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MSF Holland in Myanmar Reproductive tract infections

MSF Holland in Myanmar Reproductive tract infections. 18 MSF clinics in Myanmar Capital North East West. Yunnan China. Manipur India. Bgd. Thailand. STI management in resource poor setting. Symptoms. Lab

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MSF Holland in Myanmar Reproductive tract infections

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  1. MSF Holland in MyanmarReproductive tract infections 18 MSF clinics in Myanmar • Capital • North • East • West

  2. Yunnan China Manipur India Bgd Thailand

  3. 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

  4. 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.

  5. 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).

  6. WHO flowchart for STI TV BV Cand. - ComplaintVaginal Discharge or Vulval itching Exam + Lab yes Lower Abdom. pain 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

  7. Myanmar DOH / Unicef Guidelines for STI TV BV Cand. - 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

  8. MSF started a modified flow chart • Flow chart based on a combination of • Risk factors • Symptoms / signs • Laboratory tests

  9. MSF flowchart in Myanmar Women with or without symptoms Risk assessment - Previous STD “confirmed” = (2) - Previous STD-like complaints = (1) - 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 >= 3 Treat GC/CT Low risk High risk treat according to phys. exam + microscopy results

  10. And a new patient STI registration form • Systematically record symptoms, signs and laboratory results. • Put the records in a data base.

  11. Clinic: Reg.No : ____________ FEMALE REGISTRATION CARD Recent Complaints and Duration ………………………………………………………

  12. When ……….

  13. Laboratory request form : WOMEN

  14. 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)

  15. Risk factors Partner discharge or ulcer observed 73/270 (27%) 4.9 Sex worker 449/3632 (12%) 2.7 Partner complaint genital symptoms 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 Correlation between risk factors and GC OR GC (%)

  16. 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 Correlation between symptoms and GC

  17. Myanmar DOH / Unicef Guidelines for STI TV BV Cand. - Complaint Vaginal Discharge or Vulval itching/burning Risk assessment 1) Age > 21 2) Partner STI 3) New partner within 3 months yes Treat GC/CT Sensitivity 99% Specificity 4% 12000 patients, >10000 treated for GC no treat according to microscopy results

  18. WHO Guidelines for STI TV BV Cand. - ComplaintVaginal Discharge or Vulval itching Exam + Lab yes Lower abdom. pain Separate guideline no But the association between vaginal discharge or vulval itching and GC is not very strong! Treat GC/CT plus treat according microscopy results

  19. Comparison of 2 methods Relation Vaginal discharge and/or Vulval itching and GC (WHO) Relation Risk Assessment and GC

  20. ‘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)

  21. Compare 3 methods But all have a very low PPV …..

  22. 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 …..

  23. Prevalence of microscopy confirmed GC according to patient’s risk and follow up

  24. 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

  25. Prevalence of microscopy confirmed GC according to patient’s risk and follow up

  26. Cervical Risk assessment done for High Risk Women who visit the clinic regular

  27. Offer all women who enter a clinic RTI management

  28. 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.

  29. STI management :Low Risk women (in clinic) Step 1 Main complaint :abnormal vaginal discharge or malodour Treat for TV/BV Main complaint :vulvar pruritis Treat for Candida Step 2 Clinic with speculum exam only 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 orGC (+) any smear GC/ CT Clinic with speculum + laboratory >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

  30. STI management :High Risk women Irregular visit (>3 months) and follow up limited 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 Clinic with speculum exam only Signs of vaginitis / Cervicitis Always treat for GC/ CT and Syphilis Discharge + KOH smell (+) + pH>4.5 (2/3) TV/ BV Erythema ± discharge (white KOH smell (-) and pH <4.5) Candida Clinic with speculum + laboratory Signs of vaginitis or Lab (+) Always treat for GC / CT (+ treat syphilis if no RPR available) >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

  31. STI management : High Risk women Regular visit (within 3 months) in parlor or clinic 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

  32. 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 Clinic with speculum + laboratory Sings of vaginitis or Lab (+) Treat for GC / CT (+ treat for syphilis if no RPR available) >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

  33. Analyse risk assessment based on the relation between risk factors and laboratory confirmed GC Score 3 : treat according to Low Risk STI management Score 3 : treat according to High-risk STI management

  34. separate flow charts according to the risk of the women and the frequency of visiting a clinic

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