Prevalence of intestinal parasitic infections in children under the age of 5 years attending the Debre Birhan referral hospital, North Shoa, Ethiopia
Zemene and Shiferaw BMC Res Notes
Prevalence of intestinal parasitic infections in children under the age of 5 years attending the Debre Birhan referral hospital, North Shoa, Ethiopia
Telanesh Zemene 0
Melashu Balew Shiferaw 0
0 Parasitology Reference Laboratory, Amhara Public Health Institute , P.O. Box 641, Bahir Dar , Ethiopia
Objective: Intestinal parasitic infection is one of the major childhood health problems in developing countries. In Ethiopia, epidemiological data for several localities is limited. Hence, the aim of this study is to assess intestinal parasitic infections among under-five children attending in Debre Birhan referral hospital, which could help to decrease morbidity and mortality in children. A cross-sectional study was conducted in February, 2014. Stool specimens were collected and examined using concentration method. Results: Out of the 247 under-five children participated, 17.4% (95% CI 12.7-22.1%) of the children were infected with at least one or more protozoa parasites (14.2% [95% CI 9.9-18.5%]) and helminthes (3.2% [95% CI 1.0-5.4%]). Giardia lamblia (8.5%), Entamoeba histolytica/dispar (5.7%), Trichuris trichiura (1.6%) and Ascaris lumbricoides (1.2%) were the most identified parasites. Parasitic infection was higher in children who had source of drinking water from the river (36.8%), among children from mothers with poor hand washing practice (31.7%), and among children born from illiterate mothers (27.5%). This revealed that intestinal parasites affect the health of under-five children in the setting. Hence, improving environmental hygiene and inadequate water sanitation, and health education for behavioral changes to personal hygiene would be crucial for effective control of the parasite infections.
Parasite; Protozoa; Helminth; Under-five children; Debre Birhan
Intestinal parasitic infection is one of the major
childhood health problems in developing countries.
According to the world health organization, over 270 million
pre-school and over 600 million of school children live in
areas where the parasites are intensively transmitted [
The disease is most prevalent among the lower social
groups and in children whose parents are farmers that
are likely to come in contact with the contaminated soil.
This practice encourages the transmission of the parasites
through penetration of the infective larvae present in the
soil, and through direct or indirect fecal-oral
]. Despite there are availability of chemotherapy
and control measures, intestinal nematode infections
rank among the most wide spread of soil transmitted
intestinal parasites [
]. Younger children are predisposed
to heavy infections with intestinal parasites because of
having not fully developed immune systems and also
habitually they play in fecal contaminated soil [
Inadequate water sanitation and hygiene are
responsible for a major proportion of the burden of disease and
death. Intestinal parasitic agents increase in polluted
environments such as refuse heaps, gutters and swage
units in and around human dwelling and living
conditions of the people in crowded or unhealthy situation [
The symptoms of parasitic infection include
anemia, asthma, diarrhea, digestive disorders, fatigue, low
immune system, nervousness and skin rash. Apart from
causing morbidity and mortality, infections with
intestinal parasites have been associated with stunting, physical
weakness, low education achievements, poor
reproductive health, and low economic development [
Furthermore, chronic intestinal parasitic infections have
become the subject of speculation and investigation in
relation to the spreading and severity of other infectious
diseases such as human immunodeficiency virus (HIV)
and leprosy .
In Ethiopia, intestinal parasites are widely distributed.
Most of the intestinal parasites such as A. lumbricoides
and T. trichiura showed wider distribution [
study done in North West Ethiopia showed higher
prevalence of H. nana (13.8%), E. histolytica/dispar (9.2%) and
A. lumbricoides (5.9%) . The problem is more severe in
the region as evidenced by a study done in Delgi
Ethiopia that showed very high prevalence of A. lumbricoides
(48%), G. lamblia (41.9%), E. histolytica/dispar (27.3%), S.
mansoni (15.9%), and Hookworm (11.5%) [
]. In Jimma
Ethiopia 26.3% of S. mansoni prevalence was documented
]. Another study conducted in Eastern part of
Ethiopia also found nine species of intestinal helminths with
an overall prevalence of 27.2% [
]. However, there are
still several localities for which epidemiological
information is not available including the study area. Moreover,
under-5 years of age children are more prone to intestinal
parasites because of the low immunity they have in this
stage that needs special care and follow up [
Therefore, the objective of this study was to assess the
prevalence of intestinal parasitic infections among under-five
children in Debre Birhan. This could help health planners
to overcome the existing limitations and decrease the
mortality in under-five children.
