ORIGINAL ARTICLES ARTIGOS ORIGINAIS
Diagnóstico precoce e os fatores associados às infecções sexualmente transmissíveis em mulheres atendidas na atenção primária
Carla Gianna LuppiI; Rute Loreto Sampaio de OliveiraI; Maria Amélia VerasI; Sheri A. LippmanII; Heidi JonesIII; Christiane Herold de JesusIV; Adriana A. PinhoV; Manoel Carlos RibeiroI; Hélio Caiaffa-FilhoVI
IDepartamento de Medicina Social - Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo (SP), Brasil
IICenter for AIDS Prevention Studies (CAPS) - University of California - São Francisco (UCSF) - Califórnia (CA), EUA
IIIDepartamento de Ginecologia da Universidade de Colúmbia - Centro Médico - Nova York (NY), EUA
IVCentro de Saúde Escola Barra Funda "Dr. Alexandre Vranjac" (CSEBF Dr. Alexandre Vranjac) - Irmandade da Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brasil
VEscola Nacional de Saúde Pública da Fundação Oswaldo Cruz (ENSP"Fiocruz) - Rio de Janeiro (RJ), Brasil
VIDivisão de Laboratório Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC" FMUSP) - São Paulo (SP), Brasil
INTRODUCTION: Sexually Transmitted Infections (STIs) in women remain a public health challenge due to high prevalence, difficulties to implement early diagnosis strategies and high rates of complications.
OBJECTIVE: Identify the prevalence of STIs among users of a primary health care clinic in São Paulo.
METHODS: Women, 18 to 40 years of age, were invited to self-collect vaginal specimens to be tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by Polymerase Chain Reaction (PCR). Women were also invited to answer a demographic and sexual history questionnaire, either on the computer or face-to-face.
RESULTS: The prevalence of STIs obtained from the 781 women included in the study was: Chlamydia trachomatis: 8.4%, Neisseria gonorrhoeae: 1.9% and Trichomonas vaginalis: 3.2%. Thirteen percent tested positive for at least one out of the three STIs. The variables associated independently with a higher risk of STIs were: age under 20-years-old, more than two lifetime sexual partners, and self-perception of STI risk. The use of condoms as a contraceptive method proved to be a protective factor.
CONCLUSION: The high prevalence found among these women indicates the need for the implementation of STI screening strategies in primary care settings in Brazil.
Keywords: sexually transmitted diseases; women; Chlamydia trachomatis; diagnosis; Trichomonas vaginalis; Neisseria gonorrhoeae; primary health care.
INTRODUÇÃO: Infecções Sexualmente Transmissíveis (IST) em mulheres permanecem um desafio para a Saúde Pública: elevada prevalência, dificuldade para implantação de estratégias de diagnóstico precoce e elevada ocorrência de sequelas.
OBJETIVO: Identificar a prevalência de IST em usuárias de um serviço de atenção primária à saúde em São Paulo.
MÉTODOS: Mulheres de 18 a 40 anos foram convidadas para realizar autocoleta de secreção vaginal para a detecção de Chlamydia trachomatis, Neisseria gonorrhoeae e Trichomonas vaginalis por meio de Reação em Cadeia da Polimerase (PCR). As mulheres também responderam a um questionário com questões demográficas e relativas à história sexual face a face ou autoaplicado por meio de um computador.
RESULTADOS: Das 781 mulheres incluídas no estudo, as prevalências obtidas foram: Chlamydia trachomatis (8,4%), Neisseria gonorrhoeae (1,9%) e Trichomonas vaginalis (3,2%). A positividade para pelo menos uma das três IST foi de 13%. As variáveis associadas independentemente com maior risco de IST foram: idade menor que 20 anos, mais de dois parceiros sexuais na vida e percepção de risco para IST; o uso de preservativo como método contraceptivo foi um fator protetor.
CONCLUSÃO: A prevalência encontrada em usuárias indica a necessidade da implantação de estratégias de rastreamento de IST em serviços de atenção primária.
Palavras-chave: doenças sexualmente transmissíveis; mulheres; Chlamydia trachomatis; diagnóstico; Trichomonas vaginalis; Neisseria gonorrhoeae; atenção primária à saúde.
