REBUBLIQUE DU CAMEROON

REBUBLIC OF CAMEROON
Paix- travail –patrie
Peace-work fathers land
MINISTÈRE DE L’ENSEIGNMENT
MINISTRY OF HIGHER EDUCATION
SUPÉRIEUR

BIAKA UNIVERSITY INSTITUTE OF BUEA

(BUIB)

BOKOKO, BUEA
P.O BOX 77
MOTTO: KNOWLEDGE AND SERVICE TO HUMANITY

PROGRAMME: MEDICAL LABORATORY SCIENCE

PREVALENCE AND ASSOCIATED RISK FACTORS OF

VAGINAL CANDIDIASIS AMONG WOMEN OF CHILD-
BEARING AGE AT THE DISTRICT HOSPITAL KUMBA.

A Research Project Submitted to the Department of Allied Health, Biaka

University Institute of Buea in Partial Fulfilment of the Requirement for the
award of a Higher National Diploma(HND) in Medical Laboratory Science

PRESENTED BY:

MBANG SHERON BONGKA

(HS20HL059)
SUPERVISOR:
Dr. SANDIE MEKACHIE SORELLE
(PHD IN MEDICAL PARASITOLOGY)

January, 2023
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 CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Candidiasis is a fungal infection caused by yeasts from the genus Candida (Jose,

2020). Candida species are part of the natural vaginal flora in 20.0% – 50.0% of

healthy women but may become pathogenic under certain conditions including the

presence of invading pathogens or biochemical changes in the vaginal environment

making them common aetiologic agents of vaginitis (Emeribe et al., 2015). Invading

pathogens alter the normal microflora of the vagina while biochemical changes in the

vagina stimulate the rapid proliferation of the natural Candida population, enhance

their attachment to the epithelial cells of the vagina and promote germination of

daughter yeast cells so that normal asymptomatic colonisation becomes

symptomatic Candida infection (Wright, 2014). Protracted antimicrobial use have

been known to cause irritation in body tissues making them susceptible to penetration

and adherence by Candida species (Mbakwem, 2010).

Vaginal candidiasis; a yeast infection of the vulva and/or vagina caused by Candida

species with Candida albicans being the major culprit is the most common type of

fungal disease all over the world which affects the genital tract of women (Kamath et

al., 2013; Esmaeilzadeh et al.,2009). Infection of the estrogenized vagina and the

vestibulum that can spread to the outside of the labia minora, the labia majora, and the

intercrural region is defined as vulvovaginal candidosis (Farr et al., 2021).

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About 90% of this infection is caused by Candida albicans and 10% by other species

of Candida (Emeribe et al., 2015). This infection has been reported as the commonest

cause of vaginitis, second to bacterial vaginosis (Al-Ahmadey and Mohamed, 2014).

This infections occur when there is an imbalance in the pH of the vagina. The over-

growth of this fungus in the vagina leads to a burning sensation in the vagina vulva,

the production of heavy white/yellow curd- like discharge and/or an itchy vulva,

dyspareunia, dysuria, irritation, soreness of the vulva and other discomforting

symptoms that will ensure frequent hospital visits (Emeribe et al., 2014)

Based on the clinical presentation and antifungal response, vaginal candidiasis can be

classified as either uncomplicated or complicated. Uncomplicated vaginal

Candidiasis, mostly caused by C.albicans causes mild to moderate symptoms.

Whereas complicated vaginal candidiasis is mostly caused by non-albicans Candida

species (C. glabrata, C. tropicalis, C. krusei and C. parapsilosis) and are common

among immune-compromised individuals and pregnant women (Hainer and Gibson,

2011).

Complicated vagina candidiasis occurs in nearly 10%-20% of women necessitating

appropriate diagnosis. In the majority of cases, clinical diagnosis is apparent.

However, microscopic diagnosis with KOH mount or Gram stain, use of

immunochromatography test, and culture may be required especially in complicated

vagina candidiasis (CDC, 2015).

There are common risk factors associated with or seen among female patients with

vaginal candidiasis. These includes among other factors such as pregnancy, use of

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oral contraceptives and antibiotics, diabetes mellitus (Gonçalves et al., 2015). Some

pregnancy-related factors such as increased estrogen levels, increased vaginal

mucosal glycogen production, and decreased cell-mediated immunity are likely to

cause both asymptomatic colonization and the increased risk of vagina

candidiasis (Aguin and Sobel, 2015).

Treatment with intravaginal or systemic antifungal agents is effective in

uncomplicated cases. In a complicated or recurrent VVC, combined intravaginal and

systemic therapy may be required (CDC, 2015).

