VALIDATION OF THE WHO DIAGNOSTIC ALGORITHM AND DEVELOPMENT OF AN ALTERNATIVE SCORING SYSTEM FOR THE MANAGEMENT OF WOMEN PRESENTING WITH VAGINAL DISCHARGE IN MALAWI

Objective: To evaluate the performance of the WHO algorithm for the de tection of cervical infection in women presenting with vaginal dischar ge and modify the risk assessment score for optimum effectiveness in M alawi. Methods: 550 consecutive women presenting with non-ulcerative g enitourinary complaints were interviewed and examined. Cervical infect ion was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia. trachomatis by EIA. Other laboratory investigations includ ed wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sen sitivity, specificity, and positive predictive values (PPV) of differe nt algorithms were determined in the analysis. Results: Cervical infec tion was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydi al infection). The sensitivity/specificity/PPV of the WHO risk assessm ent were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively b y history alone, which increased to 73%/64%/33% with bimanual examinat ion and 72%/56%/29% with speculum examination. Conclusion: The sensiti vity of the WHO risk assessment is low for the detection of cervical i nfection in Malawi. Although the Malawi risk assessment performed some what better on history alone, this study identified external and biman ual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low country specific risk asse ssments can provide a framework for management until simple, affordabl e diagnostic tests for the definitive diagnosis of cervical infection are available.