Epidemiology of Trichomons vaginalis among pregnant women attending antenatal care in Ipokia Local Government Area of Ogun State, Nigeria

The study assessed the epidemiology of Trichomonas vaginalis among 200 pregnant women aged between 15-45 years attending antenatal care in three private hospitals in Idiroko, Ipokia Local Government Area of Ogun State, Nigeria. Direct wet mount microscopy and culture were used on High Vaginal swabs collected from the consented participants after the administration of questionnaire to collect their knowledge, attitude and practice (KAP) with regard to the Trichomoniasis. The educational profile showed that 23% had primary education while 60% had secondary education. Age group between 15-25years 174(67%) of the participants were traders. 30(15%) Prevalence were positive for Trichomonas from wet mount microscopy method while no positive was recorded in the cultures. There was a statistical difference between number of sexual partners, occupation, family type and previous sexually transmitted infection. 114(57%) of respondents have not heard of sexually transmitted disease while 173(86%) of respondents were not aware that Trichomoniasis is a sexually transmitted disease.

The educational profile showed that 23% had primary education while 60% had secondary education. Age group between 15-25years 174(67%) of the participants were traders. 30(15%) Prevalence were positive for Trichomonas from wet mount microscopy method while no positive was recorded in the cultures. There was a statistical difference between number of sexual partners, occupation, family type and previous sexually transmitted infection. 114(57%) of respondents have not heard of sexually transmitted disease while 173(86%) of respondents were not aware that Trichomoniasis is a sexually transmitted disease.

Introduction
Trichomonas vaginalis is an ovoid parasitic protozoan, which causes trichomoniasis in humans. The parasite lives in the female lower genital tract (vulva, vagina, or urethra), including the male urethra and prostate, where they replicate asexually by binary fission. Trichomoniasis is the most curable Sexually Transmitted Infection (STI) with a worldwide annual prevalence range of 170-180 million. It affects an estimate of 248 million people worldwide and about 40% of these people are in the African region [1].
Based on wet mount microscopy sensitivity, the World Health Organization estimated that the global prevalence, ranges from 60-80 % [2] while an estimated 42.8 million are in African region [3]. Trichomonas vaginalis is the most common Sexually Transmitted parasitic Disease (STPDs) in Nigeria; and studies on STPDs remain relatively scanty [4].
This infection ranks third after bacterial vaginosis and candidiasis among the diseases that commonly progress to vaginal symptoms [5]. Infection with Sexually Transmitted Parasitic Diseases (STPDs) has resulted in debilitation or anatomic deformities that make sex impossible as a result of direct damage to the male and female reproductive organs including impairing fertility via the inhibition of gamete production [6].
Factors such as poor personal hygiene, sexual recklessness, multiple sex partners, low socio-economic status, increase in poverty and underdevelopment are associated with high incidence of infection [7,8]. However, T vaginalis is rarely transmitted through contaminated specula or toilet seats because the parasite dies quickly in a dry environment [9].
A vaginal pH level < 4.6 has been identified as a risk factor for trichomoniasis , but Brotman et al., 2012 [10] revealed that 90% of women with trichomoniasis have a pH level > 4.5, which is a criterion for diagnosing Bacterial vaginosis, T. vaginalis infection or both. Women with trichomoniasis may notice a characteristic frothy greenish vaginal discharge; itching, burning, painful urination and may have small punctuated haemorrhagic spots on the vaginal and cervical mucosa. Symptoms are cyclic and worsen around the time of menses [11]. Trichomoniasis predisposes women to HIV, Pelvic Inflammatory Disease (PID), cervical cancer, and other sexually transmitted diseases including Chlamydia and Gonorrhea [12]. Pregnant women infected with T. vaginalis are at risk for adverse pregnancy outcomes which may include premature rupture of membranes, premature labor and post-abortion infections [13].
Available data shows that prevalence of trichomoniasis range from about 0% to as high as 58% in Nigeria [14,15]. A research study carried out by Anosike et al., 1993 [16] shows 37% prevalence among females in a higher institution in Aba, Nigeria.
Trichomoniasis is the most curable sexually transmitted infection worldwide. There is still high prevalence in Nigeria and this made it a compelling public health concern due to its contribution to poor health outcome especially to neonates. Despite the availability of drugs, trichomoniasis is relatively neglected compared to other sexually transmitted diseases. This study was therefore designed to ascertain the epidemiology of Trichomonas vaginalis among the study population as they relate to such to the risk factors that may predispose a population to the disease, and to compare the sensitivity of wet mount microscopy with culture technique in the diagnosis of trichomoniasis which will help to create awareness among participants and promote a healthy sexual life.

Study Area
The study was conducted in Idiroko, Ipokia Local Government Area of Ogun State using three major private hospitals which Includes: Mayowa Clinic and Maternity; Remi Clinic and Maternity; Ire-Ayo Maternity.
Ipokia L.G.A has a coordinate of 60 32`N 20 51`E with a land mark of 629km2 (243sq mi) and a total population of 150,426 according to 2006 census. This is a typical rural-urban settings lacking in basic amenities like good roads, electricity and poor housing made of mud with inhabitants facing poor sanitation, lack of proper drainage channels and erosion. The dominant ethnic group is Yoruba. Islam and Christianity are the common religious group.