Given the multiple risk factors, changing disease patterns with increasing number of

recurrent and complicated infections, it is essential to understand the management

strategies in special situations and different treatment strategies (Ashwini et al.,

2022).

Women are prone to this kind of infection, a good vaginal hygiene is essential in order

to reduce the probability of candidiasis occurrence (Suzie, 2018).

1.2 Statement of problem

Vaginal candidiasis is an endemic problem globally. Since Candida species are part of

the natural flora in healthy females. They become pathogen under certain conditions

such as the presence of invading pathogens or biochemical changes in the vagina

environment making them common aetiology agents to vaginitis. There is a paucity

of information on the prevalence and associated risk factors of vaginal candidiasis

especially among apparently healthy females in the South West Region of Cameroon.

Since Kumba is increasingly drawing residents from the local villages such as

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Mbonge, carrying out a study in this area will help provide value data for intervention

and provide knowledge to the population which can be extrapolated to others

communities.

1.3 Research Questions

1. What is the prevalence of vaginal candidiasis among women of the child bearing

age in Kumba Regional Hospital Annex?.

2. What is the association between socio-demograhic factors and vaginal candidiasis

prevalence in Kumba Regional Hospital Annex?.

3. What are the predisposing factors associated with vaginal candidiasis among

women of child bearing age in Kumba Regional Hospital Annex?.

1.4 Research Objectives

1.4.1 General Objectives

The main objective was to determine prevalence and risk factors associated with

vaginal candidiasis among women of child bearing age attending the District Hospital

Kumba.

1.4.2 Specific Objectives

The specific objectives of the study are;

v To determine the prevalence of vaginal candidiasis among women of the child

bearing age

v To determine the prevalence of vaginal candidiasis among women of child-

bearing age with respect to socio-demographic data.

v To determine the risk factors associated with vaginal candidiasis among

women of the child bearing age

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1.5 Rationale of the Study

Generally, there is a paucity in knowledge about the prevalence and associated risk

factors of vaginal candidiasis among women of the child bearing age in the Kumba

Health District. Also, the findings from this study will enable health planners in better

decision making and preventive strategies to manage the infection. Furthermore,

understanding the risk factors involved in the acquisition of vaginal candidiasis

among women of the child bearing age in the Kumba District Hospital is critical for

the management and reduction of the prevalence in a small scale

1.6 Scope of the study

The study is a hospital based analytical research that was conducted among women of

the child bearing age attending the Regional Hospital Annex Kumba who came for

their care and treatment between the periods December 2022 to February 2023.

1.7 Definition of terms

Ø Aetiology: It is the study of the causes of a disease

Ø Cell mediated immunity: It is an immune response that does not involve

antibodies but rather involves the activation of macrophages, the activation of

antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines

in response to an antigen.

Ø Dysuria: It is a sensation of pain and/or urethral burning, stinging or itching

of the urethra or urethral meatus associated with urination.

Ø Dyspareunia: It is the persistent or recurrent genital pain that occurs just

before, during or after sex

Ø Microflora: A community of microorganisms, including algae, fungi and

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 bacteria that live in or on another living organism or in a particular habitat

Ø Pathogen: it is an organism that causes disease

Ø Proliferation: It is the growth or production of cells by multiplication of parts

CHAPTER TWO

LITERATURE REVIEW

2.1 Vaginal Candidiasis

Vagina candidiasis is a vagina fungal infection confirmed to be caused by candida

species, in most cases Candida albicans (Sobel, 2016). Candida infections in the

vaginal area are frequently referred to as “Vulvovaginal candidosis” (VCC) or

“Candida vaginitis” (Tasfia and Fahim, 2022).

2.1.1 Etiology of Vaginal candidiasis

Candidal vulvovaginitis is caused by inflammatory changes in the vaginal and vulvar

epithelium secondary to infection with Candida species, most commonly Candida

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albicans. Candida is part of the normal flora in many women and is often

asymptomatic. Therefore, candidal vulvovaginitis requires both the presence of

candida in the vagina/vulva as well as the symptoms of irritation, itching, dysuria, or

inflammation (Farhan et al., 2019).

2.2 Epidemiology of Vaginal candidiasis

Epidemiological surveys around the world have indicated that the distribution of

Candida species responsible for vaginal candidiasis in women varies widely among

countries, regions and also the study population, and women with vaginal candidiasis

are more susceptible to HIV (Achkar and Fries, 2010). Traditionally, Candida

albicans, which is responsible for 85–95% of Candida vaginal infections, is the

predominant species (Rezaei et al., 2016). However, the raising frequency of non-

albicans Candida (NAC) species has reported worldwide, particularly C. glabrata, C.

tropicalis, C. parapsilosis, C. krusei, C. dubliniensis, with C. glabrata as the

predominant species (Makanjuola et al., 2018).

