A Study of Syndromic Case Management of RTI/ STIS

 

Yogita Amit Hiwarkar1*,Dilip N Dhekale2, Amit A Hiwarkar3, Kolhe C. G.4

1Assistant Professor, Community Medicine,

2Associate Professor, Community Medicine.

3Assistant Professor Anaesthesiology,

Dr. Ulhas Patil Medical College and Hospital, Jalgaon Kh.,(M.S.), India; 4Medical officer ESIS Dispensary no.1, Jalgaon.

 

 

ABSTRACT:

Background: Reproductive health is a crucial part of general health and a central feature of human development. Data on the epidemiology of reproductive-organ morbidity are needed to guide effective interventions, to set health-care priorities, and to target future research.

 

Objective: To study the prevalence of RTI/STI among women of reproductive age group

 

Material and methods: One hundred eighty one and one hundred four women participants from urban slums and rural area were included in the study. The RTI/STI were classified and treated according to syndromic case management.

 

Results: RTI/STI was diagnosed in 51.38% of participants in urban and 62.5% of women in rural with prevalence of 39.2% in urban and 45.19 % in rural area, the most common syndrome diagnosed  was vaginal and cervical discharge syndrome (as per syndromic case management of RTI/STIs). 

 

KEYWORDS: Vaginal and cervical discharge syndrome, RTI/STI, syndromic case management

 

INTRODUCTION:

Reproductive Tract Infection includes three different types of infection that affect the reproductive tract:

(i). Sexually transmitted infections. e.g.  Chlamydia infection, gonorrhea, trichomoniasis, syphilis, chancroid, genital herpes, genital warts (caused by the human papilloma virus) and HIV.

 

(ii). Endogenous infections. e.g. bacterial vaginosis and candidiasis

 

(iii). Iatrogenic infections. These are caused due to medical procedures like unhygienic delivery conditions, pregnancy termination, menstrual regulation, IUD insertion, sterilization procedures carried out under unhygienic conditions.

 

Reproductive tract infections are often categorized by the site of infection. E.g. vulvovaginitis or vaginitis, cervicitis, and pelvic inflammatory disease (1) (2).

 

Some sexually transmitted infections often exist without symptoms. For example, up to 70% of women and a significant proportion of men with gonococcal and/or chlamydial infections may experience no symptoms at all. Both symptomatic and asymptomatic infections can lead to the development of serious complications

In the light of International Conference on Population and Development, Government of India launched the Reproductive and Child Health project in 1997.The RCH approach broadly include services for preventing unwanted pregnancy, safe abortions, maternity care, child survival and prevention and management of reproductive morbidity e.g. RTIs, STIs and HIV/ AIDS. Also, under NACP 3 special focus is given for detection and treatment of STI/RTI. The STI OPDs are established in urban areas in the existing health set up to treat STI/RTI patients. By taking in to consideration the above facts and as per recommendations of the World Health Organization (WHO) study group, it is necessary to obtain a comprehensive picture of RTI/STI. Therefore this study was undertaken with the objective to evaluate the WHO syndromic approach based on symptoms of RTI/STIs in metropolitan city of Mumbai.

 

MATERIALS AND METHOD:

One hundred eighty one and one hundred four women participants belonging to urban field training and rural health training centre respectively attached to Seth G.S. Medical College, Mumbai-12 (M.S.) in metropolitan city were included in the study from September, 2007 to November, 2009.

 

An interview based on data collection instrument was conducted after taking consent of each participant. Confidentiality was assured. The information was asked in local language and questions were repeated until the woman being interviewed understood the meaning of the questions. As this is a sensitive topic, probing is done by asking penetrating questions to get adequate information.  This helped to reduce the bias. During the whole course of the study, just one interviewer asked the information with the objective to reduce interviewer bias. The history about the current perceived reproductive illnesses or illnesses in the preceding three months was asked. The per speculum and  per vaginal examination of women was done.

 

The syndromes such as vaginal discharge, genital ulcer disease, lower abdominal pain, and inguinal bubo based on the syndromic approach as recommended by the Government of India, Ministry of Health and Family Welfare for the management of RTIs/STDs were considered. The case definitions of these syndromes as recommended by National AIDS Control Organization were strictly followed for diagnosis and treatment of patients.

 

Syndromic Case Management refers to the approach of treating STI/RTI symptoms and signs based on the organisms most commonly responsible for each syndrome.

(1) VCD, Vaginal/cervical discharge: Includes (a) woman with symptomatic vaginal Discharge

(2) Asymptomatic patient with vaginal discharge seen on examination, and

(3) Cervical discharge seen on speculum examination (all etiological and clinical STI

 

Diagnosis relating to vaginal or cervical discharge should be included here).

2. GUD-non-herpetic, genital ulcer disease-non-herpetic: female or male, with genital or ano-rectal ulceration and with no blisters (vesicles) (all STI clinical or etiological diagnosis relating to genital ulcers, except herpes simplex 2, and LGV should be included here).

3. GUD-herpetic, Genital ulcer disease-herpetic: female or male, with genital or ano-rectal blisters (vesicles) with no ulcers.