Study Design
This was a cross-sectional descriptive study. A total of 200 consented pregnant women attending antenatal care within the ages of 15-45years were selected for the study. The sample size was computed with a 20% prevalence of Trichomonas vaginalis based on research conducted in Ogun State and a precision of 0.05% at 95% confidence interval [17].

Sample Collection
Two samples were collected from each consented pregnant woman to determine the Trichomonas vaginalis status of the individual using sterile disposable vaginal swab stick and speculum. Each sample collected was coded to matche the individual survey number on the questionnaire. Two sterile cotton tipped swab sticks, one after the other were inserted at least 2.5 cm (1 in.) with a sterile speculum into the vagina of each pregnant woman by a clinician to collect vaginal discharge.

Laboratory Analysis
The HVS samples were analyzed at the point of collection in the various hospitals while samples for cultures were taken to the Parasitology Unit of Microbiology Department of Nigerian Institute of Medical Research (NIMR) at Yaba, Lagos, Nigeria.

Parasitological Examinations
All HVS samples were examined by wet microscopy at the point of collection with the assistant of laboratory technicians after collection. A drop of the vaginal exudates was mixed with a drop of normal saline and emulsified exudates was placed on a clean grease-free slide, cover slip was gently placed. The preparation was examined for motile flagellates under the microscope using x10 and x40 objective lenses.

Culture Examination
The swabs with the vaginal discharge were removed from the Stuart's transport media and used for inoculation.
Culture were placed into Trichomonas Medium (Oxoid) enriched with sterile bovine serum. Both microscopically trichomonads negative and positive high vaginal swabs samples were cultured in labeled sterile bijou bottles. The cultures were incubated at 360C. Afterwards, the smears obtained from the culture were examined microscopically each day for 7 days at 24 hours interval for the presence of T. vaginalis and were discarded as negative on the seventh day.

Ethical Consideration
Ethical approval was obtained from the Institutional Review Board of Nigerian Institute of Medical Research, Yaba. Lagos, Nigeria. Written and verbal consent was obtained from the participating hospitals and pregnant women before the study commenced. Questionnaires were assigned unique codes and the result of each participant's questionnaire and test were kept in confidence.

Data Analysis
Data analysis was done using Microsoft Excel 2010 and Statistical Package for Social Science (SPSS), version 23.0, calculated p-values were considered to be statistically significant with p < 0.05 using Chi-square test  Table 1 shows the Prevalence of T. vaginalis in the surveyed hospitals in Ipokia Local Government Area of Ogun State, Ireti-Ayo Maternity had the highest prevalence of 18(16.7%) and Remi-Clinic with the lowest prevalence of 2(6.7%). Table 2 showed the study population comprising age group between 15-45years. The highest percentage prevalence was recorded among age group 15-25years (63%) and the lowest from 37years and above (10%).

Out
The Socio-demographic characteristics of respondents in Table 2 also discovered that participants with secondary educational status had the highest prevalence of the infection (60%) and those with tertiary having the lowest (17%). The occupation with highest prevalence are traders (67%) while Islamic religion had the highest numbers of positive cases (63%). Table 3 shows the Risk factors associated with trichomonaisis in pregnant women that participated in the study. These includes.

Discussion
Trichomoniasis is an unpleasant parasitic infection that can go undiagnosed for years and is mainly transmitted by asymptomatic carriers. These asymptomatic carries may develop symptoms like vaginitis, cervicitis, urethritis and adverse birth consequences in pregnant women as time progresses [18,19,5]. Disease prevalence is variable and diagnoses are often difficult due to the nature of the organism and the noncompliance of subject to either accept the presence of the symptoms or to submit themselves for screening probably for personal reasons. This study observed that higher prevalence was recorded in one of the hospitals (Ire-Ayo) which double as a maternity. Participants who attended the maternity were low income earners and the uneducated. This study indicated that all samples diagnosed by culture were negative which may be as a result of delay in diagnosis and transportation to the laboratory.
Meanwhile, the study shows the highest prevalence with respect to age group to be among the age range of 15-45years 108(63%), which was followed by the age range 26-35years with 72(27% Prevalence of trichomoniasis decreased with the term of pregnancy. Hence, prevalence was highest in the first trimester 16(44.4%) and lowest in the third trimester 5(7%) ( Table 4). This is in agreement with the works of Umeaku et al., 2019 andAkinbo et al., 2017 [28,29] but in disagreement with Ibekpobaoku et al., 2017 [13] who recorded that there was no infection among women in their first trimester. The study observed that number of sex partners, term of pregnancy, occupation and family type were statistically significant to infection at P<0.05.

Conclusion
Conclusively, there was a significant difference between the numbers of sexual partners and the prevalence of Trichomonas vaginalis. This is a hospital based study and may not be a representative of the general population of the study area, a more comprehensive study that will take care of the entire population is hereby recommended.