International Journal for Parasitology 42 (2012) 871–880

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International Journal for Parasitology

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Giardiasis among different tribes of Orang Asli in Malaysia: Highlighting

the presence of other family members infected with Giardia intestinalis as a main
risk factor
Tengku Shahrul Anuar a, Hesham M. Al-Mekhlafi b, Mohamed Kamel Abdul Ghani c, Emelia Osman a,
Azlin Mohd Yasin a, Anisah Nordin a, Siti Nor Azreen a, Fatmah Md Salleh a, Nuraffini Ghazali a,
Mekadina Bernadus a, Norhayati Moktar a,⇑
a
Department of Parasitology and Medical Entomology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
b
Department of Parasitology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
c
Programme of Biomedical Sciences, School of Diagnostic and Applied Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: The flagellate protozoan parasite, Giardia intestinalis, is widely distributed throughout the world with a
Received 14 May 2012 high prevalence in developing countries in the tropics and subtropics, including Malaysia. Approximately
Received in revised form 6 July 2012 200 million people are infected with the parasite globally, with 500,000 new cases reported annually.
Accepted 9 July 2012
This cross-sectional study was conducted among three tribes of Orang Asli communities in Selangor,
Available online 28 July 2012
Perak and Pahang states of Malaysia. The main objective was to determine the prevalence of and risk fac-
tors for giardiasis. Stool samples were collected from 500 individuals aged between 2 and 74 years
Keywords:
(males = 219, females = 281). The samples were examined with formalin–ether sedimentation and
Giardiasis
Giardia intestinalis
trichrome staining techniques. Socioeconomic data were collected through a pre-tested questionnaire.
Risk factors The overall prevalence of giardiasis was 20.0% with the highest prevalence in the Proto-Malays (33.3%)
Orang Asli tribes followed by Negritos (20.1%) and Senois (10.4%). The positive cases showed a decrease with increasing
Malaysia age and most of the positive cases were observed in individuals less than 24 years old. Males had signif-
icantly higher prevalence than females (v2 = 5.283, P = 0.022). Logistic regression analysis of the overall
population studied and the Senoi tribe confirmed that being a child aged less than 15 years, being male,
the consumption of raw vegetables and the presence of other family members infected with G. intestinalis
were the main risk factors for giardiasis. The presence of other family members infected with G. intesti-
nalis was the only risk factor highlighted in the Proto-Malay and Negrito tribes. Diarrhoea was signifi-
cantly associated with giardiasis. However, the cause and effect relationship has yet to be determined.
Thus, screening family members and treating the infected individuals are the main strategies that should
be adopted by the public health authority in combating this infection in Orang Asli communities as well
as health education regarding good personal and food hygiene practises.
Ó 2012 Australian Society for Parasitology Inc. Published by Elsevier Ltd. All rights reserved.

1. Introduction Giardia intestinalis accounts for a high proportion (35.2% and

Giardiasis is the most common intestinal protozoal infection
worldwide and it occurs throughout the tropical and temperate re-
gions. Prevalence varies between 2% and 5% in the developed coun-
tries and up to 20% and 30% in the developing countries (Wilson,
1984; Farthing, 1994). In developed countries, giardiasis occurs
sporadically and it is commonly described as a cause of diarrhoea
among children in day-care centres (Polis et al., 1986) and travel-
lers (Gray et al., 1994; Faustini et al., 2006). Giardiasis in developed
countries is significantly associated with water; in some studies,
⇑ Corresponding author. Tel.: +60 3 9289 7312; fax: +60 3 2698 2640.
E-mail addresses: syahbasree@yahoo.com, tsatab@lycos.com (N. Moktar).
40.6%) of water-associated outbreaks of parasitic disease (Kourenti
et al., 2007; Baldursson and Karanis, 2011). The distribution of
giardiasis was found to be associated with geographic regions
and a high incidence of giardiasis has been reported during the
summer months (Addiss et al., 1992; Judy et al., 2001; Hoque
et al., 2004). In developing countries, giardiasis is endemic and is
usually considered a faecal–oral disease. Socio-demographic fac-
tors such as poverty, poor personal hygiene and lack of proper san-
itation have been identified as significant risk factors (Lai, 1992;
Prado et al., 2003; Faustini et al., 2006; Naelah et al., 2011).
In Malaysia, giardiasis is considered an endemic infection.
The prevalence varies according to the population studied and
the infection is predominantly seen in children, especially in the

