Intestinal parasitosis, anaemia and risk factors among pre-school children in Tigray region, northern Ethiopia

BMC Infectious Diseases, Volume 20, No. 1, Year 2020

Interprétation

Background: Intestinal parasitic infections (IPIs) and anaemia are major health problems. This study assessed the prevalence of intestinal parasitic infections, anaemia and associated factors among pre-school children in rural areas of the Tigray region, northern Ethiopia. Methods: A community based cross-sectional study was conducted among 610 pre-school children in rural communities of Northern Ethiopia from June 2017 to August 2017. Stool specimens were examined for the presence of trophozoites, cysts, oocysts, and ova using direct, formal-ethyl acetate concentration, Kato-Katz, and Ziehl-Neelsen techniques. Haemoglobin was measured using a HemoCue spectrometer. Results: Among the 610 participating pre-school children in the study, the prevalence of IPIs and anaemia were 58% (95% conference interval (CI): 54.1-61.9%) and 21.6% (95% CI: 18.5-25.1%), respectively. Single, double, and triple parasitic infections were seen in 249 (41, 95% CI: 37-45%), 83 (14, 95% CI: 11-17%), and 22 (3.6, 95% CI: 2.4-5.4%) children, respectively. Of the seven intestinal parasitic organisms recorded from the participants, Entamoeba histolytica/dispar was the most prevalent 220 (36.1%) followed by Giardia lamblia 128 (20.1%), and Hymenolepis nana 102 (16.7%). Mixed infections were common among G. lamblia, E. histolytica/dispar and Cryptosporidium spp. oocyst. Intestinal parasitic infection prevalence increased from 47% in children aged 6-11 months to 66% in those aged 48-59 months; the prevalence ratio (PR) associated with a one-year increase in age was 1.08 (95% CI: 1.02-1.14, p = 0.009). Age-adjusted prevalence was higher in children who had been dewormed (PR = 1.2; 95% CI: 1.00-1.4, p = 0.045), and lower in households having two or more children aged under five (PR = 0.76, 95% CI: 0.61-0.95, p = 0.015). Anaemia rose from 28% in children aged 6-11 months to 43% in those aged 12-23 months, then fell continuously with age, reaching 7% in those aged 48-59 months. Age adjusted, anaemia was more prevalent in households using proper disposal of solid waste (PR = 1.5, 95% CI: 0.1-2.10, p = 0.009) while eating raw meat (PR = 0.49, 95% CI: 0.45-0.54, p = 0.000), any maternal education (PR = 0.64 95% CI: 0.52-0.79, p = 0.000), and household water treatment (PR = 0.75, 95% CI: 0.56-1.0, p = 0.044) were associated with lower prevalence of anaemia. Conclusions: More than half of the children were infected with intestinal parasites, while anaemia prevalence was concentrated in the 12-23 month age group. This study has identified a number of potentially modifiable risk factors to address the significant prevalence of IPIs and anaemia in these children. Improvements in sanitation, clean water, hand hygiene, maternal education could address both short and long-term consequences of these conditions in this vulnerable population. This community based cross-sectional study was carried out from June–August 2017 in rural communities surrounding the Mekelle zone, Tigray region, northern Ethiopia. Four sites namely: Serawat, Harena, Maynebri and Tsuwanet were selected using a simple random lottery method from the total of 32 administrative unit found in the surrounding districts. The population typically experience poor sanitation, poor access to safe drinking water, and low socioeconomic status. More details have been previously described elsewhere [25]. The sample size of the study was determined using a single population proportion formula, considering an estimate of 24.3% expected prevalence of IPIs among children younger than 5 years old. Assuming any particular outcome to be within a 5% marginal error and a 95% confidence interval of certainty, the final sample size with a design effect of two is 570 (based on Statulator website, http://statulator.com/SampleSize/ss1P.html). To allow for data loss, 610 participants were recruited. We used a multistage stratified sampling technique to identify study participants after the kebelles (a kebelle is the smallest local government administrative unit in Ethiopia) were stratified. In the selected kebelles, 2674 children aged 6–59 months were identified with their respective households using the registration at health posts and through the health extension workers. We allocated the calculated sample proportionally to the selected kebelles