|Year : 2008 | Volume
| Issue : 2 | Page : 76-81
Trichomoniasis among women in North India: A hospital based study
Simernjeet Kaur1, Sumeeta Khurana1, Rashmi Bagga2, Ajay Wanchu3, Nancy Malla1
1 Department of Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Department of Parasitology, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Trichomoniasis caused by protozoan parasite Trichomonas vaginalis , is the major nonviral sexually transmitted disease (STD). Clinical spectrum varies from an asymptomatic state to mild, moderate or severe symptoms. Methods: The study was planned to assess the prevalence of trichomoniasis in women with cervical intraepithelial neoplasia (CIN)/carcinoma cervix (n = 100), Human Immunodeficiency Virus (HIV) seropositive women (n = 100), and symptomatic (n = 140) and asymptomatic (n = 109) women for trichomoniasis, by direct examination and culture of vaginal washes and urine. Results: None of the cervical carcinoma or HIV seropositive Indian patients, including 30% HIV seropositive patients with CD4 + cell count less than 200/µl harbored T. vaginalis, while six (4.28%) symptomatic and four (3.66%) asymptomatic otherwise healthy subjects were found positive for T. vaginalis . Conclusion: Trichomoniasis was significantly associated ( P < 0.05) with being a housewife, belonging to the middle socioeconomic status, and nonuse of contraception. However there was no significant association with gravidity ( P > 0.05), HIV status or cervical carcinoma.
Keywords: Cervical cancer, HIV, symptomatic, trichomoniasis
|How to cite this article:|
Kaur S, Khurana S, Bagga R, Wanchu A, Malla N. Trichomoniasis among women in North India: A hospital based study. Indian J Sex Transm Dis 2008;29:76-81
|How to cite this URL:|
Kaur S, Khurana S, Bagga R, Wanchu A, Malla N. Trichomoniasis among women in North India: A hospital based study. Indian J Sex Transm Dis [serial online] 2008 [cited 2020 Aug 13];29:76-81. Available from: http://www.ijstd.org/text.asp?2008/29/2/76/48729
| Introduction|| |
Trichomoniasis caused by parasitic protozoan Trichomonas vaginalis is the most common nonviral sexually transmitted disease (STD) associated with high morbidity.  Approximately 180 million women worldwide are infected with T. vaginalis annually.  The infection elicits a broad range of clinical symptoms varying from asymptomatic to severe inflammatory manifestations. Around 25-50% of the infected females are asymptomatic, while in symptomatic females, the disease is characterized by vulvovaginitis, cervicitis, and urethritis. This may be associated dysuria, dyspareunia, and abdominal pain.  Trichomoniasis has been found to be associated with adverse pregnancy outcomes like preterm rupture of membranes, low birth weight babies, post-abortion, and post hysterectomy complications.  Cervical cancer is a major gynecological cancer in developing countries like India. There are both positive and negative reports regarding association between T. vaginalis and cervical neoplasia. , Throughout the world, 75% of HIV-1 infections are acquired through sexual contact. Physical trauma, damage from other sexually transmitted pathogens, and a vigorous host immune response, compromise the integrity of mucosal surfaces, thereby, potentially enhancing the susceptibility to infection. Trichomonas has not only been shown to be a co-factor for acquisition of HIV, but also increases the viral load and transmission of HIV .,,
Although both cervical cancer and HIV/(AIDS) Acquired immune deficiency syndrome are common in India, the reports regarding prevalence of trichomoniasis in Indian women with cervical cancer or HIV are lacking. Therefore, the present study was designed to assess the prevalence of trichomoniasis in HIV-infected females and patients with cervical intraepithelial neoplasia (CIN)/cervical carcinoma.
| Materials and methods|| |
Four hundred and forty nine women (349 from Obstetrics and Gynecology Outpatient Department (OPD) and 100 HIV seropositive patients from the Immunodeficiency Clinic) attending Nehru Hospital, attached to the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India between September 2004 to March 2006, were enrolled in the present study after taking their due consent. Patients were categorized into: Group I - Carcinoma cervix/CIN (N = 100), Group II - HIV seropositive (N = 100), Group III - women with signs and symptoms suggestive of trichomoniasis (N = 140), and Group IV - apparently healthy women, without any signs or symptoms of trichomoniasis, attending the postnatal or fertility clinic (N = 109). Their age, occupation, clinical, obstetrical history, and relevant per speculum findings were recorded on a preplanned performa. Both vaginal swabs and urine samples were subjected to wet smear examination and culture in TYIS (Trypticase yeast extract iron serum) medium for detection of parasites. 
