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A STUDY ON THE PREVALENCE OF ASCARIASIS AMONG CHILDREN AGED FOUR TO TWELVE IN BOYS TOWN, MARIKINA CITY

A Thesis Submitted to the Faculty of Pharmacy of the University of Santo Tomas

In Partial Fulfillment of the Requirements For the Degree of Bachelor of Science in Medical Technology

Alvarez, Don Nuelle Xyzka Ayala, Marie Celene Carbungco, Michael Paolo Dator, Ma. Medy Zena Gran, Rosauro Miguel Valdez, Liezel Tiffany 4E-Medical Technology August 17, 2010

UNIVERSITY OF SANTO TOMAS Chapter 1 The Problem and Its Background 1.1 Introduction

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In a developing country such as the Philippines, intestinal heminthiasis remain as the foremost determining factor to morbidity. Children, mostly are the ones who get easily infected with helminths because these are soil-transmitted. For most rural communities, children customarily tend to play with soil and thereby acquire the parasite. In fact, these helminths that cause infections in humans belong under the group of nematodes . Ascariasis, also known as roundworm infection, is caused by

Ascaris lumbricoides. It's the most common type of intestinal worm infection, occurring worldwide. Most patients recover without treatment, but complications can occur when adult worms move into certain organs and multiply, resulting in blockage of the intestine. Ascariasis never passes directly from person to person. After ingestion, A. lumbricoides ova hatch and release larvae, which penetrate the intestinal wall and reach the lungs through the bloodstream. After about 10 days in pulmonary capillaries and alveoli, the larvae migrate to the bronchioles, bronchi, trachea, and epiglottis. There they are swallowed and return to the intestine to mature into worms. Ascariasis is most common in tropical areas with poor sanitation and in Asia, where farmers use human feces as fertilizer. In the United States, it's more prevalent in the south, particularly among people ages 4 to 12 (Springhouse, 2005). . Ascariasis is associated with both chronic and acute

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morbidity, particularly in growing children, and the level of morbidity assessed as disability-adjusted life years is about 10.5 million. Like other macroparasite infections, the frequency distribution of A. lumbricoides is aggregated or overdispersed with most hosts harbouring few or no worms and a small proportion harbouring very heavy infections( C.V. Holland, 2009.). Ascaris lumbricoides is a parasite which is transmitted from soil. For indigent communtites here in the tropics, ascaris is found to be a major health concern. Among the adverse health effects are growth retardation, intestinal obstruction, hepatic and biliary diseases, impaired cognitive development, and nutritional effects such as iron deficiency anemia (Journal of Helminthology, 2008.) Individuals get infected when soil, food, or water contaminated with human feces is ingested. Raw foods such as salad and the like, are very common modes of transmission for ingestion of ascaris eggs. Poor personal hygiene, like failure to wash the hands before eating especially after handling contaminated soil, is another major cause of ascaris infection. The infective stage is said to be the fully embryonated egg which when ingested, the larvae hatches into the lumen of the small intestine and penetrates the intestinal wall. These larvae then enter the venules to go to the liver through the portal vein, on to the heart and pulmonary vessels where they break out of capillaries to enter the air sacs. In the lungs, larvae undergo molting before migrating to the larynx and oropharynx to be swallowed into the digestive tract. The eggs are deposited in the soil when a person with ascaris infection defecates indiscriminately. In the soil, it takes about two to three

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weeks for eggs to develop into the infective stage under favorable conditions with suitable temperature, moisture and humidity. The larvae reach their third stage when they molt within the egg and become embryonated. Only when this infective egg is swallowed can humans become infected with ascaris. The embryonated eggs can survive in moist shaded soil for a few months to about two years in tropical and sub-tropical areas, but for much longer in temperature regions (Belizario, 2004.) A The diagnosis of ascariasis is said to be rather inaccurate since the signs and symptoms are considerably indeterminate. Hence, there is a need to undergo microscopic examination of stool samples to verify possible infections. The risk of infection exists wherever there is poor sanitation and fecal disposal is improper. In the Philippines, as per UP National Institute of Health and Department of Health figures, 70 percent of the population has ascaris

(http://www.mb.com.ph/node/143208).

The incidence of clinical significance

associated with this parasite may seem low but it still remains as a public health concern here in our country since the prevalence and incidence rates are high. Despite its high distribution, it remains still as an overlooked disease. Currently, the burden of helminthiasis among orphans in the Philippines, is poorly understood, as only a few restricted studies on the prevalence of helminth infections have been conducted. The aim of this present study, however, is to determine whether ascariasis is prevalent in Boys Town, Marikina City. Moreover, the researchers find it significant to conduct this study since intestinal parasitic infections interfere with nutrition, growth, cognitive function, and educational performances in

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children. The study would want to know the prevalence of Ascaris lumbricoides among children aged four to twelve 8 living in the place rich in soil. This research would like to help improve the hygiene of these children and recommend a remedy to help prevent the disease from increasing. This study should help the government to be aware of this disease and to give more importance to the health status of the Philippines. 1.2 Statement of the Problem What is the prevalence ascariasis among children aged four to twelve in Boys Town, Marikina City? Specifically, the researchers also wanted to answer the following questions:
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What is the frequency and percentage of the respondents infected with Ascaris lumbricoides?

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What factors may have affected the prevalence or non prevalence of ascariasis in Boys Town, Marikina City?

1.3 Research Objectives 1.3.1 General Objectives This study aims to know the prevalence of Ascaris lumbricoides infection among the children of Boys Town Marikina City ages 4 to 12 years old. 1.3.2 Specific Objective Furthermore, it aims to:
1. determine the frequency and percentage of the respondents with ascariasis.

