ONUOHA, EDWIN ONYEODIRI PG/Ph.D/05/39458

Transcription

1 PATTERNS OF TRANSMISSION, PREVALENCE AND INTENSITY OF SOIL TRANSMITTED HELMINTHIASIS IN NSUKKA ZONE, ENUGU STATE, NIGERIA ONUOHA, EDWIN ONYEODIRI PG/Ph.D/05/39458 A thesis submitted to the Department of Zoology, Faculty of Biological Sciences, University of Nigeria, Nsukka, Enugu, Nigeria in partial fulfillment for the award of Doctor of Science in Zoology 2009

2 1i TITLE PAGE PATTERNS OF TRANSMISSION, PREVALENCE AND INTENSITY OF SOIL TRANSMITTED HELMINTHIASIS IN NSUKKA ZONE, ENUGU STATE, NIGERIA ONUOHA, EDWIN ONYEODIRI PG/Ph.D/05/

3 2 APPROVAL PAGE BY PROF. I.E. OFOEZIE SUPERVISOR PROF. J. E. EYO HEAD OF DEPARTMENT DATE: DATE:

4 3 CERTIFICATION Onuoha, Edwin Onyediri, a postgraduate student in the department of zoology has satisfactorily completed the requirements for course and research work for the degree of Doctor of philosophy (Ph.D) in parasitology. The work embodied in his thesis is original and has not been submitted in part or full for any other diploma or degree of this or any other University. PROF. I. E. OFOEZIE SUPERVISOR INSTITUTE OF ECOLOGY AND ENVIRONMENTAL STUDIES OAU, ILE-IFE. PROF. J. E. EYO HEAD OF DEPARTMENT OF ZOOLOGY UNN

5 4 DEDICATION This thesis is dedicated to the Creator, Almighty and Most High, My late parents (Mr and Mrs Emmanuel Ukaobasi Onuoha) and my most senior brother, Mr. Vincent E. Onuoha and his wife.

6 5 ACKNOWLEDGEMENT I sincerely thank my supervisor, Prof I. E. Ofoezie of the Institute of Ecology and Environmental Studies OAU, Ile-ife, for his kind and painstaking supervision. My profound appreciation goes to Prof. Fab Okafor and Dr. J. E. Eyo of the Department of Zoology UNN for their sincere encouragement throughout the period of my postgraduate programme. My thanks also go to Dr. S.V.O Soyinka (SHO) of the Department of Veternary Pathology and Microbiology for his encouragement. The HOD and the entire staff of Zoology Department are warmly acknowledged. Mr. Aluma James is also acknowledged. I equally thank my wife, Blessing Chika Onuoha and my children for their understanding and endurance.

7 6 ABSTRACT The study assessed the prevalence, intensity and environmental risk factors affecting the transmission of soil transmitted helminthiasis in eleven randomly selected communities in Nsukka and Uzouwani Local Government Areas of Enugu State, Nigeria. It also determined the effect of peoples knowledge of mode of transmission of the diseases and access to facilities for water supply and sanitation in each of the communities. This is with a view to gaining insight into the patterns of transmission and endemicity of the diseases in the area. Fifty households were systematically selected in eleven randomly selected communities in Nsukka zone. A health structured questionnaire was administered to consenting member of each selected households to collect information on personal bio-data (age, sex, state of origin, etc.), personal hygiene (toilet habits such as anal cleansing and hand washing patterns after toilet use), knowledge of mode of transmission, signs and symptoms of each disease as well as management of infected persons (type of treatment received and where). Faecal samples were collected from each individual once every 3 months for 12 months and analysed for presence and number of helminth eggs using the concentration by gravity method and the 40X magnification of the compound microscope Soil samples were collected from three sites in each community and analysed for chemical and physical properties using standard methods. Presence and number of helminth eggs in each soil sample was determined using the concentration by gravity method. Data were analysed using appropriate descriptive and inferential statistical methods. Hookworm and ascariasis were the only soil transmitted helminth infections observed in the communities. Out of a total of 2055 persons examined in all communities, overall prevalence of hookworm was 52.8%, ascariasis 74.3% and double infection 50%, while 76.7% were infected with either hookworm or ascariasis suggesting that less than a quarter were free of infection. Prevalence of hookworm ranged from 38..9% at Margaret Cartwright to 64.7% at Nkpunato; 50% in males to 55% in females; and 30.5% to

8 in 40+ and years age groups. Corresponding values for ascariasis were 61.9% and 82.6% at New Anglican Road and Ogurugu; 69.5% % in males and females; and % in and years age brackets. Overall mean intensity of hookworm was eggs per gramme faeces (epg) and ascariasis epg. Intensity of hookworm ranged from to epg at Foulton and Nkpunato, respectively; in males to epg in females; and to epg in the 40+ and years age groups respectively. For ascariasis, intensity ranged from to epg at Nkpologu and Nkpunato; in males and females; and in 40+ and 1-9 years age groups. Thus, prevalence and intensity of both hookworm and ascariasis varied significantly (p< 0.05) among the communities, sexes and age groups. They also varied with educational background, marital status, seasons and access to different facilities for water supply and sanitation. Soil texture was sandy to sandy loam and total porosity, exchangeable base (1.46 to 1.78 cmol kg -1 s) and organic carbon (1.04 g kg -1 ) contents were relatively low. The soils were also strongly ( ) to weakly ( ) acidic. Mean hookworm and Ascaris egg concentration in soil were and respectively and varied between communities, soil types and seasons. Logistic regression analysis showed that among other factors, hookworm infection was significantly explained by footwearing habits and ascariasis by hand washing and anal cleansing habits after toilet use.

9 8 TABLE OF CONTENT Title Page. Approval page.. Dedication Certification. Acknowledgement. Abstract... Table of Contents. i ii iii iv v vi vii Pages CHAPTER ONE (INTRODUCTION AND LITERATURE REVIEW) 1 Introduction Objectives of The Study Literature Review Ascaris lumbricoides (Roundworm): Morphology and Life Cycle Epidemiology Clinical Manifestation: Pathology and Pathogenesis: Enterobius vermicularis (Pinworm) Morphology and Life Cycle Epidemiology: Clinical Manifestation: Pathology and Pathogenesis: Ancylostoma duodenale, and Necator americanus (Hookworms): Morphology and Life Cycle Epidemiology: Clinical Manifestation: Pathology and Pathogenesis: Trichuris trichiura (whipworm): Parasitology: Morphology and Life Cycle: Epidemiology: Clinical Manifestation: Pathology and Pathogenesis: Strongyloides stercoralis: Morphology and Life Cycle Epidemiology: Clinical Manifestation: Pathology and pathogenesis: Toxocara Species (Toxocara spp) Morphology and life cycle Epidemiology: 23

10 Clinical Manifestations: Pathology and pathogenesis Laboratory Diagnosis of Soil Transmitted Helminths Transmission of Soil-Transmitted Helminthes Factors Affecting Transmission Occupation Educational Background Health Education Management Hygiene Environmental Control of Soil-transmitted Helminthes Chemotherapy Orthodox Drugs of Choice: Alternative Therapy: General Preventive Measures: Mass Chemotherapy: Group- Targeted Chemotherapy: Treatment of Individual Cases: Herbal Immunosuppressed Hosts: Water Supply and Sanitation 38 Chapter Two (Materials And Method) 2.1 Study Area: Questionnaire Administration and Faecal Sample Collection Collection of Soil Samples Analysis of Faecal Samples Statistical Analysis 45 Chapter Three (Results) 3.1: Demographic and Socio-economic Characteristics Personal Characteristics Water supply and sanitation Health Condition Ranking and Perception Prevalence and Intensity Patterns Prevalence and intensity of infection in communities Age and sex prevalence and intensity of infection Prevalence and Intensity of Infection by educational background Prevalence and intensity of infection by seasons Prevalence and intensity of infection by marital status Prevalence and intensity of infection by latrine type Prevalence and intensity of infection according to cleaning habits after toilet use Prevalence and intensity of infection in relation to Occupation Prevalence and intensity of infection by dry season water source ( ) Prevalence and intensity of infection by water source during the rainy season Prevalence and intensity of infection according to footwear and type Knowledge of the people concerning the infection of hookworm and ascariasis diseases ( )

