Prevalence and Effect of Personal Hygiene Ontransmission of Helminthes Infection Among Primary School Children Living in Slums

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

PREVALENCE AND EFFECT OF PERSONAL HYGIENE ONTRANSMISSION OF HELMINTHES INFECTION AMONG PRIMARY SCHOOL CHILDREN LIVING IN SLUMS

R.M. KAPILA THARANGA RATHNAYAKA & ZHONG-JUN WANG*

*Department of Statistic, Science Collage, Wuhan University of Technology, Wuhan, PR China - 433070.

ABSTRACT

Soil–Transmitted Nematode Inflections are the most common helminthes infections among the world population, while it causes serious infections in developing countries, mainly in south Asia and Africa. Day by day the rate of infection has been rising rapidly. Aim of the present survey was to explore the relationship between the prevalence and intensity of risk factors for Ascaris infection among primary school children in Badulla district, Sri Lanka, using standard parasitological techniques. In this paper we analyze these effects via two models, one multiple regressive technique, to identify the association between prevalence of infection and some risk factors, and the other multiple logistic regression analysis, to study the independent association of factors for Ascaris infection. Results provide an estimate that socio economic conditions, de-worming and rate of infection are highly co-related with each other. Authorities should pay more attention for these factors in order to control the rate and spread of infection.

KEYWORD: Ascaris infection, Helminthes infection, Kato- katz technique, Logistic Regression Analysis. ______

1. INTRODUCTION

Soil – transmitted nematode inflections are one of most plenteous nematode infections in the world today. Especially it is wide- spread throughout the developing world, including Sri Lanka and other south Asian counties. According to the World Heath Organizational (WHO) reports of 2010, approximately 0.807-1.221 billion humans have been infected with Nematode infection, 604-795 million have trichuriasis, and 576-740 million have hookworm infections all over the world. At least 20,000 people die annually due to these infections (WHO, 2010). Children and teenagers between 6 to 14 years of age are more heavily infected than the adults.

A considerable number of people in Sri Lanka live in poor living conditions (e.g.-slums), www.zenithresearch.org.in mostly in congested urban areas and also in the plantation sector. Due to the low socio-

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780 economic status, environmental conditions, and poor personal hygiene, transmission and distribution of Ascaris infection is generally higher among people living in such conditions compared with others. In addition poor sanitation and low literacy rate are the other main factors which influence the rate of infection.

According to a recent study, there are at least 60 species of nematodes, which cause parasitic infections in the Human body. Ascariasis, trichuriasis, hookworm, enterobiasis, strongy loidiasis, filariasis, and trichinosis are the main nematode species that infects to humans (G.S.A Gunawardane et. al, 2004). They are also called round worms. Ripe round worms are white or yellow in color and 15-35 cm in length. Normally their life cycle spans, 10-24 months in the jejunum and ileum of the Human intestine. While a majority of species are parasites some live freely in the nature. They can oblong with bilaterally symmetric bodies that contain an intestinal system and the body activity.

However, life cycles of nematodes are complicated and closely related with modes of transmission in to the Human body. An in-depth knowledge of their life cycles is important clinically for prevention and treatment. There are three main modes of transmission. Nematodes such as Enterobiusvermicularis are transmitted directly from infected person to non infected person. While ova of other species such as Ascaris lumbricoides, Necatoramericanus and Ancylostomaduodenale mature in soil and subsequently the adult nematode infect Human beings (R.M Andoson et. al, 1985).

This study was designed to determine the relationship between the prevalence and intensity of Ascaris infection in primary school children who live in slums in suburban and plantation regions of Badulla, Uva Province, Sri Lanaka, and factors such as availability of proper sanitary facilities, socio- economic status and health habits have affected its prevalence.

Homes of each selected individual were visited and clear instructions were given to students, parents and guardians regarding the study and collection of stool samples. Stool samples were collected from the selected population and analysis was carried out under the Kato- katz technique. Multivariate Regressive methods were performed to compare the effect of potential risk factors for helminth infection in primary school children of Badulla district in 2010. Independent associations of the variables were fully described using

Logistic Regression Methods.

All steps were conducted according to the biomedical guidelines.

2. MATERIALS AND METHODS

2.1 STUDY AREA

The study was carried out from July – November 2011, in Badula district. It is located in the hill country of the island, surrounded by many mountains with wide spread tea and rubber plantations. This area is rich in water resources; there are many streams flowing www.zenithresearch.org.in through the region which constitutes the major source of water supply to its inhabitants.

