Research, Deakin University, Geelong, Vic. 3220, Australia.

H Corresponding author. Email: caroline.vangemert@burnet.edu.au

Sexual Health - https://doi.org/10.1071/SH17070
Submitted: 30 March 2017  Accepted: 19 June 2017   Published online: 25 August 2017

Abstract

Background: Syndromic management of sexually transmissible infections is commonly used in resource-poor settings for the management of common STIs; abnormal vaginal discharge (AVD) flowcharts are used to identify and treat cervical infection including Neisseria gonorrhoea and Chlamydia trachomatis. A systematic review and meta-analysis was undertaken to measure the diagnostic test performance of AVD flowcharts, including both World Health Organization (WHO)- and locally-adapted AVD flowcharts. Methods: A systematic search of multiple electronic databases was conducted to locate eligible studies published between 1991 and 2014. Flowcharts were categorised into one of 14 types based on: 1) use of WHO guidelines or locally-adapted versions; 2) use of risk assessment, clinical examination or both; and 3) symptomatic entry. Summary diagnostic performance measures calculated included summary sensitivity, summary specificity and diagnostic odds ratio. Results: Thirty-six studies, including data on 99 flowcharts, were included in the review. Summary sensitivity estimates for WHO flowcharts ranged from 41.2 to 43.6%, and for locally adapted flowcharts from 39.5 to 74.8%. Locally adapted flowcharts performed slightly better than the WHO flowcharts. A difference in performance was not observed between use of risk assessment or clinical examination. The AVD flowchart performed slightly better when it was not restricted to symptomatic women only. Conclusions: There was considerable variation in the performance of the AVD flowchart but overall it was a poor diagnostic tool regardless of whether risk assessment or clinical examination was included, or whether the flowchart was WHO or locally developed. Many women were treated unnecessarily and many women with cervical infection were not detected. We caution against their continued use for management of cervical infection.


References

[1]  World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections. Geneva: World Health Organization; 2001.

[2]  Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sex Transm Infect 2004; 80 174–82.
Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges.CrossRef | 1:STN:280:DC%2BD2c3ntFWisA%3D%3D&md5=cf92ceb65608b8255cb2db0e219311eeCAS |

[3]  UNAIDS, World Health Organization. Consultation on STD interventions for preventing HIV: What is the evidence? Geneva: World Health Organization; 2000.

[4]  Low N, Broutet N, Adu-Sarkodie Y, Barton P, Hossain M, Hawkes S. Global control of sexually transmitted infections. Lancet 2006; 368 2001–16.
Global control of sexually transmitted infections.CrossRef |

[5]  Dallabetta GA, Gerbase AC, Holmes KK. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases. Sex Transm Infect 1998; 74 S1–S11.

[6]  Pettifor A, Walsh J, Wilkins V, Raghunathan P. How effective is syndromic management of STDs? A review of current studies. Sex Transm Dis 2000; 27 371–85.
How effective is syndromic management of STDs? A review of current studies.CrossRef | 1:STN:280:DC%2BD3M%2FmvFSrtg%3D%3D&md5=14e87b2de908fbdef79407fdf22a097aCAS |

[7]  World Health Organization. Management of patients with sexually transmitted diseases. Geneva: World Health Organization; 1991.

[8]  Pépin J, Deslandes S, Khonde N, Kintin DF, Diakite S, Sylla M, et al Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management. Sex Transm Infect 2004; 80 230–5.
Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management.CrossRef |

[9]  Vuylsteke B, Laga M, Alary M, Gerniers MM, Lebughe JP, Nzila N, et al Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire. Clin Infect Dis 1993; 17 82–8.
Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire.CrossRef | 1:STN:280:DyaK3szlslChsQ%3D%3D&md5=325a88bb6279a05fb88b6ff2a81ca43fCAS |

[10]  World Health Organisation. Guidelines for the management of sexually transmitted infections. Geneva: World Health Organization; 2003.

[11]  World Health Organization. Report of the informal technical working group meeting on STD activities in GPA; Geneva: World Health Organization; 1993.

