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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 188-193

Prevalence of genital Chlamydia trachomatis infection among patients attending a gynecological clinic in a tertiary hospital


1 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Microbiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Gwagwalada, Nigeria

Date of Submission29-Nov-2018
Date of Acceptance26-Feb-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. S Bello
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/smj.smj_64_18

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  Abstract 


Background: Chlamydia trachomatis is the most common cause of sexually transmitted infections in the world. The organism causes silent infection in women and could remain unnoticed for a very long time. Nearly 80% of women are asymptomatic. It is an established and recognized cause of pelvic inflammatory disease, ectopic pregnancy, and infertility among women. In most parts of Nigeria, including the study area, the organism is not routinely screened for, hence the paucity of information about its prevalence. Objectives: The objectives of this study were to determine the prevalence and risk factors associated with genital C. trachomatis infection among women attending the Gynaecological Clinic of Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Materials and Methods: A prospective study was carried out among new patients attending the Gynaecological Clinic of UDUTH, Sokoto. The women were consecutively recruited as they presented to the clinic until the desired sample size was achieved. A structured questionnaire was administered, and related information and consent were obtained. Endocervical swab was collected and tested using Eugene Chlamydia Rapid Test Device following manufacturer's instructions. Results: Samples were collected from a total of 400 women aged between 15 and 49 years. The prevalence of genital C. trachomatis among gynecological patients was 3.5%. The risk factors identified include age of patients below 29 years, early age of onset of sexual activity, and marital status. Conclusion: The study showed that the prevalence of genital C. trachomatis was low. The rate was higher among respondents with infertility. There is a need for routine screening of patients with infertility.

Keywords: Chlamydia, endocervical swab, prevalence, Sokoto


How to cite this article:
Bello S, Tunau K, Nasir S, Yahaya M, Panti A, Hassan M, Nwobodo E I, Ekele B A. Prevalence of genital Chlamydia trachomatis infection among patients attending a gynecological clinic in a tertiary hospital. Sahel Med J 2019;22:188-93

How to cite this URL:
Bello S, Tunau K, Nasir S, Yahaya M, Panti A, Hassan M, Nwobodo E I, Ekele B A. Prevalence of genital Chlamydia trachomatis infection among patients attending a gynecological clinic in a tertiary hospital. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:188-93. Available from: http://www.smjonline.org/text.asp?2019/22/4/188/272147




  Introduction Top


Chlamydia trachomatis is the most common cause of sexually transmitted veneral infections in the world.[1] It is an established cause of pelvic inflammatory disease, ectopic pregnancy, and infertility among women.[2] As many as 10% of women of childbearing age are infected in the United Kingdom.[3] In most parts of Africa including Nigeria, C. trachomatis is not routinely screened for, and hence relative information about the frequencies of the organism is sparse.[4] The prevalence reported varies from as high as 56.10% in Jos [1] to a much lower prevalence of 9% in Maiduguri.[5]

Approximately 4 million cases of chlamydial infections are reported every year in the United States. A prevalence as high as 14% was reported in the African–American females aged 18–26 years during 2007; approximately 1.1 million cases of chlamydia were reported to the United States Centers for Disease Control and Prevention, more than half of these constitute females aged 15–25 years.[6]

In many developed countries, screening programs for chlamydia have been set up to reduce transmission and reproductive tract morbidity.[7] The United States Centers for Disease Control and prevention recommend annual screening of all sexually active women aged 25 years or less.[8],[9] In most parts of Africa including Nigeria, C. trachomatis is not routinely screened for, and hence relative information about frequencies of the organism is sparse.[4]

A prevalence of 1.7% was found in Europe.[7] This low prevalence may be as a result of the increased awareness of chlamydial infection and easy access to laboratory diagnosis and treatment. In India, Malik et al. found a C. trachomatis prevalence of 55% among women with secondary infertility and 5.5% among healthy term pregnant women who were used as controls.[10] Furthermore, 63.3% of those positive for C. trachomatis immunoglobulin G (IgG) had tubal occlusion and 77.2% of them were symptomatic.[10] In another hospital-based study on antenatal Indian women, a prevalence of 21.3% of endocervical chlamydial infection was obtained, and this was shown to have significant association with stillbirth, premature deliveries, and low birth weight.[11] A cross-sectional study using polymerase chain reaction of first-catch urine in Iran showed that there was a prevalence of 13.8% and 11.1% of C. trachomatis infection, respectively, in 223 infertile women attending Gynaecological Clinic and 225 fertile women attending antenatal clinic. However, serology revealed chlamydia IgG in 8.6% of the infertile and 4.9% of the fertile women.[12]

