Prevalence of trichomoniasis infection among adults in Nigerian community settings

Abstract

Background:

Trichomonas vaginalis (TV) is a sexually transmitted pathogen. The study was conducted to determine its prevalence among 300 adult patients in 4 public health facilities in the Nsukka District of Enugu State, Nigeria.

Method:

The researchers collected high vagina swabs and urine samples were collected from 150 men and 150 women, respectively. The specimens were scrutinized for color, odor of discharge and urine, and motile trichomoniasis.

Results:

The prevalence of the TV was 45.0% (135/300) with women showing the highest prevalence (63.7%). Among the patients attending the University of Nigeria, Nsukka Medical Center, the prevalence was the highest at 31.9%. TV infection was more common among older adults aged 38 to 47 years (39.3%), married adults (76.3%), and those with secondary education (68.9%). Urogenital analysis reported that males with pains during urination were 51.0% and males with penile tingling were 12.2%. The highest vaginal Hydrogen ion concentration level of 6.8 was observed in women aged 38 to 47 years. Additionally, the results reported that Vaginal candidiasis, Bacterial vaginosis, and Herpes simplex virus type 2 antibodies were not independently associated with TV infection. In the unadjusted analysis, the odds of TV infection were higher in men (8.1), while Chlamydia trachomatis infection was higher in women (8.8). Among the adults diagnosed with herpes simplex virus type 2 antibodies, the odds of TV infection were 3.9 for both men and women. Men with penile human papillomavirus infection had lower odds of TV infection (1.9), while women with vaginal human papillomavirus infection had higher odds of TV infection (2.2).

Conclusion:

The prevalence of TV infection is high among sexually active adults in the Nigerian community. It is therefore crucial to implement the increased public health actions such as regular and early diagnosis to reduce its prevalence.

1. Introduction

Trichomoniasis is a sexually transmitted infection (STI) caused by the parasitic protozoan, Trichomonas vaginalis (TV).^[1,2] It is the most prevalent STI,^[3] with approximately 50% to 70% of the infections being symptomatic or asymptomatic.^[4–6] In men, TV infection is linked to balanoposthitis and epididymitis,^[7,8] while in women, it is linked to pelvic inflammatory disease, infertility, cervical neoplasia, and perinatal morbidity.^[8–12] The primary mode of transmission is through sexual contact, especially with multiple partners.^[13] Infected women may experience vaginitis, urethritis, and cervicitis. There are potential adverse outcomes such as preterm delivery, infertility, premature rupture of membranes, low-birth-weight, herpes simplex virus and human papillomavirus (HPV) infections, and cervical cancer.^[14–16] TV infection has also been linked to an increased risk of human immunodeficiency virus (HIV) transmission.^[17] the increased prevalence of TV infection poses a significant burden on communities leading to decreased capacities, higher morbidity and mortality rates, and economic setbacks.^[18,19] Therefore, early detection and treatment of trichomoniasis are crucial.^[1]

The most common method of diagnosing TV infection is the examination of vaginal discharge in women and urethra fluid in men.^[13] In women, evaluating hydrogen ion concentration (pH) level using pH paper is a common technique to differentiate TV from yeast infections. A vaginal pH of 4.5 or lower is not affected by yeast, whereas a pH of 6 or higher indicates TV infection.^[20] Therefore, it is recommended that all sex partners be treated simultaneously, and sexual intercourse should be avoided until the symptoms have disappeared.^[21] Despite the higher prevalence and severity of TV infection, the public health response has been inadequate,^[22] and TV infection has been regarded as a “neglected” STI.^[23] In addition, the asymptomatic nature of the infection and nonavailability of baseline data in many Nigerian communities, particularly in Enugu State, necessitate the assessment of the TV prevalence among adults in the study region.