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2. determine the factors that may contribute to prevalence or non prevalence of ascariasis in Boys Town Marikina City.
1.4 Significance of the Study

This study may give the prevalence of ascariasis aged four to twelve and may give significant data. To the Scientific Community Despite the magnitude of the prevalence of Ascaris Lumbricoides Infection, data from epidemiological studies are seldom translated into meaningful information and health protection measures. Communication between health services and decision-makers is essential to overcome the main obstacles for community participation. The establishment of guidelines for the development of preventive measures and health programme evaluation are of high priority. Experience shows that such an approach, as opposed to documentation of technical problems alone, allows social mobilization towards the solution of specific problems, thereby contributing to the reduction of inequities in health. To the general public By studying the prevalence of Ascaris Lumbricoides, it will help the general public by developing an environmental health indicator for use as a basis for developing preventive measures against Ascaris lumbricoides infection in children from the community chosen. The intestinal nematode Ascaris lumbricoides infects approximately 25% of the world's population annually.

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Although the infection is often asymptomatic, its effects may contribute substantially to child morbidity when associated with malnutrition, pneumonia, enteric diseases and vitamin A deficiency. To the medical technology field The development of environmental health indicators that incorporate health data obtained using scientifically based methods is one means of translating the results from epidemiological studies into preventive tools. Such indicators provide the empirical foundation for the definition of priorities within the legal framework of primary health care and environmental protection. They should be relatively easy to measure, and provide clear "warning signals" to decision-makers and nonspecialists for the institution of specific control measures. 1.5 Scope and Limitation The study conducted covered ascariasis, the infection of Ascaris lumbricoides. Ascariasis was diagnosed by looking for A. lumbricoides ova using the direct fecal smear technique. Collection of stool specimen was gathered randomly and voluntarily among children in Boys Town, Marikina City aged four to twelve years old. Prior to the collection, consent and briefing was done for childrens guardians in the orphanage regarding the proper collection of the specimen. Aside for A. lumbricoides, no others nematodes and parasites were included in the study; and medical history of the randomly selected children were not asked. Diagnosis

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was only limited to detection of parasite and the degree of infection as well as the stage of parasitism were not included in the study.

1.6 Research Hypothesis Alternative hypothesis: There is a significant relationship in the prevalence of ascariasis among children ages 4 to 8 years old in Boys Town Marikina City. Null hypothesis: There is no nificant relationship in the prevalence of ascariasis among children ages 4 to 8 years old in Boys Town Marikina City. 1.7 Definition of Terms Anemia a decrease in normal number or red blood cells (RBC) or less than the normal quantity of haemoglobin in the blood. Ascariasis - also known as roundworm infection, is caused by Ascaris lumbricoides. It's the most common type of intestinal worm infection, occurring worldwide. Direct Fecal Smear (DFS) - Very good technique for identification of motile parasites commonly used for diarrheic or mucoid fecal samples.

Helminthes - eukaryotic (one-cell) parasites that live inside the intestinal tract of their (human) host. They are organisms that live off the living hosts nutritional requirements, receiving their nutritional needs from

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nutrients within the hosts physiological system, thus causing weakness and disease.

Iron-Deficiency Anemia - a common type of anemia, and occurs when the dietary intake or absorption of iron is insufficient, and hemoglobin, which contains iron, cannot be formed.

Lofflers syndrome - a disease in which a certain type of white blood cell called an eosinophil accumulates in the lung in response to a parasitic infection.

Malnutrition - the insufficient, excessive or imbalanced consumption of nutrients.

Nematoda - they are round worms, which are cylindrical and unsegmented. People get infected with this type by ingesting eggs of the worm, direct skin penetration or an insect bite.

Normal Saline Solution (NSS) - a solution of sodium chloride, or salt, in sterile water.

Morbidity - Morbidity is another term for illness.

Mortality - Mortality is another term for death.

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Parasites - a type of symbiotic relationship between organisms of different species where one organism, the parasite, benefits at the expense of the host.

Pneumonitis - a general term that refers to inflammation of lung tissue.

Prevalence the number of all new and old cases of a disease or occurrences of an event during a particular period

Orphanages - provide an alternative to foster care or adoption by giving orphans a community-based setting in which they live and learn.

Urban Slums - a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security.

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Chapter 2 Review of Related Literature

This chapter provides facts, descriptions and related studies about the prevalence of Ascariasis. It describes Ascaris lumbricoides with its corresponding morphology, life cycle, pathophysiology, epidemiology, mode of transmission, prevention and treatment. 2. Related Literature 2.1 Parasites 2.1.1 Biological Relationships (Symbiosis) Accodring to Bogitsh (2004), organisms of different species that live together are known as symbionts, and the relationship is designated as symbiosis. However, symbiosis is not specific as to whether it could benefit or bring about damage to the symbionts. Hence, different forms of symbiosis are distinguished as to whether or not the relationship is harmful or beneficial to one of the two symbionts. There are at least four categories of symbiosis that are commonly recognized. First is commensalism, wherein one species benefits from the

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relationship without causing harm nor gaining benefits from the other. Another is phoresis, in which no physiologic interaction or dependency is involved. The third type of symbiosis is known as mutualism. This is when both symbionts would benefit from the relationship. Lastly, parasitism, wherein one of the two organisms (the parasite) would be physiologically dependent on the other (the host) for its survival. The scope of this study, however, is limited only to the fourth type of symbiosis defined which is parasitism. 2.1.2. Parasitism Parasitism as previously defined, refers to a type of symbiotic relationship which involves two organisms. The host, being one of the two organisms would provide shelter and nutrients for the benefit of another organism, the parasite. The parasitic organism derives all the benefit from the relationship. It obtains nourishment from its host, thereby causing detrimental effects to the host. The physiologic requirements of the parasite are only partially known and understood, but there is sufficient information to indicate certain categories of dependence, such as nutritional (Bogitish, 2005). These parasites obtain essential nutrients directly from their hosts. Different substances such as the blood of the host, the lymph, the cytoplasm, the tissue fluids, and the host-digested food are only few of the usual sources of parasitic nutrition. When parasites obtain these nutrients, the host may either suffer from various disorders and diseases or if fortunate enough, may show no detrimental effects. 2.1.3. Host Parasite Relationship

