Prevalence of Trichomonas vaginalis among Pregnant Women Attending Ante-Natal Care in Kano, Nigeria

Trichomoniasis, caused by the protozoan parasite, Trichomonas vaginalis, is a common but curable sexually transmitted disease affecting millions around the world. The study was aimed to determine the prevalence of T. vaginalis among pregnant women attending ante-natal care at Yan-awaki maternity in Kano, Northern Nigeria. A cross sectional study was conducted among one hundred and eighty four (184) pregnant women attending the hospital. A total of 184 High Vaginal Swabs (HVS) were collected the pregnant women with their consent and examined for presence of T. vaginalis microscopically. From the result, T. vaginalis was detected in 23 out of the 184 samples which accounted for 12.5% of the pregnant women. The pregnant women between the age category 26-30 years had the highest prevalence of 4.34 % while the least prevalence was recorded among pregnant women of age category above 40, though the difference in the prevalence among ages is not significant at p<0.05. On the basis of gestation period, pregnant women in first trimester had the highest prevalence than that of second and third trimesters. It is concluded that Trichomoniasis is one of the infections of pregnant women.


INTRODUCTION
Trichomonas vaginalis is a flagellated protozoan parasite causing disease called Trichomoniasis, a sexually transmitted infection with worldwide distribution (Schwebke and Burgess, 2004). It has been recognized as a cosmopolitan parasite of male and female genital tract (Jatau et al., 2006;Rahman et al., 2019). It has been estimated that about 180 million women worldwide are infected with T. vaginalis annually. Though about 25-50% of Trichomoniasis in women is asymptomatic, the infection may lead to significant complications such as adverse pregnancy outcomes, pelvic inflammatory disease, and cervical neoplasia in women and infertility in men. The infection is primarily transmitted through sexual contact and the incidence depends on the population screened and certain factors such as poor personal hygiene, multiple sex partners, low socio-economic status and under-development (Huppert, 2009;Sharif et al., 2019).
The infection by T. vaginalis is reported as a major cause of pathology in obstetrics and gynecology (Hobbs et al., 2006). It has also been reported that the disease causes discomfort and psychosocial distress in reported among pregnant women and non-pregnant patients may include premature rupture of membranes, premature labor, low birth weight, post abortion infections, pelvic inflammatory disease, urinary tract infection and bronchitis, pneumonia and oral lesions (Soper, 2004), and infertility (Fichorova, 2009).
Although the disease has been seen as a risk factor for other sexually transmitted agents such as Chlamydia trachomatis and Neisseria gonorrhoeae, it has also been linked to one of the predisposing factors to HIV infection, acquired immune deficiency syndrome, and cervical cancers (McClelland et al., 2007).The major symptoms of Trichomoniasis among women include; frothy greenish foul smelling vaginal discharge accompanied with vulvo-vaginal irritation, post coital bleeding, frequency in micturition, dysuria, and lower abdominal pains, preterm rupture of membranes, preterm delivery, low birth weight infants, and neonatal morbidity and mortality are symptoms associated with pregnancy (CDC, 2006;Johnson et al., 2011). T. vaginalis can be detected in women in vagina, semen and urine using different laboratory methods such as wet mount, various staining methods, culture, latex agglutination, Enzyme Linked Immunosorbent Assay (ELISA) and more recently, Polymerase Chain Reaction (PCR) (Radonjic et al., 2006;Shahen et al., 2019). The most common means of diagnosis still remains microscopic visualization of the motile trichomonads in a saline preparation of the vaginal fluid (Schwebke and Burgess, 2004). Direct examination of wet mount preparation of clinical specimen is the most rapid and least expensive technique for identifying T. vaginalis.
Several factors such multiple sexual partners, poor personal hygiene, under development, and low socioeconomic status have been reported to be associated with the high incidence of Trichomoniasis among female (Crosby et al., 2003). A high prevalence of the infection is observed in both developed and developing societies such as 7.4 million new cases in the United States and 30 million new cases in sub-Saharan Africa per year (WHO, 2001). In Iran, the prevalence of T. vaginalis infection ranges from 2% to 8% (Edrissian et al., 2007), 14.3% in India (Sugathan, 2016) and 20% in Nigeria (Olusola et al., 2010). In developing countries such as Nigeria, there has been increasing prevalence of Trichomoniasis among pregnant women (Onyido et al., 2006). Therefore, based on the public health significance of Trichomoniasis, the study was aimed to determine the prevalence of T. vaginalis among pregnant women attending ante-natal care at Yan-awaki maternity in Kano, Northern Nigeria.