2.3 Classification of vaginal candidiasis

2.3.1 Uncomplicated vaginal candidiasis

These are sporadic or infrequent vaginal candidiasis which causes mild-to-moderate

symptoms. They are mostly caused by Candida albicans and are also found in non

immunocompromised women. Some of the clinical manifestation include external

dysuria and vulvar pruritis,(CDC, 2021).

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2.3.2 Complicated vaginal candidiasis

They are caused by non-albicans candida and are common in women with diabetes,

immunocompromising conditions (e.g., HIV infection), underlying

immunodeficiency, or immunosuppressive therapy (e.g., corticosteroids). Some of the

clinical manifestation include redness, swelling and itching that leads to tears, cracks

or sores (CDC, 2021)

2.3.3 Recurrent vaginal Candidiasis

Recurrent vaginal candidiasis, usually defined as three or more episodes of

symptomatic vaginal candidiasis in <1 year, affects <5% of women but carries a

substantial economic burden. Recurrent vaginal Candidiasis can be either idiopathic

or secondary (related to frequent antibiotic use, diabetes, or other underlying host

factors). The pathogenesis of recurrent vaginal Candidiasis is poorly understood, and

the majority of women with recurrent VC have no apparent predisposing or

underlying conditions. C. glabrata and other non–albicans Candida species are

observed in 10%–20% of women with recurrent VC. Conventional antimycotic

therapies are not as effective against these non–albicans yeasts as against C. albicans

(CDC, 2021). Severe VC including extensive vulvar erythema, edema, excoriation,

and fissure formation are usually due to some women lower therapeutic response

(Workowski and Bolan, 2015).

2.4 Signs and Symptoms of vaginal candidiasis

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The over-growth of this fungus in the vagina leads to a burning sensation in the

vagina vulva, the production of heavy white/yellow curd- like discharge and/or an

itchy vulva, puritus, dyspareunia, dysuria, irritation, soreness of the vulva and other

discomforting symptoms that will ensure frequent hospital visits (Emeribe et al.,

2014).

2.5 Risk factors of Vaginal candidiasis

2.5.1.. Increased Level of Reproductive Hormones

A high level of progesterone allows the Candida yeast to implant in the vagina by

causing an alteration in the vaginal epithelium. In addition, progesterone possesses

inhibitory effects on the anti-candida activity of neutrophils. The healthy balance of

microorganisms can get upset by the increased estrogen level, which in return

enhances the possibility of vaginal candidosis establishment (Edrees et al., 2020).

High levels of estrogen have been found to facilitate the attachment of yeast to

mucosal epithelial cells of the vagina. Along with that, estrogen stimulates growth,

multiplication, hyphal formation, and enzyme elaboration for instance secreted

aspartyl proteinase and phospholipases which increase colonization (Aguin and Sobel,

2015).

2.5.2. Decreased Level of Vagina pH

Typically, the vaginal pH is maintained at 4.0-4.5, and this level of acidic

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environment prevents the establishment of many vaginal pathogens (Yadav and

Prakash 2018) stated that any physiological change affecting both beneficial and

harmful vaginal microorganisms alters the acidity of the vagina that reduces its pH to

5.0-6.5; this would thereby enhance the establishment of pathogenic organisms such

as Candida (Mtibaa et al., 2017).

2.5.3. High Amount of Glycogen Deposition

Both progesterone and estrogen contribute to the elevation of vaginal tissue glycogen

content. This high level of glycogen deposition provides an adequate source of

carbon, thus favoring the growth and germination of Candida species on the wall of

the vagina (Babic and Hukic, 2010)

2.5.4 HIV Infection

Immunocompromised women are generally at increased risk of fungal infections. It

has been shown in studies conducted earlier where increased vaginal colonization

with fungi has been caused by a loss of immune-protective mechanisms (Foessleitner

et al., 2021). In immunosuppressed patients, vaginal candidosis can be correlated well

with reduced cell-mediated immunity (Mtibaa et al., 2017).

2.5.5 Frequent Use of Oral Contraceptives

Women who have been using oral contraception are considered being at an increased

risk of developing vaginal candidiasis. Oral contraceptives cause many changes in the

vaginal environment that might be associated with the decreased ability to resist

Candida infection. Usage of high-dose contraceptive pills (75-150 μg of mestranol)

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has been observed to affect glucose resistance over a small period which may, in turn,

promote Candida adhesion or virulence by affecting the carbohydrate source in the

vaginal epithelial cells. In addition, oral contraceptives are found to be associated with

immunological changes, including the elevation of antibodies in cervical mucous and

the sera, and probably the depression of T- lymphocyte proliferation. Furthermore,

most oral contraceptives have been found to contain estrogen and progesterone, which

creates an “estrogen dominance” by disrupting the hormonal balance that results in

enhancing Candida growth (Mtibaa et al., 2017).

