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COMPARATIVE STUDY ON PARASITIC INFECTION IN

PRIVATE SCHOOL AND PUBLIC SCHOOL AT THIMI,

BHAKTAPUR, NEPAL

A

DISSERTATION

SUBMITTED TO THE DEPARTMENT OF MICROBIOLOGY

KATHMANDU COLLEGE OF SCIENCE AND TECHNOLOGYKALIMATI, KATHMANDU

NEPAL

2008

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE

AWARD OF THE

DEGREE OF MASTER OF SCIENCE

IN

MICROBIOLOGY

BY

SWASTI KUMARI SHRESTHA

DEPARTMENT OF MICROBIOLOGY

KATHMANDU COLLEGE OF SCIENCE AND TECHNOLOGY

KALIMATI, KATHMANDU

NEPAL2008

1



ABSTRACT

This study was carried out to compare the intestinal parasitosis among school children

of public and private school. A total 303 stool samples were collected from different

public (n=203) and private school (n=100) of Thimi, Bhaktapur. Stool samples

collected in clean, dry, screw capped plastic container were examined by formal ether

concentration technique. Overall prevalence of parasitic infection in boys and girls were

(36.4%) and (34.9%) (p>0.05). In case of public school, boys (40.0%) and girls (40.7%)

had similar prevalence rate (p>0.05), while in private school, boys had significantly

higher (30.0%) prevalence rate than in girls (22.0%) (p<0.05). The numbers of

protozoan were higher than helminthes in both public school and private school.

Altogether seven types of parasites were detected, G. lamblia, E. histolytica, A.

lumbricoides, T. trichiura, hookworm, H. nana and E. vermicularis were found in both

public school and Private school. However, the infection rate in public school was

significantly higher (40.3%) in comparison with the private school (26.0%) (p<0.05).

The prevalence of infection is slightly higher in children of age >10 in public school

and private school compared with age ≤10 (p>0.05). Parasitic prevalence rate was

found higher in untreated water drinking children studying in both public school

(50.0%) and private school (26.7%) compared to those drinking treated water, (19.0%)

in case of public school and (21.4%) in case of private school. However, there was

significant difference (p<0.05) in public school and no significant difference (p>0.05)

was observed in private school. In both the public and private school, parasites positive

rates were higher in children having family size >5. The prevalence of infection was

found significantly higher in both public and private school children having toilet at

home compared with children without toilet at home. So far as concern with ethnic wisedistribution, the infection rate was slightly higher (p<0.05) in Madhesi (70.0%) and

Dalit (untouchable people) (69.2%) in public school and in case of private school Dalit

(62.5%) was significantly more infected (p<0.05). The prevalence rate of infection was

significantly higher in children using well and Dhungedhara (natural spout) as a source

of water compared with children using tap as a water source in public school and

private school. Parasitic infection rate were found significantly lower among the

children who had taken antihelminthic drugs within last six months in public and

private school compared to children who had not taken drugs (p<0.05). In public school

2



children with parent occupation as labour (56.0%) had higher infection rate followed by

agriculture (30.3%), business (28.5%) and service (11.5%) (p>0.05). On other hand, in

case of private school children with parent occupation as agriculture (38.0%) had

significantly higher infection rate followed by business (20.0%), labour (14.2%) and

service (12.9%).

Keywords: - School children, public, private, Bhaktapur, Nepal

3



TABLE OF CONTENTS

Page

No.

Board of examiners i

Acknowledgement ii

Abstract iii

Table of contents v

List of abbreviations vii

List of tables viii

List of figures ix

List of photographs x

List of appendices xi

CHAPTER I: INTRODUCTION 1-4

CHAPTER II: OBJECTIVES OF THE STUDY 5

CHAPTER III: LITERATURE REVIEW 6-28

3.1 Global Scenario 6

3.2Asian Scenario 16

3.3 National Scenario 24

CHAPTER IV: MATERIALS AND METHODS 29-33

4.1 Subject and site of study 294.2 Sample collection 29

4.3 Transportation of the samples 29

4.4 Laboratory processing of the samples

4.4.1 Macroscopic Examination 30

4.4.2 Microscopic Examination 30

4.4.3 Recording of the data 32

4.4.4 Report distribution 32

4.4.5 Statistical analysis 33

4



CHAPTER V: RESULTS 34-40

CHAPTER VI: DISCUSSION AND CONCLUSION 41-46

6.1 Discussion 41

6.2 Conclusion 48

6.3 Limitation 48

CHAPTER VII: SUMMARY AND RECOMMENDATION 49-51

7.1 Summary 56

7.2 Recommendation 51

CHAPTER VIII: REFERENCES 52-67

5



LIST OF ABBREVIATIONS

STH Soil Transmitted Helminthes

A. lumbricoides Ascaris lumbricoides

S. stercoralis Strongyloides stercoralis

H. nana Hymenolepsis nana

E. histolytica Entamoeba histolytica

E. coli Entamoeba coli

I. butschlii Iodamoeba butschlii

C. mesnili Chilomastix mesnili

E. nana Endolimax nana

E. hartmani Entamoeba hartmani

B. hominis Blastocystis hominis

C. cayetanensis Cyclospora cayetanensis

T. trichiura Trichuris trichiura

N. americanus Necator americanus

P. westermani Paragonimus westermani

WHO World Health Organisation NITMPHR National Institute of Tropical Medicine

and Public health Research

Total n Total number

Pos n Positive number

6



LIST OF TABLES

Page No.

Table 1: Gender wise prevalence of parasitic infection 34

Table 2: prevalence of parasitic infection in public school and 34

Private school

Table 3: Types of parasite detected from school children 35

Table 4: Prevalence of parasitic infections in different age-groups 36

Table 5: Prevalence of parasitic infection by family size 37

Table 6: Prevalence of parasitic infection according to presence of toilet at home 37

Table 7: Prevalence of parasitic infection in different ethnic group. 38

Table 8: Prevalence of parasitic infection according to the drug used 39

LIST OF FIGURES

7



Page No.

Figure 1: Prevalence of parasitic infection according to the type of water used 36

for drinking.

Figure 2: Prevalence of parasitic infection according to the source of water used 38

for drinking.

Figure 3: Prevalence of parasitic infection according to the occupation of parents 39

LIST OF PHOTOGRAPHS

8



Photograph 1: Cysts of Giardia lamblia (Iodine mount, 40X)

Photograph 2: An egg of Ascaris lumbricoides (Wet mount, 40X)

Photograph 3: An egg of Trichuris trichiura (Wet mount, 40X)

Photograph 4: Specimen processing in the laboratory

Photograph 5: Sample collection in the school

9



LIST OF APPENDICES

Page No.

Appendix 1: Materials and chemicals used i-ii

Appendix 2: Questionnarie and report form

10



CHAPTER I

1. INTRODUCTION

Gastroenteritis is one of the major public health problems in the world having

cosmopolitan distribution. More than half of the human population in the world live in

misery pain and suffer vast economic loss due to parasites. About one fourth of the

world population is reported to be infected by one or more species of intestinal parasites

(Rai et al , 1998). Enteric pathogens, reportedly affect 3.5 billion people globally (Rai et

al , 2004).

Ascaris lumbricoides, Trichuris trichiura and hookworm infect 1.4 billion, 1.3 billion,

and 1.0 billion people world wide respectively. The protozoan parasites although being

less common are associated with the highest number of mortalities (Chan et al, 1994).

Intestinal parasitic infections are distributed virtually through out the world, with high

prevalence rate in many regions. Amoebiasis, ascariasis, trichuriasis and hookworm

infection are common among the ten top most infections in the world (Rai et al, 1998).

Intestinal parasites are endemic in most tropical and subtropical countries, particularly

in developing countries and are one of the important causes of diarrhoel diseases. Due

to diarrhoel diseases, at least 5 million deaths per year occur in developing countries.

Gastroenteritis is a major killer disease in Nepal. Every year 30-40 thousand people die

of gastroenteritis (Bista et al , 1993). Cyclospora cayetanensis, Cryptosporidium

parvum an emerging parasitic enteropathogen of human being increasingly recognized

throughout the world.

According to WHO, in many countries malabsorption, diarrhoea, blood loss, impaired

work capacity and reduced growth rate due to intestinal parasitic infections constitute

important health and social problems. Furthermore, other parasitic infections such as

abdominal angiostrongyliasis, intestinal cyclosporiasis and strongyloidiasis are local or

regional public health concern.

Intestinal parasitic infection cause significant morbidity and mortality in the population,

especially children of tropics and sub tropics, due to deficient life conditions with lack

11



of adequate hygiene and sanitation, illiteracy, overcrowding and low construction level

(Rai et al, 2004).

Nepal is a small and impoverishing country located in south Asia where intestinal

parasites are prevalent (Rai and Gurung, 1986; Rai et al, 1994a, 1994b, 1995, 1997,

1998, 2000a, 2000b; Sherchand et al, 1996, 1997; Ishiyama et al, 2001, 2003; Ono et al

2001, Kimura et al , 2005). The health status of the population is a reflection of the

socio-economic development of the country. It is influenced by a various factors like

the level of income and living standards, housing, water supply, education, sanitation

including work place environment, employment, consciousness, the coverage,

accessibility and affordability of health care delivery services, social security, and

participation in the socio-political activities of the community, recreation and human

rights. Children are more commonly infected than adult in Nepal (Rai and Gurung,

1986). There was strong association between giardiasis and malnutrition of many

school children (Chaudhary et al , 2000). Malnutrition is more common among children

aged less than five years and it is associated with child mortality. Nepalese women

suffer from chronic malnutrition (Rai et al , 2002).

Similarly, the soil contamination with helminthes eggs in Nepal is higher in wet season.

Intestinal infection like giardiasis, amoebiasis, ascariasis, ancyclostomiasis and

fascioliasis are common in Nepal (Rai and Gurung, 1986; Rai et al, 1994a, 1994b,

1995, 1997, 1998, 2000a, 2000b; Sherchand et al, 1996, 1997; Ishiyama et al, 2001,

2003; Ono et al , 2001; Kimura et al , 2005; Acharya et al , 1979). It is because of the

dirty finger and nails which might play an important role in the transmission of

intestinal parasites (Soulsa, 1975).

In Nepal, the majority of the population is living on agricultural subsistence, has diverse

geotopography with diverse climatic condition. The population densities and lifestyles

vary according to the region and ethnic groups, respectively (Rai et al , 2000a)

approximately 70% of the health problems in Nepal are infectious diseases (Rai et al ,

2000b). Intestinal parasitic infection has been attributed to poor sanitation, poverty and

lack of health education. Children are more commonly infected than adults. Less than

45.0% suburban school children have reportedly been infected. Hospital based study

conducted over one decade period has shown the intestinal parasitic infection rate

ranging from 29.0%-44.2% with a static prevalence of A. lumbricoides. There are

12



strong association between giardiasis and malnutrition of the many school children.

Malnutrition is more common among children (Rai et al , 1997).