11 Prevalence and intensity of infection according to treatment method Prevalence and intensity of infection according to treatment type ( ) Prevalence and intensity of infection in relation to common signs and symptoms Prevalence and intensity of infection according to hospital visit and rate Environmental Characteristics Soils Physical Properties Chemical Properties of Soils Summary of Helminth Egg Concentration in soil Summary of Helminth Egg Concentration in sites Relationship between soil characteristics and geohelminthes contamination: Relationship between soil characteristics and Geohelminthes contamination. 97 Chapter Four (Discussion) Demorgraphic and socio-economic characteristics Prevalence and intensity patterns of the infections Environmental factors that influence the infections Conclusion and Recommendation Reference. 108

12 11 List of Tables Table 3.1: Table 3.2: Table 3.3: Table 3.4: Table 3.5: Table 3.6 Table 3.7: Table 3.8: Prevalence of single, double and either infections of hookworm and ascariasis in eleven communities in Nsukka zone, Enugu State, Nigeria, Distribution of single, double and at least one infection of hookworm and/or ascariasis in eleven communities investigated in Nsukka zone ( ). 54 Age and sex patterns of mean intensity of hookworm and ascariasis among individuals with single, double and at least one infection in eleven communities investigated in Nsukka zone ( ) Sex distribution of prevalence of hookworm and ascariasis in different communities examined in Nsukka zone, Enugu State, Nigeria ( ). 58 Sex distribution of mean and standard deviation of hookworm and ascariasis in different communities examined in Nsukka zone, Enugu State, Nigeria ( ) Prevalence and Intensity of single and double infections of hookworm and ascariasis among different educational background in eleven communities investigated in Nsukka Zone Enugu state Nigeria ( ) 60 Prevalence & Intensity of single and double infections of hookworm and ascariasis according to marital status in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ) 62 Prevalence & Intensity of single and double infections of hookworm and ascariasis by seasons in Nsukka Zone, Enugu State Nigeria Table 3.9: Table 3.10: Prevalence & Intensity of single and double infections of hookworm and ascariasis according to access to different latrine type in eleven communities investigated in Nsukka Zone, Enugu State, Nigeria ( ) 67 Prevalence & Intensity of single and double infections of hookworm and ascariasis cleaning materials used after toilet use investigated in eleven communities in Nsukka Zone, Enugu State Nigeria ( ) 69

13 12 Table 3.11: Table 3.12: Table 3.13: Table 3.14: Table 3.15: Table 3.16: Table 3.17: Table 3.18: Table 3.19: Table 3.20: Prevalence & Intensity of single and double infections of hookworm and ascariasis by hand washing habit of people investigated in eleven communities in Nsukka Zone, Enugu State Nigeria ( ).. 70 Prevalence & Intensity of single and double infections of hookworm and ascariasis of occupation of people in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). 71 Prevalence & Intensity of single and double infections of hookworm and ascariasis dry season water source in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ).. 72 Prevalence & Intensity of single and double infections of hookworm and ascariasis rainy season water source in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). 73 Prevalence and intensity of single and double infection of hookworm and ascariasis of footwear in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). 75 Prevalence and intensity of single and double infection of hookworm and ascariasis according to footwear-type used by people investigated in eleven communities investigated in Nsukka zone, Enugu state Nigeria ( ) 76 Prevalence and intensity of single and double infection of hookworm and ascariasis according to people's belief on the causes of the diseases in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ).. 78 Prevalence & Intensity of single and double infections of hookworm and ascariasis of treatment type in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). 79 Prevalence & Intensity of single and double infections of hookworm and ascariasis of self-treatment method in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). 81 Prevalence and intensity of single and double infection of hookworm and ascariasis according to people s idea of common symptoms of stomach problem in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). 83

14 13 Table 3.21: Table 3.22: Table 3.23 Table 3.24 Table 3.25 Table 3.26: Prevalence and intensity of single and double infection of hookworm and ascariasis according to hospital visits and rates. 85 Prevalence and intensity of single and double infection of hookworm and ascariasis of hospital distance in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ) 87 Physical properties of soils collected from selected sites in eleven communities investigated in Nsukka zone, Enugu State, Nigeria 88 Chemical properties of soils collected from selected sites in eleven communities investigated Summary of Helminth Egg Concentration in Soil in Eleven Communities Investigated in Nsukka Zone, Enugu State, Nigeria.. 93 Summary of Helminth Egg concentration in Various Sites. (Dump sites, Play grounds & Market in eleven communities investigated in Nsukka zone,enugu State, Nigeria. 94 Table 3.27 Relationship between soil characteristics and Geohelminthes contamination Table 4.1 Prevalence and Intensity of Hookworm and Roundworm infection in the University community, Nsukka Urban and Rural area. 98 Table 4.2 Soil Contamination in University community, Nsukka Urban and Rural area... 98

15 14 List of Figures Fig. 1 Life cycle of Ascaris lumbricoides Scanned from Arora and Arora (2006) 5 Fig. 2 Life cycle of Enterobius vermicularis Scanned from Arora and Arora (2006) 10 Fig. 3 Life cycle of Ancylostoma duodenale Scanned from Arora and Arora (2006) 14 Fig. 4 Life cycle of Trichuris trichura Scanned from Arora and Arora (2006) 18 Fig. 5. Life cycle of Strongyloides stercoralis Scanned from Arora and Arora (2006) 21 Fig. 6 Transmission and life cycle of Ascaris lumbricoides (Cheesebrough, 2006) 31 Fig. 7 Transmission and life cycle of hookworms: Ancylostoma duodenale and Nectar americanus. (Cheesebrough, 2006). 32 Fig. 8 Transmission and life cycle of Trichuris trichiura. (Cheesebrough, 2006) 33 Fig. 9 Transmission and life cycle of strongyloides stercoralis. (Cheesebrough, 2006). 34 Fig 10 Map showing sampled areas of soil transmitted Helminthes in Nsukka Zone of Enugu State 41 Fig 11: Egg of Ascaris lumbricoides covered with uneven albuminous coat (mammilated) (x 40) 44 Fig 12: Egg of Ancylostoma duodenale with segmented ovum and four blastomeres and a clear space between the segmented ovum and the egg shell. (x 40). 44 Fig. 13 Distribution of studied population in Nsukka zone 47 Fig 13 Egg of Ascaris lumbricoides Scanned from Arora and Arora (2006) 117 Fig 14 Egg of Enterobius vermiculars Scanned from Arora and Arora (2006) 118 Fig. 15 Egg of Ancylostoma duodenale Scanned from Arora and Arora (2006) 119 Fig. 15 Egg of Trichuris trichura Scanned from Arora and Arora (2006) 120

16 15 CHAPTER ONE INTRODUCTION AND LITERATURE REVIEW 1. INTRODUCTION Soil transmitted helminthiasis are diseases caused by a group of helminthes with direct life cycle through the soil environment to man and domestic animals. The life cycle usually involves soil contamination with eggs or larvae of parasitic worms excreted by man and domestic animals, development of the eggs or larvae to infective stages and infection of man or animals either by the oral-route or active penetration of the skin (Cheesebrough, 2006). Oral-route transmission is facilitated by the use of contaminated household items, eating contaminated food or with dirty fingers. It has also been suggested that houseflies (Musca domestica) may facilitate the contamination of household items and foods and stuff. Playing in a dirty environment especially where there are unhygienic practices and sanitation is below standard facilitate transmission. Eating unwashed fruits and putting contaminated fingers in the mouth especially by children who play in the soil or with domestic animals lead to oral-route infection, playing in the soil equally leads to larval penetration of the skin. The major soil transmitted helminthes in Nigeria include Ascaris lumbricoides, Trichuris trichiura, Ancylostoma duodenale, Necator americanus, Strongyloides stercoralis, Enterobius vermicularis, and Toxocara species, A. duodenale and N. americanus which together cause hookworm infection, and Strongyloides stercoralis are transmitted by direct skin penetration while the rest gain entry by oral-route. Enterobius spp. may also be transmitted by auto-infection as a result of children scratching the anus and putting the fingers in their mouths or eating with unwashed hands (Chandler and Read., 1961; Crompton and Pawlowski, 1985; Cheesebrough, 2006).