0020-7519/$36.00 Ó 2012 Australian Society for Parasitology Inc. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijpara.2012.07.003
872 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880
underprivileged community (Norhayati et al., 1998; Al-Mekhlafi
et al., 2005; Mohammed et al., 2008). In addition to socio-demo-
graphic factors, a recent study in Malaysia identified drinking tap
water and consuming raw vegetables as risk factors for giardiasis
(Mohammed et al., 2008). A significant association of giardiasis
with protein-energy malnutrition (wasting) has also been reported
in Malaysia (Al-Mekhlafi et al., 2005).
The present study was conducted to examine the epidemiology
and risk factors of giardiasis among different tribes of Orang Asli in
Malaysia (Proto-Malay, Negrito and Senoi). We believe that this is
the first study to explore the epidemiology and risk factors of giar-
diasis in three Orang Asli tribes in Malaysia. A clear understanding
of the epidemiology and identifying the risk factors of giardiasis in
the different Orang Asli tribes may help in the implementation of
specific control and preventive strategies of giardiasis in Orang Asli
communities.
2. Materials and methods
2.1. Study area and study population
The present study was carried out from June to December 2011
in three different states of Peninsular Malaysia without discrimi-
nating age or gender. Specific villages within the locations of Jelebu
(2° 550 N latitude, 102° 40 E longitude), Gerik (5° 260 N latitude,
101° 70 E longitude) and Temerloh (3° 430 N latitude, 102° 220 E lon-
gitude) in Malaysia were included in this study (Fig. 1).
Parit Gong village, Jelebu, Negeri Sembilan state is considered a
sub-urban area with a population of 496 inhabitants. Most of the
residents are primarily involved in farming and rubber tapping.
There are also many individuals who are engaged in commercial
and professional activities such as teaching and government ser-
vice (Department of Orang Asli Development (JAKOA), 2011. Re-
search and Development Division: Information Database, Jelebu
District, Negeri Sembilan, Malaysia). The main sub-tribe residing
in this area is the Temuan and they belong to the Proto-Malay tri-
bal group.
RPS Air Banun area, Gerik, Perak state is considered a remote
area, located in a valley approximately 40 km from the town of
Gerik. The occupations of the inhabitants include farmers, rubber
tappers and some do odd jobs such as selling forest products.
The area comprises five villages with 10–15 households in each
(Department of Orang Asli Development (JAKOA), 2011. Research
and Development Division: Information Database, Gerik District,
Perak, Malaysia). The main sub-tribe residing in this area is the
Jahai which belongs to the Negrito tribal group.
Pasu village, Temerloh, Pahang state is considered a sub-urban
area which is within 10 km from the town of Kuala Krau. Out of
625 residents, 65% are farmers and rubber tappers while the
remainders are mostly government and private workers (Depart-
ment of Orang Asli Development (JAKOA), 2011. Research and
Development Division: Information Database, Temerloh District,
Pahang, Malaysia). The main sub-tribe residing in this area is the
Jahut and they belong to the Senoi tribal group.
2.2. Structured questionnaire
A structured questionnaire was developed in English and then
translated to Bahasa Melayu (the national language for Malaysia).
The questionnaire was pre-tested among Orang Asli individuals
who were admitted to Gombak Hospital, Selangor state. Trained
research assistants interviewed participants in person, asking
questions on demographic data (i.e., age, gender and education le-
vel), socioeconomic background (i.e., occupation, household in-
come and educational status), behavioural risks (i.e., personal
hygiene such as hand washing and food consumption), environ-
mental sanitation and living condition characteristics (i.e., types
of water supply, latrine system, sewage disposal system and pres-
ence of domestic animals). Participants were also asked if they had
diarrhoea and symptoms of gastroenteritis (i.e., vomiting, nausea,
abdominal pain, watery stools and blood or mucus stools). For chil-
dren, the questionnaire was completed by interviewing their par-
ents or the guardian who had given informed consent.
2.3. Faecal examination
Following the administration of the questionnaire, a wide
mouth screw-capped container pre-labelled with the individual’s
name and code was distributed to each participant for the collec-
tion of a faecal sample the next day. Their ability to recognise their
name was counter-checked. The participant was instructed to
scoop a thumb sized faecal sample, using a provided scoop, into
the container. Then, the container was placed into a zip-locked
plastic bag. Parents and guardians were instructed to monitor their
children during the sample collection in order to ensure that they
placed their faecal samples into the correct container. Approxi-
mately 10 g of each faecal specimen was kept in a 15 mL centrifuge
tube containing 3 mL Polyvinyl Alcohol (PVA). The collected faecal
samples were processed and examined for the presence of G. intes-
tinalis cysts and/or trophozoites by the formalin–ether sedimenta-
tion and trichrome staining techniques and then examined by
using a microscope at magnifications of 400 and 1000 (Fleck
and Moody, 1993). Specimens were reported to be positive if cysts
and/or trophozoites were detected by any of the two techniques.
All positive cases were treated with metronidazole prescribed by
the medical personnel from the Ministry of Health, Malaysia.
2.4. Statistical analyses
Data were entered in Microsoft Access and were cross-checked
by the technical staff in order to ensure that data were entered cor-
rectly. Statistical analysis was performed using SPSS version 20
(SPSS, Chicago, IL, USA). For descriptive analysis, rate (percentage)
was used to describe the characteristics of the studied population,
including the prevalence of G. intestinalis. A Chi-squares test (v2)
was used to test the associations between the variables. In the uni-
variate analysis, the dependent variable was prevalence of G. intes-
tinalis, while the independent variables were demographic and
socioeconomic factors, behaviour risks, environmental sanitation,
living condition characteristics and gastrointestinal symptoms.
All variables that were significantly associated with the prevalence
of G. intestinalis in the univariate model were included in a logistic
regression analysis to identify the risk factors for G. intestinalis. For
each statistically significant factor, an Odds Ratio (OR) and 95%
confidence interval (CI) were computed by the univariate and mul-
tivariate logistic regression analyses. The level of statistical signif-
icance was set as P < 0.05.
2.5. Ethical considerations
Prior to data collection, the study protocol (Reference Number:
UKM 1.5.3.5/244/FF-165-2011) was reviewed and approved by the
Ethics Committee of Universiti Kebangsaan Malaysia Medical Cen-
tre (UKMMC) and permission for field work was obtained from the
Department of Orang Asli Development (JAKOA). Village meetings
were held and village authorities and villagers were handed de-
tailed explanations of the aims, procedures, potential risks and
benefits of the study. During the meeting, they were also informed
that their identity and personal information would be kept strictly
confidential, and they could withdraw from the study at any point
of time without citing reasons for doing so. If they agreed to
 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880 873

