Pak J Med Res                                                                                                                                                                                                ORIGINAL ARTICLE

Vol. 48, No. 1, 2009

 

Parasitic Infestation in Children of District Vehari: An Underdeveloped area of Pakistan

 

Khalid Mehmood,1 Misbah ul Islam Khan Sherwani,2 Maqsood Ahmed,3 Manzoor Hussain,1 Sohail Safdar,2 Maqsood Baitu1

Children Complex Hospital at District Headquarter Hospital Vehari1, PMRC Research Center Nishtar Medical College Multan,2 Blood Bank District Headquarter Hospital Vehari3

 

Abstract

 

Objective: To determine parasitic infestation among children of rural and urban areas of district Vehari.

Setting: Children Complex Hospital, at District Headquarter Hospital Vehari and  PMRC Research Center, Nishtar Medical College, Multan, Pakistan

Methods: A cross-sectional study was done in 2006 where 500 children aged 1-10 years presenting with anaemia and malnutrition were studied. Demographic information included residential area (rural/urban), gender, socio-economic status, hygienic conditions, source of drinking water were recorded on a questionnaire. Parents were interviewed, while stool and blood samples of children were collected for parasites and to determine anemia.

Results: Parasites were found in 140(28%) children and anemia in 236(47%). Prevalence of protozoa 102 (20.4%) was greater than intestinal helminthes 38 (7.6%). The most common protozoa was Entamoeba histolytica 101 (20.2%) and in nematodes, Hymenolepis nana was seen in 28 (5.6%), Ancylostoma duodenale (hook worm) in 5 (1%), Ascaris lumbricoides (round worm) in 3 (0.6%) and Taenia saginata (tape worm) in 2 (0.4%).

Diarrhoea was seen in 254 (50.8%) cases, constipation in 191 (38.2%), abdominal pain in 245 (49%), anorexia in 181 (36.2 %) and abdominal distension in 86 (17.2%) children. Rural children were significantly more infected with parasites, 81 cases (32.27%) compared with urban children 59 cases (23.69%) (p<0.05) and same was for poor children 81 (34.9%) compared with middle income 57(21.8%) (p<0.05). Infected cases with poor hygienic conditions (77 cases 35.2%) were more infected than those with satisfactory 62 (24.4%) and good hygiene 1(3.7%). Worm infestation was common 84(35.9%) in those using drinking water from hand pumps  compared to those obtaining drinking water from government water supply 47(23.9%) and water filtration plant 9(13.%), a significant difference in infection due to poor quality drinking water was observed(p<0.05). Worm infestation and anemia were inter related and 85 (60.7%) children with anaemia had parasites against 55 (39.3%) who were not anaemic (p<0.05).

Conclusion: Poor sanitation, hygiene and source of drinking water have appeared as major contributors towards parasitic infestation. Ent.histolytica was the most common protozoal infection found compared to helminths.

Policy Message: Use of clean drinking water and good hygienic practices should be instituted throughout the country.

Key Words: Parasitic infestation, children, Pakistan.

 

Corresponding Author:

Dr. Misbah Ul Islam Khan Sherwani

PMRC Research Center

Fatima Jinnah Medical College

Lahore

E.mail: drmisbah53@yahoo.com

 


 

Introduction

 

                Parasitic disease is a major public health problem globallly1,2 with intestinal parasites being most common in developing countries; in both rural and urban communities and in poors.3 Global estimates indicate that nearly 3.5 billion people are affected from parasitic infections and that among them 450 million become ill, the majority being children.4

 

Worm infestation in children has been studied in various parts of Pakistan. In a study children were more infected (60%) with helminthes and protozoa than adults (30%) who had only protozoal infection.5 Prevalence of helminthic infestation  in children was 23% in Islamabad,6 21.7% in Bagh District,7and 31% in Quetta.8 High prevalence of worm infestation in children is reported from northern areas of Pakistan.9-12  Major factors for worm infestation are poor socio-economic status, large family size, low educational level and poor environmental sanitation.5 Anemia is seen in high percentage of cases with intestinal parasites.8,9 Single parasite infection is common,5-12 however multiple parasites has also been reported.13

Southern Punjab  is an under developed part of the country where most of the population is living near or under poverty line. Poor hygienic and sanitation conditions are prevalent and clean drinking water is not available, diahorea, malnutrition, malabsorption and anaemia are common in children of this area. Keeping in view these public health problems this study was done to find the frequency and types of parasitic infestation among children of rural and urban areas of District Vehari.

