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Indian Journal of Community Medicine

Prevalence of Reproductive Morbidity amongst Males in an Urban Slum of North India

Author(s): Y Uppal, S Garg, B Mishra, VK Gupta, R Malhotra, MM Singh

Vol. 32, No. 1 (2007-01 - 2007-03)

Abstract

Background: Studies assessing the prevalence of reproductive morbidity among males in India have chiefly focused on prevalence of Reproductive Tract Infections/Sexually Transmitted Infections (RTIs/STIs) among males attending Sexually Transmitted Disease clinics, blood donors and other selected population groups, with only few focused on the magnitude and the type of reproductive morbidity amongst Indian males at community level.
Objective: To estimate prevalence of reproductive morbidity including (RTIs/STIs) among males in the age group of 20-50 years residing in an urban slum of Delhi.
Methods: Out of 268 males in the targeted age group, selected by systematic random sampling, residing in an urban sum of Delhi, 260 males were subjected to clinical examination and laboratory investigations for diagnosis of reproductive morbidity. Laboratory investigations were done for diagnosis of Hepatitis B and C, Syphilis, Gonorrhoea, Non gonococcal urethritis and urinary tract infection.
Results: A total of 90 (33.6%) of 268 study subjects reported one or more perceived symptoms of reproductive tract / sexual morbidity in last six months. Overall reproductive morbidity based on clinical and laboratory diagnosis was present in 76 (29.2%) study subjects and of this sexually acquired morbidity accounted for 21.2% cases. Hepatitis B was most common (10.3%) reproductive morbidity followed by Urinary Tract Infection (5.0%), scabies (3.5%) and congenital anomalies (3.5%).
Conclusion: High prevalence of reproductive morbidity (29.2%) amongst males in an urban slum highlights the need for more studies in different settings. There is a need for developing interventions in terms of early diagnosis and treatment and prevention.

Keywords: Hepatitis B, Hepatitis C, Syphilis, Reproductive health, Gonorrhea, Community

Reproductive tract infections / Sexually transmitted infections (RTIs /STIs) are growing as a major public health problem with the annual world wide incidence estimated to be 340 million cases1. In the current era of HIV/AIDS, both males and females have to be targeted through focused interventions for reducing the burden of RTIs /STIs. The involvement of males becomes even more important considering the gender inequality prevalent in the developing countries. The prevalence of reproductive morbidity among males in India has been a neglected and an unexplored area. Previous Indian studies have chiefly focused on prevalence of Reproductive tract infections / Sexually transmitted infections (RTIs/STIs), among males attending STD clinics2-10 blood donors11,12 and selected population groups like rickshaw pullers13 truck drivers14,15 and prison inmates16. Only few studies have focused on the magnitude and the type of reproductive morbidity amongst Indian males at community level17-19.

Urban slum dwellers are more vulnerable to RTIs/STIs, considering that factors contributing to high STI prevalence rates like rapid influx of population, low economic and sociocultural status, limited education and insufficient health services20 are present in urban slums. Delhi, being the capital of India is a witness to migration of rural population with a large number settling in urban slums with urban slum dwellers constituting around 20 % of Delhi’s population21.

Special emphasis needs to be given to the fringe segment of population in order to control the silent epidemic of RTI/STIs. Against this background, a study was conducted to estimate the prevalence of reproductive morbidity including RTIs/STIs among males in the age group of 20-50 years residing in an urban slum of Delhi.

Material and Methods

The present study was a community based cross sectional study conducted from April 2000 to March 2001 in an urban slum situated in the vicinity of investigating institute, Maulana Azad Medical College (MAMC), New Delhi, India. The study area was chosen as the Department of Community Medicine, MAMC was providing basic health services to the community through a health centre in the slum and for ease of transportation of samples without delay to the microbiology laboratory. The study was conducted after ethical clearance from the protocol committee of Maulana Azad Medical College, New Delhi.