Fig. 1. Map showing the location of the villages in Peninsular Malaysia involved in the study (triangles).

participate, their consent was obtained in written form (signature
or thumbprint for those who were illiterate) or parents were ap-
proached for consent on behalf of their children.
3. Results
3.1. Demographic characteristics
The general characteristics of the Orang Asli (Aborigine)
communities who participated in this study are shown in Table
1. Overall, 500 individuals aged from 2 to 74 years participated in
this study with a median age of 18 years (interquartile range
(IQR) 9–35); and consisted of 150 (30.0%) Proto-Malays, 139
(28.0%) Negritos and 211 (42.0%) Senois. More than 40% of the par-
ticipants were children aged less than 15 years and more than half
of the participants were females (56.2% females and 43.8% males).
Overall, the studied population came from a low socioeconomic
background with more than half having less than 6 years of formal
education. A high percentage of household income of less than
RM500.00 was predominantly seen in the Negrito (82.7%) and
Senoi (60.7%) tribes. Most (95.3%) houses in Proto-Malay villages
had piped water supplies and toilet facilities; conversely piped
water supplies and safe sewage disposal facilities were lacking in
the villages of the Negrito and Senoi tribes.
874 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880

Table 1
General characteristics of the Orang Asli communities that participated in this study.

Characteristics/tribes Overall n (%) Proto-Malay n (%) Negrito n (%) Senoi n (%)

Age groups (years)
<15 221 (44.2) 59 (39.3) 72 (51.8) 90 (42.7)
15–24 73 (14.6) 17 (11.3) 22 (15.8) 34 (16.1)
25–44 131 (26.2) 48 (32.0) 29 (20.9) 54 (25.6)
45–74 75 (15.0) 26 (17.3) 16 (11.5) 33 (15.6)
Gender
Male 219 (43.8) 66 (44.0) 66 (47.5) 87 (41.2)
Female 281 (56.2) 84 (56.0) 73 (52.5) 124 (58.8)
Socioeconomic status
Father’s education (<6 years) 222 (74.0) 54 (66.7) 68 (77.3) 100 (76.3)
Mother’s education (<6 years) 232 (56.2) 53 (65.4) 77 (87.5) 102 (77.9)
Low monthly household income (<RM500) 260 (52.0) 17 (11.3) 115 (82.7) 128 (60.7)
Working mothers 153 (51.0) 45 (55.6) 33 (37.5) 75 (57.3)
Large family (P8 members) 171 (34.2) 32 (21.3) 63 (45.3) 76 (36.0)
Supplied with piped water 357 (71.4) 143 (95.3) 76 (54.7) 138 (65.4)
Presence of toilet at household) 308 (61.6) 143 (95.3) 48 (34.5) 117 (55.5)
Total 500 (100) 150 (100) 139 (100) 211 (100)

RM = Malaysian Ringgit (US$1 = RM3.17 at 16 July 2012).

Table 2
Prevalence of giardiasis among different Orang Asli tribes according to age groups and gender.

