Nimi D. Briggs

Reproductive tract infections and abortion among adolescent girls in rural Nigeria

Few studies from developing countries have investigated reproductive tract infections or other indicators of sexual health among unmarried adolescent girls in rural areas. We have obtained baseline demographic, clinical, and microbiological data on reproductive tract infections and induced abortion in girls in a rural area of southeast Nigeria, in order to assess the need for health care for adolescents. 868 females attended for interview and examination: 458 aged 20 and above and 410 aged 12-19, the latter representing 93.4%of the adolescent population. 43.6% of those < 17 and 80.1% aged 17-19 years were sexually active and at least 24.1% had undergone an induced abortion; only 5.3% had ever used a modern contraceptive. Vaginal discharge was reported by 82.4%, though few sought treatment. 94.1% of sexually active adolescents and 97.6% of sexually active women 20 years old or over were gynaecologically examined and screened for reproductive tract infections. Of those aged less than 17, 19.8% had symptomatic candida and 11.1% trichomonas infections. Among those aged 17-19 years, chlamydia was detected in 10.5%, and symptomatic candidosis in 25.6%; this was the group most likely to have any infection (43.8%). 42.1% of sexually active adolescents had experienced either an abortion or a sexually transmitted disease. Syphilis was the only infection for which the incidence clearly increased with age. Health-care services for adolescents in this community are needed and should include sex education, contraceptive provision (especially barrier methods), and access to treatment for reproductive tract infections. Investments in health for this age group will have an effect on subsequent reproductive health.

A birthweight nomogram for Africa, as a malaria-control indicator.

Low birthweight (LBW) attributable to malaria in pregnancy is a significant risk for millions in Africa. Infants born to primigravidae are at greatest risk and it is proposed that this excess risk can be used as a simple indicator of malaria transmission and exposure in pregnant women in Africa. Birthweight data from different regions in 11 malarious and three non-malarious African countries were investigated. A regression analysis of the excess risk of low birthweight in first pregnancies, compared with later ones, was completed and interpreted in relation to malaria-transmission intensities. The aim was to develop a simple birthweight chart (nomogram) as a tool for monitoring malaria transmission or malaria control in pregnancy. Low-birthweight risk in first pregnancies was associated with levels of malaria-transmission intensity amongst different African countries. The nomogram distinguished longitudinal changes in malaria exposure, related to season and changes in antimalarial-drug policy. Malaria is one of the most important causes of LBW in first pregnancies in Africa. As birthweight and parity are routinely recorded in many delivery centres across Africa, the nomogram provides a simple, available and inexpensive tool for monitoring malaria transmission and exposure in pregnant women and the effectiveness of malaria-control activities for this high-risk group.

How do they grow? A study of south‐eastern Nigerian adolescent girls

This study assessed the nutritional status of Nigerian adolescent girls living in two areas of south‐eastern Nigeria. A cross sectional survey was undertaken in a rural village in Ogoniland, and five secondary schools in Port Harcourt, south‐eastern Nigeria. All (386) menarcheal girls aged 14–19 y living in the rural village, and a stratified cluster sample (845) of menarcheal girls aged 14–19 in the five urban schools were investigated. Mean heights and weights of rural girls were around ‐1 Z‐score below the British reference median. 10. 4% of rural and 4. 7% of urban girls were stunted (≤2nd centile, British 1990 reference values). After calculating mean body mass index‐for‐age, various cut‐off points for low body mass index were tested. At a cut‐off of ≤9th centile, 15. 6% of rural and 8. 0% of urban girls would be classified as thin. Girls with a haemoglobin < 10. 0 g/dl were significantly more likely to have a low body mass index than those with haemoglobin values a 10. 0 g/dl. More studies are needed to refine the definition and interpretation of low body mass index in adolescents.

Protecting adolescent girls against tetanus.

