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THE PREVALENCE AND RISK FACTORS OF GENITAL TRACT INFECTIONS IN ST. PETERSBURG AND LENINGRAD OBLAST. THE REVIEW OF STUDIES PERFORMED WITHIN THE RUSSIAN-SWEDISH PROJECT "IMPROVEMENT OF THE CONTROL AND PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS"
I. O. Makhinenko 1 (imakhinenko@mail.ru), E. V. Sokolovskiy 1, A. M. Savicheva 2, G. V. Grinenko 2, N. V. Provotorhova 3, M. Domeika 4
1 Department of Dermatology and Venereal diseases with clinic, Pavlov State Medical University, St. Petersburg, Russia;
2 D.O. Ott Research Institute of Obstetrics and Gynecology, RAMS, St. Petersburg, Russia;
3 Maternity clinic, Vsevolozhsk, Leningrad Oblast, Russia;
4 Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
■ In this article a review of studies concucted in the St. Petersburg and Leningrad regions on prevalence of genital tract infections among the visitors from Maternity clinics, polyclinic departments of dermato-venereologic dispensaries and youth clinics is presented and risk factors associated with the development of such infections are noted.
■ Key words: STI, vaginitis, cervicitis, urethritis, risk factors, microscopy of genital smears
Introduction
Sexually transmitted infections (STIs) constitute a serious health problem for people throughout the world. Every year there is an increase in STIs. Russia in general and St. Petersburg and Leningrad Oblast in particular are no exception to this growing problem (1). From 1998 till 2007, the Russian-Swedish project "Improvement of the control and prevention of sexually transmitted infections" was carried out in St. Petersburg and Leningrad Oblast. The main purpose of the project was to improve the quality of diagnostics and treatment of STIs. Two of the aims of the project include the introduction of a new approach in diagnostics of some STIs during the patient's first visit at the doctor's office and to evaluate the prevalence of infections of the reproductive tract (2). In this article a review is presented of studies performed within the framework of the project.
Materials and methods
Attendees of polyclinic gynecological department of the Maternity Clinic in Vsevolozsk region (Leningrad Oblast) during 1999 and 2001 were recruited. Totally, 500 women of childbearing age (up to 35 years) were examined. A swab of epithelium from the urethra and a swab of epithelium from the cervical channel and vaginal discharge were collected. To reveal inflammatory processes in the urethra,
cervix and vagina, as well as to detect gonococci (diplococci), T. vaginalis, yeast fungi and bacterial vaginosis (BV), a method of light microscopy was applied. Vaginal smears were tested as a wet smear. Smears from the cervix and urethra were investigated after staining with a alcohol solution of methylene blue by Lofler (3). Light microscopy (bedside microscopy) was done by the doctors in their office during the first visit of the patient. Polymerase chain reaction (PCR) and direct immunofluorescence were employed to detect genital chlamydial infections (4). The patients were asked to complete a questionnaire during their first visit.
Results
The prevalence rate of infections of the urogenital tract is presented in Table 1. Among the surveyed women 42.0 % reported complaints regarding discharge and periodic itching. In the group of women with complaints at the time of the microscopic examination it was found that 37.5 %o had BV, 35.9 %% had mycelium of yeast fungi, 6.2 0% had T. vaginalis, 1.5 o% had gonococci, 14 %% had nonspecific vaginitis and 9.3 o% presented nonspecific cervicitis. For all patients, treatment was prescribed based on the results of the examination performed at the first appointment.
In 2001 - 2002, with the purpose of studying the prevalence and potential risk factors of infections in the reproductive tract, 718 gynecologic patients attending polyclinic departments of the maternity clinics in St. Petersburg and 385 patients at the maternity welfare in Leningrad Oblast were examined. The investigation was done according to the above-stated scheme, except examination for C. trachomatis was performed using a cell culture method and direct im-munofluorescence (4). A questionnaire was given to each patient.
Genital tract infections were diagnosed in 416 (57.9 0%) patients at the maternity welfare clinics in
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St. Petersburg and in 204 women living in Leningrad Oblast (53 %). In total, 620 (56.2 %) of the patients were having genital tract infections (Table 1).
Risk factors that are common for all infectious diseases of the genital tract were not observed, except that the use of barrier methods of contraception was found to have a protective effect and reduced the risk of developing infectious diseases of the urogenital tract in 40.0 % of the cases.
