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Annals of African Medicine, Vol. 5, No. 1, 2006, pp. 1 – 5 Trichomoniasis as an Indicator for Existing Sexually Transmitted Infections in Women in Aba, Nigeria 1L. N. Chigbu, 2C. Aluka and 3R. A. Eke Departments of 1Medical Microbiology, 2Obstetrics and Gynaecology, and 3Community Medicine, College of Medicine and Health Sciences, AbiaStateUniversity Teaching Hospital, AbaNigeria Reprint requests to: L. N. Chigbu, Department of Medical Microbiology, College of Medicine and Health Sciences, AbiaStateUniversity Teaching Hospital, P.M.B. 7004, Aba, Nigeria. E-mail: Lawrencechigbu@yahoo.com Code Number: am06001 Abstract Background:Trichomoniasis
is a common clinical problem. Many young women in Aba indulge in high-risk sexual behaviours. A large number of these young
women are illiterates, and are in the habit of indiscriminate use of
antibacterial agents at the slightest symptoms of a lower genital tract
infection. Evaluation of bacterial agents associated with lower genital tract
infections is therefore met with much frustration. The diagnosis of
Trichomoniasis from lower genital tract is simple and its routine screening
among women attending clinics would serve as an indicator for serious sexually
transmitted infections in Aba.
Key words: Trichomonaisis, prevalence, indicator, sexually transmitted infections, vaginal swab Résumé Fond : Trichomonase est
un problème clinique commun. Beaucoup de jeunes femmes à Aba se livrent aux
comportements sexuels à haut risque. Un
grand nombre de ces jeunes femmes sont des illettrés, et sont dans l'habitude
d'une utilité aveugle des agents antibactériens aux plus légers symptômes d'une
infection génitale inférieure. L'évaluation des agents bactériens associés aux
infections génitales inférieures a donc rencontré beaucoup de frustration. Le
diagnostic de Trichomonase de génitale inférieure est simple et son criblage
courant parmi des femmes s'occupant des cliniques servirait d'indicateur aux
infections sexuellement transmissibles sérieuses à Aba. Mots clés: Trichomonase, prédominance, indicateur, infections sexuellement transmissibles, prélèvement vaginal Introduction Trichomoniasis is a sexually transmitted infection (STI) of world wide importance. Trichomoniasis has been associated with vaginitis, cervicitis, urethritis, pelvic inflammatory disease (PID), and adverse birth outcomes.1 All these diseases associated with Trichomonas vaginalis infections have not been known to result to fatal outcomes and most of them present asymptomatically. Despite the fact that the rates of other sexually transmitted infections are declining, Trichomoniasis still remains an extremely common infection.2 The disease can be easily treated and is preventable. However, the infection is often asymptomatic, and its acquisition and transmission are often accompanied by other serious STI’s, 3 Infection with T. vaginalis may play an important role in the transmission and acquisition of Human Immunodeficiency virus (HIV) infection. The fact that the infection may be asymptomatic makes it not only a personal problem, but also a public health challenge. Trichomonas vaginalis is site specific for the genitourinary tract.1 The potential pathophysiological consequences in STI’s could best be discerned on closer look at the pathognomonic signs of the infection. There is concomitant anaerobic bacterial infection and this gives rise to increased pH of the vaginal milieu to above 7. There is also a marked reduction in number of lactobacilli in the urethra or vagina infected with T. Vaginalis.) The infection also provokes the production of polymorph nuclear leukocytes. In severe cases, the inflammatory reaction may be sufficient to produce a pathognomonic sign of Trichomoniasis, the “Strawberry Cervix”, on which localized patches of increased vascularity are seen. Contact bleeding of the cervix is also common. These pathophysiologic effects resulting from Trichomoniasis would undoubtedly suggest further predisposition to other serious sexually transmitted infections, including HIV infection. The prevalence of T. vaginalis in low – risk groups (family planning or antenatal clinic attendees) is said to be 12%.4 Among high–risk population (commercial sex workers, sexually transmitted disease clinic patients, and men whose occupations involve extended or recurrent separations from families, such as military personnel and long-distance truck drivers), the prevalence is 17%.4 It is reported that trichomoniasis may play a role in the spread of HIV – infection in sub-Saharan Africa. The prevalence among HIV-infected persons in four cities in sub-Saharan Africa has been reported as 29.3% in kisumu (Kenya); 34.3% in Ndola (Zambia); 3.2% in Cotonou (Benin) and 17.6% in Yaounde (Cameroon).4 An infection rate of 40% has been reported in Edo State, Nigeria among female subjects between 20 and 25 years old. 5 Aba is a commercial town with a population of more than 3 million. A large percentage of the population is made up of low-income earners and illiterates. Many young women in Aba indulge in high-risk sexual behaviour. The infections acquired in youth may remain sub clinical or are suppressed with inadequate antibiotic therapy, and then resurface later in life. Also the recovery of most common STI’s from lower genital tract is met with frustrations owing to indiscriminate use of antibacterial agents, ignorance and lack of specialized materials and equipment