Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349
http://www.biomedcentral.com/1756-0500/7/349RESEARCH ARTICLE Open AccessChlamydia Trachomatis and Neisseria Gonorrhoeae
prevalence among women of reproductive age
living in urogenital schistosomiasis endemic area
in Ghana
Dzidzo Yirenya-Tawiah1*, Ted N Annang1, Kwesi A Apea-Kubi2, George Lomo3, David Mensah4, Lorenzo Akyeh4
and Kwabena M Bosompem4Abstract
Background: Many studies have shown an overlap in the epidemiology of sexually transmitted infections (STIs)
and urogenital schistosomiasis among young women living in schistosomiasis endemic areas. Yet we found no
study assessing the prevalence of STI infections in urogenital schistosomiasis endemic areas in Ghana. As part of
an epidemiological study on urogenital schistosomiasis and HIV, we sought to assess the prevalence of both
Chlamydia trachomatis (CT) and Neisseria gonorhoeae (NG) infections among women living in schistosomiasis endemic
communities and explore the relationship between the sexually transmitted infections (STIs) and demographic
characteristics, sexual behaviour and self-reported symptoms.
Methods: This was a cross-sectional study in which endocervical samples were collected from 191 women aged
15–49 years from October 2005 to March 2006. Samples were examined for CT and NG using Polymerase Chain
Reaction (PCR). A structured questionnaire was also used to elicit information on study participant’s gynaecological
and obstetric history and symptoms for genital infection. Chi-square test and binary logistic regression were used
to assess association between CT and NG and other variables such as age, sexual behaviour and self-reported
symptoms.
Results: The overall prevalence of CT and NG were 6.3% and 2.6% respectively.The highest prevalence rates of
CT were in the 15 to 19 year group while only individuals between 15 and 39 years were positive for NG.
There was no association between CT and age, contraceptive use and the other variables assessed. NG on the
other hand was found to be associated with age, number of births and number of sexual partners only by
chi-square test.
Conclusions: Our research revealed higher prevalence of CT and NG infections when compared to previous
studies conducted among higher risk groups in non-urogenital schistosomiasis areas in Ghana. We therefore
recommend further studies of these STIs in urogenital schistosomiasis endemic areas in the country.
Keywords: Chlamydia, Gonorrhoeae, Urogenital schistosomiasis, Ghana* Correspondence: dzidzoy@staff.ug.edu.gh
1Institute for Environment and Sanitation Studies, University of Ghana, Legon,
Ghana
Full list of author information is available at the end of the article
© 2014 Yirenya-Tawiah et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349 Page 2 of 7
http://www.biomedcentral.com/1756-0500/7/349
Table 1 Demographic characteristics of women enrolled
in the epidemiological survey
Age group (years) Number (%)
Age (years)
15-24 35 (18.2)
25-34 72 (37.7)
> 34 84 (44.0)
Marital status
Single 38(19.9)
Married 142 (74.3)
Divorced 6(3.1)
Widowed 5 (2.6)
Education level
Illiterate 68 (35.6)
Primary 83 (43.5)
JHS 32 (16.8)
SHS 8 (4.1)
Tertiary 0 (0.0)
Occupation
Schooling 9 (4.7)
Fishing 4 (2.1)
Farming 68 (35.6)
Trading 93 (48.7)
Unemployed 6 (3.1)
Others 11 (5.7)
Length of stay in village (years)
Less than 1 4 (2.1)
Between 1 and 2 4 (2.1)
Between 2 and 5 18 (9.4)
Between 5 and 10 51 (26.7)
More than 10 114 (59.7)
JHS-Junior High Secondary.
SHS-Senior High Seconday.Background
Globally, sexually transmitted infections (STIs) are of
public health concern. It is estimated, that 499 million
new curable STI cases occur annually [1]. Among the
broad range of bacterial STIs, CT and NG are the most
prevalent bacterial STIs, with sub-Saharan Africa having
the highest prevalence rates of these infections [2].
In most cases, women infected with CT and NG are
asymptomatic [3]. Risk factors include young age, fe-
male, number and type of sexual partners and contra-
ceptive use [4-6]. Untreated CT and NG infections have
been associated with pelvic inflammatory diseases (PID):
infertility, ectopic pregnancy, chronic pelvic pain, cer-
vical cancer, spontaneous abortion, premature delivery
and low birth weight [7]. Studies suggest the possibility
of women with untreated urogenital schistosomiasis also
present with similar adverse outcomes [8-11]. According
to Gray et al. [12], CT and NG facilitate the susceptibil-
ity of women to HIV infection.