2.5.6 Prolonged Use of Antibiotics

An expanded chance of developing symptomatic VC in women following a course of

oral antibiotics has been depicted. Continuous and misuse of drugs lead to resistance

towards drugs, particularly towards the common antifungal agents utilized for the

treatment of vaginal candidosis (Yadav and Prakash, 2016). Broad-spectrum

antibiotic use (e.g., tetracycline, ampicillin, cephalosporin) is capable of

eliminating Lactobacillus spp. present in the normal defensive bacterial flora of the

vagina, which prevents germination of Candida by providing a colonization resistance

mechanism (Mtibaa et al., 2017)

2.5.7 Tight and Synthetic Clothing

In literature, the types of undergarments and clothing that usually women wear have

been proposed as a risk factor of vaginal candidiasis (Al-Aali, 2013). The overgrowth

of Candida was enhanced by the use of tight nylon underwear. Increased temperature,

moisture, or direct irritation of the vaginal area are considered the possible
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mechanisms related to this. Wearing tight clothes and synthetic underwear appears to

increase the local acidity by nourishing friction and maceration, hence increase the

fungal infection (Mtibaa et al., 2017).

2.5.8 Dietary Habits

The role of dietary habits in VC has been suggested as a risk factor because of the

altered virulence of Candida in response to the heightened availability of sugar

substrates (Altayar et al., 2016). Patients with VC were more likely to excrete sugars

such as sucrose, arabinose, and ribose. The associated dietary patterns with these

sugars were an elevated intake of milk, yogurt, cottage cheese, and artificial

sweeteners (Tasfia and Fahim, 2022)

2.6 Diagnosis of vagina candidiasis

2.6.1 Examination by direct microscopy

With clinical samples taken from the vagina, treatment with a keratinolytic substance

such as KOH is generally unnecessary. The sample taken can be directly observed in

the fresh state using a saline solution or even be examined in the fixed state on a

slide., Simple staining or a Gram staining can be performed on a smear to appreciate

the diversity of fungal elements better in the fixed state. The dyes used in the case of a

simple coloring can be Lactophenol Cotton Blue, Giemsa, or methylene blue (Arvind

et al., 2015; Deorukhkar et al., 2018).

2.6.2 Culture of clinical samples

After taking the sample, the clinical sample is seeded on a culture medium and
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incubated under appropriate conditions. The seeding techniques usually used are

between streaking, swabbing on agar medium or inoculation in broth. The colonies

are visible after 24 to 48 hours of incubation at a temperature between 30 and 37°C

for most Candida species. These microbial colonies will then allow the identification

of the germ responsible for the infection and the determination of its sensitivity

profile. Not all yeasts have the same growth requirements regarding the culture media

used. Thus, basic media allows the growth of undemanding yeasts and media enriched

with different substances allowing the growth of more demanding yeast species.

These media are generally solid and can be differential, selective or not. In medical

practice, the culture media commonly used for isolation and identification of clinical

Candida species are Sabouraud Dextrose Agar (SDA), Potato Dextrose Agar (PDA),

Fluoroplate candida, Yeast Potato Dextrose (YPD) agar, CHROMagar, Corn meal-

Tween 80 agar and Lee's synthetic medium. Several other types of culture medium

can be used depending on the objectives (Madhavan et al., 2011).

2.6.3 Rapid identification test

Rapid identification tests generally use two methods of identification, immunological

methods, and enzymatic methods. Immunological methods are based on the principle

of agglutination of latex particles sensitized by monoclonal antibodies, specifically

recognizing an antigen from the wall of the different species. The Bichrolatex

albicans test thus identifies the C. albicans/C. dubliniensis complex. A positive

reaction results in the formation of agglutinates after a few minutes. Enzymatic

methods rely on detecting specific enzymes or on the ability of yeast to hydrolyze a

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given substrate. For example, the Glabrata RTT test allows the identification of C.

glabrata and is based on the yeast's ability to hydrolyze trehalose and not maltose

(Pianetti, 2015).

