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Journal of Tropical Diseases & Public Health
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Prevalence of Intestinal Parasitic Infections and Related Risk Factors among Street Dwellers in Addis Ababa, Ethiopia

Banchiamlak Mekonnen1, Berhanu Erko2 and Mengistu Legesse2*

1Amhara Regional Health Office, Bahir Dar, Ethiopia

2Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia

*Corresponding Author:
Mengistu Legesse
Aklilu Lemma Institute of Pathobiology
Addis Ababa University
P.O. Box, 1176, Addis Ababa, Ethiopia
Tel: 251112763091
Fax: 251112755296
E-mail: [email protected]

Received Date: January 31, 2014; Accepted Date: March 05, 2014; Published Date: March 07, 2014

Citation: Banchiamlak Mekonnen, Berhanu Erko and Mengistu Legesse (2014) Prevalence of Intestinal Parasitic Infections and Related Risk Factors among Street Dwellers in Addis Ababa, Ethiopia. J Trop Dis 2:132. doi: 10.4172/2329-891X.1000132

Copyright: © 2013 Mekonnen, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Epidemiological information on the prevalence of various intestinal parasitic infections in different sectors of the society and localities is very important to develop appropriate control strategies. Many studies have been conducted to determine the prevalence of intestinal parasitic infections in Ethiopia. However, studies pertaining to the prevalence of intestinal parasitic infections among the street dwellers are limited. Therefore, the aim of this study was to determine the prevalence of intestinal parasites and associated risk factors among street dwellers in Addis Ababa. Method: A cross-sectional parasitological survey was conducted among street dwellers in Addis Ababa, between October 2012 and March 2013. Fresh stool samples were collected from the participants and processed by direct microscopy, concentration, and Kato-Katz thick smear methods. The participants were also interviewed about knowledge of intestinal parasites and risk factors for intestinal parasitic infections using structured questionnaire. Results: A total of 355 participants, 312 (87.89%) males and 43 (12.11%) females participated in the study. The mean age of the study participants was 28.4+12.4 years (age ranged from 4 to 75 years). Nine species of intestinal parasites were identified with an overall prevalence of 71.8%. The most prevalent parasites were Ascaris lumbricoides (34.9%), Trichuris trichiura (22.8%), Giardia lamblia (9.6%) and Entamoeba histolytica/dispar (8.2%). Two thirds (67.1%) of the participants responded that they had no adequate information about intestinal parasites. Consumption of leftover fruit was significantly associated with high prevalence of intestinal parasitic infections (adjusted odds ratio= 2.9, 95% CI; 1.02, 8.22). Conclusion: The study revealed high prevalence of intestinal parasitic infections in street dwellers in Addis Ababa. Thus, any community-based intervention program of intestinal parasites should consider these segments of population, since they contribute to the source of intestinal parasitic infections for the community.

Keywords

Intestinal parasites; Street dwellers; Ethiopia

Abbreviations

WHO: World Health Organization; FMoH: Federal Ministry of Health; NTD: Neglected Tropical Disease; UNICEF: United Nations Children's Fund; UNECA: United Nations Economic Commission for Africa; IRB: Institutional Review Board; ALPB: Aklilu Lemma Institute of Pathobiology; SD: Standard Deviation

Background

Intestinal parasites cause considerable morbidity and mortality, especially in developing countries [1,2]. However, they are more prevalent among people who have less access to health care services and socio-economic problems. According to World Health Organization (WHO) prevention and control of intestinal parasitic infections constitute several activities including universal or selective deworming of population groups that are at risk of developing morbidity and chronic diseases, improving environmental sanitation, personal hygiene, food and water hygiene and appropriate health education [3]. The use of water and soap or similar agents is critical for effective removal of parasite ova/cysts from contaminated hands. However, the use of soap is determined by economic and logistic factors, and also by the perception of what is dirty and what is not [4].

Homelessness/street dwellers are an increasing problem worldwide. Approximately, there are about 500 million people in the world who are homeless. Homeless people are highly affected by low socio- economic conditions, poor personal and environmental hygiene, and have limited access to clean water. The health problems of the homeless people are broad and they are at high risk for acute and chronic medical illnesses [2-5]. Homeless people have poor access to healthcare services [6], and those who visit health facilities may also encounter problems such as denial of treatment by providers due to their financial problem, neglect of service providers for services, and an inappropriate service-delivery time for them [7]. Study also suggests that homeless persons are marginalized group of people who cannot access conventional health care services due to the financial and time constraints linked to their livelihoods [8]. Hence, they remain as reservoir for infectious diseases transmission even in countries where there is an effective disease control.

