Archives of Clinical Microbiology

Keywords

Trichomoniasis; High vagina swab; Trichomonas vaginalis; Sexually transmitted diseases

Introduction

Trichomoniasis is the most common sexually transmitted disease (STD) caused by parasitic protozoa called Trichomonas vaginalis [1]. It is one of the most common curable STDs that infect the urogenital tract of sexually active women and men causing significant vaginal and cervical ulceration [2-4].

This infection ranks third after bacterial vaginosis and candidiasis among the diseases that commonly cause vaginal symptom, [5,6]. Trichomonas vaginalis, the causative organism is highly specific for the genitourinary tract and has been isolated from virtually all genitourinary structures including uterus. An estimated 2.5 to 3 million Americans contract this infection annually, about 25% of Nigerian students and up to 20% of pregnant women test positive while about one billion people suffer Trichmoniasis worldwide [4-6].

Infection is generally acquired through sexual contact and occasionally through nonsexual contact by getting in contact with formites or surfaces that are contaminated by an infected individual’s fluid [7]. Consequently, women especially those with multiple sex partners easily contact this infection through sexual contact with infected men or through vulva to vulva contact while men usually contact the same infection only through sexual contact with infected women. According to Swygard [8] over 180 million women may be infected worldwide, showing a prevalence estimate which varies between population studied and ranges from 5 to 74% in women and 5 to 29% in men. In men prevalence is less well described, the reason being that men often times show less prevalence because many are asymptomatic and do not easily seek evaluation until their partner is confirmed .However, whenever symptoms occur they usually include, irritation inside the penis, mild discharge and slight burning sensation after urination or ejaculation. Women present symptoms which usually appear within 5-28 days of exposure to infection ranging from greenish- yellow frothy vaginal discharge, painful urination, vaginal itching and discomfort during intercourse in about 50% of cases to pruritus or dysuria and Pelvic Inflammatory Disease (PID) [2,7]. Genital inflammation caused by Trichomoniasis might also increase a woman’s risk of acquiring HIV infection if she is exposed to HIV and this may increase the chances of transmitting the infection to sex partner. Most women diagnosed of Trichomoniasis infection are usually asymptomatic and usually avoid diagnosis. This observation is supported by a case in Zimbabwe were 75% of women denied symptoms on direct questioning but 16% of them tested positive after screening [9,10]. Misrepresentation of this Trichomonas infection often times seem confusing as was exemplified in a study where 74% of two hundred Nigerian women with discharge were infected with Trichomonas while in another study none of 149 Nigerian women with discharge were positive of the infection [8].

According to Patel, et al. [9,10] Trichomoniasis often times are asymptomatic in both men and women to the ratio of 50-70% which constitutes major source of transmissions of the infection. Asymptomatic nature of most infections in females adversely affects pregnancies resulting in premature birth delivery coupled with low birth weight infants that usually develop congenital health problems later in life. Trichomoniasis in children raises the question of sexual abuse and the possible exposure to other sexually transmitted diseases. However newborn infants can contact Trichomoniasis congenitally at birth [11,12].

Trichomoniasis diagnosis is commonly and mostly conducted through the examination of vaginal discharge in women and urethra fluid in men. Evaluation of PH with pH paper usually helps for the rapid differentiation of T vaginalis from yeast in women. The work of Gary [13] has it that pH level of the vagina which is normally 4.5 is not altered during yeast infestation but may rise up to 6 and above with Trichomoniasis. This simply means that Trichomonas infection increases the PH of the vagina.

Treatment of T vaginalis infection is effected with a single oral dose of 2 g of metronidazole/tinidazole .However re-infection often occur and about 1 in 5 people treated get re-infected within three months of treatment. To this effect, it is advisable to treat all sex partners at the same time and to avoid sex until every symptom disappear [14].

The absence of baseline data in many parts of the state especially in the study area and the asymptomatic nature of the infection necessitated the investigation of the prevalence among adults in the study area.

