Review: Postpartum reproductive disease and fertility in dairy cows.

This paper reviews recent data and concepts on metritis, purulent vaginal discharge (PVD), and endometritis in dairy cows and the ways in which these diseases affect reproductive performance. Metritis is characterized by fetid discharge from the uterus, with or without fever. Purulent vaginal discharge describes exudate that is >50% pus that may be attributable to uterine infection or cervicitis. Endometritis is inflammation of the uterus diagnosed by endometrial cytology with a proportion of neutrophils (typically ≥5%) that is associated with impaired fertility. Metritis and PVD are associated with uterine bacterial dysbiosis: changes in the microbiota to lesser diversity and greater abundance of pathogens, especially Gram-negative anaerobic bacteria, and Trueperella pyogenes in the case of PVD. Metritis is justifiably treated with approved antibiotics but criteria for more selective treatment without loss of performance are emerging. Purulent vaginal discharge is not synonymous with clinical endometritis, and greater precision in terminology is warranted. PVD is likely under-diagnosed and represents an opportunity for improved management in many herds. Endometritis seems in many cases to reflect persistent, dysregulated inflammation, for which the inciting cause is unclear. Postpartum uterine infection and inflammation have harmful effects on oocytes, embryo development, and the endometrium for at least three months, even if the disease is apparently resolved. Emerging concepts of the resolution and regulation of inflammation are promising for the improvement of prevention and therapy of endometritis.

Identification of volatile biomarkers of Trichomonas vaginalis infection in vaginal discharge and urine.

Trichomoniasis, a disease caused by Trichomonas vaginalis, is the most common non-viral sexually transmitted infection worldwide. The importance of its diagnosis lies in its ease of transmission and the absence of symptoms in most cases, as occurs in men, which have a significant role as asymptomatic carriers. The most widely used diagnostic methods are the fresh examination of vaginal or urethral secretions and molecular techniques. However, as they have some disadvantages and, sometimes, low sensitivity, new trichomoniasis diagnostic methods are necessary. Volatile organic compounds in clinical samples are effective in the diagnosis of different diseases. This work aimed to study, for the first time, those present in vaginal discharge and urine of patients with Trichomonas vaginalis infection to look for volatile biomarkers. The results showed that volatile compounds such as 2-methyl-1-propanol and cyclohexanone could serve as biomarkers in vaginal discharge samples, as well as 2-octen-1-ol and 3-nonanone in urine. Moreover, 3-hydroxy-2,4,4-trimethylpentyl 2-methylpropanoate found in vaginal discharge, highly correlated to positive patients, is also highly related to urines of patients with trichomoniasis. The biomarkers described in this study might be a promising diagnostic tool. KEY POINTS: • The incidence of Trichomonas vaginalis infection is increasing • Trichomonas vaginalis VOC study in vaginal discharge and urine was performed • The identification of volatile biomarkers could allow a new diagnostic method.

[Guideline for the clinical examination and report standardization of vaginal discharge].

Vaginal discharge examination is an essential clinical test used in vaginal infections diagnosis. Nowadays, both the uneven understanding of vaginal discharge and the lack of standardization of manual examination and report were apparent among the clinical laboratories in our country. Hence, combined with latest progress, technical requirements and standard operating procedure, the experts from clinical laboratory and gynaecology and obstetrics compiled Guideline for the Clinical Examination and Report Standardization of Vaginal Discharge jointly to advance the normalization and standardization of manual operation and result report. Applying to vaginal discharge manual examination in clinical laboratories, it is composed of three aspects. A considerable part is manual operation, including collection, transportation and physical, morphological and chemical examination, with commended report format and quality control filling out the remainder. The guideline aims to standardize the manual operation, result report and quality control requirements, which could provide an important reference for each segment of vaginal discharge manual examination in various medical institutions.

Etiological Surveillance of Vaginal Discharge Syndrome in South Africa: 2019 to 2020.