 

Subjects and Methods

 

                Five hundred children aged 110 years having anaemia and malnutrition along with minor complaints attending the out patient department of Children Complex Hospital at District Hospital Vehari were included in the study. To have equal representation of both rural and urban population, 250 children from rural and 250 from urban areas of district Vehari were selected using convenient sampling. Parents were inquired for residential area (rural or urban), age, gender, socioeconomic status, source of drinking water (hand pump, govt. water supply or filtration plant), hygienic conditions (assessed by the Medical Officer from physical appearance of parents and child), diarrhea (3 or more loose or watery stools in 24 hours with or without dehydration: according to WHO disease surveillance standards), constipation, abdominal pain, abdominal distention and anorexia.

Parents were asked to bring early morning stool specimens in the container provided and also bring the child for blood complete picture testing. Single stool sample was taken as children were asymptomatic for worm disease. Stool specimens were examined under direct light microscopy of smear in normal saline and iodine preparation, concentration method was used wherever required. The laboratory diagnosis of smear for parasite infestation was based on demonstration of ova, cysts or trophozoites.14 Haemoglobin was checked on Microlab. Grading of anemia was done according to WHO guidelines i.e. non-anaemic (>11g/dl), mild anaemia (9 g/dl to <11 g/dl), moderate anaemia (7 g/dl to <9 g/dl), and severe anaemia (<7 g/dl).15

Data was analyzed using SPSS-10 computer program and the frequencies and percentages of various parameters have been determined. Chi-square test was applied to see the significant difference while comparing different variables, p<0.05 was considered as significant value.

 

Results

 

                Five hundred children, 251(50.2%) from rural areas and 249(49.8%) from urban areas were included in the study. Of the total, 314(62.8%) were males and 186(37.2%) females. Socioeconomically 232 (46.4%) belonged to poor, 262 (53.4%) to middle income and 6(1.2%) to rich families. Good living environment and hygienic conditions were available to only 27(5.4%), satisfactory to 254 (50.8%) and poor to 219 (43.8%). Water from filtration plant was used by 69 (13.8%), from Government supply 197 (39.4%) and 234 (46.8 %) were using hand pump water.

                Major complaints were diarrhoea in 254 (50.8%), constipation in 191 (38.2%), abdominal pain in 245 (49%), anorexia in 181 (36.2 %) and abdominal distension in 86 (17.2%) children. About 268 (53.6%) children were non anaemic, 115 (23.2%) had mild anaemia, 78 (15.7%) moderate anaemia and 39 (7.9%) severe anaemia. Stool examination showed an overall prevalence of parasitosis as 28% (140/500).  Prevalence of protozoa (102 cases 20.4%) was greater than intestinal helminthes (38 cases 7.6%). The most common protozoa was Ent. histolytica including its trophozoite form 101(20.2%).  Among soil transmitted intestinal nematodes, the commonest infestation was of H. nana 28 (5.6%), Ancylostoma duodenale (hook worm) was found in 5 (1%), Asc. lumbricoides (round worm) in 3 (0.6%) and T. saginata (tape worm) in 2 (0.4%) (table 1). Only two cases were infected with more than one parasite.

Distribution of parasites was similar in rural and urban areas however Ent.coli was seen in only one case (0.2%) in urban areas.

 

Table 1: Distribution of parasites among children studied

 

Total Parasites =140/500 (28%)

Protozoa (cyst)

102/500 (20.4%)

Helminthes (ova)

38/500 (7.6%)

 

Ent.

Histolytia

Ent. Coli

H. Nana

Anc.

duodenale

Asc.lumbricoides

Taenia Saginata

Positive

101

(20.2%)

1

(0.2%)

28

(5.6%)

5

(1%)

3

(0.6%)

2

(0.4%)

Negative

399

(79.8%)

499

(99.8%)

472

(94.4%)

495

(99%)

497

(99.4%)

 

498

(99.6%)

Total

500

500

500

500

500

500

 

There was no significant difference in parasitic infection in male and female children (table 2), but rural children were more infected with the parasites (81 cases 32.3%) compared with urban children (59 cases 23.7%) (p<0.05) (table 2).

Worm infestation was significantly more in poor children (81/232 cases 34.9%) than in middle income (57/262 cases 21.8%) (p<0.05) or high income where only (2/6 cases 33.3%) had cyst (table 2). Worm infestation was significantly more in those having poor hygienic standards when compared with satisfactory or good hygienic conditions (p<0.05).

                Source of drinking water was hand pump in 84 (35.9%), government supply in 47 (23.9%) and filtation plant in 9 (13.0%). A significant difference in infection due to source of drinking water was observed (p<0.05) (table 2).

