ENTERIC PARASITIC INFECTION AMONG PRIMARY

SCHOOL CHILDREN IN BHAIRAHAWA

Project work Submitted to

Department of Microbiology
Universal College of Medical Sciences, Bhairahawa
Tribhuvan University, Kathmandu, Nepal
In partial fulfillment of the requirements for the degree of
Bachelor of Science in Medical Laboratory Technology (B Sc MLT)

By

Srijan Bhattarai

2019
Table of contents

Front Section Page no.

Letter of approval............................................................................................................I

Letter of recommendation..........................................................................................................II

Declaration...................................................................................................................III

Acknowledgement.......................................................................................................IV

List of Abbreviation......................................................................................................V

Abstract........................................................................................................................VI

List of Tables...........................................................................................................................VII

List of Figures.........................................................................................................................VII

Body Section

CHAPTER I......................................................................................................................5

INTRODUCTION..............................................................................................................5

1.1 General background.............................................................................................5

1.2 Statement of the problem.....................................................................................6

1.3. Rationale of the study...............................................................................................6

1.4Objectives...................................................................................................................7

1.4.1General objective:................................................................................................7

1.4.2 Specific objectives: -..........................................................................................7

CHAPTER II.......................................................................................................................7

Literature Review................................................................................................................8

Scenario of Intestinal Parasitic Infection:.......................................................................8

Scenario of Nepal..........................................................................................................10

CHAPTER III...................................................................................................................13

MATERIALS AND METHODS......................................................................................13

3.1 Study Design:..........................................................................................................13

3.2 Study Site:...............................................................................................................13

1
 3.3 Study population:....................................................................................................13

3.4 Sample size:.............................................................................................................13

3.5 Duration of the study:..............................................................................................13

3.6 Inclusion Criteria:....................................................................................................14

3.7 Exclusion Criteria....................................................................................................14

3.8 Limitations of the study:.........................................................................................14

3.9 Sampling technique:................................................................................................14

3.10 Ethical Clearance:.................................................................................................14

3.11 Data Analysis:.......................................................................................................14

3.12Dissemination Plan:................................................................................................14

3.13. Flow chart of the Procedure:................................................................................15

References.........................................................................................................................16

ANNEXURE.......................................................................................................................i

Annexure I...........................................................................................................................i

Time frame (Work plan)..................................................................................................i

Annexure II.....................................................................................................................ii

Performa..........................................................................................................................ii

Annexure III...................................................................................................................iii

Annexure IV...................................................................................................................iv

Detail Test Procedure.................................................................................................iv

Annexure V..................................................................................................................viii

INFORMED CONSENT.............................................................................................viii

2
 LETTER OF APPROVAL

On the recommendation of the Supervisor Dr. SHRISTI RAUT ADHIKARI, the

Project Work of Mr. SRIJAN BHATTARAI, entitled “ENTERIC PARASITIC
INFECTION AMONG PRIMARY SCHOOL CHILDREN IN BHAIRAHAWA”
has been approved for the examination. This project work is submitted as thesis to
fulfil requirement of Bachelor of Science in Medical Laboratory Technology (B. Sc.
MLT) is in accordance with the rules and regulations of the Institute of Medicine,
Tribhuvan University, Kathmandu, Nepal.

Supervisor Head of the Department

……………………………
Dr. Shristi Raut Adhikari
Department of Microbiology
Universal College of Medical,
Sciences, Bhairahawa
.…………………………….
Prof. Dr. K Rajeshwar Reddy
Department of Microbiology
Universal College of Medical Sciences,
Bhairahawa

Date: Date:

Program Coordinator

……………………………..
Mr. Narayan Gautam
Department of Biochemistry
Universal College of Medical Sciences,
Bhairahawa
Date:

I
 LETTER OF RECOMMENDATION

This is to certify that this Project Work entitled “ENTERIC PARASITIC

INFECTION AMONG PRIMARY SCHOOL CHILDREN IN BHAIRAHAWA”
was the work by Mr. SRIJAN BHATTARAI under our direct supervision and
guidance. His observations have been checked by me from time to time. The study
submitted as project work to fulfill requirement of Bachelor of Science in Medical
Laboratory Technology (B.Sc.MLT) is in accordance with the rules and regulations of
the Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.

Supervisor Co-supervisior

Dr. Shristi Raut Adhikari Mrs. Rita Khanal

Lecturer Assistant Professor
Department of Microbiology Department of Microbiology
Universal College of Medical Sciences, Universal College of Medical
Sciences,
Bhairahawa Bhairahawa

II
 Department of Microbiology
Universal College of Medical Sciences,
Bhairahawa, Nepal

DECLARATION

I solemnly declare that the project work titled “ENTERIC PARASITIC

INFECTION AMONG PRIMARY SCHOOL CHILDREN IN
BHAIRAHAWA’’ has not been submitted in candidature for any degree. I will have
no objection for availability of this thesis for photocopy and inter-library loans for
outside organization.

………………………
Mr. Srijan Bhattarai

Date:

III
 Acknowledgement

I take this opportunity to acknowledge for the inputs and guidance of all individuals
who directly and indirectly supported me throughout my study. Without the help,
support, suggestion and encouragement from them; I would never have been able to
finish this work.

First of all, I would like to express my sincere gratitude, appreciation and deep
indebtedness to my respected Guide Dr. Shristi Raut Adhikari, Lecturer,
Department of Microbiology and Co-guide Mrs. Rita Khanal, Assistant professor,
Department of Microbiology for their continuous guidance, encouragement, constant
advice and inspiration throughout my thesis work.

They not only taught me about the science and research, but also developed me an
independent and mature person by their excellent way of teaching and discussion.
They have given me their valuable suggestion, environment and confidence to work
freely. Being a student of theirs for 4 years during my BSc.MLT will remain an ideal
inspiration throughout my life.

I am also thankful to Professor Dr K. Rajeshwar Reddy HOD of microbiology for

his inspiration during my project work. I also express deep gratitude towards all the
faculty members of Department of Microbiology Mr. Subash Lal Karn, Mrs.
Sulochana Khatiwada Poudel for their continuous valuable suggestions and
guidance during the entire study period.

Similarly, I express my deepest gratitude to B.Sc. M.L.T Coordinator Mr. Narayan

Gautam, Associate Professor Department of Biochemistry for his continuous
guidance, support, encouragement, suggestion and constant advice during the entire
study period.

I also express thanks to Dr. Kripa Ghimire Resident of Microbiology, Mr. Nabin
Rayamajhi Central Lab Incharge, Mrs. Radha Khanal and Anita Chaudhary of
Microbiology Department for their immense support.

I would like to say especial thanks to all my friends, juniors and working staffs of
UCMS-TH for their constant encouragement, friendship, support and motivation at
each and every moment of my tenure.
IV
I would also like to thank the Principal, teachers and children of different primary
schools of the Bhairahawa. I express my deep gratitude to those school children who
supported my project by giving stool specimen. Without their time and willingness to
participate in this study, it would have been impossible.

Finally and sincerely from my heart with love, I would like to thank people who are
very close to my heart, my beloved Father Bhim Prasad Sharma, Mother
Bhagawati Bhattarai, Brothers Subash Bhattarai and Bishal Panthi, Uncle Arjun
Bhattarai and Aunt Basundhara Poudel and all my family members who are the
source of strength, perpetual inspiration and consistent help in all my endeavour.

