Coinfection with malaria, hookworm and schistosomiasis among school children in zambezi distric

Medical Journal of Zambia, Vol. 39, No. 4 (2012) Coinfection with Malaria, Hookworm and
Schistosomiasis among School Children in Zambezi:
A School-based Rapid Survey
David G. Rutagwera , Thorkild Tylleskär .
1Paediatrics Department, School of Medicine, University of Zambia PO Box 50223 Lusaka 2Centre for International Health, Faculty of Medicine and Dentistry, University of Bergen Postboks7804 N-5020 Bergen ABSTRACT
improvement activities in the School Health Nutrition programme is urgently needed to reduce morbidity and Introduction: A school based rapid survey was conducted
accelerate the reduction in the prevalence of parasitic from the 17 to the 19 of May 2011in Zambezi District of Zambia to determine the prevalence and coinfection rate of malaria, hookworm and schistosomiasis in INTRODUCTION
schoolchildren in other to inform decision maker. The wide and overlapping distribution of parasites in Methodology: The study design, sampling methods,
Africa often results in high co-infection rates of these sample collection and processing used have been parasites . Factors influencing this phenomenon, also described in WHO's guidelines for the evaluation of soil- known as multiparasitism include high frequencies of transmitted helminthiasis and schistosomiasis at parasites in the same population, similar geographical community level. Additionally height, weight and distribution of parasites, shared risk factors, common haemoglobin were measured and malaria screened.
transmission methods and genetic and immunological Results: We report high prevalence of parasitic infections
in schoolchildren in Zambezi district with 79.4% (n = malaria and helminthes is largely determined by climate , 253; 95% CI: 74.1% - 84.1%) of the children tested poverty, environmental contamination, water bodies, and positive at least to one parasitic infection. Estimated lack of effective preventative measures . Since several prevalence of malaria, hookworm, haematuria, S. parasites are endemic in Zambia and the above mentioned haematobium, S. mansoni, and E. vermicularis were predictors of multiparasitism are common in most parts 50.6% (95% CI: 44.5-56.6%), 42.4% (95% CI: 36.4- of the country, it is plausible that some individuals in 48.5%), 37.9% (95% CI: 32.2-43.9%), 29.5% (95% CI: Zambia may be infected with two or more parasites. 24.2-35.2%), 14.5% (95% CI: 10.6-19.2%), and 1.2% Therefore understanding the distribution of (95% CI: 0.3-3.2%) respectively. Generally these were multiparasitism may help explain parasitic burden and low intensity infections with the exception of S. morbidities such as anaemia in Zambian communities.
haematobium. High prevalence of anaemia (46%; Because differences in the age pattern distributions 95%CI: 40-52.1) and nutritional deficiency (79.1%; 73.9- coinfection and co-morbidity of malaria and helminthes 83.7) were also detected. The prevalence of may be had to relate. At young age, when malaria is so multiparasitism was 44.3% (95%CI: 38.2-50.4%) intense, helminth infections are generally infrequent and representing 55.7% of all parasitic infections. relatively of light intensity [9]. In school-aged children Conclusion and recommendations: There is high
where helminth infections are intense, severe malaria is prevalence and wide distribution of malaria, hookworm rare while mild malaria episodes do occur but at lower and schistosomiasis resulting in high coinfection rates incidence in area of high malaria transmission with these parasites in schoolchildren in Zambezi District. Studies are needed to understand the public health Key words: Malaria, Hookworm, S. haematobium, S. mansoni,
importance of this coinfection in the Zambian context. and E. vermicularis, haemoglobin, anaemia, haematuria, Nevertheless integration of anti malaria and iron status Medical Journal of Zambia, Vol. 39, No. 4 (2012) Asymptomatic malaria infections are however common RESULTS AND DISCUSSION
in this age group . Malaria and hookworms are also common in pregnant women . Thus, it is among school- Population characteristics
aged children and pregnant women that helminth and A total of 263 children 53.2% of which were females malaria co-infection is likely to be found. Therefore, this were enrolled into this study. All children provided study seeks to determine the co-infection rate of malaria, samples for malaria screening and haemoglobin hookworm and schistosomiasis in a population of measurement while 8 children and 2 children failed to schoolchildren in Zambia's Zambezi District who are provide stool and urine samples respectively. Selected exposed to malaria, hookworm and schistosomiasis. schools were Chilenga, Kawumbu, Lwantembu East, Lwitadi, and Mapachi which contributed 19%, 20.2%, 21.3%, 19% and 20.5% of the study population Study design and population