BACKGROUND: The syndromic management of vaginal discharge syndrome (VDS) is challenging because of the prevalence of mixed infection with sexually transmitted infection (STI) pathogens and non-STI causes, such as bacterial vaginosis and candidiasis (CA). We aimed to determine the relative prevalence of VDS etiologies in women presenting to sentinel primary health care clinics in South Africa. Secondary objectives were to ascertain the predictive value of speculum findings for the presence of STI pathogens and the proportion of women presenting with clinical features of CA who had identifiable yeast on vaginal smear microscopy. METHODS: Consecutive, consenting women with complaints of abnormal vaginal discharge were enrolled between January 1, 2019, and December 31, 2020. Genital discharge swab and blood specimens were collected and transported to a central STI reference laboratory in Johannesburg. RESULTS: A total of 364 women were enrolled at 3 sentinel sites. Bacterial vaginosis was the most common cause of VDS (163 of 361 [45.2%]; 95% confidence interval [CI], 40.1%-50.3%); however, a significant proportion had STI coinfection (71 of 163 [43.6%]; 95% CI, 35.8%-51.5%). The predominant STI etiology was Chlamydia trachomatis (73 [20.2%]; 95% CI, 16.4%-24.7%). An abnormal speculum finding had poor predictive value for STIs, and Gram stain microscopy showed yeast in only 37.2% of vaginal smears from women with CA symptoms. CONCLUSIONS: Bacterial vaginosis is the predominant cause of VDS in South Africa; however, STI coinfection is common. Clinical findings are poorly predictive of STI etiologies or candidiasis; therefore, a rapid and accurate STI point-of-care test would be useful in optimizing VDS management.

Reproductive tract disease in Irish grazing dairy cows: Retrospective observational study examining its association with reproductive performance and accuracy of 2 diagnostic tests.

The detection of reproductive tract disease (RTD) 3 wk postpartum is important because of its effect on subsequent reproductive outcomes. Numerous methods for the diagnosis of RTD are described, some of which are more practical and instantaneous in terms of diagnosis. Two of these methods involve identification of purulent vaginal discharge (PVD) and evidence of ultrasonographic uterine changes indicative of endometritis (UE). The objectives of our retrospective observational study were (1) to assess the association of PVD or UE score at the prebreeding examination (PBE) with the hazard of pregnancy within the subsequent breeding season; (2) to determine the test sensitivity (Se) and specificity (Sp) at the point of sampling of both tests using a Bayesian latent class model; and (3) to determine the effect of varying positivity thresholds on test accuracy. To achieve these objectives, we analyzed an initial data set of 5,049 PBE from 2,460 spring-calved cows in 8 herds between 2014 and 2018. Each PBE was conducted once between 25 and 86 d in milk. At each PBE, vaginal discharge was obtained with a Metricheck device (Simcro) whereas uterine contents were assessed using transrectal ultrasonography. Purulent vaginal discharge was scored on a scale of 0 to 3 depending on discharge character, and UE was scored on a scale of 0 to 4 depending on the presence and consistency of intraluminal fluid. Cows with scores of ≥2 in either test had received treatment. Fertility data were available from 4,756 PBE after data exclusion. The association between PVD or UE score at the PBE and subsequent hazard of pregnancy was analyzed using a Cox proportional hazards model. Cows with a PVD score of 2 or 3 were less likely to conceive than cows with a PVD score 0 [score 2 hazard ratio (HR) = 0.74; 95% confidence interval (CI): 0.59-0.94; score 3 HR = 0.65; 95% CI: 0.51-0.84]. Cows with a UE score of 1, 2, 3, or 4 were less likely to conceive than cows with a UE score of 0 (score 1 HR = 0.82; 95% CI: 0.73-0.93; score 2 HR = 0.79; 95% CI: 0.62-1.00; score 3 HR = 0.43; 95% CI: 0.43-0.90; score 4 HR = 0.39; 95% CI: 0.26-0.58). To determine the Se and Sp of PVD or UE score for diagnosis of RTD at the time of PBE, a Bayesian latent class model was fitted on 2,460 individual cow PBE. Flat priors were used for the Se and Sp of UE, whereas informative priors were used for PVD Se (mode = 65%, 5th percentile = 45%) and Sp (mode = 90%, 5th percentile = 80%) and RTD prevalence (mode = 20%, 5th percentile = 10%). Posterior estimates (median and 95% Bayesian probability intervals; BPI) were obtained using 'rjags' (R Studio). The optimal test thresholds (PVD and UE score ≥1) were selected by assessing the effect of different thresholds on test estimates and using a misclassification cost analysis. Based on these, median (95% BPI) Se for PVD and UE score ≥1 were 44% (29-60%) and 67% (33-100%), respectively. Median Sp for PVD and UE score ≥1 were 90% (86-93%) and 91% (86-93%), respectively. Higher scores in both tests were associated with impaired fertility, and UE scoring with a threshold of ≥1 had the highest test Se and Sp estimates although test Se was conditional on days in milk when the PBE occurred.

Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya.

Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.

Diagnostic tool for the diagnosis of physiological and pathological conditions of the uterus in cows postpartum.

OBJECTIVE: An important task of veterinarians in cattle husbandry is the early diagnosis of postpartum complications that can lead to infertility. The aim of the study was the evaluation of a new device to distinguish between physiological and pathological conditions of the uterus based on the determination of the time of uterine involution and the physicochemical properties of the vaginal discharge (lochia) during the first weeks after parturition. MATERIAL AND METHODS: A total of 173 black-and-white Holstein-Friesian dairy cows were examined for any pathological alteration of the uterine involution on days 1-2, 6-8, 11-14 postpartum and, in case of pathological findings, additionally on days 18-22, 23-27 and 28-30 after parturition. In addition to the standard examination a newly developed hand-held instrument ("Metrastatum") was used to differentiate between physiological and pathological uterine involution. It allows determination of the distance between the cervix and vulva (DCV) and simultaneous collection of lochial secretions. RESULTS: The best time to use the new instrument was 10-16 days postpartum. In healthy cows without disturbed puerperium, the average DCV was 25.7 cm (± 0.8 cm) in this phase. This distance decreased by 12.5 ± 0.3 cm compared to the first days. In contrast, in cows with postpartum problems, the DCV was significantly greater at (31 ± 0.7 cm) (p < 0.001). In these animals, the AGV was reduced only by an average of 8.4 ± 0.6 cm when compared to the first days. The mucus obtained with the dome-shaped rubber funnel of the instrument also differed in the cows of the 2 groups. In healthy cows without puerperal problems, the lochia were thick, colorless, transparent and sometimes cloudy. In case of puerperal disorders, the discharge was thin, light red to reddish brown, contained flakes and had a nasty odor depending on the form of the inflammation. CONCLUSION: The dual function of device helps to early diagnose puerperal disorders in cows and to select healthy animals for reproduction and sick cows for treatment depending on the form of uterine inflammation.

Developing an algorithm for the diagnosis of abnormal vaginal discharge in a dutch clinical setting: a pilot study.

Abnormal vaginal discharge may be caused by bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis and/or aerobic vaginitis. For the development of a diagnostic algorithm, tree-based classification analysis was performed on symptoms, signs and bedside test results of 56 patients, and laboratory tests (culture, Nugent score, qPCRs) were compared. Amplicon sequencing of the 16S rRNA gene was used as reference test for bacterial vaginosis and aerobic vaginitis, culture for vulvovaginal candidiasis and qPCR for trichomoniasis. For bacterial vaginosis, the best diagnostic algorithm was to screen at the bedside with a pH and odour test and if positive, to confirm by qPCR (sensitivity 94%; specificity 97%) rather than Nugent score (sensitivity of 59%; specificity 97%; P = 0.031). The analysis for the other infections was less conclusive due to the low number of patients with these infections. For bacterial vaginosis, the developed algorithm is sensitive, specific, and reduces the need for laboratory tests in 50% of the patients.

Prevalence of endometritis diagnosed by vaginal discharge scoring or uterine cytology in dairy cows and herds.

