MSF Holland in Myanmar
Reproductive tract infections
18 MSF clinics in Myanmar
–
–
–
–
Capital
North
East
West
Manipur
Yunnan
India
China
Bgd
Thailand
STI management in resource poor setting
⇛ Symptoms.
⇛ Lab
⇛ The syndromic STI management was developed,
which uses clinical algorithms based on STI
syndromes, with or without lab. support
Syndromic approach for the diagnosis
of cervicitis is inadequate
• Cervicitis lacks specific signs and symptoms
• A large group of women with sub-clinical and
asymptomatic cervicitis (GC 50%, CT 75%)
Syndromic approach does not address
⇛ There is not much of a syndrome.
• And microscopy is not sensitive (40-50%) for GC.
• Simple CT test not (yet) available.
Considerations for STI management
• People with high-risk behavior (SW, male
clients SW, MSM) are the main reservoir of
STI.
• For a-symptomatic STI carriers,
– regular (monthly) screening for STI
– or regular mass treatment,
– for high-risk women (and MSM).
WHO flowchart for STI
Complaint Vaginal Discharge or Vulval itching
Exam + Lab
Lower Abdom. pain
yes
Separate guideline
no
Treat GC/CT
But there is little
association between
vaginal discharge or
vulval itching and
GC or CT!
plus treat according
microscopy results
TV
BV
Cand.
-
Myanmar DOH / Unicef Guidelines for STI
Complaint Vaginal Discharge or Vulval itching
Risk assessment
1) Age > 21
2) Partner STI
3) New partner < 3 months
yes
Treat GC/CT
no
Risk
assessment
factors
appear to be
illogical
treat according
microscopy results
TV
BV
Cand.
-
MSF started a modified flow chart
• Flow chart based on a combination of
• Risk factors
• Symptoms / signs
• Laboratory tests
MSF flowchart in Myanmar
Women with or without symptoms
- Previous STD “confirmed” = (2)
- Previous STD-like complaints = (1)
Risk assessment
- Partner complains genital symptoms = (2)
- Partners discharge/ ulcer observed = (3)
- Single woman in high-risk area = (1)
- New partner within 3 months = (2)
- Husband assumed to visit SWs = (2)
- SW = (3)
<3
Low risk
>= 3
High risk
Treat GC/CT
treat according to phys. exam + microscopy results
And a new patient STI registration form
• Systematically record symptoms, signs and
laboratory results.
• Put the records in a data base.
FEMALE REGISTRATION CARD Clinic:
Reg.No : ____________
Visit date :
□ first visit
□ follow up
last visit date :
Age :
Heard about clinic?
□ from HE team
□ from HE team
□ from others
Reason for visit
□ ANC / screening
□ High-risk
□ Partner STD
□ Inside parlor
Recent Complaints and Duration ………………………………………………………
History of illness done : □ yes
Vaginal Discharge
How many days?
□ yes
Linked with menstruation
□ yes
Colour
Physical exam done : □ yes
□ no
□ no
□ no
Washed inside <1hr □ yes
Erythema of vulva □ yes
□ no
Discharge
□ visible
□ not visible
Main location
□ vagina
□ cervix
□ normal
□ abundant
□ clear
□ white
...…days
……………………………………
Amount
□ normal
□abundant
Smell
□ normal
□ foul
Color
□ no
□ no
□ yellow
Lower Abdominal Pain
□ yes
□ no
Smell
□ normal
□ foul
How many days
………..
days
Vaginal wall injury
□ yes
□ no
Fever
□ yes
□ no
Recent termination of
pregnancy ?
□ yes
□ no
pH vagina
KOH smell test
□ < 4.5
□ smell (+)
□ > 4.5
□ smell (-)
Dyspareunia
Other GI symptoms
□ yes
□ no
Cervical motion
tenderness ?
□ yes
□ no
Linked with menstruation
□ yes
□ no
Adnexal tenderness
or enlargement
□ yes
□ no
Dysuria
□ yes
□ no
Main location
□ vagina
□ cervix
how many days
………… days
Genital Ulcer
□ yes
□ no
Genital Pruritis
□ yes
□ no
Painful/painless
□ painful
□ painless
How many days
………….
days
Herpes suspected :
□ yes
□ no
Genital Ulcer
□ yes
□ no
Inguinal bubo
□ yes
□ no
How many days
………….
days
Fluctuant
□ yes
□ no
Pain
□ painful
□ painless
Tender / non-tender
□ tender
□ non-tender
Single/multiple
□ single
□ multiple
Other leg infection
□ yes
□ no
Prodromal itch / burning
□ yes
□ no
Genital Warts
□ yes
□ no
Started as vesicles/blisters
□ yes
□ no
Make drawing and describe size.
