So, what's best? Accuracy and acceptance of thermometers in triage and inpatients in a low-resource tropical setting - The MaTe study.

Objectives: We searched for the most-suitable thermometry method in the low-resource, tropical setting of Sierra Leone, both in terms of accuracy and also patient and user acceptance. Methods: We conducted a prospective comparative study of different methods of body temperature measurement. Each participant had their temperature taken by four different methods: non-contact infrared temperature (NCIT), axillary, tympanic membrane and rectal measurements. Rectal temperature was considered clinical gold standard. Primary outcome was predicted sensitivity and specificity of thermometry methods in detecting fever (rectal temperature ≥38.0 °C). Questionnaires were used to explore patient and healthcare worker attitudes towards different methods of temperature-taking. Results: 824 rectal body temperature readings were taken from 562 participants. The mean rectal temperature was 37.4 °C (IQR 37 °C to 37.7 °C), with a minimum reading of 35.2 °C and maximum of 41.0 °C. Tympanic membrane thermometry showed the highest sensitivity of fever detection using the Genius3 TM thermometer (sensitivity 70.8 %, 95 % CI 60.2%-79.9 %; specificity 97.2 %, 95 % CI 95.5-98.4 %); and Braun TM (sensitivity 51.5 %, 95 % CI 42.6%-62.0 %; specificity 98.8 %, 95 % CI 97.7-99.5). NCIT thermometry sensitivity was low (36.8 %-41.4 % for the two devices used). Axillary thermometry sensitivity was 40.6 %. Participants ranked NCIT as the most and rectal as the least preferred method. Questionnaires from 32 participating nurses showed agreeability to using NCIT, TM and axillary methods routinely, but less so for rectal thermometry. Conclusions: When combining the accuracy of different thermometry methods in detecting fever with user and patient acceptability, tympanic membrane thermometry appears most suitable but also has limitations.

Complicated Odontogenic Infections at 2 District Hospitals in Tonkolili District, Sierra Leone: Protocol for a Prospective Observational Cohort Study (DELAY).

BACKGROUND: Deficits in global oral health care are paramount, and complications of odontogenic infections constitute a considerable global health problem, particularly in low-income countries. A high mortality rate has been observed for patients who have been admitted with complicated odontogenic infections to our facilities in Tonkolili District, Sierra Leone, although exact data have not been published yet. Data regarding who in this region is at risk and why are lacking. OBJECTIVE: The Dental Abscess Study (DELAY) aims to prospectively investigate morbidity and mortality from complicated dental abscesses and to analyze patients' characteristics and microbial findings to examine predisposing factors for poor outcomes. In particular, the incidence and the clinical and microbial characteristics of complicated odontogenic infections, as well as the sociodemographic data and comorbidities of affected patients, will be studied to develop improved management algorithms based on circumstance-specific factors. METHODS: Patients who present with complicated dental infections requiring hospital admission in Masanga Hospital or Lion Heart Medical Centre will be consecutively selected for possible inclusion in the study (starting on September 4, 2021) over a study period of 1 year, and individual routine follow-ups will be conducted at least 3 months after discharge. The results of standardized questionnaires will be obtained, and clinical measurements as well as medical photos will be taken. Standard laboratory tests (eg, full blood count and HIV status tests) will be performed, and pus specimens will be examined. Local treatment guidelines will be adhered to, and data on medical and surgical treatment as well as data on outcomes will be collected. The study results will be reported according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Routine follow-ups will take place at 1 and 3 months postdischarge. RESULTS: The DELAY protocol was endorsed by the Masanga Medical Research Unit's Scientific Review Committee on June 16, 2021, and ethical approval was granted on July 5, 2021, by the Sierra Leone National Ethics Committee. The funding of the budgeted study costs was approved by Dental Health International Netherlands in August 2021. The projected start date of data collection was September 4, 2021, and the study period will most likely last for 1 year. As such, data collection is expected to be complete in November 2022. CONCLUSIONS: The aim of our prospective observational cohort study is to gain more knowledge about complicated odontogenic infections in Tonkolili District, Sierra Leone, to further improve treatment strategies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33677.

Case Report: Severe Dental Abscess Complications in Rural Sierra Leone.

Prevalence data on severe dental infections is scarce, particularly for low-income countries. Patients with dental abscess complications who presented from September 2020 until December 2020 in two hospitals in Tonkolili District, Sierra Leone, were included into this case series. We report on a total of 20 patients, median age 28 years, with severe complications of dental abscesses, with a mortality rate of 45%. This case series illustrates the severity of the dire consequences of the absence of access to basic dental and oral healthcare.