Overall Proto-Malay Negrito Senoi

n positive n tested % positive n positive n tested % positive n positive n tested % positive n positive n tested % positive
Age groups (years)
<15 59 221 26.7 23 59 39 22 72 30.6 14 90 15.6
15–24 20 73 27.4 10 17 58.8 4 22 18.2 6 34 17.6
25–44 16 131 12.2 13 48 27.1 1 29 3.4 2 54 3.7
45–74 5 75 6.7 4 26 15.4 1 16 6.2 0 33 0
Gender
Male 54 219 24.7 24 66 36.4 16 66 24.2 14 87 16.1
Female 46 281 16.4 26 84 31 12 73 16.4 8 124 6.5
Total 100 500 20 50 150 33.3 28 139 20.1 22 211 10.4

3.2. Prevalence of giardiasis
The prevalence and distribution of giardiasis is shown in Table
2. It was evident that of 500 individuals studied, 20.0% were posi-
tive for G. intestinalis infection; the Proto-Malays harboured more
G. intestinalis (33.3%) followed by Negritos (20.1%) and Senois
(10.4%). Overall, the positive cases showed a decrease with increas-
ing age and most of the positive cases were observed in individuals
of less than 24 years old. Similar findings were observed in the Pro-
to-Malay, Negrito and Senoi tribes. The overall prevalence of giar-
diasis was significantly higher in males (v2 = 5.283, P = 0.022), with
similar observations seen in all tribes.
3.3. Risk factors for G. intestinalis infection
(Tables 3–6). Logistic regression analysis of the overall population
studied again confirmed that being aged less than 15 years, being
male, eating raw vegetables and the presence of other family mem-
bers infected with G. intestinalis as the risk factors for giardiasis.
Similar observations were identified in the Senoi tribe. However,
the presence of other family members infected with G. intestinalis
was the only risk factor confirmed in the Proto-Malay and Negrito
tribes.
Table 7 highlights the association of diarrhoea and other gastro-
enteritis symptoms with giardiasis. Diarrhoea was the significant
symptoms associated with giardiasis observed in all tribes, while
diarrhoea (v2 = 13.527, P < 0.001) and other gastroenteritis symp-
toms (v2 = 18.638, P < 0.001) were significantly associated with
giardiasis in the overall population studied.

Univariate analysis identified being aged less than 15 years,

being male and being a consumer of raw vegetables and fresh fruit
as the main risk factors for the overall population studied (Table 3).
In Proto-Malays, drinking untreated water, bathing and washing in
the river, indiscriminate defecation, outdoor sewage disposal and
eating raw vegetables were identified as risk factors for giardiasis
(Table 4). In Negritos, being aged less than 15 years, drinking un-
treated water, bathing and washing in the river, indiscriminate
defecation, working mothers and a household monthly income of
less than RM500 were the risk factors for G. intestinalis infection
(Table 5). In Senois, being aged less than 15 years, being male
and eating raw vegetables were the risk factors for giardiasis (Table
6). The presence of other family members infected with G. intesti-
nalis was the only risk factor that contributed to all tribes studied
4. Discussion
The prevalence rate of giardiasis among the Orang Asli in
Malaysia has remained relatively similar over the years and our
study confirmed that this infection is still a significant infection
in these communities. The overall prevalence rate of giardiasis in
this study was 20.0% and it was mostly in agreement with previous
reports from Malaysia (Al-Mekhlafi et al., 2005; Mohammed et al.,
2008). Recent studies in developing countries elsewhere have re-
ported prevalence rates of 17.7% and 27.3% (Izabella de et al.,
2011; Naelah et al., 2011). The positive cases showed a decrease
with increasing age and most of the positive cases were observed
in individuals less than 24 years old. This observation was seen
 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880 875

Table 3
Potential risk factors associated with Giardia intestinalis infection among the overall population studied (univariate analysis, n = 500).

