Abstract

Toxoplasmosis is a disease caused by an intracellular obligate parasite called Toxoplasma gondii which is usually asymptomatic in healthy people but devastating in people with depressed immunity like HIV/AIDS patients and pregnant women. It mostly affects the Central Nervous System (CNS), inflicting extensive damage on the host.

About 6 billion people are infected with T. gondii worldwide. The main aim of this study was to assess the knowledge and practice of HIV/AIDS adult patients, on the predisposing factors in the transmission of toxoplasmosis in the Tiko Health District.

This was a Cross-Sectional study carried out in 2 HIV/AIDS treatment centers (TDH and TCC). An exhaustive sampling technique was used to collect data and 384 respondents who reported at the treatment centers were sampled. A questionnaire divided into 3 sections; socio-demographic, knowledge, and practice with close-ended and open-ended questions.

A team of 4 were trained to assist in data collection. Statistical tests were used to establish associations between knowledge and practice. Females dominated the study (69%, 265). Participants were graded into 3 levels; low knowledge, average knowledge, and high knowledge and good and poor practices respectively using a cut-off-point. 57.5% of respondents recorded high knowledge and 57.6% poor practice.

There existed a significant association (P<0.05) between the level of education attained by the respondents and their knowledge and practice. Respondents with tertiary education recorded best level of knowledge and practice, compared to those with primary education. Respondents who usually receive lecture on the prevention of toxoplasmosis during their control treatment recorded a high level of knowledge irrespective of their level of education compared to those who had never received lectures (P<0.05).

Most of the respondents had high knowledge about the transmission of toxoplasmosis but poor practice in prevention Toxoplasma infection. Health Education should be carried to educate the public on the transmission of Toxoplasma.

CHAPTER ONE

INTRODUCTION AND LITERATURE REVIEW

1.1 Introduction

Toxoplasmosis is caused by an obligate intracellular protozoan (parasite) called Toxoplasma gondii, a food and waterborne opportunistic pathogen. According to the Center for Disease Control and Prevention (CDC, 2004), the prevalence of T. gondii is about 95% in some communities or countries, but this is generally asymptomatic in people with stable immune systems.

Toxoplasma gondii was first discovered in 1908, by Nicolle, Manceaux and Splendore but was only known to affect humans in 1939 when it was discovered in the tissues of a congenital child, and subsequently, the felines (Felidae) were found to be its definitive host.

Worldwide, 30% of the world’s population have antibodies to the intracellular protozoan parasite Toxoplasma gondii and about 36·7 million people are infected with HIV, but little is known about the prevalence of co-infection with T gondii and HIV (Anuradha, 2017). Toxoplasmosis is one of the main opportunistic diseases affecting millions of people with HIV/AIDS across the world, especially when the CD4 count of the patients is less than 200 cells

/mm³. Toxoplasmosis also manifests itself in people with compromised immunity.

Nearly 30 years after the advent of HIV and ART, Central nervous system (CNS) opportunistic infections remain a major cause of morbidity and mortality in HIV positive individuals (Bowen et al., 2016). Toxoplasma gondii exists in three forms namely; tachyzoites, brandyzoites (tissue cyst), and oocysts (containing sporozoites).

One of the most outstanding effect of toxoplasmosis in immune-compromised patients is toxoplasmic encephalitis (TE) (Luma et al., 2013), found to occur in about 3% – 97% of AIDS patients. Central Nervous system symptoms such as meningitis, psychosis, and dementia also occur.

Toxoplasmic encephalitis is implicated in high mortality rate among AIDS patients. However, anti-Toxoplasma therapy and chemoprophylaxis have shown effectiveness in reducing the incidence of TE (Kagulire et al., 2007).

Non- compliance has been identified as a cause of relapse in these health conditions. Some economics and risk behaviour factors influence the spread of T. gondii (Karim, 2015). They are demographic, health, and economic factors.

Toxoplasma gondii is a water and foodborne pathogen. According to Furtado et al., (2011), infected individuals may present with the following signs and symptoms; myalgia, sore throat, fever, maculopapular rash, polymyositis and myocarditis.