A preliminary demographic survey conducted in March 2000, revealed the total population of the slum to be 3676 residing in 826 hutments. The eligible study population i.e. unmarried and married males between 20-50 years of age, constituted a total of 1092. Based on an initial pilot study done in the study area on 30 individuals in the same age group, prevalence of any reproductive morbidity was estimated to be 28.0%. Based on this prevalence, a sample size of 250 eligible males was established to be adequate, with an allowable error of 20%. To choose the participants, initially every 3rd household was selected by systematic random sampling technique for which numbers allotted to households in the demographic survey were utilized. Then, the male member of the household in the specified age group was enrolled. If more than one male member was present, random sampling by lottery was used to select one of them. If the household did not have any eligible male or was locked on three consecutive visits, the next household was taken. The visit for interviewing the participant was made as per timing convenient to him. On an average 45 minutes were spent on filling of questionnaire for an individual, after establishing rapport with the individual. At all stages of study, privacy and confidentiality was maintained.

The information collected using a pre-tested, pre-coded schedule included socio-demographic characteristics, perceived symptoms of reproductive tract/sexual morbidity in last six months, personal and genital hygiene, care seeking behaviour and contraceptive history.

Following the interview, the study subject was called for a detailed clinical examination, including general, systemic and local genital examination at the health care unit in the slum. Informed consent was obtained prior to examination and sample collection. The examination was done as per standard clinical methodology22 by a investigator who had received prior training in Department of Skin and Venereology, MAMC, Lok Nayak Hospital, New Delhi. Standard diagnostic criteria used for categorizing the clinical entities22.

After clinical examination, 5 ml. of venous blood was collected from all willing study subjects and transported using a plain vial to the laboratory. Serum was separated from samples and stored at –700C till further testing. Serological tests were done for Syphilis [Venereal Disease Research Laboratory (VDRL) test for screening, Treponema Pallidum Haem Agglutinin (TPHA) for confirmation], Hepatitis B (Detection of HbsAg by ELISA) and Hepatitis C (Anti-HCV IgM antibodies by ELISA). Fifteen ml of midstream urine was collected using the clean catch technique in a sterile container from willing study subjects who reported burning micturition at the time of interview. The urine samples were transported to the laboratory on the day of collection for microscopy and culture. Urethral swabs were taken from willing individuals who reported urethral discharge at time of interview. The samples were subjected to wet mount examination for T vaginalis in the peripheral health centre and gram staining and culture in the laboratory. The study subjects were provided with their respective reports and those found suffering from RTIs/STIs were managed as per recommended guidelines22. Patients requiring referrals/expert opinion were referred to the STD clinic run by the Department of Skin and Venereology Lok Nayak Hospital. The data were processed and analyzed in software packages (FOXBASE and EPI-INFO).

Results and Discussion

Out of a total of 275 males contacted, 268 (97.6%) were willing for participation in the study and were interviewed. Maximum i.e., 135 (50.4%) were in the age group 20-24 years and the mean age was 27.8 + 7.3 years. Majority of study subjects were Hindu by religion (58.6%), married (55.6%), literate (70.9%), employed (92.9%) and had migrated from other states to Delhi (52.7%). Only 21.3% of the employed had stable job as a government servant or washerman while 78.7% had unstable occupations like mechanic, autorickshaw driver, rickshaw puller, vendor and casual labourer. Most of the subjects (78.0%) belonged to lower or upper-lower socioeconomic group as per a classification by Gupta and Mahajan based on per capita income (23). Nearly half of the subjects (47.8%) belonged to nuclear and the rest either belonged to joint families (36.9%) or were singletons (15.3%).

Perceived symptoms of reproductive tract / sexual morbidity in study subjects: A total of 90 (33.6%) reported one or more perceived symptom of reproductive tract / sexual morbidity in last six months. The most common was weakness during sexual act (23.9%) followed by burning micturition (10.8%), premature ejaculation (9.3%), itching of private parts (5.9%), scrotal swelling (3.7%), urethral discharge (3.4%), genital ulcer (3.4%) and impotence (3.0%). Similar problems of sexual weakness, itching, burning micturition and wound or sore on penis were reported in a study conducted in slums of Mumbai (18). A study conducted among truck drivers in the central Indian state of Maharashtra reported the symptoms suggestive of STIs among them to be genital sore (25.5%), burning micturition (12.1%), pus discharge (10.0%), itching over genital area (7.6%) and swelling in groin (1.9%) (14). The higher prevalence in truck drivers may be attributed to their high risk sexual habits as evident from other studies (15,24).

