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Prevalence of bacterial vaginosis among women in Delhi, India

February 2007
The Indian Journal of Medical Research 125(2):167-72

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PubMed

Authors:

Preena Bhalla

Maulana Azad Medical College & Lok Nayak Hospital

Rohit Chawla

Maulana Azad Medical College

Suneela Garg

Maulana Azad Medical College

M. Meghachandra Singh

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Bacterial vaginosis is the most common cause of vaginal discharge among women in reproductive age. Surveillance studies on bacterial vaginosis are mostly based on specialist clinic settings. As few population-based prevalence surveys of bacterial vaginosis have been conducted, we studied the prevalence of bacterial vaginosis in the urban and rural communities in Delhi, and to associate the presence of bacterial vaginosis with demographic profile, risk factors and presence of other reproductive tract infections (RTIs)/ sexually transmitted infections (STIs). Vaginal specimens for Gram-stain evaluation of vaginal flora for diagnosis of bacterial vaginosis and culture of Trichomonas vaginalis and Candida spp, blood samples for HIV and syphilis serology, and urine for detection of Neisseria gonorrhoeae and Chlamydia trachomatis were collected from women (15-49 yr) from rural and urban areas. Information on demographic characteristics, risk factors and clinical symptoms was obtained. Bacterial vaginosis was diagnosed in 70 (32.8%) subjects. A high percentage though asymptomatic (31.2%) were found to have bacterial vaginosis. Highest prevalence was seen in urban slum (38.6%) followed by rural (28.8%) and urban middle class community (25.4%). All women with vaginal trichomoniasis were found to have bacterial vaginosis while 50 per cent of subjects having syphilis also had bacterial vaginosis.. The study showed high prevalence of bacterial vaginosis. The asymptomatic women having bacterial vaginosis are less likely to seek treatment for the morbidity and thus are more likely to acquire other STIs. Women attending various healthcare facilities should be screened and treated for bacterial vaginosis to reduce the risk of acquisition of other STIs.

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Prevalence of bacterial vaginosis among women in Delhi, India

P. Bhalla, Rohit Chawla, S. Garg*, M.M. Singh*, U. Raina**, Ruchira Bhalla & Pushpa Sodhani†

Departments of Microbiology, *Community Medicine, **Obstetrics & Gynaecology

Maulana Azad Medical College & associated LN Hospital, New Delhi &

†Institute of Cytology & Preventive Oncology, Noida, India

Received March 3, 2005

Background & objectives: Bacterial vaginosis is the most common cause of vaginal discharge among

women in reproductive age. Surveillance studies on bacterial vaginosis are mostly based on specialist

clinic settings. As few population-based prevalence surveys of bacterial vaginosis have been

conducted, we studied the prevalence of bacterial vaginosis in the urban and rural communities in

Delhi, and to associate the presence of bacterial vaginosis with demoraphic profile, risk factors

and presence of other reproductive tract infections (RTIs)/ sexually transmitted infections (STIs).

Methods: Vaginal specimens for Gram-stain evaluation of vaginal flora for diagnosis of bacterial

vaginosis and culture of Trichomonas vaginalis and Candida spp, blood samples for HIV and syphilis

serology, and urine for detection of Neisseria gonorrhoeae and Chlamydia trachomatis were collected

from women (15-49 yr) from rural and urban areas. Information on demographic characteristics,

risk factors and clinical symptoms was obtained.

Results: Bacterial vaginosis was diagnosed in 70 (32.8%) subjects. A high percentage though

asymptomatic (31.2%) were found to have bacterial vaginosis. Highest prevalence was seen in urban

slum (38.6%) followed by rural (28.8%) and urban middle class community (25.4%). All women

with vaginal trichomoniasis were found to have bacterial vaginosis while 50 per cent of subjects

having syphilis also had bacterial vaginosis.

Interpretation & conclusion: The study showed high prevalence of bacterial vaginosis. The

asymptomatic women having bacterial vaginosis are less likely to seek treatment for the morbidity

and thus are more likely to acquire other STIs. Women attending various healthcare facilities

should be screened and treated for bacterial vaginosis to reduce the risk of acquisition of other

STIs.

Key words Bacterial vaginosis - community based study - prevalence

167

Indian J Med Res 125, February 2007, pp 167-172

Bacterial vaginosis is the most common cause

of vaginal discharge among women in reproductive

age1. It is characterized by an increased vaginal pH

and the replacement of vaginal lactobacilli

(particularly those that produce hydrogen peroxide)

with Gardnerella vaginalis and anaerobic Gram-

negative rods2. Bacterial vaginosis has been

consistently associated with preterm delivery, but

its role in upper genital tract infection (pelvic

inflammatory disease), tubal damage and infertility

is less certain3. Surveillance studies on bacterial

vaginosis are mostly based on specialist clinic

settings, such as genitourinary medicine clinics4,

gynaecology and antenatal clinics5, which

underestimate the true burden of disease in the

community given the high proportion of

asymptomatic cases. Very few population based

prevalence surveys of bacterial vaginosis have been

conducted. Most of these have been carried out in

rural Africa6,7, the findings of which may be hard to

apply in other settings.

