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Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping



Objective: In marginalized setting, under-nutrition and illnesses due to infectious agents create a vicious circle. In our previous study, we reported that easy-to-do hand hygiene interventions were effective in preventing intestinal parasite infections (IPIs) and reduce the rate of anaemia among school-aged children. The aim of this study was to assess the pattern of associations between IPIs, anaemia and diarrhoea among the school-aged children and to explore if the observed impact of hand-washing and nail clipping interventions in our findings was similar across children with different baseline demographic and disease characteristics. The study was based on the analysis of data that was collected during the randomized controlled trial and hence have used the same study participants and study area. Results: Children with IPIs had a much higher chance of also being anaemic (AOR 2.09, 95% CI 1.15-3.80), having diarrhoea (AOR 2.83, 95% CI 1.57-5.09), and vice versa. Anaemia and diarrhoea were very strongly related (AOR 9.62, 95% CI 5.18-17.85). Overall, hand-washing with soap at key times and weekly nail clipping were efficacious in preventing intestinal parasite re-infection among children despite the differences in baseline demographic characteristics. Trial registration: NCT01619254 (June 09/2012).
Mahmudetal. BMC Res Notes (2020) 13:1
Associations betweenintestinal
parasitic infections, anaemia, anddiarrhoea
amongschool aged children, andtheimpact
ofhand-washing andnail clipping
Mahmud Abdulkader Mahmud1* , Mark Spigt2, Afework Mulugeta Bezabih3, Geert‑Jan Dinant2
and Roman Blanco Velasco4
Objective: In marginalized setting, under‑nutrition and illnesses due to infectious agents create a vicious circle. In
our previous study, we reported that easy‑to‑do hand hygiene interventions were effective in preventing intestinal
parasite infections (IPIs) and reduce the rate of anaemia among school‑aged children. The aim of this study was to
assess the pattern of associations between IPIs, anaemia and diarrhoea among the school‑aged children and to
explore if the observed impact of hand‑washing and nail clipping interventions in our findings was similar across
children with different baseline demographic and disease characteristics. The study was based on the analysis of
data that was collected during the randomized controlled trial and hence have used the same study participants and
study area.
Results: Children with IPIs had a much higher chance of also being anaemic (AOR 2.09, 95% CI 1.15–3.80), hav‑
ing diarrhoea (AOR 2.83, 95% CI 1.57–5.09), and vice versa. Anaemia and diarrhoea were very strongly related (AOR
9.62, 95% CI 5.18–17.85). Overall, hand‑washing with soap at key times and weekly nail clipping were efficacious
in preventing intestinal parasite re‑infection among children despite the differences in baseline demographic
Trial registration: NCT01619254 (June 09/2012)
Keywords: Intestinal parasitic infections, Anaemia, Diarrhoea, Hand‑washing, School‑aged children
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In resourcepoor settings, undernutrition and illnesses
due to infectious diseases are highly prevalent and closely
interlinked. Nutritional deficiencies predispose people
to infection, and infections lead to nutritional deficien-
cies which further reduce resistance to new infections
[13]. Children are especially susceptible to the delete-
rious effects of undernutrition [4] and infections [5] in
developing settings.
In Ethiopia, similar to many developing countries, IPIs
[6, 7] and anaemia [6, 8] are common among schoolaged
children. is suggests that schoolaged children in Ethi-
opia may be vulnerable to the cyclical illeffects of anae-
mia and illnesses due to parasitic infections. However,
there is insufficient evidence regarding the associations
of IPIs, anaemia and diarrhoea among these population
groups in the country.
Open Access
BMC Research Notes
1 Medical Microbiology and Immunology Department, Biomedical
Division, School of Medicine, Mekelle University, PO. Box: 1871, Mekelle,
Full list of author information is available at the end of the article
Page 2 of 6
Mahmudetal. BMC Res Notes (2020) 13:1
Remarkable heterogeneity is documented in the dis-
tribution patterns of IPIs [9]. Several demographic [10],
socioeconomic [11], and environmental [12] factors
influence the distribution patterns of IPIs within a com-
munity. ese factors can create different distributions of
susceptibility to reinfection by IPIs among a population,
and hence, different groups of children may be at differ-
ent risks of parasitic reinfection.
A randomised controlled trial revealed a significant
impact of regular handwashing with soap on the preven-
tion of parasitic reinfection and anaemia among children
[13]. It is unknown if certain characteristics of the chil-
dren also determined the effects of handwashing. One
could imagine, for example, that in areas where parasites
are distributed by polluted water, that handwashing
would not be effective in preventing parasitic infections.
We set out to explore if the effect of handwashing and
nail clipping interventions in our findings [13] was simi-
lar across the study population despite their different
Main text
Description ofthetrial
In our previous randomized controlled trial [13], we
reported that easy-to-do hand washing interventions
were effective in preventing intestinal parasite infections
(IPIs) and reduce the rate of anaemia among school-
aged children. is study was carried out on the analysis
of data collected during the randomized controlled trial
with the objective of assessing whether the observed effi-
cacy of the easy-to-do hand washing interventions was
universally effective to prevent infection among the same
schoolaged children with different socio-demographic
baseline characteristics. Moreover, we aimed to explore
whether infection and malnutrition were interlinked and
hence the infection prevention interventions used in the
previous study would break the vicious cycle of infection
and malnutrition in such marginalized areas for the long-
term health benefits of this population group.
Data collection procedure
Baseline data briefly, demographics (child age, gender,
latrine use, maternal age, family size, family drinking water
source, and living house ownership), socio economic
(maternal education) and preexisting disease character-
istics (IPIs, anaemia, and thinness) were included for this
analysis from data collected during the previous rand-
omized controlled trial [13].
