M.Sc. Thesis. Hiwotie Mengestie. May, Haramaya University

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1 PREVALENCE OF INTESTINAL PARASITIC INFECTIONS AMONG PEOPLE WITH AND WITHOUT HIV INFECTION AND THEIR ASSOCIATION WITH DIARRHEA IN DEBRE MARKOS TOWN, EAST GOJJAM ZONE, ETHIOPIA M.Sc. Thesis Hiwotie Mengestie May, 2014 Haramaya University

2 PREVALENCE OF INTESTINAL PARASITIC INFECTIONS AMONG PEOPLE WITH AND WITHOUT HIV INFECTION AND THEIR ASSOCIATION WITH DIARRHEA IN DEBRE MARKOS TOWN, EAST GOJJAM ZONE, ETHIOPIA A Thesis Submitted to the College of the Natural and Computational Sciences, Department of Biology, School of Graduate Studies, HARAMAYA UNIVERSITY In Partial Fulfillment of the Requirements for the Degree of Master of Science in Microbiology By Hiwotie Mengestie May, 2014 Haramaya, Ethiopia

3 APPROVAL SHEET SCHOOL OF GRADUATE STUDIES HARAMAYA UNIVERSITY As research advisors, we hereby certify that we have read and evaluated the thesis prepared by HIWOTIE MENGESTIE under our guidance, which is entitled '' Prevalence of Intestinal Parasitic Infections Among People With and Without HIV Infection and Their Association With Diarrhea in Debre Markos Town, East Gojjam Zone, Ethiopia". We recommend that the thesis be accepted as fulfilling the thesis requirement. Sissay Menkir (PhD) Major Advisor Signature Date Yitbarek Getachew (PhD) Co-advisor Signature Date As members of the Board of Examiners of the M.Sc. thesis open defense examination of Hiwotie Mengestie, we certify that we have read, evaluated the thesis and examined the candidate. We recommended that the thesis be accepted as it fulfills the requirements for the Degree of Master of Science in Microbiology. Chairperson Signature Date Internal Examiner Signature Date External Examiner Signature Date ii

4 DEDICATION This work is dedicated to my beloved mother Emebet Temesgen, to my beloved sisters and brothers for nurturing me with affection and love and for their dedicated partnership in the success of my life. iii

5 STATEMENT OF THE AUTHOR First, I declare that this thesis is my own work and that all sources of materials used for the thesis work have been duly acknowledged. This thesis has been submitted to Haramaya University in partial fulfillment of the requirements for the Degree of Master of Science and is deposited at the Library of the University to be made available to borrowers under the rules and regulations of the Library. I solemnly declare that I have not submitted this thesis to any other institution anywhere for the award of any academic degree, diploma, or certificate. Brief quotations from this thesis are allowable without requiring special permission provided that an accurate acknowledgement of source is made. Requests for permission for extended quotations from or reproduction of this manuscript in whole or in part may be granted by the head of the department or the Dean of the School of Graduate Studies where in his or her judgment, the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author. Name of Author: Hiwotie Mengestie Place: Haramaya University, Haramaya Date of Submission: Signature: iv

6 BIOGRAPHICAL SKETCH The author was born on 25 November 1990 G.C in Debre Markos Town, East Gojjam Zone, Amhara Regional State. She attended her elementary and secondary school education at Nigus Tekle Haymanot ( ) and Dibza ( ), respectively in Debre Markos town. After completion of preparatory school at Debre Markos ( ), she joined Haramaya University in September 2008 G.C and graduated with Bachelor of Science in Biology in July Soon after graduation, she was recruited by the Ministry of Education in September 2011 and joined Haramaya University, College of Natural and Computational Sciences, Department of Biology in the same year to pursue her MSc. study in the field of Microbiology. v

7 ACKNOWLEDGEMENTS I express my deep sense of appreciation and heartfelt thanks to my major advisor Dr. Sissay Menkir, for his keen interest, constant supervision, valuable guidance, kindness, encouragement, and constructive criticisms from the initial stage of thesis research proposal development to the completion of the write-up of the thesis. I am also greatly indebted to my co-advisor, Dr. Yitbarek Getachew, for his valuable comments, suggestions, and support during the course of the thesis research work. I would like to thank also DMRH staff members for their encouragement, collaboration, and warm social partnership on various occasions during my study time. I am especially very thankful to Mr. Haymanot Tilahun for his kindness and sustained support throughout my study period. My thanks are extended also to Mr. Adane Tilahun and Mr. Amlaku Atalay for their wholehearted support during the thesis research work. In addition, I would like to thank Dereje Abate and Bereket Molla for their excellent assistance in data collection. I would like to express my special thanks to my intimate friends Lealem Minuyelet, Nigist Gedfie, Hanna Tarekegn, Meseret Taddese, Almaz Kahase, Kidist Abera, Marta Haile, Mimi Balachew, Lichi Solomon and Azmera W/Yohannes. I really also wish to express my deepest gratitude to my mother Emebet Temesgen who nursed me with great affection and my eldest sisters for their inestimable contribution towards the success of my life. vi

8 LIST OF ABBREVIATIONS/ACRONYMS ART CDC CSA DMRH FHAPCO FMOH HAPCO IPIs OIs OIPs SPSS UNAIDS UNICEF WHO Antiretroviral Treatment Center for Disease Control Central Statistical Agency Debre Markos Referral Hospital Federal HIV/AIDS Prevention and Control Office Federal Ministry of Health HIV/AIDS Prevention and Control Office Intestinal Parasitic Infections Opportunistic Infections Opportunistic Intestinal Parasites Statistical Package for Social Science United Nations program on HIV/AIDS United Nations International Children Emergency Fund World Health Organization vii