Women using several methods of contraception (p = 0.0004) and women with a medical history of syphilis (p = 0.01) had BV more often. Patients with BV had pathological changes in the mucous membrane of the vagina (p = 0.0001) and in the cervix of the uterus (p = 0.02) more often than patients without BV. The most typical symptom was discharge, accompanied with unpleasant odor (p = 0.001). Women who were under specified treatment with antibiotics within the past 3 months and women who used condoms during sexual contacts (p = 0.01) had this infection less often (p = 0.03).
Our findings indicated that 64.7 % of the vaginitis cases were caused by Candida (yeast), 5.5 % by T. vaginalis and 29.8 % by nonspecific vaginitis.
Risk factors for Candida vaginitis were as follows, age (20 - 24 years, 0.02), secondary education (p = 0.01), social status (p = 0.001) or unemployment (p = 0.03), pregnancy (p = 0.001) and a candida vaginitis in the anamnesis (p = 0.01). Patients with candida infection more often had pathological changes of the vulva (p = 0.006), of the mucous membrane of the vagina (p = 0.0001) and of the cervix of the uterus
(p = 0.02). Complaints of discharge from the genital tract (p = 0.001) and itching of the external genitals (p = 0.004) were characteristic signs for vaginitis caused by candida. Candida spp. was found less often in the following patients: being employed (p = 0.01), being a housewife (p = 0.04), having a higher education (p = 0.002) and persons using a condom during sexual intercourse (p = 0.001).
Risk factors for acquiring T. vaginalis infection were age under 20 years (p=0.0004), not married (p = 0.004), being a student (p = 0.002), trichomo-nal infection in anamnesis (p = 0.003) and lack of information on the anamnesis of the sexual partner (p = 0.02). Patients having T. vaginalis infection had a pathology of the mucous membrane of the cervix (p = 0.03) more often. The most typical symptom was itching in the genital area (p = 0.02).
Age (under 20 years, p = 0.0009, and over 40 years, p = 0.01), social status (school girl/student, p = 0.004), engaging in sexual activity before the age of 18 years (p = 0.02), having had T. vaginalis infection in anamnesis (p = 0.008) and lack of information on the anamnesis of the sexual partner (p = 0.01) were risk factors for nonspecific vaginitis. These patients had pathological changes more frequently from the vulva (p = 0.004), vagina (p = 0.001) and cervix (p = 0.001). The most common symptom was discharge from the genital tract (p = 0.003). Women who used a condom during sexual contacts (p = 0.03) showed a low frequency of nonspecific vaginitis.
Risk factors regarding the development of cervi-citis were use of several methods of contraception
Table 1
The prevalence of genital tract infections among the groups tested
Infection/ Inflammatory condition Prevalence (%) among visitors of: (N - not done)
Gynecologic polyclinic Vsevologsk, Leningad oblast Gynecologic polyclinic Leningrad Oblast and St. Peterburg Youth Centers VD Dispensaries, women VD Dispensaries, men Gynecologic polyclinic, pregnant women Gynecologic polyclinic, women consulting for abortion
Bacterial vaginosis 29,3 20,6 N N N N N
Candidal infection 20,0 16,0 N N N N N
Vaginitis 11,3 24,7 N N N N N
Cervicitis 10,8 13,5 N N N N N
Urethritis HO 11,7 N N N N N
T. vaginalis 4,0 1,4 1,7 2,4 1,1 1,4 2,1
N. gonorrhoeae 0,7 0 1,0 0 4,0 0 0
C. trachomatis 3,8 4,6 10,0 4,9 5,7 3,2 6,3
M. genitalium HO HO 2,7 2,4 2,8 1,1 3,1
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(p = 0.001) and presence of urethritis in anamnesis (p = 0.03). These patients more often demonstrated pathological changes of the mucous membrane of the vagina (p = 0.001). Characteristic complaints were dyspareunia (p = 0.001) and discharge from the genital tract (p = 0.002), including vaginal bloody discharge (p = 0.03). Women using a condom (p = 0.001) had cervicitis less often than those not using a condom.