Madhyapur, Thimi municipality lies in Bhaktapur district of Central Development

Region. It covers an area of 11.47 sq. km. According to Population Census (2001), this

municipality had a density of 4298 persons per sq. km. The municipality counts up

47751 population representing 52.0% male and 48.0% female. The distribution of

population by five age groups are 0-4 (7.3%), followed by 5-9 (9.7%), 10-14 (11.5%),

15-59 (64.9%), 60 and above (6.6%). Among total literate population (31417) in the

municipality, (28.8%) has attained primary education only, (18.1%) lower secondary

and (14.8%) secondary education. Literates with SLC constituted (11.4%). The

proportion attaining higher education i.e. after SLC is (14.4%) only. There are many

caste/ethnic groups in the municipality. Among them Newar (61.1%), Chhetri (12.5%)

and Brahman (11.0%) are the main caste/ethnic groups. Others are Tamang (4.5%),

Magar (2.0%) and Rai (1.2%). Other caste/ethnic groups with less than (1.0%)

population each in the municipality are Sarki, Gurung , Tharu, Sherpa, Bhote,

Damai/ Dholi, Thakuri, Sanyasi, Muslim, Yadav, Limbu, Kayastha, Kami, Mallah and

Teli. Out of the total population aged 6 to 25 years (16889), 74.5% is attending school.

This school attendance is (76.2%) for boys and (72.7%) for girls. Although households

of Madhyapur Thimi Municipality are getting drinking water from various sources,

coverage of piped water (tap) is the highest. Out of total households (55.0%) get pipe

water. After the tap, well (24.0%) and tube-well (16.0%) rank the second, and the third

important sources respectively. Besides these sources, (3.0%) households get water

from the spring. Most of the households of Madhyapur Thimi Municipality have toilet

facility. Among the total households of the municipality, about (48.0%) have modern

flush toilet and about (40.0%) have ordinary toilet. However, about (11.0%) householdsstill use open toilet. Thimi is agricultural area. Though, this area is in the Kathmandu

valley (capital city of Nepal) still people of this area are depending on traditional

agricultural work. People of this area are uneducated and having poor knowledge of

sanitation.

Thus, this study about the prevalence of intestinal parasitic infection among school

children of Thimi may be fruitful for demarcation of health status with their low socio-

13



economic status. Moreover, this study may guide the researchers for the further studies

on the health status of school children and help planners in launching appropriate plans

and policies on their health care within the school children at Thimi, Bhaktapur, Nepal

and compare the prevalence of the parasitic infection in private school and public

school according to different factors notifying on the burden of infections of the

intestinal parasite.

CHAPTER II

14



2. OBJECTIVES OF THE STUDY

2.1 General objective

To compare parasitic infection in public school and private school at Thimi, Bhaktapur,

Nepal.

2.2 Specific objectives

• To perform stool examination for cysts and oocysts of protozoa and ova

and larvae of helminthes

• To correlate between parasitic infection and source of drinking water

and health awareness among school going children.

• To see the influence of family size and fathers occupation in parasitic

infection.

• To determine the prevalence of intestinal parasites with relation to

socio-economic conditions.

• To determine the prevalence of parasitic infection according to different

age groups and sex of the school children.

CHAPTER III

15



3. REVIEW OF LITERATURE

3.1 Global Scenario

About 80% of all illness and disease in the world is caused by inadequate sanitation,

unsafe water and unavailability of water (WHO, 2000). Intestinal parasitosis is one of

them. Both the protozoa and helminthes are responsible for the intestinal infections

leading to high mortality and morbidity, particularly in developing countries.

The global prevalence of E. histolytica was found to be 400 million (Walsh, 1986). The

global prevalence of A. lumbricoides, T. trichiura and hookworm was to be 1000

million, 900 million and 500 million respectively. It has been estimated that the global

burden of the diseases caused by these three major intestinal nematodes is 22.1 millionlost from hookworm, 10.5 million from A. lumbricoides, 6.4 million from T. trichiura

and 39.0 million from the three infections combined, in comparison to malaria at 35.7

million and Schistosomiasis at 4.5 million. The protozoan parasites although being less

common are associated with the highest number of mortalities (Warren and Mahmond,

1984).

In Finland, a survey on intestinal parasites was done among 243 inmates of institution

for the mentally retarded, 537 hospital patients from 4 areas, 100 military servicemen,

and 65 prisoners. Among the mentally retarded, the prevalence of intestinal parasites

was high, (41.3%) among children and (51.5%) among adults. The commonest parasite

was E. coli. In Helsinki, the prevalence among children in hospital was only (7.0%), but

among adult patients (18.9%). Among hospital patients in other areas, military

servicemen, and prisoners in Helsinki, the prevalence of intestinal parasites was low.

The high prevalence of E.coli, (14.8%) was among adult out-patients in Helsinki. Four

cases of trichuriasis were detected among the mentally retarded (Kyronseppa and

Pettersson, 1976).

Study conducted in California showed that stool examinations of 186 Indochinese

refugees and 90 immigrants from Mexico resettled in Contra Costa, County, California,

have shown that (60.0%) of refugees and (39.0%) of immigrants are infected with one

or more species of pathogenic protozoa and helminthes. The mean prevalent of infections among refugees and immigrants were hookworm (25 and 2.0%); whipworm

16



(22 and 12.0%); Ascaris (20 and 12.0%); G. lamblia, (11and 11.0%); Strongyloides (9

and 1.0%) and E. histolytica (2 and 4.0%). Clonorchis sinensis was found in (13.0%) of

refugees and H. nana in (9.0%) of immigrants (Arfaa, 1981).

In the United States in 1997, giardiasis cases per 100,000 state populations ranged from

1.0 to 42.3 with a national average of 9.5 cases per 100,000 populations (Furness et al,

2000). A study during 1999-2002 in Canada found that Giardia spp. infection occurred

at a rate of 19.6 per 100,000 populations per year. Although, the yearly incidence was

stable, a significant seasonal variation was observed with a peak in late summer to early

fall. Males were at significantly higher risk for development of this infection as

compared to females (21.2 Vs.17.9 per 100,000/yr) and there was a significant decrease

in risk associated with an increasing age. The incidence rate were 24.6/100000,

19.4/100000 and 6.2/100000 for the age group below 20 years, 20-64 years and above

64 years respectively. Similarly, they found that Cryptosporidium spp. infection

occurred at an overall rate of 6.0 per 100,000 populations per year although a large

outbreak of Cryptosporidium spp. infections occurred in the second half of the summer

of 2001. During August and September of 2001, the incidence of cryptosporidiosis was

55.1 per 100,000 per year as compared to 3.1 per 100,000 per year for the remainder of

the surveillance period (p<0.0001). Cryptosporidiosis was largely a disease of children

with an incidence of 17.8 per 100,000 per year occurring among those aged <20 years

of age compared to 1.25 per 100,000 per year for adult ≥20 years of age. The incidence

rate was slightly higher among male. However, it was not significant (Laupland and

Church, 2005).

A survey conducted among the rural and urban settlers and two tribal groups viz.

Nicobarese and Onges, of Andaman and Nicobar islands in 1996. The survey was

conducted between preschool school aged children and adults. Among the preschool

children, Nicobarese showed the highest overall prevalence rate (80.5%) followed by

urban (46.7%) and rural (38.6%) preschool children. A. lumbricoides was the

commonest form of parasite encountered in all the groups of preschool children,

followed by T. trichiura. The school age children among rural settlers showed an

overall prevalence rate of (61.1%) which was significantly higher than that among the

rural preschool children. The Nicobarese and Onge adults showed significantly higher

overall prevalence rates (72.2%) and (71.1%) vs. (48.6%) compared to rural adults. In

17



all the groups, studied ascariasis was the commonest form of parasitosis except in

Onges among whom trichuriasis and giardiasis were more common than ascariasis

(Sugunan et al , 1996).

In order to investigate the epidemiological situation of intestinal parasitic infections in

Laos parasitological surveys were carried out in the Vientiane Municipality. The

cumulative egg positive rate for intestinal helminthes was (61.9%). By species, the rate

for A. lumbricoides was (34.9%), hookworm (19.1%), T. trichiura (25.8%),

Opisthorchis viverrini (10.9%), Taenia sp. (0.6%) and Hymenolepis sp. (0.2%). The

northern mountainous regions such as Phongsaly, Huaphan or Saysomboune Province

showed a higher prevalence (over 70%) of soil- transmitted helminthes. On the other

hand S. mansoni eggs were detected in (1.7%) of school children. An additional small-

scale survey by cellophane anal swab detected E. vermicularis eggs in (35.7%) of 451

school children aged 6-8 years in Vientiane Municipality. Meanwhile, the mean blood

hemoglobin level of hookworm-infected children was not lower than that of children

not infected with hookworm, suggesting that nutritional factors are more important than

parasitic infection (Rim et al , 2003).

G. lamblia (15.2%) and H. nana (20.4%) were the two most frequently reported species

in a study of intestinal parasites from 1683 aboriginal people in Western Australia.

Concurrent infection with the two species was statistically significant in the 0 to3 years

age group only (p<0.01), and it was suggested that in older age groups the presence of

one of these parasites may in some way inhibit the development of the other. H. nana

infection was more common in males than in females (p<0.001). The hookworm and S.

stercoralis infections were confined to the tropical north of the State. The total or near-

total absence of infection with A. lumbricoides, T. trichiura and Entamoeba spp. (all

frequent in Western Australian aboriginal communities) was noted (Jones, 1980).

A study in Vientiane Municipality, the prevalence of hookworm, T. trichiura and A.

lumbricoides was found to be (9.8%), (5.3%) and (4.3%), respectively has been

reported. Majority of infected were healthy adults (Phompida et al , 2001).

In a study C. cayetanensis was observed in samples of only 7 of 474 (1.5%) subjects,

distributed as follows: 6 of the 157 HIV or AIDS patients (3.8%) and 1 of the 111

malnourished children (0.9%). C. cayetanensis oocysts were not observed in any of the

18



samples from the raspberry farm workers. For the 474 subjects based on wet

preparation only and Modified AF stains for coccidia, the most commonly observed

parasites were E. coli (19.6%), A. lumbricoides (14.8%), H. nana (13.3%), T. trichiura

(12.0%) and B. hominis (11.4%). C. parvum was observed in samples from 15 (3.2%)

subjects, of which 7 (6.3%) were malnourished children and 8 (5.1%) were HIV or

AIDS patients (Pratdesaba et al , 2001).

A study conducted in a community of rural Coted'Ivoire found the prevalence of

hookworm , E. histolytica / E. dispar and S. mansoni to be (45.0%), (42.2%), and

(39.8%), respectively. Three-quarters of the population harboured multi-parasites (Raso

et al , 2005).

The microscopic study of the stool samples from 1,659 children aged 15 years below in

metropolitan Lagos and showed a (71.9%) T. trichiura and (68.3%) A. lumbricoides,

respectively, while the infection rate with hookworm was (22.5%). Infection with more

than one parasite was also very common. Those children whose households had no

Toilet facilities had the lowest infection frequency with the intestinal parasites

surveyed, while those who used buckets as their means of fecal disposal had highest

rates (Fagbanro Beyioku et al , 1987).

The survey conducted for the prevalence and intensities of hookworm and roundworm

infections in the 15 farm worker communities in Zimbabwe with poor living conditions.

Examination of 1,635 fecal samples showed that hookworms were the commonest

helminthes (61.7%), followed by A. lumbricoides and T. trichiura. Age prevalence and

age intensity profiles for hookworms showed that infections increased with age, with a

peak in the adult age groups, A. lumbricoides prevalence was relatively high in children

but declined in the adults (Chandiwana et al , 1989).

An epidemiological survey of intestinal helminthiasis in Nigeria among 766 primary

school children aged 5-16 years and found a prevalence of A. lumbricoides (88.5%), T.

trichiura (84.5%), hookworm (33.1%) and S. stercoralis (3.0%). The influence of the

age and sex on infection level was obtained for pre-disposition of individuals to heavy

and light infection with A. lumbricoides ( Holland et al , 1989).