Materials and Methods

Study area

Oru-East is among the 27 Local Government Area that made up Imo state, situated in the Northeastern part of the state and shares the same geographical locations, having both savanna and rainforest zones with the state. Majority of the indigenes are business people with few civil servants, farmers and artisans

Ethical clearance

Approval to carry out the research were obtained from the medical directors of the health services used the participants who were volunteers and from the ethical committee of infectious unity of department of animal and environmental Biology, Imo state University Owerri.

Study population

The population of study comprised two hundred adults (males& females) hundred each who were attending health facilities in the study area. The inclusion to participate was purely on voluntary basis.

Sample collection

High vagina swab (HVS) was aseptically collected from the females through the assistance of the medical laboratory scientists using sterile cotton swab stick while urine specimen were collected by the men themselves using clean sterile sample bottles as directed. The specimens were immediately taken to the diagnostic laboratory section of one of the clinics for immediate analysis within an hour after collection to avoid loss of characteristic tumbling motility of the organism and death that may follow due to loss of moisture.

Specimen analysis

The specimen were macroscopically examined by direct virtualization of the vagina discharge and urine, noting the color, odor and hydrogen ion concentration(pH) levels of the discharge using pH paper strip. Microscopic examination was carried out by suspending small portion of the discharge in one drop of 0.85% of physiological saline and covered with coverslip while a drop of the deposit/ sediment of centrifuged urine samples were also dropped on a clean slide and covered with coverslip. The wet mount preparations were then examined under X10and X40 objectives [8,13].

Identification of the organism

This was done based on the result obtained from examination of the clinical specimen using wet mount technique which provided sufficient number of viable organisms with their characteristic tumbling motility.

For better understanding and interpretation of the test results, simple percentages and chi- square test were used.

Results

The result of the prevalence study among adults attending health facilities in Oru-East revealed that out of 200 men and women screened for Trichomonas vaginalis infection,81(40.5%) were positive. Of this number, women had the highest prevalence of 52.0% while men had the least prevalence of 29.0% (Table 1).

	Male			Female
Total Number Examined	Number of male Examined	Number infected (%)	Number uninfected	Number of female Examined	Number infected (%)	Number	Number infected (%)	Number uninfected   (%)
						uninfected
200	100	81(40.5)	119(59.5)	100	29(29.0)	10071(71.0)		52 (52.0%)	48 (48.0%)

Table 1: Overall prevalence of T. vaginalis in the study Area.

AwoOmamma hospital recorded highest prevalence result of 48(48.%) followed by primary health care centre Omuma with 25(41.67%) prevalence while the least prevalence was observed among those that attend Mbutu health care centre and maternity having prevalence of 8(20.0%). The highest age related prevalence was obtained among the age range of 29-39years with 34(41.5%) the least prevalence was among those of age range 60 -72,5 (21.74%), Tables 2-4 respectively. Marital status prevalence revealed that prevalence was slightly higher among the singles, (44.4%) than the married having (43.88%). Educational attainment related prevalence showed that prevalence was highest among those that had secondary education 45.45% while the least was among those with tertiary education qualification, 19.44%. Occupational related prevalence showed highest infection among traders with 58.33% (Table 6). The result of the pH level of the female vagina showed those within the age of 29- 39 having the highest value of 6.7 while the least was observed among the age range of 51-60 years,4.6 (Tables 5 and 6).

Age Range (Years)	Total Number Examined	Gender
		Male		Female
		Number infected (%)	Number uninfected (%)	Number infected (%)	Number uninfected (%)
18-28	24	4 (16.67%)	2 (8.33%)	10 (41.67%)	8 (33.33%)
29-39	22	6 (27.27%)	2 (9.09%)	12 (54.55%)	2 (9.09%)
40-50	24	2 (8.33%)	8 (33.33%)	8 (33.33%)	6 (25.0%)
51-60	15	2 (13.33%)	4 (26.67%)	2 (13.33%)	7 (46.67%)
61 and above	15	1 (6.67%)	9 (60.0%)	1 (6.67%)	4 (26.67%)
Total	100	15 (15.0%)	25 (25.0%)	33 (33.0%)	27 (27.0%)

Table 2: Age and Gender-Related Prevalence of T. vaginalis in Awo-Omamma General Hospital.

