| Abstract|| |
Background: Despite enormous sensitization and management options available for sexually transmitted infections (STIs) in the last 2 decades, these infections remain highly endemic in certain parts of Cameroon. This is a descriptive study of genital hygiene and predisposition to STIs in some women in Dschang, West Region, Cameroon. Materials and Methods: A total of 2172 consenting women seeking gynecological care at the Dschang District Hospital from 2009 to 2010 were interviewed, examined, cervical/blood specimens collected, and analyzed. Results: Inadequate healthcare systems; lack of reproductive health knowledge; vaginal washing with contaminated water or chemicals; contaminated sanitary towels or gynecologic equipment; unsterile sharps; dirty and damp lavatories; synthetic and tight underwear; multiple or concurrent sex partners; primitive traditions; myths; polygamous and inherited marriages; asymptomatic carriage of pathogens; self-medication; antibiotic abuse; traditional therapy; reinfections; poverty; poor sanitation; and illiteracy were related to genital conditions identified in 1466 (67%) study subjects, excluding 41 (2%) cases with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) only. In total, 1353 (62%) patients were infectious cases, 113 (5%) had noninfectious vaginitis, 171 (8%) were positive for HIV/AIDS serology, with 6% having concurrent genital infections. Of the 1507 patients diagnosed with STIs, 62% were symptomatic and 7% asymptomatic comprising 5% convalescent and 2% healthy carriers. Bacterial vaginosis 24%, vaginal candidiasis 18%, chlamydia 15%, and active syphilis 11% predominated over trichomonas, gonorrhea, hepatitis B, herpes, and warts with rates ≤1%. Conclusion: In mitigation, hand washing, clean toilets, sexual behaviors that contribute to STIs, delay sexual debut, condom usage, rational employment of examination methods, improved medical diagnostics testing both men and women, attitude change and prevention education were emphasized on.
Keywords: Genital health awareness, interventions, socio-cultural barriers, STIs
|How to cite this article:|
Kesah FNC, Payne VK, Asakizi A. Prevalence and etiology of sexually transmitted infections in a gynecologic unit of a developing country. Ann Trop Med Public Health 2013;6:526-31
|How to cite this URL:|
Kesah FNC, Payne VK, Asakizi A. Prevalence and etiology of sexually transmitted infections in a gynecologic unit of a developing country. Ann Trop Med Public Health [serial online] 2013 [cited 2019 Sep 17];6:526-31. Available from: http://www.atmph.org/text.asp?2013/6/5/526/133708
| Introduction|| |
Reproductive health knowledge is an integral part of sex education. The woman is the pivot of child education. Thus, it is imperative that the woman or girl child be always empowered in order to contain the ills that plaque society as a result of sexually transmitted infections (STIs).
This study was prompted by an unprecedented upsurge of STIs in Dschang, executed mainly to highlight prevention strategies. Factors were exploited on personal, genital, and environmental hygiene; awareness on reproductive health; and also on how the social and cultural arenas influence the STI problem in the study milieu.
| Materials and Methods|| |
Ethical clearance (declaration of Helsinki, 1975, revised in 2000)
Authorization to carry out this study was obtained from the Chief Medical Officer (CMO) of Menoua division.
The Dschang District Hospital (DDH) is a government general hospital in Menoua, West Region, Cameroon. The CMO of this hospital was officially informed about the study which he approved. Consulting clinicians were subsequently notified who then explained the purpose of the study to eligible patients who attended this hospital to get their consent to participate in the study. The DDH was visited daily from Monday to Friday for data and specimen collection by the researchers, from January 2009 to December 2010.
A total of 1117 heterosexual consecutive women in 2009 and 1055 similar women in 2010, with informed consent who presented at the gynecologic unit of the DDH for antenatal care or with gynecologic complain.