Study area, population and study subjects
A cross-sectional study design was conducted among
under-five children in Debre Birhan town, February 2014.
Debre Birhan is situated at an altitude of 2840 m above
sea level with mean annual temperature that ranges
from 10 to 16 °C. The population of the town is 81,775.
All under-five children who came to the Debre Birhan
referral hospital during the study period for medication
were included because of more prone to intestinal
parasites as a result low immunity they have in this stage that
needs special care and follow up. Serious health problem
and use of antihelminthic drugs within 1 month before
screening were used as exclusion criteria from the study.
However, there was no child excluded since we did not
find children with these conditions. The sample size was
determined using single population proportion formula
based on the following assumptions: 17.3% prevalence
of intestinal parasites among under 5 years children in
Gondar, Ethiopia [
], 95% confidence interval and 5%
marginal error, and by adding 10% compositions for the
non-response rate. Hence, a total of 247 study
participants were included in this study and selected
consecutively based on the arrival of their hospital visit.
Data collection and laboratory diagnosis
Data of socio-demographic and possible risk factors were
collected by two trained data collectors using structured
questionnaire from the parents or guardians of the
children. The questionnaire was developed by the authors of
this study (Additional file 1). It was pretested at nearby
health center (Debre Birhan Health Center) on 5% of
samples calculated to include in this study (twelve
underfive children) to improve the quality of data collection
tool. After the pretest, the questionnaire was modified
and corrected to make more appropriate tool for the
data collection. Moreover, expert review was included
in the development of the instrument to align with the
theoretical framework guiding the study. After the
pretest and expert inputs, the tool was modified for proper
Stool specimens, one for each study participant, were
collected from the children using clean plastic
containers. Microscopic examination was performed using
Olympus microscope (CX21FS1, Olympus Corporation,
Philippines) as soon as the specimen was collected. A
combination of direct microscopy and the formol-ether
concentration technique were used to detect the
presence of ova, larvae, trophozoite, and cyst of parasites.
Briefly, an estimated 1 g of faeces was emulsified using
applicator stick in about 4 mL of 10% formol-saline
contained in a screw-cap tube. A further 3–4 mL of 10% v/v
formol-saline was added to the tube and mixed well and
sieved. The sieved suspension was collected in a beaker.
The suspension was transferred to a conical (centrifuge)
tube. About 4 mL of diethyl ether was added to the
conical tube, mixed for 1 min, and centrifuged at 3000 rpm
for 1 min. After centrifuging, the tube was inverted to
discard the ether, faecal debris, and formol water. The
sediment was re-suspended and transferred to a slide,
and covered with a cover glass. Finally, the preparation
was examined microscopically using the 10× and/or
40× objectives [
]. Well experienced laboratory
technologists who worked in Debre Birhan referral hospital
did the stool specimen diagnosis. To ensure the quality
of the investigation, the two readers read the slides
independently and their readings were compared. Discordant
were immediately resolved with discussion of each other
and in consultation with the investigators.
Data were entered and analyzed using statistical package
for social sciences (SPSS) version 20. Summary statistics
(frequencies, proportions) in the form of tables, texts and
figures were used to express the findings. The Pierson
Chi square and related P values were used to check the
presence of association between dependent and
independent variables. P < 0.05 was considered as significant
This study was reviewed and approved by the
Ethical Review Committee of Haramaya University. Official
permission was obtained from Debre Birhan referral
hospital. Written informed consent was obtained from
the parents/guardians of the children. Those children
who were positive for intestinal parasites were linked to
the clinicians from Debre Birhan referral hospital to be
treated. Data were confidential and used only for the
purpose of this study.