9 TABLE OF CONTENTS STATEMENT OF THE AUTHOR iv BIOGRAPHICAL SKETCH v ACKNOWLEDGEMENTS vi LIST OF ABBREVIATIONS/ACRONYMS vii TABLE OF CONTENTS viii LIST OF TABLES x LIST OF TABLES IN THE APPENDIX xi LIST OF FIGURE xii ABSTRACT xiii 1. INTRODUCTION 1 2. LITERATURE REVIEW Human Intestinal Parasites Intestinal protozoan parasites Intestinal helminth parasites Life Cycle of Intestinal Parasites Clinical Signs and Symptoms of Intestinal Parasitic Diseases Epidemiology and Transmission of Intestinal Parasitic Infections HIV in Ethiopia Co-infection of HIV and Intestinal Parasites Diarrhea and HIV/AIDS Diagnosis of Intestinal Parasitic Infections Prevention and Control of Intestinal Parasitic Infections Managements of Co-infection of HIV and Intestinal Parasites Emerging and Re-emerging Disease versus HIV MATERIALS AND METHODS Description of the Study Area 27 viii

10 TABLE OF CONTENT (CONTINUED) 3.2. Study Design Sampling Procedure Methods of Data Collection Collection of Stool Samples Socio-demographic Data Collection Laboratory Parasitological Examination Procedures Direct Wet Mount Technique Formol-ether Concentration Technique Modified Ziehl-Neelsen Method Data Analysis Data Quality Control Ethical Consideration RESULTS AND DISCUSSION Age and Sex Distribution of the Study Participants Prevalence of Intestinal Parasitic Infections among the Study Participants Major Intestinal Parasite Species Identified among the Study Participants Association of Intestinal Parasitic Infections with Diarrhea among the Study Patients with and without HIV Infection Association of Identified Intestinal Parasite Species with Diarrhea among the Study Patients with and without HIV Infection SUMMARY, CONCLUSION AND RECOMMENDATIONS Summary Conclusion Recommendations REFERENCES APPENDIX 55 ix

11 LIST OF TABLES Table Page 1. Age and sex distribution of the study participants among patients with and without HIV infection who visited the Debre Markos Referral Hospital during January to March, Prevalence of Intestinal Parasitic Infections among HIV positive and HIV negative patients who visited the Debre Markos Referral Hospital during January to March, Major Intestinal Parasite species identified among HIV-Positive and HIV-Negative patients who visited the Debre Markos Referral Hospital during January to March, Relationship of intestinal parasitic infections and occurrence of diarrhea among the study patients with and without HIV infection who visited the Debre Markos Referral Hospital during January to March, Relationship of identified intestinal parasite species and occurrence of diarrhea among the study patients with and without HIV infection who visited the Debre Markos Referral Hospital during January to March, x

12 Appendix Table LIST OF TABLES IN THE APPENDIX Page 1. Prevalence of Intestinal parasitic infections by residence among patients with and without HIV infection who visited the Debre Markos Referral Hospital during January to March, xi

13 LIST OF FIGURE Figure Page 1. Map of the study area 27 xii

14 PREVALENCE OF INTESTINAL PARASITIC INFECTIONS AMONG PEOPLE WITH AND WITHOUT HIV INFECTION AND THEIR ASSOCIATION WITH DIARRHEA IN DEBRE MARKOS TOWN, EAST GOJJAM ZONE, ETHIOPIA ABSTRACT Intestinal parasitic infections are major public health problems in many developing countries including Ethiopia. Intestinal parasites are endemic in many regions of the world where HIV/AIDS cases are also prevalent. The objective of this study was to assess intestinal parasitic infections among patients with and without HIV infection and their association with diarrhea in Debre Markos town, East Gojjam, Ethiopia. A descriptive survey was carriedout for three months (January-March 2013) on 384 HIV positive and negative patients who were selected using stratified random sampling technique. Stool samples of the study subjects were examined using direct wet mount technique, formol-ether concentration and Modified Ziehl- Neelsen method. Data was entered and analyzed using SPSS software. The largest proportion of the study participants was in the age group of years old (39.3%) and the proportion of the study participants was lowest in the older age groups (7.6%). The overall prevalence of intestinal parasitic infections among HIV positive patients and HIV negative patients of the study area was 60.4% and 49.5%, respectively. Major intestinal parasite species identified among HIV positive and HIV negative patients were hookworm (16.1%), E. histolytica/e. dispar (14.3%), G. lamblia (11.7%), S. stercolaris (2.6%), A. lumbricoides (2.3%), and H. nana (1.8%). C. parvum (6.2%) and I. belli (4.2%) were found only in HIV positive patients and Taenia spp.(2.1%) were found only in HIV negative patients. The prevalence of diarrhea in HIV positive patients (59.4%) was higher than HIV negative patients (54.7%). C. parvum and I. belli were highly associated with diarrhea in HIV positive patients (P=0.003 and P=0.017, respectively), whereas E. histolytica/e. dispar and G. lamblia were significantly associated with diarrhea among both HIV positive and negative patients (P<0.05). Prevalence of both diarrhea and intestinal parasites was higher in HIV positive than HIV negative patients. Intestinal parasitic infections are common health problems among HIV positive and HIV negative patients in the study area. Therefore, collaborative works with health officers and community to improve sanitation will reduce and prevent the rate of intestinal parasitic infections in the study area. Also early detection and treatment of these parasites are important to improve the health of patients. Key words: A. lumbricoides, C. parvum, E. histolytica, G. lamblia, H. nana, Hookworm, I. belli, S. stercolaris, Taenia spp. xiii

