Original article / research
Year : 2019 Month : April Volume : 8 Issue : 2 Page : MO04 - MO07 Full Version

Intestinal Amoebiasis and Risk Factors Associated with its Transmission Among Paediatric Patients Attending a Tertiary Health Care Facility in Northern India
Sana Jamali, Saher Khan, Mohd. Parvez
1. Associate Professor, Department of Microbiology, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India. 2. Research Scholar, Department of Microbiology, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India. 3. Assistant Professor, Department of Paediatrics, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India.
 
Correspondence Address :
Sana Jamali, Saher Khan, Mohd. Parvez,
Dr. Saher Khan,
Research Scholar, Department of Microbiology, Eras Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India.
E-mail: jamalisana@yahoo.com; khansaher70@gmail.com
 
ABSTRACT
: Introduction: The occurrence of i#iEntamoeba histolyticai?i as a human intestinal parasite is a serious problem especially in developing countries. Despite the high prevalence of amoebiasis in various parts of India, unfortunately there is paucity of information with regards to the prevalence of intestinal amoebiasis in children.

Aim: To determine the prevalence of amoebiasis among children attending a tertiary care center in Lucknow and to study their socio-demographic profile.

Materials and Methods: This prospective cross-sectional study was carried out from January to June 2016, at Integral Institute of Medical Sciences and Research, Lucknow , Uttar Pradesh, India. Systemic random sampling was done to collect 185 stool samples from children aged 0-14 years before the institutional treatment. The stool samples were examined for cysts/trophozoites of i#iE. histolyticai?i using saline and iodine preparations. Statistical study of the data was done using chi-square test. The p<0.05 was taken as significant.

Results: A total of 31 of the 185 samples were positive, i.e., they contained cysts and/or trophozoites of i#iE. histolyticai?i. This study indicated that the prevalence of amoebiasis among children was 16.8% with an expected 95% confidence range of 11.4-22.2. Although, the number of males infected were more than the females, no significant association was found between prevalence and gender (?²=0.52, p=0.819). Poor hygiene was significantly associated with the children suffering from intestinal amoebiasis (p=0.021). Significant association was also observed between lower socio-economic status and prevalence of i#iE. histolyticai?i among children.

Conclusion: The present study showed that intestinal amoebiasis is a major public health problem in children particularly in younger age group. Proper and effective diagnostic techniques for the detection of i#iEntamoeba histolyticai?i and treatment of infected individuals should be encouraged and made available in hospitals and rural health centers.
Keywords : Entamoeba histolytica, Parasite, Prevalence, Socio-demographic
DOI and Others : DOI: 10.7860/NJLM/2019/41038:2342 Date of Submission: Jan 23, 2019 Date of Peer Review: Feb 12, 2019 Date of Acceptance: Feb 25, 2019 Date of Publishing: Apr 01, 2019 FINANCIAL OR OTHER COMPETING INTERESTS: None.
 
INTRODUCTION
The occurence of Entamoeba histolytica as a human intestinal parasite is a significant issue particularly in developing countries. Several species of the genus Entamoeba infect humans. These include: Entamoeba histolytica, Entamoeba dispar, Entamoeba coli, Entamoeba hartmani, Entamoeba polecki, and Entamoeba gingivalis (1). Among these, only E. histolytica is considered pathogenic and causes amoebiasis or amoebic dysentery (2).

While amoebiasis is rare in developed countries of the world yet the disease is common in the less developed and developing countries of the world. It is an important health problem, especially in developing countries (3). This condition is more prevalent in certain areas of the world including West and South-East Africa, China, the whole South-East Asia, Mexican states and western parts of South America, and also the Indian subcontinent (4). The high prevalence of E. histolytica infections is closely linked with poverty in these regions, poor environmental hygiene, poor personal hygiene, poor health service having an inadequate supply of drugs. Lack of adequate and proper awareness of the transmission mechanisms and life-cycle patterns of these parasites (5),(6),(7). Children and pregnant women are mostly vulnerable to these infections (6). Amoebiasis is the 3rd leading parasitic cause of death worldwide. It has an estimated worldwide prevalence of 500 million cases of symptomatic disease, and 40,000–110,000 deaths annually (8),(9).