19



The survey of the intestinal helminthes in children living in Cockle Province, Republic

of Panama conducted by microscopically of the stool samples from 661 children

attending primary schools. The overall prevalence of A. lumbricoides, hookworm and

T. trichiura infection found (18.2%), (12.0%) and (27.5%) respectively. There were

significant differences between the infection prevalence values for children attending

the different schools, but not with respect to age or sex. Positive association was

detected between particular pairs of the infections and these were most evident with T.

trichiura (Robertson et al , 1989).

The age target chemotherapeutic control of geo-helminthiasis in the total population

11,500 of the Island of Monserrat, West Indies. The intervention program involved the

treatment with single dose of albendazole with all children age 2-15 years in 4

sequential cycles at intervals of 4 months. Infection status was monitored by an initial

coprological survey of age stratified sample (11.5%) of the population and by surveys

of smaller samples 4-5% after 2 and 4 cycles of treatment 7and 15 months respectively.

The program delivered treatment to greater than (90.0%) of the target population in

each cycle, and reduced the prevalence and intensity of A. lumbricoides and T. trichiura

infection in the target age class, a decline in infection was also observed in the 16-25

years age–class, even though less than (4.0%) of adults received treatment. The study

demonstrates that chemotherapy targeted only at children can be implemented within an

existing health infrastructure, and can achieve an overall reduction in the prevalence

and intensity of geo-helminthes infection (Bundy et al , 1990).

The parasitological examination was performed on 485 inhabitants of four villages of

Brazil. Approximately (99.6%) of the inhabitants were infected with at least some

species of the intestinal parasites. A high prevalence of S. mansoni (82.1%), hookworm

(80.2%), T. trichiura (69.9%), A. lumbricoides (61.9%) and E. coli (36.7%) infections

were demonstrates (Gonclaves et al , 1990).

An investigation of the prevalence and intensity of the STH was undertaken in four

villages in Oyo state, Nigeria. Diagnosis was based on examination of stool samples for

the presence of helminthes ova in all age. The prevalence of A. lumbricodes ranged

from (61.5%-72.2%), T. trichiura from (65.0%-74.0%) and hookworm from (52.4%-

63.0%) depending on the village concerned (Asaolu et al , 1992).

20



165 Meo Laotians stool sample were screened for intestinal parasites. One hundred

twenty-nine had at least one pathogenic parasite detected. The hookworm was detected

most frequently, followed by G. lamblia, T. trichiura, and A. lumbricoides. The

hookworm and overall infection were more frequent in persons 4 years of age and

older, while, giardiasis, ascariasis, and trichuriasis were the most common in the 4-14

years age group. Most infections were helminthic and of no public health consequence

in the United States. However, giardiasis was seven times as prevalent in refugee

children as in the general US population, posing a potential public health risk in child-

care settings (Wiesenthal et al , 1980).

A survey determined the extent of intestinal parasite infection in Bat Dambang,

Cambodia. The overall infection rate of intestinal parasites was (25.7%) (Boys-26.2%,

girls-25.1%), and the infection rates of intestinal helminthes by species were as follows:

Echinostoma spp. (4.8%), hookworm (3.4%), H. nana (1.3%) and Rhabditis spp.

(1.3%). The infection rates of intestinal protozoa were; E. coli 4.8%, G. lamblia (2.9%),

I. butschlii (1.4%), E. polecki (1.1%), and E. histolytica (0.8%). All children infected

were treated with albendazole, praziquantel, or metronidazole according to parasite

species. The results showed that intestinal parasites are endemic in Bat Dambang,

Cambodia (Park et al , 2004).

Study of the ethno-epidemiological profile of the Pankararu others group in the State of

Pernambuco, Brazil, identified multiple intestinal parasites in nearly all members of the

community. For the detection, possible environmental risk factors were under taken

using the database from a previous survey. The sample consisted of 84 families from

the original sample of 112. Selection was based on the number of stool tests performed

in the family. The mean number of parasite species was 5.0 per family, for a mean

family size of 6.1 members. Other household characteristics and hygienic habits did not

significantly influence this number. It has been concluded that multiple intestinal

parasitism in the Pernambuco Pankararu community is frequent, to the point of being

the rule, and that it relates essentially to water source and treatment (Fontobonne et al ,

2001).

The research was done on the distribution of intestinal helminthic infections in a rural

village in Guatemala. Fecal egg count scores were used to investigate the distribution

and abundance of intestinal helminthes in the population of a rural village. Prevalence

21



of the major helminthes was (41.0%) with A. lumbricoides, (60.0%) with T. trichiura

and (50.0%) with N. americanus. Infected females had higher burdens of T . trichiura

than infected males in all age classes of the population. There were no other effects of

the host gender. Analysis of associations between parasites within hosts revealed strong

correlations between A. lumbricoides and T. trichiura. Individuals with heavy infections

with A. lumbricoides and T. trichiura showed highly significant aggregation within

households. Associations between a variety of household features and heavy infections

with A. lumbricoides and T. trichiura were described (Anderson et al , 1993).

Study showed that prevalence of intestinal helminthes parasites were assessed in a sub

urban community of Maracaibo, Venezuela by examination of stool from 342

individuals, using iron hematoxylin stained fecal smears and formalin-ether

concentration. The overall parasitic infection rate was (80.4%-65.8%) of the population

had multiple infections. T. trichiura (71.9%) and A. lumbricoides (54.0%) were the

most common parasites, particularly in schoolchildren. The high rates of parasitic and

multiple infections reflect the low socio-economic status of the community studied

(Cachin-Bonilla et al , 1992).

The survey performed for prevalence of intestinal helminthiasis among students of

Nigeria. Of the 200 students between ages 10-20 years old examined, 86 were found

infected. The most commonly found worms were hookworm, A. lumbricoides, T.

trichiura with mean egg per gram of 4800, 2600 and 1250, respectively (Alo et al ,

1993).

The examination of sample was done randomly in 2848 different study sites, with about

500 people from each site. By examinations of the stool using Kato-Katz thick smear

and larval culture techniques, overall prevalence of A. lumbricoides, T. trichiura and

hookworm infections were found (47.0%), (18.8%) and (17.2%), respectively. Higher

Prevalence of ascariasis and trichuriasis were found in the age group of 5-9, 10-14 and

15-19 years and among adults for hookworm students, farmers and fishermen were the

occupational groups with high infection rates (Xu et al , 1995).

The survey was done on two occasions to determine the prevalence of intestinal

parasites on Indonesia. Overall, 478 subjects i.e. (10.0 %) of the population from three

villagers were sampled. Using standard wet mounts techniques, fifteen different species

22



of parasites were found. The hookworm was the highest prevalent parasites in all age

groups. The other helminthes were A. lumbricoides (46.0%-57.0 %) and T. trichiura

(15.0%-25.0%) (Bangs et al , 1996).

Survey for intestinal parasites was done by using thin smear and floating method for

fecal examination in residents in Caazapa Department, Paraguay. Out of 608 samples of

residents in Boqueron, a community of Caazapa Department, 343 (56.5%) were found

positive. The most prevalent parasite was N. americanus (27.0%) followed by E. coli

(19.8%), G. lamblia (12.7%), A. lumbricoides (4.8%) and others. The infection rate

with G. lamblia and A. lumbricoides were more frequent in children than in adults

(Saito et al, 1996).

The evaluation of the impact of drug treatment on infection by A. lumbricoides,

T . trichiura and hookworms in a rural community from the sugar-cane zone of

Pernambuco, Brazil was performed. Individual diagnosis was based on eight slides

(four by the Kato-Katz method and four by the Hoffman method) per survey. Infected

subjects were assigned to two groups for treatment with either albendazole or

mebendazole. Prevalence of infection fell significantly (p<0.05) one month after

treatment: A. lumbricoides from (47.7%-6.6%), T. trichiura from (45.7%-31.8%) and

hookworm from (47.7%-24.5%). One year after treatment, infections by T. trichiura

and hookworm remained significantly below pre-control levels (Zani et al , 2004).

A prospective study was performed to determine the prevalence of B. hominis infection

in school children from Bolivar City. Altogether 446 children, between five and

fourteen years old, both sexes, using direct examination of feces and Willis Method.

They were also evaluated clinically. Results showed that B. hominis had a prevalence of

(16.8%). In 39 schoolchildren (52.0%) they found other parasites along with B.

hominis, the most frequent was T. trichiura as helminth and G. lamblia as protozoan. B.

hominis alone was found in 36 cases (48.0%) (Devara et al , 1997).

Infection with E. histolytica was studied in two slum communities in northeastern

Brazil. Twenty-eight index patients colonized with B. hominis were identified. Three

stool specimens from the index patients and their household contacts were gathered

over a 45-day period and tested for E. histolytica by means of a specific enzyme-linked

immunosorbent assay-based detection kit. Blood samples were also collected at the start

23



of the study, at 45 days, and at 6 months and analyzed for E. histolytica-specific

antibody. High rates of colonization were seen in the family units. Colonization was

self-limited, with (85.0%) of colonized patients clearing their infections within 45 days

(Braga et al, 2001).

A community-based study was conducted among randomly selected 300 children aged

less than five years selected from three camps of the police force in Khartoum, Sudan.

The commonest infestations were giardiasis (21.1%), taeniasis (10.4%) and enterobiasis

(7.4%). Non-pathogenic E. coli, E. histolytica and T. saginata were detected in (2.7%),

(0.7%) and (1.7%) of stools specimen, respectively. Children aged between 3 years and

above were the most affected group and the infection rate was highest among the

illiterate, overcrowded and large sized families. Malnourished children comprised

(9.4%). A community-based study of Blastocystis and other intestinal parasites was

done in the Asaro Valley, Papua New Guinea. Apart from infants, nearly everybody

had at least one infection, and the mean number of infections per person was around

2.7. The graph of age-specific prevalence for Blastocystis is similar in shape to those

for E. coli and H. nana, indicating probable similarity in transmission patterns and host

response (Ashford et al , 1992).

A community-based study was conducted among randomly selected 300 children aged

less than five years selected from three camps of the police force in Khartoum, Sudan.

The commonest infestations were giardiasis (21.1%), taeniasis (10.4%) and enterobiasis

(7.4%). Non-pathogenic E. coli, E. histolytica and T. saginata were detected in (2.7%),

(0.7%) and (1.7%) of stools specimen, respectively. Children aged between 3 years and

above were the most affected group and the infection rate was highest among the

illiterate, overcrowded and large sized families. Malnourished children comprised

(9.4%) of the study group but there was no significant association between malnutrition

and the overall prevalence of intestinal infestations, although G. lamblia significantly

affected the malnourished group (Karrar et al, 1995).

The study was conducted to relate personal data, socio-cultural and environmental

characteristics, and the presence of symptoms/signs with the frequencies of Giardia sp.

and B. hominis among a rural population in Buenos Aires Province, Argentina. Of the

surveyed 350 population, (3.7%) were infected with only Giardia spp and (22.9%) with

B. hominis and (2.3%) were infected with both protozoa. The frequency of infection

24



according to sex; (6.1%) of males were infected and (1.6%) of females by Giardia sp.

(26.7%-19.5%) by B. hominis, and (2.4%-2.2%) by both parasites, respectively.

Giardia sp. was detected in only three adults (over 14 years), but B. hominis was more

frequent in adults than in children (Minville et al, 2004).

A study conducted to determine the prevalence and intensity of intestinal helminthes

infections among the children belonging to lower socio-economic status. Stool samples

collected were processed by modified formalin ethyl acetate sedimentation technique.