Statistical significance was calculated by the chi-square test.
The study was cleared by the Institute's ethical committee.
| Results|| |
The mean age, socioeconomic status, working status, and contraception used by the subjects and obstetric history are given in [Table 1] and [Table 2]. The socioeconomic status (SES) was assessed arbitrarily based on family income per month and grouped as lower (Income Rs. 10000/month). Trichomoniasis was significantly associated ( P < 0.05) with being a housewife, belonging to the middle socioeconomic status, and nonuse of contraception. However there was no significant association with gravidity ( P > 0.05).
Bleeding per vaginum was the most common feature in CIN/cervical cancer patients, whereas, in the rest of the groups foul smelling vaginal discharge was the most common feature followed by pruritus and dysuria [Table 3].
Per vaginum findings
On per vaginum examination, 65% of the CIN/cervical cancer patients were having obvious growth. Out of these patients, four were of stage Ib, 23 were of stage IIb, four were of stage IIIa, and 34 were of stage IIIb. The remaining patients (n = 35) were having CIN. Per vaginum findings of all the groups are shown in [Table 4].
Isolation of T. vaginalis
T. vaginalis was not detected in any of the 100 carcinoma cervix patients or 100 HIV seropositive patients, either by wet mount, culture of vaginal swab or urine samples.
Symptomatic patients: Six (4.28%) out of 140 patients with symptoms and signs suggestive of trichomoniasis, were positive for T. vaginalis by culture of vaginal secretions, while wet mount microscopy could detect five (3.6%) cases. One out of these six patients was also positive by direct smear examination and culture of urine sample.
Asymptomatic patients: Four (3.6%) out of 109 subjects without any symptoms and signs suggestive of trichomoniasis were positive for T. vaginalis by vaginal culture, while only three (2.7%) were positive by wet mount examination of vaginal fluid. No urine sample was positive either by the direct smear or the culture technique.
Vaginal swab: Direct smear versus culture: The sensitivity of the direct smear was compared with the culture by applying the chi-square test. The value of X 2 for a probability of 0.05 was 3.84 and our calculated value was 0. The analysis indicated that the two techniques (wet mount examination and culture) were equally effective in detecting T. vaginalis .
Vaginal swab versus urine: The sensitivity of the direct smear of vaginal swab was compared with that of urine by applying the chi-square test. The analysis indicated that direct smear examination of the vaginal swab was superior to that of urine ( P < 0.05). Similarly, sensitivity of the culture of a vaginal swab was compared with that of urine examination. The analysis indicated that culture of the vaginal swab is much superior to the culture of urine, for isolation of T. vaginalis ( P < 0.05).
Different parameters of T. vaginalis positive patients
- Demographic data: Mean age of T. vaginalis positive symptomatic and asymptomatic patients was 33.67 and 31.5 years, respectively. Out of six symptomatic and four asymptomatic patients, three (33.3%) and one (25%) belonged to the lower socioeconomic status respectively.
- Contraceptive devices: Out of six symptomatic and four asymptomatic T. vaginalis positive patients, four (66.6%) and one (25%), respectively, were using barrier contraception. Two (50%) of the asymptomatic subjects were using other methods of contraception.
- Gynecological parameters: Age of menarche was between 11-15 years in five (83.3%) out of six symptomatic, and three (75%) out of four asymptomatic T. vaginalis positive subjects. Irregular menstruation was seen in one (16.6%) of the six symptomatic and in none of the four asymptomatic T. vaginalis positive subjects. Two (33.3%) out of six symptomatic patients were > second gravida, whereas, four asymptomatic subjects were in I and II gravida (two each). One (16.6%) out of four symptomatic subjects was infertile.
- Symptoms and signs of T. vaginalis positive patients: Among the symptomatic T. vaginalis infected subjects, foul smelling discharge and pruritus were the most common features observed in five (83.3%) of them. Cervical erosions and pelvic inflammatory disease were observed in one patient (16.6%) each, in the symptomatic and asymptomatic group. Strawberry cervix was not seen in any patient.
Retrospective analysis of CD4 cell count in HIV seropositive patients
Retrospective analysis of CD4 + cell count in HIV seropositive patients was attempted.
