Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh

Background In the control of reproductive-tract infections, including sexua lly transmitted infections (STIs), in low-income and middle-income countrie s, WHO recommends syndromic management for individuals with symptoms. This intervention was initially developed in areas where prevalence of such infe ctions is high. We investigated the clinical effectiveness and cost of this approach among a group of women with a tow prevalence of infection. Methods During a 5-month period, we investigated ail women complaining of a bnormal vaginal discharge and seeking care at maternal and child health/fam ily-planning centres in Matlab, Bangladesh, for the presence of laboratory- diagnosed reproductive-tract infections and STIs, Syndromic diagnoses made by trained health-care workers were compared with laboratory diagnosis of i nfection. We then calculated the costs of treating women by means of the re commended WHO algorithm and an adapted algorithm incorporating use of a spe culum and simple diagnostic tests. Findings The prevalence of endogenous infections among 320 women seen was 3 0%. Cervical infections (Neisseria gonorrhoeae and Chlamydia trachomatis) w ere found in only three women. The WHO algorithm had a high sensitivity (10 0%) but a low specificity (zero for bacterial vaginosis, candida, and Trich omonas vaginalis). The speculum-based algorithm had a low sensitivity (betw een zero and 59%) but a higher specificity (79-97%). Between 36% and 87% of costs would have been spent on uninfected women. Interpretation The high rate of overtreatment in the population studied car ries both financial and social costs-the latter in potentially exposing wom en misdiagnosed as having an STI to threats of domestic disruption or even violence. We make recommendations for management programmes in areas of low STI prevalence and low income.