Lactobacilli dominated vaginal ecology may be

an important defense against pathogen acquisition

as various studies have shown that women with

bacterial vaginosis are more likely than women with

normal vaginal flora to acquire infection due to

herpes simplex virus type-21 (HSV-2), Trichomonas

vaginalis8, Neisseria gonorrhoeae8 and HIV6,8.

Therefore, the present study was carried out to

determine the prevalence of bacterial vaginosis in

the urban and rural communities in Delhi, India, and

to associate the presence of bacterial vaginosis with

demographic profile, risk factors and presence of

other reproductive tract infections (RTIs)/sexually

transmitted infections (STIs).

Material & Methods

This study was conducted under the aegis of

National AIDS Control Organization (NACO), and

Delhi State AIDS Control Society (DSACS), Delhi,

after approval by the ethics committee of Maulana

Azad Medical College, New Delhi. The

communities studied were randomly selected and

included two urban slums (Census enumeration

block: Sanjay Amar Colony, Charge No.: 19 and

Census enumeration block: Lal Bag, Charge No.:

77), one urban middle class colony (Census

enumeration block: Tilak Vihar, Charge No.: 49)

and one rural area (Block Name: Khanjawala,

Village name: Bajidpur Thakran). Initial house-to-

house survey was carried out in 100 households in

each area; these households were selected by

systematic random sampling method. The survey

was carried out during September and December

2002 and information regarding socio-

demographic profile of the household; knowledge,

attitude and practices regarding STIs; and health

seeking behaviour was collected. The number of

eligible women (15-49 yr of age) enumerated was,

143 in Sanjay Amar Colony, 137 in Lal Bag, 132

in Tilak Vihar and 125 in Bajidpur Thakran. The

minimum number of women to be studied was 50

in each area but 65 women were selected from the

eligible women enumerated in each area by

systematic random sampling. The sample size was

decided on the basis of the findings of the previous

study9. Camps were held in the health centres

located in these areas. During the camps

demographic, risk factor and clinical data were

collected using a structured questionnaire.

Relevant specimens (vaginal specimens, blood and

urine) were collected for laboratory diagnosis of

various RTIs/ STIs after obtaining informed

consent from all participants. Women who were

menstruating, pregnant or had received antibiotics

in the past four weeks, were excluded from the

study.

Two vaginal swabs were collected from each

women, one used for preparation of saline and KOH

wet mount and smear for Gram staining. The second

swab was used for inoculation in Kupferberg

medium (for culture of T. vaginalis) and Sabouraud

dextrose agar (SDA, for culture of Candida spp.).

This was done to minimize the number of swabs to

be collected from each women. Culture for

T. vaginalis was incubated at 37°C and wet mounts

168 INDIAN J MED RES, FEBRUARY 2007

were prepared and examined after 2,4 and 7 days of

incubation10. SDA was incubated at 37°C and

examined for growth after 72 h of incubation.

Diagnosis of trichomoniasis and candidiasis was

made on the basis of positivity in direct microscopy

and/or culture. First-void urine specimen was

collected for diagnosis of N. gonorrhoeae and

Chlamydia trachomatis infection using a

commercially available multiplex polymerase chain

reaction kit (Amplicor CT/NG test, Roche

Molecular Systems, Branchburg, N.J.). The urine

specimen was transported, stored and tested as per

manufacturer’s instructions. Venous blood sample

(5 ml) was collected for HIV and syphilis serology.

For syphilis serology all serum samples were

screened by VDRL test (Serologist to the

Government of India, Kolkata) and positive results

were confirmed by treponema pallidum

haemagglutination test (TPHA) (Immunotrep

TPHA, Omega Diagnostics Limited, Scotland,

U.K.). For serodiagnosis of HIV infection, serum

samples were screened by ELISA (HIVASE 1+2,

General Biologicals Corporation, Taiwan) and

positive results were confirmed by a second rapid

and simple test (Capillus HIV1/ HIV2, Trinity Biotech

PLC, Ireland). For diagnosis of bacterial vaginosis

Gram stained vaginal smear was examined under oil

immersion objective (1000x magnification) and

graded as per standardized, quantitative,

morphological classification developed by Nugent et

al11. Composite score was categorized into three

categories, scores 0-3 being normal, 4-6 intermediate

and 7-10 as definite bacterial vaginosis.

