Environmental and human behavioral factors associated with Vulvovaginal Candidiasis among single and married Women in Eket

Vulvovaginal Candidiasis (VVC) is a fungal infection caused by genus candida, predominantly with Candida albicans which are essentially part of the vaginal fl ora. Candida albicans usually appears as oval yeast-like cell that reproduce by budding in infected areas [1]. Filamentous hyphae and pseudohyphae consist of elongated yeast cells that remain attached to each other. A few decades ago vulvovaginal candidiasis was not considered a very commonly occurring disease; however with the rise in the number of immunocompromised patients over the last two decades, vulvovaginal candidiasis has become much more common [2]. Vulvovaginal candidiasis is seen mostly frequently in women with diabetes mellitus or following Abstract


Introduction
Vulvovaginal Candidiasis (VVC) is a fungal infection caused by genus candida, predominantly with Candida albicans which are essentially part of the vaginal fl ora. Candida albicans usually appears as oval yeast-like cell that reproduce by budding in infected areas [1]. Filamentous hyphae and pseudohyphae consist of elongated yeast cells that remain attached to each other. A few decades ago vulvovaginal candidiasis was not considered a very commonly occurring disease; however with prolonged antibiotic therapy [3]. The prominent symptom is a yellow milk vaginal discharge yeast cells and other symptoms of VVC include itching, pain, and swelling. In addition, the typical vaginal discharge in VVC is described as cottage cheese-like in character [4]. It has been suggested that 75.0% of women may experience VVC during their lifetimes [5].
Risk factors for vulvovaginal candidiasis are factors that do not seem to be a direct cause of the disease, but seem to be associated in some way. Having a risk factor for VVC makes the chances of getting a condition higher but does not always lead to vulvovaginal candidiasis. Also, the absence of any risk factor or having a protective factor does not necessarily guard one against getting vaginal candidiasis [6].
Citation: Edem [7]. In this study, the relationships between personal habits, behaviors, and vulvovaginal candidiasis by analyzing a subset of data from a Health Service-based case-control study of urinary tract infection was explored. Many genital infections are related to sexual contact with infected partners.
This work seeks to determine the prevalence of candidiasis among singles and married women of different age groups with the antimicrobial sensitivity pattern of the isolates in Eket metropolis.

Materials and methods
A cross-sectional study was conducted among singles and married women seeking healthcare services in Heritage Polytechnic Health center in Eket, in the period from February to April 2020. Three hundred and sixty High Vaginal Swab (HVS) were collected, One hundred and eighty each from singles and married women respectively. Eligibility for the study was sorted on basis of reproductive age, sexually active, lifestyle related behaviors, routine hygienic practices, menstrual care, history of contraceptive intake and willingness to give informed consent. They were enrolled at the time they appeared with symptoms of vulvovaginitis at the health centre.

Laboratory investigations
Endo-cervical and High Vaginal Swabs (HVS) were collected following aseptic precautions. The samples collected were labeled appropriately, indicating the patient's name, gender, date and time. The swabs were immediately transported to the laboratory for analysis. First, a saline mount of the vaginal discharge specimen was covered with a cover-slip, and examined microscopically at ×400 magnifi cation as described by Cheesbrough (2006), then the samples were inoculated into appropriate agar plates which was Sabourand Dextrose Agar and incubated for 72 hours at 30-35 0 C for C. albicans. Colonies were identifi ed on the basis of microscopy ( Figure 1), colonial morphology and biochemical tests basically a germ tube test as described by Cheesbrough (2006). Infection with Candida albicans was examined microscopically using a 10% KOH wet mounts followed by colony identifi cation after cultivation on Sabouraud dextrose agar for the diagnosis of VVC [8].

Data analysis
All data generated during this study was subjected to statistical analysis to test for signifi cance using ANOVA and Statistical Package for Social Sciences (SPSS). The association between independent and dependent variables was tested using Pearson's chisquare or Fisher's exact test, whichever suitable, and the Odds Ratio (OR) and its corresponding 95% CI were reported.
A Multivariable logistic regression model was developed for all variables and the adjusted OR and its corresponding 95% CI were reported. P-values < 0.05 were considered statistically signifi cant.

Ethical consideration
The ethical committee of the Heritage Polytechnic Health Centre gave ethical clearance and permission to conduct the study. Patients' results were handled with confi dentiality and those found to be infected with classical sexually transmitted disease (STD) and candidiasis was treated according to the guidelines of the Ministry of Health in Nigeria.

Incidence and percentage Infection Rate
Sociodemographic characteristics: Table 2 which carries information about the Sociodemographic characteristics of the study population shows that of the total 360 population, age range 20-34 had the highest 121 (53.1%) incidence of VVC followed by >35 with 103 (45.2%). Women with advanced level of education had the highest 82 (36%) incidence of VVC while those with no formal education had the least 29 (12.7%). There was high 136 (59.6%) incidence rate of VVC among nonpregnant women while pregnant women had a low 92 (40.4%). Women residing in the urban region had a high 156 (68.4%) rate of VVC while those in rural area had a low 72 (31.6%) rate.

