Cervical precancerous changes and selected cervical microbial infections, Kiambu County, Kenya, 2014: a cross sectional study

Cervical cancer is a leading cause of morbidity and mortality among women of the reproductive age especially in low resource limited countries. Widespread screening programs, a catalyst for early detection and management of cervical precancerous changes, significantly reduce cervical cancer incidence [1]. However, these screening programs are limited in Africa and cervical precancerous changes data is scarce [2]. In Kenya, cervical cancer is the leading cancer among women in the reproductive age group [3] nevertheless the screening coverage is at 3.2% [4]. An estimated 4802 women are diagnosed with cervical cancer annually of which 51% (2451) die from the disease [3]. On the other hand, cervical microbial infections have not been quantified.

The recommended cervical cancer screening age is from 25 years and re-screening period is every 5 years except for at risk population [5]. However, cervical screening is mainly conducted in private health facilities which are out of reach to many women in this resource limited setting. We determined the prevalence of cervical precancerous changes and selected cervical microbial infections among women attending FHOK Clinic in Thika for Pap smear testing.

We observed two levels of cervical precancerous changes; CIN I and CIN II. Cervical intraepithelial neoplasia I (mild dysplasia) was the major dysplasia (83%) observed among the study participants during the study period. Candida and T. vaginalis were identified as cause of cervical inflammation among the study participants.

This study reported a low prevalence of cervical cell abnormalities (4.9%); 83.3% (10) Low-grade cervical lesions and 16.7% (2) high-grade cervical lesions. The results are comparable to a study done at an outpatient reproductive health clinic in Pakistan whereby 4.6% (32) cases had dysplastic changes of which 56.25% (18) were LSIL and 43.75% (14) HSIL [9]. Similar frequency of dysplastic smears were reported by Inamullah et al. [10]; 5% dysplasia of which 75% (6) were LSIL and 25% (2) HSIL, in a study done in Pakistan among women presenting with chronic discharge. Additionally, a study in women seeking care at a reproductive health clinic in Pakistan from February 2009 to February 2010, revealed dysplasia frequency of 3.7% (10 cases) of which 80% (8) had LSIL while 20% (2) HSIL [11]. These precancerous changes were detected among women on routine screening within age 34–60 years. This is important in Kenya; a country where 60% of cancer victims are below 70 years and 70–80% of the diagnose happening in late stages owing to lack of awareness, inadequate diagnostic facilities, lack of treatment facilities, inadequate personnel to manage invasive stages, high cost of treatment and high poverty Index [5, 12].

More than half (55%) of the study participant were having their first ever Pap smear screening of which 36% were 31–40 years. This falls within the reproductive age where most of the screening interventions should be done. The Centers for Disease Control and Prevention (CDC) epidemiological study found that 78% of the cervical cancer cases were diagnosed in women 30–39 years [13]. It is therefore not surprising that in Africa, where screening rates are low or non-existent, majority of women present with advanced disease. A study done by Sheikh and Manhua [14] in Saudi Arabia from January 2009 to January 2011 reported 83% (1224) of study participants had never been screened with Pap smear which was higher compared to our findings. In the current study, low uptake of Pap smear screening may be due to lack of awareness and/or shying away due to the invasive nature of Pap smear sample collection procedure. This illustrates that Pap smear screening programs need to be scaled up to reach more women and attain higher screening rates.

According to Burkadze and Gulisa [15], three out of four women who develop cervical cancer each year have never had a Pap smear or had not had one within the recommended intervals. Four cases (2.98%) of CIN I in this study had never had a Pap smear test before although not having a previous Pap smear test was not significantly associated with cervical precancerous changes in our study. Sheikh and Manhua [14] reported similar rates of cervical abnormalities among participants who were having Pap smear screening for the first time in Saudi Arabia, 2.91% (43). This suggests that earlier Pap smears screening would have meant earlier detection leading to an increased rate of recession and hence low mortality. Countries, such as Taiwan, with widespread organized screening programmes for cervical cancer, have substantially reduced cervical cancer incidence and mortality by 60–90% as well as increased survival rates [16‐18]. Unfortunately in resource-limited countries, where Pap screening has not been effectively implemented, cervical cancer remains a major public health problem [19].

High prevalence of inflammatory changes (97.5%) was reported in this study. Cervical microbial infections accounted for 32.8% of the inflammation cases. These results contradict previous findings by a study at National Institute of Health, Islamabad in Pakistan where lower prevalence of inflammatory changes (55.31%) was reported [20]. Similarly, Rubia and Huma [11] found 55.7% (156) frequency of inflammation and 55% (88) was documented in another study by Inamullah et al. [10]. This higher prevalence of inflammatory changes among women with high literacy level and majority working women could be due to improved health seeking behaviour due to women empowerment.

Vaginal infections are common cause of inflammation of the genital tract in all women; some are associated with sexual activity while others, such as vaginal candidiasis, are not. In this study, Candida (25.4%) and Trichomonas vaginalis (7.4%) were the specific causes of inflammation identified in the High Vaginal Swab wet preparation. Differing findings have been documented in other studies. Bhojani and Garg [21] reported 0.5% prevalence of both Candida and Trichomonas vaginalis while Claeys et al. [22] reported a prevalence of 19.1% for Candida and 10.1% for Trichomonas vaginalis. Candida was the predominant (25.4%) specific cause of inflammation. This could be due to the fact that vaginal Candida species are emerging as significant opportunistic organisms that have increased over the past few decades attributed to both inappropriate use of antibiotics, increased use of hormonal contraceptives and the increasing population of immune-compromised individuals.

Detection of Trichomonas vaginalis, a sexually transmitted micro-organism, was suggestive of existence of potential for HIV transmission and the probable explanation would be due to low utilization of barrier method of contraception such as condom, which would provide protection from sexually transmitted diseases as well as cervical cancer. Actinomyces infection is usually detected in IUCD users. The infection was not reported in even among the IUCD users. This can be attributed to the fact that all IUCD users had a history of a previous Pap tests and therefore might have been treated previously. However, inflammation characterized by presence of polymorphonuclear cells (granulocytes) was evident in 26 (44.8%) of the IUCD users through Pap smear examination and with a significant statistical association (OR 2.47 at 95% C.I.). Studies in other parts of the world revealed similar association between vaginitis, and use of IUCDs. Sieber and Dietz [23] and Amsel et al., [24] found a strong association of nonspecific vaginitis with the use of IUCDs. This could be related to the insertion method and technique leading to introduction of bacteria into the uterine cavity or the IUCDs mobilizing polymorphonuclear leucocytes since it is a foreign body. Women using IUCDs requires a regular follow up and clinical examination.

Low prevalence of cervical precancerous changes and high prevalence of cervical microbial infection was reported. Majority of the participants were having Pap smear screening for the first time with the most un-screened persons falling within 21–40 years. Yeast cell was the predominant microbial organism detected with most causes of inflammation remaining non-specific.