[12]  Zemouri C, Wi TE, Kiarie J, Seuc A, Mogasale V, Latif A, et al The performance of the vaginal discharge syndromic management in treating vaginal and cervical infection: a systematic review and meta-analysis. PLoS One 2016; 11 e0163365
The performance of the vaginal discharge syndromic management in treating vaginal and cervical infection: a systematic review and meta-analysis.CrossRef |

[13]  Gergen C, Wilkins V, Ragunathan P, Walsh J. When is syndromic management of sexually transmitted diseases useful? An analysis of the literature. 2000. Available online at: https://www.hsph.harvard.edu/ihsg/publications/pdf/No-83.PDF

[14]  Cucuzza L. Vaginal discharge: syndromic management in family planning programs. A review of the literature. World Health and Population 2001; 4

[15]  Sewankambo N, Gray RH, Wawer MJ, Paxton L, McNaim D, Wabwire-Mangen F, et al HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis. Lancet 1997; 350 546–50.
HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis.CrossRef | 1:STN:280:DyaK2svjtVKluw%3D%3D&md5=2b35e918a73a21977aab4f87bcd5e74bCAS |

[16]  Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003; 3 25–38.
The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews.CrossRef |

[17]  Higgins J, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration; 2011.

[18]  Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 2005; 58 982–90.
Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews.CrossRef |

[19]  Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21 1539–58.
Quantifying heterogeneity in a meta-analysis.CrossRef |

[20]  Rabe-Hesketh S, Skrondal A, Pickles A. GLLAMM Manual. Working Paper 160. UC Berkeley Division of Biostatistics Working Paper Series. October 2004.

[21]  Mayaud P, Grosskurth H, Changalucha J, Todd J, West B, Gabone R, et al Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics. Bull World Health Organ 1995; 73 621–30.
| 1:STN:280:DyaK287hsVentQ%3D%3D&md5=f063f5d0cbe5b83f16e642f6fbe2066dCAS |

[22]  Ronsmans C, Bulut A, Yolsal N, Agacfidan A, Filippi V. Clinical algorithms for the screening of Chlamydia trachomatis in Turkish women. Genitourin Med 1996; 72 182–6.
| 1:STN:280:DyaK28zjsV2gtQ%3D%3D&md5=f665bf4666f0b4666ba9ca3b0e0ebca7CAS |

[23]  Meda N, Sangare L, Lankoande S, Sanou PT, Compaore PI, Catraye J, et al Pattern of sexually transmitted diseases among pregnant women in Burkina Faso, west Africa: potential for a clinical management based on simple approaches. Genitourin Med 1997; 73 188–93.
| 1:STN:280:DyaK2svlt1Whug%3D%3D&md5=2d5f320e592e95c73fdd2581036418f2CAS |

[24]  Alary M, Baganizi E, Guedeme A, Padonou F, Davo N, Adjovi C, et al Evaluation of clinical algorithms for the diagnosis of gonococcal and chlamydial infections among men with urethral discharge or dysuria and women with vaginal discharge in Benin. Sex Transm Infect 1998; 74 S44–9.

[25]  Behets FM, Ward E, Fox L, Reed R, Spruyt A, Bennett L, et al Sexually transmitted diseases are common in women attending Jamaican family planning clinics and appropriate detection tools are lacking. Sex Transm Infect 1998; 74 S123-7

[26]  Bourgeois A, Henzel D, Dibanga G, Malonga-Mouelet G, Peeters M, Coulaud JP, et al Prospective evaluation of a flow chart using a risk assessment for the diagnosis of STDs in primary healthcare centres in Libreville, Gabon. Sex Trans Infect 1998; 74 S128-32

[27]  Bourgeois A, Henzel D, Malonga-Mouelet G, Dibanga G, Tsobou C, Peeters M, et al Clinical algorithms for the screening of pregnant women for STDs in Libreville, Gabon: which alternatives? Sex Transm Infect 1998; 74 35–9.
Clinical algorithms for the screening of pregnant women for STDs in Libreville, Gabon: which alternatives?CrossRef | 1:STN:280:DyaK1c3ns1GmsA%3D%3D&md5=8953897c0d41f61e0baa873c91ffe6ceCAS |

[28]  Costello Daly C, Wangel AM, Hoffman IF, Canner JK, Lule GS, Lema VM, et al Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi. Sex Transm Infect 1998; 74 S50–8.

[29]  Mayaud P, Uledi E, Cornelissen J, et al Risk scores to detect cervical infections in urban antenatal clinic attenders in Mwanza, Tanzania. Sex Transm Infect 1998a; 74 S139–46.

