title: Clinical algorithms for the screening of pregnant women for STDs in Libreville, Gabon: which alternatives?
abstract: OBJECTIVE
  Sexually transmitted diseases (STDs) remain one of the major public health problems in the developing world. To implement a systematic screening of STDs among pregnant women in Libreville, Gabon, a preliminary cross sectional study on STD prevalence and risk factors was performed in antenatal clinics. A score, integrating risk factors and elementary clinical signs for the screening of STDs, showed higher performances compared with hierarchical algorithms. The prospective validation of this score based on six criteria (risk factors and simple clinical signs) was done in 1994-5. The sensitivity (76.7%), compared with results from other studies, was acceptable for diagnosing cervical infection (Neisseria gonorrhoeae and/or Chlamydia trachomatis) but the specificity was low (50.6%). In addition, the diagnostic values for diagnosing vaginal infection (Trichomonas vaginalis and/or Candida albicans) were poor. We then proposed to evaluate an alternative flowchart for the screening of cervical and vaginal infections.
  
  
  METHODS
  In this study, 646 pregnant women were enrolled. Each woman was interviewed and examined by a physician and then was subjected to reference laboratory examinations. An algorithm in two steps, combining a risk assessment score at the beginning of a hierarchical process, followed by a second step more specifically applied to a limited number of women, was developed and evaluated.
  
  
  RESULTS
  The prevalence rate was 11.3% for cervical infection and 39.5% for vaginal infection. The first step of the algorithm, applied to all pregnant women, is based on four criteria (age, marital status, dyspareunia, coloured vaginal discharge). It allows classification of the women into three classes: high, low, and intermediate risk of cervical infection. Only the patients with intermediate risk were submitted to further investigations including speculum and microscopic examination, and subsequently chlamydial antigen detection. This flowchart was 83.6% and 81.2% sensitive and 63.4% and 62.7% specific for predicting cervical infection and vaginal infection, respectively.
  
  
  CONCLUSIONS
  Similar strategies using simple rapid tests for chlamydial and gonococcal infection would certainly constitute a good diagnostic tool. This theoretical model needs to be evaluated prospectively, not only to confirm their diagnostic value but also to evaluate their feasibility, reliability and acceptability, as well as their cost effectiveness.
authors.affiliation: Programme SIDA de l'ORSTOM, Montpellier, France.
authors.forename: A
authors.initials: A
authors.lastname: Bourgeois
authors.forename: D
authors.initials: D
authors.lastname: Henzel
authors.forename: G
authors.initials: G
authors.lastname: Malonga-Mouelet
authors.forename: G
authors.initials: G
authors.lastname: Dibanga
authors.forename: C
authors.initials: C
authors.lastname: Tsobou
authors.forename: M
authors.initials: M
authors.lastname: Peeters
authors.forename: E
authors.initials: E
authors.lastname: Delaporte
mesh_terms: D000465:Algorithms; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005260:Female; D005681:Gabon / Q000453:epidemiology; D006801:Humans; D008403:Mass Screening / Q000379:methods*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology*; D011295:Prenatal Care / Q000379:methods*; D015995:Prevalence; D012307:Risk Factors; D012749:Sexually Transmitted Diseases / Q000453:epidemiology*; D002575:Uterine Cervicitis / Q000453:epidemiology; D014627:Vaginitis / Q000453:epidemiology