Parasitological analysis Following 6months followup,
fresh stool specimens were collected from the study sub-
jects. Stool specimens were analysed using direct saline
wet mount, formalin ethylacetate concentration tech-
nique [14] and the KatoKatz technique [15]. A child was
classified as reinfected if an infection was detected by any
methods used. Subsamples of stool smears, comprising
10% of the total, were reexamined for quality control pur-
Diarrhoea incidence Data on selfreported diarrhoeal
episodes were collected using a separate questionnaire
on a weekly basis during the study period. Diarrhoea was
defined as the passage of three or more loose or liquid
stools per day [16].
Anthropometry Anthropometric measurements were
taken at the start and the end of the followup in duplicate
and the average of the two measurements was recorded.
Portable weight scales and locally made stadiometers with
a sliding headpiece were used to measure weight (to the
nearest 0.1kg) and height (to the nearest 0.1cm), respec-
tively. Each child was weighed with minimal clothing and
barefooted. e weighing scales were calibrated using
standard calibration weights of 5 kg iron bars. Height
measurements were taken with children faced forwards,
barefooted with feet flat and together, and their heels and
back against the rod. Anthropometric measurements
were converted into BMIforage Z scores using WHO
AnthroPlus software, version 1.0.4 (WHO Anthro 2007,
WHO, Geneva, Switzerland). Children below 2Z scores
for BMIforage were classified as thin.
Statistical analysis
Statistical analysis was computed using SPSS for Win-
dows version 16.0 (Chicago, USA). Associations between
postintervention IPIs, anaemia, and diarrhoea were ana-
lyzed using binary and multivariate logistic regression
models by odds ratios (OR) and 95% confidence intervals
(CI). e impact of handwashing with soap and nail clip-
ping on intestinal parasite reinfection across children
with different demographic and disease characteristics
was analysed using logistic regression models. Stratifica-
tions included baseline demographics (child age, gender,
latrine use, maternal education, maternal age, family size,
family drinking water source, and living house owner-
ship) and preexisting disease characteristics (IPIs, anae-
mia, and thinness). Possible moderating effects of each
baseline variable on the effect of intervention were iden-
tified by adding interaction terms to the regression model
[17]. Statistical significance was set at p < 0.05.
Baseline characteristics and the trial profile of the
original project have been described previously [13].
Briefly, 365 (99%) children were analysed for sixmonth
Page 3 of 6
Mahmudetal. BMC Res Notes (2020) 13:1
followup. Boys comprised 41% (n = 150) of the study
participants and mean age was 10 (SD = 2.6) years. Fol-
lowing 6months followup, 21% (95% CI 17–25%) of the
children were reinfected with intestinal parasites, 18%
(95% CI 14–22%) of the children were anaemic and 17%
(95% CI 13–21%) had diarrhoea.
Table 1 describes the multivariate logistic regression
analysis results of the associations between intestinal
parasitosis, anaemia, and diarrhoea. Effects were adjusted
for each intervention. Current intestinal parasitosis, a
history of diarrhoea in the previous week, and current
anaemia were independently associated. IPIs were sig-
nificantly associated with anaemia (AOR 2.09, 95% CI
1.15–3.80) and diarrhoea (AOR 2.83, 95% CI 1.57–5.09),
and vice versa. Anaemia and diarrhoea were also strongly
related (AOR 9.62, 95% CI 5.18–17.85), meaning that
children with diarrhoea had a very high chance of also
having anaemia, and vice versa.
Both handwashing with soap (AOR 0.32, 95% CI 0.20–
0.62, p = 0.001) and weekly finger nail clipping (AOR
0.51, 95% CI 0.27–0.95, p = 0.035) interventions were
reported to have a significant impact in reducing intes-
tinal parasite reinfection rates among the study partici-
pants [13].
In this study, we explored if these impacts were simi-
lar across children with different demographic and dis-
ease backgrounds. Overall, interventions seem equally
efficacious among children regardless of age, gender,
drinking water source, latrine use, mother’s age, mother’s
education, family size, house ownership, and history of
intestinal parasitosis, anaemia and thinness at baseline
(Table 2). e impact of handwashing was similar for
the whole group and for children who had IPIs at base-
line, but the effect significantly increased in children
who were parasitefree at baseline (AOR 0.48 vs. AOR
0.31, p = 0.048). e effects of handwashing and nail
clipping were higher for children whose drinking water
sources were wells and streams compared to those who
used pipeline and boreholes, but the effects were not
statistically significant (AOR 0.44 vs. AOR 0.08, p = 0.134
and AOR 0.68 vs. AOR 0.09, p = 0.053; respe ctively).
Findings of the present study demonstrate a clear rela-
tionship between IPIs, anaemia and diarrhoea among
children. Children with IPIs had a much higher chance
of also being anaemic and having diarrhoea. Anaemia
and diarrhoea were also very strongly related, as chil-
dren with diarrhoea had a very high chance of also hav-
ing anaemia, and vice versa. Hand-washing with soap and
nail clipping prevents the children from intestinal para-
site infections regardless their demographic differences
and hence breaks the vicious cycle of IPIs, anemia and
diarrhoea among the children.
Associations observed between anaemia and IPIs in
our data concord with other studies that showed IPIs to
be substantially linked with anaemia in children [1821].
