Middle East Journal of Family Medicine

1. Asisst. Prof. Dr., Department of Parasitology, Mustafa Kemal University School of Medicine
2. Asisst. Prof. Dr., Deparment of Family Medicine, Mustafa Kemal University School of Medicine

Correspondence to:
Asisst. Prof. Dr. Gulnaz CULHA
Mustafa Kemal University School of Medicine,
Deparment of Parasitology
Antakya/HATAY TURKEY
Phone:+90 326 2148661
Fax:+90 326 2148214
e-mail: gulnazculha@yahoo.com

ABSTRACT

Background: The aim of this study was to determine the prevalence of intestinal parasites in children and to evaluate its association with socio-economic and environmental factors.

Methods: Stool samples and cellulose tape slides of children between 1-16 years of ages living in a rural area in Antakya were investigated. Stool samples were examined by using the direct wet mount, iodine method, and sedimentation techniques.

Results: One hundred and ninenty-nine (51.3%) of the 388 children included in the study were male, and the mean age was 6,8±3,4 years (minimum 1, maximum 16). Most of the families (87.4 %) were from the lowest socio-economical level and almost all of the mothers (96.4%) were housewives. One hundred and fifty-three (39.4%) stool specimens and 114 (29.4%) cellulose tape slides were considered as positive. The most frequently detected parasites were Enterobius vermicularis (29.4%), Blastocystis hominis (19.8%), Giardia intestinalis (16.5%). No statistical significance was observed in relation to intestinal parasites detected in tape slides and stool samples and; gender (p=0,906 and p=0,751), maternal occupation (p=0,075 and p=0,410), paternal occupation (p=0,355 and p=0,354), conditions of the residence [i.e having a garden (p=0,185 and p=0,733) and stable (p=0,523 and p=0,851), water supply (p=0,675 and p=0,218), having pets or animals (p=0,856 and p=0,429), having a separate room for each sibling (p=0,927 and p=0,079)] and, having symptoms indicating intestinal parasites (p=0,126 and p=0,611).

Conclusion: High prevalences of intestinal parasites in children living in lower socioeconomic conditions showed that parasitosis remains a public health problem in Antakya.

Key words: childhood, intestinal parasites, prevalence, personal hygiene, socio-economical status.

Intestinal parasitosis is still an important public health problem in underdeveloped or developing countries⁽¹⁾. Incidence of intestinal parasitosis is affected by various factors, such as personal hygiene, dietary habits, education level of the community, socioeconomic conditions, climate and environmental factors. Also non-hygienic living conditions give rise to parasitic infections in children⁽²⁾. Intestinal parasites are more frequently encountered during childhood, since hygenic habits have not been fully developed^(3,4).

The World Health Organization estimates that more than one billion people of the world's population is chronically infected with soil-transmitted helminths and 450 million are ill as a result of these infections, the majority being children^(5,6). Non-hygienic living conditions give rise to parasitic infections in children. These infections are regarded as serious public health problems, as they cause iron deficiency anemia, growth retardation in children and other physical and mental health problems⁽⁷⁾.

Previous studies at various institutions in Turkey revealed high prevalances of intestinal parasitic infections among the following populations: 6-16 years old (10.8%), 12-16 years old (48.0%), 7-15 years old (55.1%), and 6-12 years old (88.0%)^(8,9).

Hatay province is in an underdeveloped region of southern Turkey. A number of studies indicate that G. intestinalis and E. vermicularis were endemic in children^(10,11). But there is no study revealing association between intestinal parasitic infections and sociodemographic factors.

In this study we aimed to investigate intestinal parasitic infections among children between 1-16 years of ages, and relation with the sociodemographic, environmental factors, behavioral habits and complaints in a small village near to Antakya, where the sanitary conditions are very poor, and most of the children studied reside near pools of sewerage.

Setting
This study was performed in rural areas of Antakya, which is located in southern Anatolia. Antakya is a big city with a population of 140 thousand and has a mild climate whereby temperature rises to about 35-40 C degrees in summer days. Sanitary conditions are insufficient in large parts of the city. We randomly selected a village representing a rural area of the city. We calculated the sample size as 369 (CI: 95%, predicted prevalence 40%). Six hundred and ten children between 1-16 living in the village comprised the study sample.

