Recurrent vulvovaginal candidosis among young women in south eastern Nigeria: the role of lifestyle and health-care practices

Lived experience of medical management in recurrent vulvovaginal candidiasis: a qualitative study of an uncertain journey

Background

Recurrent vulvovaginal candidiasis (RVVC) is experienced by up to 10% of pre-menopausal women globally, yet there is limited research exploring the perspective of women living with this challenging condition.

Methods

Semi-structured interviews with Australian women experiencing RVVC were conducted between April–July 2021. Interviews were transcribed verbatim, and qualitative interpretative phenomenological analysis (IPA) was conducted.

Results

Ten RVVC patients were interviewed. IPA revealed an uncertain journey living with RVVC for all participants ranging from initial symptoms and difficulties in obtaining a diagnosis, the trial and error of symptom management, to the overall debilitating impact of living with a personal and intimate health condition. Four key themes were identified: Theme 1 outlined challenges and delays in diagnosis and clinically appropriate management. Theme 2 found that health care professional (HCP) knowledge limitations impacted RVVC management. Theme 3 illustrated the consequences of a lack of HCP support leading to self-referral and self-education. Theme 4 details the significant emotional and psycho-social repercussions of RVVC.

Conclusions

This debilitating, life-long disease has a prolonged effect on women both physically and psychologically. Living with RVVC seems an uncertain journey that, to a large degree, women feel they must navigate alone. While resilience and self-empowerment were noted, better support through evidence-based treatment options, educated and evidence-informed HCPs and a sympathetic social support network is needed to decrease the disease burden. Future clinical management guidelines and patient support need to consider the findings of this study.

Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya

Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.

Estimated burden of serious fungal infections in Togo

BACKGROUND

Over the years, the focus of infectious diseases in many African countries has been mainly on viral, bacterial and parasitic infections. Serious fungal infections (SFIs) with comparable morbidity rate in these countries remain neglected.

OBJECTIVES

To estimate the burden of SFI in Togo and to stimulate efforts for improved attention.

METHODS

Literature was thoroughly searched for epidemiological data on SFI in Togo. Incidence and/or prevalence of SFI was estimated using socio-demographics, health system's information, risk-groups data and SFI rates obtained from national and international studies.

RESULTS

About 5.29% of the 7,265,286 Togolese population is estimated to suffer from SFI annually. Among HIV patients, 1,342, 1,650 and 330 may develop cryptococcal meningitis, Pneumocystis pneumonia and disseminated histoplasmosis respectively per year. Oral and oesophageal candidiasis may annually affect 19,800 and 7,535 persons, respectively, living with HIV. Estimated incidence of invasive aspergillosis (IA) was 283 cases. Prevalence of chronic pulmonary aspergillosis (CPA) was estimated at 191 cases. The annual incidence of allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS) was 4,577 and 6,042 cases, respectively. Tinea capitis and recurrent Candida vaginitis presumably affect 232,271 children and 108,979 women respectively. Candidaemia incidence is estimated at 5 cases per 100, 000 inhabitants and fungal keratitis may affect 981 persons annually.

CONCLUSIONS

SFIs in Togo are probably more significant than expected. These findings underscore the need to increase awareness among healthcare professionals, enhance diagnostic and therapeutic capacities and intensify epidemiological studies for effective management of fungal infections in Togo.

Association of sexual function and psychological symptoms including depression, anxiety and stress in women with recurrent vulvovaginal candidiasis

Objective:

Recurrent vulvovaginal candidiasis (RVVC) is a common vaginal infection which could affect the quality of life, romantic relationships, and sexual performance. There is some evidence that psychological problems result in an increased incidence of RVVC by changing the immune systems of individuals. The aim of this study was to determine the association of sexual function and psychological factors including depression, anxiety, and stress in women with RVVC.

Material and Methods:

Study design was case controlled. Equal numbers of women with RVVC and uninfected women referred to gynecology clinics were selected, using convenience purposive sampling. Two samples of vaginal discharge were prepared from each person. One sample was examined microscopically and the second was cultured on Sabouraud Agar. Data collection tools used for this study included demographic questionnaire, Female Sexual Function Index, Depression Anxiety Stress Scales-21. Data were analyzed using SPSS software (version 19).

Results:

Less sexual satisfaction [odds ratio (OR): 0.608, 95% confidence interval (CI): 0.421-0.878] and less orgasm (OR: 0.741, 95% CI: 0.530-0.998) was associated with RVVC. In patients with RVVC, the levels of depression, anxiety and stress were significantly higher compared to those of healthy individuals.