Variables No. examined Infected (%) OR (95% CI) P-value

Age (years)
<15 221 26.7 1.45 (1.13,1.86) 0.001a,b
P15 279 14.7 1
Gender
Male 219 24.7 1.28 (1.02,1.60) 0.022a,b
Female 281 16.4 1
Drinking untreated water
Yes 209 19.7 1
No 291 20.2 1.02 (0.79,1.31) 0.892
Bathing and washing in the river
Yes 143 25.2 1.15 (0.98,1.34) 0.067
No 357 17.9 1
Not washing hands after playing with soil or gardening
Yes 197 20.4 1.02 (0.85,1.22) 0.855
No 303 19.7 1
No domestic pets
Yes 191 20.8 1.04 (0.86,1.25) 0.716
No 309 19.5 1
Indiscriminate defecation
Yes 192 20.8 1.03 (0.87,1.23) 0.713
No 308 19.5 1
Sewage disposal
Outdoor 240 19.2 1
Common drainage 260 20.8 1.05 (0.83,1.33) 0.654
Eating with hands
Yes 328 19.9 1
No 172 20.2 1.01 (0.86,1.18) 0.924
Consuming raw vegetables
Yes 238 25.6 1.45 (1.11,189) 0.002a,b
No 262 14.7 1
Eating fresh fruits
Yes 395 22.9 1.98 (1.19,3.30) 0.005a
No 105 11.2 1
Father’s education
Non-educated (<6 years) 222 27.5 1.52 (0.91,2.55) 0.095
Educated (>6 years) 78 17.9 1
Mother’s education
Non-educated (<6 years) 232 25.9 1.18 (0.71,1.96) 0.524
Educated (>6 years) 68 22.1 1
Working mothers
Yes 153 28.8 1.25 (0.93,1.68) 0.125
No 147 21.1 1
Household members
P8 171 19.9 1
<8 329 20.1 1.01 (0.74,1.37) 0.962
Household monthly income
6RM500 260 19.6 1
>RM500 240 20.4 1.03 (0.83,1.27) 0.823
Other family members infected with giardiasis
Yes 136 51.5 2.78 (2.06,3.77) <0.001a,b
No 364 8.2 1

RM = Malaysian Ringgit (US$1 = RM3.17 at 16 July 2012).

Reference group marked as Odds Ratio (OR) = 1.
CI = Confidence interval.
a
Significant association (P < 0.05).
b
Variables were confirmed by logistic regression as significant predictors of giardiasis.

in Proto-Malay, Negrito and Senoi tribes. This finding was consis-
tent with the recently published report that included a study of
all age groups (Mohammed et al., 2008). The possible reasons for
this age-specific prevalence of giardiasis are probably related to
an individual’s sanitary behaviours and their dependence on and
contact with older family members. The younger age groups of
children are more susceptible to infection as they may eat indis-
criminately or in the current study, it most likely resulted from
close contact with other family members who were infected. For
children in older age groups, exposure to infection was mostly
through the habit of playing with soil, not washing their hands be-
fore eating, as well as high levels of direct transmission of this
infection within the family from members who were carriers.
The lack of effective immunity in children has also being postu-
lated to explain this age-specific pattern. Following acute giardia-
sis, the host immune response is triggered to overcome the
876 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880

Table 4
Potential risk factors associated with Giardia intestinalis infection among the Proto-Malay tribe (univariate analysis, n = 150).

Variables No. examined Infected (%) OR (95% CI) P-value

Age (years)
<15 59 39 1.19 (0.88,1.59) 0.237
P15 91 29.7 1
Gender
Male 66 36.4 1.12 (0.82,1.53) 0.485
Female 84 31 1
Drinking untreated water
Yes 9 66.7 1.10 (1.02,1.23) 0.029a
No 141 31.2 1
Bathing and washing in the river
Yes 7 85.7 1.13 (1.01,1.25) 0.003a
No 143 30.8 1
Not washing hands after playing with soil or gardening
Yes 27 42.3 1.09 (0.92,1.29) 0.286
No 123 31.5 1

No domestic pets
Yes 30 40 1.08 (0.90,1.29) 0.386
No 120 31.7 1
Indiscriminate defecation
Yes 7 85.7 1.13 (1.01,1.25) 0.003a
No 143 30.8 1
Sewage disposal
Outdoor 21 52.4 1.15 (1.03,1.36) 0.046a
Common drainage 129 30.2 1
Eating with hands
Yes 70 37.3 1.21 (0.84,1.73) 0.299
No 80 29.3 1
Consuming raw vegetables
Yes 63 44.4 1.48 (1.05,2.08) 0.014a
No 87 25.3 1
Eating fresh fruits
Yes 129 35.7 2.13 (0.76,5.98) 0.134
No 21 19 1
Father’s education
Non-educated (<6 years) 54 38.9 1.18 (0.61,2.28) 0.625
Educated (>6 years) 27 33.3 1
Mother’s education
Non-educated (<6 years) 53 41.5 1.47 (0.74,2.92) 0.251
Educated (>6 years) 28 28.6 1
Working mothers
Yes 45 37.8 1.04 (0.63,1.73) 0.877
No 36 36.1 1
Household members
P8 32 40.6 1.10 (0.91,1.32) 0.324
<8 118 31.4 1
Household monthly income
6RM500 17 52.9 1.12 (0.97,1.29) 0.069
>RM500 133 30.8 1
Other family members infected with giardiasis
Yes 59 62.7 3.00 (1.86,4.85) <0.001a,b
No 91 14.3 1

RM = Malaysian Ringgit (US$1 = RM3.17 at 16 July 2012).

