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, An interdisciplinary health care team of physicians, students and pharmacists from Based on our experience, it appears that patients often misinterpret the clinical
and make significant contributions toward morbidity and mortality in developing nations. If the Wayne State University School of Medicine traveled to Haiti to operate a 5 day long signs and symptoms of a vaginal discharge. Interactions with patients that attended this
left untreated, these infections contribute to reproductive morbidity and mortality, adverse medical clinic in March of 2014. The clinic was located in Morne de lHopital, a rural clinic would suggest that there is a general awareness of STIs in the community. However,
pregnancy outcomes, and enhanced acquisition or transmission of HIV infection. community in the mountainous area outside of Port-au-Prince. a more comprehensive womens health education would be beneficial in improving
understanding of variability of normal vaginal discharge. Experiences with past medical
An impoverished nation already, the earthquake that hit Haiti in 2010 led to the Each patient that attended the clinic had an associated patient intake form where mission trips that have used empiric treatment of vaginal discharge has contributed to the
collapse of an already fragile social, economic and health infrastructure that has been demographic information, symptoms, history of present illness, diagnosis, and treatment medicalization of discharge and a perception that all instances require pharmacologic
slow to recover. The limited financial resources, social infrastructure, community health were recorded. Patient intake forms from the clinic were reviewed for chief complaints treatment. This not only leads to an expectation of treatment when attending clinics, but
networks, and significant stigma surrounding STIs are particularly important roadblocks to related to vaginal infection along with subsequent diagnoses and treatment plan. results in patient reporting self-treatment with available antibiotics when access to clinics
proper education, diagnosis and treatment. is not available.
Diagnosis used a heavily syndromatic approach, based predominantly on clinical
The dire consequences associated with these infections and the poverty of presentation and limited diagnostic tools to rule out other possible diagnoses. Tools used This knowledge deficit suggests that educational initiatives that not only address
resources available to local health workers has led public health organizations, including were: common causes of vaginitis and STI prevention but also include education regarding the
the WHO and Haitis Ministry of Health, to promote the use of a syndromatic approach to 1) History: pertinent positives included pain or burning with urination, changes in vaginal normal discharge experienced by women could be beneficial for this and other similar
treatment. As such, all patients that present with symptoms associated with an STI are discharge, a sexual partner with a STI, lower abdominal pain, or pain/bleeding during communities. Our trip included a partnership with a local nurse to lead education sessions
treated empirically. This form of approach has been shown to have both low sensitivity sexual intercourse. for patients in Creole. Similar community-based approaches to patient education have
and specificity. 2) Physical exam, including speculum exam: pertinent positives included purulent vaginal proved successful in the past, and including this often neglected topic within these
or cervical discharge, vaginal bleeding outside of menstruation, cervical friability, initiatives could begin to fight the culture of overtreating vaginal discharge.
Woman presents with vaginal discharge and/or
itchiness
Figure 1. Protocol cervical motion tenderness, or lower abdominal tenderness.
for treatment of 3) pH test strips and the Whiff test: used to rule out bacterial vaginosis. Increased antibiotic resistance is often a key talking point for advocates of reducing
vaginal discharge 4) Urinalysis: performed to rule out urinary tract infection. such overtreatment, and it also appears that significant resources could be saved within a
If vaginal ulcerations are present, treat using and/or itchiness health system that is already strained. When you also consider patient reassurance that
appropriate algorithm
among women in what they are experiencing is normal, a more educated patient population with regards to
Haiti, Ministry of vaginal discharge offers a number of clear benefits.
Ask patient if partner has symptoms of STIs (urethral
discharge, pain/burning upon urination) Health RESULTS
Yes No
Of 304 female patients that attended the clinic, a total of 92 patients presented with a chief
Screen for the following risk factors:
complaint of vaginal infection. From these 92 patients, 51 were treated for such
Age <21 years infections.
Living alone/not living with partner
Diagnosis
>1 sexual partner during the past 6 months Vaginal Symptoms
30
New sexual partner during the past 3 months 70
65

60 25 24
>2 risk factors <2 risk factors
50 47
20
18 18
39
40
Treat patient for cervical infection and vaginitis
Provide counseling, education, and condoms to patient and
partner(s)
Treat for vaginitis
Provide counseling, education, and
30
15

10
REFERENCES
Emphasize importance of taking all medications 20
19 10
condoms to patient and partner(s)
Treat partner(s) for STIs 14
Reassess if no improvement in symptoms after 15 days 10 7
6
5 1. Smith Fawzi MC, Lambert W, Singler J, et al. Identification of chlamydia and
5 5

1
gonorrhoea among women in rural Haiti: maximising access to treatment in a
0
resource poor setting. Sex Transm Infect 2006; 82: 175-181.
AIM Burning with Discharge
urination
Frequency Itching Odor Pain Pain with
Sex
0
Atrophic
Vaginitis
Bacterial
Vaginosis
STI UTI Vaginal
Infection
Yeast
Infection
Normal
Vaginal 2. Logie CH, Daniel C, Newman PA, Loutfy MR. An HIV/STI prevention intervention for
Discharge

We looked at the prevalence of vaginal infection as a chief complaint at a clinic in internally displaced women in Leogane, Haiti: study protocol for an N-of-1 pilot
rural Haiti and compared it to the number of patients that were subsequently treated for Figure 2 . Number of patients presenting with Figure 3 . Diagnosis of patients that presented study. BMJ Open. 2012; 2:e001634
this complaint. It is suspected that many patients lack adequate knowledge of normal common vaginal symptoms with vaginal infection 3. Centers for Disease Control and Prevention. Sexually Transmitted Infections in
vaginal discharge and the variation of discharge during the menstrual cycle, leading to an Developing Countries. Atlanta: U.S. Department of Health and Human Services;
overestimation of its prevalence within the patient population. 2008.