Journal of Research in Health Sciences

• Home
• About
• Log In
• Register
• Search
• Current
• Archives
• AuthorGuidelines

JRHS 2010; 10(1):31-35

Copyright © Journal of Research in Health Sciences

Frequency of Trichomoniasis in Patients Admitted To Outpatient Clinics in Hamadan (2007) and Relationship between Clinical Diag­nosis and Laboratory Findings

Soghra Rabieea *, Mohammad Fallahb , Fatemeh Zahabic

a Department of Obstetrics and Gynecology, Fatemieh Women Hospital, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran

b Department of Parasitology, School of Medicine, Hamadan University of Medical Science, Hamadan, Iran

c General Practitioner

Corresponding author: Rabiee S (MD), E-mail addresses: rabieesogol@yahoo.com

Received: 27 May 2009, Revised: 17 April 2010, Accepted: 26 April 2010, Available online: 20 June 2010        

Abstract        

Background: Trichomoniasis is recognized as a major sexually transmitted dis­ease (STD) in the world and has the highest prevalence and incidence of STD. the prevalence strongly is related to cultural and social norms in different socie­ties, in relation to sexual partnership, monogamy, or polygamy. Our objective was to describe the frequency and natural history of infection and correlation of clini­cal signs with parasite detection.

Methods: From February 2006 to March 2007, in a cross sectional study, clinical and wet mount examination of vaginal smear along with culture were performed on 683 women attending to private outpatient clinics in Hamadan, western Iran. Trichomoniasis was diagnosed based on major clinical symptoms. Diagnosis was con­firmed using wet mount microscopically and culture in Diamond medium.

Results: Only 2.2% of patients with clinically diagnosed trichomonal vaginitis were positive for Trichomonas vaginalis by wet smear and culture. The mean age of patients was 33.6±9.7 yr, and majority of them were married and non-pregnant. Some (5 patients) infected cases were divorced and others (7 patients) hus­band were car driver. There was not statistically significant relationship be­tween clinical diagnosis and laboratory findings (P>0.5), because the most of pa­tients diagnosed trichomoniasis, were infected by Candida or other vaginal infec­tions.

Conclusion: Because of special cultural background, the vaginal trichomoniasis has minor importance problem in this population and clinical diagnosis is not effi­cient for treatment decision.

Keywords: Trichomoniasis, Prevalence, Clinical diagnosis, Iran  

Introduction

For more than a century following its ini­tial description in 1836, Trichomonas vaginalis was considered either a harm­less vaginal colo­nizer or simply a minor nui­sance [1].  More re­cently, it has been recognized that T. vaginalis in­fection may be associated with a range of ad­verse reproductive health out­comes, including preterm birth [2-4], cervical neo­plasia [5, 6], post-hysterectomy infection [7], atypical pel­vic in­flammatory disease [8, 9], and in­fertility [10]. The parasite also is a major cause of vagini­tis, cervicitis, urethritis and pelvic in­flammatory dis­ease in women and may cause nongonococ­cal urethritis, prostatitis, and per­haps other lower ge­nitourinary tract syndromes in men [11]. In recent years, it has been appreci­ated that Trichomonas may play a critical role in amplify­ing human immunodeficiency virus (HIV) transmission [12].

While there is continued debate about the causal linkage between T. vaginalis infection and ob­stet­rical, gynecological, and infectious complica­tions, it is generally recognized that the inci­dence of this sexually transmitted infec­tion (STI) has reached epidemic levels in many regions world­wide. In 1999, the World Health Or­ganization (WHO) estimated the global inci­dence of T. va­ginalis infection to be 173 mil­lion cases annu­ally, making this parasite the most common cause of non-viral STI [12]. The greatest burden of disease was observed in less developed re­gions, but a high incidence was also found in North America (8 million cases an­nually) and Western Europe (11 million cases annually) [13, 14].

Because the increasing changes of the social norms in developing countries, such as Islamic Republic of Iran, epidemiologic studies of STDs is an essential need for evaluating the health im­portance of these infections and notice them in clinical practice. Our objective was to de­scribe the frequency of T. vaginalis infection in a rela­tively traditional society and, its relation­ship with clinical symptoms. Because clinical symptoms as­sociated with vaginitis are various and result in mis­diagnosis, the clinical di­agnosis alone is often deceptive. Therefore, sec­ond objective of this study was to evaluate the accuracy of clinical di­agnosis in compari­son with laboratory findings. 