17 16 Knowledge, attitude and management of ascariasis vary greatly among different people. Most children especially the school aged are either not aware or do not care of the consequences of playing in contaminated environments. Poor hygiene habits such as not cleaning with soap and water after using the latrines also expose both children and adults to infections. Some individuals also do not seek treatment against helminthes infection while others claim that intestinal worms are useful components of food digestion. Ignorance, illiteracy and poverty have been shown to create favourable conditions upon which soil transmitted helminthes thrive. These and lack of awareness on the mode of transmission of these diseases sustain poor management strategies in most endemic communities. According to W.H.O. (1987a), people s attitude to disease control depends on what they know about such disease, its mode of transmission, pathological consequences, prognosis and economic importance. Where this knowledge are misconstrued or subsumed under a transmissionenhancing taboo or where outright ignorance prevails, transmission goes on unhindered. Soil transmitted diseases have been endemic in Nsukka and surrounding communities for a long time. However, while the literature is loaded with information on their distribution in time and space, little has been done on the knowledge attitude and management of this disease in the area. Such information is indispensable for the formation and implementation of effective and sustainable control programme against the diseases in the area.

18 Objectives of the Study. The objectives of the investigation are to: 1. Determine the profile of, and seasonal distribution of soil-transmitted diseases in selected communities of varying levels of urbanization in Nsukka zone. 2. Determine the socio-environmental factors including water supply and sanitation that affect the transmission of the diseases in the various communities 3. Ascertain the knowledge, attitude and management of the disease in different communities. 4. Determine the patterns of distribution of prevalence and intensity of infection by age, gender, occupation and other demographic variables in the various communities. 5. Identify factors that significantly contribute to the transmission of soil transmitted helminth diseases observed in the communities. 1.2 Literature Review 1.3 Ascaris lumbricoides (Roundworm) Morphology and Life Cycle Ascaris lumbricoides commonly known as roundworm is morphologically similar to earthworm. It is one of the important parasites of man and animals with a direct lifecycle (Urquhart et al., 2003). Under normal conditions of temperature and moisture eggs survive in the soil with the larva developing from L1 to L2 stage. When eggs containing L2 larvae are swallowed either with water or food they hatch in the small intestine liberating the L2 larva, these migrate to the liver via the mesenteric lymphatics or venules. Here the first molt takes place and the L3 formed are transported via the blood stream to the right heart and then to the lungs via the pulmonary artery. Here they undergo their final molt and the L4 larva grows before rupturing out of the pulmonary capillaries into the alveoli. From here they move up the bronchioles and migrate into the glottis, from where they are coughed up and swallowed a

19 18 second time. In the small intestine, larva sexually matures into an adult worm. Both male and female worms reside in the small intestine especially the jejunum. Ascaris lumbricoides exhibit clear sexual dimorphism, mature female (20-40cm) at least two times bigger and longer than the mature male (15-20cm long) (Ukoli, 1990.) Freshly expelled Ascaris worms are pinkish in colour with an appearance similar to earthworms. They measure 12-35cm in length and taper at both ends. The tail of the male is curved and has small rod- like projections (spicules). There is a small mouth surrounded by three lips ( Fig.1). The females lay unembryonated eggs into the small intestine and these are excreted with the faeces (Crompton, 1989). Usually fertilized eggs are found in faeces but occasionally infertile eggs are produced by unfertilized female worms. Fertilized egg is yellow-brown, oval or round, measuring µ m long (micrometer long) by micrometer ( µ m) wide. Shell is often covered by an uneven albuminous coat (mammilated) and contains a central granular mass which is the unsegmented fertilized ovum. The egg may have a smooth shell and appears pale yellow or colourless. Infertile egg of A. lumbricoides is darker in colour and has a thinner wall and more granular albuminous covering. It is also more elongated than a fertilized egg, measuring about 90 to 45 µ m, and contains a central mass of large granules (Cheesebrough, 2006). Morphology and life cycle of Ascaris lumbricoides (Fig.1,)

20 Fig.1 Life cycle of Ascaris lumbricoides Scanned from Arora and Arora (2006) 19

21 20 The rate of contamination with A. lumbricoides eggs is enhanced by indiscriminate defecation, poor standards of hygiene and inadequate facilities for water supply and sanitation (Asaolu and Ofoezie, 2003) Epidemiology: Ascaris lumbricoides is universally distributed around the world but is most prevalent in the tropical zones of Africa and Asia especially India and China. It is estimated that over two billion persons are infected around the world at any given moment. Global distribution is driven by climatic conditions particularly temperature and humidity. Optimal conditions for the development of larva within the egg shell are C of temperature at least 40%. At regional level, Prevalence and intensity of infection depend on the level of water supply of safe water and sanitation is high, ascariasis is generally low but increasingly high as access to these facilities decrease. In such communities according to Arfaa (1984) prevalence as high as 80% or higher is not uncommon in such communities: in terms of age dependent distribution prevalence is said to be very high between the ages of 4 and 14. It has also been reported that intensity of infection measured by worm burden after expulsion chemotherapy or by egg excretion per gram of host faeces is especially higher in children than adult, in many given community, ( Okpala, 1961; Ogunba, 1974; Nwosu and Anya, 1981; Ukoli, 1981, 1990; W.H.O. (1967); worked on the incidence and prevalence of intestinal parasites in different communities in the country. However, overall distribution of worms in any human population is over dispersed, because majority of individual in a community carry few or no worms while a few individuals carry most of the worms (Asaolu et al., 2002a, b). As a result, young children disposed to heavy worm burden are targeted for treatment due to budgetary constraints; morbidity control programmes cannot afford mass treatment of all age.

22 Clinical Manifestation: Clinical manifestations in ascariasis are related to the consequences of larval migrations (from the intestine to the livers, lungs, heart and finally back to the intestine) and the activities of the adult worms. Detoxification and high oxygen tension in the lungs destroy migrating larvae, the remains of which include most of the eosinophilia seen in ascariasis. In addition fever, cough, dyspnoea and urticarial rash may also occur. Pulmonary manifestation causes a Loeffler s pneumonia-like syndrome may manifest (Gelpi and Mustafa, 1967 Arfaa, 1984;). Adult Ascaris could induce mild abdominal pains that are seasonal. This is said to be more severe in heavily infected children (Lagundoye, 1972). The patients may be restive and have loss of appetite, occasional vomiting, intermittent loose stools or constipation and may pass several worms through the anus or through the mouth. Colicky pain abdominal distention and abdominal stomach sounds are common symptoms (Asaolu et al., 1991). Physiologically, adult worms compete for the host s age Pathology and Pathogenesis: Pathology in ascariasis are varied but are broadly classified into organ damage and host sensitive reactions due to migrating larvae, and the large size and activities of the adult worm. Pathogenesis due to larva migration through the intestinal mucosa, the liver and lungs occur as hypersensitivity reaction of the human host, due to some of the larvae granulomas. In the lungs larval migration from blood vessel into air spaces result in haemorrhage and oedema of the alveoli. Alveolar sacs are filled with serous exudates and peribronchial tissues become infiltrated with eosinophils and neutrophil aggravating mucous production in the bronchi known as Loeffler s syndrome, this condition gives rise to dry cough high fever and

23 22 bronchial asthma. The effect is severe when the number of larvae is large or when transmission is seasonal (Efem, 1987; Asaolu et al., 1991). Presence of adult A. lumbricoides in the intestine induces disordered changes in the jejunal mucosa and intestinal muscle layers. There is an architectural change in the mucosal folds which may lead to reduced rate of mucous production resulting in hypertrophy of the intestinal muscle layers (Lagundoye, 1972; Stephenson et al., 1983). It also causes intermittent colicky and in severe infections obstruction of the intestine and biliary ascariasis (Lifeschitz et al., 1987). Associated with these problems of ascariasis is protein energy malnutrition as a result of the worms competing for food nutrients with the host. (Hadidjaja et al., 1998, Lu, 1992). In addition, adult worms migrate extensively to tympanic membrane and trachea causing ulcer, Organ damage and obstructions, the severity of which depends on the organ involved. (Andrade-Junior et al.,1992). Worms moving towards the upper gastrointestinal tract may be vomited (Forrester and Scott, 1990; Villamizar et al., 1996). In heavy infections several worms may ball up and cause intestinal obstruction (Blumenthal and Shultz, 1975; Da Silva et al., 1997a.; Villamizar et al., 1996). This may be accompanied by such complications as intussusceptions, volvulus, haemorrhagic infarction and perforation of the intestine. Invasion of the biliary-duct, hepatic abscesses, acute pancreatitis, peritonitis and obstruction of the upper respiratory tract have also been reported (Pawlowski et al., 1985; Andrade-junior et al., 1992; Lindo et al., 1998; Xianmin et al., 1999). Laboratory workers exposure to materials from Ascaris worms over a long period of time have been known to develop allergic reactions like asthma, eosinophilia and urticaria (Tripathy et al., 1971; Arfaa, 1984).