Sexually transmitted infections (STIs) are the second leading cause of morbidity in young women in developing countries, after causes related to pregnancy and childbirth1.2.
It is estimated that the number of people suffering from curable STIs in the world per year is approximately 340 million3. STIs considered curable by OMS3 stands out those caused by etiological agents Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. The impact of these STIs as a public health problem occurs not only for its high prevalence but also due to bad evolution of these infections to both an acute phase or a chronic phase with sequelae due to a lack of correct diagnosis and appropriate treatment: the pelvic inflammatory processes, perinatal morbidity and infertility2.
Early diagnosis of curable STIs is extremely important in view of its synergy with HIV infection5. STIs increase the susceptibility and infectivity of the transmission of the HIV-1 infection1,3-6. Urgent STIs control measures should be implemented to contribute to the reduction of HIV transmission and for the prevention of these disease complications6.
Approximately 50-80% of infections by Chlamydia trachomatis and Neisseria gonorrhea may be asymptomatic, specially in women7,8 hindering early diagnosis.
The realization of early diagnosis of infection with Neisseria gonorrhoeae and Chlamydia trachomatis in asymptomatic individuals is possible through the use of nucleic acid amplification tests (NAATs)1. The use of tracking techniques for chlamydia and gonorrhea in young women under the age of 25 years is already implemented in many countries in Europe and America Norte1. In the United States of America (USA) Center for Disease Control and Prevention (CDC) recommended screening tests for chlamydia since 19939. Some studies have shown that screening of Chlamydia trachomatis infection reduces the occurrence of pelvic inflammatory diseases10,11. Studies with the U.S. population since 2004 pointed to a positive cost-effectiveness of screening for chlamydial infection by using the NAATs techniques12. In developing countries there are limitations in costs and in the availability of assistance facilities with appropriate technology for STIs diagnose, which impairs the application of this strategy1,4.
Estimates in Brazil, in 2003 indicated the occurrence of 1,967,200 new cases of Chlamydia trachomatis; 1,541,800 new cases of infection with Neisseria gonorrhoeae and 937,000 new infections with Trichomonas vaginalis13. High prevalence of STIs in the population shows the relevance of the implementation of strategies for early diagnosis. Thus, a study of STIs prevalence in a primary health care service which provide care to the general population is highly desirable. Results of this study pointed the feasibility of conducting prevention activities in similar services, supporting decision making deployment algorithm for early diagnosis. The aim of this study was to identify the prevalence of infections with Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis in women attending a primary health care service and to evaluate factors associated with some of these infections in the population under study.
This study is part of an investigation of the acceptability and feasibility to the use of self-collected vaginal swabs and rapid tests for diagnosis of STIs. A detailed description of the methodology is published in another Article14.
Location and study population
The study was conducted at a primary care health service located in the metropolitan region of Sâo Paulo. The territory of operation of the service is marked by heterogeneity of the population that lives and moves in the region, including residents, employees of small businesses, and people in a situation of social exclusion15.
From April 2004 to March 2005, 818 women aged from 18 to 40 years were recruited. Most women were recruited from clients enrolled in the service. Nevertheless, 30% of the sample consisted of women living or working in the catchment area of the service not previously registered. A standardized instrument for eligibility was done to evaluate enrollment of the chosen population. Inclusion criteria used were: age between 18 to 40 years and self-reporting of reading and writing literacy. Exclusion criteria were considered when there was an acute gynecological complaint or self-reported use of antibiotics at the time of recruitment. The "Why searching the health service's" reasons were organized into categories as follows: wish to participate in the research; need of gynecological assistance; need of assistance because of other non-gynecological complaints. Women who reported a need of gynecological assistance were asked about the reason they needed an urgent consultation with a health professional. If so they were classified as women who reported an acute gynecological complaint. The recruitment strategies differed according to the population characterization: women already enrolled were invited to participate when they were in the health center; non-enrolled women were invited by the research team in various community's meeting points.