Recurrent
□ yes
□ no
Herpes suspected :
□ yes
□ no
Inguinal Lymph Node
□ yes
□ no
How many days ........
………… days
Unilateral / bilateral
□ unilat
□ bilateral
Leg ulcer/other infection
□ yes
□ no
Genital Warts
□ yes
□ no
how many days
………. days
For all women who visit the STD clinic :
Single woman high-risk area (1)
SW (3)
Previous STD “confirmed” (2)
Previous STD-like complaints (1)
Score : __________
Define High or Low Risk group
Yes/No
Yes/No
Yes/No
Yes/No
New partner within 3 months (2)
Husband assumed to visit SW (2)
Partner complains genital sympt(2)
Partners genit. sympt observed(3)
Low Risk ( ≤2) □
Yes/No
Yes/No
Yes/No
Yes/No
High-risk ( ≥3) □
For SWs at regular clinic visits only : Risk assessment for Cervical Infection
o
o
o
o
Complains of ‘abnormal’ thick yellow discharge since her last visit ?
Pain during sexual intercourse ?
More than 5 clients a day (on average) ?
Unprotected sex with new clients ?
Yes □
Yes □
Yes □
Yes □
No□
No□
No□
No□
Score: If 2 questions “yes”  Risk assessment (+)  always treat for Cervicitis (GC + CT)
Condom use
□ regular
□ rare
□ never
year started use .........
Previous STD
□ yes
□ no
What ……….
When ……….
Last menstruation
□ Regular
□ Irregular
started : ....……
Pregnant Y/N
Contraception
□ yes
□ no
Other skin condition
□ yes
□ no
□ urticaria
□ crab lice
□ scabies
□ other
(Presumptive - )
Diagnosis :
GC
Yes □
No □
Syphilis
Yes □
No □
CT
Yes □
No □
Chancroid
Yes □
No □
TV
Yes □
No □
Herpes
Yes □
No □
BV
Yes □
No □
LGV
Yes □
No □
Candida
Yes □
No □
Genital Warts
Yes □
No □
PID
Yes □
No □
Others
Treatment
Allergy
When ……….
Counseling:
penicillin
Yes □
No □
sulfa
Yes □
No □
□ STD signs + symptoms
□ Prevention / Condoms
□ HIV/AIDS
□ Contraception
□ Treatment (compliance)
□ Vaginal hygiene
□ Discussion with partner
□ IVDU (needles !)
Follow up:
Clinician: ……………………..
Laboratory request form : WOMEN
Wet mount
Yes □ No □
Clue cells %1
Post. Fornix
Yes □ No □
Yes □
Yes □
Endocervix
Yes □ No □
……….…..%
…..……/ HPF
…………/ HPF
……..……/ HPF
Yes □
No □
Yes □
No □
Yes □
No □
Yes □
No □
Yes □
No □
Yes □
No □
No □
Gonococci
Candida
Urethra
Yes □ No □
……….…..%
WBC cells / HPF1
Trichomonas
Gram stain
No □
Spermatozoites
RBCs, others:
1 Normal
value : Clue cells < 20%, WBC cells < 20/HPF
Urine exam (FPU)
Yes □
No □
RPR test :
Yes □
No □
Epithelial cells
………… / HPF
Quantitative □
Qualitative □
WBC cells
………… / HPF
Reactive
Yes □
Titer
……………..
Titer last visit
……………..
Gonococci
Other bacteria
No □
100.000 patients treated for RTI
(1998-2004)
12.000 patient records from Yangon, Kachin, Rakhine
and Shan entered in the data base.
– 5500 “high risk” women
– 6500 “low risk” women
– Overall 7% GC confirmed by microscopy
 Compare the relation between risk factors, signs
and symptoms and GC (identified by microscope)
Correlation between risk factors and GC
Risk factors
GC (%)
OR
73/270 (27%)
4.9
449/3632 (12%)
2.7
105/637 (17%)
2.6
New partner within 3 months
202/1623 (12%)
2.0
Previous STD confirmed
202/1777 (11%)
1.8
Single women in high risk area
172/1742 (10%)
1.5
Previous STD like complaint
274/2828 (10%)
1.5
Husband assumed to visit SWs
152/1478 (10%)
1.5
Partner discharge or ulcer observed
Sex worker
Partner complaint genital symptoms
Correlation between symptoms and GC
Symptoms
GC (%)
OR
Dysuria
262/1738 (15%)
2.7
Genital ulcer/s
46/287 (16%)
2.5
Lower abdominal pain
219/1687 (13%)
2.2
Vaginal discharge
530/5710 (9%)
1.8
Abundant discharge
305/2744 (11%)
1.5
Malodour (discharge)
256/2193 (12%)
1.5
Pruritis genitalia
256/3338 (8%)
1.1
Myanmar DOH / Unicef Guidelines for STI
Complaint Vaginal Discharge or Vulval itching/burning
Risk assessment
1) Age > 21
2) Partner STI
3) New partner within 3 months
yes
no
treat according to microscopy results
TV
BV
Cand.