Reference group marked as Odds Ratio (OR) = 1.
CI = Confidence interval.
a
Significant association (P < 0.05).
b
Variables were confirmed by logistic regression as significant predictors of giardiasis.

infection; multiple exposures of children to this infection in the en-
demic areas will lead to the development of protective immunity
that assists in reducing the likelihood of developing subsequent
infection from future challenges (Oyerinde et al., 1977; Gilman
et al., 1985; Farthing et al., 1986; Rivera et al., 2009).
It is interesting to note that our study identified that the overall
prevalence of giardiasis was significantly higher in males than fe-
males. Similar findings were also observed in all three tribes. This
epidemiological finding has not commonly been reported before
and was inconsistent with most previous studies findings which
reported a significantly higher prevalence of giardiasis in females
than males (Norhayati et al., 1998). Eyasu et al. (2010) stated the
increased chance of exposure of females in Ethiopia to contami-
nated waters is the possible explanation as they were usually
engaged in fetching water for the family. The significantly higher
prevalence of G. intestinalis infection in males in this present study
is unexplained; males who usually have an active life outside the
house (playing or working) may get the infection through eating
 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880 877

Table 5
Potential risk factors associated with Giardia intestinalis infection among the Negrito tribe (univariate analysis, n = 139).

Variables No. examined Infected (%) OR (95% CI) P-value

Age (years)
<15 72 30.6 2.57 (1.24,5.32) 0.002a
P15 67 9 1
Gender
Male 66 24.2 1.28 (0.81,2.03) 0.252
Female 73 16.4 1
Drinking untreated water
Yes 69 27.8 2.27 (1.09,4.73) 0.009a
No 70 10 1
Bathing and washing in the river
Yes 63 31.7 2.14 (1.17,3.92) 0.002a
No 76 10.5 1
Not washing hands after playing with soil or gardening
Yes 91 22 1.26 (0.67,2.38) 0.458
No 48 16.7 1
No domestic pets
Yes 69 24.7 1.69 (0.86,3.33) 0.092
No 70 13 1
Indiscriminate defecation
Yes 91 26.4 2.28 (1.09,7.07) 0.012a
No 48 8.3 1
Sewage disposal
Outdoor 106 21.7 1.41 (0.60,3.33) 0.413
Common drainage 33 15.2 1
Eating with hands
Yes 105 20.6 1.09 (0.50,2.40) 0.823
No 34 18.8 1
Consuming raw vegetables
Yes 113 20.2 1.01 (0.42,2.45) 0.984
No 26 20 1
Eating fresh fruits
Yes 122 20.5 1.18 (0.36,3.82) 0.784
No 17 17.6 1
Father’s education
Non-educated (<6 years) 68 32.4 2.25 (0.72,7.01) 0.13
Educated (>6 years) 20 15 1
Mother’s education
Non-educated (<6 years) 77 28.6 1.06 (0.31,3.67) 0.929
Educated (>6 years) 11 27.3 1
Working mothers
Yes 33 42.4 1.59 (1.04,2.54) 0.024a
No 55 20 1
Household members
P8 63 20.6 1.03 (0.70,1.51) 0.895
<8 76 19.7 1
Household monthly income
6RM500 115 23.5 5.80 (1.09,6.31) 0.032a
>RM500 24 4.2 1
Other family members infected with giardiasis
Yes 46 47.8 3.66 (1.79,7.49) <0.001a,b
No 93 6.5 1

RM = Malaysian Ringgit (US$1 = RM3.17 at 16 July 2012).

Reference group marked as Odds Ratio (OR) = 1.
CI = Confidence interval.
a
Significant association (P < 0.05).
b
Variables were confirmed by logistic regression as significant predictors of giardiasis.

and drinking contaminated food or water outside the house or it
may be associated with increased contact with farm and pet ani-
mals and recreational water. A similar finding was observed by
Rivera et al. (2009).
To date there is only one cross-sectional community-based
study that was undertaken to determine the prevalence of giardi-
asis among different tribes of Orang Asli (Dunn, 1972). The study
was carried out in all age groups of Orang Asli and the overall
prevalence of giardiasis was reported as 11.1%; 12.4% of Proto-Ma-
lay (Temuan), 9.3% of Negrito and 5.7% of Senoi (Semelai) tribes
were infected with G. intestinalis, respectively. The overall preva-
lence of giardiasis and prevalence according to the tribes from
the study were very low compared with the present study. How-
ever, the distribution of infection between different tribes is simi-
lar; the highest prevalence was still observed in Proto-Malays
(33.3%) followed by Negritos (20.1%) and Senois (10.4%). It is
878 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880

Table 6
Potential risk factors associated with Giardia intestinalis infection among the Senoi tribe (univariate analysis, n = 211).