It has also been hypothesized that Schistosoma haema-
tobium infection may increase the susceptibility to HIV
infection [13]. Leutscher et al. [14] also reports overlap
of STIs and schistosomiasis among young adults living
in urogenital schistosomiasis endemic areas. This over-
lap occurs at the time when urogenital schistosomiasis
infection prevalence and intensity peaks and begins to
decrease in young adults, while at the same time they
begin to acquire sexually transmitted infections (STIs);
this predisposes them to concomitant STI /schistosomia-
sis infection.
While urogenital schistosomiasis is endemic in Ghana,
we found no studies assessing the prevalence of STI in-
fections in these areas. According to Apea-Kubi et al.
[15] most studies on CT and NG in Ghana have targeted
high risk groups, hospital attendees and populations in
urban settings. We therefore sought to assess the preva-
lence of both CT and NG among women living in rural
urogenital schistosomiasis endemic communities and ex-
plore the association between the STIs and various fac-
tors that may promote infection.
Methods
Study design
This study was part of a larger cross-sectional epidemio-
logical survey on urogenital schistosomiasis and HIV in
the Volta Basin of Ghana involving 1,695 women. Out of
these, 420 (24.8%) women aged 15–49 years, voluntarily
enrolled for the study on female genital schistosomiasis
(FGS) and HIV which involved screening for genital in-
fections and HIV [16]. Out of the 420, 191 of them were
randomly screened for CT and NG. The study area
spanned the Afram arm of the Volta Basin to about 40 km
downstream below the Akosombo dam. The study com-
munities are all rural and located along the Volta River.Major occupations engaged in are fishing, farming and
petty trading as shown by the demographic charac-
teristic of study participants in Table 1. The overall
adult (categorized as persons 15 years and above) urinary
schistosomiasis prevalence rate in the study area was
46.5%. The prevalence rate of the disease in males and
females is 56.5% and 36.9% respectively [16].
The eligibility criteria and recruitment procedure used
in this study has already been described elsewhere [17].
Briefly, study participants who voluntarily agreed to par-
ticipate in the study were recruited from the larger study
after informed verbal consent was provided. All partici-
pants prior to screening were administered a struc-
tured questionnaire that focused on their obstetric and
gynaecological history and self-reported gynaecological
Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349 Page 3 of 7
http://www.biomedcentral.com/1756-0500/7/349symptoms observed at the time of the study. This ques-
tionnaire was in English but was administered in private
by Research Fellows and trained Research Assistants.
Questionnaires were administered in the local languages
spoken by study participants; Ewe, Dangme and Twi.
After responding to the questionnaires, all participants
were physically examined by a gynaecologist, and we ex-
cluded pregnant women , virgins, those who have had
surgery, those who had the presence of any health con-
dition (e.g. diabetes, hypertension etc.) and women men-
struating at the time of the study. The inclusion criteria
were:
1. Age between 15 and 49 years
2. Sexually active
3. Living in study area for over a year
4. Willingness to participate in studyTable 2 Association between CT and selected characteristics o
CT infection status
Characteristics Number positive (%
Age group (N = 186)
15-24 4 (11.4)
25-34 5 (6.9)
*≥ 35 3 (3.6)
Number of births (N = 190)
0 3 (13.6)
1-3 5 (5.9)
*≥ 4 4 (4.4)
Number of sexual partners in past one year (N = 191)
0 0 (0.0)
1 11 (6.3)
2 1(16.7)
*≥ 3 0 (0.0)
Age at first intercourse (N = 189)
9-15 4 (8.2)
16-22 8 (6.1)
≥23 0(0.0)
Frequency of sexual intercourse (N = 187)
Every day 0 (0.0)
Once a week 9 (6.8)
Twice in a month 0 (0.0)
≤ once a month 3 (6.5)
Contraceptive use (N = 191)
No contraceptive use 11 (7.4)
Hormonal contraceptive use 0 (0.0)
*Non hormonal contraceptive use 1 (2.7)
*Variables used as reference category in regression model.
OR- Odds Ratio; CI- Confidence Interval.
where p-value is 0.9 and 1, no CI was computed by model.Additionally, the gynaecologist physically examined
the external and internal genitalia for any abnormality
and these were recorded. Endocervical specimens were
collected and placed immediately into 2SP transport
medium (2 M sucrose and 0.02 M phosphate) (Roche
Diagnostics, Indianapolis USA) and transported on ice
at 4°C to Noguchi Memorial Institute for Medical Re-
search (NMIMR) to be tested for Chlamydia trachomatis
and Neisseria gonorrhoeae detection.