SRIJAN BHATTARAI

V
 LIST OF ABBREVIATION

UCMS:-TH: Universal College of Medical Sciences and Teaching Hospital

IPIs: - Intestinal Parasitic Infections

A.Lumbericoides: - Ascaris lumbricoides

A. duodenale:- Ancylostoma duodenale

BMI:- Body Mass Index

G.Lamblia: - Giardia Lamblia

H.nana: - Hymenolepis nana

E.histolytica: - Entamoeba Histolytica

T. Trichuria :- Trichuris Trichuria

Kg: - Kilogram

No:- number

Pcs:- Pieces

RPM: - Revolution per minute

Sp.gr:- Specific gravity

TU: - Tribhuvan University

WHO: - World Health Organization

Ed: - edition

Spp:- species

mm :- milimeter

um :- micro meter

VI
 ABSTRACT

Background and Objective

Enteric parasites are the most common cause of parasitic disease and causes
significant morbidity and mortality, particularly in developing countries like Nepal.
The main objective of this study is to find out the prevalence of intestinal parasitic
infections among different primary school children in Bhairahawa, Rupandehi.
District, Nepal.

Materials and Methods

This is a school based cross- sectional descriptive study including 409 students
studying at primary level in government and private schools in Bhairahawa,
Rupandehi, Nepal. Stool samples were examined for detection of parasitic infections
by direct microscopy and concentration methods; formal ether sedimentation
technique and floatation technique by using 33% Zinc sulphate salt solution.

Results

The overall prevalence of the parasitic infection was 46.45% among the primary
school going children from different schools in Bhairahawa. The rate of prevalence by
routine microscopy, sedimentation and flotation are 23.25%, 41.5% and 7%
respectively. Ascaris lumbricoides (22.7%) was most common parasite followed by
Entamoeba histolytica (5%), H.nana (4%), Giardia lamblia (4%),Taenia spp (3%)
and mixed infection (9%) respectively. Factors like class in which the students are
studying, age, religion, illness, water sources, meat consumed, domestic animal in
house, consistency of stool and de-worming recently are significantly associated with
the rate of prevalence of enteric parasitic infections. Prevalence rate of the enteric
parasitic infection is slightly higher in government school (51.7%) than private school
(48.3%). Male students (49.09%) were more infected than female students (43.31%).

Conclusion

Despite of de-worming frequently by government in schools, the rate of prevalence of

enteric parasitic infection is still high among the students under 14 years of age.
Government school going children have slightly higher rate of enteric parasitic

VII
infection than private school going children. Moreover, concentration techniques were
essential for the detection of greater number of enteric parasites in stool specimens.
Many factors like class in which the students are studying, age, religion, illness, water
sources, meat consumed domestic animal in house, consistency of stool and de-
worming recently affects the rate of prevalence of enteric parasitic infections.

Keywords: Enteric parasitic infection, Nepal, Routine microscopy, Sedimentation,

Floatation.

VIII
List of Tables

Table 1: Sex wise distribution of positive and negative stool samples

Table 2: Age wise distribution of positive and negative stool samples

Table 3: Parasitic association with Body Mass Index (BMI)

Table 4: Prevalence of parasitic infection among different religion

Table 5:- Parasitic infection with and without illness

Table 6: Prevalence of the parasitic infection in association with Water sources

Table 7: Prevalence of the parasitic infection in association with Diarrhoea

Table 8: Prevalence of the parasitic infection in association with Medication

Table 9: Prevalence of the parasitic infection associated with meat consumed

Table 10: Prevalence of the parasitic infection associated with walking bare foot

Table 11: Prevalence of the parasitic infection associated with Consistency of

stool.
Table 12: Prevalence of the parasitic infection associated with Domestic Animals
Rearing

List of Figure
Figure 1: Distribution of Positive and Negative stool samples

Figure 2: Distribution of Positive and Negative stool samples by Routine

Microscopy.

Figure 3: Distribution of Positive and Negative stool samples by Sedimentation

Technique.

Figure 4: Distribution of Positive and Negative stool samples by Floatation

Technique.

Figure 5: Comparative study of stool samples from Government and Private

Schools.

Figure 6: Distribution of various parasites

Figure 7: Microscopic view of different helminthic eggs and protozoan cysts

IX
 CHAPTER I

INTRODUCTION

1.1 General background

Enteric parasitic infections are endemic worldwide and have been described as the
major cause of illness and diseases.1 Among the various types of infectious disease,
intestinal parasitic infection (IPI) is one of the major health problems.2 Protozoan and
helminthic parasites are the causative agent of intestinal parasitic infections. Giardia
intestinalis, Entamoeba histolytica, Cryptosporidium spp, Microsporidia, Cyclospora
cayetanenesis, Ascaris lumbricoides, Ancylostoma duodenale, Blastocystis spp,
Necatar americanus, Hymenolepis nana, Taenia spp, and Trichuris trichiura are the
common intestinal pathogenic parasites.3
It is estimated that 60% of the world population is infected with enteric parasites. 4
WHO estimates that one person in every four harbours parasitic worms. 5Ascaris
lumbricoides (20%), Ancylostoma duodenale (18%), Trichuris trichiura (10%) and
Entamoeba histolytica (10%) are the most common intestinal parasitic infestations
reported globally.6 WHO estimates that approximately 50 million people worldwide
suffer from amoebic infections that result in 40-100 thousands deaths yearly. Current
estimates suggest that Ascaris lumbricoides can infest more than 1 billion and
Trichuris trichiura and Ancylostoma duodenale can infest 795 and 740 million
people, respectively in a year.6 More than one third of population in South East Asian
region take medicine but still 13% of deaths in this region are related to parasitic
infections only.7 Intestinal protozoan and helminthic infection rank the third and the
fourth common intestinal parasites respectively in Nepal.8
Lack of access to clean drinking water, proper sanitation, good personal hygiene, low
socioeconomic status, illiteracy, hot-humid tropical climate and inadequate medical
care largely attributes to the burden of enteric parasitic diseases. 9 The most important
drawback of intestinal parasitic infestations is that about 90% infected individuals
remain asymptomatic.10 The signs and symptoms of these parasitic infections include
vomiting, bloody sputum and cough, low-grade fever, passing worms in stool,
shortness of breath, skin rash and abdominal discomforts. Clinical manifestations may
be in the form of growth retardation, pneumonia, hepatobiliary and pancreatic

1
diseases and intestinal obstruction.11People of all age groups are susceptible to enteric
parasitic infections. However, primary school going children are mostly affected by
intestinal parasites.12
Various studies that have been conducted in different districts of Nepal among
primary school children found the prevalence rate of enteric parasitic infections
ranging from 13.9%13 to 81.94%14. Several studies have dealt with the prevalence and
risk factors associated with intestinal parasitic infections (IPIs). Inadequate medical
facilities and lack of access to safe drinking water are the common risk factors for
IPIs.15All over the world, especially in developing countries like Nepal, enteric
parasitic infections are responsible for causing significant morbidity and mortality
among primary school children. Therefore it is also known as ‘cancer of developing
countries'.16 Direct stools smear, formal- ether and floatation techniques in the form of
stool microscopy offers many advantages over diagnostic methods for detecting
intestinal parasites. If performed correctly, it is sensitive, simple and economical.The
advantages of concentration methods are that it will recover most ova, cysts and
larvae and retain their morphology, thereby facilitating identification.
So the present study was designed to study the prevalence of enteric parasites among
the primary school going children of Bhairahawa.

1.2 Statement of the problem

Prevalence studies on intestinal parasitic infection shows variable results when same
type of studies carried in different geographical locations. The endemicity of parasite
depends upon various factors like environmental condition, hygiene and sanitary
habits of people, age of individuals, socio-economic status, nutritional habits, and
literacy rate of people in the community. We hypothesize that primary school children
of Bhairahawa are also suffering from enteric parasitic infection.
Children studying in primary schools are more prone to parasitic infection despite of
de-worming program by government in all schools six monthly. The children have the
low immunity power so they get more infected by such type of infection. Studies like
this are essential to find out the actual prevalence of enteric parasitic infection in
primary schools.

2
1.3. Rationale of the study
Studies carried out in the last decade concludes that enteric parasitic infection is one
of the foremost causes of public health problem in developing countries like Nepal
showing high morbidity and mortality among the primary school going children.
Therefore, knowing the particular enteric parasitic infection, proper treatment can be
started earlier and thus, reduce the mortality and morbidity rate. Similarly,people can
be given health education about the personal hygiene and modes of transmission of
the parasites.