Studies conducted in India reported TV infection rates ranging from 1.2% to 28.5% among obstetrics and gynecology clinic visitors, STI clinic attendees, commercial sex workers, and community-based populations.^[24–27] Among men attending sexually transmitted disease (STD) clinics, the incidence of TV varied from 2.8% to 17.0%, with highest prevalence observed among adults above 40 years of age.^[28–31] In fact, TV prevalence can reach as high as 73% among male partners of women diagnosed with vaginal trichomoniasis.^[1,32] Research suggests that risk factors for TV infection include multiple sexual partners, concurrent STI infections, low educational attainment, and advanced age.^[33,34] A study conducted in Oru-East Local Government Area of Imo State, Nigeria found TV infection in 29 out of 100 men (29%) and 81 out of 100 women (81%) who visited public health services.^[13]

2. Methods

From November 2021 to March 2022, a total of 300 registered adult patients from the 4 public health facilities in Nsukka District of Enugu State were recruited for the study. Nsukka District is 1 of 3 districts in Enugu State, Nigeria (see Figure 1). The participating health facilities included Nsukka Health Center, General Hospital Nsukka, University of Nigeria, Nsukka Medical Center (UNNMC), and University of Nigeria Teaching Hospital Comprehensive Health Center, Obukpa-Nsukka. Approval to conduct the study was obtained from the chief medical directors of these facilities. The recruited participants by the researchers were required to meet specific inclusion criteria related to high-perceived stress, severe anxiety, and depression symptoms. Adult patients who did not meet these criteria were excluded from the study. Ultimately, 135 adults who tested positive for TV infection were recruited as study participants.

Figure 1.

Map of Enugu State, Nigeria showing Nsukka as one the three Districts.

The diagnostic testing was conducted at the laboratories of UNNMC and General Hospital Nsukka. Urine samples were collected from male patients using sterile sample bottles, while high vaginal swabs were collected from female patients using sterilized cotton swab sticks and speculum in an aseptic manner. The high vaginal swabs were screened for color, and odor, and the pH levels of the vaginal discharge were determined using pH paper strips. Within 5 minutes of collection, saline wet mount preparations of vaginal secretions were microscopically scrutinized in the clinic for the presence of yeast cells, motile trichomoniasis, and clue cells. Vaginal secretion samples were cultured and monitored daily for 5 days using the InPouch TV culture kit (Biomed Diagnostic, White City, OR) to detect the presence of trichomoniasis and Vaginal candidiasis (VC). Trained technicians examined gram-stained vaginal smears using the Nugent score to identify Bacterial vaginosis (BV). Herpes simplex virus type 2 (HSV-2) antibodies were screened using an IgG type-specific enzyme-linked immunosorbent assay according to the manufacturer’s instructions (Focus Technologies, Cypress, CA).^[35]

The collated data were entered into Microsoft excel and analyzed using simple percentages, Pearson chi-square test, and Stata 9.0 (Stata Corporation, College Station, TX). TV prevalence and corresponding 95% confidence intervals (CI) were calculated. TV infection was defined based on positive wet mount microscopy results and/or a positive TV culture. A self-administered questionnaire was used to assess demographic variables and trichomoniasis urogenital symptoms. Descriptive analyses were conducted for categorical variables using Pearson Chi-square or Fisher-exact test (GraphPad Instat of GraphPad Software, USA). A P value < .05 was considered statistically significant. The categorical variables of age range, marital status and educational attainment were examined to determine their association with TV infection.

Binary variables such as VC, HSV-2 antibodies, and HPV were diagnosed in the laboratory. BV was assessed using Nugent scores, where scores of 0 to 4 were considered negative, and scores of 5 to 10 were considered positive. Adjusted and unadjusted odds ratios with corresponding 95% CI were calculated to determine the association between TV infection and preselected variables using logistic regression. A multivariable logistic regression model was used to identify significant risk factors associated with TV infection and the preselected variables.

3. Results

The study aimed to determine the prevalence of TV among adults attending public health clinics in the Nsukka District of Enugu State. Out of 300 adults screened, the highest incidence of TV infection was observed among 53 adults aged 38 to 47 years (39.3%), while the lowest incidence was on only 1 adult aged 18 to 27 years (0.7%) (Table 1). Married adults had the highest prevalence of TV infection (76.3%), whereas divorcees had the lowest prevalence (1.5%) (Table 1). Regarding educational attainment, adults with a secondary education qualification had the highest TV infection rate (68.9%), while those that had never attended formal education had the lowest rate (0.7%) (Table 1).