Multivariate analysis of selected behavioral risk factors:
In addition to sexual behavior variables, risk factors for VVC such as recent use of antibiotics, wearing of tight clothing, toilet users, toilet type, menstrual protection, birth control methods etc were evaluated and listed in Table 3.
There was no signifi cant association between VVC and intercourse frequency among singles. However, there was signifi cant association (p<0.05) with some risk factors like menstrual protection methods, direction of vaginal wiping after sex, toilet type, toilet paper used, recent antibiotic use, underwear fabric, tight clothing, birth control methods among both the married and single. Risk factor like toilet users, had no association with VVC among singles but had some level of association (p<0.05) among the married. This data is shown in Table 3.

Discussion
Vulvovaginal Candidiasis (VVC) occurs frequently in women, yet the associated risk factors are poorly understood.
Women with VVC receive different advises from physicians and other healthcare providers. These women tend to try varied pharmaceutical remedies and lifestyle modifi cations, such as medication and clothing, in an attempt to gain control over VVC. Yet data suggest the impacts of these changes are inconsistent. On this note, the current study shows that 63.3% of participants had VVC. This rate is lower than fi ndings by Nwadioha, et al. [9] and Ekanem [10], with 84% and 75% respectively. This study has a higher rate than studies at Michacan and Tanzania by Barbara, et al. [11] and Namkinga, et al. [2] with 46.4% and 45.7% incidence rates respectively. It was observed that married females had higher incidence of C. Albicans (31.9%), while the singles had lower incidence (31.4%). The high incidence of VVC among married women may not be unconnected with the elevated sexual activity and dwindling hygiene status of this group. Also females within this bracket tend to wear binding or tight fi tting undergarments such as pantyhose, nylon panties, and tights, which increase the local temperature and humidity, all of which encourage the growth of candida species.
Predominance of candidiasis in the study was highest among age group 20 -30. This age range is the most sexually active age group with highest risk of pregnancies, indulgence in family planning pills. This study suggests that age is a factor related to VVC infection and it is consistent with previous studies by Pfaller, et al. [12], Nwadioha, et al. [9] and Na, et al. [13], which suggests that incidence of Candida infection is increased with age. The high rate of VVC among married women can be explained by the high frequency of unprotected sexual intercourse and this is consistent with previous study by Abdul-Aziz, et al. [3]. Pregnancy indicates increase in hormonal infl uences and alteration in vaginal pH which suggests a relationship with VVC. Some studies by Sobel, et al. [6] and Omole-Ohonsi, et al. [14], suggest that pregnancy is an important risk factor for vaginitis. In this study, pregnant women with VVC constituted 40.4% of total population, and the rate is consistent with a 40% previous rate by Nwadioha, et al. [9]. This low rate might be due to low rate of pregnant participants in the study. Education was also closely linked to the infection. This study suggests that education was unlikely associated with VVC infection whereas a study by Na, et al. [13] suggests that patients with higher education were unlikely to come down with VVC. The possible explanation for this outcome maybe that highly educated women is believed to had mastered the knowledge of candidal vaginitis and how to protect herself from VVC infection but are still exposed to more risk factors like tight clothing, colored tissue papers and antibiotic use.

Multivariate analysis
Antibiotics and vaginal douching suppress normal bacterial

Marital status
No.  fl ora and allow Candida organisms to proliferate. Antibiotic users posed a high rate (18.6% and 16.9% for married and singles respectively) of risk to VVC in the study. These rates could be due to the fact that widespread use of antibiotics contributes to an increased prevalence of Candida vaginal infection [15] because it suppresses the bacterial growth around the vagina thereby paving way for candida to thrive. However we did not fi nd that antibiotic usage had an association with VVC infection.

Non-Candida albicans
This is consistent with a study by Namkinga, et al. [2] which shows antibiotic usage not to be a factor associated with VVC.
Other factors like wearing tight clothing; type of menstrual protection; toilet type; type of tissue paper; method of menstrual protection; birth control methods; toilet users; and underwear fabrics shows association in some variables with VVC. This shows a high level of behavioral differences between the married and single women which can lead to increased frequency of VVC.

Conclusion
The high prevalence of VVC in the present study underscores the importance for routine screening of patients with simple tests such as determination of vaginal pH and microscopy for pus cells. The results show that women are frequently and acutely victimized by candidiasis infection. It was observed that married women had the higher percentage of C.albicans, more than single women due to their sexual, poor hygienic situation, both domestically and environmentally. The government should take effective measure to create orientation in all the health sectors for both married and single women, on how to eradicate or eliminate candidiasis in order to protect health and life generally to the masses. If a woman with VVC is counseled to avoid the risks described by this analysis, evaluation of the impact of behavioral change on her infection rate should be assessed so that unnecessary curtailing of activities can be avoided. Health education interventions are recommended to raise women's awareness of vaginitis and its prevention. In addition, regular monitoring of VVC among women, educating them on effective preventive measure should be conducted between married and unmarried women. Normal sanitary pad should be used, normal cleaning tissue should be used during and after sexual intercourse, avoidance of improper wears, and antibiotics should be taken on prescription by physician. Early diagnosis and prompt treatment of VVC especially among the risk groups in order to avert the complications is highly recommended.