THE PREVALENCE OF TRICHOMONA VAGINALIS AMONG ADULTS IN “OSUMENYI” IN NNEWI SOUTH LOCAL GOVERNMENT AREA ANAMBRA STATE
INTRODUCTION
Donne first discovered and named Trichomonas Virginalis in 1836.He found the orgnaism in genital secretions 7 women and men, but it was initially regarded as non-pathogenic (Donne, 1936). Trichomonas vaginalis is a pear-shaped, flagellaatic, motile protogoa, with an undulating membrance. It is about 10-20 Hm wide, and oxide. The organism is propelled by four anterior flagella with a flagellium attached to an undulating membrance (Heine, 1993). I. Vaginalis is a eukaryrote, anaeobic and does not contain mitochoria in its cytop[lasm but instead contains specialized granules called hydrogenosomes throguh out the region of the cytoplasm with a slender posteriorly protruding regid rod called axostyle (Nester, est el, 2001 and Rultyle, 1983). I. Vaginalis exist only as a trophozoile and do not take o a cyst from (Lossick, 1990). Due to the organism’s unique energy metabolism,s the organism bears a strong resemblance to anaerobic bacteria (Petriu, 1998). In wet mount preparation of vaginal secretions, the live organism can often be recognised by its unmistakably swaying motion (Nester et al, 2001). I. Vaginalis grows best under anearobic conditions and at elevated PH levels. Masimum growth and metabolic functions are greatest at PH of 6.0 (Spence, 1992) In accord with its anaerobic state, sthese interesting cytoplasmic double –bounded organelles (hydrogenosomes) remove the carboxyl group (CooH) from pyruvate and trasnfer electrons to hydrogen gas (Nester et al, 2001). I. Vaginalis derives its glucose into oseccinate, acelate, malate, and hydrogen. In addition it produces some carbondioxide but nost via the kreb cycle pathway (Dyall and Johnson, 2000).
I. vaginalis causes sexually transmitted inecxtion (STI) called Trichomoniasis. This infection is the most common nonviral sexually transmistted disease in the world. Trichomoniasis, sometimes referred to as “Trich” is primarily an infection of the urogenital tract,. Which infects both men and women. The urethra is the most common site for I. Vaginalis infection in men. The organism can aslo be detected in the epididymis, semen and urine (Krieger, 1981). I. Vaginalis was first located in prostatie secretions from husbands of infected women (Drummond, 1936). In women, vagina is the most, common site of the infection the organism may be isolated from the cervix, vagina, bartholins glands, bladder and occasionally. The upper sreproductive / urinary tract (Reing, 1990). Over 95% of infections have been isolated from vagina and only 5% from the urinaryu tract of adult women (Grys, 1964) the urethra and skene’s glands are infected in 90% of cases. There have also been instances where organisms were isolated from bladder urine (Thoniason, 1989). Infected men are usually asymsptomatic carriers of the organisms (Krieger, 1995) which most symptomatic I.Vaginalis infection occur in women (Wolner- Hanssen, 1989). It ranks third after bacterial vaginosis and candidiasis among the diseases that commonly cause vaginal symptoms (Nester, et al, 2001). According to World Health Organisation’s annual, estimates, There are an estimated 7.4 million trichomoniasis cases each year in the united states, with over 180 million cases reported world wide (Weinstock et al, 2004). WHO in 1999 states that the infection rates have been reported by some researchers to be as high as 67% in Monogolia in 1988 (Schwebke, et al, of 40 – 60% in Africa and 40% in indigenous Australians. Trichomoniasis rates are also high in inner city populations in the united states. I . vaginal is was originally considered a commensal until in the 1950s when the understanding of its role as a sexually transmitted infection began to involve (Swygard, et al, 2004). Trichomoniasis often leads to vaginitis, an acute inflammatrory disease of genital mucosa.
