SOIL-TRANSMITTED HELMINTHIASES AND HEALTH BEHAVIORS AMONG SCHOOLCHILDREN AND COMMUNITY MEMBERS IN A WEST-CENTRAL BORDER AREA OF THAILAND

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1 SOIL-TRANSMITTED HELMINTHIASES AND HEALTH BEHAVIORS AMONG SCHOOLCHILDREN AND COMMUNITY MEMBERS IN A WEST-CENTRAL BORDER AREA OF THAILAND Mlinee T Anntphruti, Jitr Wikgul, Wnn Mipnich, Supporn Numtnong nd Somchit Pubmpen Deprtment of Helminthology, Fculty of Tropicl Medicine, Mhidol University, Bngkok, Thilnd Abstrct. The prevlence of soil-trnsmitted helminthic infections nd helth behviors relted to infections in schoolchildren nd villgers of community (4 hmlets) ws studied in Huy Kyeng subdistrict, Thong Ph Phum district, in the north of Knchnburi Province. The intestinl helminth infection rte of the schoolchildren ws 15.6%. Hookworm infection ws the most prominent (9.8%), followed by Trichuris trichiur (6.2%), nd Ascris lumbricoides (2.2%). The community showed higher prevlence rtes nd ws infected with more types of intestinl helminths thn the schoolchildren. Thirty-five point two percent (35.2%) of the residents were infected with soil-trnsmitted helminths, 30.5% with hookworm, 3.4% with A. lumbricoides nd 2.2% with T. trichiur. Almost ll hookworm cses (94.3%) were light intensity infections, while only 1.3% were hevy infections. Moreover, the hookworm infection rte in the community ws found to be much higher when stool culture method ws used (39.1%). With this technique, 2.3% Strongyloides stercorlis infections were detected in the community popultion. Exmintion of the helth behvior of the study smples showed tht pproximtely 75% lwys defected in toilet. Schoolchildren who lwys wore shoes comprised 67%, which ws lower thn the community, t 85%. INTRODUCTION Soil-trnsmitted helminth infections hve been recognized s public helth problem in Thilnd. A ntion-wide helminth control progrm ws lunched by the Ministry of Public Helth, nd the overll prevlence of intestinl helminthises decresed from 62.9% in 1957 to 22.5% in Among those infections, hookworm ws the most prevlent. In 2001, the hookworm infection rte ws 11.4%, nd when clssified into regions (Centrl, North nd Northest), the rtes were similr ( %). This figure ws lower thn in the South (20.2%) (Jongsuksntikul, 2002). However, in remote res, the prevlence is still higher thn those figures (Anntphruti et l, 2002; Mipnich et l, 2002). The border zones of western Thilnd re Correspondence: Mlinee Thirungroj, Deprtment of Helminthology, Fculty of Tropicl Medicine, 420/6 Rjvithi Rod, Bngkok 10400, Thilnd. Tel: 66 (0) E-mil: tmmtr@mhidol.c.th mostly hevily forested res comprised of mountins nd vlleys. In the west-centrl remote res, 50% or more of the indigenous people re Kren nd the snittion nd wter supply re poor. In ddition, becuse of the unstble politicl sttus of the country bordering western Thilnd, Mynmr, there is trend towrds incresing illegl migrtion into the neighboring border zones of Thilnd. Squtter settlements nd shntytowns, together with poor snittion, promote the spred of prsite eggs nd lrve. This investigtion imed to study helminthic infections nd helth behviors in reltion to the infection of schoolchildren nd inhbitnts residing in western zone of Thilnd bordering Mynmr. MATERIALS AND METHODS Knchnburi is province in western centrl Thilnd, on the Thi-Mynmr border. The study re ws Huy Kyeng subdistrict, 30 km from Thong Ph Phum district, 170 km north of 260 Vol 35 No. 2 June 2004

