MAJOR ARTICLE

Prevalence, Incidence, Natural History, and Response

to Treatment of Trichomonas vaginalis Infection
among Adolescent Women
Barbara Van Der Pol,1 James A. Williams,1 Donald P. Orr,2 Byron E. Batteiger,1 and J. Dennis Fortenberry2
1

Division of Infectious Diseases, Department of Medicine, and 2Section of Adolescent Medicine, Department of Pediatrics, Indiana University
School of Medicine, Indianapolis

(See the editorial commentary by Schwebke, on pages 20368.)

Trichomonas vaginalis infection is one of the most common sexually transmitted infections (STIs) in the United
States, with 35 million incident cases annually and up
to 20 million prevalent cases [1, 2]. T. vaginalis infection
is unique among the common, curable STIs in that its
point prevalence increases with age [35]. However,
clinical studies report a substantial number of infections among adolescent and young-adult women, and
reinfection is common [68]. T. vaginalis infections

Received 12 April 2005; accepted 1 July 2005; electronically published 8

November 2005.
Presented in part: World HIV/STI Congress, Punte del Este, Uruguay, 4 December
2003 (abstract 156).
Potential conflicts of interest: none reported.
Financial support: National Institute of Allergy and Infectious Diseases (grant
U19 AI43924).
Reprints or correspondence: Dr. J. Dennis Fortenberry, 575 N. West Dr., Room
070, Indianapolis, IN 46202 (jfortenb@iupui.edu).
The Journal of Infectious Diseases 2005; 192:203944
 2005 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2005/19212-0003$15.00

should not be considered simple vaginal infections that

serve as markers for other STIs [9]. In recent years, T.
vaginalis infections have been associated with several
adverse outcomes, including pelvic inflammatory disease, premature delivery, low birth weight, and increased susceptibility to HIV infection [1, 1013].
The high prevalence of T. vaginalis infection and the
significant morbidity associated with it suggest the importance of broadening our understanding of the epidemiologic profile of T. vaginalis infection among adolescent women, particularly in the context of the HIV
pandemic. The high prevalence of T. vaginalis infection
may serve to increase the incidence of HIV infection
in this susceptible population [13].
Because T. vaginalis infection is not reportable in the
United States, sufficient data to inform program design
for control of this disease are not readily available. The
objective of this study was to describe the prevalence,
incidence, natural history, and response to treatment
of T. vaginalis infection among adolescent women.
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Background. Trichomonas vaginalis infection is a sexually transmitted infection (STI) linked with reproductive
health complications. However, few data exist concerning the epidemiologic profile of this pathogen in adolescent
women, a group at high risk for other STIs.
Methods. Our objective was to describe the prevalence, incidence, natural history, and response to treatment
of T. vaginalis infection in adolescent women. Women 1417 years old were followed for up to 27 months. Vaginal
swab samples were obtained during quarterly clinic visits and were self-obtained weekly during 12-week diary
collection periods. The weekly samples were tested quarterly. Infections were identified by polymerase chain reaction
and were treated with 2.0 g of oral metronidazole. Analysis was performed on the subset of participants who
returned for at least 1 quarterly clinic visit.
Results. T. vaginalis infection was identified in 6.0% (16/268) of the participants at enrollment. Overall, 23.2%
(57/245) of the participants with at least 3 months of follow-up had at least 1 infection episode; 31.6% (18/57)
experienced multiple episodes. Seventy-two incident infection episodes were diagnosed. When treatment was not
documented, weekly samples from participants were positive for up to 12 consecutive weeks. After treatment, T.
vaginalis DNA was undetectable within 2 weeks in all but 3 participants.
Conclusions. The incidence of T. vaginalis infection is high among adolescent women; untreated infections
may last undetected for 3 months or longer. Reinfection is common. Treatment with oral metronidazole is effective,
and T. vaginalis DNA disappears rapidly after treatment.

