Current Status of Intestinal Parasites among Elementary School children in Sohag, Egypt

| Intestinal parasitic infections (IPIs) are of the maximum generic of human infections international, causing extensive morbidity and mortality particularly in children. Our aim was to estimate the situation of IPIs in stool and fingernails samples among elementary schoolchildren in Sohag, Egypt. In this cross-sectional research stool specimens from 200 schoolchildren were inspected macroscopically and microscopically by formol-ether sedimentation, after that staining with Kinyoun’s modified acid-fast stain. Fingernails cuts of the children were gathered, put in tubes including 10% KOH before examination by light microscope for detection of parasites. A detailed questionnaire about clinical symptoms was done. Univariate also multivariable logistic relapse models were calculated for interpretation of the danger figures for parasitic infection. 63.5% of children harbored at least one type of intestinal parasite. There were significant differences regarding infections in contrast to residence and family size. Monoparasitized children constituted 40% while 23.5% were polyparasitized. Protozoa were more frequent than helminths parasitizing (53.5% vs 4%) of the studied children. Cryptosporidium sp., G. duodenalis and E. histolytica/ dispar were the majority regular parasites found, with prevalence rates of 34%, 14.5% and 13% respectively. The predominant helminthic infection was H. nana (5%). Polyparasitzed children were more frequently symptomatized than monoparasitized children. A significant difference was detected between diarrhea and polyparasitzed children. E. vermicularis and H. nana eggs were found in 2% of the fingernail clippings. Age, gender, residence, also family size were not danger figures to polyparasitism after calculation of univariate what’s more multivariable logistic relapse models. IPIs were very common among Sohag schoolchildren. Hence, there is an insistent requirement to execute an integrated project to decrease the predominance and intensity of these infections.

gers, fruits, vegetables, instruments, and others can do the trick.Adherence of parasites to fingernails is considered a salient source of infection.Hence, their vicinity clinched alongside fingernails will be an implication of an animated contamination (Moses et al., 2013).In Egypt, IPIs are a common health trouble in children.Almost 27% of the know youngsters would endure from intestinal parasites.To realize good preventive measures, epidemiological studies are important methods for determining the occurrence of these parasitic infections (Monib et al., 2016).
The available research was to recognize intestinal parasites, both helminth and protozoa in schoolchildren through copro-microscopic techniques.

Study area
This study was evaluated in Sohag Governorate, Upper Egypt.Sohag is located in the southern part of the country, toward 467 km to the south of Cairo.It covers an extent of the Nile Valley with a total area of 1547 km 2 , with estimated 4,603,861 people.

ethicS StatemeNt aNd Study deSigN
Evaluation of this cross sectional research started from January 2015 to December 2016 in Sohag, Egypt after being authorized by the scientific ethics committee of our institute.Investment for schoolchildren was voluntary taking after demonstrating the intent of the study.Distinct agreements were obtained from selected children' guardians before data and sample collection with a short illustration of the methodology and the target of this study.

iNcluSiON criteria
200 school-aged children between 6 and 12 years (Age Mean ± SD = 8.9±1.9) had participated in this study and randomly recruited from four elementary schools (2 urban and 2 rural) in our governorate to be included in the study.119 (59.5%) were <10 years , while 81 (40.5%) were ≥10 years.103 (51.5%) of them were boys and 97 (48.5%) were girls.As regards residence they were evenly divided between rural and urban areas.As for family size <5 members were 42 (21%) of the studied group and ≥ 5 members were 158 (79%) of the studied group .

ParaSitOlOgical methOdS
Fecal Samples: Stool specimens were gathered in dry, clean and labeled containers.Macroscopic and microscopic examination of the safeguarded specimens (formalin 10%) were completed then focus toward formol-ether sedimentation (Garcia, 2016) emulated by staining with Kinyoun's modified acid-fast stain (Garcia, 2016).
Nail Clippings Examination: Fingernails of the selected kids were curtailed and gathered in little plastic bags after that converted to centrifuge tubes and 10% KOH might have been included (Alo et al., 2013).
Diagnosis: Children were considered as positive for a particular infection if one of the diagnostic methods revealed a positive result.

RESULTS
Among 200 children registered in this research, 127 (63.5%) were found to be positive for at least one intestinal parasitic species.There were significant differences regarding infection related to residence and family size.No statistically significant differences regarding gender or age were observed (Table 1).The predominant pathogenic protozoan was Cryptosporidium with a prevalence (34%).The prevalence of other detected parasitic infections is illustrated in (Table 2).
Using the modified Z-N (Kinyoun) stain, intestinal coccidian parasites prevalence are illustrated in (Table 3).Results showed that children exhibited various forms of polyparasitism (Table 4).Polyparasitism with two protozoan parasites were revealed in (17.3%) of the children.
Cases of protozoan polyparasitism are illustrated in (Table 5).Triple infection 10 7.9 Quadruple infection 5 3.9 Pentaple infection 1 0.8 To define the performance of the nail clipping inspection in expression of sensitivity and specificity, stool examination was considered the confirmatory test.Fingernail clip pings examination was performed for all enrolled children.E. vermicularis and H. nana eggs were detected.Gathering stool and fingernail examinations, a total of 4 children were infected with E. vermicularis eggs, 3 of them were positive in both stool and fingernail specimens and only one child was positive in the stool sample.Results showed that nail clipping examination 75% sensitive and 100% specific (Table 6, 7).For H. nana infection, 10 children were positive.
Of them, 4 were positive using both examinations and 6 were positive using stool examination only (Table 8).This stands for a sensitivity of 40% and a specificity of 100% (Table 9).Univariate also multivariable logistic regression tests were analyzed to identify danger figures that were expected to be significantly correlated with intestinal polyparasitism.According to our data, none of the age, gender, residence or family size were danger figures for polyparasitism.(Tables 12, 13).

DISCUSSION
IPIs are still a public health issue in many communities, especially in the developing countries including Egypt and are accompanied with elevated morbidity among schoolchildren (Al-Delaimy et al., 2014).
The data of the actual study directed over four haphazardly decided governmental primary schools in urban and rural Sohag, Egypt demonstrated that (63.5%) of the sharing children infected at least by one parasite.utilized for water treatment (Latif and Rossle, 2015).This is higher than the study evaluated in Triopli, Lebanon by Osman et al. (2016), where Cryptosporidium was (10.4%) despite using molecular methods.One illustration to this might be that the project performed in an urban zone.
G. intestinalis was the second predominant intestinal parasite in our research (14.5%) which was slightly less than the prevalence reported earlier in rural schoolchildren of our governorate by El-Masry et al. (2007) (15.2%).G. intestinalis infection reached (28.1%) among Burkina Faso school children (Erismann et al., 2017), they used the same diagnostic techniques for intestinal protozoa detection as ours.
In the existing project, (13%) of children had E. histolytica/ dispar infection.This is a high prevalence denoting that the diagnosis was based on a solitary stool test rather than the perfect three sequential tests.E. histolytica was the most prevalent (20.4%) as reported by El-Masry et al. (2007).Significantly higher prevalence (66.5%) was reported among Burkina Faso schoolchildren (Erismann et al., 2016).This may confirm the fact that both G. intestinalis and E. histolytica/ dispar are still endemic in this region.Blastocystis sp. is considered an under-reported parasite around the world, It has a prevalence far exceeding that of other intestinal parasites in the mankind's populace.Indeed, its predominance can arrive 100% in developing nations and between 1.5% and 20% in industrialized nations (Osman et al., 2016).In the existing study, (10.5%) of children were infected with Blastocystis sp.It was also discovered in 10.6% among Peninsular Malaysia schoolchildren (Nithyamathi et al., 2016).
Only 4 species of intestinal helminths were noted with prevalence lower than expected in this highly susceptible age group.
The exhibited study revealed H.nana in (5%) of the sample.The researcher expected that formol-ether concentration (FEC) method designated for identification of the low-intensity infections was expected to expose higher rates of infection.Comparable prevalence (6.5%) was reported in Burkina Faso (Erismann et al., 2017).Meanwhile, H. nana prevalence was (14.9%) among rural schoolchildren in Sohag, Egypt (El-Masry et al., 2007) ing FEC techniques which point to a promising decrease in infection prevalence in our governorate.About STHs, only A. lumbricoides and A. duodenale were detected (2% and 1.5% respectively).This is a very minimal prevalence than expected in this age group.This decrease is multifactorial.First of all, we did not perform further FEC methods such the Kato-Katz techniques to assess infection intensity and detect light infections.A. lumbricoides (6.5%), A. duodenale (5.1%) and T. trichiura (2.1%) were reported by El-Masry et al. (2007).In contrast, (27.9%) of STH was reported by Al-Delaimy et al. (2014) in rural Malaysia.The authors reported using the Kato-Katz and the Harada Mori methods.
E. vermicularis eggs were revealed in (2%) only of the studied children and this was partly expected as the scotch adhesive tape swab, being the gold standard method for diagnosis, was not performed because of compliance issues.According to El-Masry et al. ( 2007), E. vermicularis prevalence was (16.6%); they reported using the scotch adhesive swab.Mohammad et al. (2012) and Yazgan et al. ( 2015) reported higher prevalence (5.2%) and (10.4%) among Damietta, Egypt, and the town of Kayseri Turkey schoolchildren respectively.They also reported using the cellophane tape method.
The rural residence had a significant difference regarding infection (P-value 0.028).This might be due to poor environmental sanitation and lack of personal hygiene.The present results are in agreement with that recently detected by Dyab et al. (2016) andMaru (2017).They found that Intestinal parasitic infection was strongly associated with residence in rural localities in schoolchildren of Aswan, Egypt, and Northern Ethiopia.This may be due to that the human feces are usually utilized as agricultural fertilizer.Also, absence of the central sewage disposal system.
For Cryptosporidium, a statistical significance was found in relation to symptoms.(72.1%) of Cryptosporidium-infected children were asymptomatic, while (23.6%) complained of diarrhea and (4.4%) had an achy tummy.Consistently, an investigation around Spanish children attending day care facilities indicated that Cryptosporidium sp.infections were asymptomatic in 82% of cases (Mateo et al., 2014).
Blastocystis infected children complained of diarrhea (33.3%), abdominal pain (38.1%) while (28.6%) were asymptomatic.This revealed a statistically significant relationship.This finding highlights the potential pathogenicity of the infection.
Nevertheless, a positive combination regarding Blastocystis sp. and abdominal pain suggests a pathogenic impact for this parasite of questionable clinical significance (Osman et al., 2016).
Untrimmed and filthy fingernails were watched throughout information collection, and it is being likewise an autonomous danger element for the procuration of IPIs correlates with those of former studies from the developing countries.
Therefore, promoting school hygiene practices through inspection of schoolchildren for cleanliness and trimming of fingernails could have a positive impact on decreasing the burden of infections with parasites that have direct life cycles.