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

Under the local climate zone classifications, Badulla is classified under up country intermediate zone. Annual average rainfall is between 1000 and 1400 mm and average atmospheric temperature is between15to 27 0C (CCAU, 2011). The total population is approximately 1 million with multi ethnicity groups such as Sinhala, Tamils, Muslims, Malays and Burghers.

Badulla is an agricultural district. Therefore most of the people are directly involved in vegetable cultivation; livestock and working as laborers in tea estates. Due to this educational and socio-economic statuses of the inhabitants are relatively low compared to other areas in the country.

This study was conducted for the primary school children aged 6-12 from randomly selected schools, namely Haputale Tamil Collage (HTC), Koslanda Tamil Collage (KTC), Rathkarawwa Maha Vidyalaya (RMV) and Guratalawa Maha Vidyalawa (GMV). Most of the students studying in the HTC and KTV are from the Tea plantation areas, living with fewer facilities. RMV situated in rural area and GMV in sub – urban area.

2.2 DATA COLLECTION AND EXAMINATION OF SOIL SAMPLES

The study population included 500 students, from grade 1 to 5. For ease of handling samples, unique identification numbers were assigned to each and every student based on their gender, school and grade.

After obtaining informed and written consent from their parents or guardians, a structured questionnaire was distributed for collection of data such as Socio-economic status, living environment demographic data, Sanitary facilities, worm treatments and behavioral habits like washing hands before meals, drinking boiled water. Questionnaire was given in their native language (Sinhala and Tamil).

Upon completion of the questionnaires, clean and dry wide mouthed vials (with the identification numbers) were given to all the participants for collection of stool samples. Standard procedure of sample collection was explained clearly and thoroughly, to the students, their parents and guardians individually. Stool samples were collected on the following morning from their homes. All samples were kept in cold storage at 8 0C without any preservatives and taken to the laboratory for analysis, in order to minimize the sample transport time. All samples were examined by the medical laboratory technician under the supervision of the microbiologist.

Out of 500, only four hundred and sixty (460) stools samples were collected twice a week. Formal Ether Sedimentation Technique was used to determine the prevalence and intensity of nematode infection. It is a standard method used for diagnosis of the disease and also for accurate estimation of the egg count.

An applicator stick was used to mix approximately 0.2g of stool sample with one drop of saline on clean slides. According to the Kato- katz technique, egg counts were recorded in www.zenithresearch.org.in each positive sample. After that intensity of infection was categorized using cut- off values

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780 recommended by WHO [(number of positive cases in the sample/ number of samples examined) ×100].

3. STATISTICAL ANALYSIS

Collected data was transferred in to a Microsoft XL data base and analyzed using Minitab and R statistical soft ware packages. Multiple regressive techniques for continuous variables and chi-square test for categorical variables were used to identify the association between prevalence of infection and some risk factors. Furthermore, logistic regression analysis with odd ratios used to study the independent association of variables. Results were discussed under the 0.05 level of significance.

TABLE 1: NUMBER OF INFECTED STUDENTS

HTC KTC RMV GMV

Infected 88 78 38 56

Not Infected 35 40 85 60

Total 123 118 123 116

Based on results in table 1, out of 480 students, 260 (54%) of subjects were found to be excreting stools with Ascaris eggs. The students who are living in slums in tea estates had a higher prevalence of 68% as compared with others in rural areas 30% and sub urban area 48%. More Boys (57%) were infected than girls (48%), but gender was not statistically significant (p= 0.182 >0.05). Infection was higher among younger individuals (aged between 6-10-67%) than older children.

3.1 SOCIO–ECONOMIC STATUS

According to the socio–economic theories, there is a strong relationship between socio economic status of individuals and their health. In this study personal economic status such as household’s information, level of education of parents and their monthly income were obtained by interviewing students as well as their parents.

All most all subjects in plantation area (studied in HTC & KTC) lived in long terraces of one room house slums, which are called estate lines. Further, at least four or five family

members were living in a slum without any facilities. www.zenithresearch.org.in

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

However, most of the students living in urban area (studying in RMV), were living in their own detached houses. Majority of their parents were educated up to grade eight or nine and cultivate vegetables in their own lands. Based on chi-Square results (0.0487<0.05), parent’s educational level and their behaviors are significantly related with prevalence of Ascaries infection.

3.2 AVAILABILITY, USAGE AND LOCATIONS OF LATRINES

FIGURE 1: AVAILABILITY AND USAGE OF LATRINE FACILITY

According to our survey results in figure 1, latrine usage is extremely poor in plantation areas compared with urban areas. Majority (at least 68%) in estate lines have access to public latrines, which are not well defined. Only very few used well defined latrines while the rest defecate in the jungles, rivers banks or surrounding environment.