IPIs can decrease food and nutrient intake, cause intes-
tinal blood losses, induce red blood cell destruction by
the spleen, and induce autoimmune reactions leading to
chronic inflammation [20, 21]. ese effects may have
accounted for the considerable proportion of anaemia
observed among the children infected with intestinal
Although in most instances IPIs are asymptomatic,
they may also cause diarrhea [22]. IPIs can induce diar-
rhoea by increasing small intestine motility while reduc-
ing its digestive and absorptive capacities [23]. Our
finding that diarrhoea may contribute substantially to
anaemia among children was also consistent with other
reports from developing settings [24]. Diarrhoeal dis-
eases are reported to be associated with an increased
production of cytokines, interleukin 6 and tumour necro-
sis factor alpha [25]. ese cytokines are indicated to play
a significant role in causing anaemia [24]. Repeated epi-
sodes of diarrhoea in children are also reported to lead
to decreased nutrient absorption, due to injury of the
small intestine mucosa [26]. In our data, anaemia was
Table 1 Associations between intestinal parasitic infections, anaemia and diarrhoea among school-aged children,
Ethiopia (n = 365)
CI 95% condence interval, AOR adjusted odds ratio as computed by the logistic regression model, IPI intestinal parasitic infection
*Statistically signicant at 0.05
Post-intervention out-come variables (n) Post-intervention out-come variables
IPI Anaemia Diarrhoea
IPI (79) 2.09 (1.15 to 3.80)* 2.83 (1.57 to 5.09)*
Anaemia (81) 2.09 (1.15 to 3.80)* 9.62 (5.18 to 17.85)*
Diarrhoea (68) 2.83 (1.57 to 5.09)* 9.62 (5.18 to 17.85)*
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Mahmudetal. BMC Res Notes (2020) 13:1
Table 2 Impact of hand-washing on parasite re-infection rates across children withdierent base-line demographic
anddisease characteristics (n = 365)
CI 95% condence interval, AOR adjusted odds ratio
*Statistically signicant at 0.05
a Adjusted for intervention
Hand-washing vs. control Nail clipping vs. control
0.43 (0.24, 0.68) 0.59 (0.36, 0.98)
Gender Male
150 (41%)
215 (49%)
150 (41%)
215 (49%)
0.41 (0.17, 0.97) 0.39 (0.20, 0.75) 0.34 (0.14, 0.82) 0.79 (0.41, 1.51)
p = 0.923 p = 0.131
Age 6–9 years 10–15 years 6–9 years 10–15 years
208 (57%) 157 (43%) 208 (57%) 157 (43%)
0.30 (0.13, 0.66) 0.50 (0.25, 1.01) 0.50 (0.23, 1.09) 0.66 (0.33, 1.31)
p = 0.338 p = 0.604
Water source Pipeline and borehole Wells and streams Pipeline and borehole Wells and streams
321 (88%) 44 (12%) 321 (88%) 44 (12%)
0.44 (0.25, 0.76) 0.08 (0.01, 0.68) 0.68 (0.39, 1.17) 0.09 (0.13, 0.64)
p = 0.134 p = 0.053
Latrine use Yes No Yes No
139 (38%) 226 (62%) 139 (38%) 226 (62%)
0.33 (0.13, 0.81) 0.44 (0.23, 0.84) 0.48 (0.20, 1.19) 0.61 (0.32, 1.16)
p = 0.744 p = 0.791
Mother education Literate Illiterate Literate Illiterate
161 (44%) 204 (56%) 161 (44%) 204 (56%)
0.58 (0.26, 1.30) 0.28 (0.14, 0.58) 0.83 (0.37, 1.85) 0.42 (0.21, 0.84)
p = 0.198 p = 0.207
Maternal age 35 > 35 35 > 35
193 (53%) 172 (47%) 193 (53%) 172 (47%)
0.22 (0.09, 0.51) 0.58 (0.28, 1.22) 0.58 (0.21, 1.58) 0.71 (0.25, 2.02)
p = 0.085 p = 0.787
Family size 6 members > 6 members 6 members > 6 members
208 (57%) 157 (43%) 208 (57%) 157 (43%)
0.27 (0.13, 0.54) 0.69 (0.31, 1.55) 0.60 (0.30, 1.17) 0.53 (0.23, 1.20)
p = 0.082 p = 0.814
House ownership Yes No Yes No
307 (84%) 58 (16%) 307 (84%) 58 (16%)
0.45 (0.26, 0.79) 0.17 (0.03, 0.88) 0.71 (0.40, 1.24) 0.19 (0.05, 0.77)
p = 0.661 p = 0.386
Baseline parasite infection status Yes No Yes No
146 (40%) 219 (60%) 146 (40%) 219 (60%)
0.48 (0.23, 1.01) 0.31 (0.14, 0.67) 0.44 (0.20, 0.97) 0.69 (0.34, 1.43)
p = 0.048* p = 0.696
Baseline anemia status Yes No Yes No
106 (29%) 259 (71%) 106 (29%) 259 (71%)
0.59 (0.25, 1.39) 0.32 (0.16, 0.64) 0.54 (0.23, 1.26) 0.60 (0.31, 1.15)
p = 0.577 p = 366
Baseline BMI‑for‑age Thin Normal Thin Normal
150 (41%) 215 (59%) 150 (41%) 215 (59%)
0.33 0.15, 0.75) 0.45 (0.23, 0.91) 0.44 (0.20, 0.97) 0.71 (0.36, 1.42)
p = 0.577 p = 0.366
Page 5 of 6
Mahmudetal. BMC Res Notes (2020) 13:1
also an independent risk factor for both IPIs and diar-
rhoea. In agreement with our findings, Levy et al. [27]
have reported that anaemia increases rates of infection
in children. Furthermore, reports from several studies
have indicated that anaemia can predispose people to
infections by lowering host immunity [28, 29]. In general,
our findings strengthen the wellestablished notion that
infection and malnutrition are intricately linked [1, 30,
e observed significant preventive impact of hand
washing and nail clipping on intestinal parasite re
infection rates made us curious to explore whether
the intervention effect noted in the whole cohort was
homogenous across children with different backgrounds.
Handwashing with soap and nail clipping interven-
tions consistently favoured reduction of intestinal para-
site reinfection rates across each subgroup analysed.
A significant difference in the effect of handwashing
was observed only for baseline parasitic infection sta-
tus. Based on our data, it is possible to suggest that ben-
efit from the interventions is likely to be more universal
among the study groups. e observed increased benefit
of handwashing among children who were parasitefree
at baseline should be interpreted with caution, although
analyses were based on formal tests of interaction. Chil-
dren were made parasitefree at recruitment and this
might have affected our analysis at followup. e differ-
ence in effect for handwashing and nail clipping between
children who use pipeline and borehole water sources
and those using wells and streams is quite large, but not
significant because of the small number of children who
use wells and streams.