UNIVERSITY OF SANTO TOMAS Effects of the Parasite on the Host

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In most occasions, organisms that live inside the body have the ability to inflict damage to their host. Parasites make use of different mechanisms by which they bring about damage to the host. The most common mechanism is by interference with the ital processes of the host through the enzyme systems. Secretory and excretory products elaborated by many parasites allow them to metabolize nutrients obtained from the host and store these for energy production. Another means y which parasites cause injury to their host is through host tissue invasion and destruction. Moreover, parasites also cause deprivation of essential nutrients and substances. The intimate relationship between parasite and host generally exposes the host to antigenic substances of parasitic origin. Sometimes these antigens consist of the molecules that make up the surface of the parasite (somatic antigens), or they may e molecules secreted or excreted by the parasite (metabolic antigens). In either case, the host typically responds to the presence of such antigens by synthesizing antibodies. Thus, unlike phoresis and commensalism, parasitism usually involves, in addition to the physiologic dependency of the parasite, immunological responses by the host. The effect upon the host is usually the result of the host reaction to the presence of the parasite. One of the more important consequences of such reaction-which may be localized at the site of attachment or deposition or may be more generalized, perhaps throughout the entire host body-is the limitation of the populations of the parasite. Effects of the Host on the Parasite

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Although human hosts seem to be the victims in a parasitic relationship, there are also a number of factors by which the survival of the parasite on the host is determined. One factor which could influence the reaction between the host and the parasite would be the genetic make-up of the host. Another would be the nutritional status of the host such as protein rich diet which is not suitable for the development of intestinal protozoans. A diet low in protein, however, favors the risk of having amoebiasis. A high carbohydrate diet on the other hand would favor development of some tapeworms. The last important aspect is the immune processes which play an important role. Absolute immunity to reinfection occurs rarely following protozoan infections and probably never happens with helminth infections in humans. Acquired immunity may be very important in modifying the severity of the disease in endemic areas. 2.1.4. Medical Implications Most parasitic diseases occur commonly, often exclusively, in the tropics. Hence, an area of medicine attributed purely to tropical parasitic diseases was introduced. There are certain conditions which made the tropical region more vulnerable to these diseases such as unsanitary living conditions, inadequate funding for disease control and treatment, poor nutrition and lack of health education, climatic conditions, as well as compromised immune systems. The causative agents of parasitic diseases of human include organisms commonly known as protozoas, flatworms, roundworms and certain arthropods. Parasitic diseases differ from viral, bacterial, and fungal diseases in several ways.

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For example, viral, bacterial and fungal diseases multiply rapidly, producing large numbers of progeny within the human host, whereas parasites generally reproduce more slowly and produce fewer offspring. Also, viral and bacterial infection usually are more acute, often highly virulent and potentially lethal, whereas parasitic diseases are usually chronic and if death does result, it commonly comes after a lengthy period of debilitation. Finally, except for certain viral infections, parasitic diseases are generally more difficult to control than other infectious disease. A number of elements described below in the epidemiology of parasitic diseases help to explain this phenomenon. 2.1.5Types of Parasitism Definitions of the Different Types of Parasitism The host-parasite relationship is seen in many variations. Usually, parasites are distinguished according to their location. As discussed by Belizario (2004), an endoparasite is a parasite which lives inside the body of the host and results in an infection of the host. Endoparasites live in sites such as the alimentary tract, liver, lungs and urinary bladder. On the other hand, a parasite which inhabits or is attached to the outer surface of the host are known as ectoparasites which results into an infestation. As discussed by Kiser (2010), some parasites are capable of leading both a free existence (apart from the host) and parasitic existence depending on the stage of the life cycle and the availability of a suitable host. In such cases, the term facultative parasite is used. In other cases, the organism establishes a permanent residence in the host for its existence. An incidental

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parasite is one that establishes itself in a host in which it does not ordinarily live. If the parasitic organism causes injury to the host in procuring nourishment, by its migration through the tissues of the host, or by the production of toxins is a pathogenic parasite.

2.2 Helminths 2.2.1 Overview on Helminths Helminth infections caused by soil-transmitted helminths (STHs) are the most prevalent afflictions of humans who live in areas of poverty in the developing world. The morbidity caused by STHs is most commonly associated with infections of heavy intensity. Approximately 300 million people with heavy helminth infections suffer from severe morbidity that results in more than 150,000 deaths annually (Crompton 1999; Montresor et al., 2002). In addition to their health effects, helminth infections also impair physical and mental growth in childhood, thwart educational advancement, and hinder economic development. Because of the geographic overlap of these afflictions and their impact on children and adolescents, the World Health Organization (WHO); the World Bank; and other United Nations agencies, bilaterals, and civil society are working on STH control through a program of periodic school-based, targeted anthelmintic drug treatments.

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The four most common STHs are roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), and the anthropophilic hookworms (Necator americanus and Ancylostoma duodenale). Recent estimates suggest that A. lumbricoides infects 1.221 billion people, T. trichiura 795 million, and hookworms 740 million (de Silva et al., 2003). The greatest numbers of STH infections occur in the Americas, China and East Asia, and Sub-Saharan Africa. Strongyloides stercoralis is also a common STH in some of these regions, although detailed information on the prevalence of strongyloidiasis is lacking because of the difficulties in diagnosing human infection. The life cycles of Ascaris, Trichuris, and hookworm follow a general pattern. The adult parasite stages inhabit the gastrointestinal tract (Ascaris and hookworm in the small intestine; Trichuris in the colon), reproduce sexually, and produce eggs, which are passed in human feces and deposited in the external environment.

