RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE AND ADDRESS

SILAMBARASU.C1st YEAR M.SC(N), COLUMBIA COLLEGE OF NURSING, BANGALORE-560056

2 NAME OF THE INSTITUTION

COLUMBIA COLLEGE OF NURSING, NO-71, MARIYAPPANAPALYA, GNANABHARATHI POST, KENGERI HOBLI, BANGALORE-560056.

3 COURSE OF STUDY AND SUBJECT

M.Sc. NURSING CHILD HEALTH NURSING

4 DATE OF ADMISSION TO THE COURSE

14/10/2011

5 TITLE OF THE TOPIC

“A STUDY TO EVALUATE THE EFFECTIVENESS OF3 WORM INFESTATIONS’’

6.BRIEF RESUME OF THE INTENDED WORK

Introduction

Intestinal parasitism is a priority health problem. Since worm infestation is seldom the direct cause of death, they tend to be regarded as relatively unimportant. Worm infestation is probably more significant than specific vitamin and mineral deficiences in developing countries. In India, the problem is likely to be more common because of bad hygiene, poor awareness, illiteracy, misbeliefs, poverty and variety of allied factors(1). Studies carried out in various parts of India have reported a prevalence of intestinal parasitism upto 30-50% and anemia from 40-73% among school going girls1.

The percent prevalence of worm infestation was 71.73%. The maximum infestation was of Ascaris lumbricoides (23.73%) followed by Hymenolepsis nana (16.36%), Entamoeba histolytica (10.34%), Ankylostoma duodenale (8.46%) and Trichuris trichura (6.34%). In severely anemic children, Ankylostoma duodenale infestation was 4.76%, and multiple infestation was seen in 5.56% girls. Enterobius vermicularis, Giardia lamblia, and Diphylobothrium latum were demonstrated in 2.76%, 2.16% and 1.1% cases respectively. Out of 281 non-anemic girls, 177 (62.98%) had worm infestation, while of the 435 anemic girls, 334 (76.8%) demonstrated evidence of worms in their stool. Prevalence of worm infestation was 86.66%, 68.16% and 82.97% in mild, moderate and severely anemic groups respectively1.

Invasion of humans by worms, or worm infestation is a worldwide public health problem. One third of the world's population is infected with one or more species of intestinal helminthes, It is estimated to affect over 200 million people in India and public health specialists are concerned that these infections impair children's growth and

development. New research shows that parasites such as worms not only control the behavior of their hosts, they can change entire ecosystems to suit their needs. "Hookworms sink their teeth into the intestinal walls of more than a billion people every day to drink their fill of blood2.

A study about prevalence of worm infestation among communities in rural Delhi, stated that, worm infestation is a major problem in developing countries due to bad hygienic conditions. It produces nutritional deficiencies and anaemia in children, especially when hookworm infestation is present. Much number of studies has reported a high prevalence of worm infestation among school children in different parts of the country.A study about prevalence of worm infestation among communities in rural Delhi, stated that, worm infestation is a major problem in developing countries due to bad hygienic conditions. . Across sectional community study conducted in slums of Luknow stated that universal de -worming of children has been recommended in high prevalent areas of worm infestation. De-worming in school going children (5-10years) in slums of Lucknow resulted in weight and height gain among children who had a history of round worm passage3.

The Neem tree (Azadirachta indica A. Juss.) has been known as the wonder tree for centuries in the Indian subcontinent. It has become important in the global context today because it offers answers to the major concerns facing mankind.

The history of the Neem tree is inextricably linked to the history of the Indian way of life. Although the antiquity of Neem is shrouded in the mists of time, this evergreen robust looking tree has long been cherished as a symbol of health in the country of its origin. It has, for a very long time, been a friend and protector of the Indian villager. Brihat Samhita, an ancient Hindu treatise, contains a chapter of verses on plant

medicines. It contains recommendations for specific trees to be planted in the vicinity of one’s house. Neem was highly recommended . Stringent laboratory condition tests have proved the efficacy of Neem in destroying fungi, parasites and viruses without killing off beneficial intestinal flora. It is very effective in the treatment of Athletes’ Foot, thrush, candida infestations and herpes4.

Keeping in view the above information neem is having therapeutic effect of antihelmintic helps in children’s life remain the first and best step to prevent worm infestation.. Hence the researcher have chosen this topic for the study.