PARTICIPANTS, MATERIALS, AND METHODS

2040 JID 2005:192 (15 December) Van Der Pol et al.

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Participants. Participants were adolescent women receiving

health care at 1 of 3 primary health clinics in Indianapolis, Indiana. These clinics primarily serve lower- and middle-income
residents of areas that have high rates of teenage pregnancy and
STIs. Clinic patients were eligible for enrollment if they were
between 14 and 17 years old, spoke English, and were not pregnant at the time of enrollment. However, enrolled participants
who became pregnant were retained in the study cohort. Prior
sexual experience was not a requirement for participation.
Study design and procedures. Data were collected as part
of a larger longitudinal study (initiated in 1999) of risk and
protective factors associated with STIs among young women
in middle adolescence. Briefly, the parent study included up to
10 clinical interviews and examinations; these occurred at enrollment and quarterly thereafter. Vaginal swab samples for STI
diagnostics were collected during the clinic visits and were run
in real time, to provide data for clinical management. In addition, data and swab samples were collected during up to five
12-week diary collection periods during a 27-month study period. During each diary collection period, up to 11 weekly visits
(typically at the participants homes) were conducted by research staff, to collect diaries and self-obtained vaginal swabs
from participants. Diary collection periods were followed by
rest periods in which no diary information was collected. Each
diary collection period was bracketed by clinic visits for collection of interview and physical-examination data. These visits
allowed research personnel to reinforce diary collection procedures, maintain current contact information, and treat any
infections identified using the weekly samples. Informed consent was obtained from each participant, and permission was
obtained from a parent or legal guardian. This research was
approved by the Institutional Review Board of Indiana UniversityPurdue University Indianapolis/Clarian Health.
At enrollment and each subsequent quarterly clinic visit,
face-to-face interviews were used to obtain information on sexual behaviors, including condom use. Vaginal swab samples
were obtained by a research nurse practitioner for diagnosis of
STIs. These samples were tested in real time, with results available to research staff within 72 h. A prescription for 2.0 g of
oral metronidazole was provided to all participants with a T.
vaginalis infection; those found to be infected on the basis of
the weekly samples obtained during the 11 weeks preceding a
quarterly clinic visit were treated during the quarterly visit.
The diary instrument consisted of a single bar-coded, scannable sheet containing items and response options. At the time
of enrollment, participants received detailed instructions on
diary completion, as well as a unit (7) of blank diary sheets.
During the weekly visits, trained field personnel collected completed diaries and left blank diary forms. Field personnel also
provided swabs and instructed participants on the collection

of self-obtained vaginal swabs. Swabs were transported to the

laboratory within 8 h. Testing for STIs was not performed in
real time for these samples; they were frozen and run in batches
immediately before the next scheduled clinic visit. Participants
received $2.00 for each completed diary, as well as a bonus for
completion of 80% of scheduled diaries.
Detection of T. vaginalis. On receipt in the laboratory,
swabs were hydrated with water and vortexed, to elute the
sample. Samples from weekly swabs were frozen for testing in
batches immediately before a clinic visit, so that infections
could be treated at that visit. Samples from clinic visits were
never frozen and were tested in real time, to provide information back to the clinic regarding infection status. T. vaginalis
DNA was detected using the AMPLICOR CT/NG (Roche Diagnostics) polymerase chain reaction (PCR) assay, with the following modifications. Samples were processed for amplification
according to the package insert instructions for swab samples.
Amplification was performed using the provided amplification
buffer, to which T. vaginalisspecific primers had been added
[14]. Amplified DNA was detected using microwell plates coated with a T. vaginalisspecific probe. The CT/NG detection reagents, with the substitution of a hybridization buffer that was
permissive for binding of the amplified T. vaginalis sequence,
were used, and the kit protocol was followed.
Analysis. An infection episode was defined as a positive
sample obtained during a quarterly clinic visit or as 2 positive
weekly samples obtained during a diary collection period. That
the criterion for weekly visits (2 positive samples) was more
stringent than that for quarterly clinic visits was a reflection of
the difference between using a diagnostic test for screening and
following patients initially known to be negative. Although the
prevalence in a screening population may be high enough to
result in a useful positive predictive value (PPV), the prevalence
in a population of initially negative participants is expected to
be quite low, resulting in a low PPV regardless of the specificity of the assay. Therefore, a conservative definition of an infection episode was established with respect to the diary collection
period, requiring at least 2 positive results. Data from women
who attended at least 1 quarterly clinic visit were included in
the analysis of T. vaginalis prevalence and incidence. Point prevalence was calculated as the number of infections identified at
enrollment divided by the number of participants included in
the analysis. Cumulative prevalence was defined as the total number of participants ever infected during the course of the study
divided by the number of participants included in the analysis.
The first infection identified during follow-up in those participants who were negative at enrollment and infections in participants for whom effective treatment of previous infections was
documented were classified as incident episodes. Onset of an
infection episode was defined as the collection date of the first
positive sample. Duration of an infection episode was defined as