15 1. INTRODUCTION Intestinal parasitic infections are amongst the most widespread of all chronic human infections worldwide. Infections caused by intestinal parasites are widespread (Wafa, 2010). The World Health Organization (WHO) estimated that 3.5 billion people worldwide are infected with some type of intestinal parasite, and as many as 450 million of them are sick as a result. Children are most frequently infected with these parasites (Wakid, 2009). Intestinal parasitic infections are the main health problems which can cause mortality and morbidity among infected people. They are also associated with stunting of linear growth, physical weakness and low educational achievement in children (Mengistu and Berhanu, 2004). Moreover, they cause iron deficiency anemia, loss of appetite and other physical and mental problems (Amare et al., 2007). The distribution and prevalence of various species of intestinal parasites differ from region to region because of several environmental, social, and geographical factors. They spread mostly in areas with poor sanitation and are most common in tropical developing countries of African, Asian, and South American continents (CDC, 2011). They are closely associated with low household income, poor personal and environmental sanitation, overcrowding conditions, limited access to clean water, tropical climate and low latitude (Amare et al, 2007). The poor people of under-developed nations experience a cycle where under-nutrition and repeated infections lead to excess morbidity that can continue from generation to generation. People of all ages are affected by this cycle of prevalent parasitic infections, although, children are the most affected ones (Mehraj et al., 2008). Intestinal parasites are endemic in many regions of the world where HIV/AIDS case is also prevalent (Shimelis et al., 2009). The rate of infection is remarkably high in sub-saharan Africa, where the majority of human immunodeficiency virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) cases are concentrated (WHO, 2002). 1

16 Intestinal parasitic infections are caused either by protozoan or helminth parasites or both and the main clinical manifestation of the disease caused by these parasites is diarrhea (Chacon, 2003). Diarrhea, the passage of loose or watery stools at least three times in 24 hours, is one of the clinical manifestations of HIV infection and usually tends to be chronic (Kosek et al, 2003). The frequency of diarrheal and intestinal parasitic diseases in developing countries including Ethiopia is extremely high, affecting nearly all inhabitants at some point during their lives (Haileeyesus and Beyene, 2009). Among the intestinal protozoa, Giardia lamblia and Entamoeba histolytica have been associated with persistent and acute diarrhea, while Blatocystis hominis and Cryptosporidium species tend to cause marked symptoms primarily in immunocompromised hosts. The clinical course of infection with larger intestinal parasites, such as the helminths, can vary widely from asymptomatic to severe secondary complications. In Ethiopia too, the ecology of intestinal parasitism is very wide. Previous studies showed high prevalence of intestinal parasites like Ascaris lumbricoides, Entamoeba histolytica, Giardia lamblia and others in HIV positive individuals. Whereas, HIV epidemic is highly distributed throughout the country affecting the population severely with prevalence of approximately 4.4% (Moges et al., 2006). The most important intestinal parasites predominantly distributed in Ethiopia include A. lumbricoides, G. lamblia, hookworm, Hymenolepis nana, Trichuris trichiura, Enterobius vermicularis and E. histolytica/dispar; with varying prevalence in different areas (Berhanu and Girmay, 2003). Heliminthic infections are the second most predominant cause of outpatient morbidity in Ethiopia (Amare et al., 2007). It was shown that the prevalence of intestinal parasitic infection in Ethiopia is different in different parts of the country. For example, Jemaneh (1998) reported that the distribution of the three common helminths; A. lumbricoides, T. trichiura and the hookworm in school children in several communities of three altitudinal regions in Ethiopia have been shown to be different. That is, the prevalence of A. lumbricoides infection was 29% in the highlands, 35% in the temperate areas and 38% in 2

17 the lowlands. The prevalence of hookworm infection was highest in the lowlands (24%) and highland (7%) areas, while T. trichiura infection exhibited similar prevalence in all altitudinal regions (13% on the average). In addition, Mengistu and Berhanu (2004) reported that 83.8% of participants had intestinal parasites which include hookworm (60.2%), Schistosoma mansoni (21.2%), T. trichuria (14.7%), Taenia species (13.9%), E. histolytica/dispar (12.7%), A. lumbricoides (6.2%), G. lamblia (6.2%) and Strongyloides stercoralis (5.8%) from rural area close to the southeast of Lake Langano, Ethiopia. Moreover, Amare et al. (2007), in his study in Jimma, southwestern Ethiopia that T. trichiura, A. lumbricoides, E. histolytica/dispar, G. lamblia, S. stercoralis, H. nana, T. saginata, E. vermicularis and hookworm infection with prevalence of 60.9%, 40.9%, 17.1%, 13.9%, 17.5%, 2.1% 5.0%, 2.3%, 14.8% and 1.1% respectively reported. A study that was conducted in Southern Ethiopia showed low (39.6%) prevalence of intestinal parasites, where the prevalence of intestinal parasite in HIV-infected and HIV-non infected was 44.8% and 34.4%, respectively (Mohammed et al., 2003). Intestinal parasitic infection has a cosmopolitan in distribution. There has been wide distribution of intestinal parasites in Ethiopia (Amare et al., 2007). The wide distribution of intestinal parasitic infection in general is due to low level of environmental sanitation, personal hygiene, food and water contamination with human excreta and unaware of simple health promotion practices such as personal hygiene, food hygiene, effect of altitude, urbanization, irrigation, and resettlement within the country (Tekola, 2005; Kumie and Ali, 2005). In Ethiopia, most people live in low socioeconomic status. This may increase the prevalence of intestinal parasitic infections. Although several studies have been conducted on the distribution and prevalence of intestinal parasites in Ethiopia, no similar studies have been done in Debre Markos town. Therefore, the purpose of this study was to assess intestinal parasitic infection among patients with and without HIV infection and their associations with diarrhea in Debre Markos town, East Gojjam, Ethiopia. 3