Administration of questionnaires
Information relevant to the study was collected from each patient by the examining clinician and each questionnaire completed by the researchers. The researchers took turns to complete the questionnaires as a clinician interviewed each patient. However, sometimes, the clinician's notes were used to complete the questionnaires. Such data included the age, place of residence, ethnicity, marital status and type of marriage, number of sexual partners, occupation, the underlying clinical condition, the presence of rashes, warts or lice on the vulva, the type of medication, and level of education. A section of the questionnaire was intended to obtain information to guide in assessing a patient's personal hygiene vis-à-vis the number of times a patient baths a day, the type of soap, and the source of the water used; whether or not a patient douches and how often in a month, and the types of douching ingredients; the types, handling and storage of sanitary towels, the frequency of wearing and washing tights, cleaning schedules for domestic lavatories, and the use of public lavatories. Patients were also interviewed to get information on issues related to reproductive health knowledge such as the types of inner wears, direction of wiping after voiding, and frequency of sterilizing sharps in hair dressing salons. Some 41 hairdressers and 50 barbers shops in Dschang were visited to determine how often sharps were sterilized between customers. The opinion of patients was also sought on sociocultural risk factors to STIs.
Collection and processing of specimens
Three high vaginal swabs were collected from all the women by a nurse, laboratory worker, or clinician. Two of these samples from each patient were packed in a leak proof plastic bag and transported immediately to the Applied Biology and Ecology Laboratory of the Department of Animal Biology of the University of Dschang for analysis according to standard techniques.  One of the two cervical swabs from each patient was used for a direct examination, while the second was used for culture. The third cervical swab was sent to the DDH laboratory for Chlamydia trachomatis testing using the Chlamy-Check-1 kit (Chlamy check one-step Generation Trachomatis LPS Antigen Test marketed by KENZA Diagnostics KYA SAND). All the patients were also sent to the DDH laboratory for collection of blood samples for testing of syphilis, hepatitis B, and HIV/AIDS. The rapid plasma reagin test and the Wellcosyh HA 1000 V0 B5 8E 59-01 hemagglutination screening kit for the detection of antibodies to Treponema pallidum were used. The sera of patients was also tested for hepatitis B using the hepatitis B virus blood test (Hesae test strip for hepatitis BsAg5110079 fabricated by Acumen diagnostics Inc., USA). All patients were also confirmed for antibodies to the HIV using the Abbott Determine HIV-1/2. The patients involved in this study paid for all their serological tests as part of their routine screening. Genital herpes, warts, and pubic lice were diagnosed clinically.
| Results|| |
Of the 2172 consecutive, consenting heterosexual women aged 15-81 years (mean 35 years), 1507 (69%) had at least one on-going infection or irritation. Age, marital status (married, single/spinster, widowed, divorced, and separated), type of marriage (monogamy, polygamy), number of sexual partners and occupation (housewives, civil servants, self-employed, students, pupils, and the unemployed) did not influence infection rates in the study population. Prostitution, infidelity, low level of education, low economic status, frequent vaginal washing with medicated soap or chemicals (dettol, mercryl, and bleach) either directly or in water, unhygienically handling or storing sanitary napkins and constant or frequent wearing and exchange of synthetic pantyhose referred to as ''coolants'' for long without washing might have contributed enormously to genital problems in the study population. The use of contaminated water from streams, wells, springs, and rain water to wash the genitalia, infrequent cleaning of personal lavatories, nonusage of disinfectants to clean lavatories, the use of filthy public lavatories, and urinating and defecating in open dirty environments might have exposed the vagina to contamination with fecal and environmental organisms. Similarly, many infected patients spread their inner wears in poorly or nonventilated environments. Generally speaking, poor hygiene and lack of reproductive health knowledge (high usage of nylon instead of cotton pants, wiping from the anterior to the posterior end after voiding, infrequent hand washing after leaving the rest room, not mopping the floor of the bathroom after bathing, and not always sterilizing sharps in hair dressing salons) should have a tremendous impact on the occurrence of STIs. The awareness on safe sexual practices was also lacking among study subjects as some still practised unprotected and oral sex without screening partners. The act of inserting unwashed fingers into the vagina to boost sex drive was also frequent.