The eligible women were informed about the content and required to sign the Informed Consent Form (ICF). Subsequently, they answered an standardized questionnaire with questions about socio-demographic characteristics, service use, previous reproductive history, history of signs and symptoms related to STI sexual behavior, alcohol and illicit drugs and violence . Women were randomized to be included either in a group of 409 women who answered a face to face questionnaire or into another group of 409 women who should complete a self-administered questionnaire using a computer (computer assisted audio self-interview - ACASI)16,17.
The questionnaires were done privately by trained interviewers. The computerized questionnaire was answered by the user through an interface developed by the Population Council using Visual Basic 6.0® and Microsoft® Access 1997 to be audiovisual.
Procedures for specimen collection
After women applied the questionnaire to the strategy of self-collection of vaginal secretion, a new randomization were done so that 410 underwent self-collection at home and 408 in the clinic. All women received a small box containing a leaflet explaining the self-collected vaginal swabs and condoms. Women randomized to self-collection of vaginal secretion at home received a dry tube with a Dacron swab to collect vaginal swabs. They were instructed to return to the clinic and deliver the swab with a maximum of seven days. Women randomized to the self-collection of vaginal secretion in clinic were also scheduled for a maximum period of seven days. The self-collection procedures were identical in the two groups.
The material previously collected in swabs were stored (for up to three days refrigerated) and transported to the laboratory. Each swab was tested for Chlamydia trachomatis and Neisseria gonorrhoeae using the technology of Polymerase Chain Reaction (PCR) with the COBAS® Amplicor equipment, Rocheä. Additionally we performed a "homemade" PCR test for the detection of Trichomonas vaginalis using an adapted protocol from a previously developed method. This protocol was reviewed by an independent laboratory18. Samples from women in the group of the health service were also investigated for the presence of HPV, these results can be found in its proper (published) article19.
The prevalence rates of infections by Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis were described with their 95% respective confidence intervals. As there was no statistically significant difference according to the collection site (home or clinic) the results were presented together.
We analyzed the distribution of the variable presence of any STI, defined as positivity for Chlamydia and/or gonorrhea and/or trichomonas, according to variables related to socio-demographic characteristics, sexual behavior, history, symptoms related to STIs and a history of reproductive life. These variables showed statistically significant differences in distribution by type of interview (ACASI or face to face) so that the analysis of factors associated with the presence of any STI was adjusted by type of interview.
To examine the independent contribution of each factor associated influence in the presence of any STI a multivariate logistic regression was done. In this multivariate model all factors were tested in the analyses and they were adjusted by the type of interview. It was obtained a value of p<0.20 for test of likelihood ratio (MVR). We used a saturated model to obtain the final model further adjusted.
All women enrolled participated in a group activity before initiating any procedure in the investigation. In this activity, standardized information was provided as the doubts about the study procedures, its benefits, its risks and strategies to STIs prevention. After the group women who were interested and eligible were individually informed about the research by reading the ICF. It was secured that the participation of users of the health service would not be compulsory. Women included in the study were told they could leave the research at any time they wished.
Anonymity as well as treatment was guaranteed for women with positive results of any of the tests performed. The treatment would include their partners20.
The research project "The use of self-collection and self-diagnosis of STDs in a primary health care service" complied with the guidelines and standards established by Resolutions 196/96, 251/97 and 292/99, and was approved by the Ethics of the Population Council in New York and in the Irmandade da Santa Casa de Misericórdia de São Paulo (Project No. 173/03) and by the National Research Ethics (Registration No. 12466). There are no conflicts of interest between authors and funding agencies or otherwise.
1,038 women were invited to participate in the study, out of which 910 were eligible. 92 women refused to participate. The reasons given were lack of time or other pre-scheduled appointments. 818 women were included in the study and they answered the questionnaire. 31 of these women did not return to collect the material in the clinic or to deliver the material collected at home. Of the 787 samples examined, six were considered as inconclusive and are not included in this analysis.