Despite the high prevalence of amoebiasis in various parts of India, unfortunately there is paucity of information with regards to the prevalence of intestinal amoebiasis in children in our area. Therefore this study was designed to access the prevalence of amoebiasis among children attending a tertiary care center in Lucknow, Uttar Pradesh and to study their socio-demographic profile. The outcome of the study would provide necessary information to the health care providers for prevention and control of intestinal amoebiasis.
 
 
Material and Methods
The present prospective study was conducted in the Department of Microbiology at Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India. The study lasted over a period of six months from January to June 2016. The study was approved by the Institutional Research Committee (IRC) and the Ethical Review Committee (ERC) with registration number IIMSR/IEC/2016/11.

Children aged 0-14 years that were in and out-patients of our hospital, constituted the study population. Before the commencement of the study, written consent was obtained from parents/guardians of the children. A well pre-designed questionnaire was used to obtain a detailed clinical history and various socio-demographic details such as age, gender, place of residence and socio-economic status. Apart from hand hygiene, sanitation and domestic hygiene was taken into account to measure hygiene status of study subjects. Accompanying parents/guardians who refused to give consent for their children participation were excluded from the study. Children who had taken antiparasitic drug during the last three months were also excluded from the study. A cross-sectional survey was conducted to ascertain the prevalence of E. histolytica in the children. Sample size of 185 was calculated on the basis of a recent similar study (10).

Systemic random sampling was done to collect 185 stool samples from children before the institutional treatment. No child had history of receiving anti-protozoan drugs within the past three months. A clean, dry, screw capped, wide mouthed plastic faecal container with scoop was provided to their parents and instructed on how to collect the samples. They were advised to collect 1-2 ml of faeces on the scoop without contaminating it with urine and water and insert it, into the bottle. All the containers along with specimen were properly labelled with the respective sample number and date. These samples were transported to the laboratory as soon as received, usually within two hours after collection.

Sample Examination

All the faecal samples were first examined macroscopically for its colour, odour, presence of mucus, pus, visible parasites/segments and blood. The applicator sticks were used to test for consistency. Microscopic examination was subsequently done to examine cysts and trophozoites of E. histolytica, using normal saline and lugol’s Iodine on grease free slides. The preparation was examined microscopically for the presence of trophozoites and cysts.

Formal ether concentration technique was used to concentrate cysts in the stool samples by the force of gravity. Such technique not only increases the number of parasites in the sediment but also making them more visible by removing organic and inorganic debris (11). Stool sample was emulsified in 7 mL of 10% formal saline and was kept for 10 minutes. Then, it was passed through a wire gauge and filtrate collected in a centrifuge tube. Three milliliter of ether was added to it and the mixture was shaken vigorously for 1 min followed by centrifugation at 2000 rpm for 2 min. Then it was allowed to settle down. Debris was loosened with a stick; the upper part of the test tube was cleared of fatty debris. Supernatant fluid was decanted, leaving 1 or 2 drops. Deposit, after shaking, was poured on to a glass slide with the help of a fresh Pasteur pipette. A drop of iodine was put to aid the identification of cysts and covered with cover slip.

STATISTICAL ANALYSIS

Statistical study of the data was done using chi-square test. The p<0.05 was taken as significant.
 
 
Results
The study was conducted on 185 samples collected from paediatric patients. A total of 31 of the 185 samples were positive, i.e., they contained cysts and/or trophozoites of E. histoytica (Table/Fig 1). This study indicated that the prevalence of amoebiasis among children was 16.8% with an expected 95% confidence range of 11.4-22.2.

In the present study, out of 185 samples, 109 samples were collected from the inpatients with 17 (15.6%) positive samples and 76 were collected from outpatients with 14 (18.4%) positive samples. No significant difference was seen in proportion of E. histolytica in patients attending OPD and IPD units (p = 0.613).