Current study attempts to find out the prevalence rate of intestinal parasitic infection
among the primary school going children of Bhairahawa, Rupandehi Nepal and to
compare the prevalence of intestinal parasitic infection among the children of
government schools and private schools. This study also evaluates the association of
different factors like ethnicity, religion, sanitation, drinking water, personal hygiene,
eating habit and health status with enteric parasitic infection among primary school
children. Moreover, no studies have been conducted in the past in this city to compare
the prevalence of parasitic infection between primary school children of government
schools and private schools. So, this study holds utmost importance in this area.

3
1.4 Objectives

1.4.1 General objective:

 To determine the prevalence of parasitic infections among the primary school

going children of Bhairhawa.

1.4.2 Specific objectives:

 To find out the prevalence rate of enteric parasitic infections among the
primary school going children.
 To identify the various morphological forms (egg, cyst and trophozoites) of
intestinal parasites in stool specimens
 Comparison of rate of isolation of parasites with direct wet mount technique
and concentration technique.
 To compare the prevalence of parasitic infection among children below 14
years of age of Government and Private Schools.

4
 CHAPTER II

LITERATURE REVIEW
2.1 Introduction

Intestinal parasites are widely prevalent in developing countries, probably due to poor
sanitation and inadequate personal hygiene. It is estimated that as much as 60% of the
4, 17
world’s population is infected with intestinal parasites. Intestinal parasitic
infection especially helminthic infection is common in developing countries.16
Intestinal parasites are parasites that populate the gastro-intestinal tract in humans and
other animals. The two main types of intestinal parasites are helminthes and protozoa.
Hookworms, tapeworms, pinworms and roundworms are among the most common
helminthes. In their adult form, helminthes cannot multiply in the human body.
Protozoa have only one cell and can multiply inside the human body, which can allow
serious infections to develop. Intestinal parasites are usually transmitted when
someone comes in contact with infected faeces (for example: through contaminated
soil, food or water).

2.2.1 Intestinal protozoan parasites:

Protozoa are unicellular, microscopic organisms which are widely distributed. There
are about 65,000 species of protozoa of which 10,000 are parasitic. Each protozoan
cell is able to perform all the vital functions of life. The mode of reproduction could
be asexual or sexual.47

Entamoeba and Amoebiasis

Entamoeba histolytica was first discovered by Lambl in 1859 and its pathogenic
nature by described Losch in 1875 and Schaudinn differentiated pathogenic and non
pathogenic types of amoeba in 1903. The infection caused by E. histolytica is known
as amoebiasis. It may manifest as diarrhoea, dysentry and hepatic or pulmonary
amoebiasis.
The morphology of the parasites can be divided into trophozoite, precyst and cyst.
Trophozoite is feeding stage, also known as growing stage, and measuring 15-30 μm
in size. It doesnot have fixed shape because of constantly changing position. Precyst
is colourless, round or oval smaller than trophozoite but larger than cyst. It ranges

5
between 10-20 μm in size.47 Cyst becomes rounded and surrounded by a smooth wall.
The cyst is initially unicellular and then develops into a binuclear after binary fission.
These amoebae are transmitted by oral-fecal route. Poverty, ignorance, impair
personal hygiene are the major factors that facilitated the spread of disease. Amoebas
multiply rapidly in the tissue cells and use the cytolysed materials as their food.

Giardia and Giardiasis

Giardia intestinalis is also known as G. lamblia, G. duodenalis and G. intestinalis. It
was seen by Leeuwenhoeck in 1681 while examining his own stool. It is worldwide in
distribution with highest prevalence in the tropics and subtropics area. It appears in all
age groups but higher incidence in children. It is found in duodenum and the upper
part of jejunum in man.
The morphology of Giardia lamblia exists in two forms: trophozoite and cyst.
Trophozoite is feeding stage, measuring about 10-20μm in length, 6-15μm in width
and 1-3μm in thickness.47The parasite gives a typical monkey-face appearance on
microscopic examination. Trophozoite multiply in the intestine by binary
fission.Trophozoites is converted to cyst when the environmental conditions are
unfavorable. It is oval, measuring 8-14μm in length and 6-10μm in width. Cyst
contains four nuclei. Cysts are the infective stages for man, which are transmitted
through a water source.
The disease caused by Giardia lamblia is known as Giardiasis. This disease may be
asymptomatic or symptomatic manifested as malabsorption syndrome atmost.
Diarrhoea, weight loss, abdominal cramps, anorexia and headache with chills are the
symptoms produced in acute and chronic Giardiasis.

2.2.2 Intestinal helminthes parasites:

The term helminthes has been derived from a Greek word meaning worm. There are
metrozoa and are classified into two phylums: Platyhelminthes and Nemathelminthes.
Platyhelminthes is divided into two classes: Cestoidea and Trematodea while
Nemathelminthes has only one class Nematodea.
Ascaris and Ascariasis:
Ascaris lumbricoides commonly known as round worm is the largest intestinal
nematode. It was discovered by Linnaeus in 1758. It is cosmopolitan in distribution
being especially prevalent in tropical countries like India and China. The adults are

6
found in the intestine of man mainly in the jejunum and upper part of ileum. It is also
found in gorilla, apes and pigs. These are large, stout, tapering at both ends. Females
are slightly larger (200-400 × 3.6 mm) than males (150-300 × 2-4 mm). 47 When
freshly passed in the stool, the adult worm is light cream or pink in colour. The mouth
opens at the anterior end and possesses three finely toothed lips, one dorsal and two
ventral. The body is filled with irritating fluid called as ascaron or ascarase. The
posterior end of male worm is curved ventrally in the form of a hook having a conical
tip. The posterior end of female worm is conical and straight. The anus is sub-terminal
and opens directly on the ventral aspect in the form of a transverse slit.
Man acquires infection by the ingestion of eggs containing embryonated second stage
infective larva in food, drinking water and vegetables. Great majority (about 85%) of
the infections are symptomless. The symptoms can be produced by the migrating
larva and adults worms. Fever, cough, dyspnoea, bloody sputum is seen due to larva
and larva may settle in brain, heart, kidneys and spinal cord. Fevers, oedema of face,
rashes, conjunctivitis, haemorrhagic pancreatitis, meningitis are seen due to adult
worm.

Ancyclostoma and Ancyclostomiasis:

Ancyclostoma duodenale was described by Dubini in 1843 in Italy. It is also known as

Hook worm disease, prevalent throughout the tropics and sub-tropics. Adults are
small, greyish, white or brown cylindrical worms. The anterior end is slightly bent.
The hookworm species are differentiated by their buccal capsule and arrangement of
rays in the bursa. The buccal capsule of A. duodenale is provided with 6 teeth, 4
hooks like on the ventral surface and 2 knobs like on the dorsal surface. There are 5
glands associated with the digestive system which secretes an anticoagulant
substance. The male is smaller (8-11 mm × 0.45 mm) than female (10-13 mm × 0.66
mm). Posterior part of male is expanded in an umbrella like fashion whereas female is
tapering and no expanded bursa.

