Effects of Female Genital Schistosomiasis in Reproductive Tract of Women Attending Kwale Hospital in Kwale County, Kenya

Background: Female genital Schistosomiasis (FGS) caused by Schistosoma haematobium is a significant public health problem among women living in endemic areas. An estimated 45 million women in sub-Saharan Africa are infected. Chronic infection is associated with bleeding disturbances, abdominal-pelvic pain, painful sexual intercourse, uterine fibroids, spontaneous abortion, cervical cancer and increased risk for transmission of HIV. Aim: To determine the infection rate, distribution pattern and associated genital pathology in S. haematobium infection among females of reproductive age in endemic area in Kwale County, Kenya. Study Design: Descriptive cross-sectional. Study Area: Kwale level four hospital. Study subjects came from the hospital catchment area. Methodology: Prevalence of S. haematobium was determined through urine filtration and Original Research Article Gitau et al.; IJTDH, 24(1): 1-9, 2017; Article no.IJTDH.32787 2 microscopy for S. haematobium eggs and by detection of both haematuria and proteinuria using strip reagent analysis. Intensity of S. haematobium infection was determined by scoring the number of eggs per 10 ml of urine. Signs of genital pathology were determined through visual assessment of the genitalia by a gynaecologist. SPSS version 20.0 was used to analyze data. Results: Overall prevalence of S. haematobium was 23%. Intensity of infection was low with majority of infected participants (15.8%) carrying light intensity infections (≤50 eggs/10 ml of urine). Prevalence and intensity of infection was significantly high in women age group 18-23; (χ = 5.778; P = 0.017). Signs of genital pathology were recorded in 46.7% of infected women. The results of this study indicate that female genital schistosomiasis is an important health problem in Kwale County and there is need for the Ministry of Health and the County government of Kwale to improve diagnosis and treatment of the disease as well as initiate strategies to control this problem.


INTRODUCTION
Schistosomiasis remains one of the most serious and prevalent diseases worldwide with an estimated 207million people infected [1]. About 160 million of infected cases are found in Sub-Sahara Africa [2]. Schistosomiasis is a disease of the poor in the developing world where access to safe drinking water and sanitation is poor [1]. The disease is a major cause of morbidity and premature mortality in endemic areas of the world [3].
In Kenya, more than 6 million people are infected with urogenital or intestinal schistosomiasis caused by S. haematobium and S. mansoni respectively [4]. In the year 2003 a pilot control program was initiated in 86 schools in endemic areas where a total of forty thousand (40,000) school age children were involved in a yearly treatment by trained school teachers for 4 consecutive years [5]. The success of this pilot program led to implementation of a National school-based de-worming program targeting more than 8 million school age children in all endemic areas. These control programs did not include adult population, especially the most vulnerable group such as women of reproductive age [6] as well as other adults at high risk such as farmers working in irrigation schemes and freshwater fishermen [7,8].
An estimated 9-13 million women are afflicted with urogenital schistosomiasis in sub-Saharan Africa [9]. Up to 75% of women excreting S. haematobium eggs in the urine may have female genital schistosomiasis [10][11][12][13]; and up to 41% of women in endemic areas have schistosomiasis of the lower reproductive tract without eggs in urine [10]. Studies have shown that S. haematobium eggs may be distributed in all the pelvic organs with cervix being the most commonly affected, followed by the vagina, ovaries, fallopian tubes, vulva and the uterus [14]. Urogenital Schistosomiasis has been associated with bleeding disturbances, abdominal-pelvic pain, painful sexual intercourse, uterine fibroids, spontaneous abortion, cervical cancer and increased risk for transmission of HIV [11,12,15].
Kwale County in Coastal Kenya has been endemic for S. haematobium since 1981 when the first baseline study on prevalence and intensity of infection was conducted and recorded as 68.2% and 50.0 eggs/hour respectively [16]. Despite the heavy burden of the disease on human population in endemic areas of Kenya, only limited control measures and programmes have been put in place. Most of them are school-based targeting primary school children, while others are sporadic projects and short term, targeting a certain community. In Kwale the risk of S. haematobium reinfection and late disease after school-based treatment is high. Diagnosis of infection is routinely based on presence of eggs in the urine [17]. It is possible that diagnosis and treatment of genital schistosomiasis is not adequately carried out leading to chronic illness among infected females. This research therefore focuses on the infection rate, distribution pattern and genital involvement of S. haematobium infection among females of reproductive age in Kwale County, Kenya with an aim to improve diagnosis and treatment of the disease and its effects on the genital tract.