2.6.4 Molecular identification

Conventional methods for identifying Candida species are based on assimilation,

fermentation reactions, and morphology. Since some species of Candida present few

easily identifiable morphological and biochemical variations, molecular biological

techniques have been developed to overcome the limitations of phenotypic

identification methods. For molecular identification, several procedures have been

proposed to detect and differentiate Candida species both by non-DNA-based

methods and DNA based methods. The non-DNA-based methods include, for

example, Multi-locus Enzyme Electrophoresis, which characterizes fungal enzy-

matic proteins and assesses their polymorphism. The DNA based methods include

techniques like Electrophoretic Karyotyping, PCR, Nucleic Acid Sequence Based

Amplification, DNA-microarrays, Fluorescent in situ hybridization, MLP typing,

(Sudhan et al., 2016).

2.6.5 MALDI-TOF MS method

Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-

TOF MS) has been recently described as an “ongoing revolution” because it allows

rapid and accurate identification of bacteria and fungi (Yaman et al., 2012). In order

to identify a microorganism, the peaks of the experimental spectrum acquired with

15
MALDI-TOF MS are compared to signature peaks from reference spectra contained

in databases. MALDI-TOF MS allowed rapid and accurate identification of

microorganisms and became an important tool in clinical laboratories. Previous

experimental studies demonstrated that MALDI-TOF MS was less arduous than

routine identification methods like microscopy and biochemical tests. It was shown to

be a reliable, fast, and straightforward method compared to conventional ones that are

time-consuming and need trained professionals to be interpreted. MALDI-TOF MS

also provides a promising alternative for the study of antifungal resistance ( Delavy et

al., 2019).

2.6 Treatment of Vaginal Candidiasis

Acute candidal vulvovaginitis is treated with antifungal agents. Since most cases of

candidal vulvovaginitis are secondary to C. albicans species, and since C.

albicans does not have significant resistance to azole antifungals, these are the agents

of choice for this disease. Antifungals may be taken orally as a single dose

(fluconazole 150 mg) or can be applied intravaginally in a single day or 3-day

regimens that are available over the counter. In patients with uncomplicated disease

(those without immunosuppression or pregnancy who do not have recurrent candidal

vulvovaginitis) either therapy is equally efficacious. Therefore, treatment decision

may be made based on cost, patient preference, and drug interactions. If patients do

not respond to standard therapy, cultures may be warranted to look for other species

of candida, which are often resistant to azoles (Bouopda, 2020).

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Women with complicated candidal vulvovaginitis, for example those patients who are

immunosuppressed, require longer therapy. Typically, therapy includes intravaginal

azole therapy for at least 1 week, or oral treatment with fluconazole 150 mg (renally

adjusted for CrCl <50 ml/min) once every 3 days for three doses. Patients with

recurrent vagina candidiasis may benefit from suppressive therapy with weekly oral

fluconazole for 6 months. Pregnant patients should not be given oral antifungals. In

these patients, a 7-day course of intravaginal therapy is appropriate. Fluconazole is

considered safe in breastfeeding women (Rebecca, 2022)

2.7 Prevention and Control of Vaginal Candidiasis

Women are unlikely to seek advice because there is a tendency to view “white

discharge” as normal and also because the condition is associated with shame and

guilt. Usually women complain of vaginal discharge when they think it is unusual for

them or if it causes itching or discomfort (Kamath et al., 2014).

To help prevent vaginal yeast infections, you can: avoid tight-fitting synthetic

clothing, avoid local irritants, such as perfumed products, replace soaps with vulval

water-based moisturizers. These may give symptomatic relief as dermatitis commonly

co-exists; soap may also cause local irritation, change tampons and pads often during

your period, wear cotton underwear and pantyhose with a cotton crotch, change out of

wet swimsuits and exercise clothes as soon as you can, and keep blood sugar under

control if you have diabetes (Ramsay et al., 2009).

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 CHAPTER THREE

3.1 Study Area

This study was carried out at the Regional Hospital Annex Kumba. Kumba is a

metropolitan city in the Meme Division South West Region of Cameroon. The

Regional Hospital Annex Kumba is situated nearby to the police station and is the

reference Hopital in Kumba, Kumba Central Prison and the college GBTTC ENIEG.

The hospital is been headed by a medical doctor who occupies the position of a

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director. This hospitals is also made up of units, which includes the following: the

medical unit (male and female), the surgical units, the X-ray, pharmacy, maternity the

family planning unit, the paedriatic unit, the family planning unit, the laboratory unit.

3.2 Study Design

This study was a hospital-based cross-sectional study that involved women of the

child bearing age

3.3 Study Population

The study population involved all the women of the child bearing age, aged 16 to 45

years attending the District Hospital Kumba who came for care and treatment during

the study time frame. The participants were recruited based on the inclusion and

exclusion criteria listed below

3.4 Inclusion and exclusion criteria

3.4.1 Inclusion criteria

All the female of the age 16 to 45 years who gave their consent to participate in the

study and accepted to fill the consent form.

