Cultural method for large-scale screening for Chlamydia trachomatis genital infection.

Idoxuridine-treated McCoy cells grown as monolayers in 96 well microplates provide a convenient method for the isolation of Chlamydia trachomatis. Staining of infected monolayers with periodic acid-Schiff reagent (PAS) allows easy recognition of C trachomatis inclusions without the need for dark-ground microscopy. By this method 384 clinical specimens can be examined concurrently. It is sufficiently sensitive to form the basis of a chlamydial culture service for patients attending Sexually Transmitted Diseases (STD) Clinics.

Epidemiology of penicillinase-producing Neisseria gonorrhoeae in Liverpool from 1977 to 1982.

After the 1976 outbreak of penicillinase-producing Neisseria gonorrhoeae (PPNG) infections had been controlled, less than 1 per cent of cases of gonorrhoea in Liverpool in 1977 and 1978 were caused by PPNG. Thereafter the steady increase in PPNG infections to 5.6 per cent of all cases in 1982 was associated with marked changes in epidemiological pattern, plasmids and auxotypes. In 1976 nearly all PPNG infections were acquired by young black males living in the inner city from women frequenting clubs; the PPNG were all of the African 3.2 megadalton (MD) plasmid type and of arginine-requiring auxotype. Between 1977 and 1982 female patients were increasingly ship girl prostitutes associating with seamen who constituted more than 50 per cent of the male patients. These men and other travellers introduced PPNG into Liverpool from the Far East and West Africa. In 1978 PPNG of the Asian type with 4.4 MD plasmid with or without 24.5 MD transfer plasmids were isolated in Liverpool where in 1979 all PPNG carried 4.4 MD and 24.5 MD plasmids. In 1982 strains of the 'new' African type with 3.2 and 24.5 MD plasmids were isolated as were PPNG of the Asian type that had been acquired in West Africa. Auxotyping of the 1982 isolates showed that none were arginine-requiring but three other types were identified: proline-requiring: proline-arginine-requiring; non-requiring. For the control of PPNG, a strategy based on constant vigilance, appropriate diagnostic procedures, rapidly effective treatment and determined contact tracing is needed.

Sexually transmitted diseases in the tropics. Epidemiological, diagnostic, therapeutic, and control aspects.

PIP: Sexually transmitted diseases, especially syphilis, gonorrhea, granuloma inguinale, and lymphogranuloma, are on the increase in the tropics. Several environmental factors contribute to disease transmission, including polygamy, high bride price, prostitution, civil war, urbanization, and economic development. Diagnosis is generally made on clinical grounds due to inadequate laboratoary facilities, and it is not possible to differentiate syphilis from yaws. This diagnostic inaccuracy has meant that there are no reliable data with which to assess epidemiologic trends, institute control measures, and evaluate their effects. Inadequate treatment, caused by a lack of drugs and poorly trained medical attendants, is also a major problem. Inappropriate treatment has caused over 80% of gonococcal strains in some areas to be penicillin-resistant. Late complications of gonorrhea, epididymitis, and salpingitis are frequently seen and lead to sterility in many cases. These complications are as prevalent in some areas today as they were in pre-sulfonamide days. A determined effort is needed to control the spread of these diseases. A central unit with modern facilities for diagnosis and treatment should be established. Diagnostic tests, such as culture and serology, should be introduced at the district and provincial levels. Rural health centers should employ a polyvalent microscopist who is trained to recognize gonococcus in stained smears. Given the high default rates, treatment should be simplified, using a single dose schedule where possible. The impracticality of follow-up requires epidemiologic treatment of contacts in many cases. If mass screening of pregnant women is not possible, Crede's silver nitrate eyedrops are recommended to prevent ophthalmia neonatorum. High risk populations, including bar girls, migrant workers, soldiers, and sailors, should be targeted for health education campaigns. Such education should focus on regulation of sexual behavior, condom use, and, when infection is present, the importance of avoiding self-medication, early treatment, and cooperation in contact tracing.^ieng

Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda.