Methods

In this cross sectional descriptive study, a total of 683 women admitted to public and pri­vate gynecology clinics evaluated for T. vagi­nalis infection by clinical examination, di­rect wet mount and culture methods. Chief com­plain, signs and symptoms of patients re­corded, and vaginal swab samples from distal fornix were obtained dur­ing clinic visit and vagi­nal examination. One swab were examined by direct wet mount method pre­pared by saline normal, and other swab sample cultured in Dia­mond medium. Direct wet mount prepared and ex­amined immediately in clinic by an expert tech­nician. Cultured tubes were kept in an incu­bator with 37º C temperatures and examined mi­croscopically after 24 h. For negative cul­tures results, fresh medium were added in the tubes and kept for one 48 h more. Only the pa­tients diagnosed as having trichmoniasis on the basis of clinical signs and symptoms, compared with the results of wet mount examination and cul­tured vaginal specimens (in terms of being  po­sitive for T. vaginalis).

Results

The age range of study population was 15 through 68 yr. Majority (32%) of them was educated in high school and 88.7% were home­makers. The chief compliant of patients was va­gi­nal discharge, itching, burning, and chaf­ing. About 8.7% of patients mentioned the his­tory of tri­cho­moniasis (diagnosed clinically) and were already treated for this infection.

Trichomonas vaginalis infection was identi­fied in 2.2% (15/683) of the patients in both wet mount and cultured samples; however, 4.4% (30/ 683) patients had symptoms related to tricho­monal infection. The most of patients (31%) had discharge and itching that diagnosed Candida sp in the stained vaginal smears. A strik­ing finding was the infected individuals were divorced and were supporting by charity in­stitutions or, here husband were truck driver (Table 1). There was not significant relation­ship between clinical diagno­sis and laboratory findings, because most of pa­tients’ diagnosed trichomoniasis, were infected to Candida or other vaginal infections.

Table 1: Laboratory findings of 683 patients ini­tially diagnosed as trichomoniasis

Discussion

This study indicated that trichomoniasis is not a major problem, at least in some parts of Iran, especially in the traditional societies. How­ever, some reports from other parts of Iran have shown higher prevalence of trichomoni­asis in the at risk groups, such as women taken in prison [15]. Totally, trichomoniasis reported from as low as 0.46% to as high as 33.7% in dif­ferent parts of Iran [15, 16]. The differences in the prevalence of trichomoniasis between so­cieties and sub-populations almost cleared by various epidemi­ologic studies, but some minor differences in so­cial norms can influences on trichomoniasis [11]. Bacterial vaginosis and Can­dida vul­vovagini­tis are responsible for 90% of cases of vaginitis. Many cases of bacterial vaginosis are asympto­matic or present with only malodor­ous vaginal discharge and no in­flamma­tory com­plaints. There­fore, many vagi­nal infections diag­nosed tricho­moniasis clini­cally, can be bacterial vaginosis [17].

This result of this study is comparable with re­ports from some other Islamic countries for ex­ample Libya that reported a 1.2% prevalence of trichmoniasis (29/2450) from Benghazi City [18-22]. Another study conducted in Saudi Arabia Kingdom reported a prevalence of 28% (10967/ 39049 patients) trichomoniasis among to­tal SDTs recorded during 6 yr in a tradi­tional soci­ety [23]. Prevalence of trichomoniasis in­fection is different in the various parts of Iran. For ex­ample, prevalence of trichomoniasis infec­tion is 17% (12/141) in Zahedan [24]; 9.9% (100/1010) in Kashan [25]; 10.75% (43/400) in Bandar Abbas [26]; 1.37% (275/19530) in Chahar­mahal and Bakhtiari Province [15], 9% in Kerman [27] and, 5.6% in Mashad [28]. Majority of studies conducted in the gynecology clinics or mother and child health centers that could be consid­ered as representative of general popula­tion of women.

Most of epidemiologic studies of tricho­moni­asis conducted on females and in the gyne­col­ogy clinics, because of known risk fac­tors and easy access to target population [29-33]. Re­cently, in some developed countries the inci­dence of tri­chomoniasis infection is decrease by hard in­tervention and control measures such as health education, mass screening, and treat­ment of confirmed cases in high-risk groups [34].