6.1 Need for the study:

Worm infestation is a major public health problem in children of developing countries because of poor socio economic conditions and lack of good hygienic living. Helminthic infestations contribute significantly to global burden of diseases in children,especially in the tropical and sub tropical regions. Intestinal worm infestation can result in impaired nutrition and development.Handling food and drinks with unclean hand and dirty fingers is one of the causes how the thread worms enter the body, Round worms enter the body through contaminated food and drinking water,the tape worm on the other hand through raw or uncooked meat and alsonthrough the fecal matter. Hook worm enters the body when one walks with bear foot on an infected land. This is how the hygienic living conditions lead to infections. Heavy hookworm burden is the major etiology for iron deficiency anemia in young children 5

The world health organization estimates that infection with round worm{Ascaris lumbricoides}whip worm(Trichuris trichiura)and hook

worms with associated mobidity,affect approximately 250 million, 46 million and 151 million people respectively. About half the population in south india and 50% of school children in tribal areas of central india are infected with ascaris lumbricoides,Trichuria trichiura and hook worm. In the west part of Nepal , 86.7% of the preschool children are affected with a single geohelminth infection and 13.3% with mixed infections. Thus ,worm infestation as a public health problem needs immediate attention in india and other south asia

Helminthic infections have been shown to have many determental effects on children’s health and their scholastic progress. It causes not only nutritional deficiencies and anemia but can lead to intestinal obstruction in the infested children. The worm infestation can be prevented by using latrines or toilets rather than open field defecation,by avoiding raw vegetables and not to walk bear foot in known infected areas. Children can be de- wormed every six months by administration of Tab.Albendazole or Zentil or any home remedies. The magnitude of parasitic infestations among children is such as to constitute a major public health problem in many parts of the world. It has been estimated that 6/7 of the total incidence of helminthiasis is perhaps due to infective disposal of human excreta6.

The word neem originates from the word “Nimbo” which means “reliever from sickness”. All the parts of neem leaf,flower, bark and root are of medicinal value and contain innumerable chemical compounds. Pure certified organic neem leaf made up of 20% fibre, 50% carbohydrates, 15% proteins, 5% fat, 8% ash, 2% calcium, essential amini acids, carotene and ascorbic acid4.

Tender leaves along with black pepper are effective in intestinal helminthiasis. The neem leaves are extensively used as an old and popular remedy for skin disease. The fresh juice of neem leaves with

honey is used in the treatment of skin diseases and jaundice, 1 gm of neem leaves powder with jiggery for 15 days helps in worm infestation completely because of its anti-helminthic effects,the juice of neem leaves of 10 ml along with honey and asafetida powder (5gms)removes intestinal worms in children, 100gm of the extract was obtained from 10 kg of neem leaves.1113gm of the extract was administered to patients orally as single dose in empty stomach,exhibited remarkable antehelmintic property4

Since the worm infestation is a common problem among children and the neem leaves has the antihelmintic action, the investigator was interested to test it’s effectiveness

6.2 REVIEW OF LITERATURE

REVIEWS RELATED TO PREVALENCE AND ITS RISK FACTORS OF WORM INFESTATION

Cross sectional study in rural India conducted to estimate prevalence of and risk factors for intestinal geohelminths and other intestinal parasites in children aged 6 to 23 months.  Proportionate population size sampling method was used to randomly select 15 villages per block. Thereafter, house-to-house survey was done to recruit eligible children and obtain fecal sample for microbiological examination. Univariate distribution of variables was assessed and comparison between categorical variables and continuous variables was done using a Chi-square test and student's t-test, respectively. Odds ratio was calculated to assess associations. Results: Overall 926 children were recruited and 909 fecal samples examined. Combined prevalence of infestation with intestinal geohelminths treatable by albendazole and other intestinal parasites non-treatable by albendazole was 50.3% (457/909) and 51.6% (469/909),

respectively. Exclusive use of hand pump water (OR = 1.79, CI = 1.36-2.35, P < 0.001) and use of hand pump water plus field defecation increased risk of geohelminthic infection (OR = 1.75 CI = 1.34-2.30, P < 0.001) while use of well water (OR = 0.45 CI= 0.33-0.60, P < 0.001) and exclusive use of soap and water practice for hand washing after defecation was protective (OR = 0.54, CI = 0.40-0.73, P < 0.001). Conclusion: Since almost half the children are infected with intestinal geohelminths treatable by albendazole, targeted deworming of population in this age group should be considered2.

