Reviewer's report
Title:Intravaginal practices and Lactobacilli colonization among women and risk
of sexually transmitted infections in Accra, Ghana
Version:1Date:21 January 2015
Reviewer: joelle Brown
Reviewer's report:
This study aimed to investigate intravaginal practices (IVP) among Ghanaian
women in Accra and assessed the possible effects on vaginal Lactobacilli
colonization and the potential for STIs acquisition. The authors conducted a
cross-sectional study among 141 women attending a clinic in Accra, and
administered a questionnaire and collected a vaginal sample. Unfortunately, the
authors do not provide sufficient information about their methods to be able to
truly evaluate the quality of the study, nor do they appear to carry out any
analyses to achieve these aims. Worryingly, in the discussion the authors claim
that IVP are causing changes in lactobacilli, and resulting in more vaginal
infections when they have not provided data to support this conclusion.
Below see the following suggested major compulsory revisions:
1. Lines 104-107: please state your research questions and hypotheses
2. Lines 115-116 and 122-123: What other inclusion/exclusion criteria were
used? Were women allowed to use antibiotics? If not, how long since their last
use of antibiotics?
3. Line 119: please give more information on the questionnaire. What questions
were asked? Was this a paper-based self-administered questionnaire? How long
did it take participants to complete? Which of the variables came from the
questionnaire and which came from the physical exam? Was data collected on
other factors that influence lactobacilli, e.g. stage of menstrual cycle?
unprotected vaginal intercourse?
4. Line 118: How many women were screened to enroll 141?
5. Line 118-123: Was any clinical evaluation of the patient done?
6. Line 118-123: Were any diagnostic tests conducted to test for bacterial
vaginosis, syphilis, T. vaginalis, candidiasis, gonorrhea, chlamydia? Which ones
and what is the sensitivity and specificity of each test? If all of the vaginal
infection data are self-reported only, I have serious concerns about
misclassification of infection status, and the appropriateness of using these data
to make associations between lactobacilli and STIs.
7. Line 128: Unclear what authors mean by ‘as evidence for indulging in
intravaginal practices’.
8. Lines 125-146: Were the lactobacilli samples evaluated by wet mount only?
Please specify which bacterial pathogens were evaluated by culture and
biochemical assays.
9. Lines 148-152: Why were no analyses done or presented to evaluate the
association between intravaginal practices and low levels of lactobacilli? And
between low levels of lactobacilli and presence of other sexually transmitted
infections?
10. Lines 165-167 and 184 – 190: Are these data on prevalence of vaginal
infections from the questionnaire? Are any of the data on vaginal infections
supported by the samples collected, or are they all self-reported? What is the
time-frame? If these are in fact all from self-reported data, clarify that these are
self-reported infections, and the time frame when these infections occurred.
11. Line 186-187: How was ‘protective lactobacilli colonization’ defined?
12. Lines 197- 198: What is meant by ‘confirmed cases of vaginal infections’?
How were these infections ‘confirmed’? Please describe in methods.
13. Lines 197- 199. This conclusion does not follow from the analysis. Please
revise or remove.
“ The low level of lactobacilli detection and the high number of confirmed cases
of vaginal infections with STIs (Fig. 1) among the study participants thus
implicates intravaginal practices as indeed the harmful cause since women
receiving antibiotics treatment were excluded in the study.”
14. What are the limitations of the current study?
15. Tables 1 and 2 should be included in the main manuscript, not as
‘supplemental’ materials. Additional comments on Table 1 and Table 2:
- Include 95% confidence intervals for the percentages.
- Include the number of women who self-reported vaginal infections.
- In table 2, include results of the microscopy, culture, and biochemical assay
testing.
16. Figure 1.
- It is not clear if these data on vaginal infections are from self-report, and which
time period these cover (e.g. ever infected?). If these are self-reported only, I
have serious concerns about misclassification of infection status, and the
appropriateness of using these data to make associations between lactobacilli
and STIs. This reduces the usefulness of this particular analysis, and would
suggest no need for Figure 1.
- Minor Essential Revisions
Lines 98-100 and 195-197: Include reference to the large international systematic
review on intravaginal practices and risk for BV and HIV. Low et al Plos Med.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests