# Trichomonas vaginalis Infection among Pregnant Women in Jimma University Specialized  Hospital, Southwest Ethiopia

Authors: Abdurehman Eshete; Zeleke Mekonnen; Ahmed Zeynudin
Journal: ISRN Infectious Diseases
 (2013)

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## Abstract

Background. Trichomonas vaginalis is a sexually transmitted parasitic protozoan known to be responsible for an estimated 180 million new infections per year, making it the most prevalent nonviral sexually transmitted pathogen worldwide. Method. A cross-sectional study design was conducted on vaginal swabs by wet mount and Modified Columbia Agar culture technique in Jimma University Specialized Hospital (JUSH), ANC clinic, Jimma, Ethiopia. The study was done to assess the magnitude and associated risk factors of T. vaginalis infection from December to May, 2011/2012.
Result. A total of 361 pregnant women were involved in this study. From these, 18 (4.98%) of the pregnant women were positive for T. vaginalis infection by Modified Columbian Agar culture technique. Education status (AOR = 0.186, 95% CI: 0.059–0.585, P<0.05), patients with dysuria (AOR = 0.180; 95% CI: 0.046–0.704, P<0.05) and dyspareunia (AOR = 0.152; 95% CI: 0.035–0.667, P<0.05) were significantly associated with T. vaginalis infection. Conclusion. The prevalence of T. vaginalis infection at 4.89% is relatively high among young reproductive aged women. Because this infection increases the risk of HIV transmission and is associated with adverse pregnancy outcomes, there is a need for increased provision of health information concerning T. vaginalis to the community, educating women, screening, and treatment of T. vaginalis infection in Ethiopia.


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## Body

## 1. Introduction

Trichomonas vaginalis is a flagellated protozoan possessing five flagella, four of which are located at its anterior portion. The fifth flagellum is incorporated within the undulating membrane of the parasite, which is supported by a slender noncontractile costa. This parasite varies in size and shape, with the average length and width being 13 and 10 μm. The life cycle of T. vaginalis is simple and involves only the direct transmission of viable trophozoite. Unlike many protozoan parasites, it possesses trophozoite form and lacks cyst stage. It has a cosmopolitan distribution and has been identified in all racial group and socioeconomic strata; however, it has been encountered in every continent and climate, with no seasonal variability.  T. vaginalis infections are commonly associated with other sexually transmitted diseases (STDs) [1, 2].Trichomonas vaginalis, an anaerobic, parasitic, is the causative agent of trichomoniasis and is the most common pathogenic protozoan infection of humans in the industrialized countries. The flagellate was originally considered a commensal organism until the 1950s when the understanding of its role as a sexually transmitted infection (STI) began to evolve. Humans are the only known host with the trophozoite transmitted via fomites. Both males and females are infected but the majority of cases were reported among females who also present with symptomatic infection than males. In females, vaginitis is the most common manifestation of the infection. Complications include the infection of the adnexa, skin, endometrium, and Bartholin glands. The  pregnant women infected with this parasite may be at risk of an adverse birth out comes like postabortion or posthysterectomy infection, as well as infertility and enhanced predisposition to neoplastic transformation in cervical tissues [3].Trichomonas   vaginalis is   a   sexually transmitted parasitic protozoan known to be responsible for an estimated 180 million new infections per year, making it the most prevalent nonviral sexually transmitted   pathogen worldwide.  It can also be transmitted to neonates during   passage   through   an   infected birth canal, but the infection is usually asymptomatic. Trichomonas vaginalis infection   is   frequently asymptomatic in adults; it can cause urethritis in men.   Symptomatic   women   with trichomoniasis   usually   complain   of vaginal   discharge,   vulvovaginal   soreness,   and/or   irritation. Complications   of trichomonal   vaginitis   that   have   been reported include premature rupture of membranes,   premature   labour,   low birth weight [4, 5].Trichomoniasis has neither been the focus of intensive study nor of active control programs in the sub Saharan   Africa and this neglect likely a function of the relatively mild nature of the disease. However available evidence suggests thatT. vaginalis may play a critical and under recognized role in amplifying human immunodeficiency virus   (HIV)   transmission and, in some circumstances, may have a major   impact   on the epidemic   dynamics   of HIV infection   and   the   acquired   immunodeficiency   syndrome (AIDS) in the sub-Saharan Africa [6].Trichomoniasis is often asymptomatic in men, however in more than half of the infected women manifests vaginitis, cervicitis, urethritis, and irritation with frothy malodorous discharge. Negative outcomes of this infection are especially significant during pregnancy.T. vaginalis can lead to urogenital tract infection. The incidence of vaginal trichomoniasis has noticeably risen especially in developing countries and in populations with high-risk behaviors such as poor sexual activity hygiene and multiple sexual partners. Poverty, socioeconomic status, low educational level, high risk sexual behaviors, prisoners, and HIV+ or HBV+ infected people  are risk factors for acquiring STDs such as vaginal trichomoniasis [7].The parasite also causes nongonococcal urethritis, prostatitis, and perhaps other lower genitourinary tract syndromes in infected men.  Concomitant infection with other urethral pathogens such as Neisseria gonorrhoeae and/or Chlamydia trachomatis has also been found to be common in men and women with trichomoniasis.Trichomonas vaginalis infection is one of the most common curable sexually transmitted infections. Untreated infection can persist up to 5 years [8, 9]. So, the objective of this study was to assess the magnitude and associated risk factors of T. vaginalis infection in the study area.


## 2. Materials and Methods

### 2.1. Study Area

The study was conducted in Jimma University Specialized Hospital (JUSH), ANC clinic. Jimma University specialized hospital is found in Jimma town. The town is located 335 kms southwest of the capital Addis Ababa. The town has a characteristic of tropical highland climate condition, heavy rain fall, warm temperature, and long wet period [10]. The hospital serves a total of five million populations in southwest Ethiopia.


### 2.2. Study Design and Subjects

A facility-based cross-sectional study was conducted from December, 2011 to May, 2012. A total of 361 pregnant women in any of the three trimesters were participated in this study.  Pregnant women who had vaginal medication and sexual intercourse in the previous 3 days prior to data collection were excluded from the study.


### 2.3. Data Collection Procedures

Sociodemographic and data on predisposing factors were collected using predesigned questionnaire by trained nurses. Moreover,  two vaginal swabs were collected by trained clinical nurses for laboratory investigation. Wet smear was prepared from the first swab and immediately examined by experienced medical laboratory technologist. The second vaginal swab was placed in phosphate buffer saline solution and inoculated in Modified Columbia Agar (Columbia agar and Malt extract Oxoid ltd Basingstoke HANTS England, Dextrose Oxoid ltd Basingstoke Hampshire England, Streptomycin and Penicillin  CSPC Zhongnuo Pharmaceutical (Shijiazhuang) co. ltd China, Chloramphenicol KARNATAKA antibiotics and pharmaceuticals limited India, Nystatin (Mycostatin) Amman pharmaceutical industries co. Jordan) in petri dishes. Culture and identification ofT. vaginalis were done following the procedures as described by [11].


### 2.4. Data Analysis

The result was noted on data collection format. Finally the data was edited and entered into computer and analyzed using SPSS version 16.00 windows software. Descriptive statistics, Chi-square test, bivariate and multivariate logistic regressions were used for the analysis, takingP values less than 0.05 considered as significant. All the sociodemographic and clinical characteristics were tested by bivariate binary logistic regression and whose values less than 0.025 included in the multivariate binary logistic regression analysis.


### 2.5. Ethical Considerations

Ethical clearance was obtained from Jimma University ethical review committee. The purpose of the study was clearly explained for the study subjects, and written consent was obtained from each study participants. Confidentiality of the result was kept by coding patient information and specimen.


## 2.1. Study Area

The study was conducted in Jimma University Specialized Hospital (JUSH), ANC clinic. Jimma University specialized hospital is found in Jimma town. The town is located 335 kms southwest of the capital Addis Ababa. The town has a characteristic of tropical highland climate condition, heavy rain fall, warm temperature, and long wet period [10]. The hospital serves a total of five million populations in southwest Ethiopia.


## 2.2. Study Design and Subjects

A facility-based cross-sectional study was conducted from December, 2011 to May, 2012. A total of 361 pregnant women in any of the three trimesters were participated in this study.  Pregnant women who had vaginal medication and sexual intercourse in the previous 3 days prior to data collection were excluded from the study.