Study Design
This study adopted a descriptive cross-sectional design with study subjects being female patients visiting Kwale level four Hospital with gynaecological complaints.

Study Area
The site of this study was Kwale level four Hospital, located in Kwale Town, Kwale County, Kenya. Kwale County is in South Coast of Coast Province, Kenya. Drainage system is poor and consists of slow running streams. Stationary ponds and shallow open dams for animal watering are common. Such conditions provide favourable habitats for development and survival of freshwater snails associated with transmission of S. haematobium in the area.

Sampling Techniques
The study employed a non-probability sampling techniques. Purposive sampling was used to select respondents who fit the criteria of the study population i.e. adult female patients of reproductive age who visited the hospital with gynaecological complaints.

Prevalence and intensity of urogenital schistosomiasis
Prevalence and intensity of urogenital schistosomiasis was accomplished by detection of S. haematobium eggs under microscopy and detection of both proteinuria and haematuria by urinalysis reagent strip. All participants with urine containing S. haematobium eggs and/or positive urinalysis test were treated with praziquantel 40 mg/kg body weight [18].
Each participant was given a sterile 40 ml universal bottle to provide terminal urine between 10.00 am and 1.00 pm. Each bottle was labeled to correspond to the study identification number issued to each participant. From each participant, 10ml urine specimen was filtered from the sample using Nuclepore urine filtration kit as described by Kahama et al. [18]. Using a blunt ended forceps the filter was transferred to a slide. A drop of physiological saline was added and then covered with a cover glass and examined under a microscope using X10 objectives. The number of S. haematobium eggs was counted and reported as the number of eggs per 10 ml of urine, reflecting the intensity of S. haematobium infection. Intensity of infection was categorized as light if the eggs were ≥50 per 10 ml of urine, and heavy if eggs were ≤50 per 10 ml of urine [2].
Urinalysis test for presence of blood and proteins in urine was done using Uro-Labstix 3 (Miles-Sankyo Co. Ltd). All participants with negative urinalysis and parasitological tests were used as controls. A cellulose strip was dipped in a urine specimen contained in a well labeled sterile test tube. After a few seconds the strip was removed and observed for color changes. A change from light yellow to a range of blue colors indicated presence of haemoglobin while blue spots indicated intact erythrocytes. Any change of color to green indicated presence of proteins [17].

Gynaecological examination for genital involvement
The women were invited to undergo a gynaecological examination by a Gynaecologist. Examination of external genitalia, vagina and cervix was done (using disposable speculae). If pathological changes were observed in the cervix and the patient consented, cervical cancer screening tests were done using visual inspection methods. These were; Visual Inspection with 5% Acetic Acid (VIA) and Visual Inspection with Lugol's Iodine (VILI). All participants who tested positive with either VIA or VILI were referred appropriately to the next level hospital.

Data Analysis
The SPSS 20 version was used for data analysis. Descriptive statistics was done by running frequencies, means and crosstabulations. Chi-square test with 95% confidence intervals (CIs) was used to compare prevalence and intensity of S. haematobium infection between cases and controls while two sample ttest was used to compare lesions between the two study groups.

Ethical Considerations
The study protocol was reviewed and approved by Kenyatta University Ethics Review Committee (KU-ERC). Further clearance was sought from Ministry of Health Kwale County and from Kwale Hospital Medical Superintendent. Thereafter, informed written consent was obtained from each study subject.

Distribution Pattern of S. haematobium Infection among Participants
A total of 196 women were examined for S. haematobium infection with age ranges between 18 to 49 years. Most of the subjects (50.5%) were housewives in age group 30-35 years and majority (17.8%) came from Tsimba-Vuga area which is very close to Kwale town.

Intensity of S. haematobium among the Study Participants
Intensity of infection was low; women with light intensity infection were 15.8% while 7.1% had heavy intensity infection. Younger women aged 35 years and below had significantly (χ 2 = 4.077; df = 4; P = 0.018) higher intensity infection compared to those aged 36 years and above (Fig. 4).

