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JANE CHIZOMA NJOKU B.Sc., M EPIDEMIOLOGICAL STUDY OF UROGENITAL SCHISTOSOMIASIS IN APPARENTLY HEALTHY AND HIV- INFECTED FEMALES IN JOS, PLATEAU STATE, NIGERIA JANE CHIZOMA NJOKU B.Sc., M. Sc. (Jos) PGNS/UJ/0098/04 A thesis in the Department of ZOOLOGY, Faculty of Natural Sciences, Submitted to the School of Postgraduate Studies, University of Jos, in partial fulfillment of the requirements for the award of the degree of DOCTOR OF PHILOSOPHY in APPLIED ENTOMOLOGY of the UNIVERSITY OF JOS APRIL, 2014 ii CERTIFICATION This is to certify that the research work for this thesis and the subsequent preparation of this thesis by JANE CHIZOMA NJOKU (PGNS/UJ/0098/04) were carried out under my supervision. ------------------------------------------------------ Student, JANE CHIZOMA NJOKU (PGNS/NJ/0098/04) ------------------------------------------------------ Supervisor, PROFESSOR D.A. DAKUL Department of Zoology Faculty of Natural Sciences University of Jos. ------------------------------------------------------ DR. G.S. MWANSAT (READER) Head, Department of Zoology Faculty of Natural Sciences University of Jos. iii DECLARATION I hereby declare that this work is the product of my own research efforts, undertaken under the supervision of Prof. D.A. Dakul and has not been presented elsewhere for the award of a degree or certificate. All sources have been duly distinguished and appropriately acknowledged. …………………………………. JANE CHIZOMA NJOKU (PGNS/UJ/0098/04) iv ACKNOWLEDGEMENTS I am very grateful to God for His infinite mercy and provisions that have brought this study thus far. This study owes its success to the memory of Late Prof. J.A. Ajayi (my first supervisor); who just passed away, for his fatherly advice, painstaking modifications and corrections, that brought standard to this work. I am indebted to my supervisor Prof. D.A. Dakul for his encouragement, advice, continued corrections and painstaking modifications to this study. I remain indebted to the moral, financial and above all the love my entire family showered on me during this work. My appreciation goes especially to my husband whose criticism encouraged me to pursue all the aspects of this work. My gratitude also goes to the Plateau State Specialist Hospital (PSSH) authority, who granted me the ethical clearance and access to her population of patients, especially HIV-positive persons. My thanks go to Dr. S.L. Pittman (the Consultant Gynecologist, PSSH); Mr. J. Deme, Head, Diagnostics Laboratory, (PSSH) for assisting me in the collection/processing of clinical specimens. My gratitude also goes to Prof. O. Abimiku, Mr. D. Jelpe, Mrs. P. Mangdung, Mrs. R. Amos and other staffs of the Plateau State Institute of Human Virology, for allowing me the use of their laboratory space and facilities. I acknowledge the invaluable contributions and encouragements of Late Prof. M.B. Molta, Prof. C.O. Akueshi and family, Prof. H.B. Mafuyai, Dr. (Mrs.) O.O. Ajayi, Dr. (Mrs.) C.M. Adeyongo, to the Head, Department of Zoology, Dr. (Mrs) G.S. Mwansat and all my lecturers and technical staff, Dr. T.O. Ojobe, Mr. James and Mr. D. Kumbak. To all the collaborating schools: I want to say thank you to the