STH infections rarely cause death. Instead, the burden of disease is related less to mortality than to the chronic and insidious effects on the hosts' health and nutritional status (Stephenson et al. 2000; Stoltzfus et al., 1997). Hookworms have long been recognized as an important cause of intestinal blood loss leading to iron deficiency and protein malnutrition. The iron deficiency anemia that accompanies moderate and heavy hookworm burdens is sometimes referred to as hookworm disease (Hotez et al., 2004). When host iron stores are depleted, the extent of iron deficiency anemia is linearly related to the intensity of hookworm infection

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(Stoltzfus et al., 1997). Because of their underlying poor iron status, children, women of reproductive age, and pregnant women are frequently the ones most susceptible to developing hookworm anemia (Brooker, Bethony, and Hotez, 2004). Iron deficiency anemia during pregnancy has been linked to adverse maternal-fetal consequences, including prematurity, low birth-weight, and impaired lactation (WHO 2002).

Chronic STH infections resulting from Ascaris, Trichuris, and hookworm can dramatically affect physical and mental development in children (WHO, 2002). Studies have also shown that the growth and physical fitness deficits caused by chronic STH infections are sometimes reversible following treatment with anthelmintic drugs (Stephenson, Latham, and Ottesen, 2000). The effects on growth are most pronounced in children with the heaviest infections, but light infections may also contribute to growth deficits if the nutritional status of the community is poor (Stephenson, Latham, and Ottesen, 2000).

Specific occupations, household clustering, and behaviors influence the prevalence and intensity of helminth infections (Bethony et al., 2001). 2.2.2 Factor affecting Helminth infection Poverty, Sanitation, and Urbanization STH depend for transmission on environments contaminated with eggcarrying feces. Consequently, helminths are intimately associated with poverty,

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poor sanitation, and lack of clean water. The provision of safe water and improved sanitation are essential for the control of helminth infection. Although the STH infections are neglected diseases that occur predominantly in rural areas, the social and environmental conditions in many unplanned slums and squatter settlements of developing countries are ideal for the persistence of A. lumbricoides (Crompton and Savioli, 1993). Climate, Water, and Season Adequate warmth and moisture are key features for each of the STHs. Wetter areas exhibit increased transmission, and in some endemic areas, STH infections exhibit marked seasonality. Recent use of geographical information systems and remote sensing has identified the distributional limits of STH on the basis of temperature and rainfall patterns (Brooker and Michael, 2000). 2.2.3 Population at risk of Helminth Infection School-Age Children as a High-Risk Population School-age children typically have the highest intensity of worm infection of any age group, and chronic infection negatively affects all aspects of children's health, nutrition, cognitive development, learning, and educational access and achievement (World Bank, 2003). Regular deworming can cost-effectively reverse and prevent much of this morbidity. Furthermore, schools offer a readily available, extensive, and sustained infrastructure with a skilled workforce that is in close contact with the community. With support from the local health system, teachers

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can deliver the drugs safely. Teachers need only a few hours of training to understand the rationale for deworming and to learn how to give out the pills and keep a record of their distribution. School-based deworming also has major externalities for untreated children and the whole community. By reducing transmission in the community of Ascaris and Trichuris infections, deworming substantially improves the health and school participation of both treated and untreated children, both in treatment schools and in neighboring schools (Bundy et al., 1990; Miguel and Kremers, 2003). Other At-Risk Populations Not only school-age children can benefit from treatment. Preschool children (one to five years of age) are vulnerable to the developmental and behavioral deficits caused by iron deficiency anemia, and recent analyses by Brooker, Bethony, and Hotez (2004) indicate that hookworm is an important contributor to anemia in that age group (see "Estimating Intervention Effectiveness"). Women of reproductive age (15 to 49 years of age) are particularly susceptible to iron deficiency anemia because of iron loss during menstruation and because of increased needs during pregnancy (Bundy, Chan, and Savioli, 1995). 2.3 Ascaris Lumbricoides 2.3.1Brief Overview Ascaris Lumbricoides, also called the giant round worm is the most common intestinal nematode of man. It occurs most frequently in the tropics with

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an estimate of more than 1 billion individuals are infected, 70% of whom are from Asia. The soil plays a major role in the development and transmission of this parasite, thus considered a soil-transmitted helminth. It causes varying degrees of pathology including tissue reaction to the invading larvae, intestinal irritation to the adult and other complications due to extraintestinal migration. Soil-transmitted helminth infections like ascariasis are diseases of poverty. They contribute to impairment of cognitive performances and growth of children. Also, they reduce work capacity and productivity of adults. (Belizario, W. (2004). Philippine Textbook of Medical Parasitology) 2.3.2Morphology According to Rosemary Drisdelle (2007), Ascaris lumbricoides looks a lot like a large earthworm, but the two are not related. The earthworm is an annelid; it lives in the soil, feeding on organic debris. A. lumbricoides is a parasitic nematode, or roundworm; adults are found only in the intestines of humans, feeding on intestinal contents as they flow past. If you were to compare the two very carefully, you would note that the earthworm has little tufts of bristles and its body is marked with many rings, as though it was built a slender ring at a time. The body of ascaris is smooth and hairless, and the worm has three lips at the mouth end, arranged like the leaves of a three leaf clover.

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This worm has a somatic muscle arrangement in which cells are numerous and project well into the body cavity, this is so called the polymyarian type of arrangement. The males measures 10 to 31 cm and females 22 to 35 cm in length with smooth striated cuticles. The worms have a terminal mouth with three lips and sensory papillae. There is a ventrally curved posterior end with two spicules in males. Females have paired reproductive organs in the posterior two-thirds, while males have a single, long, tortuous tubule. The adults reside in but do not attach to the mucosa of the small intestines. Larval morphology is similar to the adult. The infertile eggs are longer and narrower than fertile eggs, measuring 88 to 94 m, with a thin shell and irregular mammilated coating filled with refractile granules. These infertile eggs may be difficult to identify and are found not only in the absence of males. Fertile eggs measure 45 to 70 m by 35 to 50 m. There is an outer coarsely, mammilated albuminous covering which may be absent or lost in decorticated eggs. The egg has a thick, transparent, hyaline shell with a thick outer layer as a supporting structure and a delicate vitelline, lipoidal, and highly impermeable inner membrane. At oviposition, the fertile eggs have an ovoid mass of protoplasm, which will develop into larvae in about 14 days. (Belizario, W. (2004). Philippine Textbook of Medical Parasitology)