In Africa, a prevalence of 28.5% in female sex workers was found in Dakar, Senegal, whereas a prevalence of 6% and 13% was reported among women attending antenatal clinic in Tanzania and Cape Verde, respectively. In Ethiopia, the prevalence rate for Chlamydia infection of the cervix was 5.9%.[13] Opoku et al. found a prevalence of 4.8% among 1070 women at risk of genital chlamydial and gonococcal infections in Kumasi, Ghana, using Rapid Immunoassay kit (Quickvue).[14]

In Nigeria, Mawak et al. showed a prevalence of 56.10% among 164 women attending Gynaecology clinic in Jos, using rapid diagnostic test device.[1] The high prevalence may be as a result of increase in sexual behavioral attitudes in that society as reported by the authors. However, a small sample size of 164 may not be adequately representative. In Zaria, a prevalence of 38.3% was found following a case–controlled study that was conducted on 120 patients with tubal infertility and 120 control clients attending the family planning clinic using onestep diagnostic test kits (Clinpro International Co. LLC, CA, USA) on endocervical swab.[15] A 35.7% prevalence among pregnant and nonpregnant women and their spouses attending pre- and post-natal clinics in the College of Medicine of the University of Lagos has been reported.[16] In this study, 245 patients were screened for the presence of complement-fixing antibody to C. trachomatis. A slightly higher prevalence of 40.7% has been reported from Ekpoma, south-eastern part of Nigeria.[4] The study was carried out among patients attending Gynaecology clinic using chlamydial complement-fixing antibody. At two hospitals in Benin, a case–controlled study of 81 patients with tubal infertility and 81 age-matched fertile pregnant controls were compared following analysis of their sera with immunocomb C. trachomatis IgG kit. The prevalence of serum C. trachomatis was 64.2% among the infertile women, whereas it was 17.3% among the fertile women.[17]

C. trachomatis, a small bacterium, is an obligate intracellular pathogen. Serovars A–C cause trachoma infecting the conjunctiva. Serovars D–K cause genital infections. Specific lymphogranuloma venerum (LGV) Serovars (L1–L3) cause LGV. The infectious particle is the elementary body that infects columnar epithelial cells in the genital tract. They gain entry to the cells by binding to specific surface receptors. Once inside the cell, inclusion bodies form and these contain the metabolically active reticulate bodies. These reticulate bodies divide by binary fission. After a 48-h life cycle, reticulate bodies condense into elementary bodies which are released from the cell surface. Heavily infected cells die, but it is the inflammatory response to infection that contributes most to damaging the epithelial surface.[3]

Risk factors that have been found to be associated with this type of infection include age under 25 years, multiple sexual partners, use of oral contraceptives, and failure to use barrier method of contraception. Others include a history of sexually transmitted diseases (STDs), HIV seropositivity and seroconversion, as well as cervical ectopy and low socioeconomic status.[18],[19],[20],[21]

The clinical features of chlamydial infection are nonspecific and usually asymptomatic in about 80% of women.[22] About one-third of those with symptoms will present with dyspareunia, postcoital bleeding and intermenstrual bleeding, and/or vaginal discharge. Findings include mucopurulent cervical discharge that appears yellow on a white cotton-tipped swab, cervical ectopy, cervical edema, and cervical friability.[18],[22]


  Materials and Methods Top


This was a prospective study conducted among new female patients attending the Gynaecologic Clinic of Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. They were recruited after obtaining informed consent over a period of 11 months (June 2014–April 2015), until a desired sample size of 400 was achieved. Those patients who test positive were treated with antibiotics. The study included all women who were sexually active and consented. Women who did not consent, who were not sexually active, and those who used antibiotics in the preceding 2 weeks were excluded from the study.

Sampling techniques

A convenience sampling method was employed whereby consecutive women that meet the inclusion criteria were enrolled as they presented to the Gynaecologic Clinic of UDUTH, Sokoto. Five patients per clinic were selected for the study, making a total of twenty patients per week at the Gynaecologic Clinic.