respectively. Study participants were aged 7 to 19 years old, with a mean age of 11.8 (n=263, SD=2.6) years and This was a school based rapid survey conducted from the were all born and only lived in areas around the schools in 17 to the 19 of May 2011. The study design and which they were recruited from. The mean Body mass sampling methods used have been described in WHO's index was 17.2 (n=263, SD=2.0) while the mean guidelines for the evaluation of soil-transmitted Haemoglobin concentration was 12.1 (n=263, SD=1.56) helminthiasis (STH) and schistosomiasis at community level and have been used extensively by others Prevalence of parasites, anaemia and underweight
Additionally height and weight were measured and children
capillary blood was collected by finger prick to screen for malaria and measure haemoglobin. HemoCue blood We report high prevalence of parasitic infections in hemoglobin photometer (HemoCue AB, Angelholm, Zambezi district with 79.4% (n = 253; 95% CI: 74.1% - Sweden) was used to measure haemoglobin while 10% 84.1%) of schoolchildren harboring at least one parasite. Geimsa stain was used to stain malaria slide and transfer Malaria, hookworm, Schistosoma haematobium, them to the University Teaching Hospital, parasitology Schistosoma mansoni and Enterobius vermicularis were detected in our study population. Ascaris lumbricoides and Trichiura trichuris were not detected probably due to Data collection and analysis
low population density in rural areas and the factor that A. lumbricoides and T. trichuris are typically restricted to Lab results were recorded on lab forms while participant's equatorial regions . (See Table 1on next page) characteristics were collected using and individual questionnaire. Data was entered in an excel sheet and Helminth intensity was interestingly generally low with Statistical analysis was performed using IBM SPSS the majority of hookworm (95.4%), S. mansoni (56%), Statistics 20. A wealth index based on sum of household and S. haematobium (61%) infections being light assets was constructed and prevalence was estimated as infections according to WHO classification . However has been described in WHO's guidelines . Chi square the 39% heavy S. haematobium infections translate into tests were used to test differences between groups. Since an overall prevalence rate of 11.5% (95%CI: 8.0-15.8%) missing data was very low (0-4.2%), all children were which classifies the district as category one (high prevalence, high intensity) on the WHO classification of communities for anti-helminthiasis treatment . Malaria Ethical consideration
intensity was also low with 99.2% of cases having less Good Clinical Practice principles were strictly followed than 500 malaria parasites per µl of blood. in the course of this study. Ethical approval was obtained The prevalence of detected parasitic infections and from the University of Zambia's Biomedical Research coinfections did not differ significantly by age and sex Ethics Committee. Approval was also obtained from the with the exception of S. mansoni (P=0.021), anaemia University of Zambia, School of Medicine research (P<0.001) and underweight (P<0.001) which differed forum, Ministry of Health, Ministry of Education and significantly across age groups. Only malaria (P=0.001), District Education Board Secretary office. Written anaemia (P=0.007) and haematuria (P=0.003) differed informed consent forms were obtained from guardians of significantly across socioeconomic status quintiles while pupils during school hours (school heads) as commonly Hookworm (P=0.005), S. mansoni (P<0.001), S. Medical Journal of Zambia, Vol. 39, No. 4 (2012) Table 1: Prevalence of single and multiple infections
Like many other studies [1, 17, 18], multiparasitism was common in Zambezi Prevalence of single and multiple infections Prevalence
95% CI (%)
schoolchildren harboring 2 or more parasites and 55.7% (95%CI: 48.8-62.4%) Single infections
number of parasites found in a child was 3 found in 13% (95%CI: 9.3-17.6%) of the infected children. About 90% of this triple w i t h m a l a r i a , h o o k w o r m a n d Co -infections
caused three quarters (¾) of all malaria, h o o k w o r m a n d s c h i s t o s o m i a s i s coinfections while the remaining quarter (¼) was due to coinfection with malaria, Malaria -S. haematobium -enterobius hookworm and S. mansoni. Double and triple coinfections were detected in all Hookworm -S. haematobiu m -S. mansoni schools and their prevalence in schools did not differ significantly suggesting a wide multiparasitism in Zambezi District as has Malaria and helminth multiparasitism has been studied in several places but results from these studies are often conflicting Number of infections per child
21, 22 and as such difficult to generalize. Studies are therefore needed to highlight However, because Zambezi District is classified as a high prevalence high Conditions