177 children were infected with one or more of intestinal parasites as A. lumbricoides,

T. trichiura and hookworm. The overall prevalence of infection was (82.0%). A.

lumbricoides was the most common infection with prevalence of (75.0%) followed by

T. trichiura (66.0%) and hookworm (9.0%) (Paul and Gnanamani, 1999).

Another study conducted in a small scale survey of intestinal parasites infection among

school children and adolescents in Philippines. The overall prevalence rate was (78.1%)

with T. trichiura topping the list (51.0%) followed by A. lumbricoides ( 40.0%),

hookworm (23.4%), Iodamoeba butschlii (15.6%), Endolimax nana (14.1%), E. coli

(9.4%) and G. lamblia (7.8%). The infection rate of primary school children, preschool

children and adolescent were (95.5%), (64.7%) and (87.7%), respectively. The infection

rate in urban area was (56.0%) and (92.3%) in rural areas (Lee et al , 2000).

3.2 Asian countries scenario

Several reports of patients with cysticercosis from many countries in Asia such as India,

China, Indonesia, Thailand, Korea, Taiwan and Nepal are a clear indicator of the wide

prevalence of T. Solium, cysticercosis and taeniasis. It is also a major cause of epilepsy

in Bali (Indonesia), Vietnam and possibly China and Nepal. Seroprevalence studiesindicate high rates of exposure to the parasite in several countries (Vietnam, China,

Korea and Bali (Indonesia)) with rates ranging from (0.02-12.6%). An astonishingly

high rate of taeniasis of (50.0%) was reported from an area in Nepal populated by pig

rearing farmers. Undoubtedly, cysticercosis is a major public health problem in several

Asian countries affecting several million people by not only causing neurological

morbidity but also imposing economic hardship on impoverished populations

(Rajshekhar et al, 2003).

25



A study in Sichuan Province of China found that among 310 residents of Lugao

Village, Hejiang County, (87.0%), (63.0%) and (60.0%) residents were infected with

hookworm, A. lumbricoides and T. trichiura respectively. The prevalence of hookworm

was found to rise linearly with age. The majority of these individuals harbored mixed

infection with N. americanus and A. duodenate, although the former predominated. It

was found that despite economic development which was occurring in some parts of

China, significant hookworm infections and clinical hookworm anemia existed in areas

of Sichuan Province. In Hejiang Country, it was found that the intensity of hookworm

infection had actually risen within the last 10 years. The hookworm is a medical

problem among the elderly in Sichuan (Changhua et al, 1999).

Ascariasis is the most common parasitic disease in China. According to a nationwide

sampling survey in 1988-1992 the average infection rate was 47.0% i.e. around 531

million people were infected (Feng et al, 2001a). A study in Jiangxi Province of China

has reported (72.5%) prevalence rate. The positive rate of different parasites was A.

lumbricoides-(50.9%), T. trichiura-(33.4%), hookworms-(11.4%), G. lamblia-(2.8%),

E. coli-(1.2%) and E. histolytica-(0.8%) (Chai et al, 2001a).

In a study done among people in Coastal areas of Korea, the prevalence rate was found

to be (4.2%) and (0.4%) respectively for T. trichiura and A. lumbricoides respectively.

Similarly, the infection rates for other parasites were C. parvum (3.5%), E. coli (2.2%),

G. lamblia (1.8%), E. nana (1.4%) and T. trichiura (0.2%). Among people above 60

years, T. trichiura (4.2%) was the commonest parasite followed by A. lumbricoides

(1.1%) (Chai et al, 2001b).

The G. lamblia, a gastrointestinal protozoan, is one of the most common disease-causing parasites in the world. Giardiasis is primarily encountered in areas with poor

sanitation, but it is also seen in more developed countries. A possible sequela of Giardia

infections of the bowel is reactive arthritis or synovitis. Few reports of synovitis

secondary to giardiasis exist in the literature. Arthropathy secondary to giardiasis is

uncommon, but may be underdiagnosed. A 23 year-old woman, who had polyarthritis

after G. lamblia infestation, the diagnosis of G. synovitis should be suspected by the

presence of Giardia cysts in the stool (Kim et al , 2001).

26



In a community-based study among pediatrics of Saudi Arabia, (21.1%) was found to

harbor intestinal parasites; the most affected age group being 5-9 years and no

difference in gender wise distribution. Specific prevalence rates were G. lamblia (9.0

%, E. histolytica (5.0%), H. nana (2.0%) and E. vermicularis (2.0%) (Assuhaimi et al ,

1995).

A small scale survey was performed in children of the residential institutions and street

communities in Metro Manila, Philippines. A total of 284 stool samples were collected.

The scotch tape anal swab was adapted to investigate the infection status of

E. vermicularis. It was found that (62.0%) of the children examined were positive for

one or more intestinal parasites. Multiple infections were observed in (34.2%) of the

children. Among 172 children who gave detail information, the prevalence for A.

lumbricoides, T. trichiura, and hookworm was (36.0%), (44.8%), and (7.0%),

respectively of the children examined, (47.7%) were found to be harboring parasitic

protozoa such as E. histolytica, G. lamblia, and B. hominis. The most prevalence

protozoan was B. hominis with an infection rate of (40.7%) (Eleonar et al , 2004).

A retrospective study among expatriate workers in Al-Ain city was performed in United

Arab Emirates to determine the prevalence of pathogenic parasitic infection. Stool

specimens were examined. Overall prevalence was 23.1%. The most common parasitic

found included: Ancylostoma sp. (6.7%), A. lumbricoides (6.6%), T. trichiura (6.2%),

and G. lamblia (2.4%). The distribution of intestinal parasites among expatriates was

different for all nationalities. The results showed that G. lamblia, was more prevalent

among Iranians (54.7%) and Pakistanis (42.2%), Ancylostoma sp was found to be more

prevalent among Sri Lankans (22.3%) and Indians (39.6%), A. lumbricoides was more

prevalent among Bangladeshis (3.1%) and T. trichiura was more prevalent among

Pilipino (Ibrahim et al, 1993).

Stool survey was carried out in some of the villages of Dadraul and Bhawal Khera

PHC's of district Shahjahanpur (Uttar Pradesh). Among them (29.2%) were found

positive for one or the more intestinal parasite. A. lumbricoides superseded all the

parasites by showing a positively of (17.8%). Other parasites found were hookworm,

H. nana, tapeworm, T. trichiura, E. vermicularis, and E. coli and G. lamblia. Parasitic

load was slightly higher in females (33.5%) than males (28.1%). The highest positivity

was encountered in the age groups between 6 to 14 years (Virk et al, 1994).

27



Ascaris lumbricoides infestation (ALI) is one of the most common helminthic diseases

of the gastrointestinal tract, and may cause severe surgical complications, especially in

children. A case of a 5-years old Pakistan girl treated in Italy for acute abdomen in

which ALI was detected during surgical exploration (Mosiello et al , 2003).

A study conducted in Srilanka, showed examination of total 192 stool samples from the

adult and the pre-school children) was done. E. histolytica was not seen in any of the

samples; Giardia cysts and Cryptosporidium oocysts were seen in 3 and 1 sample

respectively from the pre-school children. The overall prevalence of geohelminth

infections was (21.3%) among the adults and (24.5%) among the children.

A. lumbricoides was the predominant species in both populations (De Silva et al, 1994).

A national survey of intestinal parasitosis in Iran, intestinal parasitic infection rate was

detected as 19.3% (19.7% male, 19.1% female). In the study, G. lamblia (10.9%), A.

lumbricoides (1.5%), E. histolytica (1.0%) and E. vermicularis (0.5%) were the most

common parasites. The infection rate was highest in the 2–14 years age group (25.5%)

and in rural residents (23.7%). The prevalence rate of T. saginata, colubriformis, T.

trichiura and A. duodenate were (0.2%), (0.2%), (0.1%) and less than (0.1%)

respectively. The total prevalence of intestinal parasite among people of age group 40-

69 was (15.0%) and greater than 69 years was (11.6%). The prevalence of individual

parasites in 40-69 years age group was G. lamblia (7.3%), A. lumbricoides (1.5%), E.

histolytica (1.1%) and E. vermicularis (0.2%). The prevalence of individual parasites

was G. lamblia (5.0%), A. lumbricoides (1.2%), E. vermicularis (0.1%) and E.

histolytica (0.7%) in age group greater than 69 years (Sayyari et al, 2005).

The study was undertaken to measure the impact of periodic deworming with

albendazole on growth status and incidence of diarrhea in children aged 2-5 years in an

urban setting in India. The two study groups received two doses of albendazole (400

mg) or placebo six months apart. Mean weight increased significantly in the

albendazole group compared to the control group at three months, six months and nine

months following treatment (p<0.01, p<0.01 and p<0.001, respectively). The

albendazole group also experienced fewer episodes of diarrhoea than their control

counterparts (relative risk 1.3, 95% CI 1.07-1.53) with a (28.0%) reduction (Sur et al,

2005).

28



Study conducted in the union Territory, Chandigarh, India estimates the prevalence of

intestinal parasitic infections in different population groups. The prevalence of

intestinal parasitic infections was found to be (14.6%) with highest prevalence of

(19.0%) from the slum area. Children were the most commonly affected group (18.0%)

with those from slums showing the highest prevalence (24.6%). The most common

parasite was Giardia. spp (5.5%) followed by H. nana and A. lumbricoides (2.8% and

2.7%) respectively (Khurana et al , 2005).

Parasitic infection among primary school-going children between the age group of 5 to

10 was examined in the urban and rural areas of Manipur. A total of 248 (24.5%) were

positive for various helminthes. Among the positive cases, 110 (26.3%) were from the

urban area (city) and 138 (23.4%) from the rural areas of Manipur. Maximum number

of parasitic infection occurred in the age group of 5 to 6 years (27.0%) in both sexes.

Among the parasites, A. lumbricoides was the commonest (19.6%) followed by T.

trichiura (2.18%), H. nana (0.99%), tapeworm (0.19%), hookworm (0.09%), S.

stercoralis (0.09%), E. vermicularis (0.09%) (Singh et al , 2004).

Stool samples were collected 3 to 6 months post-treatment to study the rate of

reinfection. The cure rates for A. lumbricoides, T. trichiura and hookworms were

(70.8%), (68.7%) and (93.0%), respectively. Re-infection rates after 3 months of

successful treatment were (19.6%) for A. lumbricoides (30.9%) for T. trichiura and

(11.3%) for hookworms. Six months post-treatment, the prevalence of re-infection was

highest with T. trichiura (43.6%) followed by A. lumbricoides (35.3%). The rate of

reinfection with hookworms was lower (11.3%) six months post-treatment. The rates of

re-infection with A. lumbricoides and T. trichiura were higher in children below 15

years of age, compared with adults. The hookworm reinfection was higher in the adult

age group (15 to 39 years). The rates of new infection in previously uninfected subjects

were lower compared with the rates for re-infection (Narain et al, 2004).

The health risks of wastewater use in agriculture were investigated in the city of

Faisalabad, Pakistan, by means of a cross-sectional study. The study showed an

increased risk of intestinal nematode infection and hookworm infection. In particularly,

wastewater farmers (OR = 31.4, 95% CI 4.1-243) and their children (OR = 5.7, 95% CI

2.1-16) when compared with farming households using regular (non-wastewater)

irrigation water (Ensink et al , 2005).