 

Table 2: Parasitic infestation relationship with demographic characteristics

 

Demographic Characteristics

Parasite

Total parasites

Nos(%)

Protozoa cyst (%)

Helminth ova (%)

Gender

Male

(n=314)

64 (20.3)

27 (8.6)

9(28.9)

Female

(n=186)

38 (20.4)

11 (5.9)

49(26.3)

Residential area

Rural

(n=251)

61 (24.3)

20 (7.9)

81(32.3)

Urban

(n=249)

41 (16.4)

18 (7.2)

59(23.7)

Socioeconomic status

Poor

(n=232)

59 (25.4)

22 (9.5)

81(34.9)

Middle Income

(n=262)

41 (15.7)

16 (6.1)

57(21.8)

Rich

(n=6)

2 (33.3)

00 (0)

2(33.3)

Hygienic condition

Poor

(n=219)

58 (26.5)

19 (8.7)

77(35.2)

Satisfactory

(n=254)

43 (16.9)

19 (7.5)

62(24.4)

Good

(n=27)

1 (3.7)

0 (0)

1(3.7)

Source of drinking water

Hand pump

(n=234)

60 (25.6)

24 (10.3)

84(35.9)

Govt. supply

(n=197)

35 (17.8)

12 (6.1)

47(23.9)

Filtration plant

(n=69)

7 (10.1)

2 (2.9)

9(13.0)

 

                About 55 (20.5%) children with infestation were non anaemic, 46 (40.0%) had mild anaemia, 27 (34.6%) moderate anaemic and 12 (30.8%) had severe anaemia (table 3) (p<0.05).

 

Table 3: Parasitic infestation relationship with anaemia

 

Anemia

Parasites

Total Parasites

Nos(%)

Protozoa  cyst

Nos(%)

Helminth  ova

Nos(%)

Non-anaemic

(n=268)

38 (14.2)

17 (6.3)

55 (20.5)

Mild anaemic

(n=115)

33 (28.7)

13 (11.3)

46 (40.0)

Moderate anaemic

(n=78)

21 (26.9)

6 (7.7)

27 (34.6)

Severe anaemic

(n=39)

10 (25.6)

2 (5.2)

12 (30.8)

 

Discussion

 

                In developing countries most people live without access to proper sanitation facilities and are unaware of the importance of basic hygiene practices like hand washing after visiting toilet. Worm infestation is related to poor sanitation and lack of clean drinking water.1-4

Present study was done in one of the underdeveloped areas of Pakistan where public health facilities are scarce. In the present study, 140 children (28%) were infected with parasites while parasitc prevalence was high in Caribbean children (43.5%),16 Afghanistan (47.2%)17 Nepal (66.6%)18 and Bangladesh (53%).19 Worm infestation in children from northern areas of Pakistan is also high: Skardu (54.9%),9 Abbottabad (74.6%, 85%),10-11 and towns of Yasin and Singal (91%).12 The higher prevalence in northern and hilly areas may be due to drinking of contaminated water coming long way from hills which is polluted by human or animal wastes. Other studies in Pakistan showed prevalence of 23% in Islamabad,20 21.7% in Bagh District21 and 31% in Quetta,22 which is similar to the present study.

Dual parasites were seen in 2 cases in the present study and similar was reported in other local studies where 4 children had 2 parasites and one had three parasites,9 in some reports multiple parasite infection was also seen.13,16,23,24

In the present study no gender difference was noted in parasitic infection and same is observed by others.8,11,16,19  One report from Northern Pakistan showed high affection in girls.12

In the present study, prevalence of protozoa was higher than intestinal helminthes and same was reported by another worker5, while others have reported higher helminthic infestation.7,9-11,16-18 More protozoal than helminthes infestation in the present study may be due to the reason as most of children were from slum areas, with illiterate background, poor hygienic conditions, drinking contaminated water and lacking hand washing practices. Other studies have also shown infestation with both parasites.19,25,26,27

In Iran, the parasitic infection rate was highest in 2-14 years age group (25.5%) and in rural residents (23.7%).26 Similarly in India, worm infestation was more in rural area than urban area,25 possibly due to the poor hygienic conditions in these areas. Anemia was seen in worm infested children in the present study and others have also reported same results.9,11,17,23 Anemia is due to blood loss caused by these pathogens and during treatment of worms or parasites supporting iron therapy is also suggested.

 

References

 

1.        Adedayo O, Nasiiro R. Intestinal parasitoses. J Natl Med Assoc 2004; 96: 93-6.

2.        Small EA, Tice AD, Zheng X. Intestinal parasites of the Pacific. Hawaii Med J 2003; 62: 216-9.

3.        Farook MU, Sudharmini S, Remadevi S, Vijayakumar K. Intestinal helminthic infestations among tribal populations of Kottoor and Achankovil areas in Kerala (India). J Commun Dis 2002; 34:171-8.

4.        World Health Organization. Control of tropical diseases. Geneva: WHO; 1998.

5.        Tahir Z ,  Hafeez R,  Zafar A,  Jehangir S. Comparison of prevalence of intestinal parasites in children and adult population. Biomedica. 2002;18:74-5.