Socio-demographic profile of all the study subjects was also studied. Though age-wise difference of positivity was not significant (p=0.374), the maximum number of children suffering from intestinal amoebiasis were in the age group of 5-10 years while least numbers were in the age group of under 5 years (Table/Fig 2). In our study, the number of males infected was more than the females. Presence of E. histolytica was observed to be independent of gender. No significant association was found between prevalence and gender (?²=0.52, p=0.819).

Though area-wise difference of positivity was not significant in the present study, the maximum number of positive patients was residing in rural area followed by semi urban and urban area (Table/Fig 3).

In the present study out of 185, 122 and 63 children were following poor and good hygiene practices respectively. E. histolytica was detected in 26/122 (21.3%) children with poor hygiene status whereas only 5/63 (7.9%) children with good hygiene status were found to be suffering from intestinal amoebiasis. Upon statistical analysis it was revealed that poor hygiene was significantly associated with the children harboring E. histolytica (p=0.021).

Study subjects were divided into socio-economic group on the basis of Modified BG Prasad’s Socio-economic classification system. Significant association was also observed between lower socioeconomic status and prevalence of E. histolytica among children. In the present study, most of the positive patients were from lower social class (Table/Fig 4).
 
 
Discussion
Out of total 185 stool samples examined during the study period, 31(16.8%) cases of intestinal amoebiasis were found. The prevalence of E. histolytica recorded in this study is quite higher than those observed by some other researchers. Similar study carried out in Bareilly and Vadodara districts, low prevalence rates of 2.50% and 7.9% were reported respectively (12),(13). Similarly, Aher A and Kulkarni S in the year 2011 reported prevalence rate to be 3.9% in Ahmednagar district of Maharashtra (14). Dhanabal J et al., from Chennai and Kaur R et al., from Delhi reported the prevalence rates to be 21.8% and 11% respectively, which are similar to the result of our study (15),(16). Study conducted by Bisht D et al., from Ghaziabad showed the prevalence of E. histolytica to be 20.3% (17). Prakash O et al., and Shrivastava JB et al., have also reported a high positivity rate of 35.6% and 18.4% respectively [18,19]. In another study conducted in urban slums of Lucknow, the presence of E. histolytica was found in 11.8% of the study population (20). The prevalence rates of Entamoeba histolytica exhibit wide variation between geographic areas. Prevalence of 18.6% and 11% was reported in studies carried out in Nigeria and Degema respectively (21),(22).

In our study, with respect to gender, male patients were more affected as compared to females. Males had prevalence rate of 17.20% (20/116) while females had the prevalence rate of 15.9% (11/69). This could be attributed to the fact that due to sociocultural life style of the area, boys are more likely to interact with contaminated environment (food, water, among others) than girls. Similar findings have been reported by Yasmeen M and Singh S in the year 2015 (10). Contrary to our finding, study conducted by Panda S et al., showed higher infectivity in females as compared to males (23). Another study done by Nyenke C et al., showed females (12.3%) to be more infected than males (8.8%) (22).

Among age category represented in this study, Entamoeba histolytica was more prevalent among younger age group of 5-10 years (11/48, 22.9%) followed by 10-14 years (9/55, 16.4%). Similar findings have been reported by other researchers. If the host has increased resistance, it remains healthy and therefore the parasite is either driven away or assumes a benign relationship with the host, but if the host loses the competition, a disease develops (24). Reuben CR et al., showed high prevalence of 31.0% among younger children between age group of 6-10 years whereas least level of infection was recorded among those within age groups of 11-15 and >16 years. This could be attributed to the fact that children within this younger age group are found to be playing in the soil with little or no care. They tend to be ignorant of the gains associated with general cleanliness and high level of personal hygiene. Lower rate of infestation in the older age group children could be due to the reason that they have better personal hygiene habits than younger children. They are quite matured and are conscious about the need of personal hygiene as compared to the other age (25). The reason for the low occurrence of E. histolytica in under 5 children (11/82, 13.4%) can be attributed to their innate resistance due to the induced production of secretory immunoglobulin A (sig A) that can diminish the adhesion between E. histolytica trophozoites and epithelial cells, hence reducing new infection (26).