29



The study was designed to examine stool specimens of irritable bowel syndrome (IBS)

patients for B. hominis. One hundred fifty patients were enrolled, 95 IBS cases and 55

controls. The 95 cases (51 males and 44 females) had a mean +/- SD age of 37.8 +/-

13.2 years. Stool microscopy was positive for B. hominis in (32.0%) 30 of 95 of the

cases and (7.0%) 4 of 55 of the controls (p<0.001). Stool culture was positive in

(46.0%) 44 of 95 of the cases and (7.0%) 4 of 55 of the controls (p<0.001). Stool

culture has a higher positive yield for B. hominis than stool microscopy (Yakoob et al,

2004).

The study was conducted in Konkor, Gadap, District East, and Karachi to determine the

prevalence of intestinal parasitic infection. Out of 263 residents 185 tested for intestinal

parasites and 88 (47.5%) had pathogenic parasites. The distributions of parasites were

G. lamblia (50.0%) and E. histolytica (48.86%). Statistically none of the socio-

demographic variables were associated except education and age group (Siddiqui et al,

2002).

This study was carried out at the northern part of Bangladesh to determine the impact of

sanitary latrine use and of health education on intestinal parasites in school-aged

children. The children were between 5 and 13 years of age and stool samples revealed

that more than half (53.0%) of the study sample was still infected with one or more

intestinal parasites even after 4 years of intervention. Ascariasis was found to have the

highest prevalence rate (36.2%) and hookworm the lowest (10.7%). Intestinal parasite

infection was significantly lower (p<0.05) among those who used a sanitary latrine and

received health education (Hosain et al , 2003).

In Bangladesh, (80-90%) of human excreta found its way into soil or water. Refuses,

garden, and water sources were found to be infected predominantly by A. lumbricoides

ova. The entire soil sample collected from different households of the village of

Bangladesh was positive for A. lumbricoides and (13.3% - 22.2%) of the soil was

contaminated with the eggs of T. trichiura (Muttalib et al, 1983).

A study was done among the children of age below 4 years suffering from

gastrointestinal problem in rural Bengal. Most common parasite was G. lamblia

(17.2%), followed by E. vermicularis (12.2%) and E. histolytica and A. lumbricoides

30



both (8.1%). A significantly lower infection rate was observed in children below one

year (24.4%) than older age groups (66.4%) (Saha et al , 1995).

Socio-economic and behavioral factors affecting the prevalence of geo-helminthes in

preschool children in Sri Lanka was studied. They examined relationship between the

prevalence of geo-helminthes infection in pre-school children living in the urban slum

area and parental education, socio-economic status, the use of antihelminthic and

beliefs regarding these helminthes. Stool sample from 307 children were examined by

direct smear and concentration method. Overall prevalence was found (26.4%) and

more interestingly A. lumbricoides (90.1%) predominated all of helminthes. The

parental education level and socio-economic conditions influenced geo-helminthes

infections in children (de Silva et al , 1996).

A randomized clinical intervention trial over 24 weeks on a tea estate in north-east

Bangladesh to investigate the effect of iron supplementation and antihelminthic

treatment on the labour productivity of adult female tea pluckers. A total of 553 full-

time tea pluckers, not pregnant and not breastfeeding, were randomly assigned to one of

the four intervention groups: group 1 received iron supplementation on a weekly basis,

group 2 received antihelminthic treatment at the beginning and half-way through the

trial (week 12), group 3 received both iron supplementation as group 1 and

antihelminthic treatment as group 2, and group 4 was a control group and received

placebos. However, there was a negative association for all three worms ( A.

lumbricoides, T. trichiura and hookworms) between the intensity of helminth infections

(eggs/faeces) and all measures of labour productivity. Lower hemoglobin values and

anemia (<120 g/l Hb) were both associated with lower labour productivity and more

days sick and absent. Taller women with greater arm circumference were able to pluck

more green leaves, earn higher wages and were absent less often (Gilgen et al , 2001).

In developing countries many enteric infections are caused by acid-sensitive pathogens.

Study was conducted in 185 Bangladeshi men admitted to hospital for the treatment of

enteric infection. Patients with dysentery (amoebiasis, n=24 and shigellosis, n=19) and

culture-negative diarrhoea (n=69) had similar mean gastric acid levels (basal, 3-5

mmol/h; stimulated, 11-17 mmol/h), which remained stable in those patients studied

throughout 12 weeks of convalescence. Gastric acid levels were not associated with G.

duodenalis or S. stercoralis co-infection, fever, use of tobacco, or chewing betel nut.

31



Factors which impair gastric acid secretion may predispose to diarrhoel disease in

developing countries (Evans et al, 1997).

Stool samples from 880 residents in an urban slum in Dhaka, Bangladesh, were

collected and examined for intestinal parasites. Information on many potential risk

factors for infection was obtained by questionnaire from a respondent in each

household studied. In a crude univariate analysis of the data, several of the factors were

found to be significantly associated with S . stercoralis infection. Most of these factors

were co-variate with one another and with poverty generally (Hall et al, 1994).

The survey was done in the western region of Bhutan to assess the prevalence and

intensity of soil-transmitted helminth (STH) infections after 15 years of schooldeworming in the country. Stool samples were collected from each child as well as

nutritional indicators and general information on each school. The survey found a

cumulative prevalence of (16.5%) STH (4.8% in schools treated in the last three months

and 24% in the untreated schools). An unexpected finding was that the tapeworm

infection rate of (6.7%). These results indicate a high reinfection rate in this area. WHO

recommends (50.0%) prevalence as the threshold for the establishment of community

intervention (Allen et al 2004).

3.3 National Scenario

In Nepal due to lower socio-economic and poor hygienic conditions of the people

intestinal parasitosis is very much prevalent (Nepal and Palfy, 1980; Estevez et al ,

1983; Rai and Gurung, 1986; Sherchand et al , 1996, 1997; Rai et al , 1994a, 1994b,

1995; Ishiyama et al , 2001; Ono et al , 2001). Therefore, there is no question that

intestinal parasites are important causative agents of the major public health problems

of the country. In some rural areas of Nepal parasitic infection rate approach one

hundred percent with significant portion of parasitic infection (Reily, 1980; Estevez et

al , 1983).

A random sample study in patients in Bhaktapur was conducted to ascertain the

incidence of roundworm infection. A total 976 stool samples were collected over a 5

years period. Among them 430 samples were from adult males, 326 were from adultfemales and 220 were from children of both sexes under 12 years of age. The result

32



showed that (32.0%) of adult males, (44.0%) of adult females and (49.0%) of children

were infected giving an overall incidence of (40.0%) (Sharma, 1965).

A microscopical examination of 80 students studying in Auxiliary Health Worker’s

school was carried out by Sharma and Tuladhar (1971). They found (87.4%) students

were infected by different parasites like protozoa and helminthes. A. lumbricoides was

the commonest parasites followed by hookworm, T. trichiura, G. lamblia and E.

vermicularis. Nepal and Palfy (1980) examined 225 stools samples to find the

prevalence of intestinal parasites. Only (4.4%) of the samples showed negative result.

The most common helminth was A. lumbricoides (63.5%) followed by hookworm

(55.9%) and T. trichiura (37.6%). Among protozoa E. histolytica (28.8%) and G.

lamblia (28.8%) topped the list followed by E. coli (24.4%). presences of more than

one parasite were found in 55.1% samples.

Khetan (1980) examined 2,073 stool samples in the pathology laboratory of Narayani

Zonal Hospital during 1977 to 1980. Among them 1,592 stool samples were found

positive for parasitic infestation and (29.0%) were infected by hookworm followed by

A. lumbricoides (21.9%), T. trichiura (9.9%), G. lamblia (8.5%) and E. histolytica

(4.0%).

Estevez et al (1983) collected and examined 40 specimens of stool samples in a remote

area of Western Nepal. Among them, (90.0%) were found positive for parasites as

determined by direct wet mount and trichrome smears. In total positive samples

(83.3%) of individuals were infected with hookworm, (52.8%) with roundworm and

(5.5%) with whipworm. All of the positive samples contained several parasite species,

averaging 4 spp. per specimen.

A study conducted in Bhaktapur district by Shrestha (1983) showed stools were

positive for the eggs of STH (99.0%), A. lumbricoides (94.0%), T. trichiura (42.0%)

and hookworm (11.0%). Similarly, from the Panchkhal area in Kavre District (41.0%)

stools were positive for the eggs of helminthes. Of these (75.0%) were of T. trichiura,

(37.0%) were of hookworm, (19.0%) were of A. lumbricoides.

The study was conducted to represents the status of intestinal parasitosis in public

schoolchildren (1 to 10 classes) in a rural area of the Kathmandu Valley her habits,

33



including factors predisposing to parasitic infections. Stool samples from the children

were examined. The overall prevalence of parasitosis was 66.6% (395/533). Altogether,

nine types of parasites were recovered. The recovery rate of helminthes was higher

(76.9%) than protozoa (23.1%). T. trichiura was the most common helminth detected,

followed by hookworm, A. lumbricoides and others. E. coli was the most common

protozoan parasite, followed by E. histolytica, G. lamblia and others (Sharma et al ,

2004).

Intestinal parasitological survey was conducted to clarify the distribution of intestinal

parasites in Nepal and Lao Peoples' Democratic Republic (Lao PDR) from 2001 to

2003. The stool specimens were examined using the formalin-ether sedimentation

(FES) and sucrose centrifugal flotation (SCF) techniques. Nine species (3 Nematoda, 1

Cestoda, and 5 Protozoa) of parasites were recovered from Nepal, whereas seven

species (3 Nematoda, 1 Trematoda, and 3 Protozoa) from Lao PDR. Out of which,

(14.4%) was the most common in Nepal, and was O. viverrini (29.8%) in Lao PDR.

Infection rates were markedly different among age groups in both countries; higher

rates were observed in age groups of 10-29 years than in 0-9 years group (Takemasa et

al , 2004).

Intestinal parasites were detected in diarrheal stool samples collected from individuals

aged 1 to 68 years (males: 239 and females: 157) in Nepal. Parasites were detected by

employing the formal-ether sedimentation technique. Of a total of 396 fecal samples

investigated, 193 (49.0 %) were positive for some kind of parasite. Altogether, 15

species of parasites were detected. G. intestinalis topped the list of protozoa, whereas

T. trichiura was the most frequently detected among helminth parasites. Of the 193

positive samples, 109 (56.0 %) had single parasite infections, whereas 84 (43.0 %) had

multiple infections with a maximum of five species. Of the total positive, 45 (23.0%)

had both protozoa and helminthes whereas 37 (19.0%) had only protozoa. Females

(52.0%) and children (15 years and under) (52%) had a marginally higher prevalence

compared with males (46.0%) and adults (45.0%), respectively (p>0.05) (Uga et al ,

2004).

Study on intestinal parasites from the Kathmandu area of Nepal was done in children

(HC) and adults (HA) the total parasite load was (28.1%) and (38.8%), respectively,

whereas children (ADC) and adults (ADA) with abdominal discomfort had a load of

34



(62.7%) and (67.8%). The prevalence of nematodes in the 4 groups was significantly

higher in those with abdominal discomfort, particularly of hookworm, Enterobius, and

Ascaris, H. nana was the most common tapeworm, and with the highest incidence in

patients with abdominal complaints. T. solium and T. saginata were only found in the

two adult groups, but with low prevalence rates. The highest incidence of

Cryptosporidium was found in both groups with abdominal discomfort, notably among

children. The presence of Giardia was highest among the sick children, many "healthy"

carriers among both children and adults were noted. E. histolytica and E. dispar had a

surprisingly low prevalence in all 4 groups. B. hominis was most common among adults

with abdominal complaints (2.8%). Trichomonas spp. was also more common in this

group, in which of 34 positive specimen, 28 were from women (Sherchand et al, 1996).

