Emilia H. Koumans

The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health

Objectives: Bacterial vaginosis (BV), a disturbance of vaginal microflora, is a common cause of vaginal symptoms and is associated with an increased risk of acquisition of sexually transmitted infections, HIV, and with adverse pregnancy outcomes. We determined prevalence and associations with BV among a representative sample of women of reproductive age in the United States. Study Design: Women aged 14–49 years participating in the National Health and Nutrition Examination Survey 2001–2004 were asked to submit a self-collected vaginal swab for Gram staining. BV, determined using Nugent’s score, was defined as a score of 7–10. Results: The prevalence of BV was 29.2% (95% confidence interval 27.2%–31.3%) corresponding to 21 million women with BV; only 15.7% of the women with BV reported vaginal symptoms. Prevalence was 51.4% among non-Hispanic blacks, 31.9% among Mexican Americans, and 23.2% among non-Hispanic whites (P <0.01 for each comparison). Although BV was also associated with poverty (P <0.01), smoking (P <0.05), increasing body mass index (&khgr;2P <0.0001 for trend), and having had a female sex partner (P <0.005), in the multivariate model, BV only remained positively associated with race/ethnicity, increasing lifetime sex partners (&khgr;2P <0.001 for trend), increasing douching frequency (&khgr;2P for trend <0.001), low educational attainment (P <0.01), and inversely associated with current use of oral contraceptive pills (P <0.005). Conclusion: BV is a common condition; 84% of women with BV did not report symptoms. Because BV increases the risk of acquiring sexually transmitted infections, BV could contribute to racial disparities in these infections.

The Prevalence of Trichomonas vaginalis Infection among Reproductive-Age Women in the United States, 2001–2004

BACKGROUND Trichomonas vaginalis infection is a common sexually transmitted protozoal infection and is associated with several adverse health outcomes, such as preterm birth, delivery of a low-birth weight infant, and facilitation of sexual transmission of human immunodeficiency virus. The annual incidence in the United States has been estimated to be 3-5 million cases. However, there are no data on the prevalence of trichomoniasis among all reproductive-age women. We estimated the prevalence of T. vaginalis infection from a nationally representative sample of women in the United States. METHODS Women aged 14-49 years who participated in the National Health and Examination Survey cycles for 2001-2004 provided self-collected vaginal swab specimens. The vaginal fluids extracted from these swabs were evaluated for the presence of T. vaginalis using polymerase chain reaction. RESULTS Overall, 3754 (81%) of 4646 women provided swab specimens. The prevalence of T. vaginalis infection was 3.1% (95% confidence interval [CI], 2.3%-4.3%); for non-Hispanic white women, it was 1.3% (95% CI, 0.7%-2.3%); for Mexican American women, it was 1.8% (95% CI, 0.9%-3.7%); and for non-Hispanic black women, it was 13.3% (95% CI, 10.0%-17.7%). Factors that remained associated with increased likelihood of T. vaginalis infection in multivariable analyses included non-Hispanic black race/ethnicity, being born in the United States, a greater number of lifetime sex partners, increasing age, lower educational level, poverty, and douching. CONCLUSIONS The prevalence of T. vaginalis infection among women in the United States was 3.1%. A significant racial disparity exists; the prevalence among non-Hispanic black women was 10.3 times higher than that among non-Hispanic white and Mexican American women. Optimal prevention and control strategies for T. vaginalis infection should be explored as a means of closing the racial disparity gaps and decreasing adverse health outcomes due to T. vaginalis infection.

Characteristics of persons with syphilis in areas of persisting syphilis in the United States: sustained transmission associated with concurrent partnerships.

Background and Goal In areas with persistent syphilis, to characterize persons at higher risk for transmitting syphilis. Study Design Cohort study. Structured interviews of persons with early syphilis from four research centers were linked to outcomes of partner tracing. Results Of 743 persons with syphilis, 229 (31%) reported two or more partners in the previous month, and 57 (8%) received money or drugs for sex in the previous three months. Persons with at least one partner at an earlier stage of syphilis than themselves were defined as transmitters; 63 (8.5%) of persons with early syphilis met this definition. Having concurrent partners (two or more in one week in the last month) was independently associated with being a transmitter. Conclusion Sexual network/behavioral characteristics of syphilis patients and their partners, such as concurrency, can help identify persons at higher risk for transmitting syphilis who should receive emphasis in disease prevention activities.

