Incidence of Trichomonas vaginalis among Internally Displaced Women in Ibaka, Akwa Ibom State, Nigeria

A total of 282 outpatient pregnant antenatal and non-pregnant women from internally displaced camps attending the Poly Health Clinic (PHC) and the Enwang Health Centre (EHC) were examined for Trichomonas vaginalis infection. Direct wet mount microscopy and Giemsa staining techniques were used on High Vaginal Swab (HVS) specimens collected on sterile swab sticks. A prevalence of 20 (57.1%) was recorded using both methods; 12 (7.2%) in PHC and 08 (6.2%) in EHC Mbo local government area, Akwa Ibom State respectively. Differences among pregnant and non-pregnant women used were statistically significant (P < 0.05). Women in the age group 15 19 years had the highest prevalence of infection 03 (10.5%), closely followed by those of age group 20 24 years 6 (6.8%). A total number of 14 (6.7%) infections were recorded among married women followed by single women with 06 (10%). A higher prevalence rate of 01 (24%) was recorded among women who attended Quranic level of education and 04 (16.7%) with uneducated women, this may be due to small sample size within this group of women. 12 (6.5%) in women with primary school education and 03 (4.7%) in women with secondary school level of education. The need for improved personal hygiene in IDP camps and other effective intervention programmes among these vulnerable groups of women is advocated.

causative agent of Trichomoniasis. It is the most common pathogenic protozoan infection of humans in developing countries [1]. Infection rates between men and women are similar, with women being symptomatic, while infections in men are usually asymptomatic. Transmission usually occurs via direct, skin-to-skin contact with an infected individual, most often through vaginal intercourse. The WHO has estimated that 160 million cases of infection are acquired annually worldwide [2]. The estimates for North America alone are between 5 and 8 million new infections each year, with an estimated rate of asymptomatic cases as high as 50% [3].
Most cases of T. vaginalis remain undiagnosed as it is currently not a target of sexually transmitted infections control and besides because of its asymptomatic nature in about half of infected men and women [4]. The disease is reported as a major cause of pathology in obstetrics and gynecology [5]. It has also been reported that the disease causes discomfort and psychosocial distress in infected patients [1]. Complications of T. vaginalis that have been reported among pregnant women and non-pregnant patients may include premature rupture of membranes, premature labour, low birth weight, post-abortion infections, pelvic inflammatory disease, urinary tract infection and bronchitis, pneumonia and oral lesions, and infertility [6]. 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 [7].
Its symptoms are more commonly observed in women than in men. The symptoms in women may include frothy-greenish foul-smelling vaginal discharge accompanied with vulvovaginal irritation, post coital bleeding, frequency in micturition, dysuria, and lower abdominal pains [8]; preterm rupture of membranes, preterm delivery, low birth weight infants, and neonatal morbidity and mortality are symptoms associated with pregnancy [9]. Factors such as poor personal hygiene, multiple sexual partners, low socioeconomic status, and under development have been reported to be associated with high incidence of infection [10].
In Nigeria, there has been increasing prevalence of trichomoniasis in many states of the federation [11] [12], and based on the public health importance of T. vaginalis infection, The current study aimed to determine the prevalence of trichomoniasis and its associated epidemiological factors among women in internally displaced and Ibaka seaport settlements in Akwa Ibom State. Usually treatment consists of metronidazole and tinidazole [13].

Aim and Objectives
To determine the prevalence rates of Trichomonas vaginalis among women in IDP camps in Ibaka, Akwa Ibom State.
To determine the occurrence of Trichomonas vaginalis using socio-demographic E. E. Owowo et al. characteristics among the participants in the IDP camps. In Ibaka Communities.

Study Area
This study was carried out at the Ibaka seaport settlement in Mbo Local Government Area, Akwa Ibom State, Nigeria. The Poly Health centre used is a Government health institution saddled with the responsibility of providing health-care services for the inhabitants of Ibaka and neighboring seaport settlements.

Study Population
A total of 282 patients and subjects were recruited for this study. The study population consisted of 200 pregnant women attending antenatal clinics and 100 non-pregnant apparently healthy subjects served as controls. The age ranged from 15 to 40 years. Informed consent was sought from the participants before specimen collection. Serial sampling was employed, and the patients who did not return their consent form were excluded from the study. The protocol for this study was approved by the Ethics and Research Committee of the Ministry of Health, Akwa Ibom State. A structured questionnaire was administered to obtain demographic characteristics (such as age, marital status, level of education and occupation) from each participant.

Data Analysis
Statistical analysis of the results was conducted using Chi-square at 0.05% with an appropriate degree of freedom. A P-value of a level less than 0.05 (P ≤ 0.05) was considered statistically significant.