2 STH AND HEALTH BEHAVIORS B N Thong Ph Phum district (C) B Vjirlongkorn Dm (D) A Moo km E Moo 3 Moo 4 Moo 5 Fig 1 Mp of Thilnd (A) showing Knchnburi Province (B), Thong Ph Phum district (C), Vjirlongkorn Dm (D) nd Huy Kyeng subdistrict (E). Knchnburi (Fig 1). It is hevily forested mountinous highlnd. The mjor wter bsin is the Vjirlongkorn (Kho Lem) Dm. Most of the residents live on lnd provided by the Electric Generting Authority of Thilnd (EGAT), due to the impct of the construction of the Dm. The min occuptions of the community re griculture, livestock production nd fishing in the wter bsin of the dm. There re 8 hmlets, composed of pproximtely 2,000 households with 4,000 mles nd 3,600 femles. Ech hmlet hs primry school, nd there re 2 junior high schools. The study ws conducted with the schoolchildren nd community popultion of hmlets 2 to 5. Stool exmintion by Kto-Ktz technique ws performed with the schoolchildren in grdes 2 to 6 nd the community popultion of these 4 hmlets. The intensity of infection ws clssified into light, moderte nd hevy, ccording to the number of eggs per grm of feces. The polyethylene tube culture method, for detecting the filriform lrve of hookworms nd Strongyloides sp, ws included for the community stool smples. Questionnires were designed to obtin dt on helth behvior nd prctices in reltion to soiltrnsmitted helminth infections of the schoolchildren nd the community popultion. The children s dt were obtined from ll schoolchildren in grdes 3, 4 nd 5 of the studied schools using questionnires. The community dt were obtined from the hed of ech household by interview. The number of households to be interviewed ws bsed on the formul of Lemeshow, et l (1990). RESULTS Prsite infection rtes of the schoolchildren The soil-trnsmitted helminth infection rte of 276 schoolchildren in 4 schools (Bn Pklmpilok, Bn Huy Kyeng, Bn Prjum Mi nd Bn Rip) ws 15.6%, rnging from %. Hookworm ws the most prevlent, t Vol 35 No. 2 June

3 9.8% (rnge %), followed by Trichuris trichiur (6.2%), Ascris lumbricoides (2.2%), nd Enterobius vermiculris (0.4%) (Tble 1). Prsite infection rte of the community The prevlence of intestinl helminth infections of ech hmlet ws much higher thn for the corresponding schoolchildren. Out of 741 smples exmined, 35.2% were infected with soiltrnsmitted helminths, 30.5% with hookworm, 2.2% with T. trichiur nd 3.4% with A. lumbricoides. Other minor helminths found with prevlence less thn 1% were Strongyloides stercorlis, E. vermiculris, Teni sp nd smll intestinl fluke-like orgnisms (Tble 2). Almost ll (94.3%) hookworm infections were of light intensity, 4.4% moderte nd only 1.3% hevy (Tble 3). Stool smples of hmlets Moo 2, 3 nd 4 were cultured on filter pper in polyethylene tubes. The results showed tht higher helminthic infection positive rtes were obtined. Out of 529 smples exmined, 219 (41.4%) were found positive for either hookworm or S. stercorlis filriform lrve. The infection rtes for hookworm nd S. stercorlis were 39.1% nd 2.3%, respectively (Tble 4). Behviors nd prctices Questionnires were obtined from 254 schoolchildren in grdes 3 to 5 of 4 schools, nd community popultion of 58 in 4 hmlets. Of the children, 125 (49.2%) were mle nd 129 (50.8%) femle. Their ges rnged from 7-15 yers, with 43.7% being yers. Their prents occuptions were mostly griculture (47.2%) nd employee (32.7%). Of the community smples, 27 (46.6%) were mle nd 31 (53.4%) femle; their ges rnged from yers. Their Tble 1 Results of stool exmintion of schoolchildren in grdes 2-6 in 4 schools of Huy Kyeng, Thong Ph Phum district, Knchnburi Province, Februry 2002, exmined by Kto-Ktz method. Schools Number Number positive (%) exmined STH Hookworm Trichuris Ascris Enterobius Bn Pklmpilok (Moo 2) 64 7 (10.9) 6 (9.4) 1 (1.6) - - Bn Huy Kyeng (Moo 3) 60 9 (15.0) 5 (8.3) 2 (3.3) 1 (1.7) 1 (1.2) Bn Prjum Mi (Moo 4) (15.5) 8 (9.5) 6 (7.1) 5 (6.0) - Bn Rip (Moo 5) (20.6) 8 (11.8) 8 (11.8) - - Totl (15.6) 27 (9.8) 17 (6.2) 6 (2.2) 1 (0.4) STH = Soil-trnsmitted helminths Tble 2 Results of stool exmintion of villgers of Huy Kyeng, Thong Ph Phum district, Knchnburi Province, My 2002, exmined by Kto-Ktz method. Hmlets Number Number positive (%) exmined STH Hookworm Trichuris Ascris Strongyloides Others b Moo (34.6) 57 (30.3) 2 (1.1) 1 (0.5) 2 (1.1) 8 (4.3) Moo (34.3) 51 (30.5) 1 (0.6) 4 (2.4) 0 2 (1.2) Moo (35.9) 76 (31.0) 5 (2.0) 16 (6.5) 2 (0.8) 4 (1.6) Moo (36.2) 42 (29.8) 8 (5.7) 4 (2.8) 0 3 (2.1) Totl (35.2) 226 (30.5) 16 (2.2) 25 (3.4) 4 (0.5) 17 (2.3) STH = Soil-trnsmitted helminths b Moo 2: Teni = 2, Intestinl fluke-like= 5, Enterobius = 1 Moo 3: Teni = 1, Intestinl fluke-like = 1 Moo 4: Teni = 1, Intestinl fluke-like = 2, Enterobius = 1 Moo 5: Teni = 1, Intestinl fluke-like =2 262 Vol 35 No. 2 June 2004

