Xth International Conference on AIDS and STD in Africa, December 1997 Clinical Assessment of Cervical Status is predictive of Cervical Infection in Female STD Patients in The Seychelles Ministry of Health, Seychelles N. E. Udonwa J. Nwosu G. Furneau M. Francoise J. Freminot P. Confait Clinic of Infectious and Tropical Diseases University of Brescia, Italy A. Matteelli C. Farina F. Casteli L. Signorini Xth International Conference on AIDS and STD in Africa, December 1997 Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 ABSTRACT Objectives: Risk assessment methods has proved to be an insensitive predictors of cervical infections among women presenting with vaginal discharge in the Seychelles. We therefore assessed the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the clinical assessment of cervical status in the same population group. Methods: All consecutive women with STD related complaints attending the only categorical STD clinic in the Seychelles during the period February 1996 – March 1997 were enrolled. Anagraphic and behavioural data were collected by interview. Physical examination with speculum was performed by any of the physicians and nurses working at the STD clinic. The cervical status was categorized as normal, with mucopus, erosion, or bleeding at touch. A diagnosis of cervicitis was based on etiological evidence: N. gonorrhoea was isolated from cervical swabs onto enriches Tayer Martin agar plates; C. trachomatis antigens were detected from cervical swabs using the EIA Sanofi test. Data were computed in Dbase file and analysed with the epiinfo program. Results: 170 women were enrolled, of whom 147 (86%) had either vaginal discharge and/or lower abdominal pain. The mean age was 27 (range 14-48). 133. (78%) had a stable job, 70 (41%) were single, 151 (89%) had sex with a single partner during the previous month. Completed clinical and microbiological information was available for 149.4 (3%), 58 bleeding at clinical assessment. A diagnosis of cervical infection was made in 11 (7%), all infected by Chlamydia trachomatis including one with Gonococcal co-infection. The sensitivity, specification, PPV and NPV of the presence of any one of the above clinical abnormalities of the cervix were 100%, 42%, 12%, 100%. Comments: Clinical examination with speculum insertion is feasible at central and peripheral stations of the public health system in the Seychelles. The presence of cervical abnormalities seems to be a sensitive, though non specific, indicator of cervical infection in our sample of women with low prevalence of STD risk indicators. Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Facts The risk assessement method has proved neither sensitive nor specific in women with vaginal discharge or pelvic pain in the Seychelles. There is low prevalence of STD risk indicators and low prevalence of cervicitis in the population. Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Questions Can the presence of cervical abnormality be a sensitive indicator of cervical infection in women with low prevalence of STD Risk Indicators? Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Materials and Methods Period February 1996 to March 1997 Study population All consecutive attendancies related to genital problems during the study period Site Comunicable Diseases Control Unit (CDCU), Victoria, which acts as the only specialised STD clinic in the Seychelles Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 EIA Antigen detection (Sanofi Pasteur) wet mout preparation of vaginal specimens abnormal discharge AND vaginal PH >5 AND clue cells and vaginal Gram Culture isolation on Tayer Martin medium RPR TPHA reactive Culture onto Sabouraud destrose agar Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Facts Women presenting with genital discharge or pelvic pain in the Seychelles are much more likely to have vaginal (70%) rather than cervical infections (8%). However, cervical infections determine more severe morbidity and represent a public health problem due to sexual transmission. Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Results Study sample: Males 81 Females 170 Males Females Age mean 30 27 range 18-62 14-48 % with stable job 89 78 % with secondary education 54 58 % single 47 41 Anagraphic characteristics Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Results (Cont’d) Sexuals habits Males Females % heterosexual habit 98 100 Mean age at first coitus 16.3 17.6 % reporting oral sex 20 20 % reporting anal sex 5 1 % with > 1 partners (last month) 33 4 % changed partner (last 3 months) 28 5 % never used condom 66 71 Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Presence of clinical abnormalities of the cervix in 170 women Mucopus 4 2% Erosions 58 34% Bleeding at touch 61 36% At least one of the above 91 54% Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Aetiological diagnosis among 11 cases of cervical infection Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Cervical abnormalities at clinical examination and presence of cervicitis Cervicitis Yes No Total Yes 12 79 91 Abnormalities No 1 78 79 Tot 13 135 170 Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Clinical abnormalities of the cervix and presence of cervicitis Sensitivity 100% Specificity 42% Positive Predictive Value 12% Negative Predictive Value 100% Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Comments Clinical examination with speculum insertion is feasible at central and peripheral sations of the public health system in the Seychelles. The presence of cervical abnormalities at clinical examination has higher sensitivity than the risk score method and is feasible at central and peripheral health centres in the Seychelles. Xth International Conference on AIDS and STD in Africa, December 1997

Xth International Conference on AIDS and STD in Africa, December 1997 Poster prepared and printed with the contribution of the European Commission - Project 7 ACP RPR 28 for STD/HIV action in the Indian Ocean Xth International Conference on AIDS and STD in Africa, December 1997