Table 1.

Analysis of Trichomonas vaginalis infection status based on the sociodemographic characteristics (n = 300).

Factors	Number of patients examined	Male		Female
		Number examined	TV prevalence (%)	Number examined	TV prevalence (%)
Age range (yr)
18–27	34	12	0 (0.0)	22	1 (0.7)
28–37	31	14	0 (0.0)	17	7 (5.2)
38–47	72	33	21 (15.6)	39	32 (23.7)
48–57	42	27	13 (9.6)	15	12 (8.9)
58–67	54	26	8 (5.9)	28	21 (15.6)
68–77	32	17	6 (4.4)	15	5 (3.7)
78 and above	35	21	1 (0.7)	14	8 (5.9)
Total	300	150	49 (36.3)	150	86 (63.7)
Marital status
Single	73	32	12 (8.9)	41	13 (9.6)
Married	201	99	34 (25.2)	102	69 (51.1)
Divorced	2	0	0 (0.0)	2	2 (1.5)
Widowed	24	19	3 (2.2)	5	2 (1.5)
Total	300	150	49 (36.3)	150	86 (63.7)
Educational attainment
None	3	2	1 (0.7)	1	0 (0.0)
Primary	47	17	5 (3.7)	30	11 (8.2)
Secondary	195	111	41 (30.4)	84	52 (38.5)
Tertiary	55	20	2 (1.5)	35	23 (17.0)
Total	300	150	49 (36.3)	150	86 (63.7)

TV = trichomonas vaginalis.

Urogenital symptom examination of TV-infected male patients showed that 12.2% experienced penile tingling, while 51.0% experienced pains during urination (Table 2).

Table 2.

Analysis of urogenital symptoms of trichomonas vaginalis-infected male patients in the study area (n = 150).

Urogenital symptoms	Number of patients infected	TV prevalence (%)
None	18	36.7
Penile discharge	0	0.0
Penile tingling	6	12.2
Pain during urination	25	51.0
Lower abdominal pain	0	0.0
Total	49	100

TV = trichomonas vaginalis.

Analysis of vaginal pH levels showed that adults aged 38 to 47 years had the highest pH value of 6.8, while adults aged 28 to 37 years had the lowest pH value of 4.7 (Table 3).

Table 3.

pH value of trichomonas vaginalis-infected female patients through vagina discharge in the study area (n = 150).

Age range (yr)	Number of patients examined	Number of patients infected (%)	pH value
18–27	22	1 (4.6)	5.0
28–37	17	7 (41.2)	4.7
38–47	39	32 (82.5)	6.8
48–57	15	12 (80.0)	5.2
58–67	28	21 (75.0)	5.9
68–77	15	5 (33.3)	4.8
78 and above	14	8 (57.1)	5.1

pH = hydrogen ion concentration.

The results further showed that TV infection was more prevalent among older women aged 38 to 78 years (70.3% vs 27.6%; P < .01), married women (67.7% vs 35.4%; P < .004), and women with lower levels of education (65.7% vs 54.8%; P < .9). Women with TV infection also exhibited concurrent VC (37.8% vs 65.7%; P < .007), BV (39.3% vs 7.5%; P < .001), and HSV-2 antibodies (28.6% vs 62.0%; P < .0001) (Table 4).

Table 4.

Sociodemographic characteristics associated with trichomonas vaginalis infections among female patients in the study area (n = 150)

Characteristic	Number of patients examined	Number of patients infected (%)	P value
Age categories			.01
18–27	22	1 (4.6)
28–37	17	7 (41.2)
38–47	39	32 (82.5)
48–57	15	12 (80.0)
58–67	28	21 (75.0)
68–77	15	5 (33.3)
78 and above	14	8 (57.1)
Marital status			.004
Single	41	13 (31.7)
Married	102	69 (67.7)
Divorced	2	2 (100.0)
Widowed	5	2 (40.0)
Educational attainment			.9
None	1	0 (0.0)
Primary	30	11 (36.7)
Secondary	84	52 (61.9)
Tertiary	35	23 (65.7)
Vaginal candidiasis			.007
Present	45	17 (37.8)
Absent	105	69 (65.7)
Bacterial vaginosisa			.001
Positive (n.s. 5–10)	56	22 (39.3)
Negative (n.s. 0–4)	94	7 (7.5)
HSV-2 antibodies*			.0001
Present	21	6 (28.6)
Absent	129	80 (62.0)

^*Denominators differ because of missing data.