Statistical analysis: Data was statistically analysed

for correlation of bacterial vaginosis with

demographic profile, risk factors and presence of

other laboratory confirmed RTIs/STIs using

Chi-square test and Fisher’s exact test.

Results & Discussion

Of the total of 260 women invited to participate,

237 (91.1%) were enrolled for the study. Of these,

122 (51.4%) belonged to urban slum, while 60

(25.3%) and 55 (23.25%) subjects belonged to urban

Table I. Association between bacterial vaginosis and presence of other laboratory confirmed sexually transmitted or reproductive

tract infections

Characteristic n Vaginal flora morphology

(%) BV (%) I (%) N (%)

Trichomoniasis* Positive 6 (2.8) 6 (100) 0 (0) 0 (0)

Negative 207 (97.1) 64 (30.9) 36 (17.3) 107 (51.6)

Candidiasis Positive 36 (16.9) 9 (25) 6 (16.6) 21 (58.3)

Negative 177 (83.0) 61 (34.4) 30 (16.9) 86 (48.5)

HIV infection†Positive 2 (0.95) 0 (0) 1 (50) 1 (50)

Negative 208 (99.0) 70 (33.6) 34 (16.3) 104 (50)

Syphilis†Positive 10 (4.76) 5 (50) 1 (10) 4 (40)

Negative 200 (95.2) 65 (32.5) 34 (17) 101 (50.5)

Gonorrhea Positive 2 (0.93) 0 (0) 1 (50) 1 (50)

Negative 211 (99.0) 70 (33.1) 35 (16.5) 106 (50.2)

BV, bacterial vaginosis: score of 7-10; I, intermediate: score of 4-6; N, normal: score of 0-3; †Blood samples for serology could not

be collected from three subjects.

*P<0.001 BV vs. I+N

BHALLA et al: PREVALENCE OF BACTERIAL VAGINOSIS 169

Table II. Correlation between bacterial vaginosis and various socio-demographic and risk factors

Characteristic n Vaginal flora morphology

BV (%) I (%) N (%)

Age (yr) 15-24 38 13 (34.2) 6 (15.7) 19 (50)

25-49 175 57 (32.5) 30 (17.1) 88 (50.2)

Income (Rs) <520 4 2 (50) 0 (0) 2 (50)

520-1299 35 15 (42.8) 7 (20) 13 (37.1)

1300-2599 130 37 (28.4) 24 (18.4) 69 (53)

2600-4159 34 13 (38.2) 4 (11.7) 17 (50)

³ 4160 10 3 (30) 1 (10) 6 (60)

Religion Hindu/Sikh 176 56 (31.8) 30 (17) 90 (51.1)

Muslim 37 14 (37.8) 6 (16.2) 17 (45.9)

Literacy Illiterate 114 38 (33.3) 23 (20.1) 53 (46.4)

Just literate 27 9 (33.3) 4 (14.8) 14 (51.8)

Primary 36 12 (33.3) 5 (13.8) 19 (52.7)

Secondary 28 10 (35.7) 2 (7.1) 16 (57.1)

Higher 5 0 (0) 2 (40) 3 (60)

secondary

Graduate 3 1 (33.3) 0 (0) 2 (66.6)

Location Urban slum 106 41 (38.6) 19 (17.9) 46 (43.3)

Urban middle 55 14 (25.4) 11 (20) 30 (54.5)

class

Rural 52 15 (28.8) 6 (11.53) 31 (59.6)

Marital status Married 203 69 (33.9) 34 (16.7) 100 (49.2)

Unmarried 10 1 (10) 2 (20) 7 (70)

History of Yes 26 9 (34.6) 4 (15.38) 13 (50)

abortion No 187 61 (32.6) 32 (17.1) 94 (50.2)

Smoking Yes 15 4 (26.6) 3 (20) 8 (53.3)

No 198 66 (33.3) 33 (16.6) 99 (50)

Past history Yes 100 36 (36) 16 (16) 48 (48)

suggestive of No 113 34 (30) 20 (17.6) 59 (52.2)

RTIs/STIs

Complaint of Yes 88 31 (35.2) 14 (15.9) 43 (48.8)

vaginal discharge No 125 39 (31.2) 22 (17.6) 64 (51.2)

Complaint of Yes 41 10 (24.3) 8 (19.5) 23 (56)

lower abdominal No 172 60 (34.8) 28 (16.2) 84 (48.8)

pain

BV, bacterial vaginosis: score of 7-10; I, intermediate: score of 4-6; N, normal: score of 0-3

170 INDIAN J MED RES, FEBRUARY 2007

middle class and rural communities, respectively.