based on the total number of households with children aged 6–59 months in each kebelle. Study participants were then identified using simple random sampling of the households. In cases where households had more than one eligible child, the eldest child was included. Accordingly, the distribution of households with respect to the kebelles was, 133 from Tsawnet, 142 from Harena, 158 from Serawat, and 177 from Mynebri. After written consent was obtained from mothers or guardians of eligible children, socioeconomic, environmental, behavioural and health related data were collected using a structured questionnaire (translated from English and printed in the local Tigrigna language). Data were collected using a face-to-face administrated questionnaire and an observation method by trained data collectors, under the supervision of the principal investigators. Child hand cleanness and nail status in addition to toilet availability were assessed by direct observation. IPIs and anaemia among children aged 6–59 months (pre-school children). Gender and age of the study child, mother’s/guardian’s educational status and occupation, family size, family income, number of children 6–59 months in the household. Consumption of raw vegetables, child contact with pet animals, child deworming, habit of playing in soil, shoe wearing habit, child hand cleanliness and fingernail status. Use of soap for hand washing, water source, use of household water treatment, latrine availability, and type of drinking water source. Following the completion of consent and questionnaire, a clean, wide screw-capped plastic stool cup, labelled with names was provided to each mother/guardian. They were requested to bring about 10 g (thumb size) fresh stool from their child to the nearby health posts the following day within 10–30 min of passage. Participants who were not able to provide a sample on the first day were asked again on the following day. Finger-prick blood specimens were obtained from participants to assess Hb levels using a HemoCue analyser in the health post (HemoCue Hb 201z, Sweden) (49). The apparatus was calibrated daily using the reference micro cuvettes as indicated by the manufacturer. Definition and classification of anaemia were according to the WHO cut-offs [26]. Stool specimens were analyzed at the respective health posts by three trained laboratory technicians using direct saline wet mount, formalin ethyl acetate concentration technique [27] and single Kato–Katz technique (thick smear 41.7 mg). For the detection of Cryptosporidium spp. oocysts, modified Ziehl-Neelsen (MZN) staining was performed. Kato–Katz, wet mount preparations and modified Ziehl-Neelsen were analysed within 1 h of preparation in each respective health posts to detect hookworm eggs, protozoa parasites (E. histolytica/dispar and G. lamblia), and Cryptosporidium spp., respectively. The remaining stool specimens were transported in screw-capped cups in 10% formalin to Mekelle University Medical Microbiology Laboratory and were examined using the concentration method within 8 h after collection. After 72 h, Kato–Katz preparations were re-examined to detect helminth ova. A child was categorized as infected if the stool sample was positive for any parasite by any of the methods used. To ensure quality, each slide was examined twice by two of the three experienced laboratory technician independently. To control our data quality, 10% of the total positive specimens were randomly selected and re-examined by three experienced laboratory technicians who did not have any information about the previous results. As results among the laboratory technicians were similar, the results of the new laboratory examinations were therefore used as quality control. Data were analysed with Stata Release 15. Confidence intervals for prevalence were calculated using the Agresti-Coull formula. Negative binomial regression was used to model prevalence rate ratios. Prevalence rate ratios have several advantages over odds ratios. The first is that they are simple to interpret; they directly compare prevalence, so a prevalence ratio of 2 means that prevalence is twice as high. Second, prevalence ratios, but not odds ratios, have a mathematical property called collapsibility; this means that the size of the risk ratio will not change if adjustment is made for a variable that is not a confounder [28]. All reported p-values were two-tailed, and statistical values were considered significant when p < 0.05.