CT and NG were diagnosed using the Amplicor C. tra-
chomatis/N. gonorrheae assay (Roche Diagnostic Cor-
poration, Indianapolis, IN, USA). All tests were done
according to the manufacturer’s description/instruction on
the package Van der pol et al. [18].
Ethical approval for the study was granted by the
Noguchi Memorial Institute for Medical Research, In-
stitutional Review Board. Consent was also granted byf study subjects
Measure of association
) Number negative (%) Chi-square (P value) OR(CI) P value
31 (88.6) 2.6 (0.3) 3.4 (0.7-16.5) 0.1
67 (93.1) 2.0 (0.4-8.7) 0.3
81 (96.4)
19 (86.4) 3.4 (0.7-16.6) 0.1
73 (93.6) 2.6 (0.3) 1.4 (0.4-5.8_) 0.6
87 (95.6)
10 (100.0) 1.4 (0.4) 1.0 1.0
163 (93.7) 1.0 1.0
5 (83.3) 3.2 1.0
1 (100)
45 (91.8) 1.0 (0.8) 1.4 0.9
123 (93.9) 1.1 0.9
11 (100.0)
2 (100.0) 0.0 (0.0) 0.9
123 (93.2) 0.9 (0.9) 0.0 (0.0) 0.9
7 (100.0) 1.05 (0.3-4.1) 0.9
43 (93.5)
137 (92.6) 2.8 (0.4-23.0) 0.3
6 (100.0) 0.8 (0.6) 0.0 (0.0) 0.9
36 (97.3)
Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349 Page 4 of 7
http://www.biomedcentral.com/1756-0500/7/349District Health Management teams, Community leaders,
Community members and study participants. Partici-
pants who tested positive for both CT and NG were
treated by the gynecologist according to stipulated national
guidelines.
Data analysis
All data were double entered in Microsoft excel (Microsoft
Corporation, Redmond, WA, USA) to ensure accur-
acy and later transferred into SPSS version 18 for
analysis. First, descriptive statistics were done which
was followed by using the Chi-square test and logis-
tic regression to determine association between CT
and NG infections, the dependent variables and inde-
pendent variables such as age, sexual behaviour and
self-reported symptoms. All analyses performed ex-
cluded missing data and were conducted at 95% con-
fidence intervals (CI).Table 3 Association between NG and selected characteristics
Characteristics No. positive (%)
Age group (N = 186)
15-24 3 (8.6)
25-34 2 (2.8)
*≥ 35 0 (0.0)
Number of births (N = 190)
0 3 (13.6)
1-3 2 (2.6)
*≥ 4 0 (0.000)
Number of sexual partners in past one year (N = 191)
0 0 (0.0)
1 3 (1.7)
2 2 (33.3)
≥3 0 (0.0)
Age at first intercourse (N = 189)
9-15 1 (2.0)
16-22 4 (3.1)
≥23 0(0.0)
Frequency of sexual intercourse (N = 187)
Every day 0 (0.0)
Once a week 5 (3.8)
Twice in a month 0 (0.0)
≤ once a month 0 (0.0)
Contraceptive use (N = 191)
No contraceptive use 4 (2.1)
Hormonal contraceptive use 0 (0.0)
*Non hormonal contraceptive use 1 (0.5)
*Variables used as reference category in regression model.
OR- Odds Ratio; CI- Confidence Interval.
where p-value is 0.9 and 1, no CI was computed by model.Results
Out of the 191 women screened for CT and NG in this
study, 12(6.3%) and 5(2.6%) were positive for CT and
NG respectively, and 2 (1.0%) co-infected with both CT
and NG. The majority of study participants who were di-
agnosed with CT were within the age group 15–24 years
(Table 2). The results from Table 2 also show that, there
was no association between CT and all the factors
assessed (age, number of births, sexual behaviour).