HSV-2 = herpes simplex virus type 2.

In terms of odds ratio, men had unadjusted odds ratios of 8.1 (95% CI: 4.1, 15.9) for TV infection and 4.1 (95% CI: 1.6, 10.6) for Chlamydia trachomatis (CT) infection. Men with HSV-2 antibodies had unadjusted odds ratios of 3.9 (95% CI: 2.4, 5.8) for TV infection, while those with penile HPV infection had unadjusted odds ratios of 1.9 (95% CI: 1.5, 2.3) for TV infection (Table 5). Similarly, women had unadjusted odds ratios of 3.2 (95% CI: 1.4, 7.5) for TV infection, and 8.8 (95% CI: 4.7, 16.8) for CT infection. Women with HSV-2 antibodies had unadjusted odds ratios of 3.9 (95% CI: 2.2, 6.7) for TV infection, while those with vaginal HPV infection had unadjusted odds ratios of 2.2 (95% CI: 1.4, 3.5) for TV infection (Table 5). Notably, the diagnoses of concurrent TV infection in men were independently associated with increased unadjusted odds ratios of TV infection (adjusted odds ratios [adjOR] 8.9; 95% CI: 4.3, 18.3), CT infection (adjOR 3.9; 95% CI: 1.4, 10.8), HSV-2 antibodies (adjOR 4.0; 95% CI: 2.7, 6.0) and penile HPV infection (adjOR 1.9; 95% CI: 1.6, 2.2). Likewise, the diagnoses of concurrent TV infection in women were independently associated with increased unadjusted odds ratios of concurrent TV infection (adjOR 2.0; 95% CI: 0.93, 4.5), CT infection (adjOR 7.6; 95% CI: 3.8, 15.1), HSV-2 antibodies (adjOR 3.1; 95% CI: 1.6, 6.1) and vaginal HPV infection (adjOR 2.3; 95% CI: 1.3, 4.1) (Table 5).

Table 5.

Selected sociodemographic, reproductive health and laboratory diagnosed infections associated with Trichomonas vaginalis infection among adult patients in the study area.

Characteristic	Trichomonas vaginalis infection
	Unadjusted OR	95% CI	Adjusted OR	95% CI
Males
TV infection
Positive	8.1	4.1, 15.9	8.9	4.3, 18.3
Negative	Ref		Ref
CT infection
Positive	4.1	1.6, 10.6	3.9	1.4, 10.8
Negative	Ref		Ref
HSV-2 antibodies
Present	3.9	2.4, 5.8	4.0	2.7, 6.0
Absent	Ref		Ref
Penile HPV infection
Present	1.9	1.5, 2.3	1.9	1.6, 2.2
Absent	Ref		Ref
Females
TV infection
Positive	3.2	1.4, 7.5	2.0	0.9, 4.5
Negative	Ref		Ref
CT infection
Positive	8.8	4.7, 16.8	7.6	3.8, 15.1
Negative	Ref		Ref
HSV-2 antibodies
Present	3.9	2.2, 6.7	3.1	1.6, 6.1
Absent	Ref		Ref
Vaginal HPV infection
Present	2.2	1.4, 3.5	2.3	1.3, 4.1
Absent	Ref		Ref

CI = confidence interval, CT = Chlamydia trachomatis, HSV-2 = herpes simplex virus (type 2), HPV = human papillomavirus, OR = odds ratio, TV = trichomonas vaginalis.

4. Discussion

Trichomoniasis, caused by the protozoan TV,^[13] is associated with symptoms such as prostatitis, cervicitis, pelvic inflammatory disease, dysuria, urethritis, and adverse birth outcomes.^[36–38] The prevalence of TV was investigated among adult patients attending public health facilities in the Nsukka District of Enugu State. Out of 300 urine samples from 150 men and high vaginal swabs from 150 women, 135 (45.0%) tested positive for TV. The prevalence was higher in women (63.7%) than in men (36.3%). Among the 4 public health centers, the highest number of positive cases was recorded at UNNMC (31.9%), while University of Nigeria Teaching Hospital Comprehensive Health Center, Obukpa-Nsukka had the lowest (17.8%).