In conclusion, our findings emphasise that intestinal
parasitosis, anaemia and diarrhoea were independently
associated. Furthermore, handwashing with soap and
nail clipping were efficacious in preventing intestinal par-
asite reinfection despite baseline differences and hence
can be universally used as infection prevention interven-
tions among schoolaged children to break the vicious
cycle of infection and malnutrition for the longterm
health benefits of this population.
e following limitation should be considered when
interpreting the results of the present study: the study
was powered to determine the overall effect of the inter-
ventions in the original randomized controlled trial. Our
subgroup analyses might hence be underpowered to
detect subgroup effects, unless the differences in treat-
ment effects between subgroups would have been very
AOR: adjusted odds ratio; BMI: body‑mass‑index; CI: confidence interval; IPIs:
intestinal parasitic infections; OR: odds ratio; SD: standard deviation; WHO:
World Health Organization.
The authors are grateful for all the children and their parents and/or guard‑
ians for the participation. We thank the fieldworkers who implemented the
interventions and carried out the follow‑up. We express our sincere gratitude
to the laboratory personnel involved in the field work. Our sincere acknowl‑
edgement also goes to the Tigray Regional Health Bureau, Mekelle University,
Ethiopia and Alcala University, Spain for their support and cooperation.
Authors’ contribution
MAM participated in all phases of the study including writing the proposal,
data collection and writing the manuscript. MAM, MS, AMB, G‑JD, RBV con‑
ceived and designed the experiments. MAM, MS, and G‑JD analysed the data.
MAM and MS wrote the first manuscript. MAM, MS, AMB, G‑JD and RBV con‑
tributed to the writing of the manuscript. MS and G‑JD revised and approved
the manuscript. All authors have read, and confirm that they meet, ICMJE
criteria of authorship. All authors read and approved the final manuscript.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Ethics approval and consent to participate
The study protocol and informed consent procedure for the initial randomized
controlled trial was approved by the Institutional Review Board of the College
of Health Sciences, Mekelle University, Ethiopia. Written informed consent
was obtained from each child’s parents and/or guardians. Children diagnosed
positive for IPIs at followup were treated with standard medication [16], and
children with anaemia and/or diarrhoea were sent to the health facilities for
further medical attention.
Consent for publications
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Medical Microbiology and Immunology Department, Biomedical Division,
School of Medicine, Mekelle University, PO. Box: 1871, Mekelle, Ethiopia.
2 Department of Family Medicine, CAPHRI School for Public Health and Pri‑
mary Care, Maastricht University, Maastricht, The Netherlands. 3 School of Pub‑
lic Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia.
4 Department of Surgery, School of Medicine, Alcala University, Madrid, Spain.
Received: 29 October 2019 Accepted: 20 December 2019
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... Our final assessment of access to hygiene indicators of WASH demonstrates (1) the consequences of poor parental involvement (23% do not know if their child uses soap in schools) in monitoring WASH services and (2) the necessity to establish or improve the previously mentioned parent-teacher collaboration. The postulate of a causal link of non-compliance with the rules of personal hygiene and an increase in the incidence of diseases is constantly brought to the attention of children [18,44,45]. At the same time, the insufficient level of access to hygiene items at school creates a paradoxical situation (discrepancy between desire and opportunity) among students, which in the future could potentially become one of the triggers for the development of unwillingness to observe hygiene rules, due to accumulated negative experiences. ...
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The WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation and Hygiene (WASH) produces global estimates of the real situation of access to water, sanitation and hygiene services, and sanitation and hygiene in households, educational institutes and health care facilities; however it is lacking data on schools in Kazakhstan. Thus, the aim of this research was to assess access to WASH in schools of urban area in Kazakhstan. The study was conducted in seven schools of Central Kazakhstan during the COVID-19 pandemic and restrictive measures. Three data collection methods were used: a questionnaire for administrative staff, a questionnaire for parents and observation. Parents of offline study pupils (only second and third grades due to the pandemic) were included in the survey. Students had access to in-building toilets in all schools connected to the centralized sewer. The number of school toilets varied from 7 (KAZ200085) to 61 (KAZ200089). The average amount of toilets was 28.08 ± 16.97. Only two out of seven schools complied with the requirements of Kazakhstan national sanitary standards for the ratio of school toilets to the number of students. From the questionnaire with the school administrations, it was defined that the primary source of drinking water was the public water supply. All schools regularly disinfect and check the water supply system. At the same time, the results also revealed discrepancies in the answers between administration and parents (2.6% of parents showed that their children have rare access to drinking water), and insufficient monitoring of implementation of WASH services. This study also confirmed that the full provision of access to water and water services in the structure of educational institutions solves several SDG targets.
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Background: It is estimated that 1.5 billion people are infected with soil-transmitted helminths (STHs) worldwide. Re-infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours. Objectives: To assess the effectiveness of WASH interventions to prevent STH infection. Search methods: We used standard, extensive Cochrane search methods. The latest search date was 19 October 2021. Selection criteria: We included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non-random method (non-RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome. Data collection and analysis: Two review authors independently reviewed titles and abstracts and full-text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non-RCTs. We used a random-effects meta-analysis to pool study estimates. We used Moran's I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach. Main results: We included 32 studies (16 RCTs and 16 non-RCTs) involving a total of 52,944 participants in the review. Twenty-two studies (14 RCTs (16 estimates) and eight non-RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty-one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non-RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non-RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non-RCTs); and one on the prevalence of S stercoralis (1 non-RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non-RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non-RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non-RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis. The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate-certainty evidence) and an OR of 0.71 amongst non-RCTs (95% CI 0.54 to 0.94; low-certainty evidence). All six of the meta-analyses assessing individual worm infection amongst both RCTs and non-RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome. We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA). Authors' conclusions: Whilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.