18 General objective The main objective of this study was to determine the prevalence/incidence of intestinal parasitic infection among patients with and without HIV infection and their associations with diarrhea in Debre Markos Referral Hospital, Debre Markos town, East Gojjam Zone, Ethiopia. The specific objectives were: To determine the prevalence of intestinal parasitic infections among patients with and without HIV infection among different age groups and sex in the study area. To identify the major intestinal parasites in the study area. To assess the relation between intestinal parasitic infections and the occurrence of diarrhea among patients with and without HIV infection in the study area. 4

19 2. LITERATURE REVIEW 2.1. Human Intestinal Parasites Endoparasites are parasites that live in the internal organs of animal, especially in the gastrointestinal tracts of humans and other animals (Loukopoulos, 2007). Intestinal parasites can live throughout the body, but most prefer the intestinal wall (free encyclopedia, 2009). Intestinal parasites of humans are cause of important health problems in the most communities, especially those situated in tropical and subtropical area (Kia et al., 2008). They can cause significant morbidity and mortality throughout the world. At least one-third of the world's population is infected with intestinal parasites (CDC,2007). The public health importance of intestinal parasites as a major concern in most developing countries has been pronounced with the co-occurrence of malnutrition and HIV/AIDS. With HIV/AIDS pandemic, many intestinal parasites, previously considered to be sporadic or zoonotic infections, have become opportunistic parasites causing uncontrollable lifethreatening diarrhea (Wittner et al., 1993; Weiss and Keohane, 1997; Lindo et al., 1998 ). As compared to developed countries, the prevalence of opportunistic intestinal parasites is expected to be higher in developing countries among HIV infected population. These parasites cause morbidity and mortality in AIDS patients worldwide, and these outcomes would be expected to be appreciably higher in developing countries due to higher prevalence of infections in the population. (Lindo et al., 1998, Cimerman et al., 1999). 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 world's population is infected with gut parasites, which may play a role in morbidity due to intestinal infections. The commonest parasitic infections reported globally are Ascaris lumbricoides (20%), hookworm (18%), Trichuris trichuria (10%) and Entamoeba histolytica (10%) (WHO, 1987). 5

20 In severe cases the number of parasites may grow so large that the intestines become blocked. Some infections cause specific complications: amebiasis can affect the liver, lungs and brain; parasites migrating through the lungs may cause difficulty in breathing; and hookworm infection can cause anemia and malnutrition, which can affect growth and development in children (CDC, 2011). Parasitic infection can be a common event among patients with chronic gastrointestinal symptoms. Means of exposure includes, ingestion of undercooked meat, drinking contaminated water, and skin penetration (Corry et al., 2004) Intestinal protozoan parasites The protozoa are an extremely diverse group of unicellular organisms occurring in almost all of the ecological niches known to humans, including the bottom of hot springs and the edges of ice flows. Even though the majority of protozoa occur as free-living organisms in the soil, moist, marine or fresh water environments, a substantial number also exist as mutualists, commensals or parasites (Mehlhorn, 1988; Katz et al., 1989). Protozoan parasites are known to affect all species of vertebrates and many invertebrates. They are able to adapt to life in virtually all body sites of their hosts. Their characteristic high infectivity enhances their pathogenicity within the host (Katz et al.,1989; Neva and Brown 1994). Numerous protozoa inhibit the gastro-intestinal tract of humans. This list includes representatives from many diverse protozoan groups. The majority of these organisms can cause severe disease under certain circumstances (Stenzel and Boreham, 2004). Some can cause serious diseases of the respiratory tract (air passages from the nose to lungs), and the central nervous system (brain, cranial nerves and spinal cord), while others live in our intestines and cause symptoms like diarrhea and are not deadly. It is hard to protect ourselves from protozoan parasites that are in the environment, because they produce cysts. A cyst has very resistant walls that surround and protect the protozoan parasite and make it able to survive extreme environmental conditions, such as big changes in temperature and too much or too little water. This means that once a protozoan parasite cyst is in the environment it can wait a long time for the perfect chance to get inside our bodies to infect us. 6

21 Entamoeba histolytica/entamoeba dispar Infection Entamoeba histolytica infection is common in most developing countries. It is also becoming more frequent in the United States and other developed countries as the result of increasing tourism abroad and a rising number of refuges and other immigrants and non immigrants originating in endemic countries (Petri and Singh, 1999). The two species Entamoeba histolytica and Entamoeba dispar are morphologically identical but pathologically distinct (WHO, 1997; Petri and Singh, 1999). However, only E. histolytica is capable of causing disease (WHO, 1997). Colonization with E. dispar is said to be three times more common than E. histolytica in developing countries while it is ten times more common in developed nations (Petri and Singh, 1999). Entamoeba histolytica is reported to be responsible for approximately 50 million cases of invasive amoebiasis (Petri and Singh, 1999) and upwards of 100,000 deaths/year (WHO, 1997). Thus, it is ranked second only to malaria as the cause of mortality due to a protozoal infection (WHO, 1997). The parasite normally inhabits the large intestine but is also capable of invading other organs such as the liver, brain and spleen (Petri and Singh, 1999). The majority of amoebic infections are reported to occur in Central America, South America, Africa and Asia. These are often associated with poor water and food hygiene and sanitation practices (Petri and Singh, 1999). Humans are the most significant reservoir of infection even though morphologically identical amoebae have been isolated from certain domestic and wild animals (Katz et al., 1989). The life cycle of E. histolytica includes the infective cyst and the invasive trophozoite forms. Infection is acquired primarily through the ingestion of infective cyst forms present in fecally contaminated water and food. It also can be transmitted by person-to-person contact (Petri and Singh, 1999). The quadrinucleated cysts measure approximately 10-20μm in diameter and are resistant to gastric juices present in the human stomach. The amoeba excysts in the small 7