The prevalence of TV found in this study is higher compared to previous studies. For instance, Ijeoma et al^[13] reported a prevalence of 29% among 100 men and 81% among 100 women, Arambulo et al^[39] reported a prevalence of 6.8% among 288 women, and Jun-Hyeok et al^[1] reported a prevalence of 4.0% among 201 men. Eshan et al^[22]reported a prevalence of 1.8% among 2115 women and 0.5% among 1942 men, and Onwuliri et al reported a prevalence of 24.7% among 505 individuals.^[40] The higher prevalence in women could be attributed to the lower detection of TV infection in men and the nonavailability of modern diagnostic method.^[41] Furthermore, the high concentration of zinc and antitrichomonal substance in the prostate inhibits early detection.^[42]

The study revealed that the highest TV prevalence was observed in adults aged 38 to 47 years (39.3%), while the lowest was in adults aged 18 to 27 years (0.7%). This finding is consistent with previous studies that suggest a link between TV prevalence and sexual activity.^[13,32,43] Increased sexual activity and multiple sex partners contribute to a higher prevalence of sexual transmission of TV.^[1,13] Older adults in this study contracted TV infection after sexual contact, similar to findings in the study conducted by Tanyuksel and Doganci that focused on prostitutes as transmitters of various STDs, with TV being the most prevalent.^[44] Other studies have also shown a significant relationship between age and TV prevalence. The TV prevalence in older adults indicated that the prevalence of TV was significantly related to age.^[1] For instance, Wendel et al^[45] reported a prevalence of 13% among men above 28 years.

The results of the study found a higher TV infection prevalence among older married adults (76.3%) compared to younger and single adults (18.5%). The low incidence of TV infection in men aged below 38 (5.9%) may be due to their asymptomatic nature, leading to less frequent visits to public health facilities. The high incidence of TV infection among married adults could be attributed to the inadequate attention given to this disease,^[13] despite it being the most common STD.^[13,46]

Furthermore, the study indicated that TV infection was more prevalent among adults with lower educational attainment (12.6%) compared to those with higher educational attainment (87.4%). This finding aligns with previous studies that have shown a higher incidence of TV infection among adults with lower education levels. For instance, Sumadhya et al^[41] reported more TV prevalent among adults with lower educational attainment compared to adults with high educational attainment.

Regarding symptoms, the study found that 36.7% of TV-infected male patients did not exhibit penile discharge, odor, or lower abdomen pain. This finding contrasts with the study conducted by Jun-Hyeok et al^[1], which reported that over 80.0% of TV infections are asymptomatic. In the Nsukka District, 63.3% of TV-infected male patients experienced penile tingling and pain during urination. Early detection and treatment in men, along with rapid point-of-care diagnostics, are necessary to prevent the spread of the infection.

The analysis of vaginal pH levels showed that the highest pH value (6.8) was found in women aged 38 to 47 years, while the lowest pH value (4.7) was observed in women aged 28 to 37 years. Trichomoniasis thrives on an alkaline environment with a pH of 6 or higher and is less conducive to survival in an acidic environment with a pH of 4.5 or lower.^{[13,20,47,48]} The varying pH levels among different age groups in this study support this relationship, which is influenced by factors such as reproductive hormones, access to medical care, personal health habits, and socioeconomic position.^[36,49]

The unadjusted odds ratio analysis revealed that certain characteristics were associated with TV prevalence, and were consistent with previous studies. For instance, lower educational attainment was identified as a risk factor for TV infection.^[50–53] HSV-2 antibodies, penile and vaginal HPV infections, and concurrent BV or VC were also found to be risk factors for TV infection in multivariable analysis. The association between HPV infections and TV infection aligns with a cohort study showing slower HPV clearance rates in adults with concurrent TV infection.^[9,54] HSV-2 antibodies may serve as biomarkers of previous high-risk sexual behavior, explaining the strong link observed.^[55] Further research is needed to explore the prevalence and consequences of TV coinfection.