4 STH AND HEALTH BEHAVIORS Tble 3 Intensity of hookworm infection of villgers of Huy Kyeng, Thong Ph Phum district, Knchnburi Province, My 2002, exmined by Kto-Ktz method. Hmlets Intensity of infection Light Moderte Hevy Totl Moo Moo Moo Moo Totl 213 (94.3) 10 (4.4) 3 (1.3) 226 Tble 4 Infection rtes of Strongyloides stercorlis nd hookworm in 3 hmlets of Huy Kyeng, Thong Ph Phum district, Knchnburi Province, detected by culture technique. Hmlets Number exmined Number positive (%) Hookworm Strongyloides Totl Moo (39.0) 2 (1.4) 57 (40.4) Moo (39.2) 4 (2.4) 69 (41.6) Moo (39.2) 6 (2.7) 93 (41.9) Totl (39.1) 12 (2.3) 219 (41.4) Tble 5 Generl informtion from interviewees of schoolchildren nd popultion in the community of Huy Kyeng, Thong Ph Phum district, Knchnburi Province. Ctegories Sex, No. nd (%) Age (Rnge) Occuption, No. nd (%) Mle Femle Totl Agriculture Employee Other Schoolchildren 125 (49.2) 124 (50.8) (53.9) 83 (32.7) 34 (13.4) Community 27 (46.6) 31 (53.4) (44.8) 23 (39.7) 9 (15.5) Occuption of schoolchildren prents occuptions were minly griculture (44.8%) nd employee (39.7%) (Tble 5). Fifteen (5.9%) of the schoolchildren s houses hd no ltrine. However, 100% of the community hd ltrines (Tble 6). The percentge of schoolchildren ltrines situted outside the house ws 59.1%, wheres, the percentge of community ltrines inside the house ws 51.7% (Tble 6). Both the schoolchildren nd the community hd been tking nthelmintics during the yer before interview; more thn 50% of schoolchildren (65.7%). However, 58.6% of the community hd never tken nthelmintics (Tble 7). The helth behviors of the two interviewee groups in reltion to soil-trnsmitted helminthic infections re shown in Tble 8. Although 77.6% of schoolchildren lwys defected in toilet, 19.7% of them did sometimes, nd 1.9% never did. The results for preventive prctices for soil-trnsmitted helminthises showed tht 66.9% lwys wore shoes, nd tht only 36.2% lwys wshed their hnds before mels. There were higher percentges for prcticing sometimes, ie wshing the hnds before mels (62.6%) nd eting using the hnds without spoon (78.3%). The percentge of the community who mintined the behvior of using toilet ws similr to the schoolchildren (74.1%) who lwys defected in toilet. Higher Vol 35 No. 2 June

5 Tble 6 Number of houses with ltrines nd types of ltrine of residences of 254 schoolchildren nd 58 popultion in the community of Huy Kyeng, Thong Ph Phum district, Knchnburi Province. Ctegories Number (%) of houses Type of ltrine, number (%) With ltrine Without ltrine In house Outside house Pit Other Schoolchildren 239 (94.1) 15 (5.9) 62 (24.4) 150 (59.1) 25 (9.8) 17 (6.7) Community 58 (100.0) - 30 (51.7) 24 (41.4) 4 (6.9) - Tble 7 Prctices of 254 schoolchildren nd 57 community members in reltion to nthelmintic drug tking, during the yer before interview. Prctice Schoolchildren, No. (%) Community, No. (%) Hd nthelmintic in lst yer 167 (65.7) 23 (39.7) No nthelmintic in lst yer 87 (34.3) 34 (58.6) Totl Tble 8 Helth behvior in reltion to preventing helminthic infection of 254 schoolchildren nd 58 community members. Alwys Sometimes Never Schoolchildren Defecte in toilet 197 (77.6) 50 (19.7) 5 (1.9) b Wer shoes 170 (66.9) 82 (32.3) 2 (0.8) Wsh hnds before mels 92 (36.2) 159 (62.6) 3 (1.2) Et with hnd (without spoon) 48 (18.9) 199 (78.3) 7 (2.8) Wsh vegetble before consuming fresh 231 (90.9) 23 (9.1) - Community Defecte in toilet 43 (74.1) 15 (25.9) b - Wer shoes 49 (84.5) 8 (13.8) 1 (1.7) Wsh hnds before mels 48 (82.8) 9 (15.5) 1 (1.7) Et with hnd (without spoon) 15 (25.9) 35 (60.3) 8 (13.8) Wsh vegetble before consuming fresh 47 (81.0) 10 (17.2) 1 (1.7) c No nswers = 2; b Defecte in the forest, digging hole, t school; c Never consume fresh vegetbles percentges for community behvior over schoolchildren were wering shoes (84.5%) nd wshing hnds before mels (82.8%). Rinwter ws the min source of drinking wter in the villges, with frequencies of 93.3% for schoolchildren nd 77.6% for villgers (Tble 9). Wter from cnl/strem/nturl well ws used by 13.0% nd 20.7% of these groups, respectively. More thn hlf of schoolchildren (51.2%) nd villgers (64.0%) drnk untreted rinwter. Boiling of wter ws prcticed in 15% of both studied groups. DISCUSSION It ws concluded tht the community in the study re did provide fvorble conditions for soil-trnsmitted helminth infection. The Deprt- 264 Vol 35 No. 2 June 2004

6 STH AND HEALTH BEHAVIORS Tble 9 Prctices in reltion to drinking wter mong 254 schoolchildren nd 58 community members. Schoolchildren Community Number Percent Number Percent Type of drinking wter Rin wter Cnl/strem/nturl well Concrete well Tp wter Others Methods of tretment No tretment Filter b Boil c Other More thn one choice ws ccepted; b With thin cloth; c Sometimes ment of Communicble Disese Control, Ministry of Public Helth, found tht the rte of hookworm infection in the centrl region ws 9.3%, which took into ccount both children nd dults. The result of our study ws similr to those reported t the ntionl level in schoolchildren only. For the regulr tretment of helminthic infections of high-risk groups, prticulrly school-ge children, s endorsed by the WHO, the best method of delivering the nthelmintic drug is through the school system. From our questionnire results, over 60% of schoolchildren hd nthelmintic drugs during the yer before interview. In ddition, the uthorizing helth center, Huy Kyeng Helth Center, hd been giving nnul mss tretment of schoolchildren in grdes 1-3 for ll responsible schools (Personl communiction). The low helminth infection rtes mong schoolchildren must be due to the success of nnul mss tretment. Generlly, the pttern of hookworm infection increses ccording to ge nd reches its pek in dulthood. Our study showed tht hookworm infection in the community ws s high s four times greter thn the children, nd of cited ntionl dt. In 1987, Temchroen et l conducted study of intestinl prsites in workers, personnel nd their fmilies during construction of the Kho Lem Dm. They found tht 19.5% hrbored helminthic infections, nd tht mong these, 12.2% were hookworm infections. Over decde, from our result, hookworm hd incresed infection gret del. Trnsmission of soil-trnsmitted helminthes is linked to generlly poor living conditions, poor public helth supply, nd poor snittion. Individul helth behvior is lso n importnt fctor in prsite trnsmission. More thn 20% of the questionnires from both groups indicted tht the respondents sometimes nd never defected in toilet. Hence, the helminth eggs from the feces of infected persons were ble to contminte the environment. Wter nd soil were the importnt risk fctors for infection. Coelho et l (2001) reported the presence of Strongyloides stercorlis, Ancylostom, Ascris nd Hymenolepis in wter nd rw vegetbles consumed t nursery schools. A similr study of wter used for drinking/cooking from different plces in Hyderbd City, Indi, found the wter to be contminted with eggs of Enterobius vermiculris, Ascris, Trichuris, dult E. vermiculris, nd lrve of S. stercorlis (Jonnlgdd nd Bht, 1995). In soil smples, contmintion by soil-trnsmitted helminth eggs of Ascris, Trichuris nd hookworm, ws reported. The positive soil smples were collected from bushes, wells, shded res, house dust, plygrounds, nd lrge trees (Mipnich et l, Vol 35 No. 2 June