24 Enterobius vermicularis (Pinworm) Morphology and Life Cycle Enterobius vermicularis also know as pinworm (as a result of its shape) is one or the intestinal nematodes infections in the tropics. They are up to 12mm in length and colonize the mucous membrane of the lower small intestine and the colon. The females lay eggs in the anal region at nights (Ukoli, 1990). The eggs are usually partially embryonated, but once voided develop to infective stage within 6 hours (Chandler and Read, 1961). Infection is usually by the oral intake of embryonated egg (direct smear infection, digital autoinfection, not from foods). The swallowed eggs hatch into larva that temporarily burrow into the mucous membranes in the region of the cecum and grows into maturity in the rectum. Transmission can occur by contagious means, when the contaminated hand is used to shake another person. The migration elicits an itching sensation that makes the infected scratch the anus, contaminating the hands in the process (Klement et al., 1996). Eggs lodged in fingernails are easily transferred to others during handshake to the mouth, food, water or to any other substance that may eventually allow them reach human mouth. They may also be liberated to the air and inhaled with dust Chandler and Read (1961) observed that when heavily infected children are in the house, almost all house-hold items and floor are contaminated with the eggs of E. vermicularis. Exchanging items (Combs, towels etc) by children or grown ups also contribute to the spread of the infection. Morphology and life cycle Enterobius vermicularis (Fig.2)

25 Fig.2 Life cycle of Enterobius vermicularis Scanned from Arora and Arora (2006) 24

26 Epidemiology: It has been reported that Enterobius vermicularis exclusively infect humans. Infection is worldwide and age and sex independent although peak prevalence and intensity often occur among children and boys who also contaminate the environment more that adults and girls respectively and contribute more to the cycle of infection and re-infection in the household (Grove, 2002) Clinical Manifestation: Many infections are said to be asymptomatic but the commonest symptom is pruritus in the anal region. According to report the major problem in management is recurrence of infection. Eggs become viable for a week or so. Pajamas, bedding and underclothing are contaminated when the itchy parianal area is scratched and the patient becomes re-infected by ingestion of one of these eggs Pathology and Pathogenesis: According to David (2002) prutitus is the hallmark of this infection and is thought to be due to a cell-mediated immune response to eggs deposited on the perianal skin. 1.5 Ancylostoma duodenale, and Necator americanus (Hookworms): The hookworms reside in the gut of mammals, reptiles and amphibians. They are characterized by heavily sclenotized mouth parts and are blood feeders. Human hookworms belong to the genera Ancylostoma (family Ancylostomatidae) and Necator (family Uncinariidae) which are morphologically difficult to distinguish (Humar, 1983) Morphology and Life Cycle. The eggs containing segmented ova are passed out in faeces, mature and hatch in warm moist soil within 24 to 48 hours. The rhabdoid (Rhabditiform) larva liberated is A-B ym molts twice in the 3 rd and 5 th days, transforming into filariform which is the infective

27 26 stage. Depending on the temperature and moisture content of the soil, the filariform larvae may remain viable for about 6 weeks. On contact with human skin however it actively penetrates and migrates through the lung capillaries into air sacs, ascends the respiratory tract, past the trachea and glottis and is swallowed. Before this stage or on reaching the oesophagus the larva molts a third time and on reaching the small intestine undergoes a fourth and final molt and develops into adult stage. The adult attaches itself to the villi of the small bowel by the help of the mouth. The female worm matures and lays eggs within 6 weeks of initial infection (Crompton, 1989). Necator americanus is 7-11mm long and 1.7mm.width it obtains nutrients from the consumption of villous tissues and blood sucked from their site of attachment to the mucosa of small intestine where they can live for 3-5 years. They lay eggs in the small intestine and these are passed out in the faece. Under favourable environmental conditions the eggs hatch within 5-7 days and develop into motile infectious third stage larvae, L3. The L3 larvae may survive for several months (Dobardzic et al., 2002) but on contact with human skin they penetrate actively (Hotez et al.,1990, 1997)., migrate to host venules and lymphatic vessels and are swept into pulmonary vasculature, where they rupture the capillary vessels to enter the alveolar spaces. They then migrate to upper respiratory tract to gastrointestinal tract. Entry into the small intestine stimulates molting of L3 larvae to the L4 stage and then the adult stage. It takes approximately days to develop to adult female hookworm capable of laying eggs (Dobardzic et al., 2002). The major difference between the life cycle of A. duodenale and N. americanus is that if the larvae of A. duodenale perchance reach the small intestine firstly they develop to adults without the pulmonary migration whereas N. americanus larvae require the pulmonary migration to attain adult stage. In addition N. americanus lives longer (about 5 years) than A. duodenale (approximately 1 year) and is more virulent causing more blood loss (0.05 to

28 27 0.3ml per worm per day) and producing more eggs per female. A. duodenale and N. americanus are differentiated on the basis of their unique morphologies as adults and larvae, but the eggs fairly indistinguishable (Dobardzic et al.,. 2002). Recently developed polymerase chain reaction distinguishes different hookworm species and can detect mixed infections (Hawdon, 1996).

29 28 Fig.3: Morphology and Life cycle of Ancylostoma duodenale Scanned from Arora and Arora (2006)

30 Epidemiology: Hookworm infections according to Dobardzic et al. (2002) are important causes of morbidity in the tropical and subtropical nations between latitudes 45 0 north and 30 0 south where soil and climatic condition are optimal and prospect of contamination high due to poor water supply and sanitation, over a billion people are believed to be infected by the two common species (Chan et al., 1984; Hotez et al., 2000). The greatest number of hookworm infection is higher in rural than urban areas (Miller, 1979). Epidemiologically, hookworm exhibits patterns that are distinct from the other two major soil-transmitted helminthes, Ascaris and Trichuris (Dobardzic et al., 2002). The highest Ascaris and Trichuris worm burdens typically occur among children between the ages of 5 and 15, whereas hookworm burdens increase almost linearly with age in some endemic areas (Gandhi et al., 2001). It has been reported that in many parts of China and Southeast Asia, hookworm is common in both the elderly and children populations. (Dobardzic et al., 2002) A. ceylanicum occurs sporadically, usually producing infections with a low worm burden, in China, Southeast Asia and Surinam Clinical Manifestation: Clinical features are said to correspond to the life cycle of the parasites and intensity of infection (Strickland, 2000). Initial manifestation is a burning or stringing or ground itch sensation caused by skin penetration of larvae. This is followed by pruritus and a papulovascular rash persisting for 1 to 2 weeks. Pneumonitis is a consequent of migrating N. americanus and A. duodenale L3 from skin to intestine via lungs. Usual situations are cough and pulmonary infiltrates. The later is a sign of heavy infections. Abdominal colic with diarrhea and worked peripheral eosinophilia (1000 to 4000 cells per mm 3 ) can also develop during larval migrations and subsequent worm maturation in the small intestine. Chronic heavy hookworm infection results in chemical

31 30 hookworm disease whose hallmark is hypochromic microcytic anaemia. The development and severity of anaemia depend on the intensity of infection, the predominant species of hookworm present, the iron reserves of the host, and the availability of iron in diet. In extreme cases of chronic infections, hypoalbuminemia or kwashiorkor has occurred due to prolonged plasma protein loss (Dobardzic et al., 2002). Additional laboratory findings include a low reticulocyte count, low serum ferritin and iron levels, and elevated transferin. In many endemic areas, confounding causes of anaemia include malaria and hemoglobinopathies which must be eliminated in hookworm diagnosis (Dobardzic et al., 2002). Infantile ancylostomiasis presents with melena, profound anaemia, and malnutrition. Eosinophilic enterocolitis, an emerging zoonosis in Queenland, Australia, resulting from infection with A. caninum, produces positive serology for A.caninum, marked peripheral eosinophilia and usually negative faecal examinations (Gutierrez, 2000) Pathology and Pathogenesis: Adult stage hookworms that live attached to the small intestinal wall feed on blood and mucosal contents. Heavy worm load can cause significant plasma protein loss and iron deficient anaemia. All ages are said to be susceptible to infection, but children, adolescent and pregnant women are particularly at risk from hookworm morbidity as the physiological demands for iron are high among these groups (Dobardzic et al., 2002). In school aged children and infants, hookworm anemia may retard growth and cognitive development (Oski, 1993.,) There is also report that there is an important link between hookworm anemia and adverse pregnancy outcomes. The W.H.O. (1994) estimated that 44 million pregnant women worldwide are infected with hookworm (World Bank, 1993).

