Rural Hospital in Zimbabwe Genitourin Med: First Published As 10.1136/Sti.69.5.352 on 1 October 1993
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352 Genitourin Med 1993;69:352-356 HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from Franky Le Bacq, Peter R Mason, Lovemore Gwanzura, Valerie J Robertson, Ahmed S Latif Abstract serology was found in 64% patients. Objective-To define the epidemiological There was no statistical association with characteristics of STD patients attending current genital ulcers, though there was an outpatient clinic in rural Zimbabwe, an association with previous STD to examine the aetiologic agents causing episodes and particularly with serologi- infection and to determine their relation- cal evidence of syphilis. Apart from ship with HIV infection. yeasts, there was no association between Subjects-319 men and 146 women, mak- positive HIV-1 serology and the presence ing a sample of about 7% all patients ofpathogens in the genital tract. attending an STD clinic during the 3 Conclusions-The high prevalence of month study period. Microbiological HIV-1 antibodies in STD patients in data were collected from 104 men and 72 Karoi suggests integration of STD and women selected randomly from these. AIDS control programmes to be a neces- Pregnant women were excluded and sity. Since paid employment was a com- patients who had received antibiotics mon feature of both STD clinic within the previous 14 days were attendance and HIV-1 seropositivity, excluded from the microbiology sub- these programmes may be effectively sample. directed through the work place. Setting-An outpatient STD clinic at a District Hospital on a major truck route (Geniwurin Med 1993;69:352-356) about 300 km north of the capital, Harare. Introduction Methods-All new patients attending the Sexually transmitted diseases are a significant clinic during a 3 month period were public health problem in both urban and enrolled for clinical and epidemiological rural areas of Africa.' They occur commonly, investigations using a standard proce- have a major effect on maternal-child health dure. Specimens for microbiological and may require the allocation of a substan- investigation were taken from every sec- tial proportion of the health budget. In ond patient seen on the first three days of Zimbabwe, annual reports from the two http://sti.bmj.com/ each week. major urban centres, Harare and Bulawayo, Results-The typical patient was male have noted an increasing frequency of (m:f ratio 2.2) aged 20-29 years (68% reported cases of STD over the last decade23 patients), not married (56% men) and in and in 1990 over one million STD infections paid employment (66% men vs. 27% for were treated. Similar data may be obtained in the district). In men the most common rural communities. In Karoi District, a on October 1, 2021 by guest. Protected copyright. presenting feature was genital ulceration, mainly agricultural district some 200 km while in women, discharges were more north of Harare, the number of STD cases common. Genital warts were noted fre- rose from just over 13 000 in 1986 to almost quently in both sexes. In the sub-sample 20 000 in 1990. The district has an adult examined microbiologically, H ducreyi population estimated at 140 0004 making a Karoi District Hospital, Karoi was isolated from 46% ulcers clinically reported incidence of about 14 cases per 100 F Le Bacq diagnosed as chancroid, and motile people annually. STDs make up about 11% Department of spirochaetes were detected in 25% pain- of all new cases seen at the District Hospital, Medical Microbiology less ulcers. Neither of these were being the second most common complaint in P R Mason detected in ulcers in women, but L Gwanzura HSV adults attending out-patient clinics. V J Robertson antigen was found as frequently in ulcers The shortage of laboratory facilities and Department of from men (19%'/o) as from women (17%). personnel at rural health centres means that Medicine In patients with genital discharges, gono- most infections are diagnosed clinically. A S Latif coccal infection occurred in 64% men Accurate data on STD aetiology in University of and 17% women, while T vaginalis was Zimbabwe have been reported only for Zimbabwe Medical isolated from 390/o women and 8% School, Harare, only patients attending a referral centre in the cap- Zimbabwe men. Over 60% gonococcal isolates were ital,5 and as part of a programme on STD in Address for correspondence: PPNG, and 18% showed in vitro resis- rural centres, we investigated new cases pre- Prof P R Mason, Dept of tance to tetracycline. Yeasts, mainly C senting at Karoi District Hospital Medical Microbiology, during a University of Zimbabwe albicans were isolated from 42% women three month period. The data we present Medical School, P 0 Box with a discharge and 25% women with here cover clinical and A178 Avondale, Harare, epidemiological char- Zimbabwe. ulcers. In men the presence ofyeasts was acteristics of