Résumé de l’IA

Study Justification:

– Intestinal parasitic infections (IPIs) and anaemia are major health problems among pre-school children in rural areas of the Tigray region, northern Ethiopia.
– This study aimed to assess the prevalence of IPIs, anaemia, and associated factors in order to understand the extent of the problem and identify potential risk factors.

Highlights:

– The study found that among the 610 participating pre-school children, the prevalence of IPIs was 58% and the prevalence of anaemia was 21.6%.
– The most prevalent intestinal parasitic organism was Entamoeba histolytica/dispar, followed by Giardia lamblia and Hymenolepis nana.
– The prevalence of IPIs increased with age, while the prevalence of anaemia peaked in the 12-23 month age group and decreased with age.
– Several modifiable risk factors were identified, including improvements in sanitation, clean water, hand hygiene, and maternal education.

Recommendations:

– Implement interventions to improve sanitation facilities and access to safe drinking water in rural communities.
– Promote hand hygiene practices among pre-school children and their caregivers.
– Provide deworming treatment for children to reduce the prevalence of IPIs.
– Increase awareness and education on the importance of proper disposal of solid waste and avoiding the consumption of raw meat.
– Encourage household water treatment methods to reduce the prevalence of anaemia.
– Improve maternal education to address the long-term consequences of IPIs and anaemia in children.

Key Role Players:

– Local government authorities and policymakers
– Health professionals and community health workers
– Non-governmental organizations (NGOs) working in the field of public health
– Education institutions and teachers
– Community leaders and volunteers

Cost Items for Planning Recommendations:

– Sanitation infrastructure development and maintenance
– Provision of clean water sources and water treatment methods
– Supply of deworming medications
– Health education and awareness campaigns
– Training and capacity building for health professionals and community health workers
– Monitoring and evaluation of interventions
– Research and data collection for ongoing surveillance and assessment

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is community-based and cross-sectional, which allows for a large sample size and generalizability. The prevalence of intestinal parasitic infections (IPIs) and anaemia among pre-school children in the Tigray region of northern Ethiopia is assessed using various techniques. The study provides specific prevalence rates and prevalence ratios associated with different risk factors. The conclusions highlight the need for improvements in sanitation, clean water, hand hygiene, and maternal education to address the high prevalence of IPIs and anaemia. However, the abstract could be improved by providing more details on the sampling method, data collection process, and statistical analysis. Additionally, it would be helpful to include information on potential limitations of the study and recommendations for future research.