3.4.2 Exclusion Criteria

All those who refused to fill the questionnaires and those who refused to sign the

consent form were excluded from the study. Women who had sexual intercouse on the

eve were excluded.

3.5 Sample Size

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The sample size was calculated using the formula

n , Where;

n = Minimum sample size;

Z = 1.96; critical Z value at 95% confidence interval

P = Prevalence of vaginal candidiasis (14%) (Emeribe et al., 2015)

d = acceptable margin of error = 0.05 (5%)

Thus, n = 185

Therefore, the calculated minimum sample size of this study was 185 study

participants.

3.6 Sampling technique

A convenient sampling techniques was used in the study to recruit the participants.

3.7 Data collection tool

A structural questionnaire was use to gather information from participants in order to

help provide answers to the research questions and to establish factors associated with

Vaginal Candidiasis. This data was collected by the participants filling the

questionnaires.

3.7.1. Sample Collection

Lead pencil was used in labelling the slides and sterile vagina swab. Sterile gloves

were worn and the testing swab were removed from the tube. The left hand (index

finger and thumb) was used to separate the labia. The speculum was gently inserted

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sideways (blades closed, angled downwards) and speculum rotated at 90° for optimal

view of the cervix. The cervix and vagina walls were inspected for discharge. The

swab was rotated 10-15 seconds in the posterior fornix for 10-15 seconds ensuring the

swab collecting any discharge present. For participants who were virgin, their samples

were collected using just the swap no speculum.

3.7.1.1 Isolation and Identification of Candida albicans

SDA was prepared by suspending 65g of the medium in one litter of distilled water.

Heat with frequent agitation was later applied to the flask and allow to boil for one

minute to completely dissolve the medium. Autoclaving was done at 121˚C for 15

minutes. It was later allowed to cool to 45 to 50˚C and poured into several petri dish.

The samples collected were inoculated on the surface of previously dried SDA plate.

Primary inoculation was done by the cotton swab stick on each plate and streak out

using sterile wire loop. The plates were kept at room temperature for 2-3 days and

were examined for white cream colonies characteristics of candida species.

(Mackenzie, 1962).

3.7.1.2 Germ tube test

Small inoculum of suspected Candida cultures was inoculated into 0.5 ml of human

serum in a test tube and was incubated at 37˚C for 3 hours. After incubation, a loop

full of culture was placed on a glass slide, overlaid with a cover-slip and was then

observed microscopically for the presence or absence of germ tubes. Formation of

germ tubes was seen as long tube like projections extending from the yeast cells with

no constriction or septa at the point of attachment to the yeast cells. This is a

21
confirmatory test for the identification of Candida albicans. (Sagar Aryal August 10,

2022)

3.7.1.3 Principle of the Germ tube test

Formation of the germ tube is associated with increased synthesis of protein and

ribonucleic acid. Germ tube solution contains tryptic soy broth and fetal bovine

serum, essential nutrients for protein synthesis. It is lyophilized for stability. Germ

tube is one of the virulence factors of Candida albicans.

3.8. Data Management/ Analysis method

The data was keyed into Microsoft Excel spreadsheet and analysed using Statistical

package for social sciences (SPSS) version 25.0. The results was presented on Pie

Charts and frequency tables. The chi square test was used to determine the

significance difference of socio-demographic factors and HBV prevalence’s.

Statistical significance was considered at p < 0.05.

3.9 Ethical considerations

A letter of authorization was obtained from Biaka University Institute of Buea

together with an administrative authorization letter from the South West Regional

Delegation of Public Health. Before the commencement of the research, permissions

were obtained from the Director and General Supervisor of the District Hospital

Kumba. During data analysis, a unique identification code was assigned to the

participants to ascertained confidentiality. Written consent was obtained from all

participants prior to the test. The patients were not forced to give their consent,

22
authorisation was taking from the individuals before taking samples.

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 CHAPTER FOUR

DATA ANALYSIS

4.1 Socio-Demographic characteristics of the study participants

A total of 120 women of age between 15 – 45 years old and with mean age of

30.07.60 years were recruited from the laboratory department of the Kumba Regional

hospital annex. 4.0% of the women were less than 20years while 45.6%, 33.6% and

12.80% were between the age range 20-30, 31-40 and 41-45 respectively. Five (4.0%)

were between the ages of 14 to 20 years old and 57 (45.6%%) were 20-30 years,

42(33.6%) were between the age 31-40 and 16(12.8%) were age 41-45 years old.