Community-based strategies to identify the unmet need for care of individuals with sexually transmitted infection-associated symptoms in rural South Africa.

OBJECTIVES: To determine the unmet need for care and barriers for consulting sexually transmitted infection (STI) services at six primary healthcare (PHC) facilities in rural South Africa. METHODS: Cross-sectional study using three community-based strategies to mobilise adult individuals with STI-associated symptoms to access care. Participants were mobilised through clinic posters and referral by community healthcare workers (CHWs) and traditional leaders after training. Men with male urethritis syndrome and women with vaginal discharge syndrome were mobilised to visit participating PHC facilities on two designated days when an expert team visited the facility. Questionnaires were completed and HIV rapid tests offered. The minimal unmet need for care of individuals with STI-associated symptoms was calculated by dividing the number of cases over the adult catchment population of each PHC facility. RESULTS: We successfully mobilised 177 symptomatic individuals: 134 (76%) women and 43 (24%) men. The estimated minimal unmet need for STI care was 1:364 (95% CI 1:350-1:380) individuals in this region; the rate was higher in village than township facilities, and among women. Mobilisation through clinic posters (57%) and by CHWs (23%) was most successful. Three-quarters of individuals (132/177) reported symptoms that had been present for >30 days; 49% (87/177) had symptoms >6 months. In addition, we identified 14 individuals with untreated HIV infection amounting to a 7% HIV testing yield. Lack of awareness of symptoms (34%), and disappointment in care due to persistent (23%) or recurrent (15%) symptoms after previous treatment, or disappointment with health services in general during previous visit(s) for any reason (10%) was the most common reasons for not consulting health care. CONCLUSIONS: We demonstrate a high unmet need for care of individuals with STI-associated symptoms in rural South Africa that requires urgent attention. A multidisciplinary approach that creates service demand through community awareness and information provision by healthcare workers combined with strengthening the quality of STI services is required to improve reproductive health and prevent complications of untreated STIs in this population.

OBJECTIFS: Déterminer les besoins non satisfaits en matière de soins et les obstacles à la consultation des services pour IST dans six établissements de soins de santé primaires (SSP) en milieu rural en Afrique du Sud. MÉTHODES: Etude transversale utilisant trois stratégies communautaires pour mobiliser les individus adultes présentant des symptômes associés aux IST afin qu'ils puissent accéder aux soins. Les participants ont été mobilisés à travers des affiches dans les cliniques et sur recommandation des agents de santé communautaires (ASC) et des chefs traditionnels après une formation. Les hommes atteints du syndrome d'urétrite masculin et les femmes atteintes du syndrome de pertes vaginales ont été mobilisés à visiter les établissements de SSP participants, au cours de deux jours choisis lorsqu'une équipe d'experts était présente dans l'établissement. Des questionnaires ont été remplis et des tests de dépistage rapides du VIH ont été proposés. Le besoin minimal non satisfait de soins pour les personnes présentant des symptômes associés aux IST a été calculé en divisant le nombre de cas par la population adulte de la zone de chaque établissement de SSP. RÉSULTATS: Nous avons réussi à mobiliser 177 personnes symptomatiques: 134 (76%) femmes et 43 (24%) hommes. Le besoin minimal non satisfait en matière de soins IST était de 1:364 (IC95%: 1:350 - 1:380) individus dans cette région; le taux était plus élevé dans les villages que dans les installations des bidonvilles et chez les femmes. La mobilisation par le biais d'affiches de cliniques (57%) et par les ASC (23%) a eu le plus de succès. Les trois quarts des personnes (132/177) ont signalé des symptômes présents depuis >30 jours; 49% (87/177) présentaient des symptômes > 6 mois. En outre, nous avons identifié 14 personnes présentant une infection par le VIH, non traitée, ce qui représente un rendement de dépistage du VIH de 7%. Le manque de prise de conscience des symptômes (34%) et la déception avec les soins en raison de symptômes persistants (23%) ou récurrents (15%) après un traitement précédent, ou la déception avec les services de santé en général lors de visites précédentes pour une raison quelconque (10 %) étaient les raisons les plus courantes de ne pas consulter les soins de santé. CONCLUSIONS: Dans les zones rurales d'Afrique du Sud, nous démontrons un besoin élevé de soins non satisfaits pour les personnes présentant des symptômes associés aux IST et nécessitant une attention urgente. Une approche multidisciplinaire qui crée une demande de services par le biais de la sensibilisation de la communauté et de la fourniture d'informations par les agents de santé, associée au renforcement de la qualité des services IST, est nécessaire pour améliorer la santé reproductive et prévenir les complications des IST non traitées dans cette population.

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.

Rectal Trichomonas vaginalis infection in South African men who have sex with men.

This study from South Africa highlights the importance of rectal Trichomonas vaginalis infection as a sexually transmitted infection among men who have sex with men (MSM). We report seven MSM presenting with rectal T. vaginalis infection. Two men presented with symptoms of proctitis; 5/7 had urethral coinfection with T. vaginalis. Rectal T. vaginalis infection should be considered in MSM in areas where genital infection is endemic.

Genital Chlamydia trachomatis and Neisseria gonorrhoeae infections among women in sub-Saharan Africa: A structured review.

Chlamydia trachomatis and Neisseria gonorrhoeae constitute major public health problems among women, but the burden of infection in sub-Saharan Africa is poorly documented. We conducted a structured review of the prevalence and incidence of genital, oral and anal C. trachomatis and N. gonorrhoeae infection in women in sub-Saharan Africa. We searched Medline, EMBASE and Web of Science over a 10-year period for studies on epidemiology of genital, oral and anal chlamydial infection and gonorrhoea in women in all countries of sub-Saharan Africa. We assessed geographic and demographic differences in prevalence and incidence of infection; weighted mean prevalence estimates were calculated with a random-effect model. A total of 102 study results were included, with data available for 24/49 of sub-Saharan countries. The weighted prevalence of chlamydial infection was lower among women in community-based studies (3.9%; 95% CI: 2.9-5.1%) than for women recruited at primary healthcare facilities (6.0%; 95% CI: 4.2-8.4%, p < 0.001); the same was observed for gonorrhoea (2.2%; 95% CI: 1.2-4.0% vs. 4.2%; 95% CI: 3.2-5.6%, p < 0.001). Prevalence of Chlamydia among sex workers was 5.5% (95% CI: 4.2-7.3%) and gonorrhoea 7.6% (95% CI: 5.4-11%). Seven studies reported on incidence which varied between 0.75-28 and 2.8-17 per 100 person-years-at-risk for chlamydial infection and gonorrhoea, respectively. Only two studies reported on anal infections and one on oral infection. This overview underscores the considerable incidence and prevalence of genital C. trachomatis and N. gonorrhoeae in women in different settings in sub-Saharan Africa. Better control strategies are warranted to reduce the burden of infection and to prevent long-term complications of these infections.

Prevalence of Trichomonas vaginalis infection and protozoan load in South African women: a cross-sectional study.

OBJECTIVES: Trichomonas vaginalis is thought to be the most common non-viral sexually transmitted infection worldwide. We investigated the prevalence, risk factors and protozoan load of T. vaginalis infection in South African women. METHODS: A cross-sectional study of 604 women was conducted at 25 primary healthcare facilities in rural South Africa (Mopani district). T. vaginalis DNA was detected in vaginal and rectal swabs. In univariate and multivariate analyses, the T. vaginalis infection was investigated in relation to demographic characteristics, medical history and behavioural factors. The T. vaginalis load was determined as the logarithm of DNA copies per microlitre sample solution. RESULTS: Collected vaginal and rectal swabs were tested for T. vaginalis DNA. Prevalence of vaginal T. vaginalis was 20% (95% CI 17.0% to 23.4%) and rectal 1.2% (95% CI 0.6% to 2.4%). Most women (66%) with a vaginal infection were asymptomatic. Factors associated with T. vaginalis infection were a relationship status of single (OR 2.4; 95% CI 1.5 to 4.0; p<0.001) and HIV positive infection (OR 1.6; 95% CI 1.0 to 2.6; p=0.041). Women with vaginal T. vaginalis infection were more likely to have concurrent Chlamydia trachomatis rectal infection than those without vaginal infection (12%vs3%; p<0.001; OR 4.1). A higher median T. vaginalis load was observed among women with observed vaginal discharge compared with those without vaginal discharge (p=0.025). CONCLUSIONS: Vaginal trichomoniasis is highly prevalent in rural South Africa, especially among single women and those with HIV infection, and often presents without symptoms.