Maximum number of individuals (31.1%) who perceived themselves to be suffering from any reproductive morbidity was in the age group of 20-24 years. Different studies conducted in STD clinics have also revealed high prevalence of sexual/reproductive morbidity in younger age groups because of this age group being most sexually active (4,5,9).

Prevalence of reproductive morbidity by clinical examination and laboratory diagnosis: Among the 268 individuals interviewed, 260 (97.0%) subjects underwent clinical examination, as 8 (3.0%) did not give consent. Examination revealed signs suggestive of reproductive morbidity among 41 (15.7%) of these individuals (Table 1). The prevalence of genital ulcer in the present study was observed to be 3.8% which was lower in comparison to the figures of 10.6% and 25.5% observed among truck drivers from South15 and Central14 India respectively. The figure for the same for prison inmates in India has been reported to be 4.6%16. The high risk sexual behaviour of these population groups which may account for the difference observed.

Table 1: Distribution of reproductive morbidity by clinical examination (N= 260*)

Clinical findings** N %
Perineal skin (any lesion) 15 5.7
Scabies 9 3.5
Tinea cruris 4 1.5
Ulcer 2 0.8
Scrotum (any lesion) 15 5.7
Scabies 9 3.5
Hydrocele 5 1.9
Epididimoorchitis 4 1.5
Genital warts 4 1.5
Inguinal hernia 2 0.8
Penis (any lesion) 11 4.2
Herpes genitalis 7 2.
Genital warts 4 1.5
Irretractable prepuce 4 1.5
Condyloma acuminate 1 0.
Chancroid 1 0.3
Congenital anomalies 9 3.5
Congenital phimosis 9 3.
Hypospadiasis 2 0.8
Undescended testis 2 0.8
Urethral discharge 5 1.9
Inguinal lymphadenitis 2 0.8
Any morbidity 41 15.7
*8 of the subjects refused clinical examination.
** Not mutually exclusive.

Blood samples were collected from 260 (97.0%) willing study subjects. The prevalence of Hepatitis B was observed to be 10.4%. Other community based Indian studies by Singh et al25 and Thomas et al19 have reported the prevalence to be 3.4% and 6.0% respectively. These community based studies are not urban slum based, but have included population either from both urban and rural areas19 or all types of localities in urban areas25, which may account for the difference observed.

Prevalence of confirmed Hepatitis C by repeat Elisa (1.2%) in the current study was lower in comparison to prevalence of 5.0% reported among prison inmates from India16. The high risk sexual behaviour among prison inmates and their higher chances of coming in contact with blood or body fluids of victims while committing crimes, may be responsible for the higher prevalence16). The prevalence of Hepaitis C among ever married women aged 15-45 years in a similar setting has been reported to be 2%26.

Prevalence of Syphilis in the current study was 1.5%. Thomas et al19 have reported a prevalence of 0.3% among the general population in south India. Among select population groups a higher prevalence has been reported, being 7.7% amongst rickshaw pullers13, 4.6% amongst prison inmates16 and 13.3%15 and 21.9%14 amongst truck drivers.

Among 18 individuals who reported burning micturition, urinary tract infection (UTI) was detected in 13 (72.2%) of the subjects. Prevalence of phimosis i.e. 3.5% was comparable to the results of a study conducted at Gadchiroli in Maharashtra17 in which a prevalence of 3 % of phimosis was reported.

Urethral swabs were collected from 5 subjects who had urethral discharge. Laboratory tests confirmed two cases of gonorrhoea and only one case each of T. vaginalis infection and Candidiasis. Prevalence of gonorrhoea in the present study was 0.8%, which is lower as compared to a prevalence of 2.2% amongst rickshaw pullers13 and 1.9%15 and 6.7%14 amongst truck drivers, which are select population groups. Community based studies from Bangladesh27 and South India19 report the prevalence to be higher at 1.7% and 3.5% respectively. Prevalence of non gonococcal urethritis in the present study was 1.5%. Data for the same among males at a community level is lacking.