Although the Ethiopian government has been working to change the life style of street dwellers, the number of street dwellers has been increasing in Addis Ababa because of different reasons like individuals migration to this city from different regions of the country for job opportunity, family, social or health problems. The street dwellers sleep on streets, around bus stations, parks, open spaces, religious centers, construction sites, around graveyards, and other public places. Although it is uncertain to get the exact number of street dwellers in Addis Ababa, it is estimated at more than 100,000 (https://www.irinnews.org).

In Ethiopia, as in many other sub-Saharan African countries, parasitic infections are widely distributed and affect various segments of the population [9-12]. However, there is little information on the prevalence of intestinal parasites among street dwellers [13]. At present, the Federal Ministry of Health (FMoH) of Ethiopia has prioritized intestinal parasitic infection as one of the Neglected Tropical Diseases (NTDs) in the National Master Plan of NTDs, and planned to develop a sustainable well integrated nation-wide surveillance, operational research and control program that would enable the country to address the public health problems due to NTDs [14]. In an effort to contribute to the control of intestinal parasitic infections, we conducted this study to provide data on the prevalence of intestinal parasites in street dwelling individuals in Addis Ababa, Ethiopia.

Materials and Methods

Study population and setting

Between October 2012 and March 2013, a cross-sectional parasitological survey was conducted in street dwellers in Addis Ababa, the capital city of Ethiopia. The number of population in Addis Ababa has increased rapidly since people migrate to the City from different regions of the country for job opportunity. According to UNICEF estimation, there are more than 100,000 street dwellers in Addis Ababa (https://www.irinnews.org) [15]. The City also hosts international institutions such as the headquarters of the United Nations Economic Commission for Africa (UNECA) and numerous other continental and international organizations. However, basic facilities such as housing, safe drinking water, toilet services, energy and sanitation/appropriate solid waste disposal services are still incompatible with the need of the people of Addis Ababa. According to the 2007 national census, 98.64% of the housing units of Addis Ababa had access to safe drinking water, while 14.9% had flush toilets, 70.7% pit toilets and 14.3% had no toilet facilities [16]. In the city, around 70 public toilets are available to those who do not have domestic toilet facilities. However, the public toilets are not evenly distributed in the City and most of them are not accessible to the inhabitants. Thus, all available vacant spaces within the City (green areas, road sides and riverbanks) are common defecation sites especially for street dwellers.

Sample size estimation, data collection and examination

The sample size was estimated using a single population proportion formula with 95% confidence, assuming an overall prevalence of 67% for parasitic infections among the target study population [13] 5% of margin of error and 10% non-response rate. Thus, a total of 374 participants (age 2 years and above, who had no mental problem, who were volunteers to participate and give their consent and children who had guardians/parents) were estimated to be included in the study.

Pre-survey visit was made to see the place, the number of street dwellers in selected areas and the convenient time for data collection. Then, all the street dwellers who were living in the selected areas were approached to participate in the study until the required sample size was obtained. After the aim of the survey was explained to each participant/guardian, the participants were interviewed about intestinal parasites, types of toilets utilization, source of drinking water, source of food and feeding habit using pre-tested structured questionnaire. In case of children younger than 15 years, their parents/guardians were interviewed. Information on socio-demographic characteristics of the individuals was also included in the questionnaire. Following the interview, each participant and/or guardian was instructed on how to provide a stool sample and a coded plastic sheet was distributed to provide fresh stool sample on the next morning. The samples were transported to laboratory under a cold condition on the same morning and a portion of the stool was preserved in 10% formalin, while the rest was processed by direct and Kato-Katz thick smear methods as previously described [17]. The direct wet mount of stool was examined for the presence of eggs and motile trophozoites under light microscope, while the Kato-Katz thick smear and concentration methods were used for detection of helminth eggs and protozoan cysts [18].

Ethical Consideration

The study was conducted after obtaining ethical approval from the Institutional Review Board (IRB) of the Aklilu Lemma Institute of Pathobiology (ALIPB), Addis Ababa University. Verbal consent was obtained from each study participant/parent. Participants were also informed that all personal information is treated strictly confidential. Study participants found positive for intestinal parasites were treated for free using standard drugs by nurse.