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Background: Diabetes mellitus is emerging as a major worldwide health problem that has a social, financial, and developmental impact on developing countries. Foot complications are among the most serious and costly complications of diabetes which lead to lower extremity amputation due to diabetic foot ulcers. Poor diabetic foot self-care practice is identified by different studies as a major contributing factor to diabetic foot ulcers. Therefore, this study was intended to assess foot self-care practice and associated factors among diabetic patients attending the University of Gondar comprehensive specialized referral hospital. Methods: A hospital-based cross-sectional study was conducted from July 1 to August 30, 2021, at the University of Gondar comprehensive specialized referral hospital. A systematic random sampling technique was employed to select 384 diabetic patients. A structured pretested interviewer-administered questionnaire was used to collect data. The data was entered in epi-info version 7, analyzed using SPSS version 21, and presented using frequencies, percentages, tables, and graphs. Bivariable and multivariable analyses were investigated using a binary logistic regression model. P-value < 0.05 and an odds ratio with a 95% confidence interval were used to determine the significance and strength of the association. Results: Of the 384 diabetic patients, 46.4% (95% CI (41.1%-51.6%)) of them had poor foot self-care practice. Being male [AOR = 0.54, 95% CI (0.32, 0.89)], couldn't read and write and completed primary education [AOR = 2.35, 95% CI (1.01, 5.43)] & [AOR = 2.92, 95% CI (1.39, 6.12)], living in rural area [AOR = 3.84, 95% CI (1.91, 7.75)], having diabetic complications [AOR = 2.19, 95% CI (1.07, 4.46)], taking both injection and pills [AOR = 0.33, 95% CI (0.12, 0.88)], having previous information about foot care [AOR = 0.12, 95% CI (0.06, 0.24)], and family support [AOR = 0.57, 95% CI (0.34, 0.94)] were determinants of poor foot self-care practice. Conclusion: The adherence of diabetic patients toward foot self-care practice was poor. Being male, having low educational status, living in a rural area, having diabetic-related complications, taking both injections and pills, not having previous information about foot care, and having poor family support increases the odds of having poor foot self-care practice. Giving health education to patients and their caregivers about the basic principles of diabetes foot care, like regular inspection of feet and appropriate footwear at their regular follow-up time, should be emphasized.
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Background Recent studies have shown that dietary carbohydrate quantity and quality as well as genetic variants may contribute to determining the metabolic rate and general and central obesity. This study aimed to examine interactions between melanocortin 4 receptor gene (MC4R) rs17782313 and dietary carbohydrate intake, glycemic index (GI), and glycemic load (GL) on body mass index (BMI), waist circumferences (WC), basal metabolic rate (BMR), and BMR/kg in overweight/obese women. Methods A total of 282 Iranian women (BMI ≥ 25) aged 18–56 years were enrolled in this cross-sectional study. All participants were assessed for blood parameters, body composition, BMR, and dietary intake. Dietary carbohydrate intake, GI, and GL were determined using a valid, reliable 147-item food frequency questionnaire. MC4R rs17782313 was genotyped by the restriction fragment length polymorphism (PCR-RFLP) method. Results After adjustment for age and energy intake, significant interactions were observed between carbohydrate intake and MC4R rs17782313 in terms of BMI (P Interaction = 0.007), WC (P Interaction = 0.02), and BMR/kg (P Interaction = 0.003) in this way that higher carbohydrate intake, compared with lower intake, was associated with an increase in BMI and WC for individuals with C allele carriers (TC + CC genotypes), while related to an increase in BMR/kg for those carrying the TT genotype. No significant interaction was found between MC4R rs17782313 and GI and GL on BMI, WC, BMR/kg, and BMR. Conclusions Interactions between the MC4R rs17782313 and carbohydrate intake probably can have an effect on BMI, WC, and BMR/kg in overweight/obese women.
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SARS-CoV-2 continued circulation results in mutations and the emergence of various variants. Until now, whenever a new, dominant, variant appeared, it overpowered its predecessor after a short parallel period. The latest variant of concern, Omicron, is spreading swiftly around the world with record morbidity reports. Unlike the Delta variant, previously considered to be the main variant of concern in most countries, including Israel, the dynamics of the Omicron variant showed different characteristics. To enable quick assessment of the spread of this variant we developed an RT-qPCR primers-probe set for the direct detection of Omicron variant. Characterized as highly specific and sensitive, the new Omicron detection set was deployed on clinical and wastewater samples. In contrast to the expected dynamics whereupon the Delta variant diminishes as Omicron variant increases, representative results received from wastewater detection indicated a cryptic circulation of the Delta variant even with the increased levels of Omicron variant. Resulting wastewater data illustrated the very initial Delta-Omicron dynamics occurring in real time. Despite this, the future development and dynamics of the two variants side-by-side is still mainly unknown. Based on the initial results, a double susceptible-infected-recovered model was developed for the Delta and Omicron variants. According to the developed model, it can be expected that the Omicron levels will decrease until eliminated, while Delta variant will maintain its cryptic circulation. If this comes to pass, the mentioned cryptic circulation may result in the reemergence of a Delta morbidity wave or in the possible generation of a new threatening variant. In conclusion, the deployment of wastewater-based epidemiology is recommended as a convenient and representative tool for pandemic containment.
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This study aimed to determine the efficacy of Inoserp, Vins bioproducts, and South African Institute of Medical Research (SAIMR) polyvalent antivenoms in neutralizing Naja ashei venom-induced lethality in mice. The neutralization efficacy of the antivenoms were expressed as effective dose, median effective ratio, potency, normalized potency, volume, and the number of vials of antivenom required to neutralize 100 mg of Naja ashei venom (NAV).