Age (under 20 years, p = 0.01), being a student (p = 0.03) and being pregnant (p = 0.02) all proved to be risk factors for chlamydial infections. Patients more often exhibited pathological changes of the mucous membrane of the cervix (p = 0.001). The most common patient complaints were lower abdominal pain (p = 0.005), discharge from the genital tract (p = 0.02) and dyspareunia (p = 0.001). Chlamy-dial infection was found less often in women who used a condom during the vaginal sex (p = 0.02) and in those who had this infection in the anamnesis (p = 0.03).
Risk factors in the development of urethritis were age (under 20 years and over 40 years, p = 0.03 and p = 0.007, respectively), secondary education (p = 0.01), being a school girl or student (p = 0.003) and being pregnant (p = 0.005). Patients more often had pathological changes of the vulva (p = 0.001), vagina (p = 0.0003) and cervix (p = 0.005). Use of a condom was found to reduce the risk of developing urethritis (p = 0.008). Vulval, vaginal and cervical infections occured less often in woman with higher education (p = 0.01) and in the age group of 30 - 34 years (p = 0.03).
During 2003 - 2004 in St Petersburg, visitors of youth centers (n=300), patients from out-patient departments of dermato-venereological dispensaties (n=300) and patients from maternity welfare clinics (n=298) were tested for chlamydial, gonococcal, trychomonal and M. genitalium infections.
Urethral swabs from men and urethral, vaginal and cervical swabs from women were tested. In some cases the doctors took urogenital smears that were examined at their office in the presence of the patients (bed side test). PCR was used to detect T. vaginalis, N. gonorrhea, C. trachomatis and M. genialium. All patients were provided with questionnaire regarding the risks of acquiring STIs.
The total prevalence of STIs in teenagers was 12.6 o% (Table 1). The age of the patients was found to be an independent risk factor for the presence of STI, particularly chlamydial infection. Those who attended with complaints were younger that those attending for other reasons. Highest risk of having STIs was observed among those at age below 17 years (p = 0.04 and p = 0.01 accordingly). Among non-married but living together persons and persons
living in a civil marriage (p = 0.0007 and p = 0.005), not studying and not working teenagers (p = 0.01) and individuals who have a sexual partner using drugs (p = 0.04 and p = 0.02) STIs were occurring more often. An independent risk factor of gonorrhea was the sexual partner's use of drugs (p = 0.02). T. vaginalis was diagnosed more often in teenagers with T. vaginalis infection in the anamnesis (p = 0.01). The independent risk factor for infection that was caused by M. genitalium was marital status (p = 0.02).
In visitors of out-patient departments in der-mato-venereological services 11.0 % of the patients with infections of the reproductive tract were detected. The prevalence rates of infections of the reproductive tract in men and women were 13.0 % and 8.1 %, respectively.
When examining visitors of the dermato-ve-nereological dispensaries, men had gonococcal infection more often than women (p = 0.04). Having more than five sexual partners during the past months increased the risk of contracting STIs in men (p < 0.0001), including chlamydial infection (p = 0.0002) and gonorrhea (p = 0.03). Men who did not have a regular sexual partner (p = 0.02) had gonorrhea more often than men who have a regular partner. Lack of a regular sexual partner in women also increased the probability of STIs (p = 0.01), including chlamydial infection (p = 0.04). Patients under 21 years of age had chlamydial infection more often than patients over 21 years of age (p = 0.02). Women who had STIs in the past were diagnosed less often with STIs, including chlamydial infection (p = 0.01 and p = 0.03 accordingly).
Among pregnant women, the prevalence of STIs was 5.7% (Table 1). Patients with STIs were younger than people without STIs (p = 0.03). Increased risk of STIs in general, as well as of chlamydial infection, was observed in persons under the age of 26 years (p = 0.04), in women who are in their first pregnancy (p = 0.04 and p = 0.01, accordingly) and in persons who are married but not officially registered as being married (p = 0.01 and p = 0.007, accordingly).
The prevalence rate of STIs in women coming for abortion was 10.4 % (Table 1). Patients with STIs were generally younger than healthy people (p = 0.02). A risk factor associated with STIs was women under 26 years of age (p = 0.04). Chlamy-dial infection was diagnosed more often in women having more then one sexual partner during the past 6 months (p = 0.03).
No risk factors were noted in pregnant women and in visitors from the dermato-venereological dispensaries regarding T. vaginalis infection and symptoms associated with M. genitalium infection.