Assessing the knowledge and practice of the study participants on predisposing factors in the transmission of Toxoplasma infection would help to identify lapses in knowledge and practices for subsequent improvements through health talks and other means for better patient care and control of the spread of the disease.

1.2 Literature Review

Toxoplasmosis is a disease caused by an intracellular zoonotic obligate parasite (protozoan) called Toxoplasma gondii which is very devastating in people with immune-incompetence. T. gondii is bullet shaped with a pointed apical end.

According to Wam et al. (2016), studies in toxoplasmosis have been limited only to  urban areas in Cameroon. For example the seroprevalence of T. gondii was shown to be 69.9% among HIV/AIDS patients in the Yaoundé Teaching Hospital (Njunda et al., 2011), and 70% in pregnant women who consulted at the Douala General Hospital, Cameroon. Luma et al., (2013), reported a 14.4% prevalence of TE in a hospital based study involving 672 adult HIV/AIDS patients admitted in the Douala General Hospital, Cameroon.

The patients in the study had a median CD4 cell count 68/mm3 with a very high fatality rate. A similar study in Njinikom (North West Region of Cameroon)  focused of women attending ANC and  reported a  54.5% (97/178) seroprevalence  of  IgG and IgM antibodies (Wam et al., 2016). The titres were higher in  HIV/AIDS  infected women than in seronegative ones. In the same study toxoplasmosis was one of the main causes of stillbirths, abortions or congenital defects in pregnancy.

These latter finding corroborated those Njunda et al., (2011), who worked with pregnant women attending ANC at the Yaounde Teaching Hospital where, 65.5%, 60.6% and 50.0% of  the 110 were seropositive for IgG antibodies during the 1st, 2nd trimester, and 3rd trimesters, respectively. In Yaounde, meat consumption, potable water sources, cat ownership, and age were identified as some of the predisposing factors for T. gondii which was highest during the 1st trimester of pregnancy.

The  seroprevalence  among ANC women in Limbe, S. W. Cameroon, was 71.8%. The consumption of raw or undercooked meat, vegetables and untreated water were  the  main  risk  factors associated with toxoplasmosis in pregnant women (Unpublished data).

Nissapatorn, (2009), reported that the onset of toxoplasmosis was usually sub-acute with focal neurologic signs frequently accompanied by fever, altered mental state and headache.

Also Cerebellar, subcortical, or cortical lesions could be present in over 50% of the infected cases resulting in the hemisparesis, ambulatory, and gait significant proportion of neuropsychiatric patients can also present with neuropsychiatric disorders including psychosis, dementia, anxiety, and personality disorder. Mohamed, (2015), supported that risk behaviour could only increase the probability of contracting Toxoplasma.

The prevalence of Toxoplasma infection varies depending on the geographical area and population group and also with the age. The increase in prevalence of toxoplasmosis with age might have been due to the increased risk exposure to the risk factors (Anuradha, 2016).

1.2.1 Life Cycle of Toxoplasma gondii

The life cycle of Toxoplasma gondii is shown on Figure 2. It has two main phases, namely, the sexual and the asexual phase. Each of these require a specific host to complete its specific stages. The sexual phase of the life cycle occurs in felines only (wild or domesticated), while the asexual phase takes place in any of the prospective warm-blooded animals including humans.

Sexual Phase: The sexual phase starts with the ingestion of tissue cysts by cats, probably after eating an infected rodent. The cysts get to the stomach and intestines where they reside in the epithelial cells of the small intestinal lining. They then undergo meiotic divisions, resulting in the production of micro-(male) and macro- (female) gametocytes.

Fertilized macro-gametes develop into oocysts which are discharged into the gut lumen and excreted within 3 – 10 days after ingestion of the tissue cyst. After primary infection, cats shed millions of oocysts in their feces for about 1 – 3 weeks.

The oocysts take 1 – 5 days to sporulate. Oocytes are the infective forms. These oocysts can survive in the environment for more than one year. During this period, they can be ingested by an intermediate host.

1.3 Statement of the Problem

Toxoplasmosis poses a big problem in HIV/AIDS patients and people with depressed immune systems. Toxoplasmosis is 1 of the 5 neglected parasitic infections, (NPIs) which is the most devastating disease among HIV/AIDS patients. World Health Ranking (2014), classified HIV/AIDS related illnesses as the first killer in Cameroon with 32,061 (14.80%) of total death yearly among which toxoplasmosis was one of them.