The high prevalence of worm infestation is stressed here as worms are so closely correlated with nutrition. The continuous presence of worms in marginally nourished children can cause severe anemia and subsequently affect the growth and development of these children. In the present study, stool parasite positivity was 71.3% among school children age 6-10, which is comparatively high as compared to the study carried in the tribal areas of Madhya Pradesh, which reported 50% prevalence, in school going children7

The study was conducted among school going children (6-14 years) of Baiga, Abuihmadia and Bharia tribes of Madhya Pradesh to assess the prevalence of anaemia and intestinal parasitic infestation among themselves. A total of 776 school going children were included in the study of whom blood samples of all and stool samples of 409 were collected. Their haemoglobin was measured and stool samples were examined under microscope for ova and cysts. The results revealed that 30.3% of the children had severe anaemia (Hb < 7g/dl) and 50% children had intestinal parasites. The most common parasites were hookworn (16.3%) and A lumbricoides (18.5%). Though hookworm ova loads indicated mild to moderate infestation in most of the children, the continued presence of worms in marginally nourished children could

contribute significantly to blood loss in the intestine with resultant anaemia8

Infestation by geohelminths is an important public health problem in developing countries like India. It is a major cause of morbidity in school-age children who have the highest burden of worm infestation. Some of the morbid conditions attributed to intestinal helminthiasis are malnutrition, growth retardation,anaemia, vitamin A deficiency and impaired intellectual performance. Chemotherapy targeted at school-age children has been recommended as a cost-effective and feasible control programme for the control of geohelminths. To optimize resources a geohelminth control programme can be integrated with other existing national health programmes. The availability of drugs such as diethyl carbamazine (DEC) and albendazole, which have anthelminthic and antifilarial properties, opens the possibility of integrating a geohelminth control programme with a filarial control programme. However, co-administration of DEC and albendazole raises several issues of frequency of administration,efficacy, compliance and cost-effectiveness. Thus, integrating a geohelminth control programme with the existing mid-day meal or anaemia prophylaxis programme would be a more appropriate and cost-effective strategy to control geohelminths, alleviate the morbidity caused by them and improve the overall health of the community.

REVIEWS RELATED TO EFFECTIVENESS OF NEEM LEAVES PASTE ON WORM INFESTATION

Thirty school children with worm infestation were worm infestation were selected by purposive sampling method in st.Therasa’s high school in shanthinagar,Hyderabad. Pre experimental one group pre test post test design was used to measure the effectiveness of neem leaves paste on

worm infestation. There was significant rduction in the worm infestation after neem leaves paste among school children t= 131.94(p<0.001)9

About half of sample (36 children, 51.5% were in the 11-13 years age group and remaining (34, 48.5%) were in the 13-15 yrs. Majority of the respondents (35, 50%) belonged to joint family. . About half of the respondents parents (mother or father) (34, 48.6%) were having secondary education. About a fourth(16, 22.8%) were having higher education and graduation degrees, whereas 2/7th (20, 28.5%) were having primary education . About 30 (42.8%) parents of school children belonged to unskilled occupation, 34 (48.5%) parents of school children belonged to semi-skilled occupation and 6 (8.5%) of parents of school children belonged to skilled occupation. About 30 (43%) children were using open field for defecation and 40 (57%) were using toilets. . About half (35, 50%) of school children’s the bowel elimination habits was 1-2 times a day, and remaining half (35, 50%) had a habit of 3-4 times a day. Majority of children (60, 85.71%) were not using hand washing practice after defecation and only 14.3% (n= 10) were using hand washing practice after defecation. According to source of existing knowledge in school children 12 (17.1%) had from parents, 8 (11.4%) from friends, 12 (17.1%) from health personnel, 20 (28.5%) from teachers and 18 (25.7%) from mass media.. The mean of pre-test knowledge score was found to be 8.2 ± 1(23.4%). . The mean of post-test knowledge score was found to be 25.1 ± 19 (71.7%). The planned health education programme increased the mean knowledge drastically to about three-fold i.e., from the mean score of 8.2 ± 1 (23.4%) to about 25.1 + 19 (71.7%). There was no significant relationship between the posttest knowledge score and selected demographic variables as calculated statistically using chi-square test10.