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Figure 2.1 Ascaris lumbricoides egg, January 2008

2.3.3Life Cycle Eggs of Ascaris lumbricoides are found in warm moist soil where other infected humans have defecated. They are swallowed on unwashed raw fruits and vegetables, transferred to the mouth on soiled hands, even swallowed in untreated, unfiltered water that has washed off contaminated soils. In some cases, they may be inhaled.Eggs pass through the stomach unharmed and arrive in the duodenum, the first section of the small intestine. Worm larvae, which have lain quiet inside the eggs, emerge. Larvae burrow through the intestinal lining into the tissue underneath and continue on until they push through blood vessel walls and are carried off in the bloodstream. Larvae are carried through the liver and heart, eventually arriving in

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the lungs, where they break out into the airspace there. In the lungs, the larvae grow, passing through several stages of development. By the time they are ready to leave the lung, about nine days have passed since the eggs were swallowed. Larvae travel up the airways or are coughed up. Those that are subsequently swallowed survive their second trip through the stomach only if they are sufficiently mature to withstand the acid conditions there. Larvae remain in the small intestine and continue to mature. Females will eventually grow to 45cm in length (males are smaller). Sexually mature females begin producing eggs that are mixed with intestinal contents and passed in the stool. When an infected human defecates outside, eggs are introduced into the soil. In warm moist conditions the eggs will be infective to another person in a couple of weeks. When conditions are cold, dry, or otherwise hostile, eggs can remain dormant for long periods of time, then mature when the environment is more favorable. (Drisdelle, R. (2007))

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Figure 2.2 Life Cycle of Ascaris lumbricoides Adult worms live in the lumen of the small intestine. A female may .

produce approximately 200,000 eggs per day, which are passed with the feces

Unfertilized eggs may be ingested but are not infective. Fertile eggs embryonate and become infective after 18 days to several weeks , depending on the

environmental conditions (optimum: moist, warm, shaded soil). After infective eggs are swallowed , the larvae hatch , invade the intestinal mucosa, and are . The larvae mature

carried via the portal, then systemic circulation to the lungs

further in the lungs (10 to 14 days), penetrate the alveolar walls, ascend the

UNIVERSITY OF SANTO TOMAS bronchial tree to the throat, and are swallowed intestine, they develop into adult worms

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. Upon reaching the small

. Between 2 and 3 months are required

from ingestion of the infective eggs to oviposition by the adult female. Adult worms can live 1 to 2 years. Ascaris lumbricoides is virtually exclusively a human parasite, meaning that it does not infect dogs, cats, or other domestic animals, with the possible exception of pigs. The large intestinal roundworm of pigs, Ascaris suum, is very similar to A. lumbricoides and there is considerable evidence that A. suum occasionally infects humans and vice versa. The whole process from swallowing the egg to having mature worms in the intestine takes between two and three months. The worms live, on average, about a year and a female can produce up to six million eggs in her lifetime. No wonder this is one of the most common intestinal worms of humans. (Roberts and Janovy, 2000.) 2.3.4 Epidemiology Over one billion people globally are estimated to have ascariasis, and of these, at least 20,000 die annually, mostly young children. The risk of infection exists wherever fecal disposal is improper. The disease remains endemic in many countries of Southeast Asia, Africa and Central and South America. It's more prevalent in the south, particularly among people ages 4 to 12.

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Children are particularly vulnerable since they are at risk of ingesting embryonated Ascaris eggs while playing in soil contaminated with human feces. Ascaris is a prominent parasite in both temperate and tropical zones, but it is more common in warm countries and more prevalent in areas where sanitation is poor. In many countries, the Philippines included, the prevalence may reach 80 to 90% in certain high risk groups like public elementary school children Ascariasis is one o the soil-transmitted helminthiases but the level of transmission from soil to humans depends more on socio-economic factors than on physical factors. The main factors appear to be a high density of human population, involvement in agriculture (including use of night-soil as fertilizer), illiteracy, and poor sanitation. Poor health education on personal, family and community hygiene are also important factors contributing to the transmission of ascariasis. When over 50% of the population is infected, most of which are children, the disease is considered to be of low endemicity. (Belizario, W. (2005). Philippine Textbook of Medical Parasitology) 2.3.5 Mode of Transmission According to Springhouse (2005), A. lumbricoides is a large roundworm resembling an earthworm. It's transmitted to humans by ingestion of soil contaminated with human feces that harbor A. lumbricoides ova. Such ingestion may occur directly (by eating contaminated soil) or indirectly (by eating poorly washed raw vegetables grown in contaminated soil).

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Ascariasis never passes directly from person to person. After ingestion, A. lumbricoides ova hatch and release larvae, which penetrate the intestinal wall and reach the lungs through the bloodstream. After about 10 days in pulmonary capillaries and alveoli, the larvae migrate to the bronchioles, bronchi, trachea, and epiglottis. There they are swallowed and return to the intestine to mature into worms. 2.3.6 Diagnosis There are several methods to diagnose Ascariasis in patients. The most common laboratory tests are stool examinations. The direct fecal smear method is the most routinely used examination; it utilizes only a small amount of feces placed on a glass slide mixed with Normal Saline Solution. A cover slip is placed on top and is examined for Ascaris eggs by microscopy. Another method used is the Kato technique or Cellophane thick smear. It uses 20-60mg of sample and cellophane strips are used instead of cover glass. Kato technique is a more suitable method in comparison to the DFS in view of its sensitivity to detect even scanty parasitic infections. However, the DFS and Kato technique are only used as qualitative examinations to detect the presence of Ascaris lumbricoides eggs. In 1968, Martin and Beaver produced a modified Kato technique for the quantitative examination of helminth eggs. Unlike the Kato technique, the amount of feces to be examined is measured and can be used to make egg counts of Ascaris lumbricoides per gram of sample. The Kato-Katz technique is used to determine the intesisty of parasitic infection. Blood tests may also be used to diagnose Ascariasis. Peripheral