Abstrait

This community based cross-sectional study was carried out from June–August 2017 in rural communities surrounding the Mekelle zone, Tigray region, northern Ethiopia. Four sites namely: Serawat, Harena, Maynebri and Tsuwanet were selected using a simple random lottery method from the total of 32 administrative unit found in the surrounding districts. The population typically experience poor sanitation, poor access to safe drinking water, and low socioeconomic status. More details have been previously described elsewhere [25]. The sample size of the study was determined using a single population proportion formula, considering an estimate of 24.3% expected prevalence of IPIs among children younger than 5 years old. Assuming any particular outcome to be within a 5% marginal error and a 95% confidence interval of certainty, the final sample size with a design effect of two is 570 (based on Statulator website, http://statulator.com/SampleSize/ss1P.html). To allow for data loss, 610 participants were recruited. We used a multistage stratified sampling technique to identify study participants after the kebelles (a kebelle is the smallest local government administrative unit in Ethiopia) were stratified. In the selected kebelles, 2674 children aged 6–59 months were identified with their respective households using the registration at health posts and through the health extension workers. We allocated the calculated sample proportionally to the selected kebelles based on the total number of households with children aged 6–59 months in each kebelle. Study participants were then identified using simple random sampling of the households. In cases where households had more than one eligible child, the eldest child was included. Accordingly, the distribution of households with respect to the kebelles was, 133 from Tsawnet, 142 from Harena, 158 from Serawat, and 177 from Mynebri. After written consent was obtained from mothers or guardians of eligible children, socioeconomic, environmental, behavioural and health related data were collected using a structured questionnaire (translated from English and printed in the local Tigrigna language). Data were collected using a face-to-face administrated questionnaire and an observation method by trained data collectors, under the supervision of the principal investigators. Child hand cleanness and nail status in addition to toilet availability were assessed by direct observation. IPIs and anaemia among children aged 6–59 months (pre-school children). Gender and age of the study child, mother’s/guardian’s educational status and occupation, family size, family income, number of children 6–59 months in the household. Consumption of raw vegetables, child contact with pet animals, child deworming, habit of playing in soil, shoe wearing habit, child hand cleanliness and fingernail status. Use of soap for hand washing, water source, use of household water treatment, latrine availability, and type of drinking water source. Following the completion of consent and questionnaire, a clean, wide screw-capped plastic stool cup, labelled with names was provided to each mother/guardian. They were requested to bring about 10 g (thumb size) fresh stool from their child to the nearby health posts the following day within 10–30 min of passage. Participants who were not able to provide a sample on the first day were asked again on the following day. Finger-prick blood specimens were obtained from participants to assess Hb levels using a HemoCue analyser in the health post (HemoCue Hb 201z, Sweden) (49). The apparatus was calibrated daily using the reference micro cuvettes as indicated by the manufacturer. Definition and classification of anaemia were according to the WHO cut-offs [26]. Stool specimens were analyzed at the respective health posts by three trained laboratory technicians using direct saline wet mount, formalin ethyl acetate concentration technique [27] and single Kato–Katz technique (thick smear 41.7 mg). For the detection of Cryptosporidium spp. oocysts, modified Ziehl-Neelsen (MZN) staining was performed. Kato–Katz, wet mount preparations and modified Ziehl-Neelsen were analysed within 1 h of preparation in each respective health posts to detect hookworm eggs, protozoa parasites (E. histolytica/dispar and G. lamblia), and Cryptosporidium spp., respectively. The remaining stool specimens were transported in screw-capped cups in 10% formalin to Mekelle University Medical Microbiology Laboratory and were examined using the concentration method within 8 h after collection. After 72 h, Kato–Katz preparations were re-examined to detect helminth ova. A child was categorized as infected if the stool sample was positive for any parasite by any of the methods used. To ensure quality, each slide was examined twice by two of the three experienced laboratory technician independently. To control our data quality, 10% of the total positive specimens were randomly selected and re-examined by three experienced laboratory technicians who did not have any information about the previous results. As results among the laboratory technicians were similar, the results of the new laboratory examinations were therefore used as quality control. Data were analysed with Stata Release 15. Confidence intervals for prevalence were calculated using the Agresti-Coull formula. Negative binomial regression was used to model prevalence rate ratios. Prevalence rate ratios have several advantages over odds ratios. The first is that they are simple to interpret; they directly compare prevalence, so a prevalence ratio of 2 means that prevalence is twice as high. Second, prevalence ratios, but not odds ratios, have a mathematical property called collapsibility; this means that the size of the risk ratio will not change if adjustment is made for a variable that is not a confounder [28]. All reported p-values were two-tailed, and statistical values were considered significant when p < 0.05.

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and resources on maternal health, including prenatal care, nutrition, and hygiene practices. These apps can be easily accessible to women in rural areas, providing them with essential knowledge and guidance.

2. Telemedicine: Implement telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This can help overcome geographical barriers and provide timely medical advice and support to women in remote areas.

3. Community Health Workers: Train and deploy community health workers who can provide basic maternal health services, such as prenatal check-ups, health education, and referrals to healthcare facilities. These workers can bridge the gap between communities and healthcare systems, ensuring that women receive the care they need.

4. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to pregnant women, enabling them to access essential maternal health services, including antenatal care, delivery, and postnatal care. These vouchers can be distributed to women in need, ensuring that cost is not a barrier to receiving quality care.

5. Water, Sanitation, and Hygiene (WASH) Interventions: Implement WASH interventions in rural communities to improve access to clean water, sanitation facilities, and hygiene practices. This can help prevent infections and reduce the risk of complications during pregnancy and childbirth.

6. Maternal Health Education: Develop comprehensive maternal health education programs that target women, families, and communities. These programs can focus on promoting healthy behaviors, raising awareness about the importance of prenatal care, and addressing cultural beliefs and practices that may hinder access to maternal health services.

7. Transportation Support: Establish transportation support systems, such as ambulances or community transport services, to ensure that pregnant women can easily access healthcare facilities for prenatal care, delivery, and emergency obstetric care.

8. Maternal Health Clinics: Set up dedicated maternal health clinics in rural areas, staffed with skilled healthcare professionals who can provide comprehensive prenatal care, delivery services, and postnatal care. These clinics can serve as a one-stop solution for maternal health needs in underserved communities.