intensity community, there is urgent need malaria reservoir is also needed. Helminth schoolchildren. With an overall malaria and gametocytes prevalence of 50.6% (95%CI: 44.5-56.6%) and 4.9% (95%CI: 2.8-8.1%) haematobium (P<0.001), malaria (P<0.001), anaemia respectfully, schoolchildren are also an important active (P<0.001) and haematuria (P<0.001) differed human reservoir of malaria parasite in Zambezi District significantly in schools. Hookworm, S. haematobium and providing a continuous source of malaria parasites to malaria were detected in all schools indicating a wide and mosquitoes. Therefore integration of helminth and overlapping distribution of these parasites in Zambezi malaria control programmes would benefit both District. On the other hand, S. mansoni was detected in 3 programmes. Such integrated packages have already of the 5 schools and most of its infections (81.1%) were in been described and have shown to be efficient and cost one school, indicating a focal distribution of S. mansoni in consolidation of the school health and nutrition programme to include Provision of intermittent Medical Journal of Zambia, Vol. 39, No. 4 (2012) Table 2: Prevalence of several variables by age and sex
<0.001
<0.001
* : Linear by linear ÷2 P value **: Continuity corrected ÷2 P value Table 3: Prevalence of several variables by socioeconomic status
Prevalence by socioeconomic status quintiles Medical Journal of Zambia, Vol. 39, No. 4 (2012) Table 4: Prevalence of several variables by school (location)
<0.001
<0.001
<0.00
<0.00
<0.00
ACKNOLEDGMENTS
treated nets (LLINs), health education for prevention and We gratefully acknowledge the contribution of the study prompt malaria treatment and regular treatment with team, schoolchildren, teachers, parents, the District Education Board Secretary's office and the Zambezi Due to financial constraints, the study only collected one District commissioner's office during sample collection stool and one urine sample from each participant instead of collecting several successive samples. This could have resulted in under detection of helminthes as egg shedding REFERENCES
in helminthes is not constant. Another source of potential underreporting of helminthes is egg hatching before microscopy particularly in hookworms and S. Multiparasite communities in animals and humans: haematobium. To minimize this helminth microscopy structure and pathogenic significance. Int J was done on site soon after sample collection. Using microscopy to screen for malaria may also result in Cox, F.E.G. 2001. Concomitant infections, parasites underreporting but the factor that we used very and immune responses. Parasitology 122(suppl.): S experience technicians minimized the effect this would have on our estimation. Because of our study was Ellis, M.K., G. Laso, Y.S. Li, Z. Rong, H.G. Chen, localized and population restricted, extrapolating results and D.P. McMnus. 2007. Familial aggregation of to other districts or other sub population groups may not human susceptibility to co- and multiple helminth infections in a population from the Poyang lake region, China. Int J Parasitol 37; 1153-1161 CONCLUSION AND RECOMMENDATION
Brooker S. and E. Michael. 2000. The potential of geographical information systems and remote Malaria, hookworm and schistosomiasis occur in high sensing in epidemiology and control of human frequencies but mainly in low intensity among helminth infections. Advances in parasitology 47: schoolchildren in Zambezi district. The majority of infections detected were multiparasitic in nature and up to three parasites were found in a child. Therefore there is Booth M. 2006. The role of residential location in need to include intermittent malaria treatment, provision apparent helminth and malaria infection. Trends of mosquito nets and deworming in the School Health and Nutrition program in Zambezi district to supplement Bundy, D.A., and G.F. Medley. 1992. Immuno- deworming. Further research is also needed to determine the effect of multiparasitism on parasitic morbidity in the ecologicaland immunological determinant of worm burden. Parasitology 104(suppl): S 105-119 Medical Journal of Zambia, Vol. 39, No. 4 (2012) World Health Organization. 2002. The prevention 16. Brooker S., A.C. Clements, P.J. Hotez, S.I. Hay, A.J. and control of schistosomiasis and soil transmitted Tatem, D.A. Bundy, and R.W. Snow. 2006. The co- helminthiasis. Report of a WHO Expert Committee. distribution of Plasmodium falciparum and Geneva, WHO Technical Report Series No.912 hookworm among African schoolchildren. Malaria Carneiro I., A. Roca-Feltrer, J. T. Griffin, L. Smith, 17. Stoll, N.R. 1947. This wormy world. J Parasitol 33: M.Tanner, J. A. Schellenberg, B. Greenwood, and D. Schellenberg. 2010. Age-Patterns of Malaria Vary 18. King, C.H and A.m. bertino. 2008. Asymmetries of with Severity, Transmission Intensity and poverty: why global burden of disease valuations Seasonality in Sub-Saharan Africa: A Systematic significantly underestimate the burden of neglected Review and Pooled Analysis. PLoS ONE 5(2): tropical diseases. PLoS Negl Trop Dis 2: e209.