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Objective Workers from various industries use personal protective equipment (PPE) including masks, respirators, and hearing protection to reduce their exposures to workplace hazards. Many studies have evaluated the physiological impacts of PPE use, but few have assessed the psychological impacts. The aim of the present study was to carry out a scoping review to compile existing evidence and determine the extent of knowledge on workplace mask, respirator or hearing protection use as a psychosocial hazard (stressor) that could result in a stress response and potentially lead to psychological injury. Methods The scoping review followed recognized methods and was conducted using Ovid Emcare, PubMed, Sage Journals, ScienceDirect, Scopus, SpringerLink, Google Scholar and preprint databases (OSF Preprints and medRxiv). Articles on the stressors associated with the use of masks, respirators, and hearing protection were included. The extracted data included author(s) name, year of publication, title of article, study design, population data, stressors assessed, and key findings. Results We retrieved 650 articles after removal of duplicates, of which 26 were deemed eligible for inclusion for review. Identified factors associated with PPE use that could potentially create a stress response were identified: communication impacts, physical impacts, psychological illness symptoms, cognitive impacts, and perceived PPE-related impacts. Evidence for respirators suggest that there may be psychological injury associated with their use. However, hearing protection appears to have a protective effect in reducing psychological symptoms such as anxiety, depression, and aggression. Conclusions Mask or respirator use may lead to an increase in work-related stress. Whereas hearing protection may have protective effects against psychological symptoms and improves speech intelligibility. More research is needed to better understand potential psychosocial impacts of mask, respirator and/or hearing protection use.
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Introduction The novel (COVID-19 was first reported to have originated in Wuhan, China, in December 2019. This new strain, SARS‐CoV‐2, has spread rapidly worldwide, prompting the WHO to declare the COVID-19 outbreak a global pandemic. The main objective of this cohort study is to determine the risk factors of COVID-19, the modes of COVID-19 vertical transmission, and the maternal and fetal outcomes among non-pregnant and pregnant women and their fetuses. Methods and analysis This is a multicentre epidemiological study that will involve a prospective cohort. COVID-19 status among consulting non-pregnant and pregnant women in public hospitals in Manila, Philippines, will be determined and monitored for 6–12 months. Swab specimens from the nasopharynx, cervix, rectum, amniotic fluid, placenta, cord blood and breastmilk will be collected during consult and admission for reverse transcription-PCR (RT-PCR) testing. Blood will be collected during the postdelivery period to monitor the women and their neonates for any undue development and determine the antibody development to indicate an infective or non-infective state. Evidence of vertical transmission will be explored with the presence or absence of the virus using the maternal and fetal neonatal RT-PCR and lateral flow antibody status. Descriptive and inferential statistics will be done, including the associations between exposures and risk factors, description of clinical characteristics, and the COVID-19 status of the participants. Ethics and dissemination The Single Joint Research Ethics Board of the Department of Health has approved this protocol (SJREB 2020-30). The study results will be disseminated through conference presentations, peer-reviewed articles, and various stakeholder public forums and activities.
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Antivenom immunotherapy is the mainstay of treatment for snakebite envenoming. Most parts of the world affected by snakebite envenoming depend on broad-spectrum polyspecific antivenoms that are known to contain a low content of case-specific efficacious immunoglobulins. Thus, advances in toxin-specific antibodies production hold much promise in future therapeutic strategies of snakebite envenoming. We report anti-3FTxs monoclonal antibodies developed against N. ashei venom in mice. All the three test mAbs (P4G6a, P6D9a, and P6D9b) were found to be IgG antibodies, isotyped as IgG1. SDS-PAGE analysis of the test mAbs showed two major bands at approximately 55 and 29 kDa, suggestive of immunoglobulin heavy and light chain composition, respectively. The immunoaffinity-purified test mAbs demonstrated higher binding efficacy to the target antigen compared to negative control. Similarly, a cocktail of the test mAbs was found to induce a significantly higher inhibition (p-value < 0.0001) compared to two leading commercial brands of antivenoms on the Kenyan market, implying a higher specificity for the target antigen. Both the test mAbs and 3FTxs polyclonal antibodies induced comparable inhibition (p-value = 0.9029). The inhibition induced by the 3FTxs polyclonal antibodies was significantly different from the two antivenoms (p-value < 0.0001). Our results demonstrate the prospects of developing toxin-specific monoclonal-based antivenoms for snakebite immunotherapy
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Intestinal parasitic infections are highly endemic among school-aged children in resource-limited settings. To lower their impact, preventive measures should be implemented that are sustainable with available resources. The aim of this study was to assess the impact of handwashing with soap and nail clipping on the prevention of intestinal parasite reinfections. In this trial, 367 parasite-negative school-aged children (aged 6-15 y) were randomly assigned to receive both, one or the other, or neither of the interventions in a 2 × 2 factorial design. Assignment sequence was concealed. After 6 mo of follow-up, stool samples were examined using direct, concentration, and Kato-Katz methods. Hemoglobin levels were determined using a HemoCue spectrometer. The primary study outcomes were prevalence of intestinal parasite reinfection and infection intensity. The secondary outcome was anemia prevalence. Analysis was by intention to treat. Main effects were adjusted for sex, age, drinking water source, latrine use, pre-treatment parasites, handwashing with soap and nail clipping at baseline, and the other factor in the additive model. Fourteen percent (95% CI: 9% to 19%) of the children in the handwashing with soap intervention group were reinfected versus 29% (95% CI: 22% to 36%) in the groups with no handwashing with soap (adjusted odds ratio [AOR] 0.32, 95% CI: 0.17 to 0.62). Similarly, 17% (95% CI: 12% to 22%) of the children in the nail clipping intervention group were reinfected versus 26% (95% CI: 20% to 32%) in the groups with no nail clipping (AOR 0.51, 95% CI: 0.27 to 0.95). Likewise, following the intervention, 13% (95% CI: 8% to 18%) of the children in the handwashing group were anemic versus 23% (95% CI: 17% to 29%) in the groups with no handwashing with soap (AOR 0.39, 95% CI: 0.20 to 0.78). The prevalence of anemia did not differ significantly between children in the nail clipping group and those in the groups with no nail clipping (AOR 0.53, 95% CI: 0.27 to 1.04). The intensive follow-up and monitoring during this study made it such that the assessment of the observed intervention benefits was under rather ideal circumstances, and hence the study could possibly overestimate the effects when compared to usual conditions. Handwashing with soap at key times and weekly nail clipping significantly decreased intestinal parasite reinfection rates. Furthermore, the handwashing intervention significantly reduced anemia prevalence in children. The next essential step should be implementing pragmatic studies and developing more effective approaches to promote and implement handwashing with soap and nail clipping at larger scales.