Data Collection
The 388 stool samples and cellulose tape slides of all children between 1-16 years of ages living in the study area were collected. Educational material explaining how to supply a stool specimen and a cellulose tape slide, was given to parents of each child. Sociodemographic data including age, gender, residence, parental occupation, number of siblings, environmental factors, housing conditions, and quality of water supply were noted. Complaints of abdominal pain, nausea / vomiting, lack of appetite, abdominal distention, intestinal dismotility, salivation during sleeping, headache, irritability in sleeping, perianal itching, teeth grinding and, history of parasitic infections were also noted. An informational document about the study, including how to supply a stool specimen and cellulose tape slide, was given to every mother.

Laboratory Methods
The cellulose tape slides were prepared in our laboratory. Two slides were prepared for each child. All the mothers collected slides for examination in the early morning prior to bathing or defecation. On the same day a nurse practitioner collected the slides for microscopic examination. All plastic vials were also labeled in our laboratory. All 388 stool specimens (0.5-1.5 gr) were collected and transported to the laboratory within the same day. Stool samples were examined for the presence of parasites by direct wet mount, Lugol's iodine solution and formaline-ethyl acetate sedimentation techniques(6).

Total number of children included in the study was 388. 199 (51.3%) of them were male, mean age was 6,8±3,4 years (minimum 1, maximum 16). Three hundred and fifty five (91.5 %) of the children have at least one sibling. Most of the parents (87.4 %) reported that they have very low income.

Almost all of the mothers (96.4%) were housewives. No statistical significance was observed in relation to intestinal parasites detected in tape slides and stool samples and gender (p=0.906 and p=0.751), maternal occupation (p=0.075 and p=0.410), paternal occupation (p=0.355 and p=0.354), conditions of the residence [i.e having a garden (p=0.185 and p=0,733) and stable (p=0.523 and p=0.851), water supply (p=0.675 and p=0.218), having pets or animals (p=0.856 and p=0,429), having a separate room for each sibling (p=0.927 and p=0.079)] and, having symptoms indicating intestinal parasites (p=0.126 and p=0.611) (Table 1). 153 (39.4%) stool specimens and 114 (29.4%) cellulose tape slides were positive. The most frequently observed parasites were Enterobius vermicularis (29.4%), Blastocystis hominis (19.8%), and Giardia intestinalis (16.5%). The frequencies of parasites in the age groups are shown in Table 2.

In the present study, we aimed to determine the prevalence of intestinal parasites in children between 1-16 living in a rural area of our region, and to evaluate its association with socio-economic and environmental factors. It was found that 153 (39.4%) stool specimens and 114 (29.4%) cellulose tape slides were positive. The most frequently observed parasites were Enterobius vermicularis (29.4%), Blastocystis hominis (19.8%), and Giardia intestinalis (16.5 %). Enterobiasis occurs worldwide mostly in schoolchildren. E. vermicularis infection is transmitted by hand to mouth or person to person directly. In the study area, children are living in low hygiene conditions. Lack of enough sanitary knowledge, behaviour and attitudes such as handwashing, bathing, food preparation were thought to be possible causes of auto infection. The higher prevalance of E. vermicularis could be explained by the highly infectious nature of parasites. Non-hygienic living conditions give rise to parasitic infections in children; socioeconomic status is the best indicator for prevalence of such infections. Intestinal parasites are transmitted either directly through the contamination of water, soil and food by feces, or indirectly through poor hygienic and living conditions^(12,13).

G. intestinalis was a common intestinal parasite among our study participants. This protozoa was the common intestinal parasite living in the contaminated water, an important risk factor for the Giardiasis in Hatay region. This may be a reason for the high prevelance of G. intestinalis in our study population.

The rate of intestinal parasitosis ranges from 23.8% to 80%, based on the geographical region. According to the studies from western Anatolia (Aegean region), prevalance of intestinal parasites is between 18.5%and 48.7%. This ratio ranges between 18.4% and 62.9% in different countries^(8,9).

It is well known that parasitic diseases are more common in communities with low socio-economic conditions⁽⁴⁾. These infections deteriorate the psychological and physical development of the children. The majority of the positive cases were from underdeveloped countries and developing regions where a sewerage system was not present and using natural spring water for drinking^(14-16).