Kimura et al (2005) studied diarrheal diseases associated with C. cayetanensis in Nepal

and Lao PDR. C. cayetanensis was detected by direct microscopy using ultraviolet and

differential interference contrast microscopy. The overall positive rate in Nepal was

9.2% (128/ 1397). A higher positive rate was observed in children aged 10 years and

under (11.1%) and was lowest in the age group of 51-60 years (3.1%). A significantly

higher positive rate was observed in the summer (rainy season) (12.6%) with the lowest

prevalence in the spring (dry season) (1.8%) (p<0.05). The positive rate was closely

associated with rainfall (ml/month). Only one of the total 686 samples (0.1%) from Lao

PDR was found to be positive for Cyclospora oocysts.

Rai et al, (1999) a hospital-based study in Kathmandu showed ascariasis as major

causes of public health problem in Nepal though the extent of ascariasis-associated

morbidity and mortality has not been investigated yet. In some rural areas, over (75.0%)

people are infected with this parasite.

The prevalence of intestinal parasitic infection was carried out in Tribhuvan University

Teaching Hospital, in Kathmandu. Stool samples were examined. Among the various

types of protozoan parasites, the most common was G. lamblia followed by E.

histolytica (Rai et al , 1995).

According to Rai et al ( 1997) the health and sanitary status of Boya village was studied.

The number of households having latrine increased significantly (p<0.05) in one year

period but without significant impact on the reduction of intestinal helminth infection

35



(p>0.05). A. lumbricoides was the commonest intestinal parasite followed by

hookworm and others. Public piped line water was provided to (32.6%) households

while remaining (48.4%) and (19.0%) were using natural tap and kuwa water,

respectively. No association between the type of water source and gastro-enteritis was

observed. There was poor hygienic condition. Majority of complaints were

gastrointestinal.

The parasitic infection rate of (50.0%) has been reported by the studies conducted in the

Nepalese communities from 1979-1995 by different organizations. A. lumbricoides and

G. lamblia topped the list respectively among helminthes and protozoan. Similarly, the

hospital records showed the infection rate of 30% to 40 % (Chhetri, 1997).

Ishiyama et al (2001) has reported the parasite prevalence of 72.4% among school

children in Kathmandu. Indo-Aryans were found to have marginally high rate of

infection. Among which, (46.9%) had multiple infections. T. trichiura (30.4%) was

found to be the commonest helminth and G. lamblia (17.0%), the commonest

protozoan. No bacterial entero-pathogens were reported in the study population.

A study conducted in Jiri revealed that the prevalence of Whipworm, Roundworm and

hookworm among Jirel were (18.1%), (25.3%) and (73.5%), respectively. Similarly,

prevalence of Whipworm, Roundworm and hookworm among Sherpa above were

(11.2%), (23.6%) and (46.1%), respectively. Similarly, the prevalence of Whipworm,

Roundworm and hookworm among Hindu of age group 45 above were (7.1%), (26.2%)

and (59.5%) respectively. The study found the increasement in multiple helminthic

infections with increasement in age (Blangero et al , 1993).

Rai et al (2000a) intestinal helminthic infection and its effect on vitamin A, retinol and

β carotene, was studied in Okharpauwa Village Development Committee (VDC)

(Nuwakot district) and 79 inhabitants (mainly adults) of Boya VDC (Bhojpur District)

subjects living at an altitude of 2000 m. Most common helminth detected was A.

lumbricoides followed by T. trichiura in Okharpauwa VDC and by hookworm in Boya

VDC.

36



CHAPTER IV

4. MATERIALS AND METHODS

A list of materials, chemicals, equipments, reagents for the study is presented in

Appendix 1.

4.1 Subject and site of the study

The laboratory investigation part of this dissertation was carried out in National

Institute of Tropical Medicine and Public Health Research, Maharajgunj, Chakrapath,

Sankhamarg, Kathmandu. The study period of this investigation is September 2008 to

December 2008.

4.2 Sample collection

Each student was given the brief description about the importance of the examination of

stool to detect the parasite. They were advised not to contaminate the stool with water

and urine. The containers were labeled with patient’s name, date and time of collection.

During the process of specimen collection from each person, a questionnaire

accompanying the queries about their clinical history, hygienic practice and nutritional

37



behavior was filled. Labeled dry, clean disinfectant free wide mouthed plastic container

was distributed and asked them to bring about 20 gm stool sample next morning.

4.3 Transportation of the samples

The collected stool samples were immediately fixed with 10% formal saline mixing

with equal part of formal saline and stool. The formalin fixed samples were brought to

laboratory. Then laboratory processing was done at NITMPHR.

4.4 Laboratory processing of the samples

Each stool sample was processed in 2 steps as:

• Macroscopic examination

• Microscopic examination

4.4.1 Macroscopic examination

The direct visualization of each sample was done for the color, blood, consistency,

presence of mucus, and adult worm or worm segment.

Colour

Based on the color, the stool specimen were categorized into groups i.e. normal color of

stool (yellowish brown) and abnormal color of stool (muddy, black, pale etc.)

Consistency

Based on consistency stool specimen were classified as formed, semi-formed and loose.

The trophozoites are usually found in the soft or loose stools whereas the protozoal

cysts are found in formed and semi-formed stool. Helminthic eggs and larva can be

found in any type of stool specimen.

Blood and mucus

The stool specimens were observed whether it contains blood and mucus or not. Blood

and mucus may be found in stool from patients with amoebic dysentery, intestinal

38



taeniasis, intestinal schistosomiasis, invasive balantidiasis and in severe T. trichiura

infections. Other non parasitic conditions in which blood and mucus may be found

include bacillary dysentery, Campylobacter enteritis, ulcerative colitis, intestinal tumor

and hemorrhoids.

4.4.2 Microscopic examination

This is required for the detection and identification of protozoal cysts, oocysts, and

helminthic eggs or larva.

Microscopic examination was done by saline and iodine wet mount and the slides were

observed under low power (10x) followed by high power (40x) of the microscope.

Parasites were identified by their morphology, motility and staining characteristics.

While performing wet mount, all the samples were subjected to concentration. It

concentrates the eggs, larva and cysts when they are present in small number and

increases the sensitivity of microscopic examination. Trophozoites are destroyed in the

process. There are various floatation and sedimentation techniques of concentration.

Formal-ether sedimentation method leading to saline/Iodine wet mount.

This is the most sensitive method of concentrating cysts, eggs and larva without

distortion of their morphology. It takes short time and is the minimum chances of error.

The technique was applied as follow:

(10% formal saline was prepared by adding 10ml of formaldehyde in 90ml saline

water)

1. About one gram of stool sample was emulsified in about 4ml of 10% formal saline

solution, shaken well and the suspension was allowed to stand for 30 minutes for

adequate fixation.

2. Further 3-4 ml of 10% formal saline was added and then shaken well.

3. The suspension was sieved through cotton gauge in a funnel into a 15 ml centrifuge

tube.

39



4. 3-4 ml of ether was added and shaken vigorously for 5 minutes.

5. The tube was immediately centrifuged at 1000 rpm for 10 minutes

6. Four layers of suspension were obtained in the tube after centrifugation.

a. A small amount of sediment at the bottom of the tube containing the parasite.

b. A layer of formalin on the top of the sediment.

c. A plug of fecal debris on the top of formalin layer.

d. A layer of diethyl ether at the top.

7. The plug of debris formed between diethyl ether and formalin was removed by

rotating the tip of the applicator along the inner wall of the tube.

8. The supernatant layers of suspension were discarded and the sediment was examined

by saline and iodine wet mount.

Saline wet mount

It was used to detect helminth eggs, larvae and the protozoal cysts. A drop of normal

saline was taken on a clean glass slide; a drop of sediment from the above process was

mixed with it and observed under microscope after covering with a cover slip.

Iodine wet mount

This was mainly used for detecting protozoal cysts, however helminthic eggs were also

stained and could be detected. Iodine stained cysts showed pale refractile nuclei,

yellowish cytoplasm and brown glycogen material. A drop of 5 times diluted Lugol’s

iodine was taken on a slide and a drop of sediment from above process was mixed with

it. The preparation was covered with a cover slip and observed microscopically.

4.4.3Recording of the results

After laboratory processing of the samples the result obtained was recorded in thesis log

book.

40



4.4.4 Report distribution

The report distribution was done as the result was obtained after laboratory processing

of the samples. Positive cases were given antiparasitic drug along with the report. The

complete dose of antiparasitic drugs distributed according to the parasites detected.

4.4.5 Statistical Analysis

Chi-square test was used to evaluate apparent differences for significance. Association

of intestinal infections with different variables was tested. Results were considered

significant if P values were less than 0.05.

CHAPTER V

5. Results

A total of 303 stool samples (203 from public schools and 100 from private schools)

were included in this study. The overall positive rates found in samples are 35.6%

(108/303). Among the samples, the positive rates in boys and girls were similar (boys:

36.4% and girls: 34.9%) (p>0.05) (Table-1).

Table -1: Gender wise prevalence of parasitic infection

Sex Total n Positive n % p-value

Boys 140 51 36.4 p>0.05

Girls 163 57 34.9

Total 303 108 35.6

Table-2: Prevalence of parasitic infection in public school and private school

School Gender Total n Positive n % p-value

Public school Boys 90 36 40.0 p>0.05

Girls 113 46 40.7

Total* 203 82 40.3

Private school Boys 50 15 30.0 p<0.05

Girls 50 11 22.0

41



Total* 100 26 26.0

*prevalence of parasitic infection is significantly (p<0.05) higher (40.3%) in public

school comparison with private school (26.0%).

In case of public school boys and girls had similar prevalence rates (boys: 40.0% and

girls: 40.7%) (p>0.05). While in private school boys had higher prevalence rate then

girls (boys: 30.0% and girls: 22.0%) (p<0.05) (Table- 2)

Table -3: Types of parasite detected from school children

Overall prevalence of parasites was higher in case of public school. In public school,

total helminthes and protozoan found was (15.7%) and (24.6%) respectively. However,

in case of private school, total helminthes and protozoan found was (9.0%) and (17.0%)

respectively. The types of individual parasites are shown in (Table-3). In public school,

A. lumbricoides (7.3%) was the most common among the helminthes followed by T.

trichiura (2.9%), hookworm (2.4%), H. nana (1.9%), and E. vermicularis (1.0%).

Among the protozoa, G. lamblia (20.1%) was the most common and (4.4%) E.

histolytica was found. In private school also A. lumbricoides (4.0%) was the most

Types of parasites Public school

positive n

% Private school

positive n

%

A. lumbricoides 15 7.3 4 4.0

T. trichiura 6 2.9 2 2.0

Hookworm 5 2.4 1 1.0

H. nana 4 1.9 1 1.0

E. vermicularis 2 1.0 1 1.0

Total helminthes 32 15.7 9 9.0

G. lamblia 41 20.1 14 14.0

E. histolytica 9 4.4 3 3.0

Total protozoan 50 24.6 17 17.0

Overall parasites 82 40.3 26 26.0

42



common among the helminthes followed by T. trichiura (2.0%), hookworm (1.0%), H.

nana (1.0%), and E. vermicularis (1.0%). Among the protozoa, G. lamblia (14.0%), E.

histolytica (3.0%) was found (Table- 3).