the interval between the onset of infection and the collection

date of the first of at least 2 sequential negative weekly samples.
For missing weekly samples, infection status was considered to
be negative unless the samples collected immediately before and
after the missing sample were positive. DNA shedding was defined as a positive weekly test after documented treatment. Therapy was considered to be effective when weekly samples became
negative within 3 weeks of treatment and remained negative for
at least 2 weeks.
RESULTS

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The average age of the 268 participants enrolled in the parent

study was 15.4 years; 233 (86.9%) were black. Sixteen (6.0%
[95% confidence interval {CI}, 3.2%8.8%]) received a diagnosis of T. vaginalis infection during the enrollment visit. In this
cohort, the prevalences at enrollment of Chlamydia trachomatis
and Neisseria gonorrhoeae infection were 10.1% (95% CI, 6.5%
13.7%) and 4.1% (95% CI, 1.7%6.5%), respectively. Longitudinal analysis was restricted to the participants who had returned for at least 1 quarterly clinic visit after enrollment (245/
268). Of the 245 participants with at least 1 quarterly clinic visit, 13 (5.3%) had received a diagnosis of T. vaginalis infection
at enrollment, whereas a total of 57 (cumulative prevalence,
23.2% [95% CI 17.9%28.5%]) had at least 1 infection episode at some point during follow-up. Eighteen (31.6%) had
multiple infection episodes during the study period, with up
to 4 separate episodes in 2 women. The mean  SD number
of infection episodes in the 43 infected women who completed
follow-up was 1.6  0.9.
Forty-five (18.4%) participants had at least 1 incident infection episode, with 72 incident episodes occurring overall. Thirtyseven incident episodes were identified using the weekly samples;
in 21 of these instances, using the sample obtained during the
next scheduled quarterly clinic visit, the participants were not
found to be positive. Documentation of treatment during an
interim clinic visit was found for 11 of these 21 participants. The
mean  SD time to seeking treatment for these 11 participants
was 2.9  2.3 weeks (median, 2 weeks). The remaining 10 participants had no documented treatment, and the reason for the
subsequent negative samples is unknown.
For 42 infection episodes, documentation of treatment was
available along with subsequent weekly samples to verify treatment efficacy. For all but 3 episodes (7.0%) in 3 participants,
T. vaginalis DNA was no longer detectable within 2 weeks of
the treatment date. One participant remained positive for an
additional 8 weeks after treatment, and 2 remained positive for
an additional 12 weeks after treatment (until the next scheduled
quarterly clinic visit), at which time they were again treated.
Saline wet-mount preparation results were available for 1409
quarterly clinic visits, including 61 of 64 infection episodes that
were identified by PCR. Motile trichomonads were observed