The adult worm lives in the intestine of man particularly in the jejunum and less often
in the duodenum. Each female can lays 15,000-20,000 eggs per day. Humans are
exposed to hookworm infection when third stage filariform larvae penetrate the skin
(most common mode) exposed to contaminated soil. Penetration may occur at any site

7
on the skin. Infection also takes place by ingestion of contaminated food materials
containing filariform larvae occasionally.
Trichuris and Trichuriasis:
The disease caused by Trichuris is Trichuriasis or whipworm infection. It was first
discovered by Linnaeus in 1771. It occurs worldwide but mostly prevalent where the
sanitation is poor and warm moist climates. The adult worms live in the large intestine
of man especially in the caecum and vermiform appendix. The male measures 30-40
mm with a tightly coiled posterior end and a single spicule. The female worm is
slightly longer (40-50 mm) and both sexes have a narrow anterior portion. The
anterior thin part remains buried in the intestinal mucosa.47 The intestine and
reproductive organs are located in the posterior thick part of the body. The worm is
oviparous. After fertilization the female begins to lays about 2000-10000 eggs per day
which is barrel shaped eggs. Eggs when freshly passed are not infective to human
beings. The eggs take about 3 weeks to develop in the moist soil and remain infective
for about 2 weeks. When the embryonated eggs containing larvae are ingested by
human hosts with food and water, the shell is digested by the digestive juices and
larvae are liberated through one pole and migrate to caecum.
Patients with mild infections are usually asymptomatic. The clinical features are
abdominal pain, weight loss, anaemia, malnutrition, bloody diarrhoea, acute
appendicitis.
Hymenolepis and Hymenolepiasis:
The disease cause by hymenolepis nana is Hymenolepiasis. The species nana meaning
small is derived from the small size of the adult worm. The worm was first discovered
by Bilharz in 1857. It is cosmopolitan and more common in warm climates. The
adults are found in the lumen of the ileum with scolex embedded in the mucosa. It is
short measures 20-40 mm in length with a diameter of 1 mm and hence is called a
“dwarf tapeworm”. It seems like a mucus thread when observation through naked eye.
The scolex is 0.3mm wide, bears 4 suckers and has a retractable rostellum with 20-30
“spanner shaped” hooks. The neck is long and slender. The strobila consists of about
200 proglottids. There are 36 round testes which lie in the posterior part of each
proglottid. The eggs are spherical or oval measures 30-45 μm in diameter. 47 Some
eggs hatch out in the lumen of the small intestine and liberate embryos which directly
invade the intestinal villi. The infection is more common in children.The infection is

8
symptomatic in malnourished and immuno-compromised children. Abdominal pain,
diarrhoea, weight loss and weakness are the major clinical features.

Taenia and Taeniasis:

9
Hippocrates gave the description of Taenia saginata and Goeze differentiated it from
T. solium in 1782. It is worldwide in distribution. The scolex of the adult tapeworm
(T. saginata) is embedded in the mucosa of the wall of ileum. The adult worm is
white, semi-transparent tape like worm. It measures about 5-12 meters but sometimes
exceed 20 meters. The scolex of the adult worm is pear-shaped, 1-2 mm in diameter,
with four prominent round suckers but with no rostellum or hooks. 47 Proglottids are
upto 2000. The length of a gravid segment is 3-4 times its breadth. The common
genital pore is situated marginally near the posterior end of each segment. Eggs are
liberated by rupture of the ripe proglottids. About 80000 eggs may be present in a 7
single proglottid. Eggs are spherical in shape measure 31-43μm in diameter. 47 The
eggs are not infective to man. In the intestine, eggs rupture and onchospheres are
liberated. These penetrate the gut wall with their hooks gain entrance into the portal
vessels, finally reaching the systemic circulation. Humans are infected through eating
the uncooked beef containing cysticerci called measly beef. The clinical features are
usually asymptomatic but may be noticed abdominal discomfort, hunger pain, chronic
indigestion, diarrhoea, anorexia.
Linnaeus in 1758 discovered the parasite of T. solium. The adult worm lives in the
small intestine of man measures 2-3 meters in length. Scolex is about “pin head” size.
The head is provided with rostellum armed with a double row of alternating large and
small hooklets. The neck is short, 5-10 mm in length. There are less than 1000
proglottids. Immature proglottids are broader than longer. The genital pore is present
laterally at middle of each segment. The testes consist of 150-200 follicles. The ovary
is situated in the posterior third of each proglottid. The larval stage known as
cysticercus cellulose occurs in pig and also in man. It is small, ovoid, milky white
bladder measuring 5 mm in length and 8-10 mm in breadth. 47Eggs are
morphologically similar to that of T. saginata. The eggs are release through the
ruptured wall. Man acquires infection either by eating the inadequately cooked pork
containing cysticercus cellulosae or by ingesting the eggs of T. solium in
contaminated food and water. Taeniasis is aymptomatic in cases of man. Occasionally
mild diarrheas, abdominal pain, loss of appetite are the main symptoms due to
cysticercus cellulosae.

Scenario of Intestinal Parasitic Infection in world:

10
Intestinal parasitic infections are more common in lower and middle income
countries. Most of the studies showed Ascaris lumbricoides as the most prevalent
intestinal parasites.16 A cross sectional study conducted by Astal et.al (2005) in Gaza
strip, Palestine found 32.4% of the prevalence rate of intestinal parasite. Ascaris
lumbricoides was the most common parasite (12.8%) followed by Giardia lamblia
(8%), Entamoeba histolytica (7%), Entamoeba coli (3.6%), Trichuris trichiura (1.6%)
and Hymenolepis nana (1%) respectively in that study.18 Another cross-sectional
study conducted by Babakhani et al. (2017) on prevalence and risk factors associated
with intestinal parasitic infections among school children in Gashky, West of Iran
detected 33.0% of IPIs. 19

A Kenyan study by Kimosop et al. in 2018 showed that the overall prevalence of
enteric parasitic infection was 46.5% where Entamoeba histolytica (23.9%) was the
most common parasite detected.20 Similar type of cross- sectional study conducted in
Sudan in 2017 among the primary school children illustrated the prevalence of
intestinal parasites as 84%. Giardia lamblia was the most common parasite detected
in that study.21Another study conducted in Eastern Cape Town province South Arica
2013 also showed the rate of prevalence as 64.8% where Ascaris lumbricoides was
the most common parasite detected.22 A Nigerian study done among the primary
school children found that the overall prevalence of intestinal parasite was 13.7%.
They found Entamoeba histolytica (39.7%) as the most common parasite. 11

Similar type of cross sectional study done in Tikrit city, Iraq on prevalence of the
enteric parasitic infection detected 18.2% of IPIs where Entamoeba histolytica was
the most common parasite.41 A recent cross sectional study done in Iraq demonstrated
65.33% of IPIs where the Giardia lamblia was the most common
parasite.40Prevalence of IPIs varies from place to place within the same country. In
Iran, 33.0% of IPIs was detected by a similar type of research. 19
In another similar type of study, the prevalence rate of intestinal parasitic infections
was found to be 60.8% where 57.2% of children had multiple infections. Common
parasitic infections detected were trichuriasis (53.8%), ascariasis (34.3%), taeniasis
(9.5% ) and hookworm infection (4.1% ) respectively. 17 A study conducted in
Argentina among the school going children showed that the prevalence of the enteric
parasite was 86.6% where no significant differences were found in regard of age and
sex of the infected children.42
11
In Burkina Faso, the prevalence of the enteric parasite was 86.2% which was higher
among the children with no formal schooling (74.8%).43 In Omen, the prevalence of
the enteric parasitic infection (38.7%) was higher among the undernourished
children.44 A similar type of recent study conducted in Kenya showed that poly-
parasitism was more among the protozoan. It also seen that females were at the higher
risk of Cryptosporidium parvum infection.19 In Afghanistan, parasitic co-infections
were observed both in hospitalized adults and in the children. 45
The prevalence of different types of intestinal parasites differs from place to place
within India which is proven by various studies conducted in different states of India
at different times. A cross sectional study on the prevalence of intestinal parasites in a
tertiary care hospital in rural Bihar by Bhattacharya et al. (2017) detected 40.26% of
intestinal parasites in total number of stool samples. The prevalence rate of
Entamoeba histolytica was found to be 40.49%. Similarly, the percentage of Giardia
lamblia and Ascaris lumbricoides were 24.4% is 21.9% respectively.10
In Amalapuram, Andhra Pradesh, India; 63.9% of school going children were infected
with one or more intestinal parasites. Among the students who participated in the
research, 71.4% of the students were infected with single parasite and 28.6% were
infected with two or more parasites. The most common parasite was Entamoeba
histolytica that is 30.8% with single infection and 19.54% with multiple
infections.23Another study carried in Moradabad, Western Uttar Pradesh, India by
Mathuria et al. (2017) found that the prevalence of intestinal parasite was 15.86%.
Mixed infection with two parasites was most commonly seen in 0-10years age group
(70%). Combination of Giardia lamblia and Hymenolepis nana were most common.24
High prevalence of rate of enteric parasitic infections among primary school children
directly depends on personnel hygiene and sanitation. Maruthi et al. (2016) illustrated
the association of sanitation and parasitic prevalence among school children of
25
Visakhapatnam.

