Indirect haemagglutination test using gonococcal pilus antigen: how useful to diagnose gonorrhoea?

Serological and clinical correlates of gonorrhoea and syphilis in fertile and infertile Nigerian women

OBJECTIVE

To test the hypothesis that infertile Nigerian women have higher serum levels of antibodies against Neisseria gonorrhoea and Treponema pallidum compared with fertile controls.

DESIGN

The prevalence of serum antibodies against N gonorrhoea and T pallidum was compared in fertile and infertile Nigerian women.

SETTING

Population based case-control study in Ile-Ife, southwestern Nigeria.

SUBJECTS

60 women with infertility identified from a community based questionnaire survey of 1075 women were compared with 53 age matched fertile controls.

METHODS

Sera of fertile and infertile women were tested for the presence of gonococcal antibodies with indirect agglutination test and syphilis antibodies using rapid reagin method.

MAIN OUTCOME MEASURES

Prevalence of anti-gonococcal and anti-treponemal antibodies in cases and controls. Frequency of self reports of sexually transmitted infections (STIs) in cases and controls.

RESULTS

In comparison with fertile women, infertile women were more likely to report having had repeated lower abdominal pains (p < 0.01), yellow vaginal discharge (p < 0.004), and whitish vaginal discharge (p < 0.02). There was no significant difference between cases and controls in the proportions reporting previous STI diagnoses. However, two infertile women reported previous gonococcal infection compared with none in the fertile group. Sixteen of the infertile women (26.7%) demonstrated anti-gonococcal antibodies in their sera compared with only four of the 53 fertile controls (7.5%) (p < 0.02; OR 4.5). There was no significant difference between fertile and infertile women in the proportion showing serological reactivity to T pallidum.

CONCLUSION

Infertile women have a higher prevalence of anti-gonococcal antibodies compared with fertile controls. Infertile women are also more likely to report previous lower abdominal pains and vaginal discharge. These results provide credible evidence implicating STIs and N gonorrhoea in particular as important factors contributing to female infertility in this population. Public health measures are warranted to address the high rate of STIs and N gonorrhoea in Nigeria.

Seroepidemiological and socioeconomic studies of genital chlamydial infection in Ethiopian women

OBJECTIVE

To measure the prevalence of chlamydial genital infection in Ethiopian women attending gynaecological, obstetric and family planning clinics; to identify the epidemiological, social and economic factors affecting the prevalence of infection in a country where routine laboratory culture and serological tests for chlamydial species are unavailable; to determine the risk factors for genital chlamydial infection in those with serological evidence of other sexually transmitted diseases.

SUBJECTS

1846 Ethiopian women, outpatient attenders at two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics.

METHODS

Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV1-3), and C. pneumoniae (CPn)), in a micro-immunofluorescence test. The genital chlamydia seropositivity was analysed against patient's age, clinic attended, ethnic group, religion, origin of residence, age at first marriage and first coitus, income, number of sexual partners, duration of sexual activity, marital status/profession, obstetric and contraceptive history, and seropositivity for other sexually transmitted diseases.

RESULTS

Overall exposure to chlamydia species was found in 84%, genital chlamydial infection in 62%, and titres suggestive of recent or present genital infection in 42% of those studied. Genital chlamydial infection was highest (64%) in family planning and lowest (54%) in antenatal clinic attenders. Exposure to genital chlamydia species was influenced by ethnic group and religion. Those married and sexually active under 13 years of age had greater exposure (69%) to genital chlamydial infection than those first sexually active aged over 18 (46%). Prevalence of infection was highest in those with more than five sexual partners (78%) and in bargirls (84%). The lowest income groups had a higher prevalence (65%) of genital chlamydial infection than the wealthiest (48%). Multivariate analysis showed the most important factors to be age at first coitus, religion, prostitution and present age of the woman in that order. Risk for genital chlamydial infection was increased in those with seropositivity for syphilis, gonorrhoea, HSV-2 but not HBV infection. CONCLUSION/APPLICATION: Chlamydial genital infections are highly prevalent in both symptomatic and asymptomatic Ethiopian women. The high prevalence of infection reported reflects a complexity of socioeconomic factors: very early age at first marriage and first coitus, instability of first marriage, subsequent divorce and remarriage or drift into prostitution, all of which are influenced by ethnic group, religion and poverty--together with transmission from an infected group of prostitutes by promiscuous males to their wives, lack of diagnostic facilities and inadequate treatment of both symptomatic and asymptomatic men and women. The problem of chlamydial disease in Ethiopia needs to be addressed urgently in the context of control of STD.

