1. Behavioral and Demographic Risk Factors for Bacterial Vaginosis among Wyoming Women Presented by Jennifer Chase, MS 12 th Annual Maternal & Child Health Epidemiology Conference December 6, 2006

2. What is bacterial vaginosis (BV) ? Shift in normal vaginal flora Lactobacillus Anaerobic bacteria ( Prevotella sp., Mobiluncus sp.) Gardnerella vaginalis Mycoplasma hominis Photos: Solomon D, Nayar R. 2004. The Bethesda System for Reporting Cervical Cytologic: Definitions, Criteria, and Explanatory Notes.

3. Clinical Signs and Symptoms Malodorous “fishy” smell Thin, homogenous, white, adherent discharge Vaginal fluid pH > 4.5 Clue cells on microscopic exam

4. Who is affected?

5. Effects in Pregnant Women Preterm labor Low birth weight Premature rupture of membranes Chorioamnionitis Amniotic fluid infections Endometritis after cesarean delivery Late miscarriage Spontaneous abortion

6. Effects in All Women Increased risk of STDs –Chlamydia –Gonorrhea –HIV Pelvic inflammatory disease Post-operative infections

7. Research Objectives 1)Identify potential risk factors to explain the presence of BV and intermediate vaginal flora in Wyoming women 2)Determine if differences exist between risk factors for BV and intermediate flora compared to normal vaginal flora

8. Data Source Wyoming Women’s Reproductive Health Study (WWRHS) To provide a comprehensive assessment of women’s reproductive health Collaboration with other state, non-profit, private agencies Cross-sectional study design 4 participation options

9. Bacterial Vaginosis Testing Self-swab of vaginal fluid (Boskey et al. 2004) Nugent Method: Scores 0-10 Nugent et al. 1991. Journal of Clinical Microbiology 29 (2): 297-301. Normal (0) Intermediate (6)BV (10)

10. Research Methodology 1)Selected variables from questionnaire 2)Built two logistic regression models: a)BV compared to normal b)Intermediate compared to normal 3)Compared the two models’ covariates and odds ratios

11. BV Testing Results BV –9.5% Bad odor, p<0.01 –9.5% Abnormal discharge, p<0.01 Intermediate –3.1% Bad odor, p=0.97 –7.8% Abnormal discharge, p=0.10

12. Final BV Model Education: 5-12 years vs. > 12 years –OR = 1.80 (1.22-2.64), p=<0.01 Clinic type: public vs. private –OR = 1.59 (1.07-2.36), p=0.02 Last dental visit: > 2 years vs. ≤ 2 years –OR = 1.72 (1.07-2.78), p=0.03 Last Pap smear: > 2 years vs. ≤ 2 years –OR = 1.79 (1.03-3.11), p=0.04 Ever pregnant: yes vs. no –OR = 1.78 (1.12-2.81), p=0.01

13. Final BV Model (cont.) Condom use frequency: compared to always –Usually/sometimes OR = 2.07 (1.04-4.13), p=0.04 –Never OR = 2.57 (1.31-5.03), p=0.01 –Virgin OR = 2.71 (0.83-8.87), p=0.10 Lifetime # sexual partners: >7 vs. 0-7 –OR = 1.67 (1.11-2.51), p=0.01 Women who have sex w/ women: yes vs. no –OR = 3.19 (1.00-10.22), p=0.05 Unprotected anal sex in past year: yes vs. no –OR = 1.90 (1.04-3.49), p=0.04

14. BV Model Discussion First study to report –Time since last dental visit –Time since last Pap smear –Unprotected anal sex in past year –Virgins may be at increased risk Confirmed previous reports –Education, clinic type, ever pregnant, condom use, lifetime partners and WSW Self-reported smoking vs. cotinine urinalysis

15. Final Intermediate Model Low SES: yes vs. no –OR = 1.87 (1.01-3.16), p=0.02 Prescription hormone use: yes vs. no –OR = 0.56 (0.32-0.98), p=0.04 Condom use frequency: compared to always –Usually/sometimes OR = 1.69 (0.83-3.45), p=0.15 –Never OR = 2.01 (1.01-4.02), p=0.05 –Virgin OR = 1.72 (0.51-5.78), p=0.38

16. Final Intermediate Model (cont.) # Sexual partners in past year: >2 vs. 0-2 –OR = 2.30 (1.09-4.87), p=0.03 Women who have sex w/ women: yes vs. no –OR = 3.16 (0.99-10.10), p=0.05 Unwanted sex in the past: yes vs. no –OR = 0.52 (0.29-0.95), p=0.03

17. Intermediate Model Discussion First study to investigate intermediate vaginal flora multivariately Findings differ from univariate studies Different risk factors than BV, but –Time since dental visit almost significant, multivariately OR=1.64, p=0.08 –Virgins may also be at risk

18. Comparison Public Clinic <12 years education Lifetime partners Condom use WSW >2 years dental >2 years since Pap Ever pregnant Anal Sex Low SES Partners past year Condom Use WSW >2 years dental* Prescription Hormone Unwanted Sex BVIntermediate

19. Conclusions BV is explained by sexual and non-sexual risk factors Because risk factors for BV and intermediate are not the same, combining or ordering them may not be appropriate Future research needed on oral health, oral and anal sex transmission, and virgins Findings suggest a need for provider education and prevention efforts

20. Acknowledgements Colorado State University Committee Members: Annette M. Bachand, Ph.D. Jennifer L. Peel, Ph.D. Doreene R. Hyatt, Ph.D. All clinic staff and participants of the WWRHS Erin Croughwell Luben, MPH Wyoming Department of Health: Angi Crotsenberg, MS Debra Hamilton, RN, MS Dr. Brent Sherard, Director & State Health Officer

21. Contact Information Jennifer Chase, MS Epidemiologist Wyoming Department of Health Community & Rural Health Division 6101 N. Yellowstone Rd., Suite 420 Cheyenne, WY 82002 307-777-5769 jchase1@state.wy.us

22. “We don’t know why, but it seems that men don’t get bacterial vaginosis” --Health Education Authority leaflet on STDs