Sexual behaviour of women in rural South Africa: a descriptive study.

BACKGROUND: Sexual behaviour is a core determinant of the HIV and sexually transmitted infection (STI) epidemics in women living in rural South Africa. Knowledge of sexual behaviour in these areas is limited, but constitutes essential information for a combination prevention approach of behavioural change and biomedical interventions. METHODS: This descriptive study was conducted in rural Mopani District, South Africa, as part of a larger study on STI. Women of reproductive age (18-49 years) who reported sexual activity were included regardless of the reason for visiting the facility. Questionnaires were administered to 570 women. We report sexual behaviour by age group, ethnic group and self-reported HIV status. RESULTS: Young women (<25 years) were more likely to visit bars, practice fellatio, have concurrent sexual partners and report a circumcised partner than older women (>34 years); there was no difference for condom use during last sex act (36 % overall). Sotho women were more likely to report concurrent sexual partners whereas Shangaan women reported more frequent intravaginal cleansing and vaginal scarring practice in our analysis. HIV-infected women were older, had a higher number of lifetime sexual partners, reported more frequent condom use during the last sex act and were more likely to have a known HIV-infected partner than women without HIV infection; hormonal contraceptive use, fellatio, and a circumcised partner were less often reported. CONCLUSIONS: This study provides insight into women's sexual behaviour in a rural South African region. There are important differences in sexual behaviour by age group and ethnicity and HIV status; these should be taken into account when designing tailor-made prevention packages.

Evaluation of Presto(plus) assay and LightMix kit Trichomonas vaginalis assay for detection of Trichomonas vaginalis in dry vaginal swabs.

This is an evaluation study of the Presto(plus) Assay for T. vaginalis by comparing to the TIB MOLBIOL LightMix Kit Trichomonas vaginalis Assay using 615 dry collected vaginal and rectal swabs. Discordant samples were analyzed by the Qiagen® Microbial DNA qPCR for TV Assay. Both assays showed comparable performances (McNemar p>0.05).

Evaluation of syndromic management guidelines for treatment of sexually transmitted infections in South African women.

OBJECTIVE: To evaluate the performance of three different guidelines for the management of vaginal discharge syndrome (VDS) for women living in a rural setting in South Africa. METHODS: We conducted a secondary analysis of data from a cross-sectional study in Mopani District, South Africa. The 2015 and 2008 guidelines of the South African Department of Health (DoH) and the most recent WHO guidelines were evaluated for adequate treatment of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Trichomonas vaginalis infection. RESULTS: Of the 489 women included in this analysis, 35% presented with VDS according to the DoH and 30% per WHO definition of VDS. Fifty-six per cent of the women with VDS would be treated adequately for these STI when using the 2015 DoH guideline, whereas 76% (P = 0.01) and 64% (P = 0.35) would receive adequate treatment with the 2008 DoH and WHO guidelines, respectively. Of the symptomatic women who tested negative for all four STI, STI treatment would have been indicated for 36% as per 2015 DoH guideline vs. 69% (P < 0.001) per 2008 DoH and 67% (P < 0.001) per WHO guidelines. CONCLUSION: A considerable proportion of symptomatic women infected with these common curable STI would receive adequate treatment when using a syndromic management approach, and significant differences exist between the three guidelines. Many symptomatic women without these STI receive broad-spectrum antibiotics, so new approaches are needed to improve syndromic STI control.

Microbiological Characteristics of Chlamydia trachomatis and Neisseria gonorrhoeae Infections in South African Women.

We analyzed data of 263 women with at least one genital or anorectal sexually transmitted infection from a cross-sectional study conducted in rural South Africa. We provide new insights concerning the concurrence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis infections as well as the characteristics of bacterial loads.

Comparison of GMT presto assay and Roche cobas® 4800 CT/NG assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in dry swabs.