In considering how a public health response to T. vaginalis might be implemented, a num­ber of important questions must be addressed. For example, who would be screened and at what intervals? What type of testing should be used? What approaches would be most effec­tive for case reporting and ensuring partner treat­ment? While the answers to these ques­tions are beyond the scope of this article, it is worth noting that the essential tools for T. vaginalis control are already available. A range of diagnostic tests, including vaginal saline wet mount microscopy, culture, rapid antigen test­ing, and nucleic acid amplification and detec­tion, provide alternatives that could be used in a variety of settings [35]. Oral metronidazole and ti­nidazole offer inexpensive, effective, and gener­ally well-tolerated treatment options that are widely available [1]. This study was limited to those patients who were admitted to some se­lective gy­necology clinics. Therefore, these pa­tients might not be the representative of gen­eral population of the women in Hamadan Prov­ince.

Conclusion

This study indicated that tri­chomoniasis infection is not noticeable, as mush as other organisms such as Candida sp., thus, other bacterial vaginosis must come to atten­tion.    

Acknowledgements

This work was partially supported by Re­search Department of Hamadan University of Me­dical Science grant, hereby gratefully ac­knowl­edged. We gratefully acknowledge Miss Karim­khani and Mrs. Habibi for assistance in speci­men's collection and parasite culture. We also thank all patients for kindly cooperation. The authors declare that they have no conflicts of interest. 