The majority of the women in this investigation were

>30 yr of age (143, 63.3%), were married (226,

95.3%), and were not working (208, 87.7%). Most

of them were Hindus (177, 74.6%), illiterate (131,

55.2%), and non smokers (198, 93%).

Of the 237 women enrolled in the study, vaginal

swabs and urine specimens could be obtained from

213 and blood samples from 210 subjects. Prevalence

of laboratory confirmed STIs/ RTIs with 95 per cent

CI was as follows: bacterial vaginosis 32.8 per cent

(26.38, 39.22), trichomoniasis 2.8 per cent (0.54,

5.06), candidiasis 16.9 per cent (11.78, 22.02),

syphilis 4.7 per cent (1.84, 7.68), HIV infection 0.95

per cent (0, 2.27), gonorrhoea 0.93 per cent (0, 2.23)

and C. trachomatis infection 0 per cent.

Table I shows the association between bacterial

vaginosis and other laboratory confirmed STIs/ RTIs.

All women with vaginal trichomoniasis were found

to have bacterial vaginosis (P<0.001) while 50 per cent

of subjects having syphilis also had bacterial vaginosis.

Table II shows the association between socio-

demographic profile of the study population and

prevalence of bacterial vaginosis. The highest

prevalence was seen in urban slum (38.6%) followed

by rural community (28.8%) and urban middle class

community (25.4%). In a study conducted by Garg

et al9 in ever-married women belonging to an urban

slum in Delhi, prevalence of bacterial vaginosis was

41 per cent. Higher prevalence reported in this study

could be because of more than one method used for

the diagnosis of bacterial vaginosis. In a study

conducted in married rural women in Karnataka,

India, prevalence of bacterial vaginosis using

Nugent’s criteria was reported to be 20.5 per cent12.

In another study from Haryana, India, bacterial

vaginosis was diagnosed in a high percentage

(48.5%) of rural women13. This shows that

prevalence of bacterial vaginosis varies widely

among different areas and communities within the

country. The contrasting prevalence figures may be

because of various reasons such as differences in

economic status and educational background, study

population and method used for diagnosis of

bacterial vaginosis.

In the present study we found no association

between prevalence of bacterial vaginosis with age,

as almost equal prevalence was seen in women

between 15 to 24 yr of age and those who were

>25 yr. However, other studies showed a strong

association between the presence of bacterial

vaginosis age >25 yr4,6. Smoking has also been

reported to be associated with bacterial vaginosis14.

However, no such association was found in the

present study as number of smokers was very few.

Bacterial vaginosis (score >7) was found in 32.8

per cent of women while a shift from normal flora

(score 4-6) was observed in another 16.9 per cent of

women. Sewankambo et al6 reported bacterial

vaginosis in 50.8 per cent and intermediate flora in

31.7 per cent women. An intermediate score between

4-6 may be found among women who are either

recovering from bacterial vaginosis or who may

develop bacterial vaginosis subsequently. Such

women therefore should be followed up to confirm

the same as these alterations in vaginal microflora

may increase the risk of acquisition of other STIs

including HIV infection.

39/125 (31.2%) women not complaining of

vaginal discharge also had bacterial vaginosis. These

asymptomatic women are less likely to seek treatment

for the morbidity and thus are more likely to acquire

other serious STIs. In view of this it is suggested

that women attending various health care facilities

including antenatal clinic, gynaecology clinic,

genitourinary medicine clinic or family planning

clinic should be screened and treated for bacterial

vaginosis to reduce the risk of acquisition of other

more serious STIs.

Acknowledgment

Authors thank Shrimati Sujatha Grover and

Seema Malhotra for technical support.

BHALLA et al: PREVALENCE OF BACTERIAL VAGINOSIS 171

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Reprint requests: Dr Rohit Chawla, 4A/ 55, First Floor, Old Rajinder Nagar, New Delhi 110060, India

e-mail: rohitchawla_75@hotmail.com

172 INDIAN J MED RES, FEBRUARY 2007

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Article

May 2023

Background: Bacterial vaginosis (BV) is a highly prevalent disorder of the cervicovaginal microbiota. Molecular-BV may put women at increased risk for adverse reproductive and obstetric outcomes. We investigated the association of HIV and pregnancy on the vaginal microbiota and associations with molecular-BV in women of reproductive age from Pune, India. Setting: We studied vaginal samples from N=170 women including N=44 non-pregnant HIV seronegative (SN), N=56 pregnant SN, N=47 non-pregnant women with HIV (WWH), and N=23 pregnant WWH, and collected data on clinical, behavioral, and demographic factors. Methods: We used 16S rRNA gene amplicon sequencing to characterize the composition of the vaginal microbiota. We classified the vaginal microbiota of these women into community state types (CSTs) based on bacterial composition and relative abundance, and further categorized them into molecular-BV versus Lactobacillus-dominated states. To determine associations between pregnancy and HIV status with outcome of molecular-BV, logistic regression models were used. Results: There was a high prevalence of molecular-BV (30%) in this cohort. We found that pregnancy was associated with decreased odds of molecular-BV (adjusted OR (aOR)=0.35, 95% CI: 0.14-0.87), while HIV was associated with increased odds of molecular-BV (aOR=2.76, 95% CI: 1.33-5.73), even when controlling for multiple relevant factors such as age, number of partners, condom use and douching. Conclusion: Larger and longitudinal studies are needed to further characterize molecular-BV and the vaginal microbiota in pregnant women and WWH, and relate these factors to infectious, reproductive, and obstetric outcomes. In the long term, these studies may lead to novel microbiota-based therapeutics to improve women's reproductive and obstetric health.

