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 TECHNOLOGY KALIMATI, 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 NEPAL 2008
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 wise distribution, 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

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

TABLE OF CONTENTS
Page No. Board of examiners Acknowledgement Abstract Table of contents List of abbreviations List of tables List of figures List of photographs List of appendices CHAPTER I: INTRODUCTION CHAPTER II: OBJECTIVES OF THE STUDY CHAPTER III: LITERATURE REVIEW 3.1 Global Scenario 3.2Asian Scenario 3.3 National Scenario CHAPTER IV: MATERIALS AND METHODS 4.1 Subject and site of study 4.2 Sample collection 4.3 Transportation of the samples 4.4 Laboratory processing of the samples 4.4.1 Macroscopic Examination 4.4.2 Microscopic Examination 4.4.3 Recording of the data 4.4.4 Report distribution 4.4.5 Statistical analysis 30 30 32 32 33 i ii iii v vii viii ix x xi 1-4 5 6-28 6 16 24 29-33 29 29 29

CHAPTER V: RESULTS CHAPTER VI: DISCUSSION AND CONCLUSION 6.1 Discussion 6.2 Conclusion 6.3 Limitation CHAPTER VII: SUMMARY AND RECOMMENDATION 7.1 Summary 7.2 Recommendation CHAPTER VIII: REFERENCES

34-40 41-46 41 48 48 49-51 56 51 52-67

LIST OF ABBREVIATIONS
STH A. lumbricoides S. stercoralis H. nana E. histolytica E. coli I. butschlii C. mesnili E. nana E. hartmani B. hominis C. cayetanensis T. trichiura N. americanus P. westermani WHO NITMPHR Total n Pos n Soil Transmitted Helminthes Ascaris lumbricoides Strongyloides stercoralis Hymenolepsis nana Entamoeba histolytica Entamoeba coli Iodamoeba butschlii Chilomastix mesnili Endolimax nana Entamoeba hartmani Blastocystis hominis Cyclospora cayetanensis Trichuris trichiura Necator americanus Paragonimus westermani World Health Organisation National Institute of Tropical Medicine and Public health Research Total number Positive number

LIST OF TABLES
Page No. Table 1: Gender wise prevalence of parasitic infection Table 2: prevalence of parasitic infection in public school and 34 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. Table 8: Prevalence of parasitic infection according to the drug used 38 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

LIST OF APPENDICES
Page No. Appendix 1: Materials and chemicals used Appendix 2: Questionnarie and report form i-ii

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%) households still 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 million lost 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 smallscale 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 neartotal 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 ageclass, 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 childcare 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 studies indicate 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 diseasecausing 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 214 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 4069 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 sociodemographic 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 fulltime 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 school deworming 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 adult females 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 Workers 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 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 patients 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 Lugols 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 Boys Girls Total Total n 140 163 303 Positive n 51 57 108 % 36.4 34.9 35.6 p-value p>0.05

Table-2: Prevalence of parasitic infection in public school and private school School Public school Gender Boys Girls Total* Total n 90 113 203 Positive n 36 46 82 % 40.0 40.7 40.3 p-value p>0.05

Private school

Boys Girls

50 50

15 11

30.0 22.0

p<0.05

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 Types of parasites A. lumbricoides T. trichiura Hookworm H. nana E. vermicularis Total helminthes G. lamblia E. histolytica Total protozoan Overall parasites Public school positive n 15 6 5 4 2 32 41 9 50 82 % 7.3 2.9 2.4 1.9 1.0 15.7 20.1 4.4 24.6 40.3 Private school positive n 4 2 1 1 1 9 14 3 17 26 % 4.0 2.0 1.0 1.0 1.0 9.0 14.0 3.0 17.0 26.0

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

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 Public school Age (yrs) 10 >10 Total 10 >10 Total Total n 145 58 203 77 23 100 Positive n 56 26 82 20 6 26 % 38.6 44.8 40.3 25.9 26.1 26.0 p-value p>0.05

Private school

p>0.05

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

60 50 40 30 20 10 0

Household treated water

Public school

Untreated water
Private school

* 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 Public school Private school Family size 5 >5 Total 5 >5 Total Total n 140 63 203 58 42 100 Positive n 52 30 82 10 16 26 % 37.1 47.6 40.3 17.2 38.1 26.0 p-value p<0.05 p>0.05