22 intestine by releasing four metacystic amoeba that divide into eight trophozoites which then move down to large intestine (Neva and Brown, 1994; Katz et al., 1989; Garica, 1999; Petri and Singh, 1999). Intestinal stasis allows the amoeba to establish a foothold in the cecal area of the large intestine even though a portion may be swept along to the sigmoid rectal region or even out of the body (Neva and Brown, 1994). The chances of establishing a foothold are improved when the volume of food intake is low and the number of parasites is high (Neva and Brown, 1994). The trophozoites measure approximately 10-60μm in size (Garica, 1999). These adhere to the colonic mucin glycoproteins via a galactose and N-acetyl-D-galactosamine specific lectin (Stanley and Reed, 2001). Host colonic cells are killed via the induction of an apoptotic cascade (Petri and Singh, 1999). Colonic lesions formed by the trophozoites vary from mucosal thickenings to characteristic flask shaped ulcerations to necrosis of the intestinal wall (Neva and Brown, 1994; Petri and Singh, 1999). The trophozoites are typically found in the periphery of the necrotized tissues. Reproduction is by binary fission or the formation of cysts. These pass out with the stool and are immediately infective (Neva and Brown, 1994). In the extra intestinal invasion no cysts are formed and trophozoites proliferate solely by binary fission (Katz et al., 1989). Asymptomatic infection with E. histolytica is defined as the presence of cysts in stools in the absence of colitis or extra intestinal infection. These healthy carriers may pass millions of cysts in the stool per day as the trophozoites multiply in the intestinal lumen (Petri and Singh, 1999; WHO, 1997; Neva and Brown, 1994). However, even asymptomatic infection is associated with a small but significantly increased risk for developing invasive amoebiasis (Petri and Singh, 1999). Clinical symptoms of acute intestinal amoebiasis include diarrhea, bloody stool that may contain necrotic mucous, abdominal pain, tenderness and fever (Petri and Singh, 1999). Symptoms of amoebic liver abscess usually involve fever, right upper abdominal tenderness/ pain, weight loss and colitis (Katz et al., 1989; Neva and Brown, 1994; Petri and Singh, 1999). 8

23 Amoebiasis infection can be controlled through proper treatment and/or disposal of raw sewage and maintaining clean water supply including the protection of open wells, springs and rivers from contamination with sewage and feces. The risk for infection can also be reduced via the adequate boiling of drinking water or treatment of water with chlorine or iodine. The exterior of raw vegetables and fruits should also be washed with soap and soaked in vinegar for 15 minutes prior to consumption (Petri and Singh, 1999). Giardia lamblia Infection G. lamblia is a pear-shaped, flagellated protozoan that causes a wide variety of gastrointestinal complaints. Giardia is arguably the most common parasite infection of humans worldwide, and the second most common in the United States after pin-worm (Katz and Taylor, 2001; Leder and Weller, 2002). Between 1992 and 1997, the Centers for Disease Control and Prevention (CDC) estimated that more than 2.5 million cases of giardiasis occur annually (Furness et al., 2000). Because giardiasis is spread by fecal-oral contamination, the prevalence is higher in populations with poor sanitation, close contact, and oral-anal sexual practices. The disease is commonly water-borne because Giardia is resistant to the chlorine levels in normal tap water and survives well in cold mountain streams. Because giardiasis frequently infects persons who spend a lot of time camping, backpacking, or hunting, it has gained the nicknames of backpacker's diarrhea and beaver fever ( Dupont and Backer, 1995). Food-borne transmission is rare but can occur with ingestion of raw or undercooked foods. Giardiasis is a zoonosis, and cross-infectivity among beaver, cattle, dogs, rodents, and bighorn sheep ensures a constant reservoir (Glaser et al., 2000). The life cycle of Giardia consists of two stages: the fecal-orally transmitted cyst and the disease-causing trophozoite. Cysts are passed in a host's feces, remaining viable in a moist environment for months. Ingestion of at least 10 to 25 cysts can cause infection in humans (Katz and Taylor, 2001; Leder and Weller, 2002). When a new host consumes a cyst, the 9

24 host's acidic stomach environment stimulates excystation. Each cyst produces two trophozoites. These trophozoites migrate to the duodenum and proximal jejunum, where they attach to the mucosal wall by means of a ventral adhesive disk and replicate by binary fission. Giardia growth in the small intestine is stimulated by bile, carbohydrates, and low oxygen tension (Procop, 2001). It can cause dyspepsia, mal-absorption, and diarrhea. A recent theory suggests that the symptoms are the result of a brush border enzyme deficiency rather than invasion of the intestinal wall (Leder and Weller, 2002). Some trophozoites transform to cysts and pass in the feces. Clinical presentations of giardiasis vary greatly. After an incubation period of one to two weeks, symptoms of gastrointestinal distress may develop, including nausea, vomiting, malaise, flatulence, cramping, diarrhea, steatorrhea, and weight loss. A history of gradual onset of a mild diarrhea helps differentiate giardiasis or other parasite infections from bacterial etiologies. Symptoms lasting two to four weeks and significant weight loss are key findings that indicate giardiasis. Chronic giardiasis may follow an acute syndrome or present without severe antecedent symptoms. Chronic signs and symptoms such as loose stool, a 10 to 20 percent loss in weight, malabsorption, malaise, fatigue, and depression may wax and wane over many months if the condition is not treated. Rarely, patients with giardiasis also present with reactive arthritis or asymmetric synovitis, usually of the lower extremities (Steiger and Weber, 2002). Rashes and urticaria may be present as part of a hypersensitivity reaction. Cyst excretion occurs intermittently in both formed and loose stools, while trophozoites are almost only found in diarrhea. Stool studies for ova and parasites (O&P) continue to be a mainstay of diagnosis despite only low to moderate sensitivity. Examination of a single stool specimen has a sensitivity of 50 to 70 percent; the sensitivity increases to 85 to 90 percent with three serial specimens (Katz and Taylor, 2001; Furness et al., 2000). Because Giardia is not invasive, eosinophilia, and peripheral or fecal leukocytosis do not occur. 10