The
. They did not report us- common among schoolchildren in Sohag, Egypt.Hence, there is a pressing need to attain a modernistic control program to constrict the predominance and intensity of these infections significantly and to save these children from their negative impacts.

Table 1 :
Demographic features of the studied children in relation to infection.

Table 2 :
Parasite frequencies and percentages in descending manner

Table 3 :
Frequencies of intestinal coccidian oocysts detected by the Kinyoun stain

Table 6 :
Results of stool and nail clipping examinations for diagnosis of Enterobius infection (n=200)

Table 7 :
Sensitivity , specificity, positive predictive value (PPV), negative predictive value (NPV) of nail clipping examination for the screening of Enterobius infection arrhea and the type of parasitism.Other symptoms showed no statistical significance.Statistical significant difference was found regarding Blastocystis, Cryptosporidium, A. lumbricoides and E. vermicularis in relation to symptoms.(Table 11).The Journal of Advances in Parasitology April 2017 | Volume 4 | Issue 2 | Page 36

Table 8 :
Results of stool and nail clipping examination for diagnosis of H. nana infection (n=200)

Table 9 :
Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of nail clipping examination for the screening of H. nana infection

Table 10 :
Relation between symptoms and type of parasitism amongst parasitized children (n=127) The almost non-changing situation of IPIs in Sohag is evident from the agreement of the actual feedback with those of Hamed et al. (2013) who reported the infection in (63.31%) among Sohag rural children aged less than 12 years.Over contrast, a lower predominance rate about (38.5%) has been formerly accounted for IPIs among elementary schoolchildren in Sohag by El-Masry et al. (2007); they didn't perform any special concentration or staining procedures for diagnosis.
Several other studies have reported lower rates of IPIs among schoolchildren from other governorates, for instance, (30.7%), and (31%) in Damietta, and Aswan byMohammad et al. (2012) and Dyab et al. (2016).Changes in these proportions were correlated to the variance in sample size and methods for examination.Cryptosporidium was the most predominant parasite in this study (34%).The significant danger variable to crypto sporidium contamination may be drinking water that is defiled for oocysts.Moreover, oocysts can survive in chlorine The Journal of Advances in Parasitology April 2017 | Volume 4 | Issue 2 | Page 37

Table 11 :
Symptoms of pathogenic parasites among all infected children

Table 12 :
Univariate logistic regression test of factors associated with polyparasitism

Table 13 :
Multivariate logistic regression test of factors associated with polyparasitism in relation to symptoms.(75%) of children harbored A. lumbricoides had abdominal pain while (75%) of children harbored E.vermicularis had perianal itching.3%) of the parasitized children had two species infections.The most popular double infection was with E. histolytica/dispar and Blastocystis sp. with a prevalence of (3.1%).In addition, (2.4%) of children presented triple infections with E.histolytica, G.intestinalis and Blastocystis.Univariate What's more multivariate logistic relapse models revealed that age, gender, residence also family size were not danger figures to polyparasitism.This is consistent withAl-Delaimy et al. (2014).