To Determine the Frequency of Urinary Tract Infection in Women with Preterm Premature Rupture of Membranes: Frequency of UTI in Women with PPROM

Article

Full-text available

Jan 2023

Preterm labor affects around thirteen million of births worldwide annually and is more observed in developing nations as compared to developed world. While 2 to 3% of pregnancies develop preterm premature rupture of membranes (PPROM) that result in increased morbidity and mortality of mother and child. Pregnancy induced hypertension and ante partum hemorrhage remained other important factors to develop preterm labor. Once diagnosed, needs expert consultation and management. Objective: To determine the frequency of urinary tract infection(UTI) in women with preterm premature rupture of membranes. Methods: This Cross Sectional study was done in department of Obstetrics and Gynecology, ATH, Abbotabad. From 30th August 2019 to 29th February 2019. We included 202 patients fulfilling the inclusion criteria. Informed consent was taken. The data were collected on prepared proforma. Results: In our study 202 patients with mean age of 25.93 ± 4.70 years were included. Mean gestational age was 33.09 ± 1.69 weeks. Mean parity was 2.36 ± 0.92. In our study, frequency of urinary tract infection (UTI) in women with PPROM was found in 09 (4.46%) patients. Conclusion: This study concluded that frequency of UTI in women with PPROM was found in 4.46% patients.

PREVALENCE AND CORRELATES OF BACTERIAL VAGINOSIS AMONG WOMEN ATTENDING ANC AND STI CLINIC AT TERTIARY CARE INSTITUTE

Article

Full-text available

Nov 2022

Background- Sexually transmitted infections (STI's) are foremost community well being problems midst the women specially in developing countries. Vaginosis is conjoint gynaecological disorder stated in 5-51 % of women reliant upon demographics & whether or not they are suggestive of symptoms.1 Bacterial vaginosis is presently measured as the furthermost predominant vaginal infection. 50% of the total statistics of BV infections are symptomless. It is related with low birth weight & avoidable preterm birth. The study included 800 Methods- patients attending ANC & STI clinic who were screened for Bacterial vaginosis, candida, Gonorrhoea, Trichomonas vaginalis, HIV, Hepatitis b, Herpes simplex virus –II, Syphilis, Chlamydia by appropriate serological and bacteriological identication methods. In this study vaginal Results- trichomoniasis showed highly signicant association with bacterial vaginosis. In present study candidiasis OR=0.19 (95% CI) 0.19(0.14-0.28)( p= 0.000 ) showed highly signicant association with bacterial vaginosis. Similarly HIV (OR=5.79 (95% CI) (1.09-57.35) p=0.0138 and Syphilis OR=3.66 (95% CI) (1.16-13.57) p = 0.0108 also signicantly associated with bacterial vaginosis. A diagnosis of Chlamydia, Gonorrhoea and HSV-2 showed no signicant association with BV (all p>0.05). Screening for BV could reduce HIV Conclusions- -1 transmision. Additionally, BV is associated with STIs including HIV, so further investigation is needed to apprehend the potential role of screening and treatment of BV in STIs /HIV prevention programs.

Microbiological study of vaginitis among women of reproductive age group

Article

Full-text available

Sep 2022

: Vaginitis is the most common health problem among women of reproductive age group, which is associated with gynaecological and obstetrical complications and also increases the transmission of HIV and other sexually transmitted diseases. : This study aimed at estimating the various etiological agents causing vaginitis, different laboratory methods for its diagnosis, isolation of different species and antibiotic susceptibility pattern of aerobic bacterial isolates. : In present study, 104 clinically suspected cases of vaginitis attending gynaecology OPD was included after obtaining informed consent and various data were collected using via questionnaire. Three high vaginal swabs collected from each patient and subjected to PH, Whiff test, Microscopic examination (Grams staining, KOH mount, Acridine orange staining (AO), Saline wet mount) Culture and Biochemical reactions following standard protocols. Aerobic isolates were subjected to antibiotic susceptibility testing as per CLSI guidelines. : Out of 104 Clinically suspected cases most common type of vaginitis were Bacterial vaginosis (BV)51.9% followed by Candidiasis 41.3%, Trichomoniasis 3.9%. Most common species isolated in vulvovaginal Candidiasis is 32.5%. Majority of Gram positive organisms were susceptible to Linezolid and Gram negative organisms to Azithromycin. : Bacterial vaginosis, Candidiasis and Trichomoniasis are common problem in women of reproductive age, therefore screening of vaginal infection in women of reproductive age should be implemented. Culture and sensitivity should be mandatory and treatment should be based on invitro susceptibility testing. So that misuse of antibiotics will be avoided.

HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis

Article

Full-text available

Jan 1998

Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation

Article

Full-text available

Mar 1991

The purpose of the study was to examine intercenter variability in the interpretation of Gram-stained vaginal smears from pregnant women. The intercenter reliability of individual morphotypes identified on the vaginal smear was evaluated by comparing them with those obtained at a standard center. A new scoring system that uses the most reliable morphotypes from the vaginal smear was proposed for diagnosing bacterial vaginosis. This scoring system was compared with the Spiegel criteria for diagnosing bacterial vaginosis. The scoring system (0 to 10) was described as a weighted combination of the following morphotypes: lactobacilli, Gardnerella vaginalis or bacteroides (small gram-variable rods or gram-negative rods), and curved gram-variable rods. By using the Spearman rank correlation to determine intercenter variability, gram-positive cocci had poor agreement (0.23); lactobacilli (0.65), G. vaginalis (0.69), and bacteroides (0.57) had moderate agreement; and small (0.74) and curved (0.85) gram-variable rods had good agreement. The reliability of the 0 to 10 scoring system was maximized by not using gram-positive cocci, combining G. vaginalis and bacteroides morphotypes, and weighting more heavily curved gram-variable rods. For comparison with the Spiegel criteria, a score of 7 or higher was considered indicative of bacterial vaginosis. The standardized score had improved intercenter reliability (r = 0.82) compared with the Spiegel criteria (r = 0.61). The standardized score also facilitates future research concerning bacterial vaginosis because it provides gradations of the disturbance of vaginal flora which may be associated with different levels of risk for pregnancy complications.

HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis

Article

Aug 1997

BackgroundIn-vitro research has suggested that bacterial vaginosis may increase the survival of HIV-1 in the genital tract. Therefore, we investigated the association of HIV-1 infection with vaginal flora abnormalities, including bacterial vaginosis and depletion of lactobacilli, after adjustment for sexual activity and the presence of other sexually transmitted diseases (STDs).MethodsDuring the initial survey round of our community-based trial of STD control for HIV-1 prevention in rural Rakai District, southwestern Uganda, we selected 4718 women aged 15–59 years. They provided interview information, blood for HIV-1 and syphilis serology, urine for detection of Chlamydia trachomatis and Neisseria gonorrhoeae, and two self-administered vaginal swabs for culture of Trichomonas vaginalis and gram-stain detection of vaginal flora, classified by standardised, quantitative, morphological scoring. Scores 0–3 were normal vaginal flora (predominant lactobacilli). Higher scores suggested replacement of lactobacilli by gram-negative, anaerobic microorganisms (4–6 intermediate; 7–8 and 9–10 moderate and severe bacterial vaginosis).FindingsHIV-1 frequency was 14·2% among women with normal vaginal flora and 26·7% among those with severe bacterial vaginosis (p<0·0001). We found an association between bacterial vaginosis and increased HIV-1 infection among younger women, but not among women older than 40 years; the association could not be explained by differences in sexual activity or concurrent infection with other STDs. The frequency of bacterial vaginosis was similar among HIV-1-infected women with symptoms (55·0%) and without symptoms (55·7%). The adjusted odds ratio of HIV-1 infection associated with any vaginal flora abnormality (scores 4–10) was 1·52 (95% Cl 1·22–1·90), for moderate bacterial vagniosis (scores 7–8) it was 1·50 (1·18–1·89), and for severe bacterial vaginosis (scores 9–10) it was 2·08 (1·48–2·94).InterpretationThis cross-sectional study cannot show whether disturbed vaginal flora increases susceptibility to HIV-1 infection. Nevertheless, the increased frequency of HIV-1 associated with abnormal flora among younger women, for whom HIV-1 acquisition is likely to be recent, but not among older women, in whom HIV-1 is likely to have been acquired earlier, suggests that loss of lactobacilli or presence of bacterial vaginosis may increase susceptibility to HIV-1 acquisition. If this inference is correct, control of bacterial vaginosis could reduce HIV-1 transmission.