32 Trichuris trichiura (whipworm): Parasitology: Trichuris trichiura or whipworm is a parasite of the human gut worldwide especially in areas where the climate is worm and humid, sanitation standard is poor and precipitating massive environment contaminating with human faeces (Arfaa, 1984; Pawlowski, 1985) Morphology and Life Cycle: Adult male T. trichiura measures from 30-45mm while the female measures from 30 to 50mm in length fig. 1.1 and fig.2.2.the diameter of the anterior portion mm and the posterior portion mm. There is a simple mouth armed with a minute spear. The esophagus, which lies in the long anterior portion, consists of a short muscular part and a long glandular part situated in a row of cells called Stichosomes. The posterior portion contains the intestine, and in both sexes, a single gonad. The male worm is distinguished by the presence of a single spicule surrounded by a spiny sheath at the posterior end. The eggs are unembryonated when released and are ovoid in shape with characteristic plugs at each end. The eggs measure 50 to 54 by 22 to 24um fig In moist soil and at favourable temperature, the eggs embryonate in about 3 weeks and become infective. Transmission is by hands or when the eggs are ingested with food or drink contaminated with soil. Ingestion of eggs through any of these means marks the beginning of the life history. The eggs hatch in the small intestine releasing larvae that enter the crypts of Lieberkuhn, develop for about a week and re-enter the intestinal lumen. They migrate to the caucus, attach to the surface of the mucosa by their anterior end and mature to adult males and females. Corpulation takes place between the sexes and eggs laid by the female appear in host faeces 70 to 90 days after initial ingestion of eggs. Adults live for several years and a female worm releases from 1000 to 6000 eggs per day through out its lifespan. Under optimal conditions, Trichuris eggs can remain available in the soil for 6 years but desiccation and extreme temperatures are detrimental (Asaolu et al., 2002c).

33 32 Fig. 4 Life cycle of Trichuris trichura Scanned from Arora and Arora (2006) Epidemiology: About 500 to 700 million people are infected with T. trichiura globally, mainly in the tropical and subtropical regions of Africa, the Americas and especially Asia (Henry et al., 1993; Bundy et al., 1975). It is more prevalent in moist and warm regions than in arid and temperate counties and in rural that in urban areas (Pawlowski et al., 1991), although prevalence may sometimes be higher in urban slum children than in their village counterparts (Henry et al., 1993). In many endemic communities prevalence may be in excess of 80%.

34 33 Infection starts early in life and reaches a peak among the age group 5 to 14 years after which it falls slightly (Albonico et al., 1996) Clinical Manifestation: Infections involving less than 100 worms are usually asymptomatic, but since adult worms live for several years large numbers may gradually accumulate, especially in children, leading to an intensive T. trichiura infection. Massive infantile trichiurasis is characterized by chronic diarrhea with mucus and blood, abdominal pains, tenesmus and blood rectal prolapse. In children with severe and chronic infection, symptoms include severe anaemia, digital clubbing and growth retardation (Pawlowski, 1985) Pathology and Pathogenesis: Trichuris trichura penetrates deep into the mucosa of the colon by its oesophageal portion. This causes mechanical damage to the epithelium and underlying sub-mucosa, and consequently results in chronic haemorhage. The damage to the mucosal epithelium facilitates secondary bacterial infections and invasions by intestinal protozoan parasites. Majority of the worms concentrate in the caecum, but in heavy infections, the terminal ileum, and the whole of the large intestine including the rectum are invaded (Asaolu et al., 2002c). Infection of the appendix by T. trichiura is also linked with the cause of appendicitis (Pawlowski, 1985). The pathological changes induced in the intestinal mucosa contribute to the intestinal colitis and in some cases rectal prolapse. 1.7 Strongyloides stercoralis Morphology and Life Cycle. The adult parasites female are parthenogenetic and measure 2mm in length. It inhabits the small intestine. The parasitic males are evacuated in the faeces. The eggs are oval in shape like those of Ancylostoma duodemale and are usually deposited in the lumen of the

35 34 intestine. They contain partly developed larvae when found in stool. They have spiral movement and tend to startle the observer initially because of its rapid movement. The parthenogenetic female adult worms (2-5mm long) produces eggs which hatch in the bowel and most of them are passed in the faeces as non-infective rhabditiform larvae ready to penetrate exposed skin. Small proportions of larvae in the bowel penetrate the large intestine mucosa or the perianal skin and by the process of autoinfection perpetrate infection indefinitely (Grove, 2002).

36 Fig. 5: Life cycle of Strongyloides stercoralis Scanned from Arora and Arora (2006) 35

37 Epidemiology: Distribution is high in warm humid regions, Infection is said to occur mainly in the tropics where sanitation is known to be poor. It can be found in Europe and North America. In the U.S., it is endemic in some residents of the U.S. Appalachia and in Asian immigrants (Grove, 2002). Infection is rarely found in temperate zones. Transmission is by skin contact with infective larvae which penetrates the exposed skin of man who go barefooted in their farms, or children who play in contaminated environments Clinical Manifestation: Heavy intestinal infestations are characterized by pain, nausea and vomiting with alternating diarrhea and constipation. Patients with uncomplicated stongyloidiasis are asymptomatic or may complain of urticaria, diarrhea, weight loss and itching in the anus. In massive stongyloidiasis there may be intestinal obstruction, pneumonia, Gram negative scepticaemia and meningitis (Grove and Northern, 1986; Grove, 1989). Gastrointestinal symptoms and eosinophilia are also manifested Pathology and pathogenesis: During the larval migration into the lungs it tends to mimic bronchopneumonia. The microhabitat of the adult worms is the small intestinal epithelia layer. The host shares the digested food nutrients with the parasite. Anemia and other essential minerals are lost to the parasite apart from the ability of the worm to cause intestinal obstruction and enterocolitis. There is erythema and pruritus of the site of entry, after passage through the lungs (bronchitis, pneumonia, pleurisy). There is also diffuse abdominal pain, diarrhoea, constipation, mal-absorption, fever, and edema. Occasionally, it visibly can localize in the skin. Albendazole and several other antihelminths are used in the treatment of strongyloidiasis (Archibald et al., 1993; Armson et al., 1995). Ivermectin is, however, refractory (Ashraf et al., 1996).

38 Toxocara Species (Toxocara spp). Toxocara species namely T.cani and T. cati infect pet animal in the western countries. They belong to the soil-transmitted helminthes and their definitive hosts are the canids and felids respectively, and are commonly reported to be zoonotic helminthes (Grove and Northern, 1988; Grove et al., 2002). In their hosts they are located in the liver, lungs, eye, brain and other viscera. Detail of their morphology and life cycle is not known the mode of transmission is by ingestion of soil contaminated by dog or cat faces that contain the eggs Morphology and life cycle When a human being ingested embryonated eggs of Toxocara, the eggs hatch in the small intestine where they release larvae that perforate the intestinal wall. They then enter the blood vessel and go through the liver and lungs to the heart where they are disseminated by the systematic circulation (Grove et al., 2002). It is said that the hatched larvae have been found in the liver, lungs, hearts, eye and brain Epidemiology: The infection is worldwide. The infection is high in apparently healthy adults in rural areas (37%) and low in urban areas (5%) in the western countries (Magnaval et al., 1993) Clinical Manifestations: The clinical severity of human toxocariasis is said to be generally a function of the total number of eggs ingested as well as the frequency of ingestion (Grove et al., 2002). Human Toxocara infection elicits several different syndromes (Grove et al., 1998).