In other researches, intestinal parasites were more prevalent among the male students
than the females (23.26%). Furthermore, IPIs were more prevalent among the age
group 5 to 7 years old (5%). 2However, in similar study, females (14.4%) were more
prone to parasitic infections than males (13.5%).12

Siddig et al. in 2017 found that the overall prevalence of intestinal parasite was 84%
by the Formal-Ether Concentration technique while 65% were positive by the direct
12
saline stool wet mount preparation.23 This study proves that concentration techniques
by sedimentation method on negative stool specimens by routine microscopy are
essential to detect intestinal parasitic infection.

Scenario of Nepal

Nepal is a developing country where enteric parasitic infection is still a major cause of
morbidity and mortality in primary school going children. The rate of finding eggs,
cysts and trophozoites of different enteric parasites varies from place to place. There
have been many research conducted in the past that demonstrated diversity of results.

In Kalaiya, Bara district there was 31.7% of enteric parasites, out of which 17.1% was
Ascaris lumbricoides, 22.8% was Hymenolepis nana, 8.5% was Enterobious
vermicularis and 44.0% was Entamoeba histolytica.26 Another study by Chaulagain et
al on the prevalence and associated risk factors of parasitic infestation among children
in Eastern part of Nepal showed 24% of parasitic infection. Commonest parasite
isolated was Giardia lamblia.27 In Udaipur, 40% of children were infected with
parasites evidenced by a hospital based study.28Shah RB et al. studied the prevalence
of worm infestation and associated risk factors among the school children of Dharan,
Eastern Region of Nepal. This research observed 11.3% of worm infestation among
the school children where Taenia spp was the most common parasite.29 Similar type
of cross-sectional study carried in Kaski district in 2014 found only 11% of children
infected with intestinal parasites. Trichuris trichuria (22%) was the commonest
parasite detected among the various other intestinal parasites.2

The prevalence of intestinal parasitic infection among school children in Baglung

District of Western Nepal was 21.05%. Among the various intestinal parasites
Entamoeba histolytica had higher infection rate that is 9.23%. Moreover, higher
prevalence was seen in boys and children belonging to age group 10-14 year were
infected more.13In 2016, the enteric parasitic infection among school children at
Rupandehi was 60%. Out of all infected children, 89.2% of children had single
parasitic infection while mixed infection was seen in 10.8% of children. Ascaris
lumbricoides was the commonest parasite detected followed by Taenia spp and
Hymenolepis nana. The age group between13 to 15 were highly infected as compared
to other age group among the students who participated in this project.30

13
In 2017, in Lalitpur District of Nepal the prevalence of intestinal parasites was 16.7%.
The highest percentage of parasite was Giardia lamblia (7.4%) followed by
Entamoeba histolytica (3.4%) and Cyclospora cyantenenis (1.7%). Male children
(17.8%) and the age between 11 to 15 years (7.3%) had higher infection rate. In
addition, government school (12.2%) children were more infected. 31 Another study on
the intestinal helminth parasites in school children of Rangeli Municipality of Morang
District in Eastern Nepal in the same year showed that the prevalence of the intestinal
parasite was 83.33%. This study concluded that Ascaris lumbricoides was the major
causative agent of the parasitic infestation in Morang.32

In the Northern Eastern part of Kathmandu Valley, a research was carried among the
school going children by Sharma et al. in 2004 which illustrated 66.6% of intestinal
parasitic infection. Helminths (76.9%) were found to be more prevalent than protozoa
(23.1%) in this project. Trichuris trichiura was the most common helminth detected
followed by Ancyclostoma duodenale, Ascaris lumbricoides and others. Entamoeba
coli was the most common protozoan parasite detected followed by Entamoeba
histolytica, Giardia lamblia and others.33Similar type of study conducted in the
Northern part of Kathmandu in 2014 showed only 5% of the intestinal parasitic
infection. Personal hygiene, sanitation, literacy rate and nutrient rich food were found
to be major factors that make the difference in the prevalence rates of intestinal
parasites from 2004 to 2014.34 Yet another research conducted among the school
going children of Sukumbasi Basti in Kathmandu valley in 2011 found 43.3%
parasitic infestation. It was concluded that Giardia lamblia was the most common
causative agent for the intestinal infection among the school going children. In
addition, this study found that positive rate was higher in Tibeto-Burman (55.0%) and
the least in Indo-Aryan (25.4%) community. 35Shrestha et al. conducted a study in
Bhaktapur on school going children in 2016 which showed that the prevalence of the
intestinal parasite was 42.9%. Giardia lamblia was the most predominant parasite,
showing the incidence of 35.7%, followed by Taenia spp. (22.6%) and Blastocystis
hominis (14.3%).36

Many studies in different parts of Nepal observed prevalence of enteric parasitic

infection among primary school going children but very few studies included both
government and private school children in the same project. Prevalence rate of enteric
parasitic infestation depends on a wide range of factors such as age, ethnicity,
14
geographical location, literacy rate, socioeconomic status, personal hygiene,
sanitation, drinking water, animal rearing and many others. Identification of the actual
scenario of the enteric parasites in a particular place is essential to minimize the rate
of prevalence subsequently.

15
 CHAPTER III

MATERIALS AND METHODS

3.1 Study Design:

Comparative Cross sectional type

3.2 Sample processing Site:

Department of Microbiology at Universal College of Medical Sciences
(UCMS), Bhairahawa, Nepal
3.3 Study population:
Primary school children of Government and Private schools of Bhairahawa,
Rupandehi district, Nepal

3.4 Sample size:

409 stool samples from primary school going children

3.5 Sampling Technique:

Simple Random Sampling Technique

3.6 Duration of the study:

6 months (March 2019 to September 2019)

3.7 Inclusion Criteria:

Primary school children below the age of 14 years with or without abdominal
symptoms

3.8 Exclusion Criteria

 Children studying above 14 years

3.9 Limitations of the study:

 Time frame of the study is short.
 The sample population might not represent the whole population.
 Egg counting not done which might have been a great tool to rate the
degree of infection.

16
 3.10 Ethical Clearance:

Ethical approval was taken from Institutional Ethical Review Board. Consent was
taken from children and their parents. Samples were included in the study after
taking consent from students and their parents. Individual Performa has been
encoded for confidentiality.

3.11 Data Analysis:

All the data from cases were fed in MS Excel (Microsoft office 2007) and then
analysed by Statistical Package for Social Service (SPSS) for window version;
SPSS 22, Inc., Chicago, IL). All the data were expressed in terms of percentage
frequency, Chi square test. P-value<0.05 was considered to be statistically
significant.

17
3.11 Flow chart of the Procedure:

Sample collection

Stool examination

Macroscopic examination Microscopic examination

Colour, odour, consistency blood and mucus &Adult Direct wet mount

Parasites seen Parasites not seen

Floatation method Sedimentation method

Parasite seen Parasite not seen

Data analysis

18
 CHAPTER IV

RESULTS

Out of 409 stool samples collected from students of different primary schools
including Government and private schools, 190 samples were found to be positive for
parasites where 95 were positive by routine microscopy, 30 by floatation and 170
samples were positive by using sedimentation technique and 219 samples were found
to be negative. Thus the prevalence rate was 23.2% by routine microscopy and
46.45% by concentration methods.