Prevalence of Bacterial Vaginosis and its Association with Genital Infections, Inflammation, and Contraceptive Methods in Women Attending Sexually Transmitted Disease and Primary Health Clinics

Article

Apr 1990

Harald Moi

In an epidemiological survey of 2128 women attending a sexually transmitted diseases clinic for the first time and 200 attending two primary health clinics, 26% and 27% respectively were found to have bacterial vaginosis. The prevalence increased significantly with age, being diagnosed in 22.8% (326/1431) of women aged 14-24 years, and in 33.3% (232/697) of those aged greater than or equal to 25 years. Bacterial vaginosis was associated with gonorrhoea and with chlamydial infection, but was negatively associated with genital papillomavirus infection and yeast infection. Women using barrier contraceptives had a significantly lower prevalence of bacterial vaginosis than those using an intrauterine device or no contraceptive. Women less than or equal to 24 years old using oral contraceptives had a significantly lower prevalence of bacterial vaginosis than those not using contraceptives. Patients without gonorrhoea or chlamydial infection but with vaginal or urethral inflammatory signs had a significantly higher prevalence of bacterial vaginosis than those without inflammatory signs. These findings may have implications regarding complications associated with lower genital tract infections and may strengthen the hypothesis that bacterial vaginosis is a risk factor for pelvic inflammatory disease.

Comparison of four methods to detect Trichomonas vaginalis

Article

Oct 1988

Four methods for the detection of Trichomonas vaginalis in vaginal secretions from 88 symptomatic patients were compared: wet-mount examination, Kupferberg liquid medium, Hirsch charcoal agar, and the Papanicolaou smear. Hirsch diphasic slants and Kupferberg medium did not significantly differ in sensitivity from direct examination of wet mounts. The Papanicolaou smear identification of trichomonads was found to be the least sensitive method evaluated.

Abnormal bacterial colonisation of the genital tract and subsequent pretenn delivery and late miscamage

Article

Jan 1994

To find out whether women with bacterial vaginosis detected early in pregnancy are at increased risk of preterm delivery. Prospective description cohort study. Antenatal clinic in a district general hospital. 783 women examined during their first antenatal clinic visit and screened for recognised risk factors for preterm delivery and the presence of bacterial vaginosis or intermediate abnormal flora detected by examination of a vaginal smear stained by Gram's method. Gestational age at delivery classified as late miscarriage (16-24 weeks' gestation), preterm delivery (24-37 weeks' gestation), term delivery (> or = 37 weeks' gestation). Multiple logistic analysis showed that there was an increased incidence of preterm delivery in women with a previous preterm delivery (9/24; odds ratio 25; 95% confidence interval 9 to 70; P < 0.001) and bacterial vaginosis (9/115; 2.8; 1.1 to 7.4; P = 0.04). A further logistic analysis of data from women recruited before 16 weeks' gestation showed that preterm deliveries or late miscarriages occurred more often in women with bacterial vaginosis (12/77; 5.5; 2.3 to 13.3; P < 0.001). Late miscarriage and preterm delivery are associated with the presence of bacterial vaginosis in early pregnancy. This is independent of recognised risk factors such as previous preterm delivery.

Diagnosis microbiology of bacterial vaginosis

Article

Sep 1993
AM J OBSTET GYNECOL

Sharon L Hillier

Bacterial vaginosis is characterized microbiologically by replacement of the Lactobacillus-predominant vaginal flora by Gardnerella vaginalis, Bacteroides species, Mobiluncus species, and genital mycoplasmas. A standardized, laboratory-based diagnostic test for bacterial vaginosis is desirable in those instances in which a microscope is unavailable in the clinic or when the evaluator of the wet mount examination is inexperienced at recognizing clue cells. Vaginal cultures have excellent sensitivity for the diagnosis of bacterial vaginosis, but because the predictive value of a positive G. vaginalis culture is less than 50%, cultures are not recommended. Vaginal Gram smears are objective and reproducible, have 62% to 100% sensitivity, and have a positive predictive value of 76% to 100%. Diagnosis of bacterial vaginosis with use of Papanicolaou-stained smears has been reported, but standardized criteria have not been widely adopted. A rapid, office-based oligonucleotide probe test for high concentrations of G. vaginalis has been developed and may be useful when direct microscopy is unavailable or confidence in microscopic examination is low. Laboratory tests that detect microbial products unique to the vaginal fluid of women with bacterial vaginosis include detection of amines (putrescine, cadaverine, and trimethylamine), measurement of the relative levels of succinate and lactate in the vaginal fluid by gas chromatography, detection of proline aminopeptidase by colorimetric assay, or detection of sialidases in the vaginal fluid. Although these tests are not yet applicable to routine use, these research tests could be adapted for wider use in office laboratories. Vaginal Gram stains are more useful than culture for laboratory confirmation of bacterial vaginosis.