References

1. Schwebke JR and Burgess D. Trichomoniasis. Clin Microbiol Rev. 2004; 17:794-803.
2. Cotch M F, Pastorek JG, Nugent RP, Hillier SL, Gibbs RS, Martin DH, et al. Trichomonas vaginalis associated with low birth weight and preterm delivery. Sex Transm Dis. 1997;24:353-60.
3. Minkoff H, Grunebaum AN, Schwarz RH, Feldman J, Cummings M, Crombleholme W, et al. Risk factors for prematurity and premature rupture of membranes: a prospective study of the vaginal flora in pregnancy. Am J Obstet Gynecol. 1984;150(8):965-72.
4. Hardy PH, Hardy JB, Nell EE, Graham DA, Spence MR, Rosenbaum RC. Prevalence of six sexually transmitted disease agents among pregnant inner-city adolescents and pregnancy outcome. Lancet. 1984;2:333-7.
5. Zhang ZF, Begg CB. Is Trichomonas vaginalis a cause of cervical neoplasia? Results from a combined analysis of 24 studies. Int J Epidemiol. 1994;23:682-90.
6. Yap EH, Ho TH, Chan YC, Thong TW, Ng GC, Ho LC, Singh M. et al. Serum antibodies to Tri¬chomonas vaginalis in invasive cervical cancer patients. Genitourin Med. 1995;71(6):402-4.
7. Soper DE, Bump RC, Hurt WG. Bacterial vagino¬sis and trichomoniasis vaginitis are risk factors for cuff cellulites after abdominal hysterectomy. Am J Obstet Gynecol. 1990;163:1016-21.
8. Moodley P, Wilkinson D, Connolly C, Moodley J, Sturm AW. Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus. Clin Infect Dis. 2002;34:519-22.
9. Sherman KJ, Chow WH, Daling JR, Weiss NS. Sexually transmitted diseases and the risk of tubal pregnancy. J Reprod Med. 1988; 33:30-4.
10. Grodstein F, Goldman MB, Cramer DW. Rela¬tion of tubal infertility to history of sexually transmitted diseases. Am J Epidemiol. 1993;137:577-84.
11. Krieger JK. Trichomoniasis In: Warren KS and Mahmoud AAF, editors. Tropical and geo¬graphical medicine. 2nd edition, New York: McGraw- Hill; 1990.
12. Shafir SC, Sorvillo FJ, Smith L. Current issues and considerations regarding trichomoniasis and human immunodeficiency virus in African-Americans. Clin Microbiol Rev. 2009;22(1):37-45.
13. Ağaçfidan A, Kohl P. Sexually transmitted dis¬eases (STDs) in the world. FEMS Immunol Med Microbiol. 1999;24(4):431-5.
14. Johnston VJ, Mabey DC. Global epidemiology and control of Trichomonas vaginalis. Curr Opin Infect Dis. 2008;21(1):56-64.
15. Dibadji R, Rezaian M. Prevalence and Parasi¬tologic and serologic diagnosis of Trichomoni¬asis in the central prison of Tehran.1st Iranian Congress for Parasitology; 1999 December 11-13; Rasht, Iran.
16. Sadeghi M, Manoochehri K. Trichomonisis prevalence among women admitted to public health centers of Chaharmahal and Bakhtyari province for annual Pap smear test (1995-1996). Shahrekord University of Medical Science’ Journal. 2001;3(3): 37-41(Farsi).
17. Scott JR, Gibbs RS, Karlan BY, Haney AF. Dan¬forth’s obstetrics and gynecology. 9th Edition, Philadelphia, Williams & Wilkins, 2003.
18. Kassem HH, Majoud OA. Trichomoniasis among women with vaginal discharge in Benghazi City, Libya. J Egypt Soc Parasitol. 2006,36(3): 1007-16.
19. Mahafzah AM, Al-Ramahi MQ, Asa'd AM, El-Khateeb MS. Prevalence of sexually transmitted infections among sexually active Jordanian females. Sex Transm Dis. 2008;35(6):607-10.
20. Malkawi SR, Abu Hazeem RM, Hajjat BM, Hajjiri FK. Evaluation of cervical smears at King Hussein Medical Centre, Jordan, over three and a half years. East Mediterr Health J. 2004;10(4-5):676-9.
21. Selvitopu A, Ozçelik S, Değerli S. The incidence of Trichomonas vaginalis in vaginal specimens from gynecologic patients. Turkiye Parazitol Derg. 2006;30(3):175-7.
22. Culha G, Hakverdi AU, Zeteroğlu S, Duran N. In¬vestigation of the prevalence of Trichomonas vaginalis in women with complaints of vaginal discharge and itching. Turkiye Parazitol Derg. 2006;30(1):16-8.
23. Madani TA. Sexually transmitted infections in Saudi Arabia. BMC Infect Dis. 2006;Jan 10, 6:3 (eJournal).
24. Shabestari S: evaluation of para-clinic methods in diagnosis of Trichomoniasis in the women admitted to outpatient clinics of Qods hospital of Zahedan 1382 [MD thesis]. Zahedan, Zahedan University of Medical Science; 2004.
25. Rasti S, Taghriri A, Behrashi M: Trichomoniasis in the women admitted to Shabihkhani Hospital, Kashan 1381. Feyz. 2003;7(26):21-28
26. Shahi A: Prevalence and predisposing factors of Trichomoniasis in the women admitted to urban health centers of Bandar Abbas [MD thesis]. Tehran, Tehran University of Medical Science; 1997.
27. Akbari MR, Rezaian M. Study of Trichomons vaginalis infection in the patients admitted to health centers and Jehad Laboratory of Mashad. 1st Iranian Congress for Parasitology; 1999 December 11-13; Rasht, Iran.
28. Sharifi I, Tadayon Tahmasbi S. Prevalence of Trichomonas vaginalis in the patients with leukuhrea admitted to gynecologic clinics of Kerman. Nabz, 1994; 4(6): 7-13
29. Mondal NI, Hossain K, Islam R, Mian AB. Sex¬ual behavior and sexually transmitted diseases in street-based female sex workers in Rajshahi City, Bangladesh. Braz J Infect Dis. 2008;12(4):287-92.
30. Wang H, Wang N, Jia M, Bi A, Wang G, Ding G, Lin L, Smith K. Sexually transmitted infections among female sex workers in Kaiyuan city, Yunnan province, China: potential for HIV transmission. Sex Transm Infect. 2009;85(4):290-5.
31. Shahmanesh M, Cowan F, Wayal S, Copas A, Patel V, Mabey D. The burden and determinants of HIV and sexually transmitted infections in a population-based sample of female sex workers in Goa, India. Sex Transm Infect. 2009;85(1):50-9.
32. Cwikel JG, Lazer T, Press F, Lazer S. Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations. Sex Health. 2008;5(1):9-16.
33. Hagan JE, Dulmaa N. Risk factors and preva¬lence of HIV and sexually transmitted infections among low-income female commercial sex workers in Mongolia. Sex Transm Dis. 2007;34(2):83-7.
34. 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(10):1319-26.
35. Pillay A, Lewis J, Ballard RC. Evaluation of Xenostrip-Tv, a rapid diagnostic test for Tri¬chomonas vaginalis- infection. J Clin Microbiol. 2004;42(8):3853-6.