Literature review > Issue_2 > Review Wang et al. 

The rapid increase in STD's in China during the past two decades and the looming HIV epidemic demands new effective intervention strategies. Standardized, evidence-based algorithms are now widely used to create a platform for national STD management programs. Country validation is required to create confidence in the algorithm, to provide demonstration and training sites, and to ensure it fits. Wang and seven colleagues from four Chinese institutions, the London School of Hygiene & Tropical Medicine, and the National Center for Microbiology at Health, Canada have evaluated an algorithm for genital ulcer disease (GUD) in STD clinics in Shanghai and Chengdu.

Two hundred twenty-seven consecutive patients (89% men) meeting the case definition of GUD were enrolled, a clinical etiological diagnosis was made using the algorithm, specimens were obtained, and treatment and the 4Cs prescribed. Most patients were 'sexual risk takers'. Fifty-five % had had a new partner within the past three months and 77% had never used a condom. Only 56% returned for followup. The laboratory gold standard for syphilis was a combination of serology, darkfield, and the Multiplex PCR; for genital herpes, Multiplex PCR.

What can we learn from this study? First, that the 'clinical etiologic diagnosis' of GUD by algorithm is too frequently in error, with 12 of 106 patients with syphilis mistakenly diagnosed as genital herpes. Second, 34% of GUD patients had no laboratory diagnosis. Third, syphilis and HSV coexisted in 13% of GUD. Finally, chancroid apparently is not occurring in these two cities.

What further information would have been useful to this reader?

What physician training was carried out to standardize the use of the algorithm? How were patients previously being treated in these clinics and what changes occurred as a result of the introduction of the algorithm? Were the clinical syndrome etiologic errors widespread or made by one or two physicians? Were there any clinical patterns among the 34% of ulcers with no diagnosis to categorize them further and perhaps critique the lab routines?

This study, in retrospect, leaves most questions unanswered. Presumably, all patients with 'genital herpes' do not require treatment for syphilis. Are there any clues as to which ones do? Is it acceptable to have negative syphilis serology on 24% of patients with GUD who have positive darkfields and/or Multiplex PCR for T.pallidum? Are there pathogens that cause GUD other than the ones we know about?

As the authors note, further studies are required before this syndromic algorithm for GUD is launched throughout China. Hopefully, these studies are occurring with some urgency

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