## 2.3. Data Collection Procedures

Sociodemographic and data on predisposing factors were collected using predesigned questionnaire by trained nurses. Moreover,  two vaginal swabs were collected by trained clinical nurses for laboratory investigation. Wet smear was prepared from the first swab and immediately examined by experienced medical laboratory technologist. The second vaginal swab was placed in phosphate buffer saline solution and inoculated in Modified Columbia Agar (Columbia agar and Malt extract Oxoid ltd Basingstoke HANTS England, Dextrose Oxoid ltd Basingstoke Hampshire England, Streptomycin and Penicillin  CSPC Zhongnuo Pharmaceutical (Shijiazhuang) co. ltd China, Chloramphenicol KARNATAKA antibiotics and pharmaceuticals limited India, Nystatin (Mycostatin) Amman pharmaceutical industries co. Jordan) in petri dishes. Culture and identification ofT. vaginalis were done following the procedures as described by [11].


## 2.4. Data Analysis

The result was noted on data collection format. Finally the data was edited and entered into computer and analyzed using SPSS version 16.00 windows software. Descriptive statistics, Chi-square test, bivariate and multivariate logistic regressions were used for the analysis, takingP values less than 0.05 considered as significant. All the sociodemographic and clinical characteristics were tested by bivariate binary logistic regression and whose values less than 0.025 included in the multivariate binary logistic regression analysis.


## 2.5. Ethical Considerations

Ethical clearance was obtained from Jimma University ethical review committee. The purpose of the study was clearly explained for the study subjects, and written consent was obtained from each study participants. Confidentiality of the result was kept by coding patient information and specimen.


## 3. Results

### 3.1. Sociodemographic Characteristics

A total of 361 pregnant women of age ranging 15 to 36 years with mean age24.4±4.56 (mean ± SD) had participated in this study. Greater than half (54.8%) of the study participants were in the age range of 15–24 years. Majority of the study participants (38.8%) were unemployed. One hundred ninety three (53.5%) of the study participants were from urban areas. Majority of the study participants were married (93.1%) and literate (can read and write) (76%) (Table 1).Table 1
Demographic characteristics versus Modified Columbia Agar culture result in pregnant women at Jimma University specialized hospital, 2012.
Variables
Culture result
P value
Positive (%)
Negative (%)
Age
15–24 years
9 (4.5)
189 (95.5)
0.697
25–34 years
9 (5.8)
146 (94.2)
35–44 years
0
8 (100)
Residence
Urban
5 (2.6)
188 (97.4)
0.025
Rural
13 (7.7)
155 (92.3)
Occupation
Farmer
2 (5.4)
35 (94.6)
0.291
Merchant
1 (5.9)
16 (94.1)
Employed
0
74 (100)
Unemployed
9 (6.4)
131 (93.6)
Others
6 (6.5)
87 (93.5)
Marital status
Single
0
6 (100)
0.075
Divorced
3 (15.8)
16 (84.2)
Married
15 (4.5)
321 (95.5)
Educational status
Illiterate
12 (13.8)
75 (86.2)
0.001
1–4 grade
1 (1.9)
52 (98.1)
5–8 grade
5 (6.6)
71 (93.4)
9–12 grade
0
118 (100)
>2 grade
0
27 (100)