9. Public-Private Partnerships: Foster collaborations between public and private sectors to improve access to maternal health services. This can involve leveraging private healthcare providers and facilities to expand service coverage in rural areas and ensure quality care for pregnant women.

10. Health Information Systems: Establish robust health information systems that capture and analyze data on maternal health indicators. This can help identify gaps in service delivery, monitor progress, and inform evidence-based decision-making to improve maternal health outcomes.

It’s important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of the Tigray region in northern Ethiopia.

AI Innovations Description

Based on the study findings, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Implement a comprehensive maternal and child health program: Develop and implement a program that focuses on improving maternal and child health in rural areas of the Tigray region. This program should include interventions to address the high prevalence of intestinal parasitic infections (IPIs) and anemia among pre-school children.

2. Improve sanitation and access to safe drinking water: Implement measures to improve sanitation facilities and promote proper waste disposal in households. This can include building latrines, promoting hand hygiene practices, and providing access to clean and safe drinking water sources.

3. Increase awareness and education: Conduct health education campaigns to raise awareness about the importance of hygiene, proper nutrition, and deworming among mothers and caregivers. This can be done through community health workers, health extension workers, and other local health personnel.

4. Provide regular deworming and nutritional supplementation: Establish a regular deworming program for pre-school children to reduce the prevalence of IPIs. Additionally, provide nutritional supplementation, including iron and other essential nutrients, to address the high prevalence of anemia.

5. Strengthen healthcare infrastructure: Improve the availability and accessibility of healthcare facilities in rural areas. This can include increasing the number of health posts, training healthcare workers on maternal and child health, and ensuring the availability of essential medications and diagnostic tools.

6. Enhance maternal education and empowerment: Promote maternal education and empowerment by providing opportunities for women to access education and acquire knowledge and skills related to maternal and child health. This can include literacy programs, vocational training, and support for income-generating activities.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to a reduction in the prevalence of intestinal parasitic infections and anemia among pre-school children in rural areas of the Tigray region, northern Ethiopia.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening healthcare infrastructure: Invest in improving healthcare facilities, including the availability of well-equipped clinics and hospitals, especially in rural areas where access is limited.

2. Enhancing health education and awareness: Implement comprehensive health education programs targeting pregnant women and their families to increase awareness about the importance of prenatal care, nutrition, hygiene, and early detection of health issues.

3. Increasing availability of skilled healthcare professionals: Train and deploy more skilled healthcare professionals, such as doctors, nurses, and midwives, to provide quality maternal healthcare services, especially in underserved areas.

4. Improving transportation and accessibility: Develop transportation systems and infrastructure to ensure that pregnant women can easily access healthcare facilities, particularly in remote areas.

5. Strengthening community-based healthcare services: Establish and support community-based healthcare programs that provide prenatal care, health education, and follow-up services to pregnant women in their own communities.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather data on the current state of maternal health access, including indicators such as the number of healthcare facilities, healthcare professionals, transportation infrastructure, and awareness levels among pregnant women.

2. Define simulation parameters: Determine the specific variables and indicators that will be used to measure the impact of the recommendations. For example, the number of healthcare facilities, the number of skilled healthcare professionals, and the percentage of pregnant women receiving prenatal care.

3. Develop a simulation model: Create a mathematical or computational model that simulates the impact of the recommendations on the defined parameters. This model should take into account factors such as population size, geographical distribution, and resource allocation.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Vary the parameters to explore different scenarios and assess their effects on improving access to maternal health.

5. Analyze simulation results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Identify key findings, trends, and areas of improvement.

6. Refine recommendations: Based on the simulation results, refine the recommendations to optimize their impact on improving access to maternal health. Consider adjusting resource allocation, scaling up successful interventions, or targeting specific areas or populations.

7. Implement and monitor: Implement the refined recommendations and closely monitor the progress and outcomes. Continuously collect data and evaluate the impact of the implemented interventions to inform further improvements and adjustments.

By following this methodology, policymakers and healthcare stakeholders can gain insights into the potential impact of different recommendations and make informed decisions to improve access to maternal health.

Auteurs et co-auteurs

Statistics:

Citations: 7

Authors: 9

Identifiers:

DOI: 10.1186/s12879-020-05101-8

Research Areas:

Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

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