Socio-demographic and environmental factors were also studied in children. The prevalence of intestinal parasitic infestation depends upon various factors like, hygiene, availability of clean drinking water, poverty etc., (27). Our study reflects that poor personal hygiene and low socio-economic status of the person aids in the transmission of parasite. Most of the positive patients were following low standards of personal hygiene (26/122, 21.3%) which was significantly (p=0.021) more than the subjects practicing good hygiene habits (5/63, 7.9%). Significant association was also observed between lower socio-economic status and prevalence of E. histolytica among children. In the present study, most of the positive patients were from lower social class (26/122, 21.3%). Lower income leads to poor living conditions and poor sanitary habits aggravating their wards growth and parasitic infections (28). In our study maximum number of positive patients were residing in rural area (24/129, 18.6%) that was slightly more than semi urban (5/31, 16.1%) and moderately more than the urban area (2/25, 8.0%). Though area-wise difference of positivity was not significant (p = 0.428), this could be attributed to overcrowding and poor housing in the community which are predisposing factors for the spread of the infection (29).

LIMITATION

The major limitation of this study is inadequate sample size and short study period. Therefore data obtained is not representative of the total population but only of the study respondents. Apart from these limitations, carriers harboring E. histolytica could have been missed as we conducted study only on children presenting with some complaints. In future, a similar study can be conducted with a larger sample size including asymptomatic ones, with a view to obtain data that could be generalized to the entire population.
 
 
Conclusion
The present study shows that intestinal amoebiasis is a major public health problem in children particularly in younger age group. Poor personal hygiene, rural residence and low socio-economic status are significantly associated with prevalence of Entamoeba histolytica. There is a need to promote more public health awareness programmes towards a better understanding of the source and adverse impacts of amoebiasis among children. Improvement of sanitation, provision of safe water, good toiletry habits and proper waste disposal would help in control of the disease. Proper and effective diagnostic techniques for the detection of Entamoeba histolytica and treatment of infected individuals should be encouraged and made available in hospitals and rural health centers.
 