### 3.2. Risk Factors Associated withT. vaginalis Infection

With regard to association ofT. vaginalis infection with marital status, 336 (93.1%) of the study participants were married. From these, 15 (4.5%) were positive for T. vaginalis. There is no significant association between T. vaginalis infection and marital status (P=0.075). Whereas in relation to residence, 168 (465%) of the study participants were from rural areas. From these, 13 (7.7%) were infected by T. vaginalis infection. In association with occupation with T. vaginalis infection, 140 (38.8%) of the study participants were unemployed, from these, 9 (6.4%) were positive for T. vaginalis.  There is no significant association between T. vaginalis infection, residence and occupation (Table 1).Most of the study participants (56.5%) were in the third trimester of pregnancy. From these, 11 (5.4%) were positive forT. vaginalis. There was no significance difference (P=0.802) in T. vaginalis infection rate among the trimesters. The same as, two hundred fifty four (70.3%) of the study participants were taken shower once/week. From these, 12 (4.7%) were positive for T. vaginalis. There is no significant association (P=0.94) between T. vaginalis infection and personal hygiene. Also, about half (50.7%) of the study participants who reported presence of vaginal discharge, 15 (8.2%) were positive for T. vaginalis. Participants who reported to have vaginal discharge showed significant association with T. vaginalis infection by the bivariate analysis (P<0.05). With the same manner vaginal itching was reported by 66 (18.3%) of the study participants. From these, 11 (16.7%) were positive for T. vaginalis infection. Participants reported to have vaginal itching showed significant association by the bivariate analysis (P<0.05). Most of the study participants 293 (81.2%) who reported to have one sexual partner, 15 (15.8%) were positive for T. vaginalis. There is no significant association (P=0.809) between T. vaginalisinfection and number of sex partner. One hundred fifty one (41.8%) and 67 (18.6%) of the study participants were reported the usage of Depo-Provera and pills (oral contraceptives) before pregnancy, respectively. There is no significant association between T. vaginalis infection and contraceptives usage before pregnancy. Finally study subjects who reported sharing of internal clothes 4 (11.4%), no usage of common bath 14 (4.5%), and no sharing of toilet 18 (5.7%) were positive for T. vaginalis (Table 2).Table 2
Clinical characteristics versus Modified Columbia Agar culture result in pregnant women (n=361) at Jimma university specialized hospital, 2012.
Variables
Culture result
P value
Positive (%)
Negative (%)
Trimester
1st
1 (2.8)
35 (97.2)
0.802
2nd
6 (5)
115 (95)
3rd
11 (5.4)
193 (94.6)
Personal hygiene (shower) with soap
≥3x/week
1 (5.6)
17 (94.4)
0.94
2x/week
5 (5.6)
84 (94.4)
Once/week
12 (4.7)
242 (95.3)
Vaginal discharge
Yes
15 (8.2)
168 (91.8)
0.004
No
3 (1.7)
175 (98.3)
Vaginal itching
Yes
11 (16.7)
55 (83.3)
0.001
No
7 (2.4)
288 (97.6)
Dysuria
Yes
13 (21)
49 (79)
0.001
No
5 (1.7)
294 (83.3)
Dyspareunia
Yes
15 (15.8)
80 (84.2)
0.001
No
3 (1.1)
263 (98.9)
Sex partner
One
15 (5.1)
278 (94.9)
0.809
≥2
3 (4.4)
65 (95.6)
Contraceptives used before pregnancy
Pills
8 (11.9)
59 (88.1)
0.002
Depo-Provera
2 (1.3)
149 (98.7)
Norplant
0
5 (100)
Loop
1 (33.3)
2 (66.7)
No
7 (5.2)
128 (94.8)
Sharing of internal clothes
Yes
4 (11.4)
31 (88.6)
0.065
No
14 (4.3)
312 (95.7)
Use of common bath
Yes
0
35 (100)
0.154
No
18 (5.5)
308 (94.5)
Sharing of toilet
Yes
0
44 (100)
0.105
No
18 (5.7)
299 (94.3)After adjusting for the other variables, education status (AOR = 0.186, 95% CI: 0.059–0.585,P<0.05), patients with dysuria (AOR = 0.180; 95% CI: 0.046–0.704, P<0.05) and dyspareunia (AOR = 0.152; 95% CI: 0.035–0.667, P<0.05) were significantly associated with T. vaginalis infection by the multivariate analysis (Table 3).Table 3
Bivariate and multivariate binary logistic analyses of demographic and clinical characteristics ofT. vaginalis at Jimma University Specialized Hospital, 2012.
Variables
Culture result
COR
95% CI
AOR
95% CI
P value
Positive (%)
Negative (%)
Educational status
Literate
6 (2.2)
268 (97.8)
1
1
Illiterate
12 (13.8)
75 (86.2)
7.147
2.595–19.678
0.186
0.059–0.585
0.004
Dysuria
Yes
13 (21)
49 (79)
0.064
0.022–0.188
0.180
0.046–0.704
0.014
No
5 (1.7)
294 (98.3)
1
1
Dyspareunia
Yes
15 (15.8)
80 (84.2)
0.061
0.017–0.215
0.152
0.035–0.667
0.013
No
3 (1.1)
263 (98.9)
1
1
Statistically significant atP<0.05, COR: crude odds ratio, AOR: adjusted odds ratio, CI: confidence interval.