39 Pathology and pathogenesis Visceral larva migrans (VLM) was first described in 1952 in Children with an enlarged liver and hyper-eosinophilia (Beaver et al., 1984). Most typical VLM patients are children below the age of 7 years with a history of geophagia and exposure to puppies in the home. The acute signs of VLM associated with hepatic and pulmonary larval migration often include abdominal pain, decreased appetite, restlessness, fever, coughing wheezing, asthma and liver enlargement (Grove, 1982a). In this phase of the infection, there is usually a marked eosinophilia (greater than 2000 cells/mm 3 ) leucocytosis, and hypergammaglobulinamea. In Western countries, the VLM syndrome is rarely encountered and a review of the literature from 1952 to 1979 found only 970 such report. There is report for ocular larva migrans that typically occurs unilaterally in children and young adults. The most common symptom is visual loss with onset over a period of days to weeks (Grove, 1982b). There is also report on funduscopy and biomicroscopic examination that often reveals uveitis and ocular infection may also be sub-clinical and only detected during routine eye examination The large discrepancy between the relatively small number of reported cases of VLM and ocular larva migrans syndromes and the high seroprevalence rate, especially in rural areas, led to a search for other clinical manifestations of toxocariasis. The symptoms in French adults suffering from toxocariasis include weakness, pruritus, rash, difficulty in breathing and abdominal pains. This syndrome was termed common toxocariasis in adults (Ukoli, 1990). There is also a report from Ireland in which the most frequent clinical manifestation in children infected with Toxocara included fever, anorexia, headache, abdominal pain, nausea, vomiting, lethargy, sleep and behavioral disorders, pharyngitis, pneumonia, cough, wheeze,

40 39 limb pains, cervical adenitis and hepatomegaly. It also showed that twenty-seven percent of patients displaying high anti-toxocara titres had normal blood eosinophil counts. 1.9 LABORATORY DIAGNOSIS OF SOIL TRANSMITTED HELMINTHS Ascariasis is diagnosed by the demonstration of its eggs or adult worms in faeces either using the naked eye or nurture microscopy. The fertile ovum is broadly oval, has a thick shell with an outer coarse warty albuminous coat stained yellow or brown in the intestine, while the adult worms can be observed by direct examination of stool. It measures about 60 to 70 micron in length by 40 to 50 micron in width. The unfertilized eggs are more elongated and less regularly oval in shape. They contain amorphous substances and lack the well-defined (decorticated) round found in the fertilized eggs (Chandler and Read;1961, Asaolu et al., 1991). While several coprological methods are used in egg microscopy, the various coprological methods are based on the principle of egg concentration in a liquid medium or slide preparation of thick smears. Concentration methods are based on the relative specific gravity between the liquid media and helminth eggs. Where the specific gravity of the media is greater, eggs concentrated at the surface but where it is lesser eggs concentrate by gravity. Besides, concentration can also be achieved by centrifugation. Ascaris eggs are concentrated by saturated sodium chloride flotation technique at the specific gravity of In addition kato cellophane thick smear technique (KTS) is the best slide preparation method. Both methods are efficient, easy to prepare and relatively inexpensive and the KTS is fairly easier to use as it permits examination of large number of samples per unit time.

41 Transmission of Soil-Transmitted Helminthes. A number of factors are involved in the transmission of helminth parasites. The eggs of soil-transmitted helminthes and or their larvae must be present in the environment and in a viable condition. The environment is contaminated when eggs or larvae reach the soil in human faeces. When the human environment is contaminated man becomes exposed to these infective agents (Ugbomoiko et al., 2009). The parasites thrive well in places and communities where poverty is entrenched so that safe systems of sanitation and sewage disposal are unavailable to protect the people. The climate must favour the rapid embryo nation of the eggs to produce the infective second-stage larvae (table 3) (Crompton and Pawlowski, 1985). The higher the degree of environmental contamination with eggs and larvae of soil-transmitted helminthes, the higher the prevalence in such communities. According to Kagei (1983), apart from soil and sewage, most household items, vegetables and paper money are equally contaminated by helminth eggs especially A. lumbricoides. The eggs gain entry into man orally or by inhalation of contaminated air in the environment. Young children and adults are more at risk of ingesting eggs through playing on the ground in defaecation areas and through eating soil contaminated with eggs. Poor personal hygiene by some adults at toileting especially not washing hands or fruits before eating can place them at risk of ingesting eggs of A. lumbricoides..

42 Factors Affecting Transmission Numerous factors affect transmission of helminthiasis. Personal hygiene and bad habit at defaecation are the strongest factors. Bad habits at menstrual periods especially the use of unsanitary items contaminated with human excreta and larvae in the soil. The use of napkin that is not chenged Non-removal of wet napkins may lead to autoinfection in babies. Other predisposing factors include the use of unclean soil contaminated feeding bottles, plates, cups and other utensils. According to Crompton and Pawlowski (1985) it is not uncommon to encounter households where almost all usable items are contaminated by the helminthes eggs especially those of Ascaris lumbricoides Cleaning the ear and the eye with contaminated fingers and tissues equally leads to transmission of helminthiasis. Indiscriminate defaecation in the rural areas around houses and playgrounds of children enhances transmission by increasing rate of contamination in the environment. Consumption of contaminated fast foods such as smoked fish and meat (suyas) bean cakes etc are good sources of infection (Ugbomoiko and Ofoezie, 2007). Several categories of human behaviour have been shown to encourage helminth transmission. Of particular importance is a toilet habit: such as indiscriminate deafecation in bushes and other surroundings, improper cleaning after using the latrine, infrequent wearing of foot-wears and eating unwashed vegetables and fruits Occupation Occupation is a factor in terms of exposure to helminth infection. For instance, farmers who farm in lands where there is indiscriminate defaecation of human faeces are known to be exposed to infective egg/larvae of soil-transmitted helminthes. The farmer who uses untreated sewage water for cropping and human excreta as manure has been shown to be exposed to helminth infection.

43 42 Workers in conservancy services and unmasked sewage workers unmasked especially night soil men may inhale helminthes egg. Chicken dressers, abattoir workers (butchers), Morticians and mortuary attendants may be contaminated by helminth larvae or worms leaving the dead bodies or carcass because as soon as death occurs parasites and larvae crawl out through any available opening of the dead animal so that they will not be buried or roasted with their host. Commercial drivers or road transport workers who stop randomly to eat in hotels are at risk of ingesting helminth ova Educational background Education has been known to be very important in the life of every individual. Health education including personal hygiene is taught in schools. Importance of sanitation to reduce environmental contamination is also included in the curriculum. Sanitation to reduce environmental contamination is also included in the curriculum. Low prevalence among educated and skilled workers has been reported as well as among those whose standard of living is high (Ugbomoiko and Ofoezie, 2007). The individuals with sound educational background live in good houses with modern facilities such as water and W.C Health Education Health education is a very important tool for creating awareness and mobilizing community members against disease transmission. Several health education programmes emphasize the importance of enlisting children and teaching them good hygiene methods early in life. In order to achieve this goal health education has been included in the curriculum of primary school and secondary schools in many developing nations including Nigeria to create awareness on the importance of personal hygiene and sanitation. Countries like Malaysia have started continuous health education to students, teacher, parents and the community to increase awareness of the relationship between infections with worms and personal hygiene and other health promoting habits like washing hands, wearing shoes, and

44 43 use of toilets have also been included. At P.T.A. meeting in schools, importance of early and effective treatment of gastrointestinal diseases is being emphasized. Posters, pamphlets and pictorial fliers on the appearance, life cycle, transmission, effects and simple preventive measures against intestinal worms are used as teaching aids Management Hygiene Hygiene such as the practice of keeping yourself and your living and working areas clean, in order to prevent illness and disease of parasitic origin especially soil transmitted helminthes are important. Practice of food hygiene and personal hygiene such as washing of hands and food preparation under hygiene conditions are also important Environmental Control of Soil-transmitted Helminthes. This is essential in every country especially the underdeveloped and developing countries of the world. The first step is to determine the level of contamination of the soil and sites and the helminth eggs most involved (Kagie, 1991). Several studies imply that there is a direct relationship between rate of infection and poverty probably due to lack of safe systems of sanitation and sewage disposal. The situation is worse when the climate favours the rapid embryonation of eggs and development of infective second-stage larvae. The risk of eating or drinking contaminated food and water is much greater in such environments. There is also evidence in such areas that eggs may be inhaled and eventually swallowed as part of windborne dust particles (W.H.O., 1967; Kagei,1983). The group most at risk of environmental contamination with soil transmitted helminthes are children and young adults who ingest eggs while playing and who defaecate indiscriminately. Although helminthe eggs in the soil are under serious stress from environmental factors such as sunlight, desiccation and predators, sufficient quantity always survive to perpetrate transmission in endemic areas. Other sources of contamination of the environment with helminth eggs include use of untreated waste water for crop and the use of human excrement night-soil as fertilizers,

45 44 domestic poultry especially long range birds that eat adult female worms can contaminate the homestead. Viability is retained despite passage through the bird s alimentary tract (Urquhart, 2003). The type of soil and the depth at which the eggs are buried are said to influence the survival of the larvae within the egg shells. Though, W.H.O. (1967) reported that sandy soil is less supportive of the survival of infective eggs than clay soils. When the eggs are on the surface of the soil, the life-span is days (Janssens, 1985). Those eggs at a depth of 100mm to 200mm as long as one and half years and those at mm deep two and half years. Domestic poultry that have eaten adult female worms can spread eggs around their homestead and viability is retained despite passage through the bird s alimentary tract (Urquhart, 2003). Children and people of all ages are at risk from ascariasis in regions where human excrement (night soil) is used as fertilizer for crops. Some vegetable like radish leaves, spinach and some onions were found to be most heavily contaminated, while only three types were found to be free from eggs (Kobayashi et al., 1994). Untreated waste for crop irrigation was prohibited when it became necessary to reduce the level of contamination of soil-transmitted helminthiasis especially ascariasis. Consequently, the prevalence which was 35% dropped to 1% between 1948 and 1960 (Shuval et al., 1981). Environmental contamination by soil transmitted helminthiasis is a problem that needs serious solution in our communities (Figures 1.6, 1.7, 1.8, and 1.9).