Table-4: Prevalence of parasitic infections in different age-groups

School Age (yrs) Total n Positive n % p-value

Public school ≤10 145 56 38.6 p>0.05

>10 58 26 44.8

Total 203 82 40.3

Private school ≤10 77 20 25.9 p>0.05

>10 23 6 26.1

Total 100 26 26.0

The prevalence rate of parasitic infection according to age group, in case of public

school, children of age group ≤10 years had (38.6%) lower infection rate compared to

(44.8%) of age group >10 years with no significant difference (p>0.05). In private

school, (25.9%) found in >10 years, whereas age >10 was found to be (26.1%) with no

significant difference (p>0.05) (Table-4).

43



* Household treated water = boiled, filtered water

Fig. 1: Prevalence of parasitic infection according to the type of water used for

drinking.

Parasitic prevalence rate was found higher in household untreated water drinking

children studying in both public school (50.0%) and private school (26.7%) compared

to those drinking household treated water (19.0%) in case of public school and (21.4%)

in case of private school however, there was significant difference (p<0.05) in public

school and no significant difference (p>0.05) was observed in private school (Fig. 1).

Table-5: Prevalence of parasitic infection by family size

School Family size Total n Positive n % p-value

Public school ≤ 5 140 52 37.1 p<0.05> 5 63 30 47.6

Total 203 82 40.3

Private school ≤ 5 58 10 17.2 p>0.05

> 5 42 16 38.1

Total 100 26 26.0

The prevalence rate of parasitic infection according to family size was found to be more

in family size ≤5 than in >5 both in public school and private school. In public school,

(37.1%) in family size ≤5, whereas (47.6%) with significant difference (p<0.05) was

0

10

20

30

40

50

60

Household treated water Untreated water

Public school Private school

44



found in family size >5. In private school, (17.2%) in family size ≤5, whereas (38.1%)

with no significant difference (p>0.05) found in >5 family size (table 5).

Table 6: Prevalence of parasitic infection according to presence of toilet at home.

School Toilet Total n Positive n % p-value

Public school Yes 160 50 31.2 p<0.05

No 43 32 74.4

Total 203 82 40.3

Private school Yes 84 16 19.0 p<0.05

No 16 10 62.5

Total 100 26 26.0

The prevalence rate of parasitic infection according to presence of toilet was found to

be higher who do not have toilet than in those who have toilet in both schools. In public

school (74.4%) who do not have toilet whereas who have toilet found to be (31.2%)

with significant difference (p<0.05). In private school, (62.5%) who do not have toilet,

whereas who have toilet was found to be (19.0%) with significant difference (p<0.05)

(Table-6).

Table7: Prevalence of parasitic infection in different ethnic group.

School Ethnic group Total n Positive n % p-value

Public school Dalit 39 27 69.2 p<0.05

Madhesi 50 35 70.0

Others* 114 20 17.5

Total 203 82 40.3

Private

school

Dalit 16 10 62.5 p<0.05

Madhesi 20 8 40.0

Others* 64 8 12.5

Total 100 26 26.0

Others* = Brahmin, Chhetri, Indigenous

The rate of parasitic infection was found to be highest in Dalit group (69.23%) and

(62.5%) both in public and private school. where as parasitic infection is lowest in case

of others group. This was statistically significant (p<0.05) (Table-7).

45



The rate of parasitic infection was found to be highest in those who do not take drug

(46.2%) and (62.5%) both in public and private school. Where as parasitic infection is

lowest in children, who do not take medicine (25.0%) and (19.0%). This was

statistically significant (p<0.05) (Table-8).

Fig. 3: Prevalence of parasitic infection according to the occupation of parents.

Students having father’s occupation as service had lowest incidence rate in public

school (11.4%) and private school (12.9%) respectively. In public school infection

followed by business (28.5%), agriculture (30.3%), labour (56.0%) and in private

school infection followed by business (20.0%), agriculture (38.0%), labour (14.2%)

were found. There is significant difference (p<0.05) in private school and no significant

difference in public school (p>0.05)(Fig.3).

0

10

20

30

40

50

60

Agriculture Business Service Labour

Private schoolPublic school

47



CHAPTER VI

6. DISCUSSION AND CONCLUSION

6.1 Discussion

In this study, two third of study population were found parasite positive. This was in

agreement with previously reported finding from Nepal (Rai et al , 1986; Ishiyama et al ,

2001; Rai and Gurung, 1986; Rai et al , 2005) and elsewhere Rajeswari et al (1994).

However this result was lower than finding reported earlier from Nepal (Rai et al , 2004;

Sharma et al , 2004; Sherchand et al , 1997; Yong et al , 2000; Uga et al , 2004). On the

other hand Easaw et al , (2005) reported the lower parasite positive rate than this result.

The result for such discrepancy may be due to the over dispersion of parasites, poor

sanitary condition, lower socio-economic status and lack of health education (Rai et al ,

2005) and lower prevalence in some area could be due to detection technique.

In present study, the parasitic infection was significantly higher in public school in

comparision with the private school. High prevalence of parasitic infection in public

school was also been reported in Nepal (Rai et al , 1986; Ishiyama et al , 2001; Rai and

Gurung, 1986; Rai et al , 2005; Sharma et al , 2004; Sherchand et al , 1997) and

elsewhere (Rajeswari et al , 1994). This difference was due to poor sanitary

environment, unhygienic condition, drinking contaminated water, immunity level of the

children, and low socio-economic level of the family (Rai et al , 2000a; Rai et al , 1998;

Sherchand et al , 1997).

The overall parasite positive rate in this study, were found to be nearly similar in both

boys and girls. However, Rai et al , (1986); Ishiyama et al , (2001); Rai and Gurung,

(1986); Rai et al , (2005) had reported higher parasitic infection in case of the boys. In

contrast, Sherchand et al , (1997); Yong et al , (2000) and Uga et al , (2004) had reported

higher parasitic infection in case of the girls. Investigator from elsewhere had also

reported higher prevalence either in females (Rajeswari et al , 1994; kightlinger et al ,

1995) or males (Agi, 1995). This indicated that there are similar exposure to infestation

in both boys and girls and intestinal parasites are dispersed throughout the environment

and equal opportunity for acquiring parasitic infections (Rai et al , 2005).

48



In case of public school, the prevalence of parasitosis seems to be similar in girls and

boys. This result was in agreement with previous finding from Nepal (Rai et al , 2005).

However, this result was in contrast with the previous finding either higher in males by

Rai and Gurung, (1986); Ishiyama et al , (2003) or in females by Sherchand et al ,

(1997); Yong et al , (2000); Uga et al , (2004). It might be due to unmanaged playing

ground within the public school, low economic condition, and poor sanitary behaviour

of both sexes. In case of private school, the parasitic infestation rate is marginally

higher in boys compared with girls. This study was in the contrast with previous reports

(Rai et al , 1995, 2000, Sherchand et al , 1996; Nepal and Palfy, 1980). The result for

higher infection in boy’s comparison with girls studying in almost identical

environment in private school was not found however, one reason might be even boys

from poor families were also sent to private school due to social discrimination among

boys and girls mostly in the low socio-economic family. However, among school

children living in almost identical condition, equal positive rates between the sexes

have been reported in western Nepal by Ishiyama et al , (2001).

In this study, protozoan was dominant over helminthes in both public school and

private school. The higher rate of protozoal infection may be due to the presence of

farming land contaminated with faecal matter as using contaminated soil as the manure

also resulted due to open defeacation, lack of public awareness, use of contaminated

drinking water and also due to use of contaminated water for vegetable washing.

Protozoan infections were increases than helminthic infection it may be also due to

infectious cyst form of the protozoal parasites is relatively resistant to chlorine

(Okhuysen et al , 1999). Similar result has also shown i.e. higher protozoal infection rate

than the helminthes was by Shakya et al, (2006); Rai et al , (1986); Ishiyama et al ,

(2001); Ishiyama et al , (2003); Uga et al , (2004). However, other studies in Nepal

among general population have found higher prevalence of helminthic infection

(Estevez et al, 1983; Nepal and Palfy, 1980; Rai and Gurung, 1986; Rai et al , 1995,

2000b; Sherchand et al, 1996; Sharma et al, 1994).

In stool samples seven species of intestinal parasites were detected, which comprise two

protozoa and five helminthes. Among protozoan, G. lamblia holds greater number in

both public school and private school. This result was similar with most of the studies

carried out in Nepal (Saha et al , 1995; Rai et al , 1995, 2002b; Sherchand et al, 1997;

49



Ishiyama et al , 2001; Ishiyama et al , 2003). It might be due to harsh water quality and

lack of timely maintenance of properly functioning filtration system in municipal water

supply tanks as cyst remain viable outside in soil and water for several weeks and less

health awareness among the people (Oda et al , 2002). The cyst of G. lamblia is

resistance to the normal level of chlorination and osmotic pressure of water therefore; it

can be easily transmitted through drinking water (Rai et al , 2007).

In this study, similar rate of infection by E. histolytica was found in children of both

public school and private school. E. histolytica was found to be the second protozoan in

this study. This was in agreement with the report from Nepal and Palfy, (1980);

Ishiyama et al , (2001); Ishiyama et al , (2003); Rai et al , (1995). This might be due the

commonest nature of this protozoan parasite. As reviewed by Rai et al (2005) the

incidence of E . histolytica infection ranges from 3.0%-28.8% in Nepal. Nepal and

Palfy, (1980) reported the highest incidence rate of E. histolytica (28.8%) from Nepal.

Infection with E. histolytica was common in people of developing countries. Similar

infection rate in both public school and private school might be due to using

contaminated drinking water. Easaw et al , (2005) suggested that the possibility of

contamination of drinking water was due to close running of water pipe and sewage line

mostly in Kathmandu Valley.

In present study, prevalence of A. lumbricoides is the most common helminthes in

children of both public school and private school. The infection rate of A. lumbricoides

is seems to be nearly doubled in public school compared with private school. Higher

infection rate of A. lumbricoides in public school was also shown in the previous

research done in Nepal (Rai and Rai, 1999; Shrestha et al , 2007; Ishiyama et al , 2001;

Ishiyama et al , 2003) and elsewhere by Chai et al , (2001a); Virk et al , (1994); Singh et

al ; (2004). However, lower prevalence rate was also found in some investigation of

Nepal (Rai et al , 1998; Sherchand et al, 1996). Higher incidence of A. lumbricoides

might be due to survival of ascaris eggs in environment for longer period. It might also

be due to the over dispersion of ascaris eggs in the environment as the single female

ascaris lay relatively large number of eggs (Shrestha et al , 2007).

The infection rate of T.trichiura was higher in public school than private school.

Previous reports from Nepal showed T . trichiura was found to be the most common

50



parasites. T . trichiura topping the list of parasites have also been reported from Nepal

(Ishiyama et al , 2001; Uga et al , 2004; Sharma et al , 2004; Rai et al , 2005) and else

where (Kan, 1983; Rajeswari et al , 1994; Lee et al , 2000; Uga et al , 2005). It could be

due to ineffective deworming of single dose of antihelminthic drug particularly in case

of infection by T . trichiura. In Nepal, the prevalence of T . trichiura ranges from (5.0%)

(Houston and Schwartz, 1990) to (94.5%) was found in a backward community in

Bhaktapur district (Sahu et al , 1983). This discrepancy of infection by T. trichiura was

might be due to its special mode of attachment to intestinal mucosa, longer life span of

parasites as well as its refractory reaction to most anti-helminthic and remains in

intestine causing chronic infection.