## 3.1. Sociodemographic Characteristics

A total of 361 pregnant women of age ranging 15 to 36 years with mean age24.4±4.56 (mean ± SD) had participated in this study. Greater than half (54.8%) of the study participants were in the age range of 15–24 years. Majority of the study participants (38.8%) were unemployed. One hundred ninety three (53.5%) of the study participants were from urban areas. Majority of the study participants were married (93.1%) and literate (can read and write) (76%) (Table 1).Table 1
Demographic characteristics versus Modified Columbia Agar culture result in pregnant women at Jimma University specialized hospital, 2012.
Variables
Culture result
P value
Positive (%)
Negative (%)
Age
15–24 years
9 (4.5)
189 (95.5)
0.697
25–34 years
9 (5.8)
146 (94.2)
35–44 years
0
8 (100)
Residence
Urban
5 (2.6)
188 (97.4)
0.025
Rural
13 (7.7)
155 (92.3)
Occupation
Farmer
2 (5.4)
35 (94.6)
0.291
Merchant
1 (5.9)
16 (94.1)
Employed
0
74 (100)
Unemployed
9 (6.4)
131 (93.6)
Others
6 (6.5)
87 (93.5)
Marital status
Single
0
6 (100)
0.075
Divorced
3 (15.8)
16 (84.2)
Married
15 (4.5)
321 (95.5)
Educational status
Illiterate
12 (13.8)
75 (86.2)
0.001
1–4 grade
1 (1.9)
52 (98.1)
5–8 grade
5 (6.6)
71 (93.4)
9–12 grade
0
118 (100)
>2 grade
0
27 (100)