Sample collection and testing procedure

A brief researcher-administered questionnaire that included biodata, demographic details, sexual behavior and history of STD, ectopic pregnancy, and infertility was completed for each consented participant by the researcher. Endocervical swab was collected using a sterile plastic shaft cotton-tipped swab stick after removing excess mucus from the endocervical area. The swab was inserted into the endocervical canal past the squamocolumnar junction, until most of the tip was no longer visible. The swab was firmly rotated for 15–20 s, and then withdrawn without contamination with exocervical or vaginal cells. The swab was immediately immersed in an extraction tube containing six drops of extraction solution A (0.2 M sodium hydroxide). After 2 min of extraction, six drops of extraction solution B (0.2 M hydrochloric acid) was added and mixed. The swab was squeezed against the side of the tube to expel as much liquid as possible. The swab was discarded, and a cap was placed on the extraction tube. Three drops of the extracted sample was added to the sample well. The swab was tested using EUGENE chlamydial antigen test kit manufactured by Shanghai Eugene Biotech Co., Ltd., No. 2179, Jingshang Road 99, Jinshan District, Shanghai 201500, PR China.

The test results were read within 10 min. In the absence of a band in the control region, the test result was considered invalid. Positive result showed two bands at the test and control regions [Figure 1]. Negative result showed one band at the control region [Figure 2].
Figure 1: A positive result showing two bands at the test and control regions

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Figure 2: A negative result showing one band at the control region

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Statistical analysis

The Health Research and Ethics Committee of Usmanu Danfodiyo University Teaching Hospital, Sokoto approved the study on 30th January 2014 (UDUTH/HREC/2013/179. The study adhered to 2013 Geneva Helsinki Declaration.

Data obtained were checked manually for completeness and accuracy, and then subjected to standard statistical tests using SPSS (Statistical Package for the Social Sciences, IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.), where indicated, and some of the results were displayed in the form of charts and tables. Chi-square test was used to ascertain the level of statistical significance, and P < 0.05 was considered statistically significant.


  Results Top


The recruited patients were females of reproductive age group with a mean age of 28.26 ± 7.73 [Figure 3]. Majority of the patients were married. Of the 334 (83.5%) married women, 302 (90.4) were married in a polygamous setup, 153 (38.25%) had only Quranic education, while 109 (27.25%) had primary education [Table 1].
Figure 3: A bar chart showing the age distribution of patients

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Table 1: Sociodemographic characteristics of the patients

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C. trachomatis infection was higher among the infertile patients, but there was no significant statistical association.


  Discussion Top


The prevalence of genital C. trachomatis among 400 patients attending the Gynaecological Clinic of UDUTH, Sokoto, was found to be 3.5% [Figure 4]. The low prevalence of 3.5% in this study may be due to the strict sociocultural practice in the region. Being an Islamic state, Sharia law is practiced and in order to ensure moral values, there is restriction of females from the public. These practices are likely to ensure minimal contact between men and women leading to relatively low premarital and extramarital sexual activities. The ability of the test kit to detect only the current infection may also account for the low prevalence. The prevalence is comparable to a low prevalence of 1.7% in Europe.[7] The low prevalence in Europe may be as a result of the increased awareness of Chlamydial infection and easy access to laboratory diagnosis and treatment in developed countries. A slightly higher prevalence of 9% and 10% was found in Maidugri and Ibadan, respectively.[5]
Figure 4: Prevalence of genital Chlamydia trachomatis in relation to marital status

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A higher prevalence of 29.4%, 38.3%, 56.1%, and 74% was found by Ikeme in Enugu, Tukur in Zaria, Mawak in Jos, and Jeremiah in Port Harcourt, respectively.[1],[15],[23],[24] This may have resulted from increased sexual behavioral attitudes of individuals in that society and the difference in the cohort of patients studied. The diagnostic method used in Zaria where past and present infections are detected may have accounted for the high prevalence compared to that of the index study. This study differs from the current study in that the study groups are different; however, both share a similar method of diagnosis.

Previous epidemiological studies on C. trachomatis infection have identified a variety of risk factors such as age of onset of sexual activity, age under 25 years, and number of sexual partners. In this study, risk determinant analysis showed that the age of patients, age of onset of sexual activity, and marital status are the risk factors for C. trachomatis infection. Analysis of age-related prevalence of C. trachomatis infection in this study showed that patients in the age group of 25–29 years had a prevalence of 6.2%, which is higher than that in the age group of 20–25 years (2.8%) [Table 2]. This finding is similar to the study in Jos by Mawak; however, studies in the United States found a higher prevalence among females <25 years of age. These age groups all fall within the sexually active and adolescent age group, which could explain a higher prevalence among them. However, it was not statistically significant. Age of onset of sexual activity determined in this study constituted the age group of <15 years, with the highest prevalence of 20% [Table 3]. This implies that, the earlier an individual engages in sexual activity, the higher the chances of being infected with C. trachomatis. There was a statistically significant difference between married and unmarried women [Figure 5] and [Table 4]. A high prevalence of 33% was found among single and separated women as well. These unmarried patients who tested positive might have multiple sexual partners and C. trachomatis is a sexually transmitted infection.
Table 2: Prevalence of Chlamydia trachomatis infection in relation to age