Prevalence of hookworm infection was found to be higher in public school than private

school. This result was lower than year to year incidence ranging from (3.8% to10.7%)

in Nepal (Rai et al , 1997). Discrepancy in infection in public school and private school

children might be due to difference between the numbers of study populations. On the

other hand, in part, this difference also could be due to lack of awareness of the regular

use of shoes and slipper by most of public school children, which prevents skin

penetration by larvae (Rai et al , 1997; Shrestha et al , 2007).

In this study, H . nana detected from public was higher than private school. The

infection rate is doubled in the public school. It was reported (3.3%) in southern Nepal

by Sherchand et al , (1997) and (4.9%) in public school children of Kathmandu valley

by Sharma et al , (2004). H . nana was also reported as the commonest tapeworm in the

Kathmandu valley (Sherchand et al , 1996). Eggs of H. nana (around 2.6%) have also

been found in soil samples studied in Kathmandu valley (Rai et al , 2000b). This seems

to be due to domesticating rodents inside their home. Infection takes place by ingestion

of fleas containing infecting larvae. H. nana is most common tapeworm infecting

children in Nepal, so it seems to be correlated with the poor sanitation and low socio-

economic condition in the community. High prevalence of H. nana in public school

children in present study may be due to difference between the numbers of study

populations, and also due to faeco-oral route by ingestion of eggs from contaminated

hands, poor personal hygiene poor environmental hygiene and also the transmission

occurs from the ingestion of food contaminated with fleas harbouring the larvae.

51



In this study, Prevalence of E. vermicularis was found to be similar in both public and

private school. Very low percentage was found in both schools. Low prevalence of E.

vermicularis was also found by Sherchand et al , (1997); Sharma and Tuladhar, (1971)

and elsewhere by Singh et al , (2004). This low prevalence of E. vermicularis might be

due to the detection technique as cellophane tape method has not been used.

In case of age of the children in public school, the infection rate increases as the age

increases i.e. infection rate is lower in age group ≤10 and greater in age group >10. It is

not an agreement with the finding from Nepal (Rai et al , 1994b; Rai et al , 2002b;

Sharma et al , 2004; Rai et al, 2005). It may be due to poor knowledge of the health

education, hygienic practice of children and decrease in maintaining hygienic condition

of children by parents as the children’s age increases and also increases the frequency

of exposure in the dirty environment due to increment of their childish activity with

their age. However, in case of private school, all most all the age group had the similar

prevalence of parasites. Prevalence of parasites might be associated with their

unhygienic habit and also due to difference between the numbers of study populations.

In case of prevalence of parasitic infection according to type of water used for drinking

purpose, the parasitic infection is nearly doubled in children of public school who use

untreated water compared with private school. It may be due to direct drinking of

contaminated water and heavily contaminated drinking water source of Kathmandu

Valley (Easaw et al , 2005). However, parasitic infection seems to be higher in private

school children, who use household treated water for drinking purpose in comparison

with children of public school. It may be due to improper water treatment, improper

filtration, unhygienic habits and contaminated reservoirs within the house. Similar

finding had been reported by Adhikari et al , (1986); Ono et al , (2001).

In this study, the prevalence of parasitic infection increases according to increase in

family size in both public school and private school. This finding was consistent with

the finding of Rai et al , (2005). However, this finding was inconsistent with the finding

of Karrar and Rahim, (1995). The reason behind this result might be due to that children

of larger and socio-economically under privileged family are infected with various

infective pathogens including intestinal parasitosis. Parasitic infection is increases as

52



the parents are not been able to give attention to all children equally due to large family

size.

Parasitic infection can also be related well with the unavailability of toilet at their

house. Prevalence rate of parasitic infection was marginally lower in children having

toilet compared with without toilet in case of both public school and private school.

This result is consistent with the previous study conducted in the Nepal (Rai et al ,

2002b; Rai et al , 2005) and elsewhere (Sorensen et al , 1994; Tome et al , 1999). Lack of

the inadequate toilet affects the environmental sanitation and prevalence of STH. Due

to lack of proper toilet, indiscriminate defeacation around the houses, fields, roads, and

playground increase the chance of parasitic infection.

In this study, higher incidence of parasite was found in Dalit (lower class, untouchable

people) in both public school and private school. However, Madhesi group have also

seen to have highest prevalence of parasitosis (70.0%) in public school. Nepal is

country inhabited by the population of diverse ethnic groups. In this study, Madhesi

group are migrants from Tarai to Kathmandu Valley. A similar pattern of results has

been reported by Rai et al , (2002b) and Ishiyama et al , (2003). This may be due to

small sampling size, poor hygienic practice and low socio-economic status, poverty,

illiteracy, lack of awareness toward the health status of the Dalit and Madhesi groups,

as compared to their counter social group (Rai et al , 2002b).

High prevalence of parasite is found in children using well as water sources in public

school and Dhungedhara as water sources in private school compared with using tap as

source of water. This might be due to the poor sanitary condition around the water

source and lack of awareness, contaminated pots and lack of good sanitary practices.

Tap water is found to be safe among the sources as the water is treated in distribution

tank, flow in the covered pipes and have less chances of contamination with the sewage

and dirt.

The children who had not taken anti-helminthic drug in past six months had

significantly higher parasitic infection compared with those who had taken

antihelminthic drugs in both public school and private school. Similar findings were

also reported by Bundy et al , (1987); Albonico et al , (1999); Rai et al , (2005). This

53



clearly indicates the importance of de-worming programs as the prevalence of

helminthic infection was reduced remarkably.

Parasitic prevalence rate in children was correlated with their father’s occupation or

family business. Children with father’s occupation as service had lowest incidence rate

of infection followed by business, agriculture and labour in case of public school. And

in private school, also lower infection was found in children having father’s occupation

as service followed by labour, business and agriculture. It can be concluded that

economic status of family obviously influences the child health status. The highest rate

of parasitic infection was found in case of farmer’s and labour’s children as their family

members were more prone to get infection through the soil, contaminated with

parasites, as they are more exposed to soil and dirt. Further, while working in the field,

they were likely to be infected by the infective helminthes larvae. Ishiyama et al ,

(2003); Rai et al , (2005) reported the lowest rate of infection in the children with

father’s occupation as business. However, the education levels of parents influence the

prevalence of parasitic infection in children as reported by Ishiyama et al, (2003). High

parental literacy directly influences the family economy and better life standard and in

turn lowers the parasitic infection.

6.2 Conclusion

Hence, it can be concluded that the intestinal parasitosis is still prevalent causing the

major public health problems in public school as well as private school, however the

infection rate is slightly higher in public school in comparison to private school.

Parasitic infection is found to be directly related to the socio-economic status of family,

personal hygienic practice and health education. Finally, effective knowledge and

54



proper hygienic education should be provided to the students as well as parents to

reduce parasitic infection in both public school as well as private school.

6.3 Limitation

• Due to time factor and other constraints, the study had to be confined over

limited sample size in case of the private school. More significant findings

would have been resulted if equal samples were included from both public

school and private school under study.

• More reliable picture of the parasitic prevalence would have been revealed if

stool samples from single individual on three consecutive days were taken.• The parasitic prevalence would be more concise if the trophozoite stage of the

parasites were examined.

• The family size taken in this study is the number of whole family members.

CHAPTER VII

7. SUMMARY AND RECOMMENDATION

7.1 Summary

55



• A total 303 samples were collected from different public school (203 samples)

and private school (100 samples) of Thimi. Among 303 stool samples, in total

(35.6%) children had parasitic infection (Table-1).

• The prevalence rate was found in boys (40.0%), girls (40.7%) in public school

and boys (30.0%) and girls (22.0%) in private school. The prevalence rate was

found similar in the boys and girls (Table-2).

• In public school, total helminthes and protozoan found was (15.7%) and

(24.6%) respectively. However, in case of private school, total helminthes and

protozoan found was (9.0%) and (17.0%) respectively (Table-3).

• In public school, G. lamblia (20.1%) was the most common intestinal parasite

followed by A. lumbricoides (7.3%), E. histolytica (4.4%), T. trichiura (2.9%),

hookworm (2.4%), H. nana (1.9%), and E. vermicularis (1.0%). In private

school, G. lamblia (14.0%) was the most common intestinal parasite followed

by A. lumbricoides (4.0%), E. histolytica (3.0%) T. trichiura (2.0%), hookworm

(1.0%), H. nana (1.0%), and E. vermicularis (1.0%) (Table-3).

• The prevalence rate of parasitic infection according to age group, in case of

public school, children of age group ≤10 years had (38.6%) lower infection rate

compared to (44.8%) of age group >10 years. In private school, (25.9%) found

in >10 years, whereas age >10 was found to be (26.1%) (Table-4).

• In case of type of water used for drinking purpose, more prevalence of

parasitic infection was found in those children who used untreated water in both

public schools (50.0%) and in private school (21.4%). The safe type of water for

drinking was household treated water (19.0%) and (10.0%) in public and private

school respectively (Fig.1).

• The prevalence rate of parasitic infection according to family size was found

(37.1%) in family size ≤5, and (47.6%) in family size >5. In private school,

56



(17.2%) in family size ≤5, whereas (38.1%) in >5 family size was found (Table-

5).

•

In public school, higher positive rate (74.4%) was found in children withouttoilet at home, whereas children with toilet at home found to be (31.2%). In

private school, (62.5%) infection in children not having toilet at home was

found higher than having toilet at home (19.0%) (Table-6).

• Of different ethnic groups (Others, Dalits and Madhesi groups) Madhesi

(70.0%) and Dalits (69.2%) had high prevalence rate in public school and

Dalits (62.5%) had high prevalence rate in private school (Table-7).

• The rate of infection in public school was higher (66.0%) and (41.1%) in case of

those who use well and Dhungedhara (natural spout) as a source of water. Same

result is seen in private school (40.0%) and (42.8%) in those who use well and

Dhungedhara as a source of water. However, the rate of infection was seen

lower (30.8%) and (18.1%) in case of tap water as source of water in public

school and private school (Fig. 2).

• The rate of parasitic infection was found to be highest in those who do not take

drug (46.2%) and (62.5%) both in public and private school. Where as parasitic

infection is lowest in children, who do not take medicine (25.0%) and (19.0%).

This was statistically significant (p<0.05) (Table-8).

• In this study, the highest prevalence rate of infection was in students from lower

class labour’s family (56.0%) in public school and farmer’s family (38.0%) in

private school. Less prevalence was found whose parents were in service

(11.4%) in public school and (12.9%) in private school (Fig.3).

• 7.2 Recommendations

• Keeping in view of high prevalence of enteric parasitic infections (40.3%) in

public school and (26.0%) in private school, observed in this study conducted

among school children, this might represent the present situation of parasitosis

57



of the Bhaktapur district. However, this type of study should be undertaken

throughout the country in order to obtain the clear-cut picture.

•

Periodic administration of antiparasitic drugs is highly recommended andawareness creating activities with regard to controlling intestinal parasitic

infection should be launched.

• The prevalence of protozoa was higher than helminthes. This indicates the

contamination in water supply in the municipality. So concerned sector should

think about the proper management of water supply.

• As significance impact of various predisposing factor studied was observed,

use of toilet, maintaining hygienic conditions, not walking bare foot, proper

washing of hands, drinking of treated (boiled or filtered) water and others are

highly recommended.

• Since the transmission and persistence of intestinal parasitic infections are

influenced by human behavior, appropriate health education for parents and

children should be applied at all levels of program implementation.

CHAPTER VIII

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