25 Antigen assays use enzyme-linked immunosorbent assay (ELISA) or immunofluo-rescence to detect antibodies to trophozoites or cysts. Sensitivities range from 90 to 99 percent, with specificities of 95 to 100 percent compared with stool O&P (Leder and Weller, 2002). Despite the high yield of these studies, direct microscopy is still important, because multiple diarrheacausing infectious etiologies can be present simultaneously. Duodenal aspirates and biopsies give a higher yield than stool studies but are invasive and usually not necessary for diagnosis. Serology and stool cultures are generally unnecessary. Polymerase chain reaction (PCR) analysis, while only experimental, may be effective for screening water supplies (Leder and Weller, 2002). Cryptosporidiosis Cryptosporidiosis is a parasitic disease caused by Cryptosporidium, a protozoan parasite in the phylum Apicomplexa. It affects the intestines and is typically an acute short-term infection. It is spread through the fecal-oral route, often through contaminated water (CDC, 2009); the main symptom is self-limiting diarrhea in people with intact immune systems. In immuno compromised individuals, such as AIDS patients, the symptoms are particularly severe and often fatal (Chen et al., 2007). Cryptosporidium is the organism most commonly isolated in HIV positive patients presenting with diarrhea. Treatment is symptomatic, with fluid rehydration, electrolyte correction and management of any pain. Despite not being identified until 1976, it is one of the most common waterborne diseases and is found worldwide. The parasite is transmitted by environmentally hardy microbial cysts (oocysts) that, once ingested, exist in the small intestine and result in an infection of intestinal epithelial tissue. Cryptosporidiosis is typically an acute short-term infection but can become severe and nonresolving in children and immunocompromised individuals. The parasite is transmitted by environmentally hardy microbial cysts (oocysts) that, once ingested, exist in the small intestine and result in an infection of intestinal epithelial tissue. Infection is through contaminated 11

26 material such as earth, water, uncooked or cross-contaminated food that has been in contact with the feces of an infected individual or animal. Contact must then be transferred to the mouth and swallowed. It is especially prevalent amongst those in regular contact with bodies of fresh water including recreational water such as swimming pools. Other potential sources include insufficiently treated water supplies, contaminated food, or exposure to feces (CDC, 2009). The high resistance of Cryptosporidium oocysts to disinfectants such as chlorine bleach enables them to survive for long periods and still remain infective (Carpenter et al., 1999) Intestinal helminth parasites Parasitic worms, often referred to as helminthes are a division of eukaryotic parasites (Maizels and Yazdanbakhsh, 2003). They are worm-like organisms that live and feed off living hosts, receiving nourishment and protection while disrupting their hosts' nutrient absorption, causing weakness and disease (free encyclopedia, 2012). Ascariasis Ascariasis is infection with the parasitic roundworm Ascaris lumbricoides. Ascariasis is caused by consuming food or drink contaminated with roundworm eggs. Ascariasis is the most common intestinal worm infection. It is found in association with poor personal hygiene, poor sanitation, and in places where human feces are used as fertilizer (Kazura, 2007; Maguire, 2009). Once consumed, the eggs hatch and release immature roundworms called larvae within the small intestine. Within a few days, the larvae then move through the bloodstream to the lungs, exit up through the large airways of the lungs, and are swallowed back into the stomach and reach the small intestine. During movement through the lungs the larvae may produce an uncommon form of pneumonia called eosinophilic pneumonia. Once they are back in the small intestine, the larvae mature into adult roundworms. Adult worms live in the small intestine where they lay eggs that are present in feces. They can live months (Kazura, 2007; Maguire, 2009). 12

27 It is estimated that 1 billion people are infected worldwide. Ascariasis occurs in people of all ages, though children are affected more severely than adults. Most of the time, Ascariasis causes no symptoms. If there are symptoms, they may include: bloody sputum, cough, lowgrade fever, passing worms in stool, shortness of breath, skin rash, stomach pain, vomiting worms, wheezing and worms released through the nose or mouth (Kazura, 2007; Maguire, 2009). Treatment includes medications that paralyze or kill intestinal parasitic worms, such as albendazole or mebendazole. These drugs should not be used for pregnant patients. Pyrantel pamoate is the preferred medication for pregnant patients. If there is a blockage of the intestine caused by a large number of worms, endoscopy to remove the worms or, rarely, surgery may be needed. Most people recover from symptoms of the infection, even without treatment, although they may continue to carry the worms in their body. Complications may be caused by adult worms that move to certain organs such as the bile duct, pancreas, or appendix, or multiply and cause a blockage in the intestine. Improved sanitation and hygiene in developing countries will reduce the risk in those areas. In areas where this disorder is common, routine or preventive (prophylactic) treatment with deworming medications may be advised (Kazura, 2007; Maguire, 2009). Hookworm Hookworms (a type of roundworm) are another common intestinal parasite. The U.S. Centers for Disease Control (CDC) and Prevention estimates that 1 billion people worldwide have hookworm infestations, although improved sanitation has reduced the number of cases. Ancylostoma duodenale and Necator americanus Two species of hookworm, A. duodenale and N. americanus, are found exclusively in humans. A. duodenale, or Old World hookworm, is found in Europe, Africa, China, Japan, India, and the Pacific islands. N. americanus, the New World hookworm, is found in the Americas and the Caribbean, and has recently been reported in Africa, Asia, and the Pacific. Until the early 13