Endometritis, diagnosed either by assessing the proportion of nucleated cells that are neutrophils (PMN%) following cytology of the endometrium or by assessing the degree of purulent material within the vagina (purulent vaginal discharge or PVD score), is prevalent among dairy cows. However, limited data exist as to the degree of variation among herds in the prevalence of endometritis diagnosed by these 2 methods. Thus, we undertook a study involving uterine cytological and vaginal sampling at a median of 41 d in milk of 1,807 cows from 100 seasonally breeding dairy herds in New Zealand. The optimal cut-point for PMN% was determined by receiver operator characteristic (ROC) curve analysis using conception to first artificial insemination (AI) as the outcome variable. The prevalence of disease was then calculated at the cow and herd levels, and an estimate of the effect of clustering of cow within a herd was calculated. Reproductive outcomes were collated and associations between endometritis and reproductive outcomes assessed using multivariable models. The optimal PMN% cut-point was ≥2%. The correlation of results for cows within a herd (the intraclass correlation) was 0.03, which was significant; hence, subsequent modeling accounted for this clustering. The cow-level prevalence of PMN% ≥2% was 27.0% [95% confidence interval (CI): 25.0 to 29.1%], whereas the mean within-herd prevalence of PMN% ≥2% was 27.1% (95% CI: 24.7 to 29.6%; range: 5.0 to 63.6%), and the prevalence among herds varied significantly. An elevated PMN% (≥2%) was significantly associated with a reduction in the proportion of cows conceiving to first AI (45.8 vs. 54.5%), a reduced proportion of cows submitted for AI in the first 3 wk of the seasonal breeding program (83.7 vs. 89.3%), and a lower proportion pregnant in the first 3 (44.4 vs. 55.4%) and 6 wk (67.5 vs. 76.4%) of the breeding program relative to cows with a low PMN% (i.e., <2%). A total of 24.6% of cows had a PVD score ≥2. The herd mean prevalence of PVD score ≥2 was 25.1% (95% CI: 22.5 to 27.7%; range: 5.0 to 65.0%) and varied significantly among herds. The level of agreement (kappa) between the PVD score and PMN% was low (16.8%) and nonsignificant. The effects of PVD score and PMN% on reproductive outcomes were independent. The within-herd median prevalence of endometritis based on combining both diagnostic tests and using a Bayesian latent class model was 22.9% (Bayesian 95% CI: 10.4 to 40.1%). We conclude that more than one-fifth of dairy cows have endometritis diagnosed either by PMN% or PVD in seasonal breeding herds when assessed at an average of 41 DIM, which was, on average, 30 d before the start of the seasonal breeding program. There is large and unexplained variation in prevalence of endometritis among herds. The 2 diagnostic methods were both associated with reproductive outcomes but have low levels of agreement between them and their effects appear to be independent.

Trichomonas vaginalis in Pregnancy: Patterns and Predictors of Testing, Infection, and Treatment.

OBJECTIVE: To identify factors associated with testing for and diagnosis of trichomoniasis in pregnancy and to describe patterns of treatment and tests of reinfection or persistence. METHODS: We conducted a retrospective cohort study of women who delivered from July 2016 to June 2018 at one institution. Testing for Trichomonas vaginalis infection was done by wet mount microscopy or by nucleic acid amplification testing for routine prenatal testing or symptomatic visits. Poisson regression was used to identify factors associated with testing for trichomoniasis and testing positive in pregnancy. Treatment and re-testing patterns also were assessed. RESULTS: Among 3,265 pregnant women, 2,489 (76%) were tested for T vaginalis infection. Of the total sample, 1,808 (55%) were tested by wet mount microscopy, 1,661 (51%) by nucleic acid amplification testing, and 980 (30%) by both modalities. The sensitivity for microscopy compared with nucleic acid amplification testing was 26%, with a specificity of 99%. Factors associated with increased likelihood of being tested included younger age (adjusted risk ratio [aRR] 0.99, 95% CI 0.99-1.00) and bacterial vaginosis (aRR 1.17, 95% CI 1.01-1.37). Prevalence of trichomoniasis was 15% among those tested by any modality (wet mount or nucleic acid amplification testing). Risk factors for trichomoniasis included younger age (aRR 0.97, P<.01), being of black race (aRR 2.62, P<.01), abnormal vaginal discharge (aRR 1.45, P<.01), and chlamydia during the current pregnancy (aRR 1.70, P<.01). Women diagnosed by microscopy had a shorter time to treatment compared with those diagnosed by nucleic acid amplification testing. Most (75%) women with positive infections had a test of reinfection; 29% of these were positive. Bacterial vaginosis was associated with decreased risk of a positive test of reinfection. CONCLUSION: Although testing for and treatment of trichomoniasis during pregnancy is not routinely recommended, the high burden of infection among some pregnant women demonstrates a need to further understand patterns of T vaginalis testing and infection. Opportunities exist for improving timely treatment of trichomoniasis and test of reinfection.

Effectiveness of an educational intervention on vulvo-vaginal discharge for family healthcare workers: A nonrandomized controlled trial.