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

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 Public school Private school Toilet Yes No Total Yes No Total Total n 160 43 203 84 16 100 Positive n 50 32 82 16 10 26 % 31.2 74.4 40.3 19.0 62.5 26.0 p-value p<0.05 p<0.05

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 Public school Ethnic group Dalit Madhesi Others* Total Dalit Madhesi Others* Total Total n 39 50 114 203 16 20 64 100 Positive n 27 35 20 82 10 8 8 26 % 69.2 70.0 17.5 40.3 62.5 40.0 12.5 26.0 p-value p<0.05

Private school

p<0.05

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

70 60 50
40

30 20 10 0

Tap

Well
Public school Private school

Dhungedhara

Fig. 2: Prevalence of parasitic infection according to the source of water used for drinking. Significant difference (p<0.05) was observed in both public and private school. 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). Table-8: Prevalence of parasitic infection according to the drug used. School Public school Private school Antihelminthic drug taken Yes No Total Yes No Total Total n 56 147 203 84 16 100 46 Positive n 14 68 82 16 10 26 % 25.0 46.2 40.3 19.0 62.5 26.0 p-value p<0.05 p<0.05

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).

60 50 40 30 20 10 0

Agriculture

Business
Public school

Service
Private school

Labour

Fig. 3: Prevalence of parasitic infection according to the occupation of parents. Students having fathers 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).

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 boys 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 socioeconomic 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 childrens 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 fathers occupation or family business. Children with fathers 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 fathers 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 farmers and labours 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 fathers 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 (Table5). In public school, higher positive rate (74.4%) was found in children without toilet 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 labours family (56.0%) in public school and farmers 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 and awareness 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
8. REFERENCES
1. Acharya S (1979) Malnutrition and diarrhoel disease. Inst Med J (Nepal) 1:21-23 58

2. Arfaa F (1981) Intestinal parasites among Indochinese refugees and Mexican immigrants resettled in Contra Costa County, California. Fam Pract J 12:223-236 3. Alo EB, Anosike JC and Danbhuran JB (1993) A survey of intestinal helminthes among students of post primary institution in Adamawa State, Nigeria. Applied Parasitol 34:161-167 4. Agi PL, (1997) Comparative helminth infections of man in two rural communities Niger Delta, Nigeria. West Afr J med 16:232-236 5. Anderson TJC, Zizza CA, Leche GM, Scott ME and Solomons NE (1993) The distribution of intestinal helminth infections in a rural village in Guatemala. Mem Inst Oswaldo Cruz 88:53-65 6. Adhikari RK, Rai SK, Pokhrel BM and Khadka JB (1986) Bacterial study of drinking water of Kathmandu Valley. J Inst Med (Nepal) 8:313-316. 7. Ashford RW, Atkinson EA (1992) Epidemiology of Blastocystis hominis infection in Papua New Guinea: age-prevalence and associations with other parasites. Ann Trop Med Parasitol 86:129-136 8. Assuhaimi SA, al-Eissa YA, Abdullah AM, AboBakr AM, al-Husain MA, alNasser MN and al Borno MK (1995) Prevalence of intestinal parasites in Saudi children: a community-based study. J Trop Pediatr 41:47-49 9. Allen H, Sithey G, Padmasiri EA and Montresor A (2004) Epidemiology of soil-transmitted helminths in the western region of Bhutan. Southeast Asian Trop Med Public Health J 35:777-779 10. Ali MB, Ghenghesh KS, Aissa RB, Abuhelfaia A and Dufani M (2005) Etiology of childhood diarrhoea in Zliten, Libya. Saudi Med J 26:1759-1765.