This infection is associated with preterm delivery, low birth weight and increase in infant mortality. It also pre-disposes individuas to HIV/AIDS and cervical cancer (Cohen, 2000 and Upcroft and Upcroft, 2001). Among both women and men, I. Vaginalis is emerging as one o the most important factors in transmission and acquisition of HIV infection (Sorvillo, 1998). In women, the health complications include increased risks for the following, infertility, development of a typical pelvic inflammatory disease (PID), infection following gynecologic suggery and cervical inflammatory neoplasia. There have also been high rates of correlation between trichonioniasis and pregnancy complication in women (Cotch, 1997). In men, I vaginals has been linked to main factor in infertility and as a common cause of non-gonococcal urethritis (NGU) in men (Sch webke 2002, and soper, 2004). Minkoff, et al (1984) identified a strong association between I vaginalis infection and prefern rupture of membrane. Several studies have showns I. Vaginalis to be a rish factor for tubal infertility (El-Shazly, 2001). Sorvillo (1998) states that I.Vaginalis may amplify HIV – I transmission by increasing subceptibity in an HIV-1 negative person and the infectiousness in an HIV-1positive patient. He further stats that I. Vafinalis is emerging as one of the most important cofactor in amplifying HIV transmission particularly in African American Communities in the united state (Sorvillo, 2001). The association of trichomoniasis with HIV amplification is seen among men as well (Hobbs, 1999). I. Vaginalis has a significantly increased incidence of HIV transmission (Jackson, et al, 1998). I vaginalis elicits an aggressive local cellular immune response with a heavy influx of target cells in HIV. This response may increase a seronegative individual. Conversely in an HIV-seropisitive individual, punctuate haemorrhages, That are frequently associated wit I vaginalis infection, increased shedding and subsequent transmission of the virus (Cohen, et al, 1997).
In women, the infection is often characterised by vaginal i.e a thin foamy yellow – green, frothy vaginal discharge, vaginal odour, sometimes macodoros, pains with sexual intercourse, pain with urination and vulvovaginal sorness (Itching) (Rein, 1990, and Nester et al, 2001). (Common clinical signs include vulva erythema, inflammation excess of white blood cells seen on a wet mount preparation of vaginal discharge, numerous polymorphonuclear nuetrophils (Similar in size with Trichomonads) and occasional red blood cell (Rein, 1980), motile trichomonads in the wet mount preparation and a vaginal PH above 5.0, most of which overlap with Baterial vaginosis (Rein, 1984, and Wolner-Hassen, 1989). The wall of the vagina and vulvu are diffusely red and slightly swollen (Nester et al, 2001). I vaginalis infection is a persistant disease of genitourinary tract, characterised with foul odour, serve cases, puncstuate or scattered pinpoint haemorrhagos are present. It may also cause preumonies bronchitis (public Health Agency of Canada. (PHAC) 2001, and MC Laren, et al, 1983). These symptoms usually appear within four to twenty days of exposure. In men, the infection is more difficult to detect as the majority of infections remain a symptomatic and readily available diagnotic techniques are inadequate this is problematic since long tewrm carriage of I vaginalis in a symptomatic men have been documented up to 4 months (Kreiger, 1993). Most men seeking treatment do so because of htier infected partners (Hager, 1994). Up to 50% males are usally a symptomatic with the organism persisting in their prostate gland or seminal vesicles (Krieger, 1995). Symptoms in men typically include Urethral discharge, dysuria, mild prurities licting burning after intercourse (Kreiger 1995, and Latif, 1987). These may casue Urethritis, prostatis, reversible sterility and semen PH is 78.1 – 8.0 (Gopalkrishnan, 1990). This changes have been attributed to the mechanical trauma by the moving protozoa, but toxins or exotoxins have not be ruled out by the organism. The frothy discharge is probably due to gas produced by the organism (Nester, et al, 2001).
The life cycle of I. Vaginalis is still poorly understood. The trophozoite lives in close association with the epithelia of the urogenital tract (Latif et al, 1987) and reproduces by longitudinal binary fission (Nester et al. 2001). I vaginalis is distributed world wide as a human parasite and has no other reserviors (Nester et al, 2001) the mode of transmission is by intimate or direct copntact with vaginal and urethral discharges of infected persons during sexual intercourse rarely occurs by intimate contact with contaminated articles. The highest rate of infection with multiple sex partners and congenital infection is possible (That is from infected mother to infant at child birth althought infrequent). New born girls can acquire the infection from their infected mothers through birth canal. In such cases, the infection tends to remain a symptomatic unstil puberty (Nester et al, 2001, Bradley, et al, 1993 and public Health Agency Canada (PHAC) 2001). The organism can survive for hours on moist objects such as damp towels clothes and bathtubs of infected women (Lossick, 1989 and Nester et al, 2001). Nonsexual transmission is extremely rare sine i. Vaginalis infection is generally rstricted to a specific sites namely the urogenital tract Ithomason (1989). The only known nonviral form of transmission is through perinatal acquisition. Approximately 5% of female babies born of infected mothers contract the infection (Bramley, 1976). Nevetheless, I. Vaginalis infection in children should at least raise the question of sexual abuse and p[ossible exposure to other sexually transmitted diseases (Nester et al, 2001). Evidence for sexual transmission of I. Vainalis is very strong as prevalence is highest among patients with increased sexual acitivity and mul;tiple partners. Approximately 14-65% of male partners of infected females are also infected (Krieger, 1995, and Sena, 2003). The incubation period before symptoms arise is 4-28 days and years for persistat infection (PHAC, 2001). There is high percentage of a sympstomatic carriers especially among men and this fosters tranmission of the disease (Nester et al, 2001). Asymptomatic infected individuals factors in trichomoniasis transmission. Many studies have shown that treatment of the male partner (s) of infected women improves bsoth cure rates and recurrence rates (Hager, 1980 and lyng, 1981).
1. To determine the prevalence of I. Vaginalis among adults in”Osumenji” in Nnewi South Local Government Area of Anambra state.
2. To determine the age level which are msore susceptible to the infection
3. To determine the sex with higher prevalence of the infection
1.2 HYPOTHESIS
Ho - The prevalence of I. Vaginalis is higher in women than in men.
Hi - The prevalence of I vaginalis is not higher in women than in men
H2 - The prevalence of I vaginalis occurs more in young adults than in older people.
1.3 LIMITATION/SCOPE OF THE STUDY
This study is limited to adults in “Osumenyi” in Nnewi south local Government Area of Anambra state.
1.4 LIMITATION IN THE STUDY
1 There is high cost of the materials involved in the practical work.
2 Also, many individuals failed to willingly give out specimens for analysis due to unawareness and superstitious belief among people ind developing countries when a survey needs volunteers for a case study.
3 Optimal diagnostic method for detecting trichomoniasis among men are unavailable, contributing to low detection inmmen (Krieger, 1993).
1.5 STATEMENT OF PROBLEM
Trichomoniasis is a prevalent sexually transmitted disease (STB) pathogen that will not go away because we ignore it (Bowden and Garneth, 1999). Moreover, according to Duboucher (2003), data collected suggest that trichomonads are overlooked parastites and may be mplicated in various pathologies. Therefore it I pertinent to determine the prevalence of I. Vaginalis among adults.
1.6 JUSTIFICATION OF THE STUDY
The ressults project research revealed high prevalence of I. Vaginalis among adults, therefore, there is need for screening of the adult population from time to time. This is done either individually or by Government policy so as to promote the health of the populace.
LITERATURE REVIEW
Prevalence reflects the number of total existing cases both old and new in a given population at risk at a time (Nester et al, 2001). Prevalence rates of I. Vaginalis vary depending on the patients population studied and diagnostic method used. Disease occurrence correlates with the level of sexual activity of the group of people being studied. Evidence for sexual transmission of I. Vaginalis is very strong as prevalence is highest among patients with increased sexual activity and multiple sex partners. Aproximately 14-65% of males partners of infected females are also infected (Krieger, 1995 and Sena, 2003. In asymptomatic patients attending family planning Clinics, 5% of women had the disease, 13-25% of women attending gynecology clinics, 1-40% of women in sexually transmitted disease (STB) clinics, and 50-75% prostitutes had been diagnosed with
The infection (Heine, 1993). More recently, a prevalence of 16.2% was found among high school students (Both females and males) population (Gaydos, 2003). Prevalence men in infect is characterized by fewer organism than in women. This is possible due to high concentration of zinc and anti-trichomanal substances found in the prostate (Krieger, 1982).