7 1995). In our study, untreted wter from cnls or strems, s well s nturl well wter were sources of drinking wter. Although no study ws undertken to determine prsite contmintion in drinking wter in the study re, helminth eggs nd lrve probbly contminte the wter or soil. This my be the reson for the reltively high prevlence of hookworm nd S. stercorlis infection in the community. Kto s thick smer method ws widely used for the dignosis of soil-trnsmitted helminthises. By this technique, the overll prevlence of Strongyloides stercorlis infection in Thilnd in 2001 ws 0.6% (Jongsuksntikul, 2002). However, detection of infective filriform lrve by culture method is suitble for dignosing strongyloidisis. By polyethylene tube culture method, the infection rte in schoolchildren ws 1.8% in Nkhon Si Thmmrt Province (Anntphruti et l, 2000). In our present study in the community, higher infection rte ws found, lmost double tht found in previous investigtion or s much s four times when compred with report of Jongsuksntikul, in To control soil-trnsmitted helminthises, combined progrm must be initited nd introduced to the trget community; the progrm includes micronutrient supplementtion, improvement of environmentl snittion, clen wter supplies, nd bsic food sfety. All these components should be pcked nd chnneled through the helth-promoting schools network. Regulr mss deworming of school-ge children nd other high-risk groups should be proposed. Schoolbsed strtegies for helminth control should be ctivted nd expnded in prllel with other school-bsed helth progrms; this includes helminth-helth eduction cmpign with medi tools nd personl hygiene prctice. Preprtion nd production of pproprite helth eduction mterils re required to support the control progrm. It is necessry to implement control progrm in our study re in the future. ACKNOWLEDGEMENTS This work ws supported finncilly by the Government budget of Mhidol University. Thnks re extended to Vjirlongkorn Dm Electricity Generting Authority of Thilnd for supporting ccommodtion during the fieldwork. REFERENCES Anntphruti MT, Mipnich W, Muennoo C, Pubmpen S, Sngunkit S. Hookworm infections of schoolchildren in southern Thilnd. Southest Asin J Trop Med Public Helth 2002; 33: Anntphruti MT, Numtnong S, Muennoo C, Sngunkit S, Pubmpen S. Strongyloides stercorlis infection nd chronologicl chnges of other soil-trnsmitted helminthises in n endemic re of southern Thilnd. Southest Asin J Trop Med Public Helth 2000; 31: Coelho LM, Oliveir SM, Milmn MH, Krsw KA, Sntos RD. Detection of trnsmissible forms of enteroprsites in wter nd vegetbles consumed t school in Sorocb, So Pulo stte, Brzil. Rev Soc Brs Med Trop 2001; 34: (In Portuguese). Jongsuksntigul P. Soil-trnsmitted helminthises control in Thilnd. Lecture note presented t ACIPAC Interntionl Trining Course on School-bsed Mlri nd Soil-trnsmitted Helminthises Control for Progrmme Mngers t the Fculty of Tropicl Medicine, Mhidol University, Bngkok, Thilnd on September 6, Jonnlgdd PR, Bht RV. Prsitic contmintion of stored wter used for drinking/cooking in Hyderbd. Southest Asin J Trop Med Public Helth 1995; 26: Lemeshow S, Hosmer DW, Klr J, Lwng SK. Smple size for smple surveys. Adequcy of smple size in helth studies. Chichester: John Wiley nd Son, 1990; 8: Mipnich W, Itiponpny N, Rojekittikhun W, et l. Intestinl prsitoses mong hilltribe people nd soil contmintion in Nn Province, Northern Thilnd. J Trop Med Prsitol 2002; 25: Mipnich W, Wikgul J, Phuchon W, Muennoo C, Visiessuk K. Contmintion of soil-trnsmitted helminth eggs in soil smples from Nkhon Si Thmmrt Province. J Trop Med Prsitol 1995; 18: Temchroen P, Chulrerk U, Viboolyvtn J. Intestinl prsites mong the workers nd their fmilies t three electricity generting dms in Thilnd. Southest Asin J Trop Med Public Helth 1987; 18: Vol 35 No. 2 June 2004