One hundred and four (83.2%), 10 (8.0%) 6 widow were single, married and widow

respectively.

Twenty-four (19.20%), 80(64.0%), 6(4.8%) and 10 (8.0%) had complete their

primary, secondary,high school and university education respectively. Fourteen

(11.20%), 54(43.20%), 43 (34.40%), and 9(7.20%) of the participants were students,

business people, unemployed and employed respectively (Table 1).

Table 1: Demographics characteristics of the participants

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 Parameters Variables Number Percentage

Age range(years) Less than 20 5 4.0%

20 – 30 57 45.60%

31 – 40 42 33.60%

41-45 16 12.80%

Marital status Married 10 8.0%

Single 104 83.2%

Widow 6 4.80%

Level of education Primary 24 19.20%

Secondary 80 64.0%

High school 6 4.80%

University 10 8.0%

Occupation Student 14 11.20%

Business 54 43.20%

Unemployed 43 34.40%

Employed 9 7.20%

Prevalence of candidiasis among women of child bearing age base on

demographic data
25
Candidiasis was more prevalent among 20 single women(16.0%), making 14women

of ages 20-30years (11.2%), 13 women of secondary school(10.4%) and followed by

business and unemployed persons 6.4% while it was least prevalence among married

women(0.8%), women less than 20years(1.6%), university and women 41-45 years of

age(1.6%), widows and employed women(2.4%)

parameters categories Positive Negative

Number percentages Number Percentag

Age range Less than 20 2 1.6% 3 2.4%

20 – 30 14 11.2% 43 34.4%

31-40 6 4.8% 36 28.8%

41-45 2 1.6% 14 11.2%

Marital status Married 1 0.8% 9 7.2%

Single 20 16.0% 84 67.2%

Widow 3 2.4% 3 2.4%

Level of Primary 6 4.8% 18 14.4%

education Secondary 13 10.4% 67 53.6%

High school 3 2.4% 3 2.4%

University 2 1.6% 8 6.4%

26
Occupation Student 5 4.0% 9 7.2%

Business 8 6.4% 46 36.8%

Unemployed 8 6.4% 35 28.0%

Employed 3 2.4% 6 4.8%

Total 120/100% 24 20% 96 80%

Prevalence of candidiasis among women of child bearing age

Of the 120 participants, 24 (20.0%) had growth candida species on sabouraud

dextrose agar while 96 (80.0%) had no growth tested negative. .

Prevalence of candidasis among women of child bearing age

90.00%

80.00%

70.00%

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%
Candidiasis Positive Negative

27
Prevalence of candidiasis among women of child bearing age base on risk factors

A total of 120 women, from the figure below the level of awareness was 12.5% while

28
those who had no idea about candidiasis was 87.5%. 12.5% practice douching while

87.5% do not.4.17% were diabetic while 10% of the women were on drugs. Lastly,

we discover that 75.83% of women dress in cotton pants account for the low

prevalence (20%) in the study while 24.17% put on nylon pants.

Risk factors
Positive Negative

95.83%

89.17%
87.50%

87.50%

75.83%
24.17%
12.50%

12.50%

10.83%
4.17%

knowledge of Douching Diabetic On drugs Material

Candidiasis

Prevalence of candida albicans and other candida species

Out of the 120 participants, the prevalence of candida positive was 20% and negative

80%.
29
But we noticed that the prevalence of candida albicans was 12.8% (16 participants),

candida species was 7.2% (8 participants) and no growth was 80% (96 participants).

prevalence of candida albicans, candida species

and no candida growth
90
80
70
60
50
40
30
20
10
0
Candida albicans Candida species No growth

No growth candia albicans Ccandida species

30
 prevalence in percentages

12.8

Candida albicans Candida species No growth

CHAPTER FIVE

31
 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS

5.1 Discussions

Candidiasis is an infection caused by a fungus called Candida; most commonly the

Candida albicans variety. The Candida infection (also known as a yeast infection)

usually affects the skin and/or the mucous membranes of the mouth, intestines, or the

vagina. Candida infections are rarely serious in otherwise healthy people. In rare

cases, it may spread through other parts of the body if the patient’s immune system is

not functioning properly.

Candidiasis is a fungal infection due to any type of Candida (a type of yeast). When

it affects the mouth, in some countries it is commonly called thrush. Signs and

symptoms include white patches on the tongue or other areas of the mouth and throat.

Other symptoms may include soreness and problems swallowing. When it affects the

vagina, it may be referred to as a yeast infection or thrush. Signs and symptoms

include genital itching, burning, and sometimes a white "cottage cheese-like"

discharge from the vagina. Yeast infections of the penis are less common and

typically present with an itchy rash. Very rarely, yeast infections may become

invasive, spreading to other parts of the body. This may result in fevers along with

other symptoms depending on the parts involved.