## 3.2. Risk Factors Associated withT. vaginalis Infection

With regard to association ofT. vaginalis infection with marital status, 336 (93.1%) of the study participants were married. From these, 15 (4.5%) were positive for T. vaginalis. There is no significant association between T. vaginalis infection and marital status (P=0.075). Whereas in relation to residence, 168 (465%) of the study participants were from rural areas. From these, 13 (7.7%) were infected by T. vaginalis infection. In association with occupation with T. vaginalis infection, 140 (38.8%) of the study participants were unemployed, from these, 9 (6.4%) were positive for T. vaginalis.  There is no significant association between T. vaginalis infection, residence and occupation (Table 1).Most of the study participants (56.5%) were in the third trimester of pregnancy. From these, 11 (5.4%) were positive forT. vaginalis. There was no significance difference (P=0.802) in T. vaginalis infection rate among the trimesters. The same as, two hundred fifty four (70.3%) of the study participants were taken shower once/week. From these, 12 (4.7%) were positive for T. vaginalis. There is no significant association (P=0.94) between T. vaginalis infection and personal hygiene. Also, about half (50.7%) of the study participants who reported presence of vaginal discharge, 15 (8.2%) were positive for T. vaginalis. Participants who reported to have vaginal discharge showed significant association with T. vaginalis infection by the bivariate analysis (P<0.05). With the same manner vaginal itching was reported by 66 (18.3%) of the study participants. From these, 11 (16.7%) were positive for T. vaginalis infection. Participants reported to have vaginal itching showed significant association by the bivariate analysis (P<0.05). Most of the study participants 293 (81.2%) who reported to have one sexual partner, 15 (15.8%) were positive for T. vaginalis. There is no significant association (P=0.809) between T. vaginalisinfection and number of sex partner. One hundred fifty one (41.8%) and 67 (18.6%) of the study participants were reported the usage of Depo-Provera and pills (oral contraceptives) before pregnancy, respectively. There is no significant association between T. vaginalis infection and contraceptives usage before pregnancy. Finally study subjects who reported sharing of internal clothes 4 (11.4%), no usage of common bath 14 (4.5%), and no sharing of toilet 18 (5.7%) were positive for T. vaginalis (Table 2).Table 2
Clinical characteristics versus Modified Columbia Agar culture result in pregnant women (n=361) at Jimma university specialized hospital, 2012.
Variables
Culture result
P value
Positive (%)
Negative (%)
Trimester
1st
1 (2.8)
35 (97.2)
0.802
2nd
6 (5)
115 (95)
3rd
11 (5.4)
193 (94.6)
Personal hygiene (shower) with soap
≥3x/week
1 (5.6)
17 (94.4)
0.94
2x/week
5 (5.6)
84 (94.4)
Once/week
12 (4.7)
242 (95.3)
Vaginal discharge
Yes
15 (8.2)
168 (91.8)
0.004
No
3 (1.7)
175 (98.3)
Vaginal itching
Yes
11 (16.7)
55 (83.3)
0.001
No
7 (2.4)
288 (97.6)
Dysuria
Yes
13 (21)
49 (79)
0.001
No
5 (1.7)
294 (83.3)
Dyspareunia
Yes
15 (15.8)
80 (84.2)
0.001
No
3 (1.1)
263 (98.9)
Sex partner
One
15 (5.1)
278 (94.9)
0.809
≥2
3 (4.4)
65 (95.6)
Contraceptives used before pregnancy
Pills
8 (11.9)
59 (88.1)
0.002
Depo-Provera
2 (1.3)
149 (98.7)
Norplant
0
5 (100)
Loop
1 (33.3)
2 (66.7)
No
7 (5.2)
128 (94.8)
Sharing of internal clothes
Yes
4 (11.4)
31 (88.6)
0.065
No
14 (4.3)
312 (95.7)
Use of common bath
Yes
0
35 (100)
0.154
No
18 (5.5)
308 (94.5)
Sharing of toilet
Yes
0
44 (100)
0.105
No
18 (5.7)
299 (94.3)After adjusting for the other variables, education status (AOR = 0.186, 95% CI: 0.059–0.585,P<0.05), patients with dysuria (AOR = 0.180; 95% CI: 0.046–0.704, P<0.05) and dyspareunia (AOR = 0.152; 95% CI: 0.035–0.667, P<0.05) were significantly associated with T. vaginalis infection by the multivariate analysis (Table 3).Table 3
Bivariate and multivariate binary logistic analyses of demographic and clinical characteristics ofT. vaginalis at Jimma University Specialized Hospital, 2012.
Variables
Culture result
COR
95% CI
AOR
95% CI
P value
Positive (%)
Negative (%)
Educational status
Literate
6 (2.2)
268 (97.8)
1
1
Illiterate
12 (13.8)
75 (86.2)
7.147
2.595–19.678
0.186
0.059–0.585
0.004
Dysuria
Yes
13 (21)
49 (79)
0.064
0.022–0.188
0.180
0.046–0.704
0.014
No
5 (1.7)
294 (98.3)
1
1
Dyspareunia
Yes
15 (15.8)
80 (84.2)
0.061
0.017–0.215
0.152
0.035–0.667
0.013
No
3 (1.1)
263 (98.9)
1
1
Statistically significant atP<0.05, COR: crude odds ratio, AOR: adjusted odds ratio, CI: confidence interval.


## 4. Discussion

The prevalence ofT. vaginalis in this study area was 4.98%. The finding of this study was lower than reports from Nigeria 18.66% [12], Tehran 10.2% [13], India 8.5% [14], Zambia 27.1% [15], Sri Lanka 6.9% and 7.2% [16, 17], Maharashtra India 12.06% [18], Sudan 7.3% [19], and Maryland 12.6% [20].On the other hand, the prevalence of this study was higher than the studies conducted in US 2.8% [21] and Iran 2.1% [22]. Also, the prevalence of this study was comparable with the study conducted in Iraq 5.4% [23] and Argentina 4% [24]. The observed difference in the rate of infection could be due to variation in age distribution, personal hygiene practice, climatic conditions, socioeconomic and literacy status of the pregnant women.In this study risk factors like vaginal discharge, vaginal itching, dysuria, dyspareunia, and contraceptives used before pregnancy had significant association withT. vaginalis infection which is consistent with other studies conducted in Iran [13], Sri Lanka [16, 17], and India [14].In this study most of theT. vaginalis infected women were married and reported their spouse were their main sex partner which was consistent with the studies done in India [14], but inconsistent with the study done in Tehran [13].  Most of the T. vaginalis infected pregnant women in this study were illiterate (cannot read and write) which is different from the study conducted in Sri Lanka [17] and Hamadan city, western Iran [22].Majority of the pregnant women who used pills (oral contraceptives) before pregnancy were more infected byT. vaginalis infection which is consistent with the study conducted in Tehran [13].



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