Worm infestation is a major public health problem in children of developing countries because of poor socioeconomic conditions and lack of good hygienic living. It causes not only nutritional deficiencies and anaemia but can lead to intestinal obstruction in the infested children. The purpose of this study was to determine the frequency of intestinal worms’ infestation in children of rural Peshawar area. Material & Methods: This cross-sectional community based study was undertaken in rural area of Peshawar.The study population included 200 primary school children of 5-10 years age group of both sexes. Stool examination for ova detection was performed at Department of Pathology, Khyber Medical College Peshawar on three consecutive days. The results obtained were analyzed using SPSS software. Results: Out of 200 children examined, 132 (66%) were found positive for various intestinal helminths infestation. There were 6 different types of helminths found in the specimens examined. The highest frequency of 45.5% (91 cases) was noted for Ascaris lumbricoides. Relatively high frequency of 8% (16 cases) was also seen for Hymenolepis nana. Other helminths found were Enterobious Vermicularis 4% (16 cases), Hookworm 3.5% (7 cases), Whipworm 3.5% (7 cases) and Tapeworm 1.5% (3 cases).Conclusion: A high percentage of primary school children from rural Peshawar have intestinal worm infestation and majority of them have Ascaris lumbricoides.11

For thousands of years in India Ayurveda has recommended the use of Neem to rid the body of all forms of parasites. Simple aqueous extracts of Neem leaves have been the standard treatment for external parasitic infestation in villages throughout India. Neem’s effectiveness against parasites is due to compounds that mimic hormones. This activity interrupts the life cycle of parasites by inhibiting the ability of the parasites to feed, and preventing parasite eggs from hatching. Neem has demonstrated these effects against lice, and against itch mites which

cause scabies. Intestinal worms are treated and prevented throughout the tropics by regular consumption of Neem teas.Neem has both curative and preventative effects on the Malaria parasite the methods for accomplishing this are as varied as the active ingredients in Neem. There are two compounds in Neem, which are clinically proven to be as effective against the malarial parasite as both quinine and chloroquine; they are gedunin, a limonoid and quercetin, a flavonoid. The leaves can be chewed and consumed on a daily basis as a preventative like quinine and Neem leaf extracts are clinically proven to be as effective as chloroquine against the malarial parasite.In addition, other studies show that Neem leaf extracts are effective against chloroquine sensitive and chloroquine resistant strains of the malarial parasite. In another study, with a resistant strain, 100% of all the malarial plasmodia were dead within 72 hours due to the toxic effects of an active ingredient from Neem leaves known as Irodin A. There is still another study, which shows that Neem leaf extracts prevent the normal development of the malarial plasmodia by increasing the state of oxidation in the red blood cells.One of the most impressive accomplishments of Neem against parasites is its effectiveness against encephalitis. In a paper delivered to the American Chemical Society at its annual meeting in March 1993 R.O. Larson describes how an outbreak of Japanese encephalitis in India was eradicated. This was accomplished by giving children two doses of crushed Neem leaves daily12.

This study was Conducted To Evaluate The Anthelmintic Effect Of Neem (azadirachta Indica) On Nematode Parasites Of Sheep. Twelve Santa Ines Cross Bred Sheep From A Government Farm were randomly selected and equally divided into control (n = 6) and treated groups (n =6). Faecal egg counts (FEC) using the modified McMaster technique and the FAMACHA score for assessing clinical anaemia were carried out daily and recorded for 6 weeks. At the end of the study all the

animals were slaughtered and the total worm count (TWC) was done. The results of FEC showed that worm burden estimations the number of parasites was significantly higher in the control group compared to the treated group (p < 0.05). This result indicated that feeding Neem had an effect on worm numbers in sheep, but was not reflected in their faecal egg counts. Further work is needed to reconfirm the effect of Neem on helminth infections of sheep13.