Seroepidemiological study of gonorrhoea in Ethiopian women. 1. Prevalence and clinical significance

OBJECTIVE

To measure the prevalence of gonorrhoea in Ethiopian women attending gynaecologic, obstetric and family planning clinics: to determine the reliability of patient self history of sexually transmitted disease (STD); to correlate the serological diagnosis of gonorrhoea with clinical evidence of pelvic infection in order to define a reliable clinical diagnosis of gonorrhoea in a country where pelvic inflammatory disease is very common but where routine laboratory culture and serological tests for gonorrhoea are unavailable.

SUBJECTS

1851 Ethiopian women: 50% symptomatic, 50% asymptomatic.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

METHODS

The indirect haemagglutination test with gonococcal pilus antigen as an epidemiological tool was used in a cross-section study to screen 1851 sera for evidence of past or current gonococcal infection. The gonococcal antibody test (GAT) seropositivity was correlated with patient's history of STD, age, clinic attended and the clinical evidence of infection in "gonococcal target organs" urethra, salpinges or Bartholin glands.

RESULTS

Fifty nine per cent of the study group were seropositive for the gonococcal antibody test, 22% with titres greater than or equal to 1/320, indicative of current, recent or recurrent infection. Seropositivity indicating past or present gonococcal infection was highest in those who gave a history of having had treated syphilis (85%), in women aged 40-49 (72%), and family planning attenders (EFGA) (66%) of whom 31% had titres greater than or equal to 1/320. Fifty per cent had clinical evidence of past or present infection in the urethra, salpinges or Bartholin glands. Gonococcal antibodies were present in 54% of women with no evidence of clinical infection, compared with 91% of those with pyosalpinx and 86% of those with triple infection of urethra, salpinges and Bartholin glands.

CONCLUSION

The high prevalence of gonococcal antibodies in Ethiopian women, especially in asymptomatic clinic attenders must be of concern for all health workers especially those in gynaecology and obstetrics and the related disciplines of family planning and neonatal paediatrics. While seropositivity was highest in those giving a past history of syphilis, the patient's history of STD was unreliable, as of those who denied having any history of STD, fifty per cent were GAT seropositive. Despite a high correlation between GAT seropositivity with pyosalpinx and clinical evidence of infection in urethra, salpinges and bartholin glands, gonococcal antibodies were present in 54% of women with no clinical evidence of infection. Thus we were unable to define a diagnostic clinical picture of gonorrhoea in Ethiopian women.

Seroepidemiological study of gonorrhoea in Ethiopian women. 2. Socioeconomic picture

OBJECTIVES

To determine aetiological factors associated with the prevalence of gonorrhoea in Ethiopian women to enable subsequent formulation of intervention policies.

SUBJECTS

1851 Ethiopian women: 50% symptomatic, 50% asymptomatic.

SETTING

Gynaecological outpatient departments, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

METHODS

Using the indirect haemagglutination test with gonococcal pilus antigen, sera were tested for the presence of gonococcal antibodies indicating past or present infection. The socioeconomic facts were analysed against gonococcal seropositivity of these women.

RESULTS

Gonococcal infection was associated with very early age at first marriage and first coitus, more than one sexual partner and marital status/profession. The highest prevalence and titres were found in bargirls (100%) prostitutes (89%) and sellers of local beer (85%). The lowest prevalence and titres were found in the highest income group, those married over the age of 18 years, those with only one husband or sexual partner, and those with a sexual life of less than 5 years duration.

CONCLUSIONS

National measures which could contribute to reduction and control of gonorrhoea include effective raising of the age of first marriage and first coitus, as has already been defined by law; the education of all girls up to fifth grade or equivalent; the provision of financial support to prevent widows and divorcees from drifting into prostitution; regular health checks and treatment of prostitutes; and education of men. While gonorrhoea per se is a major public health problem, our findings must have serious implications in the wider context of possible transmission of HIV through the community.