Age Range (Years)	Total Number Examined	Gender
		Male		Female
		Number infected (%)	Number uninfected (%)	Number infected (%)	Number uninfected
					(%)
18-28	15	2 (13.33%)	9 (60.0%)	2 (13.33%)	2 (13.33%)
29-39	15	4(26.67%)	2 (13.33%)	7 (46.67%)	2 (13.33%)
40-50	12	2 (16.67%)	4 (33.33%)	3 (25.0%)	3 (25.0%)
51-60	10	1 (10.0%)	5 (50.0%)	1 (10.0%)	3 (30.0%)
61 and above-	8	1 (12.5%)	4 (50.0%)	2 (25.0%)	1 (12.50%)
Total	60	10 (16.67%)	24 (40.0%)	15 (25.0%)	11 (18.33%)

Table 3: Age and Gender-Related Prevalence of T. vaginalis in Primary Health Care Centre Omuma.

Age Range (Years)	Total Number Examined	Gender
		Male		Female
		Number infected (%)	Number uninfected (%)	Number infected (%)	Number uninfected (%)
18-28	8	-	3 (37.5%)	1 (12.5%)	4 (50.0%)
29-39	16	2 (12.5%)	9 (56.25%)	3 (18.75%)	2 (12.5%)
40-50	16	2 (12.5%)	10 (62.5%)	-	4 (25.0%)
51-60	-	-	-	-	-
61 and above	-	-	-	-	-
Total	40	4 (10.0%)	22 (55.0%)	4 (10.0%)	10 (25.0%)

Table 4: Age and Gender-Related Prevalence of T. vaginalis in Mbubu Health Care and Maternity.

Age Range	Number Examined	Number Infected	Number Uninfected	PH Value
		(%)	(%)
18-28	27	13 (48.15)	14 (51.85)	5.8
29-39	28	20 (71.43)	8 (28.57)	6.7
40-50	24	11 (45.83)	13 (54.17)	5.1
51-60	13	3 (23.08)	10 (76.92)	4.6
61AND ABOVE	8	3 (37.50)	5 (62.50)	4.7

Table 5: pH value of vagina discharge among screened women.

	Number Examined	Number infected (%)	Number uninfected (%)
Age RANGE
18-28	47	19(40.43%)	28 (59.84%)
29-39	53	34 (64.15%)	19 (35.84%)
40-50	52	17 (32.69%)	35 (67.31%)
51-60	25	6 (24.0%)	19(76.0%)
62-72	23	5 (21.74%)	18 (78.26%)
Total	200	81 (40.5%)	119(59.5%)
Marital Status
Single	72	32(44.4%)	40 (55.56%)
Married	98	43 (43.88%)	55 (56.12%)
Divorced	9	2 (22.22%)	7 (77.78%)
Widowed	21	4 (19.05%)	17 (80.95%)
Total	200	81 (40.5)	119 (59.5%)
Education
Primary	32	14 (43.75%)	18 (56.25%)
Secondary	132	60 (45.45%)	72 (54.54%)
Tertiary	36	7 (19.44%)	29 (80.56%)
Total	200	81 (40.5%)	119 (59.5%)
Work Status
Traders	72	42 (58.33%)	30 (41.67%)
Public Servant	12	4 (33.33%)	8 (66.67%)
Artisans	26	11 (42.31%)	15 (57.69%)
Unemployed	42	11 (26.19%)	31 (73.83%)
Student	48	13 (27.08%)	35 (72.92%)
Total	200	81 (40.5%)	119 (59.5%)

Table 6: Socio-Demographic Profile of those attending the Three Various Health Care Centre’s.