A series of tests to examine the utility of Neem leaves as anthelmintic effect on Haemonchus contortus in goats was conducted. In vitro test revealed that the pure azadirachtin tested at graded level on motility of Haemonchus contortus L3 larvae had the maximum anti larval activity at 1000 microgram concentration. The motility of Haemonchus contortus L3 larvae was not reduced up to 400 μg. The concentration of azadirachtin content in the Neem leaves was determined to be 0.0244%. In yet another experiment involving twelve weaned nondescript male kids for a duration of 63 days, the efficacy of feeding Neem leaves as an anthelmintic source was studied by infecting with 5000 larvae of Haemonchus contortus (L3) on animals fed with or without Neem leaves. It was inferred that feeding Neem leaves reduced the Egg per Gram (EPG) count from 42nd day and worm count was also significantly reduced compared to infected groups fed with complete diet that did not contain Neem leaves. Hence, it is hypothecated that a continuous feeding of Neem leaves for more than 6-9 weeks would result in reducing the EPG count as well as the worm count. It is suggested that at least during the epizootics of worm infection, Neem leaves could play a role as an alternate non-chemical organic source of anthelmintic. Thus Neem can be considered as a potential candidate for organic farming as apart from delivering nutrient and organic source of anthelmintic14.

Effects of neem, betel leaf, devil’s tree, jute and turmeric against natural gastrointestinal nematodes in sheep and on some hematological parameters (TEC, Hb and PCV) and body weight were studied. Thirty (30) naturally parasitized sheep were randomly divided into six groups(A, B, C, D, E and F), each consisting of five sheep. Ten percent water extract of leaves of neem, betel leaf, devil’s tree and jute were administered orally to the sheep of group A, B, C and D, respectively. Sheep of group E was treated orally with 10% water extract of rhizome of turmeric. Sheep of group F was kept as infected control group. Fecal samples, hematological parameters and body weight were examined before the treatment and on 7 , 14 , 21 and 28 day. A significant (p<0.01) reduction of EPG count was found following administration of neem (37.60-47.03%), betel leaf (6.43-14.00%), devil’s tree (3.04-11.04%), jute (0.50-5.26%) and turmeric (0.46-8.30) in sheep. The EPG count of the control group (F) were significantly (p<0.01) increased up to the last day of experimental period. After treatment with neem, betel leaf, devil’s tree, jute and turmeric total erythrocyte count (TEC), hemoglobin (Hb) content and packed cell volume (PCV) were increased significantly (p<0.01 and p<0.05) in sheep. The body weight was increased significantly (p<0.01 and p<0.05) in neem, betel leaf, devil’s tree, jute and turmeric treated sheep. On the other hand, body weight was decreased in untreated control group. The present study reveal that 10% water extract of neem was moderately effective and betel leaf, devil’s tree, jute and turmeric were relatively less effective against gastrointestinal nematodes in sheep15.

6.3 PROBLEM STATEMENT

A study to assess the effectiveness of neem leaves paste on worm infestation among school children in selected school, Bangalore

6.4 OBJECTIVES OF THE STUDY

To assess the worm infestation before and after administration of neem leaves paste among school children

To test the association between the mean difference of worm infestation and background factors among school children

6.5 OPERATIONAL DEFINITIONS

School children:

Refers to children attending school between 8-13 years at Bangalore

Worm infestation:

Refers to the invasion of the parasites which affect the health of the individual and the worms included are round worm,hook worm and pin worm. Worm infestations are confirmed through the evaluations of lab investigations.

Neem leaves paste:

Refers to an ayurvedic leaves having anti helmintic ,anti fungal,anti setic and anti inflammatory action. I gm of neem leave paste will be given to the children

Effectiveness :

Refers to the reduction in worm infestation after administration of neem leave paste. It will be measured by the pre and post tests

6.6 HYPOTHESES

There will be significant difference in worm infestation before and after administration of neem leaves paste among school children

There will be significant association between the mean difference in worm infestation and background factors among school children

6.7 RESEARCH VARIABLES

Variables are concepts at various levels of abstraction that are measured, manipulated or controlled in the study

Independent variable

Independent variable is neem leaves paste to children of 8-13 years suffering with worm infestation

Dependent variable

A dependent variable is the outcome or the response that the researcher wants to predict or explain. In this study the dependent variable is worm infestation

6.8 ASSUMPTION

Neem leaves have anti helminthes effect Nurses can incorporate neem leaves paste as a part of nursing

intervention in the community set up in treating worm infestations Its cost effective No side effects

6.9 DELIMITATION

• The study is delimited to the children 8-13 years of age

• Data collection is delimited to children who are willing to participate during data collection

• Data collection period is delimited to four weeks.