for diagnosis. The diagnosis of trichomoniasis from lower genital tract is simple and control of the infection has received relatively little emphasis from the public health programmes. Therefore the diagnosis of Trichomonas vaginalis from lower genital tract (vagina) of sexually active persons would not only serve the purpose of case reporting of trichomoniasis in Aba, it would indirectly reflect the prevalence of other existing STI’s in the community. This study is aimed at evaluating the pattern and prevalence of trichomoniasis as an indicator for other existing more serious sexually transmitted infections in Aba, Nigeria. Patients and Methods The study was conducted in a Hospital for women (PrincessMarryHospital), Aba. This is a community-based hospital with about 40 beds. The hospital is located on the outskirt of Aba metropolis – in Ogbor Hill. In this study, 360 subjects were randomly selected from women attending the family planning clinic, fertility clinic and antenatal clinic. Others selected for study were patients with gynaecological problems and those presenting with obvious symptoms of genital infection (vaginal discharge and vaginal itching) and those who visited the hospital for “well women examinations”. The subjects were considered eligible for the study if they were 15 to 65 years old, had not used any antibiotics within the past 14 days and were able to give informed consent. The resident gynaecologist carried out the clinical evaluation of each subject selected for study. This included detailed sexual history, current genitourinary tract complaints like vaginal discharge, vaginal itching, perineal pains, urinary frequency and dysuria. These data and the subjects’ personal data were entered in a questionnaire provided for each subject. For each subject, a sterile speculum examination was carried and high vaginal swab (HVS) was taken using a commercially prepared sterile swab stick. The consultant gynaecologist in the hospital took all the specimens. The samples were immediately transferred to the laboratory for examination. When delay was anticipated, the samples were transferred to the laboratory in sterile Stuart’s transport medium. In the laboratory, a portion of the vaginal secretion on the swab stick was inoculated onto plates containing chocolate agar, blood agar and Sabouraud’s dextrose agar. The inoculate were streaked out with sterile wire loop and incubated at 370C for 24 – 48 hours. The remaining portion was examined microscopically by direct wet mount preparation and Gram staining techniques. In the wet mount preparation technique, a portion of the vaginal secretion was emulsified on a clean slide containing 2-3 drops of normal saline covered with cover slip and examined under the microscope using the x 40 objective lens. Trichomonas vaginalis was identified by observing their characteristic motility (twisting movement). The slides were also examined for the presence of pus cells, and number expressed in high power per field. The densities of the epithelial cells were used to assess the presence of “Clue cells” in Gram stained smears. The Gram smears also revealed the presence of bacterial cells. For the identification of Neisseria gonorrhoeae, moist translucent colonies on chocolate agar after 48hour incubation were screened by the Gram stain, catalase and oxidase production. The organism was further confirmed by the fermentation test with maltose, glucose and sucrose. Candida albicans was identified using the Germ tube test and the reduction of Nitrate and fermentation of sugars. Statistical analysis of the results was carried out using the chi-square to test any difference in the age specific prevalence of T. vaginalis. Results A total of 360 patients were studied. The recovery rate of specific organisms in various categories of patients is shown in table 1. About 36.7% of the population sampled attended STI clinic with specific indications, while 28.3% were for antenatal clinic. Others were gynaecological clinic and those coming for routine examination. Those for routine examination yielded the highest recovery rate of Trichomonas viginalis (47.8%). About 12.9% were positive among patients who attended STI Clinic. No Trichomonas vaginalis was recovered among the Gynaecological Clinic attendees. Out of 360 patients examined for trichomoniasis, only 40 (11.1%) were positive. The age group 30-34 years and 35-39 years gave relatively high percentage of 21.4% and 16.7% respectively (Table 2). There was statistically significant difference (p<0.01) in the distribution of T. Vaginalis among women of various age groups, with women aged ≥45 years and above yielding the highest (50%). Table 2 shows the prevalence of specific organisms by age. Mixed infections of Trichomonas vaginalis, N. gonorrhoeae, T. viginalis and G. vaginalis of 0.6% each were noted. Table 1: Recovery rate of specific organism in 360 vaginal swabs
TV: Trichomonas vaginalis; NG: Neisseria gonorrhoeae; CA: Candida albicans; GV: Gardnerella vaginalis; STD: Sexually transmitted diseases Table 2: Prevalence of specific infections and age in 360 women