Variables No. examined Infected (%) OR (95% CI) P-value

Age (years)
<15 90 15.6 1.64 (1.06,2.89) 0.036a,b
P15 121 6.6 1
Gender
Male 87 16.1 1.69 (1.09,2.97) 0.024a,b
Female 124 6.5 1
Drinking untreated water
Yes 131 11.5 1.23 (0.65,2.33) 0.503
No 80 8.6 1
Bathing and washing in the river
Yes 73 13.7 1.22 (0.82,1.81) 0.258
No 138 8.7 1
Not washing hands after playing with soil or gardening
Yes 79 11.4 1.07 (0.74,1.53) 0.722
No 132 9.8 1
No domestic pets
Yes 92 10.9 1.04 (0.70,1.55) 0.853
No 119 10.1 1
Indiscriminate defecation
Yes 94 10.6 1.02 (0.68,1.52) 0.928
No 117 10.3 1
Sewage disposal
Outdoor 113 10.6 1.02 (0.63,1.66) 0.922
Common drainage 98 10.2 1
Eating with hands
Yes 153 11 1.19 (0.53,2.66) 0.699
No 58 8.9 1
Consuming raw vegetables
Yes 62 16.9 1.43 (1.01,2.19) 0.039a,b
No 149 7.5 1
Eating fresh fruits
Yes 144 12.1 1.33 (0.71,2.51) 0.343
No 67 8 1
Father’s education
Non-educated (<6 years) 100 18 2.61 (0.68,10.09) 0.118
Educated (>6 years) 31 6.5 1
Mother’s education
Non-educated (<6 years) 102 15.7 1.13 (0.44,2.89) 0.802
Educated (>6 years) 29 13.8 1
Working mothers
Yes 75 17.3 1.26 (0.67,2.38) 0.447
No 56 12.5 1
Household members
P8 76 10.5 1.01 (0.72,1.40) 0.972
<8 135 10.4 1
Household monthly income
6RM500 128 11.7 1.26 (0.67,2.39) 0.446
>RM500 83 8.4 1
Other family members infected with giardiasis
Yes 31 35.5 1.79 (1.17,2.72) <0.001a,b
No 180 6.1 1

RM = Malaysian Ringgit (US$1 = RM3.17 at 16 July 2012).

Reference group marked as Odds Ratio (OR) = 1.
CI = Confidence interval.
a
Significant association (P < 0.05).
b
Variables were confirmed by logistic regression as significant predictors of giardiasis.

interesting to note that in spite of better housing conditions and
adequate provision of basic amenities, the Proto-Malays showed
a higher prevalence of giardiasis compared with Negrito and Senoi
who experience poorer sanitary conditions. A study in Brazil re-
ported that giardiasis and soil-transmitted helminthes (STH) can
still persist and continue to infect people who have good housing
conditions and free access to public health care and education (Iza-
bella de et al., 2011). In this study, six significant variables which
included drinking untreated water, bathing and washing in the riv-
er, indiscriminate defecation, outdoor sewage disposal, eating raw
vegetables and the presence of other family members infected with
giardiasis were observed as significant risk factors in the univariate
analysis for the Proto-Malay tribe. However, these variables lost
the strength of association with only the presence of other family
members infected with giardiasis retained as a significant risk fac-
tor in the logistic regression model. Considering these findings, it is
 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880 879

Table 7
The association of diarrhoea and gastroenteritis symptoms with Giardia intestinalis infection among Proto-Malays, Negritos, Senois and the overall population studied.

Tribe/characteristics No. examined Infected (%) v2 P-value

Proto-Malay
Diarrhoea 6.66 0.010a
Yes 14 64.3
No 136 30.1
Other symptoms of gastroenteritis 3.01 0.083
Yes 72 40.3
No 78 26.9
Negrito
Diarrhoea 4.76 0.029a
Yes 11 45.5
No 128 18
Other symptoms of gastroenteritis 0.52 0.47
Yes 19 26.3
No 120 19.2
Senoi
Diarrhoea 3.98 0.046a
Yes 22 22.7
No 189 9
Other symptoms of gastroenteritis 3.54 0.06
Yes 23 21.7
No 188 9
Overall population
Diarrhoea 13.53 <0.001a
Yes 47 40.4
No 453 17.9
Other symptoms of gastroenteritis 18.64 <0.001a
Yes 114 34.2
No 386 15.8
a
Significant association (P < 0.05).