59

11. Albonico M, Crompton DW and Savioli L (1999) Control strategies for human intestinal nematodes infections. Adv Parasitol 42:277-341 12. Asaolu SO, Holland CV, Jegede JO, Fraser NR, Stoddard RC and Crompton DWT (1992) The prevalence and intensity of soil-transmitted helminthiasis in rural communities in Southern Nigeria. Ann Trop Med parasitol 86:279-287. 13. Bangs MJ, Purnomo, Adersen EM and Anthony RL (1996) Intestinal parasites of humans in a highland community of Ivian Jaya, Indonesia. Annals of Trop Med and Parasitol 90:49-53 14. Bista MB and Gautam A (1993) Acute diarrhoea- An epidemic in Nepal in 1992. J Nep Med Assoc (Nepal) 31:78-81 15. Bundy DA, Cooper ES, Thompson DE, Anderson RM and Didier JM (1987) Age-related prevalence and intensity of T. trichiura infection in a St. Lucian community. Trans R Soc Trop Med Hyg 81:85-94 16. Braga LL, Gomes ML, Da Silva MW, Faanha FE, Fiuza L and Mann BJ (2001) Household epidemiology of Entamoeba histolytica infection in an urban community in north-eastern Brazil. Am Trop Med Hyg J 65:268-271 17. Blangero SW, Adhikari BN, Blangero J, Uprety RP, Robinson ES and Pyakurel S (1993) Helminthic infection in Jiri, Nepal : Analysis of age and ethnic group effects. Inst Med J (Nepal) 15:210-216 18. Chan MS, Medley GF, Jamison D, Bundy DA (1994) The evaluation of potential global morbidity attributable to intestinal nematode infection. Parasitol J 109:373-387 19. Changhua L, Xiaorong Z, Dongchuan Q, Shuhua X, Hotez PJ, Defu Z, Hulian Z, Mingden L, Hainan R, Bing Z, Haichou X, Hawdon J and Zheng F (1999) Epidemiology of human hookworm infections among adult villagers in Hejiang and Santai Counties, Sichuan Province, China. Acta Tropica 73:243-249 60

20. Chai J, Chen H, Zeng X, Jiang W, Yong T, Feng Z and Rim H (2001a) Epidemiological studies of A. lumbricoides in Jiangxi Province, China, with comparative analysis with data previously obtained in the republic of Korea. In: Collected papers on the control of soil transmitted helminthes. The Asian Parasite Control Organization 7:56-63 21. Chai JY, Han ET, Guk SM, Seo M, Choi MH and Lee SH (2001b) Intestinal parasitic infection among people residing in several coastal areas in Korea. In: Collected papers on the control of soil transmitted helminthes. The Asian Parasite Control Organization 7:5-10 22. Chai JY, Kim NY and Guk SM (2001c) High prevalence and seasonality of cryptosporidiosis in a small rural village occupied predominantly by aged people in the Republic of Korea. Am J Trop Med Hyg 65:518522 23. Chacin LB, Bonilla E, Parra AM, Estevez J, Morales LM and Suarez H (1992) Prevalence of E. histolytica and other intestinal parasites in a community from Maracaibo, Venezuala. Ann Trop Med Parasitol 86:373-80 24. Chaudhary B (2000) Hospital and community based study on infection of human intestinal parasites in relation to socio-medical aspects. MSc thesis central department of Zoology, Tribhuvan University, Kirtipur (Unpublished) 25. Chhetri MK (1997) Parasitic infection in Nepal. Nep Med Assoc J 35:60-65 26. Chandiwana SK, Bradley M and Chombo F (1989) Hookworm and roundworm infections in farm worker communities in the large scale agricultural sector in Zimbabwe. J Trop Med Hyg 92:338-344. 27. Devera RA, Punos GN, Velasquez VJ, Catanese JA and Meneses RG (1997) Prevalence of Blastocystis hominis infection in schoolchildren from Bolivar City. Venezuela Bol Chil Parasitol 52:77-81