The rate of E. vermicularis mostly depends on socioeconomic situations, education level, and personel hygiene and dietery habits. Çulha has investigated the prevalance of E. vermicularis in 70 children between 0-7 years of age and 60 boys and 55 girls between 7-17 years in three different institutions of Hatay Orphanage. Prevalence of E. Vermicularis was found to be 71.4 % in 0-7 age group, 0.08 % in boys and 0.14 % in girls between 7-17 age group. This is the only study which has been done for more than ten years for the determination of the prevalance of E.vermicularis in Hatay region⁽¹¹⁾. The infection rate was similar in both sexes (p=0.906 and p=0.751). In infected groups the mean age of the children was found to be 7.7±3.2 years and in uninfected groups 6.4±3.4 years.

Although there was no association between age of the children and prevalence of intestinal parasites detected in stool samples (p=0.769), E. vermicularis were significantly more prevalent in elder children.

Infections with intestinal parasites and malnutrition are common in developing countries and with the exception of hookworm; intestinal parasites affect mostly children⁽¹⁷⁾. The accelerated and unplanned growth of many cities in developing countries has created, in urban slums and shanty towns, sanitary conditions which may be as favorable for transmission of some intestinal parasites as those found in most poor and remote, rural areas^(1,14,18).

Okyay et al⁽⁸⁾ collected 456 stool specimens from 7-14 year old schoolchildren from Aydin to identify an association between socio-demographic and environmental factors, behavioral habits and also related complaints. 145 students (31.8%) were infected with one or more intestinal parasites. 29 (6.4%) of the students were infected with more than one parasite, 26 (5.7%) with two parasites and 3 (0.7%) with three parasites. The result of this study revealed that the three most common parasites were E.vermicularis, G.intestinalis, and E.coli. They also found that intestinal parasite prevalence was higher in rural areas, in children with less than primary school educated mothers, in children who use hands for washing the anal area after defecation, and in children who seldom or never use toilet paper.

Çeliksöz and colleagues reported that E.vermicularis were positive in 15.6% of participants with cellophane slides and Taenia spp eggs were positive in 1.6% of participants in a study comprising 2,200 school children in 6 schools in Sivas⁽¹⁹⁾.

Ulukanligil et al⁽¹⁵⁾ investigated intestinal parasites in a total of 1820 schoool children in three primary schools between 7-14 years of age. The prevalance of helminthic infections were 77.1% of the schoolchildren in shanty towns, 53.2% in apartment districts and 53.1% in rural areas. They found that Ascaris lumbricoides was the most prevalant species and that was followed by Trichuris trichura, Hymenolepis nana and Taenia species in three schools. Sanitation surveys indicated that the tap water was limited in shantytown schools, in shantytowns and rural areas, whereas the school in the apartment area was well sanitised.

In our study we found that 153 (39.4%) stool specimens and 114 (29.4%) cellulose tape slides were positive. The most frequently observed parasites were Enterobius vermicularis (29.4%), Blastocystis hominis (19.8%), Giardia intestinalis (16.5%).

In the present study no relation was observed between water supply and parasites identified. Thus we think that parasites were transmitted either directly through the contamination of soil and food by faeces, or indirectly poor living conditions. We investigated the relationship between sociodemographic data and environmental factors. No relation was identified between the presence of intestinal parasites and gender, maternal and, paternal occupation, housing conditions, keeping animals, and parasite related symptoms. Very low family income was found to be a risk factor for having parasites. As a matter of fact all the participants were from a low socio-economical status, but we dichotomised the group as low and very low income according to their reports.

We have so many limitations. We select a low socio-economical group of patients from a rural area of our region. Their living conditions are almost homogenous. The study group represents their socio-economical class but homogenity of the participants may lead low statistical significance between the risk factor previously reported. Our study may actually have underestimated the true prevalence of parasitic infections because we carried out the study in a relatively small sample and observed one stool sample and a tape slide.

To our knowledge the present study is the only study in Hatay region about intestinal parasites in children. Thus the present study will provide information about prevalence of intestinal parasites in children living in lower socioeconomic conditions, risk factors and alert health authorities to the matter. In conclusion, parasitic infections remain a serious health problem in our region.