TV: Trichomonas vaginalis; NG: Neisseria gonorrhoeae; CA: Candida albicans; GV: Gardnerella vaginalis; Discussion Trichomoniasis is a readily diagnosed and treatable infection. However, it is not a frequently reported infection and its control therefore has received relatively little emphasis from public health STI control programmes 2. Recent reports have shown that there are appreciable high rates of association of the disease with HIV infection and other serious STI’s 2, 6, 7 among women with adverse out comes of pregnancy. In this study, attempts have been made to associate the infection of Trichomoniasis with other STI’s among women attending a womenHospital in Aba, Nigeria. At the same time the results of the study has provided data for the prevalence of Trichomoniasis in Aba and its environs, since routine screening for the disease has not been reported in this community in the past. Certain sociodemographic factors, which are important for the predilection of T. vaginalis infection, have been left out since the study was carried out in a particular women Hospital in Aba. The prevalence of specific vaginal infections of 11.1%, 1.7%, 13.3% and 38.9% for T. vaginalis, N. gonorrhoeae, G. vaginalis and C. albicans may not reflect the true prevalence in Aba and its environs. The reasons being that these women were highly selective group, having come from a particular hospital. In various other studies where the community as a whole with a larger sample population, were studied, among women, higher prevalence rates were found 4, 8 for trichomoniasis. A coinfection rate of trichomoniasis with gonorrhoea (an important STI), candidiasis and G. vaginalis of 0.6%, 2.8% and 0.6% respectively is low. However,Trichomoniasis may have played a role in the transmission of N. gonorrhoeae. The lower recovery rate of N. gonorrhoeae may be due to the problems associated with the isolation of the organism in routine culture media today. Although the prevalence of trichomoniasis is said to be significantly higher in the high HIV in the sub–Saharan Africa, and other countries,1,9 its association was included in this study as consent for HIV screening was not obtained. Sexually transmitted infection clinic attendees are said to belong to the high-risk population. The finding of 12.9% recovery rate among this class of patients almost corroborates other studies in which 17%1 prevalence rate has been reported. The prevalence rates of 9.1%, 8.5% and 4.9% among family planning, fertility and antenatal clinics attendees respectively also come close to the 12% prevalence rates which have been reported among these classes of patients in Edo State, Nigeria.5 The fact that no trichomoniasis was reported among Gynaecological Clinic attendees could be seen from the reason of the peculiarity of their problems and the class (Educational/ Economic Status) of this group of patients. The 47.8%, among the routine examination clinic attendees, showing the highest prevalence of Trichomoniasis in this report seems to agree with the fact that Trichomoniasis most often presents asymptomatically. This class of patients had no specific complaints and as such yielded the highest prevalence rate in this report. This finding has further given credence to the fact that trichomoniasis is a common sexually transmitted infection. Many of the victims are asymptomatic and so are healthy carriers with high public health risks. Screening of sexually active women for the disease should therefore be a matter of routine procedure. The relatively high prevalence of Trichomoniasis among the age bracket 30 – 34 years (21.4%), and 35 – 39 years (16.7%) and the highest of 50% from 45 years and above are not surprising. Most women from the age of 30 years get married and in this study, subjects under study have visited the women hospital for problems, which are common among married women. The relatively high recovery rate of this infection among these age brackets may be resulting from the increasing sexual promiscuity, especially among men, who probably would transfer the organism to the unsuspecting spouses. The increased mobility of husbands for economic reasons may be a major risk factor for the persistence of the infection. Also, the availability of various family planning methods in older women (contraceptives) 10 may encourage multiple sexual partners and therefore spread of sexually transmitted infections. The highest prevalence of 50% found among women of age 45 years and above could represent sub clinical infections acquired at younger age, which persisted till late in life. The role of Trichomoniasis in other serious STI’s has been reported.3 The prevalence rates of N. gonorrhoeae 1.7%, G. vaginalis 13.3% and C. albicans 38.9% have provided more evidence on the role of T. vaginalis in predisposing individuals to other STI’s including HIV infection. Concerning Trichomoniasis co-infection with other STI organism, the isolation rate of T. vaginalis with N. gonorrhoeae and T. vaginalis with G. vaginalis, even as low as 0.6% each, still supports the potential role of T. vaginalis in enhancing other existing STI’s. From the results of this study, we suggest that examination of vaginal and / or cervical smears of women visiting any women hospital should be routinely done. Although this study was undertaken in one specialist (women) Hospital, a well organized health education campaign and public enlightenment on the benefits of routine vaginal smears among married women would encourage a wider population screening. The screening exercise and the consequent adequate treatment and health education would tremendously offer a good public health control tool to STI’s in general and Trichomoniasis in particular. References
Copyright 2006 - Annals of African Medicine
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