Discussion

Trichomoniasis is a sexually transmitted disease caused by parasitic flagellate protozoa-Trichomonas vaginalis that is highly site specific being associated with symptoms ranging from T vaginitis, cervicitis, urethritis, pelvic inflammatory disease(PID) dysuria, prostatitis and adverse birth consequences as a result of asymptomatic nature of many of the infections in both women and in men [8,15,16]. The organism is formally considered a commensal parasite until in the 1960s when the understanding of its role as one of the sexually transmitted disease began to unfold [8]. Disease prevalence is variable and diagnosis are often difficult due the nature of the organism and the noncompliance of subject to either accept the presence of the symptoms or to submit themselves for screening perhaps for personal reasons. This singular attitude contributes immensely to the spread and transmission of the infection as many are undiagnosed [17,18].

The prevalence of Trichomonas vaginalis among adult in “Oru- East L.G.A. of Imo state was studied within age range 18-72 years. Out of 200 (Two hundred) samples of urine from male and high vaginal swab (HVS) from female from the three hospital and health centres used, 81 (40.5%) were positive. The highest number of positive cases was seen in Awo-Omamma General Hospital with 48 (48.0%) cases. This was followed by Primary Health Care Omuma with 25 (41.67%) cases and least in Mbubu Health Care and maternity with 8 (20.0%). The prevalence was not in agreement with 149 (74.5%) obtained by Galandanci et al. [19] out of 200 patients examined which can be attributed to certain factors such as the rate of sexual activities in the rural areas compared to the urban areas and coupled that his work was also based on vaginal discharged only (females throughout). This present work can be compared to the work of Anosike et al. [20] who worked amongst pregnant women in Jos areas of plateau state of Nigeria. The survey gave 37.6% for those in the metropolis while those in the rural area have 24.8%. This high prevalence in the rural area could be as a result of sexual activities and multiple sexual partners usually practiced in rural settings.

However, the prevalent rate in this present work is high when compared with the work of Arambulo et al. [21] in Fillipino among women in which 19 (6.8%) were positive out of 288 women. According to Onwuliri et al. [22], 24.7% were positive out of 505 individuals examined of T. vaginalis and it was appreciably higher in female than in males. He further stated that T. vaginalis infection had been significantly higher in females than in males in the second and third than fourth and fifth decades of life (P<0.05) and also that the infection increases progressively with increase in the number of sexual partners and neglect of condom during sexual intercourse.

Nevertheless, in the present work, the highest was observed among the age range of 29-39 years with 34 (41.5%) which was followed by the age range 18-28 years with 19 (23.46%). According to Krieger [23] and Sena [24], the disease occurrence correlated with the level of sexual activity of the group of people being studies. Also, the evidence for sexual transmission of T. vaginalis is very strong as prevalence is highest among patients with increased sexual activities and multiple sex partners. They further stated that approximately 14-65% of male partners of infected females were also infected. The present work showed that adults within the age range of 18-28 years and 29-39 years were likely to contact the infection during sexual intercourse. This was also agreed by Tanyuksel et al. [25], who said that prostitutes were an important group for the transmission of a number of sexually transmitted disease (STDs) all over the world and infection with T. vaginalis as one of the most common, thus in his work using 225 prostitutes vaginal wet smear in Ankara, Turkey, 64 (25%) were positive which was high. Another study conducted by Wendel [26], showed T. vaginalis prevalence as 13% in men over 28 years old. Also Saxena [27] in his own work had 58% positive, out of 85 men within the age range 16-22 years in determining the prevalence of T. vaginalisin young men at high risk for sexually transmitted diseases. These indicated that in the present work, adults within the age range 29-39 years were supposed to have increased sexual activities and multiple sex partners which justified the result obtained. The reasons for this increase in infection among age range of 29-39 may be due to their inability to stick to their sexual partners, to avoid contact with infected articles like towels, bathtubs, clothes etc, having no control of their sexual urge .This is high when compared with findings of Woken [28] in some part of Niger Delta Region River state. This high prevalence of trichomoniasis may be attributed to little or no attention given to this disease of public health importance. This observation was also reported by Achalonu [29] and Petrin et al. [30]. They observed that trichomoniasis is the most prevalent sexually transmitted parasitic infection worldwide, yet it appears to be highly neglected.

In Nigeria, it has been reported by previous workers that sexually transmitted disease has been blamed on increase in poverty, unemployment and violence among women and children [31,32], including other factors like sexual recklessness, lack of awareness and personal hygiene .