The prevalence of chancroid in present study was 0.38%, which is much lower as compared to studies conducted in STD clinics where higher prevalence ranging from 3.5% to 28% has been observed2-5. Higher prevalence rates of 1.1% and 2.0% have been reported among truck drivers15 and rickshaw pullers13 in India respectively.

In the current study the prevalence of scabies was (3.1%), which was higher in contrast to other studies conducted in different STD clinics, which have found prevalence of scabies between 0.7% to 0.8%6,7. The difference in the present study could be because of overcrowded and unhygienic living conditions in the slums.

Table 2: Prevalence of confirmed reproductive morbidity amongst study subjects (N=260*)

Confirmed reproductive morbidity* N %
Hepatitis B 27 10.3
Urinary tract infection 13 5.0
Congenital anomalies 9 3.5
Scabies 9 3.5
Herpes genitalis 7 2.6
Genital warts 7 2.6
Hydrocoele 5 1.9
Syphilis (VDRL confirmed by TPHA) 4 1.5
Taenia crusis 4 1.5
Infertility** 4 1.5
Epididmoorchitis 4 1.5
Non gonococcal urethritis 3 1.1
Hepatitis C 3 1.1
Gonorrhoea 2 0.8
Inguinal hernia 2 0.8
Chancroid 1 0.3
Condyloma acuminata 1 0.3
* 8 of the subjects had refused clinical and lab examination
** Not mutually exclusive
*** Infertility diagnosis based on earlier investigations as reported by study subjects.

Overall reproductive morbidity based on clinical and laboratory diagnosis was present in 76 (29.2%) study subjects and of this sexually acquired morbidity accounted for 21.2% cases. Hepatitis B was most common (10.3%) reproductive morbidity followed by UTI (5.0%), scabies (3.5%) and congenital anomalies (3.5%) (Table 2). In comparison, a very high prevalence (82.8%) of reproductive morbidity was reported amongst males in a community-based study in Gadchiroli area of Maharashtra. The difference could be due to high prevalence of hydrocoele, infertility and testicular atrophy in that study because of endemicity of filarisis in the region17. However, the prevalence of STDs (20.6%) is comparable with the present study17.

To conclude, an overall prevalence of 29.2% of reproductive morbidity was observed in the present study conducted in amongst males in an urban slum setting. There is paucity of data regarding reproductive morbidity amongst males in the community setting. The findings of the study call for undertaking similar studies in this field and developing appropriate need based interventions.

Acknowledgements

The study was a part of a research study “Socio-epidemiological study of reproductive morbidity amongst males in an urban slum of Delhi” conducted in the Department of Community Medicine, Maulana Azad Medical College (MAMC), New Delhi, India. The study was conducted in collaboration with Departments of Microbiology, GB Pant Hospital and Department of Skin and Venerology, MAMC. Special thanks to Dr SV Singh, Associate Professor, Department of Community Medicine, MAMC and Dr BSN Reddy, Professor, Department of Skin and Venerology, MAMC for their valuable inputs.