UNIVERSITY OF SANTO TOMAS Eosinophilia may be seen is infections of Ascariasis, but is not reliable as it increases along with other diseases. (Springhouse, 2005)

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Imaging tests may also be used to detect the presence of Ascaris lumbricoides. Large worm burdens may be visible using an X-ray of the abdominal area. Also, this can be used to detect larvae that have migrated to the lungs. An ultrasound may be used to view adult A. lumbricoides in the pancreas or liver, and CT scans and MRIs are used to detect worms that obstruct liver and pancreatic ducts. (Roberts and Janovy, 2000.) 2.3.7 Treatment Many medications have been used in the past to treat A. lumbricoides infections. Oil of chenopodium and santonin are effective drugs but are very toxic. A mixture of oil of chenopodium and tetrachlorethylene is usually successful . Hexylresorcinol capsules were also available. Fasting for 12 hours before and 4 hours after the dosage is required, followed by sodium sulfate to expel the dead worms. This is a highly effective treatment but only in 40-80% of cases and is very tedious. The most common antihelminthic medications available today include Pyrantel Pamoate, Mebendazole, and Albendazole. Pyrantel Pamoate temporarily paralyzes the worms permitting peristalsis to expel them from the body. Mebendezole and Albendazole eliminates the parasites by blocking off helminth nutrition.

UNIVERSITY OF SANTO TOMAS 2.4 Ascariasis 2.4.1 Brief Overview

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The three main soil-transmitted helminth infections, ascariasis, trichuriasis, and hookworm, are common clinical disorders in man. The gastrointestinal tract of a child living in poverty in a less developed country is likely to be parasitised with at least one, and in many cases all three soil-transmitted helminths, with resultant impairments in physical, intellectual, and cognitive development (Lancet; 5/6/2006, Vol. 367 Issue 9521, p1521-1532).

Ascariasis is the most common helminthic infection to infest man. Usually the adult worm lives in the small intestine. Rarely it migrates through the ampulla of vater and enters the common bile duct. We are reporting a case of gall bladder ascariasis causing acute cholecystitis treated by laparoscopic cholecystectomy. Presence of Ascaris lumbricoides in gallbladder is rare entity as it is diffi cult to reach their due to the narrow and tortuous cystic duct (Journal of Minimal Access Surgery; Oct2008, Vol. 4 Issue 4, p108-110).

2.4.2 Symptoms After entering the bile duct, the ascarids excrete various types of polypeptides that produce allergic manifestations and cause spasm of the sphincter of Oddi by acting as chemical irritants. The resultant biliary stasis coupled with

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infected intestinal contents carried by the worms leads to pyogenic cholangitis, cholecystitis, and pancreatitis.1517 In endemic areas, 5% of patients with biliary ascariasis develop recurrent pyogenic cholangitis over a period of 2 years. Occasionally the worms enter the intrahepatic ducts, invade the liver parenchyma, and produce local inflammation which leads to necrosis and abscess formation. In a study conducted by our group over a period of 10 years on 510 patients, 75(14.5%) patients presented with liver abscess that was causally related to ascariasis.18 Rarely, the worm may obstruct the cystic duct, leading to empyema of the gallbladder (World Journal Of Surgery [World J Surg] 2006 Aug; Vol. 30 (8), pp. 1500-6). Patients can remain asymptomatic for very long periods of time. As larval stages travel through the body, they may cause visceral damage, peritonitis and inflammation, enlargement of the liver or spleen, toxicity, and pneumonia. A heavy worm infestation may cause nutritional deficiency; other complications, sometimes fatal, include obstruction of the bowel by a bolus of worms (observed particularly in children) and obstruction of the bile or pancreatic duct.

2.4.3 Complications of Ascariasis

The Department of Health (2004) gave a list of some complications of Ascariasis the following are as follows:

UNIVERSITY OF SANTO TOMAS 1.

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Loefflers's syndrome is an allergic eosinophilic infiltration of the

lung usually seen in hypersensitive individuals. 2. Pathology in the liver, brain, or eyeball as larvae, migrating through

the bloodstream, may eventually be lodged in these organs. 3. Wanderlust or erratic behavior of the worms result in erratic migration which, in turn, may lead to: Acute appendicitis when a worm blocks the appendix Acute pancreatitis when a worm blocks the pancreatic duct Acute cholecystitis when a worm blocks the ampulla of vater Multiple liver abscess when a worm invades the liver parenchyma Peritonitis when a worm causes bowel perforation

4. Intestinal obstruction results when there is a bolus of worms or when the worms become entangled. 2.4.4 Cause Depending on its origin, wastewater can contain a great diversity of pathogenic microorganisms (Amahmid et al. 2002; Madera et al. 2002; Leclerc et al. 2002). Bacteria, viruses and parasites capable of infecting both animals and

UNIVERSITY OF SANTO TOMAS humans alike, can all be present (Kuick et al. 2004; Srikanth & Naik, 2004; Norhayati et al. 2003). The presence of such microorganisms in wastewater

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discharged into the environment present an increased risk to animal and human welfare and is thought to be associated with a number of epidemics (Crompton 1999; Peng et al. 2003; Rodriguez-Garcia et al. 2004). The city of El Jadida, on the Moroccan Atlantic Ocean has several sewers all dumping untreated waste directly into the sea (Kaimoussi et al. 2002). This problem is compounded when these discharges are deposited in the vicinity of low-income neighborhoods where basic hygiene practices are totally lacking. The residents of these neighborhoods are permanently exposed to the risks of contamination especially children who make up a large proportion of this population (International Journal of Environmental Health Research; Apr2005, Vol. 15 Issue 2, p135-142, 8p). Primary Cause of Ascariasis Ascariasis is caused by the parasite Ascaris lumbricoides, the largest intestinal nematode found in humans. It is placed among the most prevalent parasitic infections in the world, with approximately 25% of the world population, or 1.4 billion people, infected, and 60,000 deaths annually (Bundy & De Silva 1998). Transmission of the disease is usually fecal-oral (hand-tomouth) and by contaminated food, water, and agricultural products. Rarely, transmission can occur via inhalation of eggs or swallowing contaminated respiratory secretions. The high worldwide prevalence of Ascariasis can be attributed to the ubiquitous nature of the helminth and the number of eggs produced per parasite, the durability of the eggs,