Percentage distribution of Positive and Negative Samples

Positive Negative

46%

54%

Figure 1: Distribution of Positive and Negative stool samples.

19
 Routine Microscopy
Positive
23%

Negative
77%

Figure 2: Distribution of Positive and Negative stool samples by Routine

Microscopy.

Figure 3 Illustrates the increase in the rate of prevalence of the parasitic infection
from 23.2% to 41.5% by sedimentation technique.

Sedimentation Technique

Positive
42%

Negative
59%

Figure 3: Distribution of Positive and Negative stool samples by Sedimentation

Technique.

20
Figure 4 shows the percentage of parasites detected by floatation technique that is 7%
of the total stool samples. As this technique only detects the parasitic eggs and cysts
that floats in saturated salt solution, this method was helpful to detect the parasites
that were missed by sedimentation technique.

Floatation Technique
Positive
7%

Negative
93%

Figure 4: Distribution of Positive and Negative stool samples by Floatation

Technique.

21
Figure 5 shows the comparison between Government and Private School children
where the number of the positive cases was found higher among the government
school children (51.7%) than private school children (48.3%). From this data it is seen
that government school going children were slightly more prone to enteric parasitic
infection than private school going children. However, this finding is not statistically
significant

300

250

200

Positive
150
Negative
Total
100

50

0
Goverment Private

Figure 5: Comparative study of stool samples from Government and Private

Schools.

22
Class wise distribution of Positive and Negative stool samples

A total of 409 students participated in our research from different primary schools of
Bhairahawa from class 1 to class 5. Out of them, 190 were found to be infected with
various enteric parasites. It was observed that higher positivity rate was seen in class 1
(58.46% n=38) followed by class 2 (51.5% n=34), class 5 (46.45% n=72), class 4
(45.09% n=23) and class 3 (31.9% n=23) as shown in figure 6 respectively.

180

160

140

120

100
Parasite Seen
Parasite Not Seen
80
Total
60

40

20

0
1 2 3 4 5

Figure 6: Class wise distribution of positive and negative stool samples

23
 Distribution of Various Parasites

Ascaris lumbricoides
22%

Not detected Entamoeba histolytica

54% 5%

Giardia lamblia
4%
Taenia spp
Mixed 3%
9%
H nana
4%

Figure 7: Distribution of various parasites

Figure 7 illustrates the distribution of different parasites observed in our study. Parasites were
not detected in 53 % of the samples. The frequency of Ascaris lumbricoides was the most
(22%) while Taenia spp. was found in only (3%) of the samples being the least frequent.

24
Table 1 Illustrates the prevalence of enteric parasitic infection was found higher
among male children as compared to female children. However, this finding is not
statistically significant.

Table1: Sex wise distribution of positive and negative stool samples.

Sex Total samples Positive (%) p- value

Male 222 109 (49.09%) 0.295
Female 187 81 (43.31%)
Total 409 190 (46.45%)

In this study, students below 14 years of age were involved. Table 2 illustrated that
the occurrence of parasitic infection was highest 72.22% among the age group below
7 years of age. This study also showed that the rate of the prevalence of the parasitic
in association with the age group was found to be statistically significant (p-value:
0.004).

Table 2: Age wise distribution of positive and negative stool samples

Age group Total samples Positive (%) p- value

(years)
<7 18 13 (72.22%) 0.004
7-10 242 96 (39.66%)
11-14 149 81 (54.36%)
Total 409 190(46.45%)

Table 3 shows the prevalence of infection was higher among the children between the
BMI 13 to 15 (50.46%) followed by BMI above 21(50%), 9-12(46%), 19-21(43%)
and 16-18(39.47%).

25
Table 3: Parasitic association with Body Mass Index (BMI)

BMI category Total Positive/% p-value

9-12 50 23 (46%) 0.245
13-15 214 108 (50.46%)
16-18 114 45 (39.47%)
19-21 23 10 (43.47%)
Above 21 8 4 (50%)
Total 409 190(46.45%)

Table 4 shows that the prevalence of the parasitic infection was highest among the
children who follow the Christian religion (85.71%, n=6). The prevalence rate of the
enteric parasitic infection was significantly associated with the religion followed by
the children
Table 4: Prevalence of parasitic infection among different religion

Religion Total Positive (%) p- value

samples
Hindu 343 151 (44.02%) 0.056
Buddhist 18 11 (61.11%)
Muslim 41 22 (53.65%)
Christian 7 6 (85.71%)
Total 409 190(46.45%)

Illness is significantly associated with the prevalence of the parasitic infections.

Table 5 illustrates that enteric parasitic infection was higher (58.02%, n=47) among
the children who were ill.
Table 5:- Parasitic infection with and without illness.
Illness Total Positive p- value
samples
Yes 81 47 (58.02%) 0.045

No 328 143 (43.59%)

Total 409 190 (46.45%)

26
Table 6 Illustrates that water sources is significantly associated with the prevalence of
the parasitic infection. It was observed that the rate of the prevalence of the parasitic
infection is higher (65.51%, n=38) among those who consumed water from wells as
the sources of drinking water.

Table 6: Prevalence of the parasitic infection in association with Water sources

Water sources Total samples Positive (%) p-value
Boring 126 46 (36.5%) 0.001
Hand pump 225 106 (47.11%)
Wells 58 38 (65.51%)
Total 409 190(46.45%)

27
Table 7 shows that the rate of prevalence of the enteric parasitic infection is not
significantly associated with the variable diarrhoea. From the table it was concluded
that children who have suffered from the diarrhoea (52.38%) recently were infected
more with intestinal parasites.
Table 7: Prevalence of the parasitic infection in association with Diarrhoea

Diarrhea Total Positive (%) p-value

sample
Yes 105 55 (52.38%) 0.97
No 304 135 (44.40%)
Total 409 190(46.45%)

Table 8 showed that there was no any significant association between rate of
prevalence of the enteric parasitic infection and the medication used by the children. It
was concluded that children who had taken recent medicine for illness were more
infected (50.94%) with intestinal parasitic infection.
Table 8: Prevalence of the parasitic infection in association with Medication

Medication Total Positive (%) P-

samples value
Yes 159 81(50.94%) 0.089
No 250 109 (43.6%)
Total 409 190(46.45%)

28
Table 9 demonstrates that the prevalence of the enteric parasitic infection among the
primary school going children is significantly associated with meat consumed. It was
also observed that the rate of the prevalence of the parasitic infection is higher among
those students who consumed all type of the meat chicken mutton, buff, fish and pork
(100%, n=9)
Table 9: Prevalence of the parasitic infection associated with meat consumed.

Meat taken Total sample Positive (%) P-value

Chicken, Mutton 148 64(43.24%) 0.002
Chicken, Mutton, Fish 146 59(40.41%)
Chicken, Mutton, Buff 46 27(58.69%)
All 9 9(100%)
No 60 31(51.66%)
Total 409 190(46.45%)

Table 10 Illustrates that the parasitic infection was common among those students
who walked bare foot.

Table 10: Prevalence of the parasitic infection associated with walking bare foot.

Walk bare Total Positive (%) p-value

foot samples
Yes 401 185(46.13%) 0.287
No 8 5(62.5%)
Total 409 190(46.45%)

29
Table 11 shows that the consistency of the stool is significantly associated with
prevalence rate of an enteric parasitic infection. It was observed that higher rate of
prevalence was seen among those children who had loose (65.71%) stool sample.
Table 11: Prevalence of the parasitic infection associated with Consistency of
stool.