all patients, and the results of Accepted for publication associated with superficial ulceration microbiological investigations on a represen- 28 June 1993 and itchiness of the glans. Positive HIV-1 tative sample of these. HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe 353 Materials and methods and the serum separated and stored at Patient selection -20°C. Sera were subsequently tested for All new patients presenting to the outpatient antibody to HIV-1 by a single ELISA (Abbott department of Karoi District Hospital with Labs, USA), and by RPR, TPHA and FTA- suspected STD during March to May 1991 Abs for syphilis serology. Genitourin Med: first published as 10.1136/sti.69.5.352 on 1 October 1993. Downloaded from were enrolled in the study. Patients were given a thorough clinical examination and a Microbial identification standard questionnaire was taken for details All cultures were incubated under appropri- of past history, with particular regard to pre- ate atmospheric and temperature conditions. vious STD and treatments. Women who were Neisseria gonorrhoeae was identified on the suspected to be pregnant were referred to the basis of colony morphology, Gram stain, oxi- ante-natal rather than the STD clinic, and so dase activity and utilisation of glucose but not were excluded. maltose. All isolates were tested for fl-lacta- Because of limited finance and facilities, mase (Intralactam, Mast Labs, UK) and for microbiological data were collected on a sub- disc sensitivity to penicillin G (2 units) and sample selected as every second patient seen tetracycline (25 ug). Diamond's cultures were at the clinic during the first three days of each examined daily for 3 days, and T vaginalis week. Patients who had documentary evi- was identified by microscopy. H ducreyi was dence of antibiotic treatment within the past identified on the basis of colony morphology, two weeks were excluded, despite having including a "push test", Gram stain and neg- symptoms, because of the effect this may ative porphyrin test. Gram negative, metro- have had on the microbial flora. No speci- nidazole sensitive organisms growing on mens were taken from asymptomatic patients selective medium and able to hydrolyse starch because of ethical and financial constraints. and raffinose were identified as G vaginalis. Yeasts were tested for germ tube production, Specimen collection and negative isolates were identified using Cotton tipped swabs were used to collect commercial tests (API Systems, France). specimens of urethral, vaginal and/or cervical discharge from men and women. These were Statistics inoculated immediately on to Thayer-Martin The data were recorded on database for agar for gonococci, and then into Diamond's analysis by either chi square or Fisher's exact medium for maintenance of Trichomonas test. Probabilities are recorded as <0 01, vaginalis and yeasts. For the latter, a drop of <005 or not significant (NS). the medium was subsequently inoculated on to Sabourauds dextrose agar (SDA) with 50 mg/l chloramphenicol. A second swab was Results taken into transport medium for detection of Patients chlamydial antigen (Chlamydiazyme, Abbott In all 465 patients were enrolled, making were Labs, USA). Genital ulcers irrigated about 7% of all outpatients at Karoi District http://sti.bmj.com/ with about 2 ml sterile saline and the washing Hospital during the study period. There were was injected into a sterile bottle. A drop of 319 men and 146 women, giving a this fluid was examined by dark ground male:female ratio of 2.2. The age and gender microscopy within 10 mins. Further samples distribution is shown in table 1. Eighty nine were inoculated onto two media (Mueller- (61%) women claimed to be married, com- Hinton agar with 3 mg/l vancomycin, horse pared with 139 (44%) men (p < 0.01). The blood and isovitalex, and Brain-Heart mean age of married men was 31 years com- on October 1, 2021 by guest. Protected copyright. Infusion containing 10% foetal bovine serum pared with 24 years for unmarried men (p < plus 3 mg/l vancomycin) for isolation of 00 1), but there was no significant difference Haemophilus ducreyi.6 7 A second drop was in the mean ages of married (26 years) and inoculated onto SDA with chloramphenicol unmarried (25 years) women. The majority for yeasts. Smears were prepared on glass of women (121, 83%) were not in paid slides, fixed in acetone and stored at-20°C employment, while the majority of men (210, for detection of herpes simplex virus types 66%) were employed either in town or on I and II (HSV) using fluorescein labelled surrounding commercial farms. monoclonal antibody (provided by California There was a previous STD history in 86 State Dept Health Services, Berkeley, USA). (59%) women and 235 (74%) men, though For women with a discharge, the vaginal data on the exact nature of the STD were not vault was irrigated with about 2 ml sterile saline, and the saline-discharge mixture was injected into a sterile bottle.