Overall, this study provides valuable insights into the prevalence and risk factors associated with TV infection among adult patients in the Nsukka District of Enugu State, Nigeria.

5. Conclusion

Trichomoniasis is associated with significant public health concerns, including HIV transmission and other STDs. The majority of adults infected with trichomoniasis are asymptomatic carriers, leading to varied presentation of the infection. Due to the protozoa’s sensitivity to drying and ambient oxygen, diagnosing trichomoniasis infection can be challenging. It often goes undiagnosed and untreated, becoming a major source of spread and transmission. While sexual contact is the most common mode of transmission, trichomoniasis can also be transmitted through fluid-contaminated formites, and congenital sources. nonsexual modes of transmission can also occur through moist secretions, particularly in women.

Addressing trichomoniasis requires a significant public health response, yet there seems to be inadequate actions from the Nigerian government in combating the infection. Therefore, it is crucial to increase public awareness and understanding of trichomoniasis. Educational materials about trichomoniasis should be incorporated into existing public health initiatives for HIV and STD prevention. Routine screening and treatment should be provided to men and women in high-prevalence communities, such as those in the Nsukka District of Enugu State, regardless of their HIV status. Screening efforts should go beyond STD clinics. While there may be limited empirical evidence on the impact of these strategies in controlling the epidemic in Enugu State, Nigeria, it would be unfair to continue ignoring the significant of this STI until such data is made available.

Trichomoniasis remains a common infection among adults in Nsukka District of Enugu State, despite the availability of accurate diagnostic methods and efficient treatment options. To reduce its prevalence, increased efforts are needed in public health. Community-based interventions should be employed to enhance the quality of syndromic management for trichomoniasis. Continuous surveillance of trichomoniasis prevalence at both local and national levels is necessary to inform the development and implementation of effective public health initiatives.

Acknowledgments

The authors sincerely thank the medical directors of the public health facilities and participants, without whom this study would not have been possible.

Author contributions

Conceptualization: K. Chukwuemeka Obetta, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ngozi Uzoamaka Chuke, Onyinyechi Elizabeth Okoye.

Data curation: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Ogechi Nkemjika.

Formal analysis: K. Chukwuemeka Obetta, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Ogechi Nkemjika.

Funding acquisition: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Kenneth Okonkwo Ugwu, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ngozi Uzoamaka Chuke, Ogechi Nkemjika, Onyinyechi Elizabeth Okoye.

Investigation: Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Ngozi Uzoamaka Chuke, Ogechi Nkemjika, Beatrice N. Onah.

Methodology: K. Chukwuemeka Obetta, Kenneth Okonkwo Ugwu, Beatrice N. Onah, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ngozi Uzoamaka Chuke, Ogechi Nkemjika, Onyinyechi Elizabeth Okoye.

Project administration: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Beatrice N. Onah, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ngozi Uzoamaka Chuke, Onyinyechi Elizabeth Okoye.

Resources: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Joseph O. Acha, Ngozi Uzoamaka Chuke, Onyinyechi Elizabeth Okoye.

Software: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Ogechi Nkemjika.

Supervision: K. Chukwuemeka Obetta, Dorida Nneka Oyigbo, Beatrice N. Onah, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ogechi Nkemjika, Onyinyechi Elizabeth Okoye.

Validation: Innocent Okonkwo Ogbonna, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Ogechi Nkemjika, Beatrice N. Onah.

Visualization: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Beatrice N. Onah.

Writing – original draft: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ogechi Nkemjika, Onyinyechi Elizabeth Okoye.

Writing – review & editing: K. Chukwuemeka Obetta, Innocent Okonkwo Ogbonna, Dorida Nneka Oyigbo, Oliver Onyemaechi Ugwu, Kenneth Okonkwo Ugwu, Beatrice N. Onah, Chinasa Maryrose Ugwunnadi, Joseph O. Acha, Ngozi Uzoamaka Chuke, Ogechi Nkemjika, Onyinyechi Elizabeth Okoye.