Consistency Total Positive (%) p - value

samples
Loose 35 23(65.71%) 0.053
Semi formed 260 118(45.38%)
Formed 114 49(42.98%)
Total 409 190(46.45%)

Table 12 shows that the Domestic animal rearing is significantly associated with
prevalence rate of an enteric parasitic infection. It was observed that higher rate of
prevalence was seen among those children who rear the domestic animals at their
home. (p=0.035)
Table 12: Prevalence of the parasitic infection associated with Domestic Animals
Rearing

Domestic animal Total Positive (%) p-value

at home sample
Yes 169 88(52.07%) 0.035
No 240 102(42.5%)
Total 409 190(46.45%)

There are many factors associated with enteric parasitic infections in humans. Some
factors are statistically significant and some are not. Inspite of de-worming frequently
by government in schools, the rate of prevalence of the enteric parasitic infection is
still high among the students under 14 years of age. Government school going
children have slightly higher rate of enteric parasitic infection than private school
going children.

CHAPTER V
DISCUSSION

30
The intestinal parasitic infection among the school going children is one the major
public health problem throughout the world. Intestinal parasitic infection is most
predominant in lower and middle income countries such as Nepal. Protozoan like
Entamoeba histolytica, Giardia lamblia and helminthes like Ascaris lumbricoides,
Taenia spp, Ancylostoma dudonale and H.nana are the major parasites to cause
intestinal infections.
Our cross-sectional study included examination of stool specimens of 409 samples
inclusive of both the sexes male and female and aged below 14 years children going
to different primary schools of Bhairahawa, Rupendehi. Samples collected from
different primary schools both government and private were further processed in
Microbiology laboratory of Universal College of Medical Science for the routine
examination. Various morphological forms of different enteric parasites were
observed.

In this study, out of 409 stool samples, 190 samples were found to be positive for
parasite. The overall prevalence of parasitic infection was 46.45% which is higher
than the same type of cross- sectional study conducted in the Kaski district by Jaiswal
et.al in 2014.2 The most common parasite detected in this research were Ascaris
lumbricoides (22.2%), Entamoeba histolytica (4.6%), H.nana (4.2%) and G .lamblia
(3.7%). Similar study carried out in Rupandehi district by Khanal et al (2016) found
60% of parasitic infection30 which is slightly higher than our study. Ascaris
lumbricoides was the most common parasite detected which is 80% out of the positive
cases. 30Another study conducted among the primary school going children of Rangeli
Municipality of Morang district showed 83.3% of parasitic infection 32, which seems
to be higher than that of our study. The rate of the detection of parasite is almost
double than our study. This might be due to the lack of knowledge of personal
hygiene, sanitation, poverty and low literacy, and low socio economic status of the
children.There was no any egg of Ancyclostoma duodenale detected in our study.
However, 44.56% of Ancyclostoma duodenale was detected in the same study.32
People in Terai region are dependent on the agriculture and the maximum children
follow their parents to the field bare footed which might be a reason to explain the
high incidence of hookworm infection in this area. Similar study conducted in Dharan
among the primary school going children by Sah RB et al. (2013) showed 11.3% of

31
prevalence rate of enteric parasitic infection which is lower than that of our study. The
commonest parasite detected was Taenia spp of the total stool samples.37

A another important finding of our study show that government school going children
(51.7%) are more prone to enteric parasitic infection as compared to the private
school going children. However, this finding is not statistically significant. This
finding is consistent with result of a study done in Kathmandu valley. 8 Another
similar type of study done in Bara district in 2014 also revealed that the enteric
parasitic infection was high among the public school going children.26

In Birgunj, the prevalence of the parasitic infection was found highest among the
children of ≤5 years.13 That is similar to the finding of our study that showed the
highest prevalence among <7 years of the age. Another illustration of our study was
that the rate of prevalence of the enteric parasitic infection was higher among the male
students. This finding is consistent with the result of a study done in Baglung
District.38 Whereas the study done in Kathmandu Valley in 2018 showed higher
prevalence among the female students (70.8%).8

The another finding of our study is that the rate of prevalence of the enteric parasite is
higher among those children whose BMI ranges from 13 to 15 which is also similar to
the finding of the study done in Rupandehi that showed higher prevalence among the
children whose BMI was less than 16. 30 Again this finding is also not statistically
significant.

This study showed that the rate of prevalence of parasitic infection was higher among
the symptomatic children which are similar to the result of a study done in
Kathmandu 2018.8 However another study conducted in Rupandehi district in 2016
showed that enteric parasitic infection was more common among the asymptomatic
children.30

Another important finding of our study is that the rate of prevalence of the enteric
parasitic infection was higher among the children who belonged to Chhetri ethnicity
(46.05%). However, Yadav et.al in 2016 found higher prevalence of enteric parasites
among Dalit group.39 Our study also explained, the prevalence of the parasitic

32
infection was higher among the children who used wells water as a source of drinking
water (65.51% ) whereas similar study in Kathmandu showed higher prevalence
among those who used direct tap water as the main source of drinking water (45.9%).8

Our study illustrated that the rate of prevalence of the intestinal parasitic infection was
higher among those students who cut the nail within in 15days (51.6%) which seems
to be consistent with the study done among primary school going children in
Kathmandu valley in 2014(62.81%).39

The finding of our study regarding habit of defecation of children in Bhairahawa is

that enteric parasitic infection is more common among the students who defecated in
open places. This finding is consistent with the result of a study done in Gujarat. 9
Moreover, our study showed that the rate of prevalence of the enteric parasitic
infection was slightly higher among the children who were vegetarian (50%) whereas
the study done in Kathmandu valley showed that higher prevalence among the non
vegetarian students.8 In addition, this study explained that the rate of prevalence of the
intestinal parasitic infection was higher among those who used the direct tap water for
drinking which resembled with the study done in Lalitpur District 48.92%.40

Findings of different studies show different rate of prevalence of the enteric parasitic
infection that depends on multiple factors such as age, religion, illness, water sources,
meat taken, de worming, domestic animal rearing habit and consistency of stool.
Some associations are statistically significant and some are not.

33
 CHAPTER VI
Conclusion
Despite of de-worming frequently by government in schools, the rate of prevalence of
the enteric parasitic infection is still high among the students under 14 years of age.
Government school going children have slightly higher rate of enteric parasitic
infection than private school going children. Moreover, concentration techniques were
essential for the detection of greater number of enteric parasites in stool specimens.
The rate of detection of the parasites increased by two fold after performing
concentration techniques, both sedimentation and floatation methods. Many factors
like class in which the students are studying, age, religion, illness, water sources, meat
consumed domestic animal in house, consistency of stool and de-worming recently
affects the rate of prevalence of enteric parasitic infections. .

Recommendation

 There is a need for an intensive and habitual health education related to

personal hygiene and mass treatment for the effective control of intestinal
parasitic infections.
 The control measures include the treatment of the infected individuals,
improvement of sanitation practices and provision of safe drinking water.
 Schools should provide anti helminthic drugs for their students in every 6
months along with maintenance of personal hygiene.

34
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39
1
ANNEXURE
Annexure I
Time frame (Work plan)

Phase Particulars Research Duration in months Rem

arks
First Preparatory phase 1 2 3 4 5 6
1. Identification and presentation of
research topic
2. Literature review
3. Approval of research topic from
the research committee
4. Preparation of research proposal
5. Presentation of research proposal
6. Finalization of research proposal
and instrumentation
Secon Empirical phase
d
7. Data collection
8. Data analysis
Third Report writing phase
9. Data interpretation report writing
10. Prepare first draft report and
consultation with the supervisor
11. Preparation of second draft as
necessary
12. Preparation of final draft report
Fourth dissemination phase
13. Presentation of report
14. Finalization of report and
submission to the
supervisor/coordinator
15. Final Evaluation
Annexure II
Performa

ENTERIC PARASITIC INFECTION AMONG PRIMARY SCHOOL CHILDREN

IN BHAIRAHAWA

i
[Universal College of Medical Sciences, Bhairahawa, Nepal]

QUESTIONNARIE

Date…………… Patient
ID……………

1. Name …………..
2. Class …………….
3. Age ………………
4. Sex …………….
5. Weight …………
6. Height …………
7. Religion...........
8. Ethnicity...........
9. Family size........
10. Any underlying illness() Yes ( ) No
11. Hand washing after toilet ( ) Yes ( ) No
12. Hand washing before meal ( ) Yes ( ) No
13. How many times you go to toilet daily.........................?
14. Where do you defecate?
a) Open place b) River bank c) In toilet
15. Source of consumption of water
a) Boring b) Pond c) Hand pump d) Wells
How do you use water for drinking?

a) Boiling b) By filtration c) Direct.