PIP: Concern for venereal disease (VD) in Uganda led to the building of a special hospital in 1912-13 to provide treatment. This was later to become the national reference hospital, now called Mulago Hospital. Within a few years more VD treatment centers operated by trained indigenous clinical assistants were opened. These centers formed the basis of the future expansion of the general medical services in some parts of Uganda in the 1920s. In regard to the present VD services, they cannot be described in isolation. There are no special VD services in Uganda except in the largest hospital. To understand how and where these services are provided requires a description of the relevant parts of the organization of Uganda's health services. Currently, Uganda has a reasonable network of health services throughout the country. These are primarily provided by the government and are organized on a regional and district basis--hospitals being situated in the main towns with health centers, dispensaries, and aid posts serving the rural areas. All basic health services provided by the government are free of charge. Private practitioners are concentrated in the main towns. There are also some missionary medical units and a few provided by industry. Rural health centers and dispensaries form the backbone of the health services and cater to over 90% of the population. These are frequently understaffed with mostly well trained general duty medical auxiliaries but laboratory facilities and supplies of appropriate drugs are inadequate. VD is diagnosed and treated in all the medical units mentioned, mostly on an outpatient basis by auxiliaries with no special training in this area. Some important developments in the VD service in recent years include a reawakening of interest and a beginning of the recognition of the problem, the establishment of a few centers on a scientific basis, and the appointment of a specialist at the Mulago Hospital. As there are several problems more important than VD which require personnel, money, and materials, the possibilities for improvement in VD services within the existing framework are limited. Specialist and all but simple laboratory services will continue to be confined to the capital city of Kampala for some time to come. The bulk of VD patients in the remainder of the country will continue to be seen by the auxiliaries in the district hospitals and the rural medical units with variable amounts of supervision by doctors within the existing framework.^ieng

In search of an ideal single-session penicillin schedule for the treatment of gonorrhoea in Uganda.

PIP: To determine the most effective, economical therapy for gonorrhea in Uganda, 5 single-session penicillin schedules were compared in a group of 460 university students with urethral discharge. A total of 590 episodes of gonococcal urethritis were treated. Patients were randomly allocated to 1 of 5 schedules. Treatment schedules and cure rates were as follows: 1) aqueous procaine penicillin 2.4 m.u. (125 cases), 90.3%; 2) procaine penicillin 2.4 m.u. plus ampicillin 1 gm (143 cases), 97.1%; 3) procaine penicillin 3 m.u. (90 cases), 89.8%; 4) procaine penicillin 3 m.u. plus probenecid 1 gm (103 cases), 97.1%; and 5) probenecid 1 gm orally followed by benzyl penicillin 5 m.u. (129 cases), 96.8%. 30 of the 31 treatment failures were successfully treated with an alternate schedule. The results obtained with procaine penicillin alone are considered unfavorable. Although highly effective, the probenecid and benzyl penicillin regimen is expensive and requires the preparation of penicillin with lignocaine solution and an extra 30-minute wait, making it inappropriate for Uganda's busy multipurpose clinics. The procaine-ampicillin combination was also highly effective, but its high cost limits it use to private practice. The 3rd highly effective schedule, the combination of procaine penicillin and probenecid, appears to most closely approximate the ideal single-session penicillin schedule for treatment of gonorrhea in Uganda. It is both inexpensive and easily administered. Moreover, the prolonged penicillinemia achieved by 3 m.u. procaine penicillin may be more effective in eliminating cases of incubating syphilis than benzyl penicillin. Long-acting procaine penicillin in oil with aluminum monostearate (PAM), which is the most widely used treatment regimen in the rural medical units of Uganda, is no longer indicated and may, in fact, be encouraging the spread of less sensitive strains of gonorrhea. Any change toward a more effective treatment schedule must, however, be accompanied by improvement in the diagnostic and treatment facilities in the country.^ieng

Persistent urethritis due to Ureaplasma urealyticum in conjugal or stable partnerships.

A study of four conjugal partnerships is described in which the male partners presented with persistent or recurrent non-gonococcal, non-chlamydial, but ureaplasma positive urethritis. Resolution of symptoms and signs in the male partners was achieved only after treatment to eliminate Ureaplasma urealyticum from both partners.