Principals, Staffs and students of Bilroe Primary/Secondary School, Abattoir; Government Secondary School, Abattoir, Abbah Memorial High School, Abattoir and Government Secondary School, Tudun Wada. To all the Heads of the village communities and their subjects who participated in the study, I want to say a big “thank you” for participating in the study and also giving me free access to their homes. My thanks also go to Mr. G. Njoku of the Medical Illustration Unit, JUTH for the use of their expertise in micro and photography. I remain very grateful to you all. v DEDICATION Dedicated to my dear children, especially little Anita Njoku, for their love and care. vi TABLE OF CONTENT TITLE PAGE CERTIFICATION PAGE …………..…………………………… ii DECLARATION PAGE …………….….………………………. iii ACKNOWLEDGEMENTS ……………….…….………………… iv DEDICATION ………………………….…….…………………. v TABLE OF CONTENTS………………….….………………….. vi LIST OF TABLES ………………………….….………………… xi LIST OF FIGURES ……………………….….…………………. xii LIST OF PLATES ……………………………..………………… xiii Abstract …………………………………………..………………. xiv CHAPTER ONE 1 INTRODUCTION 1 1.1 FEMALE UROGENITAL SCHISTOSOMIASIS (FUGS) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV) …..………….. 1 1.2 BACKGROUND AND RATIONAL ………………..…………... 2 1.3 SIGNIFICANCE OF THE STUDY ……………….……………. 5 1.4 HYPOTHESES …………………………………..…….…………… 7 1.5 AIM AND OBJECTIVES…………………………………………… 8 CHAPTER TWO 9 LITERATURE REVIEW 9 2.1 HISTORICAL BACKGROUND ……………………….………… 9 2.2 MORPHOLOGY OF Schistosoma SPECIES ………….…………. 10 2.3 TAXONOMY………………………………………….………….. 13 2.4 LIFE CYCLE …………………………………..……..…………… 16 2.5 DISTRIBUTION ..…………………………………...…………….. 20 2.6 EPIDEMIOLOGY………………………………………………. 21 vii 2.6.1 Environmental Transmission……............................................... 21 2.6.2 Intermediate Hosts and Transmission of Schistosomiasis …….. 22 2.6.3 Human Infection Pattern ………………………………………... 28 2.7 CLINICAL MANIFESTATIONS OF SCHISTOSOMIASIS…... 29 2.8 FEMALE UROGENITAL SCHISTOSOMIASIS ……………... 31 2.9 PATHOGENESIS AND PATHOLOGY ………………………. 32 2.9.1 Definitive Host Response to Schistosoma Infection ………..…… 32 2.9.2 Clinical Manifestation of Female Urogenital Schistosomiasis … 33 2.10 EPIDEMIOLOGY OF FEMALE UROGENITAL SCHISTOSOMIASIS… 34 2.11 DIAGNOSIS ……………………………………………………. 36 2.11.1 Direct Methods …………………………………………………. 37 Urine filtration technique ………………………………………. 37 2.11.2 Indirect Methods ……………………………………………….. 38 Symptoms ……………………………………………………… 38 Clinical examination …………………………………………… 38 Demonstration of eggs in tissue ……………………………….. 38 Indirect disease markers ……………………………………...... 40 Soluble egg antigen ……………………………………………. 40 Circulating adult worm antigen ……………………………… 41 Eosinophil cationic proteins (ECP) …………………………… 42 Ultrasonography ……………………………………………….. 44 2.12 CYTOKINES AND CELL MEDIATED IMMUNITY………… 44 2.13 CD4+ T-LYMPHOCYTE CELLS ……………………………… 45 2.14 IMMUNOEPIDEMIOLOGY OF FEMALE UROGENITAL SCHISTOSOMIASIS …………………………………………... 49 2.15 TREATMENT ………………………………………………….. 51 2.15.1 Chemotherapy…………………………………………………… 51 2.15.2 Surgery …………………………………………………………. 55 2.15.3 Vaccination …………………………………………………….. 55 2.16 CONTROL OF SCHISTOSOMIASIS …………………………. 56 2.17 HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) .............................. 