MATERIALS AND METHODS
Ethical Approval -The ethical approval for the study was obtained from Department of health, Kano Municipal Local Government based on the consent of Yan-awaki maternity ethical committee Study Area -The study was conducted at Yan-awaki Maternity in Kano, Northern Nigeria. Kano State is located in the North-west Nigeria located at latitude 11 0 30N and longitude 8 0 30E. It share borders with Kaduna state to the south-west, Bauchi state to the South-East, Jigawa state to the East, Katsina state to the North. It has a total area of 20,131 km 2 (7,777 sqm) and estimated population of 13.4 million (NPC, 2014).

Sample Size Determination -
The sample size for the study was determined from a standard formula for the calculation of minimum sample size (Nasir et al., 2018). Sample size was given by the formula;

N = (Z 1 -a) 2 (p) (1-p)/d 2
Where N = minimum sample size, Z 1-a = value of standard normal deviate which at 95% confidence interval has found to be 1.96, P = the best estimate of prevalence obtained from literature review (14.1%) and d = difference between the true population rate and sample that can be tolerated, this is the absolute precision (in percentage) on either side of the population. Study Population -A total of 184 pregnant women were used as a subject in this study. The subjects are attending ante-natal care at Yan-awaki maternity in Kano, Northern Nigeria from March to August, 2017.
A simple structured questionnaire was administered to the subjects to obtained demographic data such residential area, age, education level, gestation period and education level.
Samples Collection and Examination -During sample collection, High Vaginal Swab was collected from the consenting subject. Vaginal exudates were collected using a sterile swab stick with the aid of sterile speculum (Olusola et al., 2010).
Wet preparation of the vaginal exudates collected were made using a drop of normal saline on microscope slide covered with a cover slip and immediately examined microscopically using ×10 and ×40 objective lenses (Cheesbrough, 2000). The parasite T. vaginalis was identified morphologically by it shape, size, characteristic jerking and twisting movement (Sugathan, 2016).
Statistical Analysis -Statistical analysis Package for Social Science (SPSS) version 10.0 was used for statistical analysis of the data generated. Chi square was used to compare between two or more variables. Statistical significance was considered at p-value <0.05.

Demographic Distribution of the Subjects -
The demographic distribution of the study subjects is presented in Table 1. A total number of 184 subjects participated in the study. The subjects were categorized on the basis of their age categories, socioeconomic status, resident, education level and gestation age of the pregnancy.

Prevalence of T. vaginalis -
The prevalence of T. vaginalis among pregnant women coming for antenatal at the study center is presented in Table 2 below. The results showed that out of the total of 184 subjects, 23 subjects were found positive for T. vaginalis which accounted for 12.5 % of the subjects. Prevalence of T. vaginalis among pregnant women showed that higher incidence found among subjects of age category 26-30 (4.34%). Rural dwellers occupy large percentage prevalence of T. vaginalis occurrence (7.07%) when compared to urban dwellers (5.43%). On the basis of socio-economic status, most of the subjects positive for T. vaginalis were unemployed (9.79%). Prevalence of T. vaginalis among pregnant women based on the age of gestation period showed higher prevalence among subjects in 1 st trimester (7.07%). The educational level of the subjects showed higher prevalence among subjects without formal education for which accounted for 4.89%.  Initially, Trichomoniasis is consider as inconsequential infection but lately, it has attracted more attention because of its co-factor role in spread of Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STIs), adverse pregnancy outcomes, predisposition to cervical and prostate cancer, premature rupture of the placental membrane, and other compelling public health concern (Moodley et al., 2004;Islam et al., 2020).

Infection with T. vaginalis causes
In the present study, the prevalence of T. vaginalis was found to be 12.5%. Several studies were conducted on prevalence of T. vaginalis worldwide (Edrissian et al., 2007;Sugathan, 2016). T. vaginalis infection prevalence ranges from 5% to 10% in healthy women populations while it could be as high as 50% in prostitutes and female prisoners.
The prevalence of 12.5% of T. vaginalis in this study could be considered slightly higher than the normal range. The prevalence observed in this study is higher than that of Jombo et al. (2006)  vaginalis infection has been demonstrated in persons with poor personal hygiene and low socioeconomic status.

CONCLUSION:
Based on the finding of this study, the prevalence of T. vaginalis among pregnant women was found to be 12.5%. Age, socio-economic status, residential area, Gestational age and educational status significantly affected the prevalence of Trichomoniasis among pregnant women. Rural dwellers occupy large percentage prevalence of T. vaginalis occurrence when compared to urban dwellers. On the basis of socio-economic status, most of the subjects positive for T. vaginalis were unemployed. Prevalence of T. vaginalis among pregnant women based on the age of gestation period showed higher prevalence among subjects in 1 st trimester. The educational level of the subjects showed higher prevalence among subjects without formal education. It is recommended that routine screening for T. vaginalis infection among pregnant women should be encouraged.