Data Analysis

Data was computerized using Epi Data version 3.1 and analyzed using SPSS version 21.0. Different variables were summarized using frequency tables. Association between the dependent and independent variables were assessed using logistic regression analyses. Results were considered to be statistically significant when p-value was less than 0.05.

Results

Socio-demographic Characteristics of the Study Participants

A total of 355 participants (87.9% males and 12.1% females) provided stool samples. The mean age of the study participants was 28.4 (SD=12.4) years (age ranged from 4 to 75 years). A considerable number of the study participants (76.9%) were illiterate. When asked what factors led them to become street dwellers, the majority of the participants (64.1%) mentioned that they migrated from rural to Addis Ababa in search of job opportunity and about 40.3% have been living on the street for more than two years (Table 1).

Characteristics   Number (%)
Sex Male 312 (87.9)
Female 43 (12.1)
Age group (year) <20 72 (20.9)
  20-29 142 (40.0)
   30-39 87 (24.5)
  >39 54 (15.2)
Ethnicity    Amhara
Oromo
Guragie
Tigrie
148 (42.2)
113 (32.2)
46 (13.1)
44 (12.5)
Educational level Illiterate
primary
secondary
269 (76.9)
62 (17.7)
19 (5.4)
Factors that led to street dwelling Poverty  associated 
Substance abuse associated
Pear pressure associated   
Divorce and family related problems
Pregnancy associated
Educational problem
223 (62.8)
85 (24.0)
12 (3.4)
11 (3.1)
11 (3.1)
6 (1.7)
Duration as street dweller For a month
For a year
For two years
For more than two years
13 (3.7)
73 (20.7)
124 (35.2)
142 (40.3)

Table 1: Socio- demographic characteristics of the study participants

Parasite species Prevalence of infection (%)
Protozoa Entamoeba histolytica /dispar 29 (8.2)
Giardia lamblia 34 (9.6)
Helminths Ascaris lumbricoides 124 (34.9)
Trichuris trichiura 81 (22.8)
Taenia species 62 (17.5)
Strongyloides stercoralis 19 (5.4)
Hymenolepis nana 14 (3.9)
Hookworms 6 (1.7)
Enterobius vermicularis 4 (1.1)
Over all prevalence 255 (71.8)

Table 2: Prevalence of intestinal parasitic infections and species among the study participants

Table 3 shows prevalence of parasitic infections by age groups, duration of stay and stool consistence among the study participants. The prevalence of intestinal parasitic infections was higher (76.4%) among children younger than 20 years though it was not statistically significant. Similarly, the prevalence of infections was higher among illiterates (73.6%) than among primary (69.4%) and secondary (63.3%) schools completed individuals. Relatively higher prevalence was also observed among street dwellers who lived on the street for short durations (77.0%) compared to among individuals who lived on the street for more than two years (68.0%).

Characteristics Number (%) of study participants  Number (%) positive for any parasite
Age gropu (year)
<20
20-29
30-39
+40
72 (20.2)
142 (40.0)
87 (24.5)
54 (15.2)
55 (76.4)
100 (70.6)
64 (73.6)
36 (66.7)
Educational status Illiterate
primary
secondary
269 (76.9)
62 (17.7)
19 (5.4)
198 (73.6)
43 (69.4)
12 (63.2)
Durations  as street dweller
For a month
For a year
For two years
More than two years
13 (3.7)
73 (20.7)
124 (35.2)
142 (40.3)
10 (77.0)
51 (69.9)
95 (76.6)
97 (68.0)

Table 3: Prevalence of intestinal parasitic infections among the study participants by age groups, duration of stay as street dweller

Intestinal parasitic infections and related risk factors

The prevalence of intestinal parasitic infections was higher among individuals who had domestic animals (82.4%) compared to those who had no domestic animals (71.7%). The prevalence of intestinal parasitic infections (83.0%) was also higher among street dwellers who get their food source from individual houses compared to those individuals who get their food from hotels (71.7%). A higher prevalence was also observed among individuals who didn’t have hand washing habit (72.4%) than others (Table 4).