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School age children are one of the groups at high risk for intestinal parasitic infections especially in developing countries like Ethiopia as the supply of good quality drinking water and latrine coverage are poor. Though there are previous data on the prevalence of soil transmitted helminths (STHs) and Schistosoma mansoni infection among these high risk groups current status in the study area is unknown. Therefore, the aim of this study was to determine the current prevalence and associated risk factors of STHs and S. mansoni infections among school children. A cross-sectional study was carried out in Gorgora and Chuahit towns, North Gondar Zone, North West Ethiopia from January 20 to February 25, 2012 involving 261 school children. A pre-tested and structured questionnaire was used to collect socio-demographic data and possible risk factors. Stool samples were collected and examined for intestinal parasites using Kato Katz method. Chi-square test was used to see if there is association between sociodemographic factors and other risk factors for STH and S.mansoni infection and odds ratio with 95% CI was computed as measures of association. P < 0.05 was taken as statistically significant. Out of the 261 study participants, 174 (66.7%) were infected with one or more species of intestinal parasites. Ascaris lumbricoides was the predominant isolates (39.8%) followed by Trichuris trichiura (6.1%) and Hookworms (4.9%). Schistosoma mansoni was detected in 33.7% of the children. Among infected individuals, 9.5% were coinfected by S.mansoni and A.lumbricoides and 1.5% with S.mansoni and T.trichiura. Swimming habit (OR: 2.536, 95% CI: 1.122, 5.737, P = 0.022) was significantly associated with S.mansoni infection. The prevalence of STH and S. mansoni was high among school children. This should call for implementation of an integrated strategy to reduce morbidity and control of transmission of STH and S. mansoni.
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Anemia is a major health problem worldwide. Because of health and socioeconomic problems, the prevalence of anemia is higher in developing countries. Children and pregnant women are the most vulnerable groups to anemia. The aim of the present study was to determine the magnitude of anemia among school children. A cross-sectional household survey was conducted in January 2011 on 423 children, aged 6-14 years, selected through systematic random sampling method. Sociodemographic and anthropometric data were collected using a pre-tested questionnaire. Capillary blood was taken from the fingertip of each child and hemoglobin was measured using HaemoCue digital photometer. All the necessary safety measures were taken during blood collection. Anthropometric indicators were measured using WHO's guideline. Data analysis was made using SPSS Version 16.0 for Windows. The association between predictors and outcome variables were measured by a stepwise logistic regression model. Ethical permission was obtained; consent of the parents/guardian was taken and confidentiality was maintained.Result: A total of 404 children were studied. The mean age was 10.21(SD +/- 1.89) years. The proportion of females was 217(53.7 %). The mean hemoglobin level for both sexes was 11.59(SD +/- 1.97 g/dl). The current prevalence of anemia was 152(37.6 %), out of which, 73(18.1 %) had mild while 79(19.6 %) of them had moderate anemia. The prevalence of anemia among the age group of 6-11 years was 118(40.5 %) while the prevalence among the group of 12-14 years old children was 34(30.1 %). Among the selected variables in the logistic regression analysis, low family income [OR = 4.925, 95%CI(1.063,22.820)], mothers' education [OR = 4.621,95%CI(1.383,15.439)], intake of plant food [OR = 3.847,95%CI(2.068, 7.157)] and intake of animal food [OR = 2.37, 95%CI(1.040,5.402)] were significantly and independently associated with anemia. Anemia is a moderate public health problem in the study area. Family income, educational status of parents and inadequate plant and animal food intake are the predictors of anemia. Improving the economic status of the family, women education and health education about balanced animal and plant food consumption are recommended strategies to reduce the burden of anemia.
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Diarrhea is still responsible for high rates of morbidity and mortality in children under 5 years of age. The prolongation of the acute episode may cause digestive and absorptive malfunction and, consequently, malnutrition, raising the risk of death. The objective of this review is to supply the most recent knowledge in the field of persistent diarrhea and to contribute to the decrease of its incidence. Some possible etiologic agents may be involved, including viruses, bacteria, and parasites. Treatment must be addressed to avoid malabsorption of the nutrients of the diet, associated with replacement of the hydroelectrolytic losses, to prevent its prolongation. In the great majority of the episodes, antibiotics are not indicated. Breastfeeding, introduction of safe dietary strategies to prevent protein-energy malnutrition, and improvement of sanitary conditions and hygiene are measures to be promoted with the objective of decreasing the morbidity/mortality of the diarrheic disease in children less than 5 years of age.
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Background More than 1 billion people are currently infected with soil-transmitted helminths and schistosomes. The global strategy to control helminthiases is the regular administration of anthelmintic drugs to at-risk populations. However, rapid re-infection occurs in areas where hygiene, access to clean water, and sanitation are inadequate. Methodology In July 2011, inhabitants from two villages and seven hamlets of the Taabo health demographic surveillance system in south-central Côte d’Ivoire provided stool and urine samples. Kato-Katz and ether-concentration methods were used for the diagnosis of Schistosoma mansoni, soil-transmitted helminths (Ascaris lumbricoides, Trichuris trichiura, and hookworm), and intestinal protozoa. Urine samples were subjected to a filtration method for the diagnosis of Schistosoma haematobium. A questionnaire was administered to households to obtain information on knowledge, attitude, practice, and beliefs in relation to hygiene, sanitation, and defecation behavior. Logistic regression models were employed to assess for associations between questionnaire data and parasitic infections. Principal Findings A total of 1,894 participants had complete data records. Parasitological examinations revealed prevalences of hookworm, S. haematobium, T. trichiura, S. mansoni, and A. lumbricoides of 33.5%, 7.0%, 1.6%, 1.3% and 0.8%, respectively. Giardia intestinalis and Entamoeba histolytica/E. dispar were detected in 15.0% and 14.4% of the participants, respectively. Only one out of five households reported the presence of a latrine, and hence, open defecation was common. Logistic regression analysis revealed that age, sex, socioeconomic status, hygiene, and defecation behavior are determinants for helminths and intestinal protozoa infections. Conclusions/Significance We found that inadequate sanitation and hygiene behavior are associated with soil-transmitted helminths and intestinal protozoa infections in the Taabo area of south-central Côte d’Ivoire. Our data will serve as a benchmark to monitor the effect of community-led total sanitation and hygiene education to reduce the transmission of helminthiases and intestinal protozoa infections.