Urogenital Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most prevalent bacterial STIs worldwide. Molecular tests are the standard for the detection of CT and NG, as these are difficult to culture. The recently introduced CE-IVD marked GMT Presto assay promises to be a valuable addition in CT and NG diagnostics. The advantage of the Presto assay is that it works on many PCR systems and the DNA can be isolated by any system.We compared the Presto assay to the widely used Roche cobas® 4800 CT/NG test for the detection of CT and NG in 612 vaginal and rectal dry collected swabs. Discrepant samples were tested by the TIB MOLBIOL Lightmix Kit 480 HT CT/NG assay. The alloyed gold standard was defined as two concurring Presto and cobas® 4800 results, or, with discrepant Presto and cobas® results, two concurring results of either test together with the Lightmix Kit 480 HT CT/NG assay. For the Presto assay,we observed 77 CT positive (13%) and 22 NG positive (3,6%) vaginal samples, and 41 CT positive (6,7%) and 11 NG positive (1,8%) rectal samples. For the cobas® 4800 assay,we observed 77 CT positive (13%) and 21NG positive (3,4%) vaginal samples, and 39 CT positive (6,4%) and 11 NG positive (1,8%) rectal samples. Ten CT samples were discrepant between Presto and cobas® 4800 CT/NG assays, while two NG samples were discrepant. CT sensitivity in both assays was 100% compared to the alloyed gold standard. The sensitivity was 100% for both vaginal and rectal dry swabs, underlining the suitability of these sample types for detection of CT and NG. The Presto assay is therefore valuable for molecular detection of CT and NG in dry vaginal and rectal swabs.

High-resolution multilocus sequence typing reveals novel urogenital Chlamydia trachomatis strains in women in Mopani district, South Africa.

OBJECTIVES: Recently, we reported a high prevalence (16%) of urogenital Chlamydia trachomatis infections among women in a rural setting in South Africa. Molecular epidemiological studies on C. trachomatis infections could provide insights into the characteristics of this epidemic, yet such data are not available. The objective of this study was therefore to assess the distribution of C. trachomatis strains among women from a South African rural community, the Mopani district, and to compare it with strains from Amsterdam, the Netherlands. METHODS: High-resolution multilocus sequence typing (hr-MLST) was used to study urogenital C. trachomatis infections in women visiting primary healthcare facilities across rural Mopani District in Limpopo Province, South Africa. Sequence types (STs) were compared with 100 strains from women visiting the sexually transmitted infection clinic in Amsterdam, the Netherlands. RESULTS: Full hr-MLST data were obtained for C. trachomatis infection in 43 women from Mopani district. Using the complete hr-MLST profile of all 43 women from Mopani district, 26 STs could be identified, of which 18 (69%) were novel to the hr-MLST database. The remaining STs clustered together with strains from Amsterdam. CONCLUSIONS: Hr-MLST data revealed a diverse molecular epidemiology with novel STs and a specific cluster for the Mopani district. Also C. trachomatis types that occur worldwide were detected.

Prevalence and macrolide resistance of Mycoplasma genitalium in South African women.

Remnant specimens from 601 women obtained in a cross-sectional study from rural South Africa were tested for Mycoplasma genitalium. Overall, 10.8% of women were infected with M. genitalium either in the vagina or in the rectum. Macrolide resistance, although of low prevalence, in M. genitalium is described for the first time in Sub-Saharan Africa.

Cross-sectional study of genital, rectal, and pharyngeal Chlamydia and gonorrhea in women in rural South Africa.

BACKGROUND: Epidemiological data of genital chlamydia and gonorrhea, required to inform design and implementation of control programs, are limited for rural Africa. There are no data on the prevalence of rectal or pharyngeal infections among African women. METHODS: A cross-sectional study of 604 adult women visiting 25 primary health care facilities in rural South Africa was conducted. Vaginal, anorectal, and oropharyngeal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae. RESULTS: Prevalence of genital chlamydia was 16% and that of gonorrhea was 10%; rectal chlamydial infection was diagnosed in 7.1% and gonococcal in 2.5% of women. One woman had pharyngeal chlamydia. Most women with genital chlamydia (61%) and gonorrhea (57%) were asymptomatic. Independent risk factors for genital chlamydia were younger age (adjusted odds ratio [aOR], 0.96 per year; 95% confidence interval [CI], 0.93-0.98), hormonal contraceptive use (aOR, 2.2; 95% CI, 1.3-3.7), pregnancy (aOR, 2.4; 95% CI, 1.3-4.4), and intravaginal cleansing (aOR, 1.7; 95% CI, 1.04-2.8). Intravaginal cleansing was associated with genital gonorrhea (aOR, 1.9; 95% CI, 1.1-3.3). CONCLUSIONS: Genital and rectal, but not pharyngeal, chlamydia and gonorrhea are highly prevalent and frequently asymptomatic in women in rural South Africa. Young women attending health care facilities for antenatal care or family planning should be prioritized in control efforts.