Vaginal Lactobacilli, Microbial Flora, and Risk of Human Immunodeficiency Virus Type 1 and Sexually Transmitted Disease Acquisition

Article

Jan 2000

A prospective cohort study was conducted to examine the relationship between vaginal colonization with lactobacilli, bacterial vaginosis (BV), and acquisition of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted diseases in a population of sex workers in Mombasa, Kenya. In total, 657 HIV-1—seronegative women were enrolled and followed at monthly intervals. At baseline, only 26% of women were colonized with Lactobacillus species. During follow-up, absence of vaginal lactobacilli on culture was associated with an increased risk of acquiring HIV-1 infection (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.2–3.5) and gonorrhea (HR, 1.7; 95% CI, 1.1–2.6), after controlling for other identified risk factors in separate multivariate models. Presence of abnormal vaginal flora on Gram's stain was associated with increased risk of both HIV-1 acquisition (HR, 1.9; 95% CI, 1.1–3.1) and Trichomonas infection (HR, 1.8; 95% CI, 1.3–2.4). Treatment of BV and promotion of vaginal colonization with lactobacilli should be evaluated as potential interventions to reduce a woman's risk of acquiring HIV-1, gonorrhea, and trichomoniasis.

Community based study of reproductive tract infections among ever married women of reproductive age in a rural area of Haryana, India

Article

Jan 2000
J Comm Dis

A community based study was carried out to estimate the load of reproductive tract infections (RTIs) among ever married rural women aged 15-44 years and utilisation of a mobile village based treatment facility by them, during 1997. Complete household survey was done in 10 randomly selected villages of Mahindergarh district in Haryana, India. A total of 2325 women were interviewed by auxiliary nurse midwives and were invited for medical examination in a health camp set-up in their village. Sixty-one percent (1415/2325) women reported symptoms of RTIs. Only 35% (812/2325) had their per-speculum examination done. Out of those examined, 32% (263/812) had vaginitis, 21% (175/812) had cervicits, and 19% (156/812) had pelvic inflammatory disease. Vaginal smear of those having discharge revealed that 48% (231/476) had bacterial vaginosis, 0.8% (4/476) had fungal infection 9% (44/496) had trichomonal infection and none was found to be having gonococcal infection. Tests for chlamydial infection could not be performed as the cost was not affordable. Eighty-nine percent of women who reported symptoms of RTIs had not consulted anyone for their problem prior to our village based camp. Only 42% symptomatic and 24% asymptomatics availed the services even in the village based camps. Study revealed high load of reproductive tract infections and low utilisation of treatment facility. In-depth studies are required to understand for high RTI morbidity load and low treatment seeking rate so as to design an appropriate RTI control programme.

The burden of reproductive-organ disease in rural women in The Gambia, West Africa

Article

May 2001

Data on the epidemiology of reproductive-organ morbidity are needed to guide effective interventions, to set health-care priorities, and to target future research. This study aimed to find out the prevalence of reproductive-organ disease in a sample of rural Gambian women. A questionnaire on reproductive health was administered by fieldworkers to women aged 15-54 years living in a rural area under demographic surveillance. A female gynaecologist questioned and examined the women (including speculum and bimanual pelvic examinations). Vaginal swabs were taken to test for Trichomonas vaginalis, Candida albicans, and bacterial vaginosis, cervical smears for cytology, cervical swabs for Chlamydia trachomatis PCR and Neisseria gonorrhoeae culture, and venous blood for haemoglobin, HIV, herpes simplex virus 2, and syphilis serology. 1348 (72.0%) of 1871 eligible women took part. Reproductive-organ symptoms were more likely to be reported to the gynaecologist (52.7% of women) than to the fieldworker (26.5%). Menstrual problems, abnormal vaginal discharge, and vaginal itching were the most commonly reported symptoms. A minority of women said they had sought health care for their symptoms. The frequencies of reproductive-organ morbidity were high: menstrual dysfunction 34.1% (95% CI 29.6-39.1), infertility 9.8% (8.2-11.6), reproductive-tract infections 47.3% (43.7-51.0), pelvic tenderness 9.8% ((7.0-13.5), cervical dysplasia 6.7% (5.2-8.4), masses 15.9% (12.5-20.1), and childbirth-related damage to pelvic structures 46.1% (40.1-52.3). 948 (70.3%) women had at least one reproductive-organ disorder. For these rural women, whose lives depend heavily on their reproductive function, reproductive-organ disease is a large burden. In inadequately resourced rural areas, with poor education, heavy agricultural and domestic labour, and limited access to quality health care, many women are not able to attain and maintain reproductive health and wellbeing.