Responses from the questionnaire also indicated that some localities did not have health posts or good roads such that residents of such areas, most of whom were poverty stricken, did not have access to health personnel to diagnose and treat infections. Also, laboratories were nonexistent in some health facilities, and where present were poorly equipped sometimes manned by ill-trained and insufficient staff, resulting in poor diagnosis of diseases. Patients reported that there were events in this society which warranted grand celebrations and so people congregated with various objectives in mind including sexual promiscuity which predisposed to STIs. More still, poverty, unemployment, or domestic violence had led to many other troubles such as prostitution, infidelity, illiteracy, lack of medical care, delinquency, child abuse, teenage sex, substance abuse, and alcoholism (drinking sprees with abled friends) with transmission of STIs being among expected sequels of such behaviour. Again, marriage or funeral customs still prevailed in this society which predisposed to STIs. Typically, "men sleep with young single ladies on the night of the wake keeping of a very important personality to give birth to the deceased," or a successor takes over the numerous wives of his father especially traditional rulers (inherited marriage). In such circumstances, purported infidelity or sexual dissatisfaction (since numerous wives take turns) has led to sexual promiscuity. Dschang has actually witnessed increased sexual promiscuity over the past 2 decades (1995 to date), following increasing urbanization and improved social amenities such as the creation of the University of Dschang, improved road infrastructure, and proliferation of hotels and hostels at every nook and cranny of the town.
Surprisingly, during the study period, hairdressers, barbing salons, and traditional medicine homes had their contributions to the STI problem, most often compounded by ignorance, due to no formal or low level of education, or insensitivity to the hazards posed to society through nonsterilization of equipment or non-usage of one sharp per person. Only 6 (15%) of 41 hairdressers interviewed had alcohol or bleach for sterilization of sharps at the time of sampling, whereas all the 50 barbers salons had alcohol or methylated spirit, although only 3 (6%) of them always sterilized shaving kits between customers but did on requests by customers. Hairdressers, barbers or traditional practitioners (TPs) themselves were also at risk of cross-infections from inappropriate handling of sharps; and certain habits such as unconsciously putting needles into their mouths as they worked, or TPs lacerating patients without wearing gloves in order to introduce herbal concoctions into the body. Another reported ramification to the STI saga was the fact that the population was at risk of infection from medical personnel, barbers, hairdressers, TPs, and even friends, relatives or neighbours who were positive for HIV/AIDS and still render high-risk services to the public.
A few women encountered in this study attributed genital infections to natural and supernatural forces, that is, to the wrath of ancestors, enemies, or witchcraft, and were forcefully brought to the hospital by relations. Some other study subjects recognize their infections but had no means to visit the hospital. Some other patients were advised by friends or family member to visit healers or soothsayers for easily affordable concoctions to treat themselves. Such cases presented at the hospital when the infections were unbearable. Noncompliance to medication led to reinfections.