References

  1. World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections- overview and estimates. Geneva: World Health Organization, 2001. (WHO/HIV_AIDS/2001.02)
  2. Vora NS, Dove JN, Mukhopadhyay AK et al. A profile of sexually transmitted diseases at Apex ESIS hospital, Ahmedabad. Indian J Sex Transm Dis 1994; 15: 36-8.
  3. Bhargava RK, Gupta BK. Pattern of STD in Jaipur, Rajasthan. Indian J Sex Transm Dis 1983; 4: 23-5.
  4. Bhargava NC, Singh OP, Lal N. Analytical study of 100 cases of veneral diseases. Indian J Dermatol Venereol Leprol 1975; 41: 70-3.
  5. Jaiswal AK, Bhushan B. Pattern of sexually transmitted diseases in North Eastern India. Indian J Sex Transm Dis 1994; 15: 19-20.
  6. Sharma PK. A profile of STD in Port Blair. Indian J Sex Transm Dis 1994; 15: 21-2.
  7. Rajnarayan, Kar HK, Gautam RK et al, Pattern of STD in a major hospital of Delhi. Indian J Sex Transm Dis 1996; 17: 76-8.
  8. Kura MM, Hira S, Kohli M et al. High occurrence of HBV among STD clinic attenders in Bombay, India. Int J STD AIDS 1998; 9: 231-3.
  9. Gupta SK, Jain VK. A profile of STD patients at Rohtak. Indian J Sex Transm Dis 1995; 16: 28-9.
  10. Risbud A, Mehendale S, Basu S et al. Prevalence and incidence of hepatitis B virus infection in STD clinic attendees in Pune, India. Sex Transm Infect 2002; 78: 169-173. #. Irshad M, Singh YN, Acharya SK. HBV status in professional blood donors in North India. Trop Gastroenterol 1992; 13:112.
  11. Roy Choudhary A, Bhattacharya DK et al. Incidence of hepatitis B carriers in Calcutta, West Bengal. JAPI 1989, 37:160.
  12. Jain D. 1993. Doctor of Medicine (MD) dissertation for MD in Preventive and Social Medicine submitted to University of Delhi.
  13. Gawande AV, Vasudeo ND, Zodpey SP et al. Sexually transmitted infections in long distance truck drivers. J Commun Dis 2000; 32: 212-5.
  14. Manjunath JV, Thappa DM, Jaisankar TJ. Sexually transmitted diseases and sexual lifestyles of long distance truck drivers: A clinico-epidemiologic study in South India. Int J STD AIDS 2002; 13: 612-7.
  15. Singh S, Prasad R, Mohanty A. High prevalence of sexually transmitted and blood borne infections amongst the inmates of a district jail in Northern India. Int J STD AIDS 1999; 10: 475-8.
  16. Bang AT, Bang RA, Baitule M et al. High prevalence and wide spectrum of reproductive morbidities in males in Gadchiroli, India. Paper presented in Workshop of SEARO Initiative in Reproductive Health, Pune, 1997.
  17. Verma R, Rangaiyan S, Narbhede M et al. Cultural perception and the categorization of male sexual health problems by practitioners and men in a Mumbai slum populations. Paper presented at the workshop on Reproductive Health, Indian Institute of Health and Family Welfare Hyderabad, February 1998.
  18. Thomas K, Thyagrajan SP, Jeyaseelan L et al. Community prevalence of sexually transmitted diseases and human immunodeficiency virus infection in Tamil Nadu, India: A probability proportional to size cluster survey. Nat Med J Ind 2002; 15: 135-140.
  19. Temmerman M. Sexually transmitted diseases and reproductive health. Sex Transm Dis 1994; 21 (Suppl): S55-8.
  20. Planning department, Government of NCT Delhi. National capital territory of Delhi. Socio economic profile of Delhi 2003- 04.Delhi: Planning Department, Government of NCT of Delhi, Delhi Secretariat 2004:10.
  21. Holmes KK, Mardh PA, Sparling PF, Wiesner PJ eds. Sexually transmitted diseases.3rd Edition. New York: Mc Graw Hill Information Services Company, Health Professionals Division, 1999.
  22. Mahajan BK, Gupta MC. Textbook of Preventive and Social Medicine. New Delhi: Jaypee Brothers, Medical Publishers Private Limited, 1995.
  23. Rao KS, Pilli RD, Rao AS et al. Sexual lifestyle of long distance lorry drivers in India: questionnaire survey. BMJ 1999; 318: 162-3.
  24. Singh J, Bhatia R, Khare S et al. Community studies on prevalence of HBsAg in two urban populations of Southern India. Ind Ped 2000; 37: 149-152.
  25. Garg S, Sharma N, Bhalla P et al. Reproductive morbidity in an Indian urban slum: need for health action. Sex Transm Infect 2002; 78: 68-9.
  26. Sabin KM, Rahman M, Hawkes S et al. Sexually transmitted infections prevalence rates in slum communities of Dhaka, Bangladesh. Int J STD AIDS 2003; 14: 614-621.

(1)Department of Community Medicine, Maulana Azad Medical College, New Delhi-02.
(2)Department of Microbiology, GB Pant Hospital, New Delhi-02.
E-mail: [email protected]
Received: 30.3.06

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