Out of 100 HIV seropositive patients, the CD4 + cell count was available in 89 patients. Mean CD4 + cell count was found to be 361.1/ul (range: 56-1118). CD4 + cell count was <200/µl in 30%, 200-500/ µl in 40.1% and >500/µl in 29.9%. In the present study, T. vaginalis was not isolated in any of the HIV seropositive patients, even with CD4 + cell count <200/µl.
| Discussion|| |
Trichomoniasis is one of the most common nonviral STD infecting an estimated 180 million females annually. 
In the present study, cervical carcinoma and HIV seropositive patients were of mean age 55.41 ± 7.32 years and 33.1 ± 8.1 years, respectively. Seventy three (73%) of the cervical carcinoma patients were in age group 40-60 years and 27 (27%) were >60 years. Seventy seven (77%) of the HIV seropositive patients were of age <40 years and 23% were in the age group ranging between 40 and 60 years. The present study supported the well-known fact that carcinoma cervix occurred in old age patients, while most of the HIV-infected individuals were younger. ,, In the present study, 72.1% of the symptomatic patients (with symptoms and signs suggestive of trichomoniasis) and 63.3% of the asymptomatic patients (without any symptoms suggestive of trichomoniasis) were of age <40 years. This is in agreement with the earlier studies where maximum incidence of trichomoniasis has been reported in age group of 20-45 years. ,
In the present study, cervical carcinoma patients are mainly (73%) of lower socioeconomic status. Other studies have also shown a significant association between lower socioeconomic status and development of cervical carcinoma. ,, In the present study, 58% cervical carcinoma patients are multigravida (≥4) as compared to 10% HIV seropositive patients, 18.6% symptomatic patients, and 14.7% asymptomatic patients. Similar association of cervical cancer and high parity is also reported by other authors. 
In our study, trichomoniasis was significantly associated with being a housewife, belonging to middle socioeconomic status, and nonuse of contraception. Many studies have found significant association with poverty , and contraception.  However few other studies reported significant association with noncontraception use.  We did not find any association with gravidity similar to the observation of Cotch et al . 
Isolation of T. vaginalis
Cervical carcinoma patients : T. vaginalis was not detected in any of the 100 cervical carcinoma (CIN) patients. Although, a study conducted in Durban indicated, T. vaginalis infection in 39% of the CIN-positive patients and 15% of CIN negative patients, yet the difference was not statistically significant.  In contrast, there are few studies, whereby, higher prevalence of T. vaginalis in cervical carcinoma patients has been reported. In a meta-analysis of 24 studies, a significant association was found between T. vaginalis and CIN and risk of carcinoma development was found to be double in the presence of T. vaginalis .  Other studies have found T. vaginalis in 29.3% and 39% of the cases of CIN. , Although, it is true that inflammatory changes may mimic dysplasia. However, the patients in our study group were diagnosed as CA cervix or CIN after cervical biopsy. The cervical biopsy had been taken after the patient was treated, usually with metronidazole or tinidazole. However, the time of sampling in most of the patients was at least a month after treatment and thus may not have affected the isolation of Trichomonas . The reason for different results may be because of the geographical and sociocultural differences in the population studied, however, studies on large number of cervical carcinoma Indian patients may ascertain the actual reason.
HIV seropositive patients: In the present study, T. vaginalis was not detected in any of the 100 HIV seropositive patients, including 30% HIV seropositive patients with CD4 + cell count less than 200/µl, thereby, indicating no association between HIV positivity and acquisition of T. vaginalis . The present study is in agreement with the study from Tanzania by Klinqer et al .,  wherein T. vaginalis infection was not associated with HIV infection; Susan et al .,  have shown T. vaginalis in 9.4 - 29.5% HIV positive and 8.2 - 23.4% HIV seronegative women ( P > 0.05) from four cities of USA. Also there was no difference according to HIV status and CD4 cell count and T. vaginalis infection. Minkoff et al .,  New York reported T. vaginalis in 20.4% of the HIV-infected and 24.2% of HIV-uninfected females ( P = 0.23). Frankel et al .,  reported trichomoniasis in 27% of the HIV positive patients and in 28% of the HIV negative patients. On the other hand, many studies have shown preinfection with T. vaginalis as a risk factor for acquisition of HIV infection and increased viral load. ,,
Symptomatic and asymptomatic trichomoniasis patients: In the present study, the overall prevalence in symptomatic (with symptoms suggestive of trichomoniasis) and asymptomatic (without any symptoms suggestive of trichomoniasis) patients was 4.01%. T. vaginalis was isolated in 4.28% of symptomatic and 3.66% of asymptomatic patients. T. vaginalis prevalence from 0-65% has been reported in different geographical locations. ,, Prevalence of 7.59% has been reported in antenatal women and 9.21% in women with gynecological disorders compared to 3.62% in postnatal and 2.83% in infertile women.  In a study by Malla et al .,  prevalence was found to be 10%. Kaul et al .,  have shown an overall prevalence of 3.8%, out of which 4.09% were symptomatic and 3.45% were asymptomatic patients. Similarly a study by Yadav et al .,  showed an overall prevalence of 4.2%, and T. vaginalis was isolated in 4.15% of symptomatic and 4.25% of asymptomatic patients. This difference in prevalence might be explained by different socioeconomic status, different sexual habits, and practices of people in various geographical regions.