Poor diagnostic method may be another factor contributing to low detection, as the optimal sampling site in men has not been establisheed. Diagnostic method used in men consist of culture techniques, wet mount, and various staining methods (Gram’s, Giemsa, Papancolaou’s, periodic acid-shift, and Acridine orange). Polymerase chain reaction (PCR) has recently emerged as a highly accurate diagnostic method, but presently is used only in research settings. Wet mount examinaation is approximately 50-70% accurate in women and less relaible in men. Urethral cultures will grow I. Vaginalis in only 60% of cases. Staining methods are also accusrate than direct examination and require confirmation by a second method (Prieger, 1995). The prevelance of I. Vaginalis in men varies according to the setting and diagnostic method used. A study by chwebke (2002) comparing PCR to combined urine and urethral cultures found 17% prevalence (52/300). Weadel (2003) studied the prevalence of I. Vaginalis using urine PCR in 355 men. The results shown I.Vaginalis prevalence at 13% versus Chlamyia at 11%. In men over 28 years old, I vaginalis prevalence was 13% versus chamylis at 4%. Saxena conducted study in 1991 using 85 men aged 16-22 years to determine the prevalence of I vaginalis in young men at high risk for sexually trasnmited disease. Prealence of I. Vaginalis was 58% among this high risk group. No single test proved to be ideal for diagnosis. The direct fluorescent antibody test (DFA), using a combination of urethral culture and urine sediment culture as the “gold standard resulted in 60% sensitivity and 73% specificity. The pap smear showed a 3% sensitivity with 96% specificity and wet mount was 33.3% sensitive and 84.6% specific.
A study conducted at the Denver Department of public Helath, of 214 men older than 30 years, showed that trichomoniasis was diagnosed in 5.1% whereas chlamydia was found in 3.3% and gonorrhea in 2.8% Trichomomasis was diagnosed using urine sediment and chlamydia by polymerass chain reaction of urine, and gonorrhea by urethral swab culture. In addition, the duration of symptoms of urethritis was longer among men with either chlamydia (media, 7 days) or gonorrhea (median, 3 days) (Joymer, 2000). According to a study conducted by sena (2003), male partners of I> vaginaliss infected women have a high prevalence of I. Vaginalis. Due to the large number of asymptomatic cases in males and the difficulty in diagnosis, prevalence figures are lower among males an not as readily available compared to the female population (Rein, 1990). A study on sthe incidence of I. Vaginalis amonst pregnant women in Jos area of plateau state of Nigeira was conducted by Anosike et al (1991), using women from Jos rural area. The survey gave 37.6% for those in the metropolis while those in the rural area had 24.8% the PH range of the infected women was found to lie between 6-8. Their vaginal discharges were found ato be frothy and grenish – yellow with a typical a\odour. Some had vulval irritations. Some reported that they had slight temperature rises above 370‑c in the nights. The infected woman either belonged to the working class or were self employed. There was more infection amongst the working class women in the metropolis while the opposite was the case in Jos rural area. Some of the infected women had trichomoniasis alone while some were found to have mixed infections like, trichomoniasis and candidosis, trichomoniasis and gonorrhea. A survey conducted by onwuliri al,(1993) using a total of 2048 urine specimens were examined to asses the infection prevalence and epidemiological factors of 1.vaginals anongst students in Nigeria higher institution. Five hundred and five students were infected (24.7%). This included 131 (15.6%) males and 374 (31 .0%) female. More male than female students were found to be asymptomatic. Infection was significantly higher in females than in males andin the second and third than the fourth and fifty decades of life (p<0.05). infection increase progressively with increase in the number of sexual partners. The use and neglect of condoms were also assessed. The PH range of the vagina of most infected females bwas between 5.8-8.2. clinical symptoms noted among females were local tenderness, vulval pruritus and intermittent in addition to profuse vaginal discharges.