The prevalence of Chlamydia trachomatis infection was 8.4% (95%CI 6.5-10.4), Neisseria gonorrhoeae infection 1.9% (95%CI 0.9-4.3) and infection by Trichomonas vaginalis was 3.2% (95%CI 0.2-4.3) (Table 1). Of the 781 women surveyed, 13% (95%CI 10.6-15.3) were positive for at least one STI investigated. Only one woman investigated had all three STIs. There was a woman with Chlamydia trachomatis and Neisseria gonorrhoeae and two women with Chlamydia trachomatis and Trichomonas vaginalis. There was difference in the prevalence of Chlamydia trachomatis depending on the initial reason for visiting the service. Women with gynecological self-reported complaints showed higher positivity for Chlamydia trachomatis (p<0.05).
The prevalence of STIs according to socio-demographic characteristics is presented in Table 2. The analysis of sociodemographic characteristics according to type of interview is published16,17. It was found 22% prevalence of STIs in women younger than 20 years, the lower the age reported by these women was the greater prevalence of STIs (χ2 for trend=10.35, p<0.01). In relation to other demographic variables is emphasized that despite the small number of women with skin color as indigenous self-reported, this group showed high STI prevalence (58%). The number of years of schooling was not associated with higher prevalence of STIs. Women who reported living with a sexual partner had lower STI prevalence 10.5%.
In relation to the signs and symptoms, women who reported pain in lower abdomen showed a higher prevalence of STIs, but this result was not statistically significant. The history of vaginal discharge and self-perceived risk of acquiring an STI were associated with higher prevalence of STI (p<0.05).
Women who reported using condoms as a contraceptive method had a lower prevalence of STIs (10.5%). Characteristics of reported sexual behavior was observed in the analysis adjusted only by the type of interview that the factors associated with a statistically significant greater prevalence of STIs were more than two lifetime sexual partners (p<0.01), more than two sexual partners in last six months (p<0.01), and use of alcohol or drugs before last sexual intercourse (RMV adjusted for type of interview=7.79, p=0.0053).
In the final model of logistic regression analysis, variables that remained independently associated with STIs variables adjusted among themselves, including the type of interview variable, namely: age, skin color, self-reported, number of sexual partners in life, self perception of risk for STIs and using condoms as a contraceptive method. The final adjusted model is presented in Table 3.
The prevalence of Chlamydia trachomatis infection found in this study was 8.5% in women aged 18 to 40 years. Comparing the prevalence of this study with those obtained in other research conducted in Brazil, with the detection of Chlamydia trachomatis infection through use of laboratory techniques of PCR or ligase chain reaction (LCR), we observed that the results were similar. It is important to note that this diagnostic method has high sensitivity and specificity and it is considered the most effective one for diagnosis in asymptomatic individuals and in particular with the use of less invasive way of collecting a sample of urine or vaginal secretion collection21. The prevalence of Chlamydia trachomatis infection ranged from 8.5% to 17.1%22-26 in studies conducted in public health services in different municipalities. In a study conducted in Rio de Janeiro in 2001, results showed found a prevalence of 8.5% (95%CI 5.0-13.3) in women attending a testing and counseling center (TAC)22. In the city of Vitória, they showed a prevalence of 8.9% (95%CI 6.5-11.9) in a group of 464 adolescents surveyed at 200223. In a multicenter national study carried out in various capitals of Brazil with 3,303 women, in 2005, results showed a prevalence of 9.3% (95%CI 8.9-10.5) for Chlamydia trachomatis24. In other prevalence study conducted in Bahia in 2000, results were positive for Chlamydia trachomatis infection of 11.4% in 202 women volunteers who attended family planning clinic, 17.1% in women from a high school, and 12.9% in women living in the area and who enrolled in a health family team25. In Goiânia (GO) results showed a prevalence of 14.5% (95%CI 11.4-18.3) from Chlamydia trachomatis obtained by collecting endocervical cells in 427 adolescents (15 to 19 years) recruited from the local community in 2002 to 200326.
The prevalence of Neisseria gonorrhoeae obtained was 1.9% in a population with low exposure, slightly higher than that found in other surveys with collection of endocervical secretion. In Salvador, found a prevalence of 0.5% in 202 users of a clinical planning familiar25.