46 45 TRANSMISSION 1. Infective eggs ingested in food or from contaminated hands. HUMAN HOST 2. Larvae hatch. Migrate through liver and lungs. 3. Pass up trachea and are swallowed. 4. Become mature worms in small intestine. 5. Eggs produced and Passed in feaces ENVIRONMENT 6. Eggs become infective (embryonated) in soil in days. 7. Infective eggs contaminate the environment. Fig.1.6: Transmission and life cycle of Ascaris lumbricoides (Cheesebrough, 2006)

47 46 TRANSMISSION 1. Infective filariform Larvae penetrate the skin, e.g. feet. A. duodenale also transmitted by ingestion of larvae. HUMAN HOST 2. Larvae migrate. Pass Up trachea and are Swallowed. 3. Become mature worms in Small intestine (attach to wall and suck blood). 4. Eggs produced and passed in faeces. ENVIRONMENT 5. Eggs develop. Rhabditiform larvae Hatch. Feed in soil. 6. Infective eggs contaminate the environment. 7. Filariform larvae contaminate soil. Fig.1.7. Transmission and life cycle of hookworms: Ancylostoma duodenale and Nectar americanus. (Cheesebrough, 2006).

48 47 TRANSMISSION 1. Infective eggs ingested in food or from contaminated hands. HUMAN HOST 2. Larvae hatch. Develop in small Intestine. Migrate to Ceacum. 3. Become mature worms. 4. Eggs produced and Passed in feaces. ENVIRONMENT 6. Eggs become infective (embryonated) in soil after 3 weeks. 7. Infective eggs contaminate the environment. Fig.1.8 Transmission and life cycle of Trichuris trichiura. (Cheesebrough, 2006)

49 48 TRANSMISSION 1. Infective filariform Larvae penetrate Skin, e.g. feet. Autoinfection also occurs. HUMAN HOST 2. Larvae migrate. Pass up trachea and are swallowed. 3. Become mature worms in small intestine. ENVIRONMENT 6. In soil larvae become free living worms. Produce more rhabditiform larvae.. Free-living cycle can be repeated several times. 7. Become infective Filariform larvae in the soil. 4. Eggs laid. Hatch rhabditiform larvae in intestine. 5. Rhabditiform larvae: - passed in faeces, or - become filariform Larvae in intestine, causing autoinfection. Fig.1.9 Transmission and life cycle of strongyloides stercoralis. (Cheesebrough, 2006).

50 Chemotherapy Orthodox The drugs which are used for expelling worms are known as anti-helmintics (Liu and Weller, 1996). The ideal anti-helmintics is one which effectively kills or expels the particular worms for which it is used, is not injurious to the host in the dose required, is easily administered, is active against larval and immature stages and is cheap (Chandler and Read, 1961; Gupta et al., 1991). No single anthelmintic can kill all the worms even the intestinal worms though near all lead to reduction in morbidity (Lynch et al., 1997). Nematodes and trematodes, which have digestive tract respond similarly to many drugs although susceptibility to specific drugs and mode of action vary greatly (Holland et al., 1986; Martin, 1997; Horton, 2000). Pyrantel Pamoate (anthelmintics) was seen to be effective against A. lumbricoides only when given in a single dose. Observation did not show it to be particularly effective to hookworms neither has it been proved to be effective against Trichuris trichiura. Deworming annually or biannually was said to be insufficient especially in areas where rates of transmission and re-infection were high as in the case in most endemic areas in Malaysia (Pawlowski, 1989). Very often only school children are treated (Janssens, 1985; Kohler 2001) Drugs of Choice: Mebendazole: Cure rate is said to be 90% in enterobiasis. The drug is active against E. vermicularis that live in the intestinal lumen. A small. Toxicity is negligible when given in single dose. It is not to be given to children below two years of age Alternative Therapy: These include pyrantel (Davis, 1985).

51 50 Pyrvinium available in Canada. Ivermectin and Albendezole a newer drug (Davis et al., 1985; Gann et al., 1994). Antiparasitic Agent prophylaxis. This can only serve as part of a comprehensive programme to eradicate infection from a community such as a child s home in which infection is widespread. It is recommended that a single dose of anti helmintic may be given to everyone in the family on three or more occasions two weeks apart in conjunction with the general hygienic measures (Davis et al., 1985) General Preventive Measures: To eradicate infection from a family a number of measures are required because of persistent contamination of environment and poor personal hygiene among children. Measures such as frequent bathe, cutting finger nails short, careful hand washing, washing of beddings, pyjamas, under clothes and towels in warm or hot water regularly, frequent evacuation of rooms, treating all members of the house hold at the same time with anthelminitic drugs and repetition of treatment in 2.3 weeks twice to eliminate re-infection have been recommended Mass Chemotherapy: The strategy is most appropriate in areas where existing knowledge suggest that all groups are at equal risk of infection. Treatment is thus, given to all members of the population without prior laboratory diagnosis. The cost of technical skill and equipment for diagnostic procedure is saved although some cost is lost treating the uninfected. This method of control has been reported as the most effectives and has been used with satisfactory results in several endemic settings (Albonico et al., 1995) Group- Targeted Chemotherapy: The strategy is most appropriate in population when previous studies suggest that some groups are more at risk than others. Chemotherapy is thus targeted at the group with the

52 51 highest risk of morbidity after random diagnosis. Grouping is usually on the basis of age, occupation or any other demographic characteristic (Albonico et al., 1996; W. H. O., 1987). According to reports targeted chemotherapy also benefits the untreated population groups due to the drastic reduction in community egg load and subsequent fall in overall risk of infection (Bundy et al 1975; Asaolu et al., 2002b,) Treatment of Individual Cases: Individuals in endemic areas take anthelmintic drugs periodically to prevent infection. Identification and treatment of these individuals is carried out mainly at the hospital level when such persons present with symptomatic complaints. This approach is most useful for identifying and treating individuals predisposed to infection with heavy worm burden in a community because it is only severe symptomatic manifestations often associated with very heavy infections that encourages individuals to go to hospitals for alternative treatment (Jessen et al., 1986; Hlaing, 1987). In spite of the selective nature of hospital cases, it also helps to reduce overall community egg load.(ofoezie et al., 2002) Herbal Herbs are generally a safe way to strengthen and tone the body s systems. As with any therapy, it is important to work with your health care provider on getting your problem diagnosed, before you start any treatment.. Many of the herbs used to treat intestinal parasites have toxic side effects (Xianmin, 1999) and should be administered under supervision. Some of the drugs used by herbal specialists include garlic (Allium sativum), barberry (Berberis vulgaris), goldenseal (Hydrrastis canadensis) (Xianmin, 1999). Plant-based anti-helmintic formulations have been accepted in China where they now serve as an important alternative to the treatment of complications especially biliary ascariasis (Xianmin et al., 1999). The major ingredients for the formulation of traditional