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Summary
• STIs of the reproductive tract were widely noted in visitors from the maternity welfare clinic, youth consultation clinics and dermato-venereological dispensaries;
• microscopy of urogenital smears that is performed in the doctor's office is a rapid method for diagnosing inflammatory processes of the urethra, cervix and vagina. Moreover, it is an informative method for detecting changes of bacterial flora in vagina (BV) and in detecting the presence of some microorganisms (yeast fungi, trichomonas and gonococci) [5]. Furthermore, this method allows the possibility to prescribe treatment already during the patient's first visit to the doctor's office. The method can be used to help define a group of patients with a high risk of infection (e.g., having urethritis or cervicitis), making it possible to examine this group further in order to detect specific microorganisms (N. gonorrhoeae, C. trachomatis and M. genitalium);
• high rates of the reproductive tract infections point out at necessary to use the possibility of screening for those infections, especially among the teenagers attending youth clinics and women who come for pregnancy termination. To make screening more cost-saving, selection for such screening can be made based on microscopic findings of genital smears, behavioral determinants or using a sample-pooling method at the laboratory [6];
• patients from the dermato-venereological dispensaries should be examined for STIs according to existing algorithms for these patients.
References
1. Smirnova T.S. The STI situation in Saint-Petersburg. / Smirno-va T. S. // Z. Akus. Zen. Bolezn. Special edition — 2004 — Vol. LIII. — P: 78 - 79.
2. Domeika M. Summarized report about the Russian-Swedish projects: "Improvement of the prevention and control on STI in Leningradskaya oblast", 1998 - 2006, and "Improvement of the prevention and control on STI in St. Petersburg", 2002 - 2006 / Domeika M. // Z. Akus. Zen. Bolezn. Special edition — 2006 — Vol. LV. — 40 - 52. [in Russian]
3. Savicheva A.M. Compendium on microscopy diagnostics of STD / Savicheva A. M., Sokolovskiy E. V., Domeika M. — St. Petersburg: "Pholiant". — 2004. [in Russian]
4. Diagnosis of Chlamydia trachomatis in Russia — in house PCR assays may be effective but overall optimization and quality assurance are urgently needed / Shalepo K., Savicheva A., Shipitsyna E. [et al.] // APMIS. — 2006. — P. 114 (7 - 8), P. 500 - 507.
5. The bedside microscopy of urogenital smears — some "pro" arguments / Savicheva A., Vagoras A., Butylkina R., Sokolovsky E., Hallen A., Domeika M.
6. Pooling samples — the key to sensitive, specific and cost-effective diagnosis of Chlamydia trachomatis in low-resource countries / Shipitsyna E., Shalepo K., Savicheva A. [et al.] // Acta Obstet. Gyn. Scand. — 2007. — Vol. 87 (2). — P. 140 - 144.
EPIDEMIOLOGIC SITUATION WITH SEXUALLY TRANSMITTED DISEASES (STDs) IN ST. PETERSBURG IN 2006
T. S. Smirnova (gorkvd@bk.ru), O. V. Gaivoronskaya, N. U. Gultceva, L. M. Malkova
Dermato-venereology dispensary, St. Petersburgy, Russia.
The general epidemiologic situation in St. Petersburg regarding sexually transmitted insections (STIs) continues to be a problem. Though the general number of syphilis, gonorrhea, trichomoniasis, urogenital herpes, venereal warts, bacterial vaginosis, urogenital candidosis cases has decreased, morbidity is still very high and in 2006 was 1541 per 100 000 inhabitants. Syphilis and gonorrhea morbidity in St. Petersburg is below the average Russian rates, indicating their incomplete registration.
In 2006, general morbidity due to STIs decreased 1.4 %%, though morbidity due to syphilis, urogenital herpes and venereal warts increased on 6.1 %%, 2.9 % and 6.6 %%, respectively (Table 1).
The number of severe syphilis cases was found to increase (30 %%) at the expense of late forms of the disease. Compared with 2005, the number of neurosyphilis cases increased by 2.5 %% (from 4.5 to 7.0 %%). Forms of latent syphilis (early and late latent syphilis) continue to increase (45. %% of the general syphilis morbidity), which makes both diagnosis and treatment difficult. Such a situation promotes seroresistance and could eventually lead to disability. Along with late forms of syphilis, decreasing cardiovascular and visceral syphilis are essentially not detected, showing imperfect diagnostic tests and the necessity for more thorough examination of the patients with the latent forms. In 2006, number
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