The Ministry of Health found 1.5% prevalence of infection with Neisseria gonorrhoeae in a multicenter study with a sample of 2,913 women24. The prevalence in a population of VCT in Rio de Janeiro was much higher than 9.5% (95%CI 5.8-14.4)22; the difference to that found in this study may be attributed to the characteristics of this population that possibly VCT has greater exposure, or the occurrence of false-positive results that can happen due to the use of PCR for detection of Neisseria gonorrhoeae.
The prevalence of Trichomonas vaginalis found (3.2%) was very similar to that found in other studies in Brazil, even using different laboratory techniques. In a retrospective study conducted in Minas Gerais, we analyzed the results of direct examination of vaginal secretion obtained by collecting material for the Pap smear test in women who sought health care in 1998, found 3.4% of positive results27. In cross-sectional study conducted in 2000 with the first visit of pregnant women antenatal care in the state of Ceara in two municipalities (630 in Fortaleza Arati and 389 residents), we found prevalences of Trichomonas vaginalis 4.4 and 6.2% respectively28.
In our study, we found a prevalence of 13% of at least one of the three STIs investigated with positive results in a population attending a primary care service, a population with low exposure. Risk factors independently associated with the presence of at least one of the three STIs investigated were: being young, the greater number of lifetime sexual partners, race or ethnicity self-reported as indigenous and high perception of risk. The protective factor was found to use condoms as a contraceptive method.
Younger women under the age of 24 years had increased odds of a positive result for at least one of the three STIs investigated. STIs can be taken as a major health risk of active sexually population29. Young people can be considered extremely susceptible to STIs due to several conditions, such as higher incidence of cervical ectopy and hormonal changes4. Moreover, young women are more likely to have a larger number of sexual partners, unprotected sex and more sex partners exposed to risks4.
In Brazil, several studies have pointed to the increased risk of STIs among adolescents. In a study conducted in Manaus in 2004 with 1762 people found a prevalence of Chlamydia trachomatis infection in adolescents aged 15 to 19 years 14.8%30. In Goiania, found a prevalence of 19.6% for Chlamydia trachomatis infection in 296 adolescents, of whom approximately 70% were assintomáticas31. In the State of Ceará, in research with 592 women, found that age less than 19 years was a risk factor for STD32. Being young was also a risk factor for STIs in a multicenter study of pregnant women conducted by the Ministry of Health, the chance of infection in pregnant women under the age of 20 years to present was OR=2.1 (95%CI 1.3-3.5)24.
The use of condoms as a contraceptive method reduced the risk of STIs. In other studies in Brazil the use of condoms as a contraceptive method was also a protective factor in relation to IST23,25. The possibility of dual protection is a powerful tool for the control of STIs in women. In comparison between two population-based surveys on sexual behavior conducted in Brazil in 1998 and 200533, there was an increase in condom use from 19% to 33% in subjects who reported stable sexual partner in the last 12 months. Household survey conducted in the cities of Salvador, Rio de Janeiro and Porto Alegre, in 2002, with 4,634 youths aged 18 to 24 years, it was found that a higher likelihood of condom use by women at last intercourse with stable sexual relationship34. It was also noted that the frequency of choice of condoms as a contraceptive method is still low in Brazil. In 2003, in São Leopoldo (RS), in research conducted with 578 women found a prevalence of condom use 17.3% as a method contraceptivo35.
Skin color or ethnicity was associated with positivity for one of the three investigated STI: women who reported themselves as indigenous had higher risk of STIs. This result must be treated with caution because the number of women who reported themselves as indigenous in this study was very small, only 12. Further investigation should be conducted to investigate this issue.
Some limitations in our study are worth mentioning. First, the study participants were recruited from a single primary health care service. Even the 30% who were not enrolled in the service were all living and/or working in the catchment area. Therefore, the results cannot be generalized. Despite its central location, the women who attend this service have several peculiarities inherent to the heterogeneity observed in the territory of the central region of metropolitan Sao Paulo. In our study only 10% of participants who were recruited out of service and in the clinic had a gynecological problem. Therefore, this study may represent a picture of the general population with low exposure to sexually transmitted infections.