More than 20 types of Candida can cause infection with Candida albicans being the

most common. Infections of the mouth are most common among children less than

one month old, the elderly, and those with weak immune systems. Conditions that

result in a weak immune system include HIV/AIDS, the medications used after organ

32
transplantation, diabetes, and the use of corticosteroids. Other risks include dentures,

following antibiotic therapy, and breastfeeding. Vaginal infections occur more

commonly during pregnancy, in those with weak immune systems, and following

antibiotic use. Individuals at risk for invasive candidiasis include low birth weight

babies, people recovering from surgery, people admitted to intensive care units, and

those with an otherwise compromised immune system.

Efforts to prevent infections of the mouth include the use of chlorhexidine mouthwash

in those with poor immune function and washing out the mouth following the use of

inhaled steroids. Little evidence supports probiotics for either prevention or treatment,

even among those with frequent vaginal infections. For infections of the mouth,

treatment with topical clotrimazole or nystatin is usually effective. Oral or

intravenous fluconazole, itraconazole, or amphotericin B may be used if these do not

work.[6] A number of topical antifungal medications may be used for vaginal

infections, including clotrimazole. In those with widespread disease,

an echinocandin such as caspofungin or micafungin is used. A number of weeks of

intravenous amphotericin B may be used as an alternative. In certain groups at very

high risk, antifungal medications may be used preventatively.

Infections of the mouth occur in about 6% of babies less than a month old. [7] About

20% of those receiving chemotherapy for cancer and 20% of those with AIDS also

develop the disease. About three-quarters of women have at least one yeast infection

at some time during their lives. Widespread disease is rare except in those who have

risk factors.[21]

33
At of total 120 participants that took part in this study 24(20%) were positive and

96(80%) were negative. In Garoua prevalence 55.4% a study carried yout Moussa et

al 2013[1] was higher compared to our study. The prevalence of 20% obtained in the

study was similar to the prevalence 20.7% obtained in a study in Aligarh, India by

Anis et al 2009[2], in Thailand 10.7% by Kasidis et al 2023[3], in Cairo, Egypt

17.3% obtained in a study by Sahar et al 2022[4]. The differences in the results could

be due to difference in the sample sizes and test methods used. Another was carryout

in india which had prevalence of 28.8% by Ravinda et al 2007[5] which higher

compared to our study (20%), this high prevalence could be due to sample size and

the test method al 2011[6]..

Out of the 120 participants recruited for this study, about 75.83% of the participant

were putting on cotton pants and 24.17% were putting nylon pants which account for

20% prevalence in this study, compared to a similar study carry out in nigeria among

women of similar underwear and shows the prevalence of candidiasis 82.6% and

25.7% respectively for both nylon and cotton underwears by Ekpenyong et Diabetis ,

douchinching, kwowledge on candidiasis, drugs had percentage of participants as

4.1%. 12.5%,12.5%, and 10.8% respectively. The prevalence(18.8%) of study carry

out in brazil by Setsuko et al 2014 [7] was higher compared to our study, on drugs

5.3% by mara et al 2018, douching 76.7% which was by far higher in this study. The

difference in results maybe due differences in sampls size and the knowledge on the

spread of condidiasis.

5.2 Conclusions
34
The prevalence of candidiasis was low compared to study carried in Garoua cameroon

and other parts of Africa and the world. Based on the range, Candidiasis was

prevalent among women age 20-30 years accounting for 11.2%, also secondary

school girls had a high prevalence compared to other levels of educational field

studied in the study. Single women had the higher prevalence compared to married

women and widows.the prevalence was less in university graduates or those who have

had university education. Business women and unemployed women had a high

prevalence compared to student and women who were employed. Women who were

putting on nylon pants, douching, on drugs were at high risk of contracting Candida

albicans or other species of Candida.

5.3 Recommendations

1. There is a very urgent need for interventional programs such as screening and

treating the infected women in the community to reduce the prevalence of

Candidiasis

2. There is need for regular health education for women of child bearing age in

antenatal clinics, academic institutions, trader etc. to inform them about their

health, avoidance of risky behaviors and the risk of infections with Candidiasis

3. There is urgent need for male partners to accompany their spouse to antenatal

clinics for screening of sexually transmitted disease. This will increase their

knowledge on these infections and reduces the risk of contracting the

infections.
35
 4. There should be a more comprehensive population based study to establish the

incidence and outcomes related to Candidiasis among women of childbearing

age and other vulnerable groups.

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