by microscopy in 31 wet-mount preparations, including 26

(42.6%) of the 61 from clinic visits during which infection
episodes were identified by PCR. Five positive wet-mount preparations were not positive by PCR using the sample obtained
during that clinic visit. However, 3 of 5 participants who had
positive wet-mount preparations but negative PCR results were
never positive by PCR during the subsequent 12 weeks of follow-up; this suggests the possibility of false-positive wet-mount
preparation results. These 3 participants with positive clinical
tests were classified as being uninfected, on the basis of the
PCR results. The remaining 2 participants had subsequent positive weekly samples and were classified as being infected. Taken together, these data suggest that the sensitivity of the PCR assay is between 91.8% and 96.7%.
Information on symptoms was available for 54 of the 61
quarterly clinic visits for which wet-mount preparation results
were available. Seventeen (54.8%) of the 31 positive wet-mount
preparations were from symptomatic participants, all of whom
had vaginal discharge. In our study population, abnormal discharge was observed in 29 (53.7%) of 54 participants who were
positive for T. vaginalis infection by PCR. Thus, negative wetmount preparations or the absence of vaginal discharge are
insufficiently sensitive to reliably rule out T. vaginalis infection.
Bacterial vaginosis (diagnosed on the basis of the whiff test and
the presence of clue cells) was identified in 11.5% of the T.
vaginalisinfected participants, and yeast infection was diagnosed microscopically in 18.6%.
A variety of patterns of positive and negative test results were
observed during follow-up; examples of some typical patterns
observed in the participants who were included in the analysis
are shown in figure 1. Many of the patterns are easily interpreted, such as test results after successful treatment, test results
for an incident infection episode for which interim treatment
was sought, and test results for an incident infection episode
that persisted until the next quarterly clinic visit (examples 1,
2, and 3, respectively, in figure 1). However, the interpretation
of other patterns is more subjective. We interpreted example 4
as successful treatment followed by reinfection, on the basis of
information on coital activity contained in the diary. Example
5 could be the result of identical exposures, as seen in example
4, because there was a weekly period with missing data; however, in the absence of any documented coital activity and with
only 1 week of documented negative test results, the period
was classified as potential treatment failure.
Example 6 was interpreted as a single infection episode, on
the basis of the absence of documented treatment and a high
level of coital activity during the diary collection period. The
occasional negative test results were assumed to be the result
of either low organism load or inadequate sample collection.
However, there are a number of possible scenarios that could
result in a similar pattern. Missing data also hamper the in-

one was treated within 2 weeks, 2 were treated within 4 weeks,

and the remaining 3 had no record of treatment. Sample quality
may explain why some samples were negative even though the
participants sought interim treatment. The 3 samples from participants for whom no treatment was documented could represent false-positive results or the detection of DNA in the
absence of active infection that had cleared spontaneously.
The durations of infection episodes were limited by treatment during quarterly clinic visits or during interim clinic visits
in all but 10 instances. Eleven participants sought treatment
during an interim visit, and 8 of 11 did so within 2 weeks of
onset; the remaining 3 participants did not seek treatment until
67 weeks after onset. This rate of seeking treatment within 2
weeks (72.7%) is similar to the percentage of infections that
were symptomatic when identified during quarterly clinic visits (68.5%).

Figure 1. Eight examples of patterns of positive and negative test results over 12 consecutive weeks. Each square represents a weekly selfobtained vaginal swab sample and diary collection unit, with the hatched
squares indicating positive test results and the missing squares indicating missed collection weeks. The black arrows indicate quarterly clinic
visits, the black triangles indicate treatment with oral metronidazole, and
the white hearts indicate coital activity. The patterns were interpreted
as follows: (1) successful treatment; (2) incident infection episode for
which interim treatment was sought; (3) incident infection episode that
persisted until the next quarterly clinic visit; (4) successful treatment
followed by possible reinfection, on the basis of information on coital
activity; (5) potential treatment failure, on the basis of there being only
1 week of documented negative test results, compounded by no documented coital activity; (6) single infection episode, on the basis of the
absence of documented treatment and a high level of coital activity
(however, this complicated pattern of positive and negative results, coital
events, and missing data could be the result of a number of possible
scenarios); (7) undocumented treatment, natural clearance of infection,
or an infection level below the limit of sensitivity of the assay; and (8)
exposure without infection or false-positive result.

terpretation of such patterns. Patterns such as example 7 are

also subject to multiple interpretations, including undocumented treatment, natural clearance of infection, or an infection level below the limit of sensitivity of the assay.
Example 8 shows a single positive weekly sample. Because
an infection episode was defined as at least 2 positive weekly
samples, the analysis did not include those participants who
had an isolated positive weekly sample. This happened in 7
instances. One participant was treated during the same week,
2042 JID 2005:192 (15 December) Van Der Pol et al.