logical to postulate that there was high transmission occurring
within the family and infected family members served as a source
of infection. The infection is probably transmitted directly through
human-to-human contact. However, accidental ingestion of cysts
in drinking water or raw vegetables cannot be ruled out in this
environment where the carrier rates are high, and personal and
food hygiene levels are always compromised. Thus, screening and
treating family members, especially those aged less than 24 years
is crucial as almost 66% of infected individuals are identified in that
age group.
Logistic regression analysis of the Senoi tribe identified children
aged less than 15 years, being male, eating raw vegetables and the
presence of other family members infected with G. intestinalis as
the risk factors for giardiasis. The presence of other family mem-
bers infected with G. intestinalis was the only risk factor identified
in Proto-Malay and Negrito tribes. Individuals residing in the Pro-
to-Malay, Negrito and Senoi villages with the presence of other
family members infected with G. intestinalis were at a 10.9-fold,
12.18-fold and 13.24-fold higher risk of getting giardiasis, respec-
tively. To the best of our knowledge, there is a paucity of studies
reported on the association of presence of other family members
infected with G. intestinalis as a risk factor for giardiasis. Norhayati
et al. (1998) reported individuals with family members infected
with G. intestinalis were 3.8 times more likely to be infected com-
pared with individuals not at risk. A similar finding was also re-
ported by Chute et al. (1987). In the Senoi tribe, the logistic
regression model identified children less than 15 years old, males
and those consuming raw vegetables were at 9.65-fold, 6.05-fold
and 7.50-fold higher risk of infection with giardiasis, respectively.
Consuming raw vegetables was first reported in Malaysia as one
of the risk factor for giardiasis in the Orang Asli community by
Mohammed et al. (2008). Consuming these raw vegetables with
contaminated hands or without sufficient washing of the vegeta-
bles was postulated as an explanation of the association. Besides
screening and treating other family members infected with G.
intestinalis, health education on good personal and food hygiene
practises are highly recommended for the prevention and control
of giardiasis in the Senoi tribe.
The present study showed a significant association between
giardiasis and diarrhoea but not with other symptoms of gastroen-
teritis such as vomiting, nausea and abdominal discomfort. This
association was observed in all of the three tribes. Analysis of the
overall population studied indicated a strong association between
diarrhoea and other symptoms of gastroenteritis with giardiasis.
Similar observations have been reported previously (Mohammed
et al., 2008). Lokman et al. (2007) reported that G. intestinalis was
the most common parasite isolated in an acute diarrheal illness
outbreak caused by rotavirus in the Orang Asli community. Thus,
in the present study the cause and effect relationship was not pos-
sible to determine due to the limitation of the cross-sectional de-
sign used in this study. On the other hand, no attempt was made
to rule out other bacterial or viral causes of diarrhoea. Giardiasis
presents with a wide spectrum of clinical expression and most
infections are asymptomatic or with mild clinical features; diar-
rhoea is the most frequent symptom seen in giardiasis. Acute giar-
diasis is usually a self-limiting illness; prolonged diarrhoea with
malnutrition and growth failure in young children that is usually
seen in chronic illness have been described before (Sackey et al.,
2003; Al-Mekhlafi et al., 2005). A study by Al-Mekhlafi et al.
(2005) reported giardiasis as a strong predictor of significant wast-
ing in children of Orang Asli.
In conclusion, our findings highlight that giardiasis is still a pub-
lic health problem in Orang Asli communities and a significantly
high prevalence rate of giardiasis is observed among the Proto-Ma-
lay tribe. The presence of other family members infected with G.
intestinalis is the significant risk factor identified in all tribes. In-
fected family members served as the source of infection and direct
transmission through human-to-human contact is postulated as
the main mode of transmission. Based on these findings, we sug-
gest identifying and treating the carriers and infected individuals
880 T.S. Anuar et al. / International Journal for Parasitology 42 (2012) 871–880
within the family as the main strategy in the control and preven-
tion of giardiasis in all Orang Asli tribes. In addition, health educa-
tion pertinent to good personal and food hygiene practise may
help in reducing the prevalence of giardiasis in Orang Asli
communities.
Acknowledgements
We gratefully acknowledge the Department of Orang Asli
Development (JAKOA), Ministry of Rural and Regional Develop-
ment, Kuala Lumpur, Malaysia for granting us permission to con-
duct this research. We also thank all of the participants from
Parit Gong village, Pasu village and the RPS Air Banun area for their
commitment and contribution in providing their faecal samples.
The work presented in this paper was funded by the UKMMC
Fundamental Research Grant (FF-165-2011), Special Research Uni-
versity Grant (UKM-GUP-2011-316) and Geran Galakan Penyelidik
Muda (GGPM-2011-080) from the Universiti Kebangsaan Malaysia.
During this project, T.S.A. also received fellowship support from the
Ministry of Higher Education, Malaysia and Graduate Research
Assistantship scheme from the Universiti Kebangsaan Malaysia.
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