[30]  Mayaud P, et al Validation of a WHO algorithm with risk assessment for the clinical management of vaginal discharge in Mwanza, Tanzania. Sex Transm Infect 1998b; 74 S77–84.

[31]  Moherdaui F, Vuylsteke B, Siqueira LF, dos Santos MQ, Jardim ML, de Brito AM, et al Validation of national algorithms for the diagnosis of sexually transmitted diseases in Brazil: results from a multicentre study. Sex Transm Infect 1998; 74 S38–43.

[32]  Ndoye I, Mboup S, De Schryver A, Van Dyck E, Moran J, Samb ND, et al Diagnosis of sexually transmitted infections in female prostitutes in Dakar, Senegal. Sex Transm Infect 1998; 74 S112–7.

[33]  Diallo MO, Ghys PD, Vuylsteke B, Ettiegne-Traore V, Gnaore E, Soroh D, et al Evaluation of simple diagnostic algorithms for Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in female sex workers in Abidjan, Cote d’Ivoire. Sex Transm Infect 1998; 74 S106–11.

[34]  Passey M, Mgone CS, Lupiwa S, Tiwara S, Lupiwa T, Alpers MP. Screening for sexually transmitted diseases in rural women in Papua New Guinea: are WHO therapeutic algorithms appropriate for case detection? Bull World Health Organ 1998; 76 401–11.
| 1:STN:280:DyaK1M%2FitVCgsA%3D%3D&md5=7634c96689f5a605298982fbb3ab817cCAS |

[35]  Ryan CA, Zidouh A, Manhart LE, Selka R, Xia M, Moloney-Kitts M, et al Reproductive tract infections in primary healthcare, family planning, and dermatovenereology clinics: evaluation of syndromic management in Morocco. Sex Transm Infect 1998; 74 S95–105.

[36]  Schneider H, Coetzee DJ, Fehler HG, Bellingan A, Dangor Y, Radebe F, et al Screening for sexually transmitted diseases in rural South African women. Sex Transm Infect 1998; 74 S147–52.

[37]  Wi T, Mesola V, Manalastas R, Tuazon C, Mugrditchian DS, Perine P, et al Syndromic approach to detection of gonococcal and chlamydial infections among female sex workers in two Philippine cities. Sex Transm Infect 1998; 74 S118–22.

[38]  Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Peeling RW, et al Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet 1999; 354 1776–81.
Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh.CrossRef | 1:STN:280:DC%2BD3c%2FktlGksw%3D%3D&md5=b1e2fb2c8c188ae17e42f296d7d3a8dbCAS |

[39]  Fonck K, Kidula N, Jaoko W, Estambale B, Claeys P, Ndinya-Achola J, et al Validity of the vaginal discharge algorithm among pregnant and non-pregnant women in Nairobi, Kenya. Sex Transm Infect 2000; 76 33–8.
Validity of the vaginal discharge algorithm among pregnant and non-pregnant women in Nairobi, Kenya.CrossRef | 1:STN:280:DC%2BD3c3nslWlsQ%3D%3D&md5=62c48fcba3593cd8001fe0f9598ed5dbCAS |

[40]  Iskandar MB, Patten JH, Qomariyah SN, Vickers C, Molyneaux SI. Detecting cervical infection among family planning clients: difficulties at the primary health-care level in Indonesia. Int J STD AIDS 2000; 11 180–6.
Detecting cervical infection among family planning clients: difficulties at the primary health-care level in Indonesia.CrossRef | 1:STN:280:DC%2BD3c7ovFCktQ%3D%3D&md5=b001871414f1bdee259efae7d679d10dCAS |

[41]  Vishwanath S, Talwar V, Prasad R, Coyaji K, Elias CJ, de Zoysa I. Syndromic management of vaginal discharge among women in a reproductive health clinic in India. Sex Transm Infect 2000; 76 303–6.
Syndromic management of vaginal discharge among women in a reproductive health clinic in India.CrossRef | 1:STN:280:DC%2BD3cvns1yiuw%3D%3D&md5=451607c91b34d87d580b4728d833295aCAS |

[42]  Ward E, Spruyt A, Fox L, Johnson L, Wong E, Behets F, et al Strategies for Detection of Sexually Transmitted Infection Among Family Planning Clients in Jamaica. International Family Planning Perspectives 2001; 27 201–7.
Strategies for Detection of Sexually Transmitted Infection Among Family Planning Clients in Jamaica.CrossRef |