When comparing behavioral habits of infected and non infected groups, the factor regular washing of hands with soap before meals(0.002<0.05) and after defecation(0.021<0.05) was

strongly associated with increasing spread of diseases. www.zenithresearch.org.in 3.3 SOURCE OF WATER SUPPLY

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

Figure 2 summarizes the distribution of water supply. Almost all subjects who studied in HTC (86%), KTC (92%) and GMV (72%) drank tap water from local pools of collected water and from the public water supply. However students who were living in the rural area (RMV) obtain their water directly from public and other wells. Only a few numbers of students drank water that had been boiled. However during school time most of the students drink tap water and only few students will take water bottles from their home.

FIGURE 2: SOURCE OF WATER SUPPLY

Ascaries infection was found to be lower among the subjects who drink boiled water (0.001<0.05).

3.4 MULTIVARIATE LOGISTIC REGRESSION ANALYSIS

By using Chi–Square test results as shown in table 2, boiling of drinking water, washing hands before meals, washing hands after defecation, latrine facilities, worm treatment periods and place of residence, were found to be more significant for ameliorating the

prevalence of Ascaries infection. www.zenithresearch.org.in

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

TABLE 2: MULTIPLE LOGISTIC REGRESSION RESULTS

Variables Code Odd 95% Regression P Value Ratio Confidence Coefficient Interval

Constant 1.521

Sex SEX 0.182

Female SF 1.00

Male SM 1.25 (0.45 - 2.32) 0.089

Age AGE 0.0752

12 or More A1 1.00

9 -11 A2 1.35 (0.56 – 1.45) 1.765

6 – 8 A3 1.52 (0.87 – 3.25) 2.876

Boiling of Drinking Water BDW 0.001

Always B1 1.00

Sometimes B2 1.83 (0.83 – 2.64) 3.876

Not at all B3 3.02 (0.56 – 8.98) 6.989

Washing Hands before Meals WHM 0.002

Regularly C1 1.00

Really or never C2 4.02 (0.46 – 6.89) 4.768

Washing Hands using soap after defection WHD 0.021 www.zenithresearch.org.in

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

Regularly

Really or never D1 1.00

D2 3.42 (0.02 – 4.97) 3.712

Toilet in house hold

Yes TH 0.032

No E1 1.00

E2 2.05 (0.09 – 3.78) 3.332

Ethnic Group

Sinhala EG 0.174

Tamil F1 1.00

Muslim and Others F2 3.95 (1.87 – 8.97) 3.876

F3 2.85 (1.56 – 5.53) 3.665

Living Place

Rural LP 0.011

Sub- Urban G1 1.00

Estate lines G2 2.06 (0.54 – 3.42) 2.897

G3 4.54 (0.98 – 6.76) 8.547

Take warm Treatments

Less than 6 months TT 0.001

More than or equal 6 H1 1.00

H2 4.06 (1.56 -10.4) 9.997

Logistic regression analysis methods were applied to determine the predictive effect to the various factors investigated on the prevalence of infection. Table 2 represents the multiple logistic regression results with regression coefficients for each variable. Using these www.zenithresearch.org.in Regression coefficients, we can obtain the new fitted model.

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

0 1.5210 , 1 0.089 , 2 1.765 , 3 2.876 , 4 3.887 , 5 6.989 , 6 4.768 ,

7 3.712 , 8 3.322 , 9 3.447 , 10 3.665 , 11 2.897 , 12 8.547 ,

13 9.989 ,

So that new infection model is given (in logit form) by,

Logit [pr (Y = 1)] 1.5210 + 0.089 SM + 1.765 A2 + 2.876 A3 + 3.887 B2 + 6.989 B3 = + 4.768 C2+ 3.712 D2 + 3.322 E2 + 3.447 F2 + 3.665 F3 + 2.897 G2 + 8.547 G3 + 9.989 H2

Suppose that one of the independent variable is “BDW (boiling of drinking water)” which has been coded as “B1 (Always)”, “B2 (Sometimes)” and “B3 (Not at all)”.

To compare BDW results, two design variables were necessarily used. They are D1 and D2 .

B1 represent the base group. So D1 and D2 both be set equal to 0. Table 3 illustrated these results. By using the logistic transformation, we can present final conclusion.

TABLE 3: DESIGN VARIABLE FOR BDW

Identification Code D1 D2

B1 0 0

B2 1 0

B3 0 1

After applied Table 3 results for the new fitted model (in logic form),following equations were obtained.