16. Are you a) vegetarian b) Non-vegetarian

If non vegeterian which meat frequently you take?
a) pork b) chicken c) Buffalo d) Mutton e) Fish
17. Do you have domestic animal at home? If yes mention …………………
18. Have you taken any medication in last 3 months? If yes mention
…………………….
19. Have you taken de worming tablet or not?
ii
 a) Last week b) 1month ago c) 3 month ago
20. How do you treat in case of infection?
a) Traditional method b) By taking medicine c) By consulting
21. Use of toilet ( ) yes ( ) No
22. Walking bare foot ( ) yes ( ) No
23. How often you cut your nail?
a)Twice a week b) Once a week c) Once a 15 days.
24. How often you go for swimming?
a) Once a week b) Once a 15 days c) Once a month d) Within a six months.
25. Have you suffered from diarrhea or dysentery? If yes then When.

iii
Annexure III

Reagents, Instrument, Chemicals

Material Required

S.N Materials Required Quantity Required (pcs)

.
1 Container (Disposable 500
plastic container with
wooden stick)

2 Marker 4
3 Centrifuge machine 1
4 Test tube 510
5 Glass slide 700
6 Cover slip 10 box
7 Bamboo stick 1 bundle
8 Microscope 1
9 Forceps 2
Reagents Required

1) Normal saline
2) Distilled water
3) Lugol’s Iodine solution
4) 33% Zinc sulfate
5) 10% V/V formal saline
6) Ether

iv
Annexure IV

Detail Test Procedure

Sample collection

Students in the class were given the brief description about the importance of
examination of stool and impact of intestinal parasite upon the health. Before collecting
the stool sample written consent from the parents and school administration was taken.
Plastic containers were labelled with the children name and roll number, date and time of
collection. During the distribution of containers questionnaire accompanying the queries
about name, age, family size, clinical history and hygienic practices was filled. They
were advised not to mix the stool with the water and asked to bring the stool samples
about half of the container.

Laboratory processing of the samples

Each stool sample was processed in two steps as:

A) Macroscopic examination
B) Microscopic examination
A) Macroscopic examination: The direct visualization of each sample was done for
the color, consistency, presence of mucus, blood and adult worm or worm
segment.
B) Microscopic Examination

Microscopic examination was done for the detection and identification of protozoan
cysts, oocysts, trophozoites and helminthes eggs or larva. Microscopic examination
was done by saline and logul’s wet mount. The slides will be observed under low
power first (10x) and followed to high power (40x) of the microscope. Parasitic cysts
and trophozoites were identified by their morphology, motility and staining
characteristics.

All samples were concentrated by centrifugation before performing wet mount.

Centrifugation concentrates the eggs, larva and cysts when they are present in the low
number and increases the sensitivity.

v
Stool analysis

1. Direct Wet mount

Microscopic examination of the smear made directly from the sample was viewed
under high power which enables to find the eggs or larvae.

Procedure

A) Saline mount preparation

1) A drop of normal saline was placed on the centre of glass slide.
2) Using an applicator sticks the fecal material was taken and mixed with a drop
of normal saline.
3) Cover slip was placed over the specimen avoiding the formation of air
bubbles.
B) Iodine mount preparation
1) A drop of lugol’s iodine was placed on the centre of glass slide.
2) Using an applicator sticks the fecal material was taken and would mix with a
drop of normal saline.
3) Cover slip was placed over the specimen avoiding the formation of air
bubbles.

2) Concentration Technique

A) Floatation technique (33% Zinc Sulphate solution)

Principle

The faecal material is dissolved in a solution of a higher density than that of the eggs
and the suspension was left undistributed. A zinc sulphate solution was used which
has a specific gravity of 1.80-1.20. In the case, the eggs and the cysts float on the top
or superficial portion of the suspension.

Procedure: -

About 1-2 g of freshly collected stool was added in a test tube.

One quarter full with 33% zinc sulphate solution was added and emulsified the

vi
 specimen using a stick.

Coarse faecal particle was removed by staring through a wire gauge

The suspension was allowed to stand in a vertical position in a rack.

Further 33% zinc sulphate solution was added to ensure the tube will be filled to the
brim.

A grease free cover slip was carefully placed on top of the tube , avoiding any air
bubbles

The cover slip was pulled upwards and placed its face downwards on a slide after 30-
45 minutes.

Microscopically examination was done using the 10X objectives followed by 40X
objectives.

B) Sedimentation method (Formal ether concentration)

The faecal material was dissolved in the solution of low specific gravity so that the
eggs and the cyst was sediment at the bottom.

Principle

In the Ridely modified method , faeces are emulsified in formal water, the suspension
is strained to remove large faces particles, ether is added, and the mixed suspension is
centrifuged .Cysts, eggs and larva are fixed and the faecal debris is separated in the
layer between the ether and the formal water. Faecal fat is dissolved in the ether.

Procedure

About 1-2gm stool specimen was emulsified in a test tube containing 4 ml of 10%
formal water

Add further 3-4 ml of 10% formal water and mixed well.

Emulsified faeces were sieved and the sieved suspension was collected in the small
breaker.

vii
Suspension was transferred to a centrifuged tube and was added 4 ml of diethyl ether
and mixed vigorously.

Centrifugation at 2500 rpm for 1 minute was done

Four layers was seen i.e. a top layer of ether, a plug of debris at the interface, formal
water layer and the sediment at the bottom.

Carefully the upper three layers was removed with the help of the Pauster pipette

The sediment part was suspended with a few drop of normal saline

A drop of sediment was taken in a two clean glass slide

Cover slip was applied directly over the sample placed on the first glass slide.

To the second glass slide containing sample a drop of iodine will was added and
covered with cover slip.

Observation of both the slides was done first under low power of the objective and
later changed to high power objectives.

viii
Annexure V

INFORMED CONSENT

I, Mr. / Ms. / Mrs. ............................ age ........................ resident of

..............Zone .........................District......................... VDC/Municipality, wardno.......
Granddaughter/Grandson of ..........................., son/daughter/wife of .........................
hereby give consent to participate in this research study.

I have been fully explained about the study. This study has been done in other parts of
the world and no adverse consequences have been reported so far. I deserve my right to
withdraw from this study at any time.

Patient’s Name: ............................ Guardian’s Name:……...………….

Signature: ....................................... Signature: .........................................

Date: ………………….................. Relation: .........................................

ix
मञ्जुरीनामा

मिति:............

.............. अञ्चल .............. जिल्ला ..........गा.वि.स. / न.पा., वडानं ......बस्ने ........कोनाति / नातिनी ...................कोछोरा / छोरी /

पत्नी,........वर्षलाई .......रोगलागेकोचिकित्सकहरुबाटथाहाहुनआएकोलेरसोरोगकोउपचारार्थआवश्यकजाँचविधियनि
ू भर्सलकलेजमेडिकल ,

भैरहवामागराउनमञ्जरु छु|

उक्तजाँचकोबारे माचिकित्सकलेमलाईपर्णू जानकारीदिईसके कोरजाँचविधिलाईअनसु न्धानगर्नकोलागिमलाईकुनैआपत्तिनभएकोहुनालेममञ्जरु ीनामागर्दछु|

विरामीकोसहि / छापविरामीकोनातेदारकोसहि / छाप

नाम ............................... नाम ...............................

ठे गाना ............................. नाता ................................

ठे गाना .............................

दायाF af याF दायाF af याF