[43]  Mukenge-Tshibaka L, Alary M, Lowndes CM, Van Dyck E, Guedou A, Geraldo N, et al Syndromic versus laboratory-based diagnosis of cervical infections among female sex workers in Benin: implications of nonattendance for return visits. Sex Transm Dis 2002; 29 324–30.
Syndromic versus laboratory-based diagnosis of cervical infections among female sex workers in Benin: implications of nonattendance for return visits.CrossRef |

[44]  Desai VK, Kosambiya JK, Thakor HG, Umrigar DD, Khandwala BR, Bhuyan KK. Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India. Sex Transm Infect 2003; 79 111–5.
Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India.CrossRef | 1:STN:280:DC%2BD3s7ntFylsQ%3D%3D&md5=a977472172ac21c96583aef6e0c3a8a6CAS |

[45]  Vuylsteke BL, Ettiegne-Traore V, Anoma CK, Bandama C, Ghys PD, Maurice CE, et al Assessment of the validity of and adherence to sexually transmitted infection algorithms at a female sex worker clinic in Abidjan, Cote d’Ivoire. Sex Transm Dis 2003; 30 284–91.
Assessment of the validity of and adherence to sexually transmitted infection algorithms at a female sex worker clinic in Abidjan, Cote d’Ivoire.CrossRef |

[46]  García PJ, Chavez S, Feringa B, Chiappe M, Li W, Jansen KU, et al Reproductive tract infections in rural women from the highlands, jungle, and coastal regions of Peru. Bull World Health Organ 2004; 82 483–92.

[47]  Pépin J, Deslandes S, Khonde N, Kintin DF, Diakite S, Sylla M, et al Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management. Sex Transm Infect 2004; 80 230–5.
Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management.CrossRef |

[48]  Råssjö EB, Kambugu F, Tumwesigye MN, Tenywa T, Darj E. Prevalence of sexually transmitted infections among adolescents in Kampala, Uganda, and theoretical models for improving syndromic management. J Adolesc Health 2006; 38 213–21.
Prevalence of sexually transmitted infections among adolescents in Kampala, Uganda, and theoretical models for improving syndromic management.CrossRef |

[49]  Smith Fawzi MC, Lambert W, Singler J, Leandre F, Nevil P, Bertrand D, et al Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting. Sex Transm Infect 2006; 82( 175–81.
Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting.CrossRef |

[50]  Romoren M, Sundby J, Velauthapillai M, Rahman M, Klouman E, Hjortdahl P. Chlamydia and gonorrhoea in pregnant Batswana women: time to discard the syndromic approach? BMC Infect Dis 2007; 7 27
Chlamydia and gonorrhoea in pregnant Batswana women: time to discard the syndromic approach?CrossRef |

[51]  Zribi M, Mansour KB, Abid F, Masmoudi A, Fendri C. Syndromic approach to sexually transmitted infections in Tunisian women: bacteriological validation. Int J STD AIDS 2008; 19 112–4.
Syndromic approach to sexually transmitted infections in Tunisian women: bacteriological validation.CrossRef | 1:STN:280:DC%2BD1c7ns1WjsQ%3D%3D&md5=0881b2fcc246f47746f511e44b4654deCAS |

[52]  Clark JL, Lescano AG, Konda KA, Leon SR, Jones FR, Klausner JD, et al 2009; 4 e7201

[53]  Guimarães EM, Guimaraes MD, Vieira MA, Bontempo NM, Seixas MS, Garcia MS, et al Lack of utility of risk score and gynecological examination for screening for sexually transmitted infections in sexually active adolescents. BMC Med 2009; 7 8
Lack of utility of risk score and gynecological examination for screening for sexually transmitted infections in sexually active adolescents.CrossRef |

[54]  Ndoye I, Mboup S, De Schryver A, Van Dyck E, Moran J, Samb ND, et al Diagnosis of sexually transmitted infections in female prostitutes in Dakar, Senegal. Sex Transm Infect 1998; 74 S112–7.

[55]  Causer LM, Hengel B, Natoli L, Tangey A, Badman SG, Tabrizi SN, et al A field evaluation of a new molecular-based point-of-care test for chlamydia and gonorrhoea in remote Aboriginal health services in Australia. Sex Health 2015; 12 27–33.
A field evaluation of a new molecular-based point-of-care test for chlamydia and gonorrhoea in remote Aboriginal health services in Australia.CrossRef |



Export Citation