Women's delay in seeking medical advice for abnormal vaginal discharge can cause serious effects such as infertility, ectopic pregnancy, and advanced cervical cancer. Family healthcare workers are in a unique position to help in the promotion of vaginal health. A nonrandomized controlled trial was conducted among a sample of family healthcare workers in the intervention (n = 37) and a control (n = 37) group to assess the effectiveness of an educational intervention, which was a 2-day intensive workshop combining reading materials. Data were analyzed using SPSS software (version 20), and the effectiveness of the intervention was determined using a mixed between-within subjects analysis of variance. The total knowledge and attitude scores were significantly greater for family healthcare workers in the intervention group immediately and at 3 and 6 months after the educational intervention, compared to the control group. A substantial main effect was observed concerning the time, showing an increase in family healthcare workers' knowledge and attitude scores across the four time periods. A statistically significant difference in the median overall health education competency score across the two groups was also observed. The mean score differences in all sub-competencies in health education were significantly higher among the intervention group, compared to the control group between second postintervention and the baseline. The educational intervention had revealed successful and sustainable improvements in family healthcare workers' knowledge, attitude on vaginal discharge, and health education competency. This can be implemented as an in-service program for family healthcare workers to improve health education practices.

Latent class analysis of symptoms for sexually transmitted infections among Iranian women: Results from a population-based survey.

A preliminary symptom-based screening test would lower the financial burden of sexually transmitted infections (STIs) caused by clinical testing. To develop such a screening method, we should first identify the most specific STI symptoms. We aim to distinguish the specific STI symptom(s) that are most likely to be found in the truly infected individuals. We used data from a population-based survey that was conducted in Iran, in 2014. Using Latent Class Analysis (LCA) in R software, we classified 3049 Iranian women, 18-60 years old, with reference to seven self-reported STI-associated symptoms. Using LCA, we categorized nearly 1% of women as "probably STI-infected". Above 70% of participants reported the "seven symptoms" that are associated with STIs, except for genital ulcer. These symptoms could be used to distinguish healthy participants from infected ones. The "probably healthy" class incorporated about 77% of the participants. Lower abdominal pain and abnormal vaginal discharge were the most frequently reported symptoms of this class. The LCA determined classes along with the WHO syndromic guidelines for STI diagnosis can help physicians to make a more accurate diagnosis. Hence, cost-effectively, only patients who are classified as probably infected need to be referred to medical laboratories for further investigations.

Purulent vaginal discharge diagnosed in pasture-based Holstein-Friesian cows at 21 days postpartum is influenced by previous lactation milk yield and results in diminished fertility.

In a subset of dairy cows, prolonged pathological uterine inflammation results in purulent vaginal discharge (PVD), which can have negative consequences for both fertility and milk production. However, unlike for intensive systems, analysis of the effects of PVD in predominantly pasture-based herds is limited. The objective of this study was to assess the effect of PVD in spring-calving, pasture-based dairy cows on production and reproduction indices, stratified according to previous full-lactation milk yield. We assessed clinical disease as defined by vaginal mucus score (VMS) in 440 Holstein-Friesian cows from 5 farms. Cows were categorized as healthy (VMS 0) or having PVD (VMS 1-3) at 21 d postpartum. We recorded 305-d milk, milk protein, and milk fat yields (kg) before and after disease diagnosis, as well as fertility data, such as services per conception and the calving-conception period (CCP). Using SAS 9.4 (SAS Institute Inc., Cary, NC), we analyzed data using PROC MIXED, PROC PHREG, and PROC LOGISTIC to determine the least squares means differences and hazard and odds ratios between the groups, respectively. Overall, a 60% prevalence of PVD was recorded at 21 d postpartum. Milk yield and milk constituents were similar between all VMS categories and between healthy cows and cows with PVD. Although cows in the 4 VMS categories had statistically similar CCP, cows with PVD had a significantly longer CCP than healthy cows on average (9 d). The hazard ratio for cows with PVD was 0.66, indicating a 34% higher risk of a prolonged CCP than healthy cows. Odds ratio analysis determined that cows with PVD were 3 times more likely not to conceive at all, twice as likely not to conceive at first service, twice as likely not to conceive by 100 d postpartum, and 3 times more likely to fail to conceive before 150 d postpartum compared with healthy cows. Cows were retrospectively categorized as having low or high milk yield, based on whether they were above or below the median 305-d milk yield of the study population (6,571 kg) in the lactation before vaginal mucus scoring. Based on a univariate odds ratio, high-yield cows were 1.6 times more likely to present with PVD in the subsequent lactation. The number of services per conception did not differ between healthy and PVD cows in the low- and high-yield groups. In the high-yield group, cows with PVD were 4.9 times more likely not to conceive, 2.7 times more likely to require multiple services to conceive, 2.1 times more likely to remain not pregnant by 100 d postpartum, and 4.4 times more likely to remain not pregnant by 150 d postpartum. The CCP was also significantly longer in cows with PVD than their healthy counterparts (115.9 ± 4.9 and 104 ± 7.4 d, respectively). In conclusion, PVD significantly increased the CCP in all cows, but to a greater extent in cows with a high milk yield in the lactation before disease diagnosis.