Conclusion:

Depression, anxiety and stress in the past four weeks are related to an increased risk of RVVC. There is an association between depression, anxiety and stress, sexual satisfaction, and orgasm with RVVC. It may be that psychological interventions and sexual counseling can be effective in improving RVVC.

Estimated Burden of Serious Fungal Infections in Ghana

Fungal infections are increasingly becoming common and yet often neglected in developing countries. Information on the burden of these infections is important for improved patient outcomes. The burden of serious fungal infections in Ghana is unknown. We aimed to estimate this burden. Using local, regional, or global data and estimates of population and at-risk groups, deterministic modelling was employed to estimate national incidence or prevalence. Our study revealed that about 4% of Ghanaians suffer from serious fungal infections yearly, with over 35,000 affected by life-threatening invasive fungal infections. Incidence of cryptococcal meningitis, Pneumocystis jirovecii pneumonia, and disseminated histoplasmosis cases in AIDS was estimated at 6275, 12,610 and 724, respectively. Oral and esophageal candidiasis collectively affect 27,100 Ghanaians and 42,653 adult asthmatics are estimated to have fungal asthma. We estimate a prevalence of 12,620 cases of chronic pulmonary aspergillosis (CPA and an incidence of 1254 cases of invasive aspergillosis (IA). Estimated cases of candidemia and candida peritonitis cases were 1446 and 217, respectively. The estimated prevalence of recurrent vulvovaginal candidiasis (RVVC) and tinea capitis was 442,621 and 598,840, respectively. Mucormycosis and fungal keratitis each may affect 58 and 810 Ghanaians. These data highlight the urgent need for intensified awareness to improve diagnosis and management.

The changes of antifungal susceptibilities caused by the phenotypic switching of Candida species in 229 patients with vulvovaginal candidiasis

OBJECTIVE

This study was to investigate the changes of antifungal susceptibilities caused by the phenotypic switching in patients with vulvovaginal candidiasis (VVC).

METHODS

229 women were enrolled in this study. The vaginal smears of these patients were collected and gram stained for fungal microscopic observation. The vaginal discharge of them in cotton swabs was cultured in sabouraud's agar with chloramphenicol medium. After fungal culture, fungal identification was analyzed using CHROM agar Candida chromogenic and identification medium. Then, the in vitro antifungal susceptibility testing was carried out using the standardized CLSI M27-A2 broth microdilution method.

RESULTS

64.63% of Candia species in patients with VVC were Candida albicans and the remainders were non-albicans Candida species. The phenotypic switching was observed in 91.22% of C. albicans infection. In antifungal susceptibility testing, the susceptible rates of C. albicans to voriconazole, fluconazole and itraconazole were significantly higher than that of non-albicans Candida species (P = 0.00, 0.00, 0.00). No matters in patients infected with C. albicans or with non-albicans Candida species, the susceptible rate to fluconazole of the clinical isolates with phenotypic switching was significantly higher than that without phenotypic switching (P = 0.01, 0.01).

CONCLUSIONS

In the study, C. albicans was the commonest pathogenic species in patients with VVC, in which the phenotypic switching was easy to occur. The susceptible rates of C. albicans to all antifungal drugs were higher than that of non-albicans Candida species. The susceptible rate to fluconazole was all influenced by the phenotypic switching in C. albicans and non-albicans Candida species.

Estimated Burden of Serious Fungal Infections in Mozambique

Mozambique is a sub-Saharan African country with limited information on the burden of fungal disease. We estimate the burden of serious fungal infections for the general healthy population and for those at risk, including those infected with HIV, patients with asthma, as well as those under intensive care. We consult the Mozambican National Institute of Statistics Population and Housing Census report to obtain denominators for different age groups. We use modelling and HIV data to estimate the burdens of Pneumocystis jirovecii pneumonia (PCP), Cryptococcal meningitis (CM) and candidiasis. Asthma, chronic obstructive pulmonary disease and tuberculosis data were used to estimate the burden of allergic bronchopulmonary aspergillosis (ABPA) and chronic pulmonary aspergillosis (CPA). In 2016, the Mozambique population was 26.4 million with 1.8 million people reported to be HIV-infected. Estimated annual incidence of fungal infections was: 33,380 PCP, 18,640 CM and 260,025 oral and oesophageal candidiasis cases. Following pulmonary tuberculosis, estimated numbers of people having chronic pulmonary aspergillosis (prevalence) and allergic bronchopulmonary aspergillosis complicating asthma are 18,475 and 15,626, respectively. Tinea capitis is common in children with over 1.1 million probably affected. We also highlight from studies in progress of high incidences of Histoplasmosis, CM and Pneumocystis jirovecii in adult HIV-infected patients. Prospective epidemiology studies with sensitive diagnostics are required to validate these estimates.

