MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom.
MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom.
PLoS Med. 2024 May 20;21(5):e1004385. doi: 10.1371/journal.pmed.1004385. eCollection 2024 May.
Syndromic management is widely used to treat symptomatic sexually transmitted infections in settings without aetiologic diagnostics. However, underlying aetiologies and consequent treatment suitability are uncertain without regular assessment. This systematic review estimated the distribution, trends, and determinants of aetiologies for vaginal discharge, urethral discharge, and genital ulcer in sub-Saharan Africa (SSA).
We searched Embase, MEDLINE, Global Health, Web of Science, and grey literature from inception until December 20, 2023, for observational studies reporting aetiologic diagnoses among symptomatic populations in SSA. We adjusted observations for diagnostic test performance, used generalised linear mixed-effects meta-regressions to generate estimates, and critically appraised studies using an adapted Joanna Briggs Institute checklist. Of 4,418 identified records, 206 reports were included from 190 studies in 32 countries conducted between 1969 and 2022. In 2015, estimated primary aetiologies for vaginal discharge were candidiasis (69.4% [95% confidence interval (CI): 44.3% to 86.6%], n = 50), bacterial vaginosis (50.0% [95% CI: 32.3% to 67.8%], n = 39), chlamydia (16.2% [95% CI: 8.6% to 28.5%], n = 50), and trichomoniasis (12.9% [95% CI: 7.7% to 20.7%], n = 80); for urethral discharge were gonorrhoea (77.1% [95% CI: 68.1% to 84.1%], n = 68) and chlamydia (21.9% [95% CI: 15.4% to 30.3%], n = 48); and for genital ulcer were herpes simplex virus type 2 (HSV-2) (48.3% [95% CI: 32.9% to 64.1%], n = 47) and syphilis (9.3% [95% CI: 6.4% to 13.4%], n = 117). Temporal variation was substantial, particularly for genital ulcer where HSV-2 replaced chancroid as the primary cause. Aetiologic distributions for each symptom were largely the same across regions and population strata, despite HIV status and age being significantly associated with several infection diagnoses. Limitations of the review include the absence of studies in 16 of 48 SSA countries, substantial heterogeneity in study observations, and impeded assessment of this variability due to incomplete or inconsistent reporting across studies.
In our study, syndrome aetiologies in SSA aligned with World Health Organization guidelines without strong evidence of geographic or demographic variation, supporting broad guideline applicability. Temporal changes underscore the importance of regular aetiologic re-assessment for effective syndromic management.
CRD42022348045.
在没有病因诊断的情况下，症状性性传播感染的综合管理被广泛用于治疗有症状的性传播感染。然而，如果不进行定期评估，就无法确定潜在病因和相应的治疗适宜性。本系统评价估计了撒哈拉以南非洲（SSA）阴道分泌物、尿道分泌物和生殖器溃疡的病因分布、趋势和决定因素。
我们从 Embase、MEDLINE、全球健康、Web of Science 和灰色文献中检索了 1969 年至 2022 年期间在 SSA 有症状人群中报告病因诊断的观察性研究，检索时间截至 2023 年 12 月 20 日。我们调整了观察结果以反映诊断试验的性能，使用广义线性混合效应荟萃回归生成估计值，并使用经过改编的 Joanna Briggs 研究所检查表对研究进行批判性评估。在 4418 条确定的记录中，我们纳入了来自 32 个国家的 190 项研究的 206 份报告，这些研究于 1969 年至 2022 年期间进行。在 2015 年，阴道分泌物的主要病因估计为念珠菌病（69.4% [95%置信区间（CI）：44.3%至 86.6%]，n=50）、细菌性阴道病（50.0% [95% CI：32.3%至 67.8%]，n=39）、衣原体（16.2% [95% CI：8.6%至 28.5%]，n=50）和滴虫病（12.9% [95% CI：7.7%至 20.7%]，n=80）；尿道分泌物的主要病因是淋病（77.1% [95% CI：68.1%至 84.1%]，n=68）和衣原体（21.9% [95% CI：15.4%至 30.3%]，n=48）；生殖器溃疡的主要病因是单纯疱疹病毒 2 型（HSV-2）（48.3% [95% CI：32.9%至 64.1%]，n=47）和梅毒（9.3% [95% CI：6.4%至 13.4%]，n=117）。时间变化很大，尤其是生殖器溃疡，HSV-2 取代了软性下疳，成为主要病因。尽管 HIV 状况和年龄与几种感染诊断显著相关，但每种症状的病因分布在各区域和人群中基本相同。本综述的局限性包括在 SSA 的 16 个国家中没有研究、研究观察结果存在很大的异质性以及由于研究报告不完整或不一致而无法评估这种变异性。
在我们的研究中，SSA 的综合征病因与世界卫生组织指南一致，没有明显的地理或人口差异证据，支持广泛的指南适用性。时间变化强调了定期进行病因重新评估以实现有效的综合管理的重要性。
PROSPERO 注册号：CRD42022348045。