61

28. Estevez EG, Levine JA and Warren J (1983) Intestinal parasites in a remote village in Nepal. J Clin Microbiol 17:160-161. 29. Easow JM, Mukhopadhyay C, Wilson G, Guha S, Jalan BY and Shivananda PG (2005) Emerging opportunistic protozoa and intestinal pathogenic protozoal infestation profile in children of western Nepal. Nepal Med College J 7:134-137 30. Evans CA, Gilman RH, Rabbani GH, Salazar G and Ali A (1997) Gastric acid secretion and enteric infection in Bangladesh. Trans R Soc Trop Med Hyg 91:681-685 31. Eleonar T Baldo, Vicente Y, Belizario, Winifreda LJ, Dev Leon, Hyun Hee Kong and Dong Chung (2004) Infection status of intestinal parasites in children living inresidential institutions in Metro Manila, Phillipines. Korean J Parasitol 42:62-67 32. Ensink JH, van der Hoek W, Mukhtar M, Tahir Z and Amerasinghe FP (2005) High risk of hookworm infection among wastewater farmers in Pakistan. Trans R Soc Trop Med Hyg 99:809-818 33. Furness BW, Beach MJ and Roberts JM (2000) Giardiasis surveillance United States, 19921997. MMWR CDC Surveill Summ 49:1-13 34. Feng Z, Xu L, Chnang J, Chen P, Lin X, Wang H, Zhao X, Huang Q, Zhou C, Zhang X, Li X, Zhao J, Chang X, Wei Z, Ji T, Ren D, Wu Q, Zhang F and Liu Y (2001a) Study of biology of Ascaris infection - Relationship between egg count and worm burden. In: Collected papers on the control of soil transmitted helminthes. The Asian Parasite Control Organization 7:52-55 35. Fagbanro-Beyioku FA and Oyerinde JPO (1987) Parasitic intestinal infections of children in Lagos (Nigeria). Niger J Pediatr 14:89-96.

62

36. Fontobonne A, Freese-De-Carvalho E, Acioli MD, S GA and Cesse EA (2001) Risk factors for multiple intestinal parasites in an others community of the State of Pernambuco, Brazil. Cad Saude Public a 17:367-373 37. Gilgen DD, Mascie-Taylor CG and Rosetta LL (2001) Intestinal helminth infections, anaemia and labour productivity of female tea pluckers in Bangladesh. Trop Med Int Health 6:449-457 38. Gonclaves JF, Tanabe M, De Paulo F, De Melo M, Goncalves FJ, Da Silva Aca I, Da Motta SRN, Seiki S and Takeuchi T (1990) Parasitological and serological studies on amoebiasis and other intestinal parasitic infections in the rural sector around recife, Northeast Brazil. Rev Inst Med Trop Sao Paulo 32:428-435. 39. HI J (1980) Intestinal parasite infections in Western Australian Aborigines. Med J Aust 2:375-380 40. Hosain GM, Saha S and Begum M (2003) A Impact of sanitation and health education on intestinal parasite infection among primary school aged children of Sherpur, Bangladesh. Trop Doct J 33:139-143 41. Hounston R and Schwarz E (1990) Helminthic infections among peace corps volunteers in Nepal. J Amer Med Assoc 263: 373-374. 42. Holland CV, Asaolu SO, Crompton DWT, Stoddart RC, Macdonald R and Torimiro SE (1989) The epidemiology of Ascaris lumbricoides and other soil-transmitted helminthes in primary school children from IIe-Ife, Nigeria. Parasitology 99:275-286. 43. Hall A, Conway DJ, Anwar KS and Rahman ML (1994) Strongyloides stercoralis in an urban slum community in Bangladesh: factors independently associated with infection. Trans R Soc Trop Med Hyg 88:527-530

63

44. Hesham MS, Mekhlafi AL, Azlin M, Nor Aini U, Shaikh A, Saiah A, Fatmah MS, Ismail MA, Ahmad MS, Aisah MY, Rozlidas AR and Norhayati M (2006) Prevalence and distribution of soil-transmitted helminthiasis among Orang Asli children living in peripheral Selangor, Malaysia. Southeast Asian J Trop Med Public Health 37:40-49. 45. Ishiyama S, Rai SK, Ono K, Rai CK, Rai G, Tsuji H, Sharma AP and Chaudhary DR (2001) Study of enteropathogens and its predisposing factors in a suburban public school children in Kathmandu, Nepal. Nepal Med College J 3:5-9 46. Ishiyama S, Rai SK, Ono K and Uga S (2003) Small-scale study on intestinal parasitosis in a remote hilly village in Nepal. Nepal Med College J 5:28-30. 47. Ibrahim OMG, Bener A and Shalabi A (1993) Prevalence of intestinal parasites among expatriate workers in Al-Ain, UAE. Ann Saudi Med 13:126129 48. Jones HI (1980) Intestinal parasite infections in Western Australian Aborigines. Med J Aust 2:375-380

49. Kyronseppa H and Pettersson T (1976) The occurrence of human intestinal parasites in Finland. Scand J Infect Dis. 8:199-202.