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Table 3: Prevalence of Chlamydia trachomatis infection in relation to marital status

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Figure 5: The prevalence of genital Chlamydia trachomatis infection in the study group was 3.5%

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Table 4: Prevalence of Chlamydia trachomatis infection in relation to age at the onset of sexual activity

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The prevalence of C. trachomatis was found to be highest among patients with infertility as 10 (4.7%) out of the 14 patients who tested positive had infertility [Table 5]. This was also the finding by Tukur in Zaria and Jeremiah in Port Harcourt where the prevalence was higher among infertile patients than the compared control group of family planning clinic patients and pregnant women, respectively.[15],[24] This finding, however, is contrary to that of Ikeme in Enugu where the prevalence was higher among asymptomatic women.[23] The finding in this study is expected, as C. trachomatis is one of the most common organisms causing tubal factor infertility.
Table 5: Prevalence of Chlamydia trachomatis infection in relation to the patient's provisional diagnosis

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  Conclusion Top


The study showed that the prevalence of genital C. trachomatis infection was 3.5%, and there was a significant association between marital status and genital C. trachomatis infection. However, there was no significant statistical association between C. trachomatis infection and age of onset of sexual activity. The rate of C. trachomatis infection was higher among respondents with infertility, but this was not statistically significant.

Acknowledgment

We thank Kaoje I, a laboratory scientist, who assisted us in procuring the test kits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Leili CT, Batool R, Fedyeh H, Ramezanzadeh F, Mamak S, Abbas RF, et al. Prevalence of Chlamydia trachomatis infection in fertile and infertile women; a molecular serological study. J Reprod Infertil 2009;10:32-41.  Back to cited text no. 12
    
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Buve A, Weiss HA, Laga M, Van Dyek E, Musonda R, Zekeng L, et al. The epidemiology of gonorrhea, Chlamydia infection and syphilis in four African Countries. AID 2001;15:579-88.  Back to cited text no. 13
    
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Opoku BK, Sarkodie Y. Prevalence of genital chlamydia and gonococcal infections in at risk women in the Kumasi Metropolis, Ghana. Ghana Med J 2010;44:21-4.  Back to cited text no. 14
    
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Tukur J, Shittu SO, Abdul AM. A case control study of active genital Chlamydia trachomatis infection among patients with tubal infertility in Northern Nigeria. Trop Doct 2006;36:14-6.  Back to cited text no. 15
    
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Okoror LE, Omilabu SA, Orue PO, Ajayi G. Seroepidemiological survey of chlamydia in patients attending pre and post natal clinic at the college of Medicine of the University of Lagos, Nigeria. Open Trop Med J 2008;1:83-6.  Back to cited text no. 16
    
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Isibor JO, Ugbomoiko D, Nwobu GO. Detection of chlamydia antigen in cervical specimens from antenatal clinic attendees in Benin city, Nigeria. Afr J Clin Exp Microbiol 2005;6:208-11.  Back to cited text no. 17
    
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21.
Van Duynhoven YT, van de Laar MJ, Schop WA, Mouton JW, van der Meijden WI, Sprenger MJ, et al. Different demographic and sexual correlates for chlamydial infection and gonorrhoea in Rotterdam. Int J Epidemiol 1997;26:1373-85.  Back to cited text no. 21
    
22.
Konar H, editor. Sexually transmitted infections: In: Textbook of Gynaecology Including Contraception. 5th ed. Kolkata: New Central Book Agency Kolkata; 2009. p. 142-54.  Back to cited text no. 22
    
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Ikeme AC, Ezegwui HU, Ikeako LC, Agbata I, Agbata E. Seroprevalence of Chlamydia trachomatis in Enugu, Nigeria. Niger J Clin Pract 2011;14:176-80.  Back to cited text no. 23
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24.
Jeremiah I, Okike O, Akani C. The prevalence of serum immunoglobulin G antibody to Chlamydia trachomatis in subfertile women presenting at the university of Port Harcourt teaching hospital, Nigeria. Int J Biomed Sci 2011;7:120-4.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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