4. LAP, Lower abdominal pain: Check if patient has lower abdominal pain or tenderness or cervical motion tenderness.

5. IB, Inguinal bubo: if the person has inguinal bubo and no genital ulcer

6. Genital warts: If patient, have genital warts.

 

OBSERVATIONS AND DISCUSSION:

On analysis of the collected data,  RTI/STI was diagnosed in 51.38% of participants in urban and 62.5% of women in rural area, according to a syndromic case management (Table-I).  With prevalence of 39.2% in urban and 45.19 % in rural area, the most common syndrome diagnosed was vaginal and cervical discharge syndrome(Table-II, Figure-I) while 14.42 and 8.29 percent was APS in rural and urban women respectively.1.92 percent each of genital scabies and GUDNH was reported from rural patients in comparison to 1.66 and 0.55 percent each of urban women. Table further reveals that 0.55 percent urban women reported Genital warts, in comparison none of rural counterparts had genital warts. As far as GUDH is concerned, it was detected in 1.10 and 0.96 percent of women respectively among urban and rural women. 

 

Table I: Presence of RTI/STI in study participants

Presence of RTI/ STI

Urban

Rural

Frequency

Percent

Frequency

Percent

Yes

93

51.38

65

62.5

No

88

48.61

39

37.5

Total

181

100

104

100

 

 

FIGURE-I-Distribution of RTI/STIs according to syndromic case management

TABLE-II-Classification of RTI/STIs according to Syndromic case management

Syndromic case management

Urban

Rural

Frequency (n = 181)

Percent

Frequency (n = 104)

Percent

APS

15

8.29

15

14.42

Genital scabies

3

1.66

2

1.92

Genital warts

1

0.55

0

0.00

GUDH

2

1.10

1

0.96

GUDNH

1

0.55

2

1.92

VCD

71

39.23

47

45.19

 

 

In metaanalysis by latha et al marked variation between studies was evident for both cervicitis (ranging from eight per cent in the rural Gujarat study to 40 per cent in the Bombay study) and for cervical erosion (from two per cent in the rural West Bengal study to over 20 per cent in the rural Gujarat and the Bombay studies). Vaginitis was also an important source of morbidity (10-15 per cent of women) in all but the rural West Bengal study. Rates of pelvic inflammatory disease ranged between one per cent and 17 per cent in all studies (4). In study done by Savita Sharma et al the most common presentation among women was vaginal discharge (51.9 per cent) which is comparable with the present study. Similarly, second most common syndrome was lower abdominal pain and less than 2 per cent of women had genital ulcer disease and inguinal lymphadenopathy (5).

 

Ranjan R. Sharma and Mehta A.K. (6) (2003) carried out a study on 300 currently married women attending obstetric and gynecology clinic at Lady Hardinge Medical College, Palam to evaluate the sensitivity and specificity of WHO syndromic approach in diagnosing reproductive tract infection. The prevalence of RTI’s was 37% by syndromic approach based on symptoms, 51.7% by clinical examination and 36.7% by laboratory investigations. The sensitivity and specificity of syndrome approach to diagnose RTI was 53.6% and 72.6% respectively, while clinical examination had 68.2%, sensitivity and 60.5% specificity. They study concluded that the WHO syndromic approach based on symptoms had a low sensitivity (53.6%) than clinical examination (68.2%). Thus, the findings of the present study were more or less in accordance of the findings of the various studies conducted by various researchers across the country.

 

CONCLUSION AND RECOMMENDATIONS:

WHO syndromic approach based on symptoms of RTI/STIs in the present scenario in the country seems to be successful. To enhance the rate of success the authors recommend the followings-

 

(a).Health personnel should routinely ask married women, attending OPDs or immunization sessions, if they are experiencing gynecological symptoms, as most women don’t readily come to seek the treatment only for reproductive morbidity. Even a single complaint related to gynecological morbidity should not be ignored.

 

(b).The peripheral health workers should be oriented and sensitized for identifying various sign and symptoms of RTIs. They should be able to refer the patients to the primary health centers for early and prompt treatment.

 

Community health worker should instill self-concern in women for their own health needs.

 

(c).Women with even a single symptom of RTI/STI should be motivated to bring their husband for screening of sexually transmitted infection. This will ensure early diagnosis and preventive measures to be undertaken.

 

(d).Counselors should be appointed in health centers to bring about behavior change and communication in patients of RTI/STI and to ensure compliance to the treatment.

 

REFERENCES:

(1)     www.pdhre.org/rights/women_and_health.html

(2)     Garg Narendra K..: Evaluation of the impact of emesis and emesis plus purgation Therapy; Research J Pharmacology and Pharmacodynamics (2) March-April; 2010:201-202.

(3)     Garg Narendra K. and Sharma A.B. Epidemiological profile of patients attending a tertiary care hospital, Muktsar, Punjab (India); Research J Pharmacology and Pharmacodynamics:3 (6)

(4)     Latha, K; Kanani, S. J; Maitra, N.: Prevalence of Clinically Detectable Gynaecological Morbidity in India: Results of Four Community Based Studies. The Journal of Family Welfare. Dec 1997. 43(4). p.8-16

(5)     Savita Sharma, BP Gupta, The prevalence of reproductive tract infections and sexually transmitted diseases among married women in the reproductive age group in a rural area, Indian journal of Community Medicine, Vol.34, issue 1, pg 62-64.

(6)     Ranjan R, Sharma AK, Mehta G. Evaluation of WHO diagnostic algorithm for RTI among married women. Indian J Commun Med 2003;28:81-4.

 

Received on 21.02.2013

Modified on 20.03.2013

Accepted on 08.05.2013

© A&V Publication all right reserved

Research J. Pharmacology and Pharmacodynamics. 5(2): March–April 2013, 129-131