50. Karrar ZA and Rahim FA (1995) Prevalence and risk factors of parasitic infections among under-five Sudanese children: a community based study. East Afr Med J 72:103-109 51. Kim JP, Lee IH, Jung JH, Sohn YW, and Kim SY (2001) One case of Giardia lamblia-associated arthritis in a 23 year-old woman. Korean J Med 61:82-85

64

52. Khurana S, Aggarwal A and Malla N (2005) Comparative analysis of intestinal parasitic infections in slum, rural and urban populations in and around union Territory, Chandigarh. Commun Dis J 37:239-243 53. Khetan RP (1980) Incidence of parasitic infestation in Narayani Zone. J Nepal med Assoc 18:29-31. 54. Kimura K, Rai SK, Rai G, and Uga S (2005) Study on Cyclospora cayetanensis associated with diarrheal disease in Nepal and Loa PDR. Southeast Asian J Trop Med Public Health 36:1371-1376 55. Kightlinger LK, Seed JR and Kightlinger MB (1995) Epidemiology of Ascaris lumbricoides, Trichuris trichiura and hookworm in children in the Ramonafana rainforest, Madagaskar. J parasitol 81: 159-169 56. Laupland KB and Church DL (2005) Population-based laboratory surveillance for Giardia spp. and Cryptosporidium spp. infections in a large Canadian health region. BMC Infectious Diseases 5: 72 57. Lee J, Park GM, Lee DH, Park SJ and Yong TS (2000) Intestinal parasite infection at an institution for the handicapped in Korea. Korean J Parasitol 38:179-81. 58. Minvielle MC, Pezzani BC, Cordoba MA, de Luca MM, Apezteguia MC and Basualdo JA (2004) Epidemiological survey of Giardia sp. and Blastocystis hominis in an Argentinian rural community. Korean J Parasitol 42:121-127 59. Mosiello G, Adorisio O, Gatti C, Boeris Clemen F, Dall'Oglio L, Federici and Abriola G (2003) Ascariasis as a cause of acute abdomen: a case report. Pediatr Med J 25:452-454 60. Municipal Database of Madhyapur Thimi Based On National Census - 2001

65

61. Muttalib MA, Huq M, Huq JA and Suzuki N (1983) Soil pollution with Ascaris ova in three village of Bangladesh. In: Collected papers on control of soil-transmitted helminthiasis. Asian Parasite control Organ 2:66-71. 62. Narain K, Medhi GK, Rajguru SK and Mahanta J (2004) Cure and reinfection patterns of geohelminthic infections after treatment in communities inhabiting the tropical rainforest of Assam, India. Southeast Asian J Trop Med Public Health 35:512-517 63. Nepal M and Palfy BA (1980) Study of prevalence of intestinal parasites in the Mahankal Panchayat and their relation with hemoglobin levels. J Inst Med (Nepal) 2:175-182. 64. Okeniyi J, Ogunlesi T, Oyelami O and Oyedeji G (2005) Asymptomatic Intestinal Parasitosis among Semi-Urban Nigerian Children. Internet Journal of Epidemiology 2:2 65. Okhuysen PC, White AC (1999) Parasitic Infections of the Intestine. Curr Opin Infect Dis; 12:467-472. 66. Oda Y and Sherchand JB (2002) Study of the prevalence of parasitic infection among students in Kathmandu related to drinking water. J Nepal Assoc Med Lab Science 4: 36-41. 67. Ono K, Rai SK, Chikahira M, Fujimoto T, Shibata H, Wada Y, Tsuji H, Oda Y, Rai G, Kawamura T and Uga S (2001) Seasonal distribution of enteropathogens detected from diarrheal stool and water samples collected in Kathmandu, Nepal. Southeast Asian J Trop Med Public Health 32:520-526. 68. Phompida S, Vannachone B, Laymanivong S and Phommasansack M (2001) Current status of intestinal parasitic diseases in Vientaine municipality. In: Collected papers on the control of soil transmitted helminthes. The Asian Parasite Control Organization 7:64-67