A total of 247 children were selected for investigation.
Of these, 129 (52.2%) were females and 101 (40.9%) were
between age group 3–5 years. Children from mothers
with illiterate, primary and, secondary and above
education level were accounted 69 (27.9%), 96 (38.9%) and 82
(33.2%), respectively. One hundred two (41.3%) children
were from families having monthly income between 1000
and 2000 Ethiopian Birr (Table 1).
Parasitic infections and associated factors
Among the 247 children participated in this study, 43
(17.4% [95% CI 12.7–22.1%]) children were infected
with at least one or more parasites. Protozoa parasites,
35 (14.2% [95% CI 9.9–18.5%]), were the most dominant
parasitic infections among the children. G. lamblia and
E. histolytica were the pathogenic protozoan parasites
found with a prevalence of 21 (8.5% [95% CI 5.0–8.0%])
and 14 (5.7% [95% CI 2.8–8.6%]), respectively. Eight
(3.2% [95% CI 1.0–5.4%]) children were infected with
helminth parasite(s). Double infection (G. lamblia and E.
histolytica) was found in only five children. The
distribution of identified parasites among under-five children is
described in Fig. 1.
About 32% of the children with poor hand washing
practice had significantly higher parasitic infections (X2:
17.5, 95% CI 26.2–37.8%, P < 0.001). Those who had no
nail trimming (28.3%) were more infected (X2: 13.6, [95%
CI 22.7–33.9%, P < 0.001). Similarly, 27.5% of the
children born from illiterate mothers were highly infected
(X2: 7.0, 95% CI 21.9–33.1%, P 0.03). Drinking water from
river source was rated as the highest associated risk with
36.8% of parasitic infections (X2: 6.5, [95% CI 30.8–42.8%,
P 0.039) (Table 2).
Intestinal parasites are one of the leading causes of death
among children in the developing countries. Hence,
adequate information about the prevailing state is an
important epidemiological tool in evaluating existing
or new intervention programs [
]. In this study, the
overall prevalence of intestinal parasitic infection was
17.3%. This is in line with findings from Gondar Ethiopia
(17.3%) and from Tanzania (15.1%) [
]. The finding
is lower as compared to studies done in Wondo Genet
(85.1%) , in Yergalem hospital (49.5%) [
], and in
Kenya (25.6%) [
]. This variation could be due to
different geographical distribution of the parasites, timeline
and implementation of different prevention and control
measures. However, the finding of our study is still higher
according to the national safe environment strategy in
the extension program in Ethiopia.
Pathogenic protozoa infections are known to cause
diseases in children [
]. The transmission of these
parasites occurs by ingestion of cysts through the fecal–oral
route, either directly, via person to person contact or
indirectly, via contamination of surface water or food [
]. In the present study, G. lamblia was the
predominant protozoan parasite with a prevalence of 8.5%. This
causes malaise, abdominal cramps, weakness, weight
loss, distention, and flatulence. Children are more liable
to massive infection with severe clinical manifestations
]. The more chronic stage is associated with vitamin
B12 mal-absorption, disaccharides deficiency and
lactose intolerance [
]. This study also found that E.
histolytica was the second prevalent (5.7%) protozoan parasite
among the study participants. The organism may invade
the liver, lung and brain where it produces abscesses that
result in liver dysfunction, pneumonitis, and encephalitis
]. The highest prevalence of protozoa parasites could
be due to contaminated water as this study has shown
that significantly higher parasitic infections (36.8%) were
found among under-five children who drank water from
Public health interventions such as the provision of
clean water, community health education, observation of
food hygiene, and maintenance of functioning sanitation
systems are fundamental to long-term intestinal
parasite control [
]. In this study, about 32% of the parasitic
infection of the children was due to poor hand washing
practice of mothers. This problem is also reported in
University of Gondar community school [
under-five children born from illiterate mothers were
more infected (27.5%). Similarly, nail hygiene and
educational level of mothers were closely associated with the
prevalence of intestinal infections [
]. All these
evidences have shown that there should be effective
implementation of intervention activities to control the spread
of intestinal parasitic infections in the setting.