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Health inequities are a common problem for all countries and are the result of not only adverse social conditions but also poor public policies. Today chronic diseases represent the most relevant threats and are a current challenge. Parasitic infections, a leading cause of child morbidity affecting low-income populations, can be transmitted because of an unhealthy environment. Notwithstanding, scarce data have been published on the epidemiological profile of intestinal parasitoses in asymptomatic children living in shantytowns. Vulnerable populations settled in slums are growing in Argentina, particularly in Buenos Aires city. Consequently, this work intended to screen healthy carriers of enteric parasites and determine the epidemiologic profile in asymptomatic children residing in one of those communities, to explore risk factors associated with the transmission of parasites, and to initiate a basic health education campaign to promote healthy behavior in the community. Fecal samples (n = 138) were analyzed by conventional parasitological methods and a survey gathered data on symptoms, family composition, and environmental and hygiene-related variables. High prevalence of feco-orally-transmitted parasitoses (83·3%) and polyparasitism were remarkable findings. The main environmental health determinants were those related to excreta disposal and water provision. Health promotion actions were performed through the diffusion of a set of posters with iconic images and brief messages for health education. Results suggest the need for an environmental sanitation policy to complement health promotion actions. It is essential to spread the results of investigations that address inequities and social determinants of health in order to integrate data with local political processes and alert on acceptable actions for developing appropriate interventions.
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Intestinal parasite infections have been known to compromise the quality of human life since prehistoric times. Throughout the ages, human civilizations have fought against parasitism, including intestinal parasites. During the second half of the last century, the focus of disease-combating efforts moved to other imminent public health issues, under the notion that the fight against infectious diseases had been won. However, the disease incidence data indicate that these diseases continue to wreak havoc on human productivity across the globe. Lately, chemotherapeutic intervention has been stressed for the control of intestinal parasitic infections. In this paper we evaluate the need for a holistic approach to address this issue and make recommendations for this cause.
Research on associated risk factors for intestinal parasitic infections and malnutrition in various geographic regions is needed for the development of appropriate control strategies. The aim of this study was to determine the risk factors associated with intestinal parasitic infections, anaemia, and malnutrition in school children, living in urban and rural areas of northern Ethiopia. Six hundred school children, aged 6-15 years, were randomly selected in a cross-sectional survey from 12 primary schools. Sociodemographic and anthropometric data were collected. Faecal samples were examined using direct, concentration, and the Kato-Katz methods. Urine specimens were analysed for Schistosoma haematobium ova. Haemoglobin was measured using a HemoCue spectrometer. The overall prevalence of intestinal parasitosis was 72% (95% confidence interval (CI): 66-76%). The prevalence of anaemia, stunting, and thinness were 11% (95% CI: 8-13%), 35% (95% CI: 31-38%), and 34% (95% CI: 30-38%), respectively. Poor personal hygiene habits were generally associated with anaemia and nutritional deficiency (low body mass index). Multivariate logistic regression models related Schistosoma mansoni infection with boys. Boys were also more likely to be malnourished. Hookworm infection was associated with anaemia and unhygienic finger nails. Access to clean water and latrines, with some hygiene and sanitation communication activities, could improve health of children in Ethiopia. The use of smartphone technology in demographic data collection proved to be successful. The potential advantage offered by this technology for parasitological field surveys merits further investigation.
Infections are an uncommon cause of chronic diarrhoea. Parasites are most likely, including protozoa like giardia, cryptosporidia and cyclospora. Bacteria are unlikely to cause chronic diarrhoea in immunocompetent individuals with the possible exception of Yersinia, Plesiomonas and Aeromonas. Infectious diarrhoea can trigger other causes of chronic diarrhoea, including inflammatory bowel disease, irritable bowel syndrome and "Brainerd-type" diarrhoea. A thorough evaluation should detect most infections causing chronic diarrhoea.
Giardia is a protozoan parasite of the small intestine, and a leading cause of diarrhoeal disease worldwide in a variety of animals, including humans. The host-parasite interaction and pathophysiological processes of giardiasis remain incompletely understood. Current research suggests that Giardia-induced diarrhoeal disease is mediated by small intestinal malabsorption and maldigestion, chloride hypersecretion and increased rates of small intestinal transit. Small intestinal malabsorption and maldigestion results from the CD8+ lymphocyte-induced diffuse shortening of brush border microvilli. Activation of CD8+ lymphocytes occurs secondary to small intestinal barrier dysfunction, which results from heightened rates of enterocyte apoptosis and disruption of epithelial tight junctions. Both host and parasite factors contribute to the pathogenesis of giardiasis and ongoing research in this field may elucidate genotype/assemblage-specific pathogenic mechanisms. Giardia infections can result in chronic gastrointestinal disorders such as post-infectious Irritable Bowel Syndrome and symptoms may manifest at extra-intestinal sites, even though the parasite does not disseminate beyond the gastrointestinal tract. The infection can cause failure to thrive in children. Furthermore, there is now evidence suggesting that Giardia symptoms may vary between industrialised and developing areas of the world, for reasons that remain obscure. More research is needed to improve our understanding of this parasitic infection which was recently included in the World Health Organisation "Neglected Disease Initiative".