The second limitation is related to both types of interview for the questionnaire to women: ACASI and face to face. The women interviewed by ACASI showed the difference in frequency of responses, with many reporting sensitive behaviors or unwanted. This information bias social desirability was minimized with the analysis of factors associated with STI adjusted for type of interview.
Another issue to be addressed is related to the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae, as they may vary according to population, the method of specimen collection, as well as the detection method36. It is noteworthy that the research method of collecting the material for the detection of Chlamydia trachomatis: self-collected vaginal swabs and not endocervical. Apparently, the collection did not affect the outcome prevalence was very similar to those obtained in other studies. Self-collection of vaginal secretion is already widely used for screening of Chlamydia trachomatis infection due to its convenience and practicality. In a systematic review35 found that the prevalence of Chlamydia trachomatis obtained by self-collection and collection for detection of endocervical Chlamydia trachomatis PCR were very similar. In our study, the acceptability of self-collection for both groups of women were above 90%, those who collected material in the clinic or home14.
Finally, we must also take into account that women who reported any acute gynecological complaint would not be included in the study, this could also partly explain a slightly lower prevalence of STIs found. However, few women were excluded for the presence of an acute gynecologic complaint.
The relevance of the results presented in this study is above all the fact that it was conducted in a primary health care service, with women attending usual, and therefore, mostly asymptomatic. The prevalence of 13% positivity for at least one of the three STIs investigated in this study was an urgent need to adopt effective strategies for early detection of sexually transmitted infections in asymptomatic women, however the absence of laboratory testing at an affordable cost, and available to the population remains a major challenge. It also highlights that new techniques for collecting vaginal discharge, such as self-collection is possible and feasible in our reality, thus enabling a better grip of asymptomatic women.
Another important consideration is the need to strengthen the guidance for the use of condoms as a contraceptive method, due to its effective performance as a protective factor for twin pregnancy and STIs in particular in young women at greatest risk of STIs.
Researchers Paul Hewett and Barbara Mensch of the Population Council of New York, and the researcher Janneke van de Wijgert, University of Amsterdam, who contributed in the design and implementation of the study. The team of Centro de Saúde Escola Barra Funda that worked directly in the research activities. The whole staff of the Laboratory of Molecular Biology Faculty of Medical Sciences, Santa Casa de São Paulo.
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31. Araújo RSC, Guimarães EMB. Estudo da infecção genital por Chlamydia trachomatis em adolescentes e jovens do sexo feminino no distrito sanitário leste do município de Goiânia: prevalência e fatores de risco. RBGO. 2002;24:492.
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34. Teixeira AMF, Knauth DR, Fachel JMG, Leal FA. Adolescentes e uso de preservativos as escolhas dos jovens de três capitais brasileiras na iniciação e na última relação sexual. Cad Saúde Pública. 2006;22:1385-96.
35. Carreno I, Dias-da-Costa J, Olinto MTA, Meneguel S. Uso de métodos contraceptivos entre mulheres com vida sexual ativa em São Leopoldo, Rio Grande do Sul, Brasil. Cad Saúde Pública. 2006;22:109-18.
36. Cook RL, Hutchison SL, Ostergard L, Braithwaite S, Ness RB. Systematic Review: Noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Annals of Internal Medicine. 2005;142:914-26. Correspondência: Submitted on: 31/05/2011 Trabalho realizado no Centro de Saúde Escola Barra Funda "Dr. Alexandre Vranjac" (CSEBF Dr. Alexandre Vranjac) - Irmandade da Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brasil.
Dra. Carla Gianna Luppi - Av. Abrãao Ribeiro 283
CEP: 01133-020 - São Paulo (SP), Brasil
Final version presented on: 23/03/2011
Accepted on: 11/04/2011
Conflito de interesse: nada a declarar.
Fonte de financiamento: Population Council Nova York por meio de recursos do Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, Nº HRN-A-00-99-00010.
Submitted on: 31/05/2011
Trabalho realizado no Centro de Saúde Escola Barra Funda "Dr. Alexandre Vranjac" (CSEBF Dr. Alexandre Vranjac) - Irmandade da Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brasil.