Schistosoma haematobium Infection and Genital Pathology
A total of 46.7% of women with S.haematobium infection had signs of genital pathology as follows; genital ulcers 17.8%, contact bleeding 20%, sandy patches 20% and tumor-like lesions 8.9% (Fig. 5). Two-Sample t-test showed that t h e mean number of sandy patches, tumorous lesions and bleeding sites was significantly higher in positive women (t = 3.382; P = 0.004, t = 2.246; P = 0.013 and t= 2.138; P = 0.017) respectively. Distribution of ulcers was not associated with S. haematobium infection (Fig. 5).

DISCUSSION
Findings of this study indicate that S. haematobium infection is still a health concern in Kwale County, Kenya. Infections are sustained by the high presence of Bulinus species of freshwater snails which are the vectors for S. haematobium [19]. Earlier studies reported a high prevalence of infection in the area; 33.4% [6], 18.2% [20], 43.2% [21], 32.4% [22] and 53.8%, [23]. Infection rate in the current study was significantly higher in women of younger age group 18-23 and 24-29 years.

. Prevalence of S. haematobium infection by residence
Earlier studies associated such high infection rates to raised water contact activities in younger age groups [16,24]. Majority of infected women in the current study were fishmongers. It is expected that fishmongers and housewives have higher water contact level in course of their daily chores as compared to women in other occupations. According to a report by WHO, 2016 [7] adults considered to be at risk in endemic areas are people with occupations involving contact with infested water, such as fishermen, farmers, irrigation workers, and women whose domestic tasks bring them into contact with snail infested water [7,8,24,25].

. Genital lesions and contact bleeding in infected and non-infected women
Prevalence and intensity of S. haematobium varied among villages with Chirimani and Tshiba-Vuga area demonstrating higher prevalence than other areas 36.4% and 28.6% respectively. This could be attributed to the local streams that are perennial and slow running hence local people are continuously exposed to the infection all year round. Secondly there are no major control programmes in Chirimani, Tsimba and Vuga area. Considering the chronic nature of schistosomiasis, the women in these villages could have been suffering from the infection for a long time without seeking treatment. Another study in Kwale observed high infection with S. haematobium in some villages and attributed it to continuous contact with snail infested water and consistent lack of intervention such as mass de-worming in the area [6]. Lower infections were observed in Mtsangatamu and Mwachinga villages. These are in Kwale hinterland and had a long exposure to schistosomiasis control programmes [26,27]. Earlier projects provided piped water to the community in Mtsangatamu and a community dispensary in Mwachinga village where praziquantel (drug of choice for treatment of schistosomiasis) up to now has been included in the medicine kit [26,27].
Intensity of infection was found to be high in younger women aged 35 years and below.

Type of Lesion
Infected women

Non-infected women
Women in this age bracket who live in schistosomiasis -endemic regions could spend most of their reproductive life either pregnant or lactating, hence delayed administration of praziquantel coupled with low immunity to infections [6]. Delay in treatment of more than one year could lead to heavy infection and significant morbidity. Other research findings indicate that intensity of infection follows the same trend as prevalence whereby the younger ages of 16 -35 years consistently harbor heavier parasitic burdens, as measured by parasite egg load [28,29].
Genital abnormalities were recorded in 46.7% of the infected women, spread on the cervix and the vaginal wall. This was a strong pointer to female genital schistosomiasis morbidity due to chronic infection. Poggensee et al. [13] observed that pathological lesions in the urogenital system in heavy S. haematobium infection were important hidden morbidity. Other clinical studies of women living in areas where S. haematobium was endemic yielded similar findings [30][31][32]. The current study identified tumorous lesions in 3.6% of women participants. These lesions were significantly more in the S. haematobium infected women. Recently, more additional cases of female genital malignancy in association with evidence of S. haematobium infection have been published [32].

CONCLUSION
Female genital schistosomiasis among women of reproductive age is high in Kwale and there is need to conduct proper community diagnosis and treatment of the disease.

RECOMMENDATIONS
The County government of Kwale in collaboration with the national government should put control programmes in place and enhance community sensitization on transmission and prevention of the disease.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the authors.

ETHICAL APPROVAL
As per international standard or university standard, written approval of Ethics committee has been collected and preserved by the authors.