Burden of fungal infections in Senegal

Senegal has a high rate of tuberculosis and a low HIV seropositivity rate and aspergilloma, life-threatening fungal infections, dermatophytosis and mycetoma have been reported in this study. All published epidemiology papers reporting fungal infection rates from Senegal were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in each to estimate national incidence or prevalence. The results show that tinea capitis is common being found in 25% of children, ~1.5 million. About 191,000 Senegalese women get recurrent vaginal thrush, ≥4 times annually. We estimate 685 incident cases of chronic pulmonary aspergillosis (CPA) following TB and prevalence of 2160 cases. Asthma prevalence in adults varies from 3.2% to 8.2% (mean 5%); 9976 adults have allergic bronchopulmonary aspergillosis (ABPA) and 13,168 have severe asthma with fungal sensitisation (SAFS). Of the 59,000 estimated HIV-positive patients, 366 develop cryptococcal meningitis; 1149 develop Pneumocystis pneumonia and 1946 develop oesophageal candidiasis, in which oral candidiasis (53%) and dermatophytosis (16%) are common. Since 2008-2010, 113 cases of mycetoma were diagnosed. In conclusion, we estimate that 1,743,507 (12.5%) people in Senegal suffer from a fungal infection, excluding oral candidiasis, fungal keratitis, invasive candidiasis or aspergillosis. Diagnostic and treatment deficiencies should be rectified to allow epidemiological studies.

Estrogen treatment predisposes to severe and persistent vaginal candidiasis in diabetic mice

Background

Increased levels of estrogen and diabetes mellitus separately predispose to vaginal candidiasis (VC). However, the compounding effect of estrogen on the severity and persistence of VC in diabetic females is not clear.

Methods

To address this issue, a diabetic mouse model with estrogen-maintained VC was developed and evaluated for vaginal fungal burden (VFB) and immune competence at different time points throughout the study period.

Results

Blood glucose levels in estrogen-treated diabetic mice were consistently lower than that in untreated counterparts. Estrogen-treated C. albicans-infected non-diabetic mice experienced persistent episodes of VC as compared with naïve controls (P < 0.01). However, severity and persistence of VC in estrogen-treated C. albicans-infected diabetic mice was significantly greater than that in non-diabetic counterparts (P < 0.05). Mortality rates among estrogen-treated C. albicans-infected diabetic mice were significantly higher (P < 0.05) than that in non-diabetic counterparts. Statistically significant (P < 0.05) and persistent suppression of the delayed hypersensitivity response (DTH) was evident in estrogen-treated C. albicans-infected diabetic and non-diabetic mice as compared with controls. Levels of expression of the inhibitory molecule CD152 on vaginal and splenic T cells isolated from estrogen-treated C. albicans infected mice was significantly higher than that in naive untreated controls (P < 0.01).

Conclusions

These findings suggest that estrogen treatment in diabetic females may protect against the progression of DM on the one hand and predispose to severe and persistent VC on the other. The later outcome could be related to the immunosuppressed status of the host.

Ethnicity, family socioeconomic inequalities, and prevalence of vaginal douching among college students: the implication for health

OBJECTIVE

This study assessed the association between ethnicity and family socioeconomic status (SES) as it relates to the prevalence of vaginal douching among female undergraduates in a university community.

PARTICIPANTS AND METHODS

This was a cross-sectional survey conducted between September 2011 and February 2012 among 1,535 female undergraduates using a semistructured behavioral questionnaire adapted by the authors from previous research related to vaginal douching practice.

RESULTS

The overall prevalence of vaginal douching was 79.35% and the practice was significantly associated with the mother's age, ethnicity, low SES (educational level, occupation, and monthly income), and area of residence. The father's age and SES were statistically nonsignificant.

CONCLUSION

Ethnicity and low SES of mothers were significantly associated with a higher prevalence of douching in daughters. These factors should be considered among others in any intervention to discourage vaginal douching among college women.