The gender prevalence rate was higher in females with 52(52%) cases compared to males with 29(29%) cases. This is similar to the work of Onwuluri et al. [33] who observed 374(31.0%) females and 131(15.6%) males this is possible due to the low detection of T. vaginalis in men using wet mount microscopy, also an optimal diagnostic method is unavailable. Moreover, there is high concentration of zinc and anti-trichomonal substances in the prostate, which affects detection [34].

Cloudiness of urine within the time of analysis indicated the presence of epithelial cells and mixed bacteria flora which indicated vaginal flora contamination brought about by Vaginalis infection in the present work but not generally observed in all the 81 (40.5%) positive cases, the presence of polymorph nuclear neutrophils, trichomonads and epithelial cells during microscopic examination of urine from male and high vaginal swab from female indicates Vaginalis infection. All the negative samples were macroscopically clear and had foul, frothy or normal odors. Although the presence of typical acute symptomatic disease was not established among the majority of adults screened, significant T. vaginalis was confirmed in the positive specimens.

The study of Sumadhya in Sri Lanka [35] showed that the prevalence of T. vaginalis infection was higher in women with low educational level than women with high educational level as it was showed in this study while Annang’ study in USA [36] showed that educational status was not uniformly protective against STDs for black and white females in US. In the present study, the prevalence of T. vaginalis infection in low educational level of adult was higher than in high educational level. Also finding in this work in relation to occupation showed that traders have the highest prevalence of 42 (58.33%) followed by the students 13 (27.08%).

Subsequently, the prevalence rate of T. vaginalis among adults in Oru-East L.G.A of Imo state was high, probably due to poor sanitary condition of toilet facilities in rural areas. Other factors could be reckless sexual promiscuity among adults, wearing of dirty pants, tissue, pads, dirty towels, clothes, bathtubs and fingering during love making [7,37]. Sorvillo [38] stated that T. vaginalisis emerging as one of the most important factors in transmission and acquisition of HIV infection. Cohen [39] and Upcroft and Upcroft [40] in their own separates studies stated that T. vaginalis infection was associated with preterm delivery, low birth-weight and increased in infant mortality.

They further stated that it also predisposed individuals to HIV/AIDS and cervical cancer. Cohen [41] stated that T. vaginalis infection in women had increased risk factor for health complications, such as infertility development of pelvic Inflammatory disease (PID); infection following gynecologic surgery and inflammatory neoplasia.

Schwebke [42] and Soper [15] also stated that in men, T. vaginalis had been linked to main factors in infertility as a common cause of non-gonococcal urethritis (NGU) in men. The high acidity (low pH) of the vaginal environment (4.8) recorded among the age group 61 and above may have contributed to low infection within that age group,. This could be justified since Trichomonas grows best in more alkaline environment 6 and above than in the acidic environment 4.5 [13]. Consequently low pH of the vagina environment is highly unfavorable to Trichomonas vaginalis survival and this agrees with high PH level and infestation observed within age range of 18-28and 29-39 .Therefore, the mean PH level of the three groups differ significantly(p<0.05) among groups, is in line since infection is proportional to pH variations of the vagina [13,43,44]. This association most probably may depend on the reproductive hormones in the older women and also on the personal health habit, access to medical care and socioeconomic status of the subjects [8,45].

Conclusion

Generally, Trichomoniasis, though with its low prevalence is clearly associated with significant public health problems including HIV transmission and other sexually transmitted disease. Infection presentation is highly variable as majority of the women and men are often asymptomatic carriers who usually escape diagnosis and treatment thereby constituting major source of Spread and transmissions. Diagnosis of Trichomonas infection is usually problematic due to high sensitive nature of the parasite to drying effect and to atmospheric oxygen. The parasite therefore does not survive beyond few hours once they leave the human body. Even though, sexual contact has been tagged the most common route of transmission, other sources such as fluid contaminated formites, congenital and other non-sexual source aid in transmission through moist secretions occasionally especially by women.

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