An estimated 8 million infants and 2 million children and adults may die from tetanus during the 1990s despite efforts by the World Health Organization (WHO) to eliminate it by 1995. Vaccination to prevent postabortal and maternal tetanus has been neglected. The immunization of preschool children and of pregnant women has omitted adolescent girls, who are therefore at risk. Data collected on 1101 cases of maternal tetanus in developing countries between 1958 and 1990 indicated that 27% were attributed to postabortal and 67% to postpartum sepsis. In southeastern Nigeria where abortion rates are high, a high proportion of girls were also seronegative for tetanus antibodies. Many unvaccinated pregnant women cite the lack of money for obtaining vaccination when obtaining prenatal services. The WHO is promoting vaccination of women of reproductive age by screening their tetanus toxoid status, but adolescents are poorly covered because they are not regular attenders. Expressly targeting girls would be feasible, as it would require 5 injections providing protection for life. Even 4 injections may protect for 20 years if delivered at the end of primary school. Thus a school health service delivering tetanus vaccination may improve the vaccination of adolescent girls. This could be combined with distribution of vitamin A and antihelminthics whereby the response to the vaccine could be improved significantly. In addition, it has also been suggested that a late dose of an acellular pertussis vaccine and a second dose of measles vaccine given in adolescence would reduce the pool of susceptible girls, just as girls have been targeted for rubella vaccination. Implementation of tetanus vaccination would require local schools vaccination days, immunization cards, high potency primary vaccination, and tetanus boosters free of charge with a system to monitor antibody responses.

Pattern of primary gynecological malignancies as seen in a tertiary hospital situated in the Rivers State of Nigeria

Between January 1984 and December 1987, out of a total gynecological admission of 1706 patients at the University of Port Harcourt Teaching Hospital, 72 had primary cancers of the female genital organs (excluding malignant trophoblastic diseases). Of those, 53 had cervical, 10 ovarian, 6 endometrial and 3, vulval cancers. There were no cases of vaginal or fallopian tubal cancers. Ovarian cancer was the commonest gynecological cancer before the age of 40 while cervical cancer was commonest after 40. Germ cell tumors of the ovary were frequent. Patients with endometrial cancer reported early to hospital for treatment but those with other types of cancers generally reported late. On account of late arrival to hospital, inadequate medical facilities and a high defaulting rate, the outcome of treatment was very poor. Since evidence exists to the effect that cervical cancer may be sexually transmitted, a plea is made for the promotion of the widespread use of condoms in order to reduce the prevalence of invasive carcinoma of the cervix in developing countries.

A flowchart for managing sexually transmitted infections among Nigerian adolescent females

OBJECTIVE To devise a flowchart suitable for assessing risk of trichomoniasis, chlamydia and gonorrhoea in an adolescent population, not all of whom will be sexually experienced or currently in a relationship. METHODS The data used to derive the flowchart were generated from cross-sectional microbiological surveys of girls aged 14-19 years in Port Harcourt, Nigeria. The flowchart screened on the basis of: (i) sexual experience; (ii) recent sexual activity; (iii) a positive urine leukocyte esterase (LE) test; and (iv) among LE negatives, a history of malodorous/pruritic discharge. FINDINGS Using this flowchart, we found that 26.2% of all adolescents screened would receive treatment for cervicitis and vaginitis. Chlamydial, gonococcal, and trichomonal infections were correctly diagnosed in 37.5%, 66.7%, and 50% of the cases, respectively. CONCLUSION Although the flowchart is more suitable for an adolescent population than the vaginal discharge algorithm used in syndromic management protocols, it still lacks precision and needs adapting to local settings.

Tetanus antibody levels among adolescent girls in developing countries.

Neonatal and maternal tetanus infections remain an important cause of death in many countries. Few studies have reported tetanus toxoid antibody levels of adolescent girls. As part of the Expanded Programme on Immunization most girls receive up to 3 injections in early childhood, and many subsequently do not receive booster vaccinations until pregnant. We determined (by ELISA) tetanus antibody seropositivity in adolescent girls from Malawi (in 1996), Nigeria (in 1993) and Pakistan (in 1996), and response to tetanus vaccination in adolescent girls from Pakistan. Geometric mean titres (GMT, IU/mL) were 0.94 in 117 Malawian, 0.32 in 154 Nigerian and 1.08 in 162 Pakistani girls. In Nigeria, 54.7% of adolescents were seronegative, of whom 26.8% had a history of unsafe abortion. In Malawi and Pakistan all girls were seropositive and in Pakistan, following a booster vaccination, titres increased 3-fold, with a lower response in older girls. The results indicated that adequate childhood immunization is likely to provide protective levels through adolescence. Booster vaccination in late childhood/early adolescence should protect the majority of women throughout their reproductive lives. This practice would reduce the risks of girls exposed to infection through unsafe abortions, and may be the best option for countries seeking to improve their vaccination schedule, especially where tetanus vaccine coverage in pregnant women is unacceptably low.

Brenner tumor as encountered in a southern Nigerian Hospital

Brenner tumor is an uncommon ovarian tumor whose etiology and hormonal activity have aroused controversies. The salient features of three cases of this tumor seen at the University of Port Harcourt Teaching Hospital, Nigeria, between March 1981 and March 1987 are discussed.