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the lack of intermediate hosts, and poor socioeconomic conditions, especially in endemic areas (Valentine et al. 2001). Genetic and environmental factors influence the estimates of the prevalence of Ascariasis. However, socio-environmental factors have more significance in predicting the elevated prevalence of disease (Haswell-Elkins et al. 1988). 2.4.5 Statistics International Setting According to WHO (2004), roughly 1.5 billion individuals are infected with this worm, primarily in Africa and Asia. Ascariasis is endemic in the United States including Gulf Coast; in Nigeria and in Southeast Asia. One study indicated that the prevalence of ascariasis in the United States at about 4 million (2%) . In a survey of a rural Nova Scotia community, 28.1% of 431 individuals tested were positive for Ascaris, all of them being under age 20, while all 276 tested in metropolitan Halifax were negative. Deposition of ova (eggs) in sewage hints at the degree of ascariasis incidence. A 1978 study showed about 75% of all sewage sludge samples sampled in United States urban catchments contained Ascaris ova, with rates as high as 5 to 100 eggs per litre. In Frankfort, Indiana, 87.5% of the sludge samples were positive with Ascaris, Toxocara, Trichuris, and hookworm. In Macon, Georgia, one of the 13 soil samples tested positive for Ascaris. Municipal wastewater in Riyadh, Saudi Arabia detected over 100 eggs per litre of wastewater and in Czechoslovakia was as high as 2401050 eggs per litre .

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Ascariasis can often be measured by examining food for ova. In one field study in Marrakech, Morocco, where raw sewage is used to fertilize crop fields, Ascaris eggs were detected at the rate of 0.18 eggs/kg in potatoes, 0.27 eggs/kg in turnip, 4.63 eggs/kg in mint, 0.7 eggs/kg in carrots, and 1.64 eggs/kg in radish. A similar study in the same area showed that 73% of children working on these farms were infected with helminths, particularly Ascaris, probably as a result of exposure to the raw sewage. Philippine Setting Ascaris is endemic in our country, with prevalence rates of 80-90% in some areas. Furthermore, it affects the most vulnerable sector of the population, children age 2-14 years. Ascariasis thrives in areas where there is lack of sanitation practices, like slum areas in urban centers. The transmission takes place predominantly in yard/compound contaminated with human feces, in field that has been fertilized with human feces and by consumption of contaminated vegetables. When prevalence rate is high in children and low in adults, it means that the household type of transmission prevails, a case in which the area around the house is heavily contaminated through indiscriminate defecation by young children.
Seasonal variations in the incidence of ascariasis show the major peaks for infection; highest infection rate is from July to August while, lowest infection rate is in October and January. It appears that ascaris reinfection and transmission are highest when rainfall is minimal and lowest when rainfall is heaviest.

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Source: B. D. Cabrera, Reinfection and Infection Rates of Ascaris Among Children in Relation to Seasonal Variation, Quezon City, Philippines, Presented at the 6th & 7th APCO Parasitologists' Meeting, Nepal and Tokyo, 1984 and 1985, respectively

Figure 2.3 Infection and Reinfection Rates of Ascaris Among School Children in Relation to Seasonal Variations, Quezon City, Philippines 1984-1985 (Benjamin D. Cabrera)

2.4.7 Prevention Existing Programs of DOH

Soil-transmitted helminthiasis is a persistent problem in the Philippines and it is the only disease concern identified in the National Health Plan which does not have a definitive control plan. Accordingly, the Communicable Disease Control Service has created the Soil-transmitted Helminthiasis Control Program, funded in 1999 under General Appropriations Act (Republic Act 8735 number lll. A.10). There are a number of activities that the Department of Health had organized in order to prevent Ascariasis from spreading; Advocacy, Prevalence

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survey, KAP survey, Manpower development, Building Family Competencies, Mass treatment and Research. A. Advocacy 1. Presentation to and networking of the program with LGUs, NGOs, and other stakeholders to solicit participation in project (e.g., Presentation to provincial boards for possible project site. Presentation to large NGOs for fund assistance to project site) 2. Information dissemination through print materials, and conduct of group meetings and symposia/fora, or other multimedia B. Prevalence survey Purpose of prevalence survey

Prevalence survey is done to get baseline data/information concerning the burden of STH in the community.

It will also guide the planner in designing an appropriate strategy or intervention for the specific area.

The World Health Organization (WHO) recommends that data be collected from schoolchildren since they are representative of the disease burden in the community and are most easily accessible in the schools.

UNIVERSITY OF SANTO TOMAS C. KAP survey

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KAP survey will be conducted in the prevalence survey sampling site to determine the levels of difference in the knowledge, attitude, and practice of the people in the community. Purpose of the KAP

Determine adjustments required in implementing IEC plan. Measure effectivity of IEC plan/development of family competencies at the end of the project.

D. Manpower development Program manpower development

Academic training for national program experts should be comprehensive but condensed to equip trainees on all aspects of program management. Participants in this training will include national and regional coordinators.

Field program training will include structured field experiences in actual program implementation in selected sites with ongoing programs on STH control. Participants in this training will be national and regional coordinators and selected provincial supervisors.

The basic and advanced laboratory skills in STH control training aims to improve the knowledge and skills of medical technologists in laboratory

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identification of STH. Participants will be national, regional, and provincial personnel.

Computer software and applications training (GIS, EPI-INFO, etc.) aim to improve computer skills relevant to database development for parasite control programs. Participants will be national, regional, and provincial personnel.