28 1900s, N. americanus infestation was endemic in the southern United States and was only controlled after the widespread use of modern plumbing and footwear. Even though the prevalence of these parasites has drastically decreased in the general population, the CDC reports that in the United States, hookworm infection is the second most common helminthic infection identified in stool studies (CDC, 1992). N. americanus ranges from 10 to 12 mm in length for females and 6 to 8 mm for males. It is distinguished from its slightly larger European cousin by its semilunar dorsal and ventral cutting plates at the buccal cavity compared with A. duodenale's two pairs of ventral cutting teeth. The eggs of both worms are 60 to 70μm in length and bounded by an ovoid transparent hyaline membrane; they contain two to eight cell divisions. Both species share a common life cycle. Eggs hatch into rhabditiform larvae, feed on bacteria in soil, and molt into the infective filariform larvae. Enabled by moist climates and poor hygiene, filariform larvae enter their hosts through pores, hair follicles, and even intact skin. Maturing larvae travel through the circulation system until they reach alveolar capillaries. Breaking into lung parenchyma, the larvae climb the bronchial tree and are swallowed with secretions. Six weeks after the initial infection, mature worms have attached to the wall of the small intestine to feed, and egg production begins. While larvae occasionally cause pruritic erythema or pulmonary symptoms during their migration to the gut (Kitchen, 1999), hookworm infection rarely is symptomatic until a significant intestinal worm burden is established. A transient gastroenteritis-like syndrome can occur because mature worms attach to the intestinal mucosa. The greatest concern from infection is blood loss. Aided by an organic anticoagulant, a hookworm consumes about 0.25 ml of host blood per day. The blood loss caused by hookworms can produce a microcytic hypochromic anemia (Ali-Ahmad et al., 2000). Compensatory volume expansion contributes to hypoproteinemia, edema, pica, and wasting. The infection may result in physical and mental retardation in children. Eosinophilia has been noted in 30 to 60 percent of infected patients. While clinical history, hygiene status, and recent travel to endemic areas can give important clues, definitive diagnosis rests on microscopic visualization of eggs in the stool. 14

29 Enterobius vermicularis E. vermicularis, commonly referred to as the pinworm or threadworm, is a nematode, or roundworm, with the largest geographic range of any helminthes (Neva and Brown, 1994). It is the most prevalent nematode in the United States. Humans are the only known host, and about 209 million persons worldwide are infected. More than 30 percent of children worldwide are infected (Goldmann and Wilson, 1997). Adult worms are quite small; the males measure 2 to 5 mm, and the females measure 8 to 13 mm. The worms live primarily in the cecum of the large intestine, from which the gravid female migrates at night to lay up to 15,000 eggs on the perineum. The eggs can be spread by the fecal-oral route to the original host and new hosts. Eggs on the host's perineum can spread to other persons in the house, possibly resulting in an entire family becoming infected. Ingested eggs hatch in the duodenum, and larvae mature during their migration to the large intestine. Fortunately, most eggs desiccate within 72 hours. In the absence of host autoinfection, infestation usually lasts only four to six weeks. Disease secondary to E. vermicularis is relatively innocuous, with egg deposition causing perianal, and vaginal irritation (Macpherson, 1999). The patient's constant itching in an attempt to relieve irritation can lead to potentially debilitating sleep disturbance. Rarely, more serious disease can result, including weight loss, urinary tract infection, and appendicitis (Saxena et al., 2001; Dickson et al., 2003). Pinworm infection should be suspected in children who exhibit perianal pruritus and nocturnal restlessness. Direct visualization of the adult worm or microscopic detection of eggs confirms the diagnosis, but only 5 percent of infected persons have eggs in their stool. The cellophane tape test can serve as a quick way to clinch the diagnosis (Parija et al., 2001; Procop, 2001). Strongyloidiasis Strongyloidiasis is a human parasitic disease caused by the nematode (roundworm) Strongyloides stercoralis, or sometimes Strongyloides fülleborni. It can cause a number of 15

30 symptoms in people, principally skin symptoms, abdominal pain, diarrhea and weight loss. In some people, particularly those who require corticosteroids or other immunosuppressive medication, Strongyloides can cause a hyperinfection syndrome that can lead to death if untreated. The diagnosis is made by blood and stool tests. The drug ivermectin is widely used in the treatment of strongyloidiasis. It is thought to affect million people worldwide, mainly in tropical and subtropical countries. Worldwide efforts are aimed at eradicating the infection in high-risk groups. Strongyloidiasis was first described in France in Strongyloides infection occurs in five forms. On acquiring the infection, there may be respiratory symptoms. The infection may then become chronic with mainly digestive symptoms. On re infection (when larvae migrate through the body), there may be respiratory, skin and digestive symptoms. Finally, the hyperinfection syndrome causes symptoms in many organ systems, including the central nervous system (Montes et al., 2010; Marcos et al., 2008). Gastrointestinal system symptoms include abdominal pain and diarrhea. Pulmonary symptoms can occur during pulmonary migration of the filariform larvae. Dermatologic manifestations include urticarial rashes in the buttocks and waist areas. Blood eosinophilia is generally present. Strongyloidiasis can become chronic and then become completely asymptomatic. Disseminated strongyloidiasis occurs when patients with chronic strongyloidiasis become immunosuppressed. It presents with abdominal pain, distension, shock, pulmonary and neurologic complications and septicemia, and is potentially fatal. The worms enter the bloodstream from the bowel wall, simultaneously allowing entry of bowel bacteria such as Escherichia coli. This may cause symptoms such as sepsis (bloodstream infection), and the bacteria may spread to other organs where they may cause localized infection such as meningitis (Graeff et al., 2009) Life Cycle of Intestinal Parasites Intestines of human mostly infected by two types of parasites protozoa and helminthes. The mature cysts of protozoa are infective forms of the parasites and enter into man through contaminated food and drinking water, the cyst enter into the elementary canal pass unaltered 16