This study revealed that intestinal parasite infections,
especially protozoan parasites, were prevalent that affect
the health of under-five children in the setting. Although
these findings are limited to one hospital, it may
represent the population of the area because of the wide
range of health service provision in the hospital. Hence,
improving environmental hygiene and inadequate water
sanitation, and health education for behavioral changes
to personal hygiene would be crucial for effective control
of intestinal parasitic infections.
As limitation, only stool concentration method was used
because of budget shortage that restricted us not to use
more advanced methods like Kato-Katz, Harada Mori
and Baermann techniques that may hide the true
burden of intestinal parasitic infections. Children are only
recruited within a single month, and there may be
seasonal fluctuations of the prevalence of intestinal parasite
in the study area.
Additional file 1. Questionnaire.
CI: confidence interval; HIV: human immunodeficiency virus; X2: Chi square.
TZ designed the study, collected the data, analyzed the data, and drafted and
wrote the paper. MBS analyzed the data, drafted the manuscript and wrote
the paper. Both authors read and approved the final manuscript.
The authors acknowledge parents/guardians of the study participants. We also
acknowledge laboratory staff and the management of Debre Birhan referral
hospital for the cooperation to carry out this study.
The authors declare that they have no competing interests.
Availability of data and materials
All data supporting these findings is contained within the manuscript.
Consent to publish
Not applicable. This manuscript does not contain any individual persons’ data.
Ethics approval and consent to participate
This study was reviewed and approved by the Ethical Review Committee of
Haramaya University. Official permission was obtained from Debre Birhan
referral hospital. Written informed consent was obtained from the parents/
guardians of the children. Those children who were positive for intestinal
parasites were linked to the clinicians from Debre Birhan referral hospital to be
treated. Data were confidential and used only for the purpose of this study.
The authors do not receive specific support or funding to report.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
1. UNICEF. The state of the world's children , 2008 . https://www.unicef.org/ sowc08/docs/sowc08.pdf. Accessed 10 Aug 2017 .
2. WHO. Soil-transmitted helminthiases: eliminating as public health problem soil-transmitted helminthiases in children: progress report 2001-2010 and strategic plan 2011-2020 . http://apps.who.int/iris/bitstr eam/10665/44804/1/9789241503129_eng. pdf. Accessed 1 Sept 2017 .
3. WHO. Soil-transmitted helminthiasis: number of children treated 2007-2008: update on the 2010 global target . Wkly Epidemiol Rec . 2010 ; 85 : 141 - 8 . http://www.who.int/wer/2010/wer8516.pdf?ua= 1 .
4. Osman M , El Safadi D , Cian A , Benamrouz S , Nourrisson C , Poirier P , et al. Prevalence and risk factors for intestinal protozoan infections with Cryptosporidium, Giardia, Blastocystis and Dientamoeba among schoolchildren in Tripoli, Lebanon . PLoS Negl Trop Dis . 2016 ; 10 ( 3 ):e0004496. https://doi.org/10.1371/journal.pntd. 0004496 .
5. Shrestha A , Narayan KC , Sharma R . Prevalence of intestinal parasitosis among school children in Baglung districts of Western Nepal . Kathmandu Univ Med J . 2012 ; 10 ( 37 ): 3 - 6 .
6. Heidari A , Rokni MB . Prevalence of intestinal parasites among children in day-care centers in Damghan-Iran . Iran J Public Health . 2003 ; 32 ( 1 ): 31 - 4 .
7. Uhuo AC , Odikamnoro OO , Ani OC . The incidence of intestinal nematodes in primary school children in Ezza North Local Government Area, Ebonyi State Nigeria . Adv Appl Sci Res . 2011 ; 2 ( 5 ): 257 - 62 .
8. Gelaw A , Anagaw B , Nigussie B , Silesh B , Yirga A , Alem M , Endris M , Gelaw B . Prevalence of intestinal parasitic infections and risk factors among schoolchildren at the University of Gondar Community School, Northwest Ethiopia: a cross-sectional study . BMC Public Health . 2013 ; 5 ( 13 ): 304 .