Demonstration of T. vaginalis by direct smear and culture: Culture of vaginal swab had a significantly higher ( P < 0.05) isolation rate of T. vaginalis (100%) as compared to direct smear examination (80%), while T. vaginalis was detected by direct smear and culture in urine samples of only 10% of the symptomatic patients. In the present study, the isolation rate of T. vaginalis from vaginal samples was found to be similar to that reported earlier. ,, However, the sensitivity of urine for direct demonstration and isolation in the present study was found to be much lower (only 10%) than that reported in earlier studies, where culture of urine and direct smear examination were found to have >50% sensitivity. ,,
Symptoms and signs in T. vaginalis positive subjects: In the present study, in T. vaginalis infected symptomatic patients, foul smelling purulent vaginal discharge and pruritus were the main symptoms (83.3%), followed by dysuria and dyspareunia in 16.6% each. On per vaginum examination also, discharge was the most common finding (83.3%) followed by cervical erosions and features of pelvic inflammatory disease (PID) (16.6% each). Earlier reports from our center as well as from other centers also support our findings of discharge being the most important feature. ,,
| Conclusion|| |
The study indicated that none of the 100 cervical carcinoma or 100 HIV seropositive Indian patients harbored T. vaginalis . However, T. vaginalis was reported in otherwise four healthy (3.66%) asymptomatic and six (4.28%) symptomatic subjects for trichomoniasis. Trichomoniasis was significantly associated ( P < 0.05) with being a housewife, belonging to the middle socioeconomic status, and nonuse of contraception. However there was no significant association with gravidity ( P > 0.05), HIV status or cervical carcinoma.
| References|| |
|1.||Krieger JN, Alderete JF, Sparling PF, Mardh PA, Lemon SM, Stamm WE, et al . Sexually transmitted diseases. New York: McGraw Hill; 1999. p. 587-604. |
|2.||Swygard H, Sena AC, Hobbs MM, Cohen MS. Trichomoniasis: Clinical manifestations, diagnosis and management. Sex Transm Infect 2004;80:91-5. |
|3.||Schwebke JR, Burgess D. Trichomoniasis. Clin Microbiol Rev 2004;17:794-803. [PUBMED] [FULLTEXT]|
|4.||Zhang ZF, Begg CB. Is T. vaginalis a cause of cervical neoplasia? Results from combined analysis of 24 studies. Int J Epidemiol 1994;23:682-90. |
|5.||Boyle CA, Lowell DM, Kelsey JL, Livolsi VA, Boyle KE. Cervical intraepithelial neoplasia among women with Papillomavirus infection compared to women with T. vaginalis infection. Cancer 1989;64:168-72. |
|6.||Laga M, Manoka A, Malele B, Kivuvu M, Tulija M, Nzila N, et al . Non-ulcerative sexually transmitted diseases as risk factor for HIV-1 transmission in women: Results from a cohort study. AIDS 1993;7:95-102. |
|7.||McClelland RS, Sangare L, Hassan WM, Lavreys L, Mandaliya K, Kiarie J, et al . Infection with trichomonas vaginalis increases the risk of HIV acquisition. J Infect Dis 2007;195:698-702. [PUBMED] [FULLTEXT]|
|8.||Sharma P, Malla N, Gupta I, Ganguly NK, Mahajan RC. Comparison of wet mount, Culture and Enzyme linked Immunosorbent assay for the diagnosis of trichomonasis in women. Trop Geogr Med 1991;43:257-61. [PUBMED] |
|9.||Susan CU, Hyejin KO, Denise JJ, Joseph WH, Paula S, Jean A, et al . Prevalence, incidence and persistence or recurrence of trichomoniasis among HIV positive and among HIV negative women at high risk for HIV infection. Clin Infect Dis 2002;34:1406-11. |