Risk  factors  Frequency (%) Prevalence of intestinal parasites n (%)
 Having domestic animals
Have no domestic animals
17 (4.8)
318 (89.6)
14 (82.4)
288 (71.7)
Source of water
Public tap
Private tap
89 (26.3)
249 (73.1)
70 (78.7)
174 (69.9)
Type of latrine  
Near the shelter
Common latrine
Private latrine
17 (5.0)
130 (38.5)
191 (56.5)
13 (76.5)
95 (73.1)
136 (71.2)
Hand washing habit before meal
Yes     
56 (15.8) 38 (67.0)
 No 272 (76.6) 198 (73.0)
Habit of cut  nails
Yes
54 (15.2) 37 (68.5)
No  276 (77.7) 200 (72.5)
Source of food
From hotel
From individuals house
Mixed ( from hotel, house, garbage)

254 (71.6)
41 (11.6)
41 (11.6)

182 (71.7)
34 (83.0)
27 (66.0)

Table 4: Prevalence of intestinal parasitic infections in relation to different risk factors among study participants

Knowledge of the study participants about intestinal parasitic infections

Knowledge of the study participants about intestinal parasites is summarized in Table 5. The majority (67.1%) of the participants responded that they had no adequate information about intestinal parasitic infections. However, out of 106 (32.9%) participants who had information, 49.4% suggested that intestinal parasites can be transmitted from one person to other person. About two thirds (62.0%) of them responded that intestinal parasites can infect any individual, while most (78.3%) of them responded that intestinal parasites are preventable.

Characteristics Response categories Number (%)
Heard about intestinal parasites Yes
No
106 (32.9)
216 (67.1)
Cause of intestinal parasites (n=106) Contaminated food
Contaminated water
Sexual contact
77 (72.6)
14 (13.2)
15 (14.2)
  Can intestinal parsites transmit (n=106)? Yes
No
63 (49.4)
43 (40.5)
 Mode of transmission (n=63) Direct contact
Sexual contact
Fecal   contamination
Other
40 (63.5)
16 (25.4)
28 (44.4)
22 (34.9)
 Intestinal parasites infect all age groups (n=106) Yes
No
66 (62.3)
40 (37.7)
Do they have treatment (n=106)? Yes
No
84 (79.2)
22 (20.8)
Intestinal parasitic infection is  preventable (n=106) Yes
No
83 (78.3)
23 (21.7)
 Preventive  methods  (n=83) Personal hygiene
Food hygiene
Drinking alcohol
Drinking kerosene
Drinking  koso
Chewing chat & eating garlic
57 (68.7)
6 (7.2)
20 (24.1)
7 (8.4)
13 (15.7)
3 (3.6)

Table 5: Knowledge of the study participants (age over 18 years) about intestinal parasitic infections

Results from logistic regression analysis for any parasitic infection are summarized in Table 6. Consuming over left fruit was significantly associated with high prevalence of intestinal parasitic infection (adjusted odds ratio= 2.9, 95% CI; 1.02, 8.22).

Characteristics Prevalence* Crude OR (95% CI) Adjusted OR (95%CI)
Sex 
female
male
76.7%
71.2  
1.3 (0.63,   2.83)
Reference
1.3 (0.47, 2. 68)
Reference
Age (year)
<20
20-29
30-39
40+
76.4%.
70.6%
73.6%
66.7%
1.6 (0.74,   3.55)
1.2 (0.61,   2.33)
1.4 (0.66,   2.92)
Reference
2.2 (0.76,  6.54)
1.3 (0.61,  2.75)
1.4 (0.63,  3.23)
Reference
Having domestic animals
yes
no     
82.4%
71.3%
1.8 (0.52,   6.56)
Reference
1.4 (0.37,  5.40)
Reference
  Educational level
Illiterate
Primary
Secondary& above
73.6%
69.4%
63.2%
1.6 (0.62, 4.30)
1.3 (0.45, 3.88)
Reference
1.2 (0.40,  3.60)
1.0 (0.31,   3.43)
Reference
 Eating  fruit 
Yes
No
85.7%
70.4%
2.5 (1.02,   6.22)
Reference
2.9(1.02,  8.29)
Reference
 Hand washing habit
yes
No 
67.0%
73.0%
Reference
1.3 (0.68,  2.36)
Reference
3.9(0.20, 75.40)
 cutting  nails
yes
No
68.5%
72.5%
Reference
1.2(0.64, 2.28)
Reference
2.9(0.14,  58.21)
Awareness about intestinal parasites
Yes
No
71.6%
72.68%
Reference
1.1 (0.65, 1.78)
Reference
1.33(0.74,  2.4)