In this longitudinal observational study, T. vaginalis infection was

found to be common, occurring in 23.2% of the study participants. The point prevalence at enrollment (6.0%) was in the
range of that seen for C. trachomatis (10.1%) and N. gonorrhoeae (4.1%) infection. The prevalences of all of these STIs is
particularly high when one considers that not all of the participants were sexually active during the entire study. The participants were not required to be sexually active to be included,
and the young women often experienced extended periods of
abstinence. As a result of our not controlling for this type of
state change, the denominators in our calculations produced
underestimations of the actual prevalences of infections. In
future analyses, we hope to include behavioral data to control
for such exposure variables as coital activity, use of condoms,
and partner infection status.
As we have previously documented, reoccurrence of infection
also appears to be common in a similar population studied; in
that population, 130% of the ever-infected participants experienced 11 T. vaginalis infection episode [8]. In part, the high
reinfection rate may reflect a lack of aggressive efforts to identify
and treat infected sex partners for this nonreportable infection;
however, we were unable to find evidence in clinical trials that
would indicate the efficacy of partner treatment in reducing T.
vaginalis reinfection rates. Also, it should be remembered that
we were unable to distinguish reinfection from persistence or
treatment failure in the present study. The difficulty with these
types of analyses can be seen in the complexity of the patterns
of positive test results shown in figure 1.
Compared with wet-mount preparation microscopy, the standard in most settings, the use of PCR for detection of T. vaginalis
DNA offered a significant improvement in the ability to identify
infections. As a result of the behavioral nature of the parent
study, the number of samples collected was kept to a mini-

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DISCUSSION

Because of the method we used for determining the onset of

an infection episode, the actual average duration of infection
may be longer than the results presented here. For example, if
a participant was first positive in her third weekly sample, she
may actually have acquired the infection 6 days previously. If
the infection cleared before the quarterly clinic visit or after
treatment, the infection may have actually lasted up to 6 days
after the last positive sample was obtained. Clearly, truncating
the time results in a conservative estimate of the duration of
infection.
In the present study, had we been able to diagnose T. vaginalis infection only on the basis of a combination of wet-mount
preparation microscopy and clinical signs, we would have detected only 68.5% of infections. This suggests a somewhat higher frequency of infection than what has been assumed in the
literature, especially in the absence of systematic surveillance
efforts. The lack of symptoms during a large proportion of
infections (31.5%) is an additional cause for concern with respect to the management of sexual health in adolescent women.
It appears likely that a large number of infections, lacking both
symptoms and clinical signs, remain undetected. Although the
current recommendations for STI control include at least annual screening for C. trachomatis and often concurrent testing
for N. gonorrhoeae, the potential for T. vaginalis infection is
largely ignored, even though it may be more prevalent than
chlamydia infection and gonorrhea combined in some populations. As urine and self-obtained vaginal swabs become more
widely accepted as source samples for STI screening, use of a
self-obtained swab for saline wet-mount preparations in clinical
settings may be prudent [16]. The commercial availability of
DNA amplification tests and more-sensitive point-of-care tests
would be additional useful tools [17].
The present data also demonstrate that treatment with 2.0
g of oral metronidazole appears to be an efficacious regimen
with a failure rate of, at most, 7.0%. For 85% of the participants, T. vaginalis DNA shedding was undetectable within
2 weeks of treatment. Given the risk of complications (including adverse outcomes of pregnancy and HIV infection)
and the availability of effective treatment, our data suggest
that increased attention should be paid to the control of T.
vaginalis infection, concurrent with chlamydia infection and
gonorrhea control programs.

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