Indications for Therapy and Treatment Recommendations for Bacterial Vaginosis in Nonpregnant and Pregnant Women: A Synthesis of Data

Accumulating evidence has associated bacterial vaginosis (BV) with serious medical complications such as premature delivery. The present article synthesizes available data on the treatment of nonpregnant and pregnant women with BV to prevent preterm delivery. A literature search identified articles published since 1976 that evaluated treatment of BV. An intention-to-treat sensitivity analysis was performed, to better compare studies. Studies that evaluated therapy efficacy varied with regard to diagnostic criteria, patient characteristics, clinicians, and laboratories. Therapies varied in efficacy for cure 4 or more weeks after therapy, from 48% to 85%. Intervention studies to reduce BV-related adverse outcomes of pregnancy differed in populations studied, medication used, type of therapy (oral or intravaginal), and timing of treatment. The benefit of treating women at high risk with oral metronidazole has been shown in several studies; however, the effect of treating women without a history of premature delivery is unclear. The use of intravaginal clindamycin therapy, especially during the latter half of the second trimester and thereafter, appears to increase infections during the neonatal period.

Preventing adverse sequelae of bacterial vaginosis: a public health program and research agenda.

Background The cause of bacterial vaginosis remains poorly understood. Recent evidence strengthens the association between bacterial vaginosis and serious medical complications. Goal To review the evidence linking bacterial vaginosis with adverse pregnancy outcomes, complications after gynecologic procedures, and HIV infection, and to identify prevention strategies. Methods In March 1999, the Centers for Disease Control and Prevention organized a conference to accomplish this goal. Results Better understanding is needed concerning the etiology, epidemiology, and natural history of bacterial vaginosis. More efficacious treatment of bacterial vaginosis and strategies to reduce maternal complications associated with bacterial vaginosis, such as premature rupture of the fetal membranes, chorioamnionitis, premature labor and delivery, postdelivery endometritis, and postpartum infant complications should be developed. Recent evidence shows that screening and treatment of bacterial vaginosis before abortion reduces postabortion pelvic inflammatory disease, and that anaerobic coverage during hysterectomy reduces postoperative complications. Better understanding concerning the relation of bacterial vaginosis to acquisition of sexually transmitted diseases and HIV infection are needed as well as possible prevention strategies. Conclusions A national prevention effort should be guided by the results of research that addresses current knowledge gaps.

Trichomonas vaginalis prevalence, incidence, risk factors and antibiotic-resistance in an adolescent population.

Objective: To determine the prevalence and incidence of trichomoniasis, risk factors for infection, and the prevalence of metronidazole- and tinidazole-resistant Trichomonas vaginalis (T. vaginalis) in female adolescents. Methods: Nonpregnant, HIV-seronegative, sexually active females (13–19 years) visiting an inner city public primary care clinic were tested for T. vaginalis by wet mount and culture, and interviewed about risk-taking behavior every 6 months. Infected patients were treated with a 2 g oral dose of metronidazole. Isolates from positive T. vaginalis cultures were tested for in vitro resistance to metronidazole and tinidazole. Results: Among 467 study participants, 67 (14.4%; 95% confidence interval, 11.3–17.5) were diagnosed with trichomoniasis at first T. vaginalis culture. Significant risk factors for T. vaginalis infection were having an older sex partner and concurrent Neisseria gonorrhoeae infection. The incidence was 22.1 cases per 100 person-years. Among 42 participants who had a prevalent infection and returned for follow-up, 13 (31.0%) had at least 1 more episode of trichomoniasis. Resistance testing was completed for 78 isolates: 37 at first visit and 41 during follow-up. One (2.7%; 95% confidence interval, 0.07–14.2) of the 37 first-visit isolates was moderately resistant to metronidazole (minimal lethal concentration = 200 &mgr;g/mL). Of the 41 follow-up visit isolates, 1 was moderately resistant to metronidazole and 2 had borderline resistance (minimal lethal concentration = 50 &mgr;g/mL). The prevalence of tinidazole resistance was 0% (0.0%–9.5%). Conclusion: The study population had high prevalence and incidence of trichomoniasis. The prevalence of antibiotic-resistant T. vaginalis among female adolescents was low.