-
Treat GC/CT
Sensitivity
99%
Specificity 4%
12000 patients,
>10000 treated
for GC
WHO Guidelines for STI
Complaint Vaginal Discharge or Vulval itching
Exam + Lab
Lower abdom. pain
yes
Separate guideline
no
Treat GC/CT
But the association
between vaginal
discharge or vulval
itching and GC is
not very strong!
plus treat according
microscopy results
TV
BV
Cand.
-
Comparison of 2 methods
Relation Vaginal discharge and/or Vulval itching and GC (WHO)
Vaginal Discharge
and/or vulval itching
GC positive
Yes
581/6493 (9%)
No
296/5416 (6%)
OR
Sens.
Spec.
PPV
NPV
1.7
66%
46%
9%
95%
OR
Sens.
Spec.
PPV
NPV
4.1
75%
58%
12%
97%
Relation Risk Assessment and GC
Risk Assessment
High
Low
GC positive
663/5340 (12%)
222/6668 (3%)
‘Improved’ risk factors based on results
analysis
+
‘Less factors’ (MOH)




New risk factors ;
Previous STI (complaint or confirmed) – (2)
New partner within 3 months – (2)
Sex worker – (3)
Patient complaint of dysuria or genital ulcers – (3)
 Partner complaint of genital symptoms (3)
Compare 3 methods
VD or itching
GC positive
Yes
581/6493 (9%)
No
296/5416 (6%)
OR
Sens.
Spec.
PPV
NPV
1.7
66%
46%
9%
95%
4.1
75%
58%
12%
97%
4.7
79%
56%
13%
97%
OLD Risk
Assessment
High
Low
663/5340 (12%)
222/6668 (3%)
NEW Risk
Assessment
High
Low
655/5234 (13%)
176/5948 (3%)
But all have a very low PPV …..
Conclusion
Don’t limit the flowchart to “women with vag. discharge /
itching but include all women. (miss >> 50% cervicitis)
The risk assessment is more sensitive and specific than
the vag. discharge./itching flow chart.
Risk assessment specific for each country / region….
Flow charts will have to be updated when prevalence
rates change. (With a lower prevalence of STI, over-treatment
gets worse if we use the same flow chart.)
End 1 …..
Prevalence of microscopy confirmed GC
according to patient’s risk and follow up
15%
Low Risk Women
10%
High Risk Women,
regular follow up
High Risk Women,
irregular follow up
5%
0%
GC (+) confirmed
MSF flowchart in Myanmar
Women with or without symptoms
Risk assessment
Low risk
High risk
Regular visitor
Irregular visitor
Cerv. risk assessment
-
+
Treat GC/CT
treat according to phys. exam + microscopy results
Prevalence of microscopy confirmed GC
according to patient’s risk and follow up
15%
Low Risk Women
HR, regular, risk 2
low
HR, regular, risk 2
high
High Risk Women,
irregular follow up
10%
5%
0%
GC (+) confirmed
Cervical Risk assessment done for High Risk Women
who visit the clinic regular
Score
Abnormal thick yellow discharge
2
Partner discharge/ ulcer observed
2
Unprotected sex with new clients
2
Dysuria
1
Lower abdominal pain
1
Pain during sexual intercourse
1
Risk assessment (+) if score ≥2, automatically treat for GC/CT
Risk Assessment
GC positive
≥2
100/666 (15%)
<2
70/1243 (5.6%)
OR
Sensi Speci
-tivity -ficity
PPV
NPV
3.0
59%
15%
94%
66%
Offer all women who enter a clinic RTI management
Risk assessment; High or Low risk ? 
Low risk
History, physical + lab  Treat positive findings
High risk
Irregular visitors
Presumptive treatment GC/CT
High risk
Regular visitors
Risk assessment cervicitis
 High risk  Presumptive treatment GC/CT
 Low risk  Treat positive findings
Differentiate between “high risk” women
who visit regularly and irregular
• Women who visit irregular have more STI.
 As a precaution we treat more aggressively.
• Women who visit regular have less STI.
 We want to treat less aggressively.