Predicting the probability of conception in dairy cows with clinical endometritis based on a combination of anamnestic information and examination results.

The objective of this study was to improve prediction of the probability of conception in dairy cows with clinical endometritis by means of a combination of examination results. For this purpose, a total of 1386 dairy cows were screened for clinical endometritis and data from 286 cows were collected including the calving history, puerperal or concurrent diseases and cow-specific data (breed, parity, BCS at puerperal control 1 (PC 1 = 22-45 days in milk (DIM)), and daily milk yield). The diagnosis of clinical endometritis was made at PC 1 by vaginal discharge scoring with a Metricheck device on a scale from 1 to 3 (endometritis score (ES) 1 to 3). A detailed clinical and gynecological examination including external inspection, transrectal palpation and ultrasonographic examination of the genital tract (cervix, uterus, and ovaries), vaginoscopy and microbiological analysis of the intrauterine content were performed. All cows with clinical endometritis (n = 286) were treated according to the ovarian findings (corpus luteum, dominant follicle) at PC 1. A second puerperal control was performed 21 ±â€¯1 days later. Data was collected until 200 DIM. The risk factors for ES 3 and their effect on the distribution of ES were determined by the Chi-square test and binary logistic regression. Multivariable implications of a large sum of examination parameters on the pregnancy outcome at different DIM (100, 150 and 200 DIM) were analyzed on the basis of conditional inference trees. The prevalence of clinical endometritis was 28%. The ovarian findings at PC 1 did not have any impact on reproductive performance. Puerperal diseases prior to the study, visible vaginal discharge (VVD) and the presence of Trueperella pyogenes (TP) were associated with an ES 3. The prediction of pregnancy status for all DIM times was dominated significantly by VVD or TP as decisive factors. Cows with VVD or TP had lower conception rates at all DIM times than cows without these findings, but the predictive accuracy was similar for both groups. These results suggest that VVD is a valuable and practical examination parameter, which can be used for pregnancy prediction on farm. Therefore, it might facilitate early breeding decisions in cows with clinical endometritis under farm conditions.

Provision of Sexually Transmitted Infection Services in a Mobile Clinic Reveals High Unmet Need in Remote Areas of South Africa: A Cross-sectional Study.

BACKGROUND: The burden of sexually transmitted infections (STIs) in areas of sub-Saharan Africa with poor access to health care services is not well documented. In remote areas of South Africa, we investigated the prevalence of STIs and approaches to providing STI services through a mobile clinic. METHODS: We recruited 251 adult women visiting a mobile clinic that normally provides general health education and screening services, but not STI care. Clinical and sexual history was obtained and vaginal specimens were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium infection and for Candida albicans and bacterial vaginosis. RESULTS: Laboratory test was positive for 133 (53%) of 251 women for at least 1 STI: C. trachomatis was observed in 52 (21%) women, N. gonorrhoeae in 39 (16%) women, T. vaginalis in 81 (32%) women and M. genitalium in 21 (8%) women. Eighty-one (32%) women met the criteria for vaginal discharge syndrome, of which 58% (47/81) would have been treated accurately. Among asymptomatic women 84 (49%) of 170 were diagnosed with an STI but untreated under the syndromic approach. We could not identify factors associated with asymptomatic STI infection. CONCLUSIONS: There is a high unmet need for STI care in rural South African settings with poor access to health care services. Provision of STI services in a mobile clinic using the syndromic management approach provides a useful approach, but would have to be enhanced by targeted diagnostics to successfully address the burden of infection.