Comparison of Methods for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae Using Commercially Available Nucleic Acid Amplification Tests and a Liquid Pap Smear Medium

ABSTRACT Annual screening for Chlamydia trachomatis infection is currently recommended for sexually active women 15 to 25 years old and for women older than 25 if they have a new or multiple sex partners and have not used condoms during the previous 3 months. Annual screening for cervical abnormalities using the Pap smear has achieved a substantial reduction in morbidity and mortality from cervical cancer. Screening for Neisseria gonorrhoeae infection has likely contributed significantly to the reduction in the rates of gonococcal infection. The introduction of liquid Pap smear methods using exfoliated cervical cells presents an opportunity to screen for these three conditions using one specimen. We evaluated the preservation of C. trachomatis and Neisseria gonorrhoeae DNAs from ThinPrep liquid media (PreservCyt; Cytyc Corp., Boxborough, Mass.); tested the feasibility of using a clinical specimen of this medium for the detection of cytologic abnormalities, C. trachomatis, and N. gonorrhoeae; evaluated the agreement between ligase chain reaction (LCR) performed on PreservCyt and LCR performed on a cervical specimen; and compared the performance of LCR performed on PreservCyt to those of LCR performed on a cervical specimen, culture, PCR performed on a cervical specimen, on urine, and on a vaginal specimen (a multiple-site infection status standard), and transcription-mediated amplification (for C. trachomatis only) from 255 sexually active adolescent women. The agreement between LCR performed on PreservCyt and LCR from a cervical swab in LCx transport medium was high (for C. trachomatis, agreement = 0.97 and kappa = 0.92; for N. gonorrhoeae, agreement = 0.99 and kappa = 0.96). Test performances were similar for LCR-urine, LCR-cervix, and LCR-ThinPrep, with sensitivities from 93 to 99% for C. trachomatis and 81 to 83% for N. gonorrhoeae and specificities from 95.5 to 99% for C. trachomatis and 99.1 to 99.6% for N. gonorrhoeae using a PCR-based multiple-site infection status standard. This is the first study to examine the agreement between liquid cytologic media and multiple nucleic acid amplification tests for the detection of C. trachomatis and N. gonorrhoeae from patient samples. Cytologic fluid shows promise for simultaneous screening for cytologic abnormalities and sexually transmitted infections.

Investigation of Metronidazole Use during Pregnancy and Adverse Birth Outcomes

ABSTRACT To assess whether treatment with metronidazole during pregnancy is associated with preterm birth, low birth weight, or major congenital anomalies, we conducted chart reviews and an analysis of electronic data from a cohort of women delivering at an urban New York State hospital. Of 2,829 singleton/mother pairs, 922 (32.6%) mothers were treated with metronidazole for clinical indications, 348 (12.3%) during the first trimester of pregnancy and 553 (19.5%) in the second or third trimester. There were 333 (11.8%) preterm births, 262 (9.3%) infants of low birth weight, and 52 infants (1.8%) with congenital anomalies. In multivariable analysis, no association was found between metronidazole treatment and preterm birth (odds ratio [OR], 1.02 [95% confidence interval [CI], 0.80 to 1.32]), low birth weight (OR, 1.05 [95% CI, 0.77 to 1.43]), or treatment in the first trimester and congenital anomalies (OR, 0.86 [0.30 to 2.45]). We found no association between metronidazole treatment during the first or later trimesters of pregnancy and preterm birth, low birth weight, or congenital anomalies.

Effects of intimate partner violence on pregnancy trauma and placental abruption.

AIMS Intimate partner violence (IPV) during pregnancy increases womens risk of pregnancy complications and adverse birth outcomes. The goal of this study was to examine the association between IPV and prenatal trauma and placental abruption during pregnancy. METHODS Prenatal and hospital obstetrical charts were reviewed for 2873 women who gave birth between January 2000 and March 2002 in a Northeastern city. We examined associations among sociodemographic characteristics, health-related variables, IPV, and pregnancy trauma and placental abruption using univariate and multivariate logistic regression. RESULTS Of the 2873 women in the analyses, 105 (3.7%) reported IPV during prenatal care. After controlling for sociodemographic variables; tobacco, alcohol, and drug use; preeclampsia; and gestational diabetes during pregnancy, women who reported IPV also had higher odds of pregnancy trauma and placental abruption (adjusted odds ratio [OR] 32.08, 95% confidence interval [CI] 14.33-71.80, p < 0.01, and OR 5.17, 95% CI 1.37-19.51, p < 0.05, respectively). CONCLUSIONS This study found that IPV is a significant and independent risk factor for pregnancy trauma and placental abruption after controlling for factors typically associated with these outcomes. This study has implications for partner violence screening and intervention policies among pregnant women and highlights the importance of making distinctions about the type of IPV that women experience.

Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014

Teen childbearing can have negative health, economic, and social consequences for mothers and their children (1) and costs the United States approximately