66

69. Pratdesaba RA, GonzaLez M, Piedrasanta E, MeRida C, Contreras K, Vela C, Culajay F, Flores L and Torres O (2001) Cyclospora Cayetanensis in three populations at risk in Guatemala. J Clin Microbiol 39:29512953 70. Paul I and Gnanamani G (1999) Re-infection estimation of soil-transmitted helminthes among slum school children in Visakhapatnam, Andhra Pradesh. J Commun Dis 30:245-249. 71. Rim HJ, Chai JY, Min DY, Cho SY, Eom KS, Hong SJ, Sohn WM, Yong TS, Deodato G, Standgaard H, Phommasack B, Yun CH and Hoang EH (2003) Prevalence of intestinal parasite infections on a national scale among primary schoolchildren in Laos. Parasitol Res J 91:267-272 72. Raso G , Luginbh A, Adjoua AC, Tian-Bi NT, Silu KD, Matthys B, Vounatsou P, Wang Y, Dumas M, Holmes E, Singer H, Tanner M, N'Goran EK and Utzinger J (2005) Multiple parasite infections and their relationship to self-reported morbidity in a community of rural Cte d'Ivoire. International Journal of Epidemiology 33:1092-1102 73. Rajshekhar V, Joshi DD, Doanh NQ, van De N and Xiaonong Z (2003) Taenia solium taeniosis/cysticercosis in Asia: epidemiology, impact and issues. Acta Trop 87:53-60 74. Rai SK and Gurung CK (1986) Intestinal parasitic infection in high school level students of Birgunj City. J Inst Med (Nepal) 8:33-38. 75. Rai SK, Bajracharya K, Budhathoki S, Sharma CM, Shrestha MK, Shrestha HG, Prasai BR, Sibata H, Sumi K, Nakanishi M, Kubo T and Matuoka A (1994b) Prevalence of intestinal protozoan parasitic infection in Nepal. Hyogo J Med Tech (Japan) 15:39-44. 76. Rai SK, Bajracharya K, Budhathoki S, Khadka JB, Rai KK, Shrestha MK, Sharma CM, Nakanishi M, Kubo T and Shrestha HG (1995) Status of

67

intestinal parasitosis at TU Teaching Hospital. J Inst Med (Nepal) 17:134142. 77. Rai SK. Parasitology. In Textbook of Medical Laboratory Technology. Edit. Nakanisi M, Shrestha HG and Rai SK, 1st edition, Medical Education Project, JICA/TUTH, Kathmandu, Nepal 1996:447-559 78. Rai SK, Hirai K, Ono Y and Matsumura T (1997). Village health profile and sanitary profile from eastern hilly region, Nepal. Kobe J Med Sci (Japan) 43:121-133 79. Rai SK, Nakanishi M, Upadhya MP, Rai CK, Hirai K, Ohno Y, Shrestha HG, Ono K, Uga S and Matsumura T (1998) Effect of intestinal helminth infection on some nutritional parameters among rural villagers in Nepal. Kobe J Med Sci (Japan) 44:91-98 80. Rai SK and Rai G (1999) Ascaris, Ascariasis and its present scenario in Nepal. Inst Med J (Nepal ) 21:243-250 81. Rai SK, Matsumura T, Ono K, Oda Y, Uga S, Rai N and Shrestha HG (2001) Intestinal parasitosis in an unknown disease out break hit rural hilly area in western Nepal. Nepal Med College J 2:61-64 82. Rai SK, Nakanishi M, Upadhyay MP, Hirai K, Ohno Y, Ono K, Uga S, Shrestha HG and Matsumura T (2000a) Effect of intestinal helminth infection on retinal and -Carotene status among rural Nepalese. Nutr Res 20:15-23 83. Rai SK, Uga S, Ono K, Rai G and Matsumura T (2000b) Contamination of soil with helminth parasite eggs in Nepal. Southeast Asian J Trop med Public Health 31:388-393. 84. Rai SK, Hirai K, Abe A and Ohno Y (2002a) Infectious disease and malnutrition in Nepal an overview. Malayasian J Nutr 8:191-200.