Table 6: Factors associated with intestinal parasitic infections among study participants

Discussion

The results of the present study showed high prevalence of intestinal parasitic infections among street dwellers in Addis Ababa which is slightly higher or comparable to the findings of previous studies among street dwellers in Gondar City, north west Ethiopia [13], in Philippines [19] and from Peru [20], while it is lower compared to the overall prevalence of intestinal parasitic infections reported from street children in Nepal [21]. In the present study, multiple intestinal parasitic infections were found and Ascaris lumbricoides being the predominant parasite followed by Trichuris trichiura, Taenia species, Giardia lamblia and Entamoeba histolytica/dispar. High prevalence of ascariasis is a good indicator of improper fecal disposal, while that of giardiasis reflects use of poor water quality among the study participants. Previous study among street dwellers in Ethiopia showed high prevalence of Ascaris lumbricoides, followed by hookworms, Trichuris trichiura and Giardia lamblia [13]. A study conducted in Rio de Janeiro among 82 street dwellers living in the streets of Rio de Janeiro City, showed high prevalence of Ascaris lumbricoides followed by Trichuris trichiura and hookworms [22]. A study conducted in street children in Philippines also showed multiple intestinal parasitic infections including Ascaris lumbricoides, hookworms, Trichuris trichiura, Entamoeba histolytica, Giardia lamblia and Blastocystis hominis [19]. Multiple intestinal parasitic infections were also observed among street children in Argentina [23]. In the present study, the prevalence of Taenia species was considerably higher next to Ascaris lumbricoides and Trichuris trichiura, which is in contrast to the results of earlier study among street dwellers in other part of Ethiopia [23].

The overall prevalence of intestinal parasitic infections observed in this study also is comparable to the findings of various previous community/school children based studies in Ethiopia [11,24,25]. The proportion of infected female participants with intestinal parasites was slightly higher than the proportion of infected male participants. This finding is inconsistent with the result of previous study from Ethiopia [13]. Concerning the relation of age group and parasitic infection, the study revealed relatively a higher infection rate in the age group younger than 20 years. This indicates a common pattern of behavior and susceptibility to infection because of children has a habit of playing with soil and poor personal hygiene. Other study[23] also reported a high overall prevalence of intestinal parasitic infections in younger street children. Previous urban community based study in Ethiopia also showed high prevalence of intestinal parasitic infections in teenagers [24]. In the present study, relatively a higher infection rate was observed among illiterate, which is in agreement with the result of previous studies in Ethiopia [9,13,26].

In general, street dwellers do not have access to latrine facilities and their excreta could be a potential source of soil, water and street-vended food contamination in the surroundings. In view of this, the present study indicated that some of the study subjects defecated on road-side opens space, drains and near the shelter and this practice of the street-dwellers could be potential source of contamination of soil, water and street-vended food which is hazards to health [8]. Hygiene depends on the availability of water like hand washing after defecation or before eating food seems like extravagance among street dwellers. The present study also revealed that considerable proportion of study participants do not wash their hands before meal (76.6%), while hand washing can reduce the risk for infection with intestinal parasites.

In this study it was also noted that considerable number of street dwellers had no adequate information about intestinal parasitic infections which is similar to the results of previous study in other community [25]. This could be also other potential risk factor for intestinal parasitic infections.

In conclusion, the results of the present study showed high prevalence of intestinal parasitic infections among street dwellers in Addis Ababa and associated risk indicators which in turn could be a potential source of the contamination of soil, water and street-vended food in Addis Ababa. Unless the intestinal parasites prevention strategies consider these segments of the population of Addis Ababa, they constitute major sources of intestinal parasitic infections for the community though further community-based prevalence study of intestinal parasitic infections is needed in Addis Ababa.

Acknowledgements

We thank the School of Graduate Studies and Aklilu Lemma Institute of Pathobiology, Addis Ababa University, for financial support. We thank Dr. Girmay Medhin for his sincere statistical advice and technical staff of the Medical Parasitology Research Unit for their cooperation during laboratory work. We also thank the study participants.

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