Table 3 shows the relationship between NG infection
and factors studied. All the subjects infected with NG
were between the ages of 15 to 34 years. In analyzing for
any association between NG and the various factors by
chi-square test, the study showed a significant difference
between NG and age (p = 0.002), NG and number of
births a woman has undergone (p = 0.04) and NG and
number of sexual partners a woman had in the past year
(p = 0.00). We also found only 1.0% of women who hadof study subjects
No. negative (%) Chi-square P value OR (CI) P value
32 (91.4) 7.0 (0.03)) 1.5 (0.0) 0.9
70 (97.2) 4.6 (0.0) 0.9
84 (100.0)
19 (86.4) 12.9 2.5 (0.0) 1
76 (97.4) (0.002) 4.2 (0.0) 1
91 (100.0)
10 (100.0) 23 1.0 (0.0) 1.0
171 (98.3) (0.00) 2.8(0.0) 1.0
4 (66.7) 8.0(0.0) 1.0
1 (100.0)
48 (89.0) 3.3 1.1
127 (96.9) 0.6 (0.9) 5.0 1.1
11 (100.0)
2 (100.0) 2.2 (0.)) 1.0 1.0
127 (96.2) 6.3 0.9
7 (100.0) 1.0 1.0
46 (100.0)
144 (75.4) 0.2 (1.0) 1.0 1
6 (100.0) 0.0 0.9
36 (18.8)
Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349 Page 5 of 7
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Table 4 Association between CT infection and self- reported symptom
Symptoms CT status Measure of association
No. positive (%) No. negative (%) Chi-square OR (CI) p value (CI)
Vaginal itch (N = 120)
Yes 6 (7.3) 76 (92.7) 0.1 1.1 (0.1-2.0) 0.9
*No 3 (7.9) 35 (92.1)
Lower abdominal pain (N = 191)
Yes 7 (6.6) 99 (93.4) 0.4 0.9 (0.3-5.0) 0.8
*No 5 (5.9) 80 (94.1)
Dyspareunia (N = 191)
Yes 4 (5.3) 71 (94.7) 0.2 1.3 (0.4-4.5) 0.6
*No 8 (6.9) 108 (93.1)
Vaginal discharge (N = 191)
Yes 9 (7.7) 108 (92.3) 1.0 0.5 (0.1-2.0) 0.3
*No 3 (4.1) 71 (95.9)
*Variables used as reference category in regression model.
OR- Odds Ratio; CI- Confidence Interval.never given birth and 1.6% of women who had given
birth 1 to 3 times to be infected with NG. The rest of
the women who had given birth 4 times and more were
NG negative (Table 3). The majority of participants (174)
had had one sexual partner in the preceding year to the
study. Regarding having multiples sexual partners, only 6
participants reported having 2 sexual partners and 1 par-
ticipant reported having 5 sexual partners in the year pre-
ceding this study. Ten of them indicated they had had no
sexual partners in the past year (Table 3). Among subjects
found to be positive for NG, 1.6% of them had no sexual
partner and 1.0% had a single sexual partner. There was
no association found between number of sexual partnersTable 5 Association between NG infection and self- reported
Symptoms NG status
No. positive (%) No. neg
Vaginal itch (N = 120)
Yes 3 (3.7) 79 (92.3
*No 1 (2.6) 37 (94.4
Lower abdominal pain (N = 191)
Yes 2 (1.9) 104 (98
*No 3 (3.5) 82 (96.5
Dyspareunia (N = 191)
Yes 4 (5.3) 72 (94.7
*No 1 (0.9) 115 (99
Vaginal discharge (N = 191)
Yes 4 (3.4) 113 (96
*No 1 (1.4) 73 (98.6
*Variables used as reference category in regression model.
OR- Odds Ratio; CI- Confidence Interval.and NG infection and contraceptive use and NG both by
chi-square and logistic regression.
Tables 4 and 5 also show the distribution of self-
reported symptoms by CTand NG infection status respect-
ively. The study revealed that the majority of participants
with self-reported symptoms were negative for CT and NG
respectively. There was also no association found between
the STIs and any of the reported symptoms both by chi-
square and logistic regression.
Discussion and conclusions
This study reports on CT and NG prevalence among
women of reproductive age living in rural urogenitalsymptom
Measure of association
ative (%) Chi-square OR (CI) p value
) 0.08 (1.0) 0.7 (0.07-7.1) 0.7
)
.1) 0.5 (0.7) 1.9 (0.3-11.7) 0.4
)
) 3.5 (0.08) 2.8 (0.3-25) 0.4
.1)
.6) 0.8 (0.7) 0.4 (0.004-3.5) 0.4
)
Yirenya-Tawiah et al. BMC Research Notes 2014, 7:349 Page 6 of 7
http://www.biomedcentral.com/1756-0500/7/349schistosomiasis communities in the Volta Basin of Ghana.