Role of the medical auxiliary in the control of sexually transmitted disease in a developing country.

Venereal diseases are becoming a major health problem in many developing countries where the greater part of primary medical care is undertaken by medical auxiliaries. Under these circumstances, the medical auxiliary has an important role to play in the control of these diseases but he can only do this with adequate training, support, and supervision from the professional doctors and specialists. In this paper, the role of the medical auxiliary is outlined and a case is also made for a specially-trained cadre for venereal disease work in busy urban clinics in developing countries.

PIP: The role of the medical auxiliary is outlined and a case is made for a specially trained cadre of medical auxiliaries for venereal disease work in busy urban clinics in developing countries. Evidence exists that all forms of venereal disease are very common in urban and rural areas of several developing nations. Very high rates of gonococcal strains less sensitive to penicillin and other antibiotics have been reported in Uganda, Kenya, Bombay, Ethiopia, and Thailand. The situation in these countries and possibly elsewhere in Africa and The Far East is much worse than in Europe. The fear of the spread of venereal syphilis after mass campaigns against the endemic treponematoses and the consequent loss of cross immunity from yaws is already becoming a reality in some developing countries. In many developing nations venereal diseases are often seen late in the natural history of the condition when complications have set in and the medical auxiliary is called on to treat not merely an irritating symptom but a serious complication or an emergency. Peripheral units in most developing countries are now considered to be the ideal units, offering an integrated service comprising all basic health care. Such health centers are also appropriate for urban communities. These health centers are staffed with trained medical auxiliaries, preferably indigenous to the area concerned. Many countries are unable to provide in every unit the full team of auxiliaries required to run all the basic health services. Dispensaries may be operated by a less well-trained cadre of medical auxiliaries supervised from the Health Center or District Hospital. Where the full range of basic health services are offered there is considerable opportunity for team work. In big cities the medical care in most developing countries is provided by Government Hospitals, Urban Health Centers operated by the City Councils, and private practitioners. Venereal disease clinics form part of the outpatient departments in big hospitals and Urban Health Centers. The overall scarcity of fully qualified professional workers means that tasks which are the strict prerogative of doctors and specialists in the developed countries must be delegated to auxiliaries. If equipped with better knowledge and skills their contribution to venereal disease control can be improved. Where sexually transmitted diseases are most common and the daily number of patients very great, as in urban areas, medical auxiliaries should undergo extra training.

Clinical, cultural, and demographic aspects of gonorrhoea in a rural community in Uganda.

PIP: The attempt is made in this discussion to provide a more precise and detailed description of gonorrhea among men and women of a remote rural area of Uganda. The study was part of an intensive Demographic Research Project that had as its objectives investigation of the cultural, social, medical and economic factors related to differential rates of population growth and testing methods of collecting accurate data on vital events. 2 rural districts were selected as having low and high fertility respectively--the Teso District in the Eastern Region with low fertility and Anokole District in the Western Region with high fertility--and gonorrhea was found to be 1 of the most important factors responsible for these differences. Of the 166 men examined in Ankole, only 7 were found to have gonorrhea. Of the 168 women who were adequately examined, only 4 were found to have gonorrhea. Gonorrhea was found to be highly prevalent in the Teso District. Due to the fact that 1/3 of those affected were symptomless, there is little question that many more cases would have been diagnosed if other diagnostic procedures had been included, such as obtaining urethral material from all subjects. In addition to the current evidence of gonorrhea, the following features were noted in the Teso men, and these may be considered as diagnostic concomitants (and some as determinants) of the gonorrhea status of the community. Of the 270 men interviewed, 70 indicated that they were unable to pass urine freely or easily. This total included 15 cases of currently diagnosed gonorrhea. 150 of the 270 men gave a past history of urethral discharge. 1 of the most significant features encountered was the nodular thickening of the lower pole (globus minor) of the epididymis, or more extensive involvement in some cases. 61 of the 270 men gave a past history of genital sores. Of those with more than 1 wife, 75.0% reported a past history of discharge, as compared with 55.6% of those who only had 1 wife. This difference was significant.^ieng