6.        Tanwani AK, Qazi SA, Hashimoto K, Khan MA. Intestinal parasites in stool samples from children at the Children`s Hospital Laboratory, Islamabad.  Pak Ped J. 1995; 19: 61-4.

7.        Khan A, Sultana A, Dar AMK, Rashid H, Najmi SAA. A study of prevalence, distribution and risk factors of intestinal helminthic infestation in district Bagh (Azad Kashmir). Pak Armed Forces Med J. 2004; 54: 243-8.

8.        Wadood A, Bari A, Rehman A, Qasim KF.  Frequency of intestinal parasite infestation in Children Hospital Quetta. Pak J  Med Res 2005; 44: 87-8.

9.        Alam M,  Khaltak AL,  Talha M. Anemia and intestinal parasitic infestations in school children in Skardu. Pak Armed Forces Med J. 2007;57:77-81.

10.      Hussain SM, Raza MI, Naeem S. Prevalance of intestinal Parasites in Northern Areas of Pakistan (Baltistan Division-Skardu).  Biomedica. 1997; 13: 60-4.

11.      Ahmed AK, Malik B, Shaheen B, Yasmeen G, Dar JB, Mona KA. Frequency of intestinal parasitic infestation in children of 5-12 years of age in Abbottabad. J.Ayub Med Coll Abottabad. 2003;15:28-30.

12.      Waqar SN, Hussain H, Khan R, Khawaja A, Majid H, Malik S, et al. Intestinal Parasitic Infections in Children from Northern Pakistan. Infect Dis J.2003; 12:73-7.

13.      Raso G, Luginbuhl A, Adjoua CA, Tian-Bi NT, Silue KD, Matthys B, et al.  Multiple parasite infections and their relationship to self-reported morbidity in a community of rural Cote d'Ivoire.  Int J Epidemiol. 2004; 33: 1092-1102.

14.      Fleck SL,  Moody AH. Diagnostic techniques in medical parasitology.  New York: - John Wright Publishing Co. 1988

15.      WHO. Nutritional Anemias. Report of a WHO Scientific Group. World Health Organization. Tech Rep Ser. 1968; 405: 9-10.

16.      Lindo JF, Validum L, Ager AL, Campa A, Cuadrado RR, Cummings R, et al. Intestinal parasites among young children in the interior of Guyana. West Indian Med J. 2002; 51(1): 25-7.

17.      Gabrielli AF, Ramzam M, Nauman C, Tsogzolmaa D, Bojang B, Khoshal MH, et al. Soil-transmitted helminths and haemoglobin status among Afghan children in World Food Programme assisted schools.  J Helminthol. 2005; 79: 381-4.

18.      Sharma BK, Rai SK, Rai DR, Choudhury DR. Prevalence of intestinal parasitic infestation in schoolchildren in the northeastern part of Kathmandu Valley, Nepal. Southeast Asian J Trop Med Pub Health. 2004; 35: 501-5.

19.      Hosain GM, Saha S, Begum A. Impact of sanitation and health education on intestinal parasite infection among primary school aged children of Sherpur, Bangladesh. Trop Doct. 2003; 33: 139-43.

20.      Tanwani AK, Qazi SA, Hashimoto K, Khan MA. Intestinal parasites in stool samples from children at the Children`s Hospital Laboratory, Islamabad. Pak Pediatr J 1995; 19: 61-4.

21.      Khan A, Sultana A, Dar AMK, Rashid H, Najmi SAA. A study of prevalence, distribution and risk factors of intestinal helminthic infestation in district Bagh (Azad Kashmir). Pak Armed Forces Med J. 2004; 54: 243-8.

22.      Wadood A, Bari A, Rehman A, Qasim KF.  Frequency of intestinal parasite infestation in Children Hospital Quetta. Pak J Med Res. 2005; 44: 87-8.

23.      Pathmeswaran A, Jayatissa R, Samarasinghe S, Fernando A, De Silva RP, Thattil RO, et al. Health status of primary schoolchildren in Sri Lanka. Ceylon Med J.  2005; 50: 46-50.

24.      Okyay P, Ertug S, Gultekin B, Onen O, Beser E. Intestinal parasites prevalence and related factors in school children, a western city sample--Turkey. BMC Public Health. 2004; 4: 64.

25.      Singh HL, Singh NB, Singh YI. Helminthic infestation of the primary school-going children in Manipur.  J Commun Dis. 2004; 36: 111-6.

26.      Sayyari AA, Imanzadeh F, Bagheri Yazdi SA, Karami H, Yaghoobi M. Prevalence of intestinal parasitic infections in the Islamic Republic of Iran. East Mediterr Health J. 2005; 11: 377-83.

27.      Xu LQ, Yu SH, Jiang ZX, Yang JL, Lai LQ, Zhang XJ, et al. Soil-transmitted helminthiases: nationwide survey in China. Bull World Health Organ.