19. Brooker S., W. Akhwale, R. Pullan, B. Estambale, S. Brooker S., N. Peshu, P. A. Warn, M. Mosobo, H. L. E. Clark, R. W. Snow and P.J. Hotez,. 2007. Guyatt, K. Mash, and R. W. Snow. 1999. The epidemiology of hookworm infection and its infection in Africa: Population at risk, potential contribution to anaemia pre-school children on the impact on aneamia and prospects for combining Kenyan coast. Transactions of the Royal Society, of control. Am J Trop Med Hyg 77 (6): 88-89.
Tropical Medicine and Hygiene 93: 240-246.
20. Su, Z., M. Segura, K. Morgan, J. C. Loredo-Osti and 10. Mungwi T. W., A. Ross, R. W. Snow, and K. Marsh. M. M. Stevenson. 2005. Impairement of protective 2005. Case definitions of clinical malaria under immunity to blood stage malaria by concurrent different transmission conditions in Kilifi district, nematode infection. Infection and Immunity 73: Kenya. Journal of infectious Diseases 191: 1932- 21. Ezeamama A. E., S.T. McGarvey, L. P. Acosta, S. 11. Kimbi H. K., N. W. Awah, K. J. Ndamukong, and J. Zierler, D. L. Manalo, H. Wu, D. J. Kurtis, V. Mor, V. Mbuh. 2005. Malaria infection and its M. R. Olveda, and F. J. Friedman. 2008. The consequences in school children. East African synergistic effect of concomitant Schistosomiasis, Hookworm and Tricuris infections on childrens 12. Shulman C. E., E. K. Dorman, F. Cutts, K. Anemia burden. PLos Negl Trop Dis 2(6): e 245. Kawuondo, J. N. Bulmer, N. Peshu, and K. Marsh. 22. Mupfasoni D., B. Karibushi, A. Koukounari, E. 1999. Intermittent sulphadoxine-pyrimethamine to Ruberanziza, T. Kaberuka, et al. 2009. Polyparasite prevent severe anaemia secondary to malaria in Helminth Infections and Their Association to pregnancy: a randomized placebo-controlled trial. Anaemia and Undernutrition in Northern Rwanda. P L o S N e g l T r o p D i s 3 ( 9 ) : 13. Montresor, A., D.W.T. Crompton, A. Hall, and D.A.P. Bundy. 1998. Guidelines for the evaluation 23. Hotez, P.J., D.H. Molyneux, A. Fenwick, J. o f s o i l - t r a n s m i t t e d h e l m i n t h i a s i s a n d Kumaresan, S. Ehrlich Sachs, and J.D. Sachs. 2006. schistosomiasis at community level. A guide for Incorporating a rapid impact-package for neglected managers of control programmes. Geneva: World tropical diseases with programs for HIV/AIDS, Health Organization. WHO/CTD/SIP/98.1 Tuberculosis and Malaria. PLoS Medicine 3 (5): 14. Sturrock H. J. W., P. W. Gething, A. C. A. Clements and S. Booker. 2010. Optimal survey designs for 24. World Health Organization. 2006. Preventative targeting chemotherapy against soil-transmitted chemotherapy in human helminthiasis, coordinated helminths: effect of spatial heterogeneity and cost use of anti helminthic drugs in control interventions: efficiency of sampling. Am. J. Trop. Hyg. 86 (6): a manual for health professionals and programme 15. Standley, J. C., M. Adrico, M. Alinaitwe, F. Kazibwe, 25. Midzi, N., S. Mtapuri-Zinyowera, D. Sangweme, et N. B. Kabatereine, and J. R. Stothard. 2009. al. 2011. Efficacy of integrated school based Intestinal schistosomiasis and soil-transmitted deworming and prompt malaria treatment on helminthiasis in Ugandan school children: a rapid helminths –Plasmodium falciparum co-infections. mapping assessment. Geospatial Health 4(1): 39- BMC International Health and Human Rights 11:9.

Source: http://www.mjz.co.zm/sites/default/files/journals/4.%20COINFECTION%20WITH%20MALARIA,%20HOOKWORM%20AND%20SCHISTOSOMIASIS%20AMONG%20SCHOOL%20CHILDREN%20IN%20ZAMBEZI%20DISTRIC.pdf