Human activities and life styles expose many, especially those with depressed immune systems to risk of contracting T. gondii infection. Toxoplasmosis being a food and waterborne disease is mostly transmitted into human through oral route.

Climate change plays a vital role for the survival of this pathogen as the cysts are capable of surviving for more than a year during unfavourable conditions enabling the T. gondii to reach it host. It is transmitted to human through; contaminated water and food, raw or undercooked meat, unwashed vegetables or fruits, unwashed hands, infected organ transplant, contaminated blood transfusion, and vertical transmission.

Cultural factors and beliefs are some of the catalysts for the transmission of Toxoplasma infection like; eating with unwashed hands after working in the farm because “if you wash your hands, you would wash all the seeds away”, “dirty water no di kill black man”. Keeping domestics cats around and feeding with raw meat and rats can only predispose one to Toxoplasma infection.

Although billions of people are infected with T. gondii, those with depressed immune systems like HIV/AIDS patients carry the greatest burden with very high Disability Adjusted Life Years (DALYs) (Simon et al. 2013).

Toxoplasmosis causes the following problems in HIV/AIDS patients; chororeioretinitis, scotoma, sore throat, fever, maculopapular rash, polymyositis, myocardiatis, seizures, epilepsy, cerebella dysfunction, meningitis, death (Muluye et al., 2013, and Namme et al., 2013). Vertical transmission in HIV/AIDS infected pregnant women may cause the new born with the retinochoroiditis, hydrocephalus, stillbirth, abortion, mental retardation (Njunda et al., 2011), and epilepsy with attributed burden approximately 620 DALYs annually and fetal loss in Netherland, (Furtado et al., 2011).

According to Wang et al., (2017), HIV/Toxoplasma co-infection varies and low income countries are the most hit. During the last community internship in THD, we realized that, some patients with HIV/AIDS do develop mental complications that make it difficult for them to comply with follow-up treatment.

We also realized that, patients diagnosed with HIV were not screened for T. gondii. The few patients we met during this internship said, they were victims of witchcraft and not a disease. For this reason, we decided to investigate the knowledge, and practice of HIV/AIDS infected persons on the Predisposing factors involved in the transmission of Toxoplasma infection.

1.4 Rationale

Many studies have been carried out on toxoplasmosis in HIV/AIDS infected persons, and in pregnant women, but toxoplasmosis remains one of the most common and devastating opportunistic infection in people with HIV/AIDS, especially those who do not know their HIV status and those who do not comply with the Antiretroviral Therapy (ART). Most of the studies have been concentrated only in the laboratory to know the seroprevalence, with very little on knowledge and practice.

Patients diagnosed with HIV were not screened for T. gondii, nor educated on the prevention of toxoplasmosis. As such, HIV patients may be predispose to Toxoplasma infection. The aim of this work was to create awareness for proper intervention against toxoplasmosis through the various prevention methods.

1.5 Research Questions

1. What is the level of knowledge of the respondents of the predisposing factors for the transmission of Toxoplasma infection?
2. What are the Practices of the respondents on reducing the risks of Toxoplasma infection?
3. Is there an association between determinants and the knowledge, and practice of respondents on the predisposing factors in the transmission of Toxoplasma infection?

1.6 Hypothesis:

There would be no association between the knowledge and practice of the respondents vis-à-vis Toxoplasma infection, irrespective of the level of knowledge and practices applied.

1.7 Objectives

1.7.1 General Objective;

To assess the knowledge, and practice of HIV/AIDS adult patients on the predisposing factors in the transmission of Toxoplasma infection in Tiko Health District, SW Cameroon.

1.7.2 Specific Objectives;

1. To assess the knowledge of the respondents on the predisposing factors in the transmission of Toxoplasma infection.
2. To assess the Practice of the respondents in the predisposing factors in the transmission of Toxoplasma infection.
3. To find out the association between and the knowledge, and practice of respondents on the predisposing factors in the transmission of Toxoplasma infection.