A comparative study of trichomonas vaginalis prevalence among Fillipino women was conducted using 288 women randomly drown from various sources, including social hygiene clinics gealth center and family planing centers in the metropolitan manila area. Ninteen cases (6.8%) were found positive either by wet mount or stained smear method prevalence was significanthy higher among singles than married woen and five times higher among the waitress/ hostesses than housewife other groups. Infection was related to parity and was significantly higher among nulliparous women. Likewise, a significant relationship was observed between prevalence of infection and gravidity. Prevalence decreases with increasin gravidity. No relationship in prevalence was observed bteween the use and non use of contraceptives, and the method of contraceptives used. These was no signifcant association between the presence of the parasite and symptoms (Arambulo et al 1977).
There was prevalence of Trchomoras Vaginalis among prostitutes in Turkey. Prostitutes are an important group for the transmission of a number of sexually transmitted disease (STD) all over the world. Infection with I vaginalis is one of the most common. Prostitutes in Ankara Turkey 64 (25%) of 225 vaginal. There was no significancediffernece between the detection rates of direct phase contrast microscopy and culture for the identification of I. Vaginalis (Tanyukseli, et al, 1996). I. Vaginalis infection is estimated to be the most widely prevalent monviral sexual transmitted infection in the world. Wet-mount microscopy is the most common diagnostic method, although it is less sensitive than culture. The OSOM Trichomonas Rapid test (Henzyme Diagnostic Cambridge, Mass) referred to as Osom is a new point-of-care diagnostic assay for I. Vaginalis. That used an immunochromatographic capillary flow (dipstick) assay and provides results in 10 mins. The test characteristics of OSOM compared to those of a composite reference standard (CRS) comprised of Wet mount microscopy and I. Vaginalis culture. This multicentre cross sectional study enrolled sexually active women > or = 18 years of age who presented with symptoms of vaginitis, exposure to I. Vaginalis, or multiple sexual partners. The prevalence of I. Vaginalis in the sample was 23.4% (105 of 449) by the CRS. The sensitivity and specificity of OSOM vaginal – Swab specimens were 83.3 and 98.8%, respectively, while wet mount had sensitivity and specificity of 71.4 and 100% respectively, compared to the CRS. OSOM performed significantly better, the west mount (P=0.004) and detected I. Vaginalis in samples that required 48 to 72 hours of incubation prior to becoming culture positive. The performance of the rapid test was not affected by the presence of coinfections with chlamydia and gonorhea. The Osom Trichomonas Rapid Test is a simple, objective test that can be expected to improve the diagnosis of I. Vaginalis expected to improve the diagnosis of I. Vaginalis especially where microscopy and culture are unavailable (Wendel et al, 2005).