REFERENCES
1.
Ash L, Orihel C. Atlas of human parasitology 2nd Ed. Chicago: American Society of Clinical Pathologists. 1980;22-32.
2.
Sateriale A, Huston CD. A sequential model of host cell killing and phagocytosis by Entamoeba histolytica. J parasitol Res. 2011;1:1-10.
3.
Haque R, Mondal D, Kirkpatrick BD, Akther S, Farr BM, Sack RB, et al. Epidemiologic and clinical characteristics of acute diarrhea with emphasis on Entamoeba histolytica infections in preschool children in an urban slum of Dhaka, Bangladesh. Am J Trop Med Hyg. 2003;69(4):398-405.
4.
Ravdin JL, Petri WA. Entamoeba histolytica (Amoebiasis). In: Principles and Practice of Infectious Disease, 4th Ed. Churchill Livingstone, New York. 1995;2395-98.
5.
Adeyeba OA, Akinlabi A. Intestinal parasitic infections among school children in a rural community, southwest Nigeria. Nig J Parasitol. 2002;23:11-18.
6.
Montresor A. Schistosomiasis and Intestinal Parasites Unit, WHO, Child Health Dialogue. 1998;10:9.
7.
Mbanugo JI, Onyebuchi CJ. Prevalence of intestinal parasites in Ezinifite Community in Aguata LGA of Anambra State. Nig J Parasitol. 2002;23:27-34.
8.
John CC, Salata RA. Amebiasis. In: Kliegman RM, Stanton B, St. Geme J, Schor N, Behrman RE, editors. Nelson textbook of pediatrics. Philadelphia: Saunders; 2010;1123-25.
9.
Pham Duc P, Nguyen-Viet H, Hattendorf J, Zinsstag J, Dac Cam P, Odermatt P. Risk factors for Entamoeba histolytica infection in an agricultural community in Hanam province, Vietnam. Parasit Vectors. 2011;4:102.
10.
Yasmeen M, Singh S. Study of the prevalence of intestinal parasitic infection in children of Ghaziabad. Indian J Res. 2015;4:43-45.
11.
Foreyt WJ. Diagnosis parasitology. Vet Clin North Am Small Anim Pract. 1989;19:979-1000.
12.
Rashid MK, Joshi M, Joshi HS, Fatemi K. Prevalence of intestinal parasites among school going children in Bareilly District. NJIRM. 2011;2:35-37.
13.
Lakhani SJ, Khara R, Joshi S, Vasisht S. Intestinal parasitic infestations among school children in Piparia village, Vadodara District. IJSR. 2013;2:434-36.
14.
Aher A, Kulkarni S. Prevalence of intestinal parasites in school going children in a rural community. IJBR. 2011;2:605-07.
15.
Dhanabal J, Selvadoss PP, Muthuswamy K. Comparative study of the prevalence of intestinal parasites in low socioeconomic areas from south Chennai, India J Parasitol Res. 2014;2014:630968. Available from: http://dx.doi.org/10.1155/ 2014/630968.
16.
Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK. Intestinal parasites in children with diarrhea in Delhi, India. Southeast Asian J Trop Med Publ Health. 2002;33:725-29.
17.
Bisht D, Verma A, Bhardwaj HHD. Intestinal parasitic infestation among children in a semi-urban Indian population. Trop Parasitol. 2011;1:104- 07.
18.
Prakash O, Tandon BN. Intestinal parasites with special reference to Entamoeba histolytica complex as revealed by routine concentration and cultural examination of stool samples from patient with gastrointestinal symptoms. Indian J Med Res. 1966;54:10-14.
19.
Shrivastava JB. A survey of intestinal parasites in human population in Bombay with special reference to Entamoeba histolytica. Indian J Med Res. 1977;21:29-33.
20.
Khanna A, Gupta P. Gastrointestinal disorders amongst children in urban slums of Lucknow. IJAR. 2013;3:469-470.
21.
Gimba UN, Azare AB, Alao AO. Evaluation of Entamoeba histolytica transmission rates amongst primary school children in five selected communities in Gwagwalada Area Council, Fct, Abuja, Nigeria. J Biol Agric Healthc (Online). 2014;4(27):SSN 2224-3208 (Paper) ISSN 2225-093X (Online).
22.
Nyenke C, Chukwujekwu, DC, Stanley HO, Awoibi NK. Prevalence of intestinal amoebiasis in infant and junior school children in Degema general hospital and environs. J Appl Sci Environ Manag. 2008;12:83-87.
23.
Panda S, Rao UD, Sankaram KR. Prevalence of intestinal parasitic infections among school children in rural area of Vizianagaram. Int J Pharm Biol Sci. 2012;3:42-44.
24.
Schmidt GD, Roberts LS. Introduction to Parasitology. In: Foundations of Parasitology. Eighth Edition. New York: Mc Graw-Hill Companies; 2009;767.
25.
Reuben CR, Katsa M, Hassan SC. Prevalence of intestinal amoebiasis in school age children in Lafia, Nassarawa State, Nigeria. Int Res J Biol Sci. 2013;2:42-45.
26.
Haque R, Diggal P, Ali IM, Hossaing MB, Mondal D, Sack RB. Innate and acquired resistance to amoebiasis in Banglandesh children. J Intnl Dis. 2002;186:547-52.
27.
Norhayati M, Oothuman P, Azizi O, Fatmah MS. Efficacy of single dose albendazole on the prevalence and intensity of infection of soiltransmitted helminthes in Orang Asli children in Malaysia. Southeast Asian J Trop Med Pub Health. 1998;28:563-69.
28.
Nema K, Bankwar S, Dhanvijay V, Kumar A. Intestinal parasitic infections and demographic status of school children in Bhopal region of Central India. J Pharm Biol Sci. 2014;9:83-87.
28.
Rufai AM, Awi WG. Prevalence of human gastrointestinal parasitic infections in relation to human and industrial activities in among Rumuohemi community, Rivers State. African J App Zoology Environmental Biol. 2006;8:62-66.  [Google Scholar]
 
TABLES AND FIGURES