57 2.17.1 Mode of Infection ………………………………………………. 59 2.17.2 Biology …………………………………………………………. 59 2.17.3 Classification …………………………………………………… 59 2.17.4 Burden of HIV Pandemics ……………………………………… 63 2.17.5 Human Immunodeficiency Virus in Nigeria …………………… 64 2.18 HIV/AIDS IN AFRICA ………………………………………… 65 2.18.1 Routes of HIV Transmission …………………………………… 65 viii 2.18.2 Risk Factors for HIV Transmission …………………………….. 66 Heterosexual transmission …………………………………….. 66 Blood transfusion ……………………………………………….. 67 2.19 DIAGNOSIS OF HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME ……………… 68 2.19.1 HIV Screening Assays ………………………………………….. 69 Enzyme linked immunosorbent assay (ELISA) ………………... 69 Simple tests ……………………………………………………... 69 2.19.2 Confirmatory Assays …………………………………………… 69 Western blot analysis …………………………………………… 69 Polymerase chain reaction (PCR) ………………………………. 70 2.20 FEMALE UROGENITAL SCHISTOSOMIASIS AND HIV/AIDS 70 CHAPTER THREE 77 MATERIALS AND METHODS 77 3.1 ETHICAL APPROVAL AND INFORMED CONSENT ……… 77 3.2 DESCRIPTION OF STUDY AREA …………………………… 77 3.3 SOCIOECONOMIC INFORMATION AND ACTIVITIES…… 78 3.4 SELECTION OF STUDY SITES AND STUDY POPULATION 82 3.5 EPIDEMIOLOGICAL STUDY ………………………………... 83 3.5.1 Sampling of Snail Intermediate Host …………………………… 83 3.5.2 Observation of Water Contact Patterns ………………………… 83 3.6 SPECIMEN COLLECTION For PARASITOLOGIC, URINALYSIS AND IMMUNOASSAY STUDIES………………………………... 88 3.6.1 Sample Collection……………………………………………….. 88 3.6.2 Assessment of FUGS Immunopathology Using Cytokines and T Cells. 89 3.6.3 Treatment ………………………………………………………. 89 3.7 LABORATORY STUDIES …………………………………….. 90 3.7.1 Determination of Schistosoma haematobium egg in Subjects by 90 Parasitology…………………………………………………….. 3.7.2 Determination of Schistosoma haematobium egg in Subjects Genitalia 90 Using High Vaginal Swab …………………………… 3.7.3 Screening of Human Sera for HIV Infection …………………… 93 ELISA procedure using capillus ………………………………. 93 3.8 IMMUNODIAGNOSIS OF FEMALE UROGENITAL SCHISTOSOMIASIS ………………………………………….. 94 3.8.1 Laboratory Studies of FUGS Pathology ……………………… 94 3.8.2 Laboratory Studies of Urinary Tract Pathological Indicators ….. 94 ix Urine Reagent Strip Test Procedure ……………………………. 94 3.8.3 Circulating Cathodic Antigen in Urine …………………………. 95 3.8.4 Measurement of Immunological Markers of FUGS ……………. 96 Estimation of Levels of Inflammatory Cytokine: Interferon gamma (IFN-γ), tumor necrosis factor(TNF-α) and IL-4 in Study Population 96 Enzyme immunoassay (EIA) for interferon gamma (IFN-γ) ….. 97 Enzyme immunoassay (EIA) for TNF-α in the study population 101 Estimation of levels of Interleukin-4 in the study population …. 102 3.9 CD4 COUNT DETERMINATION …………………………….. 102 3.10 STATISTICAL ANALYSIS ………………………..…………... 103 CHAPTER FOUR 104 RESULTS 4.1 PREVALENCE OF UROGENITAL SCHISTOSOMIASIS.......... 104 4.2 DISTRIBUTION OF SNAIL HOST SPECIES IN THE STUDY AREA …………………………………………………………... 114 4.3 DISTRIBUTION OF RISK ACTIVITIES IN THE STUDY COMMUNITIES……………………………………………….. 121 4.4 SEROPREVALENCE OF HIV IN THE STUDY COMMUNITIES… 125 4.5 PREVALENCE OF URINARY SCHISTOSOMIASIS AND HIV CO- INFECTION IN THE STUDY COMMUNITIES……. 128 4.6 PATHOLOGICAL MARKERS
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