68

85. Rai SK, Hirai K, Abe A, Ishiyama S, Rai G, Ono K and Uga S (2002b) Intestinal parasitosis among school children in a rural hilly area of Dhading District, Nepal. Nepal Med College J 4:54-58 86. Rai SK, Sherchand JB and Bhatta DR (2004) Study of enteropathogens and its predisposing factors in gastroenteritis suspected children attending Kanti Children Hospital, Kathmandu, Nepal. J Nepal assoc Med Lab Sciences 6:4853 87. Rai DR, Rai S.K, Sharma BK, Ghimire P and Bhatta DR (2005) Factors associated with intestinal parasitic infection among school children in a rural area of Kathmandu Valley, Nepal. Nepal Med College J 7:43-46 88. Rai CK, Shrestha A, Shah RP, Rai SK (2007) Study of intestinal parasitosis among patients visiting Health Care Centre in Kathmandu Valley. Nep Med Assoc J 8:33-36 89. Robertson LJ, Crompton DW, Walters DE, Nesheim MC, Sanjur D and Walsh EA (1989) Soil-transmitted helminth infections in School children from Cockle Province, Panama. Parasitol 99:287-292. 90. Reily C (1980) Gorkha Report, Dooly foundation, Nepal. 91. de Silva NR, Layapani VP and de Silva HJ (1996) Socioeconomic and behavioral factors affecting the prevalence of geohelminthes in preschool children. Southeast Asian J Trop Med Public Health 27:36-42. 92. Sugunan AP, Murhekar MV and Sehgal SC (1996) Intestinal parasitic infestation among different population groups of Andaman and Nicobar islands. Commun Dis J 28:253-259 93. Svenungsson B, Lagergren A and Ekwall E (2002) Enteropathogens in adult patients with diarrhoea and healthy control subjects: A1-year prospective

69

study in a Swedish clinic for infectious diseases. Clinical Infectious Diseases 35:14521453 94. Saito S, Gimenez H, Ohinishi M, Luz Cricedela Ignacia Romero De Malinas, Carlos Maria Romero Arce, Kobayakawqa T and Sendo F (1996) epidemiological survey for intestinal parasitosis as a part of primary care project in Caazapa Dept, Paraguya, Yamagata Med J (Japan) 14:25-31 95. de Silva NR, Layapani VP and de Silva HJ (1994) Socio-economic and behavioral factors affecting the prevalence of geohelminthes in preschool Panminerva. Med Asian J Trop Med Public Health 27:36-42 96. Sayyari AA, Imanzadeh F, Yazdi SAB, Karami H and Yaghoobi M (2005) Prevalence of intestinal parasitic infections in the Islamic Republic of Iran. Eastern Mediterranean Health J 11:377-383. 97. Sur D, Saha DR, Manna B, Rajendran K and Bhattacharya SK (2005) Periodic deworming with albendazole and its impact on growth status and diarrhoeal incidence among children in an urban slum of India. Trans R Soc Trop Med Hyg 99:261-7 98. Singh HL, Singh NB and Singh YI (2004) Helminthic infestation of the primary school-going children in Manipur. Commun Dis J 36:111-116 99. Siddiqui MI, Bilqees FM, Iliyas M and Perveen S (2002) Prevalence of parasitic infections in a rural area of Karachi, Pakistan. Pak Med Assoc J 52:315-320 100. Saha DR, Gupta DN, Sengupta PG, Mondal SK, Ghos S, Saha NC,

Sikder SN and Sircar BK (1995) Intestinal parasitism: a childhood problem in rural Bengal. Commun Dis J 27:170-174.

70

101.

Sherchand JB, Larsson S and Shrestha MP (1996) Intestinal parasites in

children and adults with and without abdominal discomfort from the Kathmandu area of Nepal. Trop Gastroenterol 17:15-2 102. Sherchand JB, Ohara H, Sherchand S, Cross JH and Shrestha MP (1997)

Intestinal parasitic infection in rural areas of Southern Nepal. J Inst Med (Nepal) 19:115-121. 103. Sharma BP (1965) Roundworm and other infestation. J Nepal Med

Assoc 3:120-123. 104. Sharma BK, Rai SK, Rai DR and Choudhury DR (2004) Prevalence of Health

intestinal parasitic infestation in school children in the NorthEastern part of Kathmandu Valley, Nepal. SouthEast Asian J Trop Med Public 35:501-505 105. Sharma RP and Tuladhar NR (1971) A study on intestinal parasites

amongst auxiliary health workers students in Kathmandu. J Nepal Med Assoc 9:257-261. 106. Shrestha IL (1983) Soil-transmitted helminthiasis. J Inst Med (Nepal)