The prevalence levels found were 6.3% and 2.3% for CT
and NG respectively. Earlier prevalence studies conducted
in Ghana among high risk populations (gynaecologic clinic
attendees, women recruited from drinking bars, night
clubs, female hostels and work places of apprentice seam-
stresses and hairdressers) reported CT prevalence rates
ranging from 1.5% to 4.8% and NG prevalence rates ran-
ging from 0 to 3.1% [4,15,19,20]. Another study conducted
in a health facility in Zambia found prevalence rate of CT
and NG among HIV infected women to be 1% and 1.4%
respectively [21]. On the other hand, the CT prevalence
rate determined by our study is consistent with findings
from a similar study by Leutscher et al. [14] in a uro-
genital schistosomiasis community in Madagascar where
they found CT prevalence rate of 9.8% among their study
participants.
The higher prevalence of CT reported by this study
when compared to others conducted in Ghana in non-
urogenital schistosomiasis endemic areas reported may
be explained by the fact, that schistosomiasis infection
which usually occurs in childhood among people living
in endemic areas may compromise the reproductive
tract by causing ulceration and thinning of the epithe-
lium before an individual reaches the sexual active age.
This allows for easy penetration and implantation of any
STI that may be contracted when an already positive
schistosomiasis case becomes sexually active as a young
adult [22]. In a community based study in Northern
Tanzania, Poggensee et al. [23] found high prevalence of
FGS in all age groups and the high levels of pathologic
cervical alterations such as swollen and disrupted epithe-
lium, supporting the hypothesis that FGS was a risk fac-
tor for the transmission of STI infections.
Our findings did not reveal any association between
self-reported symptoms and STIs studied. Nevertheless,
we observed only a few, less than 10.0%, of the STI posi-
tive cases to report the presence of some symptom(s).
As shown by Romoren et al. [2], many CT and NG in-
fected individuals are asymptomatic. A meta-analysis of
several studies by Wasserheit [24] demonstrated, that
only 28% of women with CT and NG infection reported
symptom of vaginal discharge. She also found, that 92%
of cases with vaginal discharge to be neither infected
with CT nor NG. Similar observations were also made
by this study. As such this study supports earlier sugges-
tions that a syndromic approach should not be used as a
screening tool for CT and NG [25-28].
Our study was limited in a number of ways. Firstly,
the fact that participation was on a voluntary basis cre-
ated selection bias and therefore our sample participants
may not be representative of the population in the study
area. Also, our study participants presented (with) simi-
lar characteristics and this may account for the weakrelationship observed between the infections and the
factors studied. For instance the majority of the partici-
pants were married and were not expected to have mul-
tiple partners, hence it was not surprising that there was
no association between number of sexual partners and
CT and NG. Likewise, contraceptive use in most African
rural settings, particularly in marital relationships is low.
It was therefore expected that contraceptive use would
be low and this also accounted for the fact that no asso-
ciation was observed between STIs and contraceptive
used. Secondly, because of the small sample size, study
results may not be robust and therefore should be inter-
preted with caution. Thirdly, we did not consider anti-
biotic usage among participants which may have also
impacted on STI prevalence rates observed.
This study, nevertheless, serves as a baseline study for
future studies on STIs in schistosomiasis endemic areas.
There is a need for community screening and treatment,
and health educational campaigns on STI infections in
urogenital schistosomiasis endemic communities in the
country.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Contribution of the authors is as follows; DYT, KAAK and KMB designed the
study and wrote the protocol. DYT, TA, KAAK, GL and LA collected data.
KAAK and GL collected gynaecological samples, and LA conducted
bacteriological assessment. Authors DYT and DM, worked on the data
analysis and DYT and KMB drafted the manuscript. All authors read and
approved the final manuscript.
Acknowledgement
We acknowledge the involvement of study participants and community
leaders, the institutional support from the various District Health
Management Teams and contributions from staffs of the Volta River
Authority, Noguchi Memorial Institute for Medical Research and the Volta
Basin Research project of the University of Ghana. This study received
funding from DANIDA, through the Ministry of Water, Works and Housing
and the Ghana AIDS Commission.
Author details
1Institute for Environment and Sanitation Studies, University of Ghana, Legon,
Ghana. 2Department of Obstetrics and Gynaecology, University of Ghana
Medical School, Korle-bu, Accra, Ghana. 3Ridge Hospital, Accra, Ghana.
4Noguchi Memorial Institute of Medical Research (NMIMR), Legon, Ghana.
Received: 24 September 2013 Accepted: 2 June 2014
Published: 9 June 2014
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doi:10.1186/1756-0500-7-349
Cite this article as: Yirenya-Tawiah et al.: Chlamydia Trachomatis and
Neisseria Gonorrhoeae prevalence among women of reproductive age
living in urogenital schistosomiasis endemic area in Ghana. BMC
Research Notes 2014 7:349.Submit your next manuscript to BioMed Central
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