|10.||Madge S, Phillips AN, Griffioen A, Olaitan A, Johnson MA. Demographic, clinical and social factors associated with HIV infection and sexually transmitted diseases in a cohort of women from the United Kingdom and Ireland. Int J Epidemiol 1998;27:1068-71. [PUBMED] [FULLTEXT]|
|11.||Kharsany AB, Hoosen AA, Moodley J, Bagaratee J, Gouws E. The association between sexually transmitted pathogens and cervical intra epithelial neoplasia in a developing community. Genitourin Med 1993;69:357-60. [PUBMED] [FULLTEXT]|
|12.||Madhi NK, Gany ZH, Sharief M. Risk factors for vaginal trichomoniasis among women in Barsa, Iraq. East Mediterr Health J 2001;7:918-24. |
|13.||Bowden FJ, Paterson BA, Mein J, Sawaqe J, Fairley CK, Garland SM, et al . Estimating the prevalence of T. vaginalis , C. trachomatis, N.gonorrhoeae and Human papilloma virus in indigenous women in northen Australia. Sex Transm Infect 1999;75:431-4. |
|14.||Ngelangel C, Munoz N, Bosch FX, Limson GM, Festin MR, Deacon J. Causes of cervical cancer in Philippines: A case- control study. J Natl Cancer Inst 1998;90:43-9. |
|15.||Katz SJ, Hofer TP. Socioeconomic disparities in prevention can persist despite universal coverage. Breast and cervical cancer screening in Ontario and the US. J Antimicrob Agents 1994;292:530-4. |
|16.||Sorvillo F, Smith L, Kerndt P, Ash L. Trichomonas vaginalis , HIV and Africans-Americans. Emerg Infect Dis 2001;7:927-32. [PUBMED] [FULLTEXT]|
|17.||Klinqer EV, Kapiquasn, Sam NE, Aboud S, Chen CY, Ballard RC, et al . A community based study of risk factors for T. vaginalis infection among women and their male partners in Moshi Urban district, North Tanzania. Sex Transm Dis 2006;33:712-8. |
|18.||Sutton M, Sternberg M, Koumans EH, McQuillan G, Berman S, Markowitz L. The Prevalence of Trichomonas vaginalis Infection among Reproductive-Age Women in the United States, 2001-2004. Clin Infect Dis 2007;45:1319-26. [PUBMED] [FULLTEXT]|
|19.||Cotch MF, Pastorek JG, Nugent RP, Yerg DE, Martin DH, Eschenbach DA; et al . Demographic and behavioral predictors of trichomonas vaginalis infection among pregnant women. Obstet Gynecol 1991;78:1087-92. |
|20.||Garcia A, Exposto F, Prieto E, Lopes M, Duarte A, Correia da Silva R. Association of Trichomonas vaginalis with sociodemographic factors and other STDs among female inmates in Lisbon. Int J STD AIDS 2004;15:615-8. [PUBMED] [FULLTEXT]|
|21.||Minkoff HL, Eisenberger-Matityahu D, Feldman J, Burk R, Clarke L. Prevalence and incidence of Gynecological disorders among women infected with HIV. Am J Obstet Gynaecol 1999;180:824-36. |
|22.||Frankel TL, Monif GR. T. vaginalis and bacterial vaginosis: Coexistence in vaginal wet mount preparations from pregnant women. J Reprod Med 2000;45:131-4. |
|23.||Lossick JG. Epidemiology of urogenital trichomoniasis. In: Honigberg BM, editor. Trichomonads parasitic in humans. NewYork: Springer-Verlag; 1990. p. 311-23. |
|24.||Sharma P, Malla N, Gupta I, Ganguly NK, Mahajan RC. Prevalence of trichomoniasis in symptomatic and asymptomatic subjects using different contraceptive devices. Indian J Med Microbiol 1988;6: 315-22. |
|25.||Malla N, Wattal C, Khan I, Kaul R, Raina V. Study of trichomoniasis in Kashmir, North India. Indian J Med Microbiol 1989;7:121-6. |
|26.||Kaul P, Gupta I, Sehgal R, Malla N. Trichomonas vaginalis : Random amplified polymorphic DNA analysis of isolates from symptomatic and asymptomatic women in India. Parasitol Int 2004;53:255-62. [PUBMED] |
|27.||Yadav M, Dubey ML, Gupta I, Malla N. Cysteine proteinase 30 (CP30) and antibody response to CP30 in serum and vaginal washes of symptomatic and asymptomatic Trichomonas vaginalis -infected women. Parasite Immunol 2007;29:359-65. |
[Table 1], [Table 2], [Table 3], [Table 4]