9. Ayalew A , Debebe T , Alemayehu W. Prevalence and risk factors of intestinal parasites among Delgi school children North Gondar, Ethiopia . J Parasitol Vector Biol . 2011 ; 3 ( 5 ): 75 - 81 .
10. Mengistu M. Prevalence of schistosoma mansoni and other intestinal parasites among individuals living nearby three rivers of Jimma town and the risk factors involved . http://etd.aau.edu.et/handle/123456789/2974. Accessed 10 Aug 2017 .
11. Tadesse G. The prevalence of intestinal helminthic infections and associated risk factors among school children in Babile town, eastern Ethiopia . Ethiop J Health Dev . 2005 ; 19 ( 2 ): 140 - 7 .
12. Valiathan R , Ashman M , Asthana D. Effects of ageing on the immune system: infants to elderly . Scand J Immunol . 2016 ; 83 : 255 - 66 .
13. Aleka Y , G/egziabher S, Tamir W , Birhane M , Alemu A . Prevalence and associated risk factors of intestinal parasitic infection among under five children in University of Gondar Hospital, Gondar. Northwest Ethiopia. Biomed Res Ther . 2015 ; 2 ( 8 ): 347 - 53 .
14. Cheesbrough M. District Laboratory practice in tropical countries, part 1 . 2nd ed. New York: Cambridge University Press; 2006 .
15. Achi EC , Njoku OO , Nnachi AU , Efunshile AM , Mbah JO , Aghanya IN , Nnemelu PO . Prevalence of intestinal parasitic infections among under five children in Abakaliki local government area of Ebonyi state . EJPMR . 2017 ; 4 ( 04 ): 218 - 22 .
16. Vargas M , Gascon J , Casals C , Schellenberg D , Urassa H , Kahigwa E , Ruiz J , Vila J . Etiology of diarrhea in children less than five years of age in Ifakara, Tanzania . Am J Trop Med Hyg . 2004 ; 70 ( 5 ): 536 - 9 .
17. Nyantekyi LA , Legesse M , Belay M , Tadesse K , Manaye K , Macias C , Erko B . Intestinal parasitic infections among under-five children and maternal awareness about the infections in Shesha Kekele, Wondo Genet , Southern Ethiopia. Ethiop J Health Dev . 2010 ; 24 ( 3 ): 185 - 90 .
18. Firdu T , Abunna F , Girma M. Intestinal protozoal parasites in diarrheal children and associated risk factors at Yirgalem Hospital, Ethiopia: a case-control study . Int Sch Res Not . 2014 . https://doi.org/10.1155/ 2014 /357126.
19. Mbae CK , Nokes DJ , Mulinge E , Nyambura J , Waruru A , Kariuki S. Intestinal parasitic infections in children presenting with diarrhoea in outpatient and inpatient settings in an informal settlement of Nairobi, Kenya . BMC Infect Dis . 2013 ; 27 ( 13 ): 243 .
20. Tinuade O , John O , Saheed O , Oyeku O , Fidelis N , Olabisi D. Parasitic etiology of childhood diarrhea . Indian J Pediatr . 2006 ; 73 ( 12 ): 1081 - 4 .
21. Cox FEG . Modern parasitology: a textbook of parasitology . 2nd ed. New York: UK Blackwell Science Ltd; 2009 . http://onlinelibrary.wiley.com/ doi/10.1002/9781444313963.fmatter/pdf.
22. Stoker AR , Simon GL , Hotez PJ , Tsuji M. Medical parasitology . Austin: Landes Bioscience; 2009 .
23. WHO Expert Committee . Prevention and control of schistosomiasis and soil-transmitted helminthiasis . World Health Organ Tech Rep Ser . 2002 ; 912 (i-vi): 1 - 57 .
24. Harhay MO . Epidemiology and control of human gastrointestinal parasites in children . Expert Rev Anti Infect Ther . 2010 ; 8 ( 2 ): 219 - 34 .