31 through the stomach (cyst wall is not dissolved by the action of gastric juice), and then reach the large and small intestines, where each cyst liberates a single protozoan parasites active motile called trophziotes. The trophziotes (vegetative form) cause distortion and necrosis of the intestinal surface, sometime enter into the deeper layer, some might reach the liver, as in the case of Entamoeba hitolytica (Maiti, 1995). Several helminthes have direct life cycle and relatively involving one host species and a brief period of development of an infective stage, an example pinworm (Enterobius vermicularis), in others the life cycle involves essential Introduction development in one or more intermediate hosts as in the filarial worms and Diphyllobothrium latum. In general, all nematodes undergo similar stage in their development, the egg mature into a larva that passes through four larval stages then to the immature adult (juveniles). Many nematodes have free living stage outside the host, and thus differ from trematodes and cestodes (Neva and Brawn.1994). Cestodes life cycle with exception of H. nana the common tape worms of man require one or more intermediate host, the larva form develops in the intermediate host following ingestion of the ovum and the adult worm is in the definitive host. In most cestodes there is fairly high degree of species selectivity in both intermediate and definitive host for instance the final host for T. solium is man and the intermediate host is a hog, and for T.saginata man and cattle respectively; complete development usually fails to take place in other species. Trematodes have a rather complicated life cycle in two or more hosts consisting of three or more generations constituting different larval stages to reach adult stage. The first larva is called miracidium, the next three stages named sporocyst, redia and cercaria respectively, occures in the snails and the final infective stage, the metacercaria in Tetmatodes other than schistosomes where cercaria is the infective stage, is found in mollusk or on vegetation or in fish or crustacean (Raza and Sami, 2009). 17

32 2.3. Clinical Signs and Symptoms of Intestinal Parasitic Diseases Intestinal parasites can cause different signs and symptoms in patients. A list of common symptoms include: abdominal pain, central nervous system impairment, chest pain, chills, chronic fatigue, colitis, coughing, diarrhea, digestive disturbance, fever, enlargement of various organs, headaches, jaundice, joint pain, weight loss due to malnutrition, weakness, immunodeficiency, nausea/vomiting, swelling of facial features, sweating, insomnia, skin ulcers, rectal prolapse, mental problems, lung congestion, memory loss, night sweats, muscle spasms and hair loss or thinning. In some people, intestinal worms do not cause any symptoms, or the symptoms may come and go. If you have some of these symptoms, it does not necessarily mean that you are infected. These symptoms are also indicative to other diseases. Common signs and complaints include coughing, cramping, abdominal pain, bloating, flatulence and diarrhea. Some parasites also cause low red blood cell count (anemia), and some travel from the lungs to the intestine, or from the intestine to the lungs and other parts of the body. Many other conditions can result in these symptoms, so laboratory tests are necessary to determine their cause. In children, irritability and restlessness are commonly reported by parents (Dariel, 2007) Epidemiology and Transmission of Intestinal Parasitic Infections The high prevalence of intestinal parasitic infections in developing countries is mainly due to deficiency of sanitary facilities, unsafe human waste disposal system, inadequacy and lack of safe water supply, and low socioeconomic status (Ali et al., 1999).Immigrants may also be partially responsible for spreading intestinal parasites among the local population (Musiageer and Gregory, 1990).Low educational standards and overcrowded living conditions have an effects on the distribution of human intestinal parasites. Geographical distribution of intestinal parasites is influenced by the requirements of suitable hosts being present in sufficient 18

33 numbers, as well as the need for favorable external environmental conditions like animal and insects, soil, irrigation sewage, rainfall, humidity, and temperature. Virulence of intestinal parasitic infection of human being may be related to several human factors such as, age, sex, occupation, defecation, and habitats. Intestinal parasites are spread when fecal matter bits of feces get into the mouth. This can be happening through contaminated food or water, oral and anal sex play or non-sexual intimate contact, such as diaper changing. They may also penetrate the body through the skin or if contaminated soil is ingested accidentally. Other parasites live in animals, such as pigs and cows. People can become infested with these by eating undercooked meat or drinking unpasteurized milk. Parasites can also spread when a person eats contaminated food (such as unwashed raw fruits or vegetables, which can carry parasites from the soil or from people who have handled them) or drinks water contaminated by feces. Swimming in contaminated water also may result in infestation by certain parasites. Parasitic intestinal infestations often occur in outbreaks, when several people have symptoms at the same time. This is especially likely if many people come into contact with the same supply of contaminated food or water (CDC, 2011) HIV in Ethiopia It has now been three decades since the AIDS pandemic had been noticed. According to the UNAIDS report at the end of 2009 there were 33.2 million people living with HIV/AIDS globally.during the same year 2.5 million infections and 2.1 million deaths have also occurred. Of the global total 22.5 million living with AIDS 1.7 million new infections and 1.6 million deaths were in sub-saharan Africa (UNAIDS/WHO, 2007). Ethiopia is not spared from this epidemic.the country is one of the three Sub-Saharan countries that have the highest number of HIV infected persons The federal HIV/AIDS prevention and control office (HAPCO) in conjunction with international and local partners made single point estimate for adult HIV prevalence in Ethiopia. Accordingly the adult HIV infection prevalence was estimated at 2.1% and this figure is used in all planning exercises 19

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