6.10.PROJECTED OUTCOME

Neem leaves paste significantly will reduce the worm infestation

7.SOURCES OF DATA

Chidren having 8-13 years

7.1.1 RESEARCH DESIGN

Quasi experimental design - one group pre test post test design

7.1.2 SETTING

This study will be conducted in selected schools, Bangalore

7.1.3 POPULATION

School Children having 8-13 years

7.1.4 SAMPLE PROCEDURE

7.1.5 SAMPLE SIZE

30 children with the age group between 8-13 years

7.1.6 SAMPLING TECHNIQUE

Purposive sampling technique

7.1.7. INCLUSION CRITERIA

Specified school children who will be screened and diagnosed with worm infestation

Age group between 8 to 13 years Both female and male children Children who understand Kannada or English

7.1.EXCLUSION CRITERIA

Subjects who are not will to take part in the study

7.2 INSTRUMENTS INTENDED TO BE USED

Section 1: Related to demographic variables

Section 2: stool test for ova

7.2.1 DATA COLLECTION

A total of 30 children will be obtained after screening positive children in the study by purposive sampling technique.clean container will be given to the school children in the evening and will ask them to collect the morning stool specimen 5-6ml in the container. Lab investigation for verifying ova . screened children will be administered I gm neem leaves paste with two spoons in the daily morning for five days in a house. Sixth day children’s stoll will be tested for the worm infestation .

7.2.2 ANALYSIS

The data will be analyzed by using descriptive and inferential statistics

7.2.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS IF SO PLEASE DESCRIBE BRIFELY

Yes. Neem paste will be delivered to the pre schol children

8.Referrals

1.Vinod Kumar CS,Anand Kumar H.,Sunita V.,Indu Kapu, prevalence of worm infestations in school going girls, Indian Pediatrics 2003;40:70-72

2. S. Awasthi, T. Verma, P. Kotecha, V. Venkatesh, V. Joshi, S. Roy, Prevalence and risk factors associated with worm infestation in pre-school children (6-23 months) in selected blocks of Uttar Pradesh and Jharkhand, India.Indian journal of medical sciences, 2008 December

3.Bharathit A,Sruthi B,Singh G,Malnutrition among under-five children in Lucknow :scarcity in plenty,Journal of Clinical and Diagnostic Research 2010 December4; 1:183-187

4.WWW,neemtreeforms.com.

5.Ghai.O.P, Essential paediatrics,3rd edition,new delhi, W.B.saunders publications,2000, Pp246-250

6.WHO,worm infestation in pre school children,Indian Journal medical science 2008, December, volume 62, No 12,486

7.Chakma T, Rao PV, Tiwary RS. Prevalence of anemia and worm infestation in tribal areas of Madhya Pradesh. J Indian Med Assoc 2000; 98: 567-670.

8.SHANTHI ANANTHAKRISHNAN, P. K. DAS, Integrated programme for control of geohelminths:A perspective,THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, NO. 3,2001,148-53

9.Sikha Kotamma,effectiveness of neem leaves paste on worm infestations, the Nurse , volume 4, No 1, Jan-Feb 2012

10.Geeta Panwanda, Effect of Health Education Programme on Worm Infestation in School Children,The Nursing Journal of India, November 2011 , VOL. Cll No. 11

11..Ikram Ullah, Ghulam Sarwar, Sabina Aziz, Muhammad Hussain Khan, INTESTINAL WORM INFESTATION IN PRIMARY SCHOOL CHILDREN IN RURAL PESHAWAR, Gomal Journal of Medical Sciences July-December 2009, Vol. 7, No. 2

12.http://www.netowne.com/alt-healing/ayurveda/

13Chandrawathani P, Chang KW, Nurulaini R, Waller PJ, Adnan M, Zaini CM, Jamnah O, Khadijah S, Vincent N. Daily feeding of fresh Neem leaves (Azadirachta indica) for worm control in sheep. Trop Biomed. 2006 Jun;23(1):23-30.

14.L. Radhakrishnan, S. Gomathinayagam and V. Balakrishnan , 2007. Evaluation of Anthelmintic Effect of Neem (Azadirachta indica) Leaves on Haemonchus contortus in Goats. Research Journal of Parasitology, 2: 57-62.

15.M. R. Amin1, M. Mostofa2, M. N. Islam3 and M. A. Asgar4 Effects of neem, betel leaf, devil's tree, jute and turmeric against gastrointestinal nematodes in sheep, J. Bangladesh Agril. Univ. 8(2): 259–263, 2010