Specimen Collection and Processing
High vaginal swab was collected from each participant using a sterile swab stick. Briefly, exudate from the vagina was collected using a sterile swab stick aided with sterile speculum. To the exudate collected, a drop of normal saline was added and mixed. A drop of the emulsified vaginal exudate was placed on a grease-free slide and a coverslip mounted. The preparation was immediately examined microscopically using ×10 and ×40 objective lenses. Using its characteristic morphology and darting motility, T. vaginalis was identified.

Identification of T. vaginalis
Wet mounts of all swab samples were made in sterile normal saline on clean slides, covered with a cover slide and examined under the low power (10×) and high power (40×) magnifications for presence of motile trichomonads. Pear-shaped, motile flagellates were seen moving with characteristic jerky, wobbling and rotating motions.
A smear of the secretion was also made on a slide, air-dried and fixed in absolute methanol for one minute. Diluted Giemsa stain was poured on the smear and allowed to stain for 10 minutes after which it was washed, air dried and examined under microscope with oil immersion (×100) magnification for presence of trichomonads.

Discussion
The result of this study has demonstrated the prevalence and incidence of T. vaginalis infection in pregnant and non-pregnant women in Mbo, Akwa Ibom State. T. vaginalis was found in 13 (7.2%) of the pregnant women and 07 (6.9%) among non-pregnant women examined in this study ( Table 1). The study shows the prevalence rate of 20 (7.1%) of both pregnant and non-pregnant women in the IDP camp (  [21]. There is a general consensus that the prevalence of T. vaginalis varied according to settings therefore, these disparities in prevalence could be attributed to the different environmental backgrounds and hygienic condition of the subjects studied. Amongst the different age groups investigated, T. vaginalis infection distribution was highest in women aged 15 -19 years (10.5%), followed by women aged 25 -29 years (7.3%) and non in women aged 40 years and above ( Table 3). The result of this study is in agreement with generally observed fact that the incidence of sexually transmitted diseases (STDs) including trichomoniasis, by the number of cases treated each year, is highest among the 15 -30 years age group. These age groups reported by other researchers [12] are documented to be persons with the greatest sexual activity and that incidences decrease with age.  Women with pregnancy were observed to be more infected with T. vaginalis (7.2%), followed by non-pregnant women with (6.9%). Information retrieved from pregnant women revealed that the frequency of sexual intercourse during pregnancy decreases as number of children increases and this may likely be the reason for the low incidence of infection among advance marriages (Table 1).
Our finding is consistent with previous report in Imo state, Nigeria [11] who reported that young marriages had the highest prevalence of STDs.
However, this observation was in contrast with findings in Abakaliki, Nigeria who reported that advance marriages were more infected with T. vaginalis in their study. Marital status of pregnant women examined for T. vaginalis in this study was also found to be significantly associated with infection acquisition (P < 0.05). Single (unmarried) pregnant women were found to be more infected (10%) than the married (6.7%) ( Table 4). This pre-supposes that unmarried women are unattached thus free to indulge in more sexual activities probably involving multiple sexual partners. This corroborates findings by Okpara et al.
[10] who reported that single women were more infected in their study. In a related study a statistically significant association was found between trichomoniasis, prostitution, no condom use and other STDs [10].
Occurrence of T. vaginalis infection by level of education revealed that, illiterate women (16.7%) and (24%) women with Quranic education had the highest infection with T. vaginalis recorded in this study (Table 5), followed by women with the primary school leaving certificate categories with (6.5%) and secondary school certificate holders (4.7%). This was clearly due to the extremely small number of women in those groups examined as shown in Table 5  widely utilized diagnostic test for the infection in most hospitals and this is reported to have a sensitivity of only about 60% -80% [18]. According to some researchers [14], culture method is considered to be far superior to wet mount examination for the detection of the organisms and is currently the gold standard which should be considered for widespread clinical use.
The high incidence of T. vaginalis infection worldwide, co-infection with other sexually transmitted infections and attendant high risk of pelvic inflammatory diseases and tubal infertility make trichomoniasis a compelling public health concern [22]. Certain factors such as poor personal hygiene, multiple sex partners, and low socio-economic status with under development are also associated with high incidence of infection [23]. Neonatal trichomoniasis can be acquired during passage through an infected birth canal and it is estimated that 2% -17% of female babies acquire trichomoniasis through direct vulvo-vaginal contamination. Trichomoniasis is an infection of multiple sites (e.g. vaginal epithelium, skene glands, bartholin glands and urethra), thus prompt diagnosis is important for eliminating infection in the patient and sexual partners and treatment of sexual partners is thought to increase cure rates [24].

Conclusion
Our study has confirmed the endemicity of Trichomonas vaginalis infection E. E. Owowo et al. among pregnant women in Ibaka, Mbo local government of Akwa Ibom State and suggests that the control of trichomoniasis can best be accomplished by public health programmes through persistent efforts to educate people on the need to improve on their personal hygiene, screen, diagnose, treat patients and sexual partners and follow up on the high risk individuals within communities.