Eq1

Logit [pr (Y = 1)] 1.5210 + 0.089 SM + 1.765 A2 + 2.876 A3 + 3.887 (0) + = 6.989 (0) + 4.768 C2 + 3.712 D2 + 3.322 E2 + 3.447 F2 + 3.665 F3 + 2.897 G2 + 8.547 G3 + 9.989 H2

Eq2

Logit [pr (Y = 1)] 1.5210 + 0.089 SM + 1.765 A2 + 2.876 A3 + 3.887 (1) + 6.989 = (0) + 4.768 C2 + 3.712 D2 + 3.322 E2 + 3.447 F2 +3.665 F3 +

2.897 G2 + 8.547 G3 + 9.989 H2 www.zenithresearch.org.in

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

According to the equations Eq1 and Eq, only the Intercepts were different.

Compared with other results, those who never drink boiled or filtered water were more than 3 times more likely to be infected with an odd ratio (OR) of 3.02 with (0.56 – 8.98) confidence level. Also the individuals who will never wash hands using soap after defections were more than 4 times likely to be infected compared with subjects, washing hands regularly (OR=3.42, CI= (0.02 – 4.97). Also it was found that the infection were independent with sex (0.182> 0.05) and race (0.174> 0.05).

Based on our results, we can suggest that Ascaries infection and medical treatments are highly related with each other. Because students who did not take worm treatment within 6 months were 4 times more likely to be infected compared with others (OR=4.06, CI= (1.56 – 10.45)). According to our survey, de-worming tablets were obtained from the public health inspector in their division (45%), hospitals (35%) and private pharmacies (20%).

5. DISCUSSION

Soil transmitted infections are the most common helminthic infection in the world today. The infection rates have been increasing rapidly compared with past records. The best example is number of people with Ascaries infection were nearly 0.807-1.221 billion in 2005 which has increased to approximately about 2.5 billion by the end of 2010 (WHO, 2011) as shown in figure 3.

FIGURE 3: ACARIES INFECTIONS FOR SCHOOL CHILDREN, 2003–2009

www.zenithresearch.org.in Source: WHO records 2002 – 2010 (WHO, 2011).

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

This survey was done in 2011, to explore the prevalence and risk factors for Ascaries infection in primary school children. According to our results, faeces of 260 out of 480 (54%) subjects were found to be contaminated with Ascaris ova. Helminthic infections are wide spread among people who live in line rooms in tea estates with low socio-economic status and poor sanitary facilities. Among them, majority of the subjects living in slums in tea estates (70%) and sub urban area (57%) used not well defined public toilets and open ground for their defecation.

According to our results the prevalence of infection was greatest among the younger children (OR=1.52, CI= (0.87-3.25)) who were aged between 6 to 8. R.S Houmsou, E.U Amuta and T.A Olusi also carried out a similar kind of research for primary school children in Makurdi, Benue state in Nigeria in 2010. According to their findings high prevalence among younger children is seen because of the level of soil contact activity and low personal hygiene. Also male children were more infected than females. But compared with others, gender (0.182>0.05) was not significant.

Unfortunately in our research we have not taken measurements of height and weight for the individuals. But according to some recent foundlings, there is a co-relation between stunted growth levels and malnutrition among children and prevalence of infection (S.O Oninla et. al, 2007).

Among the infected children, majority drank tap water from local pools of collected water and from the public water supply (HTC (86%), KTC (92%) and GMV (72%)). Only a few number of students drank water that had been boiled. However boiling of drinking water (OR=3.02, CI= (0.56- 8.98) is highly co- related with Prevalence of infection.

Lot of research work is being carried out to find a solution for this problem. Different treatment modalities have been developed to counter the spread of infection. Most of the available data are from studies carried out in South and West African regions. The simulation results coincide with those investigated by R karunaithas, A Murugarathan and S kanathasan. They have carried out their study in Vadamarachi educational zone, Jaffna.

The key identified factors which are responsible for the prevalence of Ascaris infection, according to the results of our study are, frequency of worm treatment during the last 6 months, drinking unboiled water, washing hands without soap before meals and after defection.

Day by day the rate of infection has been rising rapidly in humans. Therefore the authorities should pay more attention to control and prevent the spread of infection. An Island wide awareness, health education and a de-worming program would help enormously to reduce prevalence and also to curb the spread of infection. A program of this magnitude can be carried out with the cooperation of the Ministry of Health, Ministry of Education and the Local Authorities. The Republic of Korea was faced with a very serious prevalence of STH infection since 1965 to 1971. Overall prevalence was 84.3%, they managed to reduce it down to 2.4% by 1997 (K.Gunawardena et. al, 2007) with such www.zenithresearch.org.in nationwide programs.

ZENITH International Journal of Multidisciplinary Research Vol.2 Issue 7, July 2012, ISSN 2231 5780

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