Of the 2172 women, 1,466 (67%) had genital diseases excluding those with HIV/AIDS only (41, 1.9%). Significant growth of one or more pathogens was identified in 1353 patients, giving an incidence of 62% of infectious genital diseases, 113 cases (5%) had noninfectious vaginitis. The pH of cervical swabs ranged from 3.5 to 8.5 for infected samples, and from 3.0 to 4.5 for samples void of pathogens. Samples from 171 (8%) patients showed positive for HIV/AIDS serology, with 130 (6%) of them having concurrent genital infections. A total of 1630 (75%) episodes of genital diseases were identified in the 1336 (62%) patients, 161 (7%) patients had multiple infections excluding HIV/AIDS only. Increased rates were observed in 2009 for chlamydia, syphilis and HIV/AIDS [Table 1]. Although only 820 (38%) patients tendered abnormal symptoms of the genital tract, 1350 (62%) symptomatic cases were elicited by direct interrogation or inspection by the medical staff. A total of 157 patients (7%) established asymptomatic did not know they were carriers [Table 2]. Among the 157 asymptomatic cases were 101 (5%) convalescent carriers and 56 (2%) healthy carriers. Convalescent carriers harbored pathogens with no disease symptoms and reported having a STI treated in the preceding 6 months. Healthy carriers harbored pathogens but did not have disease symptoms nor had a recent history (≤6 months) of past genital infection. Antibiotic abuse was common among convalescent carriers-taking antibiotics without prescription; mixing antibiotics and alcohol; mixing antibiotics and traditional herbal concoctions; not getting medication at the right time or not taking medication as directed; wrong prescription either from friends, associates, quack medical personnel, patent medicine stores, or stalls; and visiting multiple pharmacies, drug stores, or stalls to seek cheaper alternatives of drugs prescribed. Undertaking of drugs due to noticeable side effects, disappearance of clinical symptoms, or occasional forgetfulness; and overtaking of drugs due to occasional forgetfulness was also noted. Unknowingly taking or buying fake or substandard drugs or herbal concoctions on the open market, transport vehicles, or commercial avenues from uneducated peddlers to treat genital infections was also problematic. Self-medication stemming from ignorance, scarcity, or inaccessibility of qualified medical personnel was yet another common practice; compounded by the uncontrolled way and manner in which drugs are sold to the public in markets, patent medicine stores, buses, or train stations and in transport vehicles.
|Table 1: Sexually transmitted infections in women attending the gynecologic unit of the Dschang district hospital|
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|Table 2: Symptomatic and asymptomatic sexually transmitted infections in the study population|
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Staphylococcus aureus (22%) significantly caused bacterial vaginosis (P = 0.001) [Table 3]. Polymicrobial infection was observed in 165 specimens.
|Table 3: Aetiologic agents of sexually transmitted infections in the study population|
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| Discussion|| |
STIs have caused health conditions such as infertility, ectopic pregnancies, preterm births, neonatal infections, liver diseases, cancers and even deaths, with attendant negative socioeconomic, cultural, and political ramifications. ,,, In Cameroon, a child is cardinal in marriage. Separations and/or divorces or family conflicts have been witnessed in situations of childlessness stemming from an unhealthy reproductive tract. STIs have also been associated with celibacy, stigma, and hindrance to development, population growth, and man power. When the woman or girl child is healthy, a country is certain of a growing population which will ensure a vibrant labor force, and thus, sustainable economic development. More still, moral decadence, substance abuse, drug, or alcohol dependence and psychological trauma have heightened among individuals abandoned by parents who have died of STIs, thereby affecting the productivity and/or economic growth of many countries. Over the years, societal mishaps such as prostitution, infidelity, poverty, teenage sex, drug abuse, alcoholism, vandalism, and juvenile delinquency have been linked to STIs. ,, STIs remain prevalent worldwide and implicated pathogens can also be present in and be spread by patients who do not have symptoms or are not aware of their infection. ,,
Genital infections present one of the most common reasons for gynecologic consultation in sexually active women. Thus, it was not surprising that in this work, 69% of the women who sought out an obstetrician or gynaecologist were found to harbor genital infections or irritations. This result agrees with reports elsewhere.  Most infections encountered in this study (62%) were symptomatic, although 22% symptomatic women failed to recognize and report their symptoms. Such attitude also obtains outside this subregion. ,,,
Of the 2172 participants, 62% had infectious vaginitis. These findings compared favorably with a 64.2% prevalence reported in Ghana  and 63% in rural South Africa  but much lower than a 96.4% prevalence in Nigerian women.  Bacterial vaginosis (24%) and vaginal candidiasis (18%) were in preponderance in this study. Bacterial vaginosis has been reported as one of the most common genital infections worldwide with a prevalence range of 20%-50% in the general population.  The incidence of chlamydia was 15%, syphilis 11%, HIV/AIDS 8%, and trichomoniasis 1%. Rates were below 1% for gonorrhea, pubic lice, hepatitis B, and genital warts. These results conform to findings in Brazil, Zimbabwe, Argentina, Ghana, Nigeria, and the USA. ,,,,,, The present findings were also in accordance with those of other researchers. ,,, A higher prevalence rate for trichomonal vaginitis has been reported in China.  The higher rates obtained in 2009 in this study for chlamydia and syphilis might have been due to medication abuse and/or reinfections. In this study also, vaginal candidiasis, bacterial vaginosis, and trichomonas were frequent in patients positive for HIV/AIDS, a finding which also obtains elsewhere. ,
Practices such as inserting unwashed fingers into the vagina to stimulate sexual drive might have predisposed to bacterial vaginosis. A prevalence range of 20%-50% intravaginal practices has been documented.  In this study, 46% of the women douched with chemicals or disinfected water and 33% used medicated soap to wash the vagina.
