Comparing “Vaginal Infection” as Chief Complaint to Subsequent Treatment at a Clinic in Rural Haiti World Health Student Organization John Dawdy1; Dr. Jeffrey Van Laere, M.D.2; Justin Gerard1; Priyanka Singh1; Terrie Ahn1; Dr. Diane Levine, M.D.3 1Wayne State University School of Medicine; Detroit Medical Center, 2Department of Emergency Medicine and 3Department of Internal Medicine INTRODUCTION METHODS DISCUSSION Sexually transmitted infections are among the most common infectious diseases, and make significant contributions toward morbidity and mortality in developing nations. If left untreated, these infections contribute to reproductive morbidity and mortality, adverse pregnancy outcomes, and enhanced acquisition or transmission of HIV infection. An interdisciplinary health care team of physicians, students and pharmacists from the Wayne State University School of Medicine traveled to Haiti to operate a 5 day long medical clinic in March of 2014. The clinic was located in Morne de l’Hopital, a rural community in the mountainous area outside of Port-au-Prince. An impoverished nation already, the earthquake that hit Haiti in 2010 led to the collapse of an already fragile social, economic and health infrastructure that has been slow to recover. The limited financial resources, social infrastructure, community health networks, and significant stigma surrounding STIs are particularly important roadblocks to proper education, diagnosis and treatment. Each patient that attended the clinic had an associated patient intake form where demographic information, symptoms, history of present illness, diagnosis, and treatment were recorded. Patient intake forms from the clinic were reviewed for chief complaints related to vaginal infection along with subsequent diagnoses and treatment plan. The dire consequences associated with these infections and the poverty of resources available to local health workers has led public health organizations, including the WHO and Haiti’s Ministry of Health, to promote the use of a syndromatic approach to treatment. As such, all patients that present with symptoms associated with an STI are treated empirically. This form of approach has been shown to have both low sensitivity and specificity. Figure 1. Protocol for treatment of vaginal discharge and/or itchiness among women in Haiti, Ministry of Health Woman presents with vaginal discharge and/or itchiness If vaginal ulcerations are present, treat using appropriate algorithm Ask patient if partner has symptoms of STIs (urethral discharge, pain/burning upon urination) Yes No Screen for the following risk factors: • Age <21 years • Living alone/not living with partner • >1 sexual partner during the past 6 months • New sexual partner during the past 3 months Diagnosis used a heavily syndromatic approach, based predominantly on clinical presentation and limited diagnostic tools to rule out other possible diagnoses. Tools used were: 1) History: pertinent positives included pain or burning with urination, changes in vaginal discharge, a sexual partner with a STI, lower abdominal pain, or pain/bleeding during sexual intercourse. 2) Physical exam, including speculum exam: pertinent positives included purulent vaginal or cervical discharge, vaginal bleeding outside of menstruation, cervical friability, cervical motion tenderness, or lower abdominal tenderness. 3) pH test strips and the Whiff test: used to rule out bacterial vaginosis. 4) Urinalysis: performed to rule out urinary tract infection. RESULTS Increased antibiotic resistance is often a key talking point for advocates of reducing such overtreatment, and it also appears that significant resources could be saved within a health system that is already strained. When you also consider patient reassurance that what they are experiencing is normal, a more educated patient population with regards to vaginal discharge offers a number of clear benefits. Diagnosis Vaginal Symptoms 70 30 65 24 25 <2 risk factors 50 47 20 •Treat patient for cervical infection and vaginitis •Provide counseling, education, and condoms to patient and partner(s) •Emphasize importance of taking all medications •Treat partner(s) for STIs •Reassess if no improvement in symptoms after 15 days This knowledge deficit suggests that educational initiatives that not only address common causes of vaginitis and STI prevention but also include education regarding the normal discharge experienced by women could be beneficial for this and other similar communities. Our trip included a partnership with a local nurse to lead education sessions for patients in Creole. Similar community-based approaches to patient education have proved successful in the past, and including this often neglected topic within these initiatives could begin to fight the culture of overtreating vaginal discharge. Of 304 female patients that attended the clinic, a total of 92 patients presented with a chief complaint of “vaginal infection”. From these 92 patients, 51 were treated for such infections. 60 >2 risk factors Based on our experience, it appears that patients often misinterpret the clinical signs and symptoms of a vaginal discharge. Interactions with patients that attended this clinic would suggest that there is a general awareness of STIs in the community. However, a more comprehensive women’s health education would be beneficial in improving understanding of variability of normal vaginal discharge. Experiences with past medical mission trips that have used empiric treatment of vaginal discharge has contributed to the medicalization of discharge and a perception that all instances require pharmacologic treatment. This not only leads to an expectation of treatment when attending clinics, but results in patient reporting self-treatment with available antibiotics when access to clinics is not available. 18 39 40 18 REFERENCES 15 •Treat for vaginitis •Provide counseling, education, and condoms to patient and partner(s) 30 19 20 10 10 14 6 10 AIM We looked at the prevalence of “vaginal infection” as a chief complaint at a clinic in rural Haiti and compared it to the number of patients that were subsequently treated for this complaint. It is suspected that many patients lack adequate knowledge of normal vaginal discharge and the variation of discharge during the menstrual cycle, leading to an overestimation of its prevalence within the patient population. 7 5 5 1. 5 1 0 Burning with Discharge urination Frequency Itching Odor Pain Pain with Sex Figure 2 . Number of patients presenting with common vaginal symptoms 0 Atrophic Vaginitis Bacterial Vaginosis STI UTI Vaginal Infection Yeast Infection Normal Vaginal Discharge Figure 3 . Diagnosis of patients that presented with “vaginal infection” 2. 3. Smith Fawzi MC, Lambert W, Singler J, et al. Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting. Sex Transm Infect 2006; 82: 175-181. Logie CH, Daniel C, Newman PA, Loutfy MR. An HIV/STI prevention intervention for internally displaced women in Leogane, Haiti: study protocol for an N-of-1 pilot study. BMJ Open. 2012; 2:e001634 Centers for Disease Control and Prevention. Sexually Transmitted Infections in Developing Countries. Atlanta: U.S. Department of Health and Human Services; 2008.