• A separate risk assessment (Cervical risk
assessment) can help to select which of these
patients should be treated.
STI management : Low Risk women (in clinic)
Step 1
Main complaint : abnormal vaginal
discharge or malodour
Main complaint : vulvar pruritis
Treat for TV/BV
Treat for Candida
Step 2
Clinic with
speculum exam only
Clinic with
speculum + laboratory
Cervical pus or
Yellow vagina discharge or
Cervical motion tenderness
GC/ CT
Discharge + KOH smell (+) + pH>4.5
TV/ BV
Erythema ± discharge (white KOH smell (-)
and pH <4.5)
Candida
Cervical pus or
yellow vaginal discharge or
Cervical motion tenderness or
Cervical smear  20 PMNL or
GC (+) any smear
GC/ CT
>20% clue cells + KOH smell (+) + pH>4.5 +
homogenous discharge (≥ 3) or TV
TV/ BV
Erythema ± discharge ± candida (KOH smell () and pH<4.5)
Candida
STI management : High Risk women
visit (>3 months) and follow up limited
Irregular
Step 1
Main complaint : abnormal vaginal
discharge or malodour
Treat for TV/BV
Main complaint : vulvar pruritis
Treat for Candida
Step 2
Outreach Treatment (no
privacy? / speculum / lab)
Always treat for GC / CT + Syphilis + Chancroid
Always treat for GC/ CT and Syphilis
Clinic with speculum
exam only
Discharge + KOH smell (+) + pH>4.5 (2/3)
TV/ BV
Signs of vaginitis / Cervicitis
Erythema ± discharge (white KOH smell (-) and
pH <4.5)
Candida
Always treat for GC / CT (+ treat syphilis if no RPR available)
Clinic with speculum +
laboratory
Signs of vaginitis or Lab (+)
>20% clue cells + KOH smell (+) + pH>4.5 + +
homogenous discharge (≥3 out of 4) or TV+
TV/ BV
Erythema ± discharge ± candida (KOH smell (-)
and pH<4.5)
Candida
STI management : High Risk women
visit (within 3 months) in parlor or clinic
Regular
Step 1
Main complaint : abnormal vaginal
discharge or malodour
Treat for TV/BV
Main complaint : vulvar pruritis
Treat for Candida
Step 2
Do risk assessment for cervical infection for high risk women
Score
Abnormal thick yellow discharge
2
Partner discharge/ ulcer observed
2
Unprotected sex with new clients
2
Dysuria
1
Lower abdominal pain
1
Pain during sexual intercourse
1
If score  2  Risk assessment (+)  automatically treat for Cervicitis GC/CT
If score < 2  Risk assessment (-)  treat for Cervicitis according to findings
Step 3
Next page
Continue from previous page
Step 3
Outreach Treatment (no privacy? /
speculum / lab)
Treat for GC / CT, if possible take blood for RPR (quantative)
treat accordingly next day
If no RPR available, treat syphilis every 3 – 4 months
Clinic with speculum
exam only
Sings of vaginitis / Cervicitis
Cervical pus, or yellow vaginal discharge,
or cervical motion tenderness
TV/ BV
Discharge + KOH smell (+) + pH>4.5 (2/3)
TV/ BV
Erythema ± discharge (white KOH smell (-)
and pH <4.5)
Candida
Treat for GC / CT (+ treat for syphilis if no RPR available)
Clinic with speculum +
laboratory
Sings of vaginitis or Lab (+)
>20% clue cells + KOH smell (+) + pH>4.5 +
+ homogenous discharge (≥3 out of 4) or TV+
TV/ BV
Erythema ± discharge ± candida (KOH smell () and pH<4.5)
Candida
Analyse risk assessment based on the relation between
risk factors and laboratory confirmed GC
Score
3
OR
2.7
Patients complaints of genital ulcers
Sex worker
Woman has seen partner’s discharge or ulcer
3
3
3
2.5
2.7
4.9
Partner complaint of genital symptoms
Patient complaint of lower abdominal pain
New partner within 3 months
2
1
1
2.6
2.2
2
Previous STI confirmed
Previous STI like complaint
1
1
1.8
1.5
Patients complaints of Dysuria
Score 3 : treat according to Low Risk STI management
Score 3 : treat according to High-risk STI management
separate flow charts according to the risk of the
women and the frequency of visiting a clinic
GC (+)
Women with low risk assessment.
Low risk
222/6668 (3.3%)
Women with high risk assessment who do
not visit the clinic regularly.
High risk
495/3467 (14.3%)
Women with high risk assessment who
visit the clinic regularly for STI screening.
Medium risk
168/1873 (9.0%)