Prostitution, infidelity, low level of education, polygamous and inherited marriages, low economic status, failure of traditional medication and/or reinfections were linked to genital problems. These facts are alike with reports outside this subregion. ,,,,
Majority of this study population did not use cotton pants and exchange of tights was common among students. Most study subjects preferred the aesthetic rather than the health value of inner wears, it is true to say that most appealing and affordable inner wears on the market in this environment are synthetic. Many study subjects exposed sanitary towels to contamination by dust particles or pests which were also handled with dirty hands, thus, these could easily serve as likely sources of potential pathogens in the genital tract. Thus, complains of genital itches after menstruation by some patients could be attributed to exposure to contamination or unhygienic handling and the types of sanitary napkins used. Toilet paper or pieces of cloth used as sanitary towels might have been contaminated during storage or handling. Also, in this environment, shops or stores which sell sanitary materials were not left out in these unhygienic practices of poor handling and storage, as dust often accumulates on packets of sanitary materials, some of which were torn thereby exposing the contents to contamination, especially by dusty air, household pests, and rodents. This is a cause for concern since most women or girls are ignorant or not conscious of the hygienic condition of these materials they buy or use. It is common practice for vendors to dust packets of sanitary materials with fingers and hand over to consumers. More so, the majority of the population of Dschang and its environs do not have access to potable water; many use well, spring, rain, and stream water for bathing and other purposes, another reason why study subjects added large quantities of antiseptics to water for personal and genital hygiene, since the water quality is poor and is often treated only for drinking purposes.  With water shortage, thorough rinsing of chemicals used to wash inner wears is also doubtful and these can affect the genitalia.
Yearly gynecological checks for all females of reproductive age were recommended. All females were advised to be vigilant about body changes and report symptomatic STIs to clinicians. Menopausal women should always consult for best options. In boarding houses, exchange (begging, borrowing, stealing) of inner wears, towels, clothing and beddings; common storage of garments, sleeping together, and sharing of sharps were discouraged.
Ancient myths, traditional herbal medication, antibiotic abuse, primitive traditional marriage or funeral customs, social gatherings, the multifaceted consequences of poverty, increasing urbanization and development, and unsafe sexual practices have been documented the world over to have a profound impact on the transmission of STIs. ,,
S. aureus, Candida albicans, C. trachomatis, and Treponema pallidum topped the list of pathogens. Similar reports exist in Spain  and Argentina.  The World's AIDS day urged all to have access to sexual health services and interventions.  The Dschang community was educated on how to prevent genital infections.
| Acknowledgement|| |
We are grateful to the management and staff of the DDH for their co-operation which made this work successful. Immense thanks to Mrs Katte Bridget Fonge for technical assistance.
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Fusi-Ngwa Catherine Kesah
Department of Animal Biology, Faculty of Science, University of Dschang, 67 Dschang, West Region
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]