Health information and community mobilization techniques training will involve principles, concepts, and methods of health information and community mobilization for parasite control programs. Participants will be national, regional, and provincial personnel.

Research training and fellowship will give national and regional personnel basic and advanced training on research principles and actual research.

E. Building family competencies Strategies for and scheduling of the development of family competencies 1-5 should be worked out by LGU using recommended tools to obtain optimum effect. F. Mass treatment G.Research 1. Operational research is encouraged at all levels, with provision for a system of awarding of grants.

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2. Research priorities are on measurement of the effects of control programs, specially on nutrition and educational performance. 3. Alternative intervention Monitoring Monitoring will keep track if work is being carried out the way it should be in accordance with time and budget. It will facilitate early resolution of operational problems. Practical Prevention The ultimate transmission of ascaris depends on contamination of the soil by the egg-laden faeces. Therefore, provision of proper sanitary facilities, coupled with hygiene education, is the best means of prevention and control. There is no practical means of killing the eggs in clay soil under favourable conditions of warmth and moisture. In endemic areas where re-infection rates are high, mass or targeted treatment plans have been quite successful. Human faeces should not be used for fertilizing crops, and no vegetable or fruit from such a field should be eaten raw. It must be noted that even with proper pretreatment of night soil, ascaris eggs retain viability and infectivity than otrher helminthic eggs. It has been reorted that upto 90% of ascaris eggs

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survived sludge treatment for upto 30 weeks and were able to develop motile larvae. Both the eggs are still at the unicellular stage. Eggs are normally at this stage when passed in the stool. Complete development of the larva requires 18 days under favorable conditions.

Chapter 3 Research Methodology 3. 1 Pre-Analytical Phase 3.1.1 Research Design Cross sectional study design is used in this study. The data were obtained from children aged four to twelve in Hospio de San Jose. Determination of Sample Size Random Sampling

Data Collection

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Microscopic analysis, Interpretation and Reporting of Results

Direct Fecal Smear Technique

Stool Sample Collection

Figure 3.1. Schematic Diagram of Research Methodology 3.1.2 Subject of the Study Stool samples were collected from randomly selected children aged four to twelve years old in Hospicio de San Jose. This age group of children was chosen as the subject of the study because they are mostly exposed in soil, the primary medium of transmission of A. lumbricoides, due to lack of proper hygiene, hence, making them more prone in ascariasis.

3.1.3 Sampling Technique Random Sampling was used as the sampling technique in this study. This gives all members of the target age group of four to twelve years of age in Hospicio de San Jose equal chances to participate in the study. 3.1.4 Collection of Specimen Wide mouthed sterile stool specimen containers were provided by the interns. Stool samples were collected by the respondents with the help of the

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Medical Technology Interns. Stool samples were collected by the respondents with the help of the Medical Technology Interns. Samples that were not tested immediately were preserved with 10% formalin and immediately transported to the National Childrens Hospital, Laboratory Department for laboratory analysis. 3.2 Analytical Phase 3.2.1 Direct Fecal Smear Examination The laboratory exam to diagnose the infection of Ascaris lumbricoides among the target population of this study was Direct Fecal Smear Examination. Procedures are as follows: 1. Phisical examination of stool specimen by taking note of color and consistency. 2. Place one drop of NSS/Lugols iodine in the slide. 3. Using an applicator stick get a pinch on stool and then stir it on NSS/Lugols iodine. 4. Place a coverslip, and then view under the microscope. 5. Look for A. limbricoides ova to diagnose positive to ascariasis. 3.3 Post Analytical Phase 3.3.1 Statistical Analysis Prevalence proportion was used to determine the number of existing cases of ascariasis at a given time divided by the population of the age group of four to twelve years old in Boys Town Marikina City.

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Pearson coefficient correlation test was used to evaluate the data and identify possible significant correlation of the factors that may affected the prevalence of ascariasis in Boys town Marikina City.

BIBLIOGRAPHY BOOK: Belizario, V. Y. (2004). Philippine Textbook of Medical Parasitology (2nd ed.). Philippines: University of the Philippines Manila. JOURNAL: Anonymous. (2010). Anemia; Research reports on anemia from Public Health Institute provide new insights. Hematology Week. 474. Galzerano, A., Sabatini, E. & Duri, D. (2010). Ascaris lumbricoides infection: an unexpected cause of pancreatitis in a western Mediterranean country. Eastern Mediterranean Health Journal, 16, 350.

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M S Hesham Al-Mekhlafi; M' Azlin; U Nor Aini; A Shaikh; et al. (2006). Prevalence and Distribution of Soil-Transmitted Helminthiases Among Orang Asli Children Living in Peripheral Selangor, Malaysia. Southeast Asian Journal of Tropical Medicine and Public Health, 37, 40. De Leon, P., Lebensohn, N., Foresto, P., Valverde, J. (2009). Ascaris lumbricoides: Alteration of the erythrocyte superficial charge using the Partition method in Aqueous Two-Phase System. Revista do Instituto de Medicina Tropical de So Paulo, 51, 219. Sivakumar,K., Varkey, S., George, M., Rajendran, F., Hema, R. (2007). Biliary ascariasis. J Indian Assoc Pediatr Surg. 12. Retrieved from http://www.jiaps.com Wani, S. , Ahmad, F., Zargar,S., Dar, P., Dar, Z., and Jan, T. (2008). Intestinal helminths in a population of children from the Kashmir valley, India. Journal of Helminthology. 82, 313-317. Legesse, W. & Gebre-Selassie, S. (2007). Sanitary survey of residential areas using Ascaris lumbricoides ova as indicators of environmental hygiene, Jimma, Ethiopia. Ethiop.J.Health Dev. 21.

INTERNET:
Ascaris lumbricoides: Large Intestinal Roundworm of Humans (n.d.). Retrieve fromhttp://human-

nfections.suite101.com/article.cfm/ascaris_lumbricoides#ixzz0sndaUvww