Prevalence of Trichomonas Vaginalis in patients with vaginal discharge in Lagos Nigeira was conducted by Galadanci, et al (2001). High vaginal swabs were taken from consenting adults with vaginal dischaged. The quantity, colour and odour were noted. Wet-mount microscopy of Giemsa stairing and culture in oxoid ® Trichomonas medium was perormed on each swab. A total of 200 patinents were examined. One hundred and forty-nine (74.5%) had I. Vaginalis there are no statistically significant association between age, marital status, parity, number of sexual partners and prevalence of I. Vaginalis the colour of the discharge was white in 104 (69.8%). None was frothy or greenish. The discharge was heavy white in 50 (33.6%) and malodorous in 51 (34.2%). The PH range 4-7 and 42 (28.2%) normal PH of 4.0. in 4.7 (31.5%) the amino test was negative and the prevalence of I. Vaginalis discharge was high. Women complaining of vaginal discharge should be thoroughly screened for I. Vaginalis using all available method (haladanci, et al, 2001). High prevalene of trichomoniasis in rural men was found in Mivanza, Tanzania: by Buve, et al, (2000). A cross sectional study of 1004 men afed 15-54 years in a total rural community in north west Tanzania was conducted using wet preparation and culture. Neisseria gonorrhea by culture, Chlamydia trichomatis by Ligase chain reaction and non-specific urethretis by Gram stain. Men were interviewed 2 weeks later to document men symptons and signs of Urethritis. Complete Laboratory results were available on 980 men. One in four men had laboratory evidence of urethritis. I. Vaginalis was found in 109 individuals (11%), gonorrhea in eight (0.8%) and Chlamydia infection in 15 (1.5%). Over 50% men with Urethritis were asymptomatic. The prevalence of signs and symptoms was similar among men with I. Vaginalis alone compared with men with other urethral infection. The sensitivity and specificity of the leucocytes esterase dipstick (LED) test for deteching I. Vaginalis were 80% and 48% respectively in symptomatic men and 60% and 68% in asymptomatic men. Factors associated with trichomoniasis included religion types of employment and marital status. A high prevaelnce of urethritis was found in men in the community based study. More than half of the urethral infections detected were a symptomatic.The most prevalent pathogen was I… vaginslis.Studies are needed on the prevalence of Tricchomasis in men presenting to health services with complaints suggestive of urethritis sincce treatment for T.vaginalis is not included in the syndromic management of urethritis in most countries.The performance of the LED test as a screening test for trichomoniasis was unsatisfactory in both symptomatic and asymptomatic men. Improved screening test are urgently needed to identify urethral infections that are asymptomatic and which aaaaare not covered by current sydromic management algorithms.
Although Trichomonas vaginalis is common sexually transmitted pathogen, the significance and natural history of trichomoniasis remaining on defined in the male patients. According to rieger etal (19893) a longitudinal study was conducted to examine the relationship of I. Vaginalis to nongonococcal urethritis in men and to ilncrease our understanding of the natural history of this infection. As previously reported; I. Vaginalis was isolated from 50 of 447 men adding a sexially transmitted disease clinic by culture of urethra, first void urine at external genitalia. Semen cultures proved valuable for documentation in selected cases, including of instances when concitant cultures of the external of the external genitatia, Urethral and first-void urine sediment were all negative.
Three hundred and twenty five men with confined urethral trichomoniasis were seen at sexually trasnmitted clinics in Harare, Zimbabwe, in 1983-1984. The mean age of these patients was 30 years. The most common symptoms were 30 years. The most common symptoms were urethral discharge and urethral irritation trichomoral, non gonococcal urethritis had had symptoms for this length of time. In most patients with trichomoniasis (99.4%). The discharge was milky white and fluid in nature; when a smear of the discharge was made on a glass slide, small climps of mateirals were noted. Microscopic examination of the gram-stained smear showed relatiive epithelial cells. Although Trichomonas vaginalis was readily demonstrated by microscopy of both Urethral secretions and centrifuges deposits urethral exudates. Concomitant infection with I. Vaginalis was uncommon in patients with proved gonococcal urethritis. Treatment of 400mg of metronidazole thrice daily for five days gave a cure rate of 100% (Latif, et al, 1987).
Recently, a growing body of literature has limked I. Vaginalis infection to a variety of health complications among both men and women. The associationn between I. Vaginalis and cervical neoplasia has been reported in many studied since the early 1950s. it has been suggested that this organism is responsible for the indduction of of change in the human cervical mucosa result in dyplasia or carcinonia 9bech told, 1952). A prospective, longitudinal cohort studyu following over 19,000 women screening program for up to 10 years period was done to determine if women with cytologically diagnosed infection (I. Vaginalis, herpe, or HIV) preceded developmnet of cervical neoplasis I. Vaginalis was shown to be associated with a high relative risk (or 6.4) of subsequent cervical neoplasia. This was similar to risks found with HPV (OR = 5.5) or herpes infection (OR=12) and development of subsequent cervical neoplasia (ViiKKi, 2000).
Studies have shown I. Vaginalis to be a risk factor in infertility. Trichomonads attach to Mucosa membrane and many serve as vectors for spread of other organisms by carrying these pathogens up to the fallopia
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