5:193-196. 107. Sharma BK, Rai SK, Rai DR and Choudhury DR (1994) Prevalence of

intestinal parasitic infestation in school children in the North-Eastern part of Kathmandu Valley, Nepal. South-East Asian J Trop Med Public Health 35:501-505 108. Shakya B (2006) Study on intestinal infections by parasite and some

bacteria among eldery people of kathmandu valley. Nepal Med College J 8(4):243-247 109. Sahu RB, Gurbacharya VL and Updhaya DP (1983) Effect of

indigenous drug, Butea monosperma in parasite infection in Nepal. In: 71

Collected papers on the control of soil-transmitted helminthiasis. Asian parasite Control Organ 2:138-144. 110. Shrestha A, Rai SK, Basnyat SR, Rai CK, Shakya B (2007) Soil

transmitted helminthiasis in Kathmandu, Nepal. Nepal Med College J 9(3):166-169 111. Soulsa VO (1975) Intestinal parasitism in Pokhara. Nepal Med Assoc J

15:9-13 112. Sorensen E, Ismail M, Amarasinghe DK, Hettiarachchi I and Dassenaike

TS (1994) The effect of the abailability of latrines on soil-transmitted nematode infection the plantation sectors in Sri Lanka. Am J Trop Med Hyg 51:36-39 113. Takemasha K, Kimura K, May SI, Rai SK, Ohyama F, Wu Z, Kimura D

and Uga S (2004) Epidemiological survey of intestinal parasitic infections of diarrhoeal in patients in Nepal and Lao PDR. Nepal Med College J 6:7-12 114. Tome A, Miyagi I, Kamimura K, Tokuyama Y, Hasegawa H, selom

Dahlan D, Majid I, Hasanuddi I, Ngatimin R, Mogi M and Kuwavara M (1999) Questionnaire survey and prevalence of intestinal helminthes infections in Baru, Sulawesi, Indonesia. South Asian J Trop Med Public Health 30:68-77 115. Uga S, Rai SK, Kimura K, Ganesh R, Kimura D, Wakasugi M, Miyake

Y, Ishiyama S, and Rajbhandari TP (2004) Parasites detected from diarrheal stool samples collected in Nepal. Southeast Asian Trop Med Public Health J 35:19-23 116. Virk KJ, Prasad RN and Prasad H (1994) Prevalence of intestinal

parasites in rural areas of district Shahjahanpur, Uttar Pradesh. Commun Dis J 26:103-8

72

117.

WHO (1987) Prevention and control of intestinal parasitic infections.

Technical report series 749 118. WHO (2000) Hookworm infection and iron deficiency anaemia

119.

Walsh JA (1983) Problems in recognition and diagnosis of Amoebiasis:

Estimation of the global magnitude of morbidity. Rev Infect Dis 228-238

120.

Warren KS and Mahmond AAF (1984) Tropical and geographical

medicine. Mc Graw-Hill Book Company, NewYork

121.

Wiesenthal AM, Nickels MK, Hashimoto KG, Endo T and Ehrhard HB

(1980) Intestinal parasites in Southeast-Asian refugees. Prevalence in a community of Laotians. J AMA 5:254-256 122. Yu JR, Lee JK, Seo M, Kim SI, Sohn WM, Huh S, Choi, HY and Kim TS (2004) Prevalence of Cryptosporidiosis among the villagers and domestic animals in several rural areas of Korea. Korean J Parasitol 42:1-6 123. Yong TS, Sim S, Lee J, Ohrr H, Kim MH and Kim H (2000) A Small-

scale survey on the status of intestinal parasite infections in rural villages in Nepal. Korean J Parasitol 38:275-277. 124. Yakoob J, Jafri W, Jafri N, Khan R, Islam M, Beg MA and Zaman V

(2004) Irritable bowel syndrome: in search of an etiology: role of Blastocystis hominis. Am J Trop Med Hyg 70:383-385 125. Xu LQ (1995) Soil transmitted helminthiasis: Nationwide Survey in

China. Bulletin of the World Health Organization 73:507513

73

126.

Zani LC, Favre TC , Pieri OS and Barbosa CS (2004) Impact of

antihelminthic treatment on infection by Ascaris lumbricoides, Trichuris trichiura and hookworms in Covas, a rural community of Pernambuco, Brazil.Rev Inst Med Trop (Sao Paulo) 6:6

74