53 52 Chinese medicine (TCM) are derived from plants. Detailed information on the type of plants has been described by several workers (Yi, 1984; Lid et al., 1991., Lu, 1992; Xianmin et al., 1999). The traditional herbs are said to be taken singly or in combination with the recent orthodox antyhelminthic drugs. Recent studies have shown that the efficacy of only TCM when compared with a combination therapy has a slight advantage because it is associated with reduced episodes of vomiting thus reducing electrocyte imbalance and the risk of dehydration (Xianim et al., 1999) Immunosuppressed Hosts: It has been consistently indicated that ascariasis is a non-oportunistic enteric infection in HIV-Positive and AIDs Patients (Conlon et al., 1990, Sher, 1992, Pozio, 1995). Also there is a greater tendency for Ascaris to infect HIV- negative individuals than HIV-positive patients without chronic diarrhea than their counterparts with chronic diarrhea suggesting that the infection is not a cause of diarrhea which is a leading cause of morbidity and mortality among AIDS patients (Henry et al; 1986) No evidence is available to show that intensity and severity of ascariasis are higher among HIV-positive and AIDS patients than their uninfected counterparts suggesting that the immunocompromised status in HIV-positive and AIDS patients does not predispose ascariasis. It has also been reported that treatment of ascariasis among HIV and AIDS patients should follow the normal procedure using the common anthelmintic drugs. The immunocompromised status of the HIV-positive and AIDS patients are considered in treating complicated cases especially those involving the unusual sites Water Supply and Sanitation To minimize environmental contamination in developing countries, the communities should be provided with good sources of drinking water, like stand pipes at different points in the community. Recently boreholes are being sunk here and there in different communities through community efforts. To wait for the government will be a big joke. Administrative

54 53 protocols will kill the project. Usually, the boreholes or standpipes are maintained by the communities. Morbidity control of parasitic diseases was therefore one of the targets of the international decade on water supply and sanitation which aimed at increase access to better facilities both in the rural and urban communities (W.H.O., 1987b; Ugbomoiko and Ofoezie, 2007). Toilet need to be properly constructed, well maintained and adequately located for full and proper usage by both children and adults. A member of the community should be engaged to supervise cleaning and maintenance of the toilet. Improvement of personal hygiene such as washing of hands, use of toilets and footwear can only be accurately observed if health personnel actually spend some time in the community of the pupils who received such health education (Crompton and Pawlowski, 1985).

55 54 CHAPTER TWO MATERIALS AND METHOD 2.1 Study Area: This investigation was carried out in eleven selected communities within Nsukka and Uzu-Uwani local Government Areas of Enugu State, Nigeria. The areas generally known as Nsukka zone are located about 64km North-West of Enugu, the administrative capital of Enugu State approximately on Longitudes 6 o 54E and E and latitude 6 o 30 and 7 o 60 N (Fig 3.1). Nsukka zone covers an area of over 60,000km 2 comprising seven local government areas (LGA) including the two investigated (fig. 3.1).fig. 10 The inhabitants of the zone are predominantly Ibos, although other tribes such as Tiv, Hausa, Yoruba, and Idoma may also be found. The main occupations of inhabitants are farming, trading and civil service. The major agricultural products include yams, cassava, maize, pigeon peas, palm products, pepper and honey. The climate is typically tropical with well-defined wet and dry seasons spanning April-October and November- March respectively. Annual precipitation is about 1600mm with a mean annual temperature of 27 o C. The soil is characteristically re-ferratic and hydromorphic, and favour water logging (Nwafor et al., 2001). As a result soil moisture storage capacity is virtually zero during the dry season (November-March). The characteristically torrential and heavy rainfall during rainy season gives rise to pronounced incidence of soil erosion and water logging (Ofomata and Eze,2001)

56 55 Fig 10 Map showing sampled areas of soil transmitted Helminthes in Nsukka Zone of Enugu State (Obtained from Nsukka Town Planning Authority) Humidity is generally low with intense sunshine during parts of the year. Forest fires are common and vegetation is characterized with fire resistant trees and shrubs comprising derived savannah described as forest-savannah mosaic by (Ofomata and Phil-Eze, 2001). This comprises a juxta position of grasses, shrubs, savannah trees and a few forest trees scattered in batches of varying concentrations. Using a blind selection method, eleven communities were selected from a pool of community list in a black plastic bag.

57 56 Individuals were selected for the study either at the household level or a gathering in a traditional ruler s residence. Where selection was at household level, every third house in a street was selected and all members of the household included in the study. Where selection was made at the traditional ruler s residence, individuals were selected randomly without regard to age, sex and household. A total of 200 persons were selected in each of the eleven communities. Out of 2200, 2055 consented and they were sampled. 2.2 Questionnaire Administration and Faecal Sample Collection Each selected individual was properly briefed on the objectives of the investigation and once an informed consent was obtained, they were administered structured questionnaire by participatory approach. Information obtained included name, age, occupation, marital status, educational background, and knowledge on common sign and symptoms, mode of transmission, treatment and control of soil transmitted helminthiasis (See Appendix III for details). Faecal samples were obtained from each individual once every three months for 12 months. During each round of faecal sample collection, each individual received a pre-labeled screw-capped 20ml plastic container with an applicator stick and advised on how to collect their early morning stool. A repeat trip was made the following morning to collect the samples. Each sample was fixed with 10% formaldehyde, and returned to the laboratory at the University of Nigeria Nsukka for examination for the presence and number of characteristic egg of different soil transmitted helminthes. 2.3 Collection of Soil Samples Top soil samples were collected from three different sites in each community and returned to the laboratory in black polythene bags for the analysis of soil physical and chemical characteristics and presence and number of helminth eggs. The three sites were selected from any of the following places; within each community: playground, dumpsites, and market places.

58 Analysis of Faecal Samples Two grams of each faecal or soil sample was measured out using an Ohaus Havard trip balance Florham Park USA calibrated in 0.1gram. This was aseptically transferred into a 250mI conical flask containing 60ml of saturated sodium chloride solution. Each sample was thoroughly mixed with a glass rod and rocked as it is passed through a sieve of mesh size 250µ. (See Appendix IV for details). With a graduated glass pipette a 0.3mI of the mixture was withdrawn and transferred into the two chambers in the McMaster Slide (Krecek, 2004) (See Appendix V). The total number of eggs in each chamber was counted under X40 magnification of a compound microscope, starting from the etched areas. The total number of eggs in the two chambers were determined and multiplied by 100 to obtain the total number of eggs in 1 gramme of faeces or soil. This is based on the following estimations: Weight of faecal or soil sample = 2g Volume of salt solution = 60mI Volume of mixture examined = 0.3mI If number of eggs in 0.3mI = x Number of eggs in 60mI (i.e.2g) = 60*X 0.3mI Therefore Number of eggs per gram of faeces = 200X = Number of eggs in 2g. = 200X 2 = 100X

59 58 Fig 11: Egg of Ascaris lumbricoides covered with uneven albuminous coat (mammilated) (x 40) Fig 12: Egg of Ancylostoma duodenale with segmented ovum and four blastomeres and a clear space between the segmented ovum and the egg shell. (x 40)

60 Statistical Analysis Chi square values from the contingency tables were used to determine the difference in prevalence of each parasite infection between different explanatory variables. Differences in the number of eggs in faecal and soil samples (intensity of human and soil infection) performed using the Student t-test for dichotomous variable and one way analysis of variance (Oneway ANOVA) for explanatory variables with more than two levels. Multivariate logistic regression was applied to identify factors that most explain patterns of infection in the communities (Zar, 1992). All analysis was performed using the SPSS version II on a personal computer.

61 60 CHAPTER THREE RESULTS 3.1: Demographic and Socio-economic Characteristics Personal Characteristics Over 98% of the subjects had at least a primary education, while 44.4% had tertiary education. About 81% of the respondents were either civil servants or students and almost 50% were either married (45.5%) or widowed (6.5%).Fig. 11A-D. The rest were single Water supply and sanitation The level of access to different types of facilities for water supply and sanitation as well as modes of hygiene practices of the respondents are shown in Figures 11E-I. Out of the 2055 persons examined, only 565 (27.5%) had access to pipe borne water; 82% of which live in Ezeopi (32.9%), FouIton (33.1%) and Margaret Cartwright (15.8%). About 91% of the pipe connections were in-house and only 9% within compound. No street connections were observed. In the communities with little or no access to pipe borne water, major sources of water supply were shallow wells, streams and rivers, which such communities included Akpugoeze; and water vendors in Edem, Nkpunato, Ogurugu and Site Road.

62 61 A B C D Figure 11: Distribution of studied population in Nsukka zone according to A (educational background); B (occupation); C (marital status) and D (number of children in each house hold).

63 Number in group Ezeopi Edem Akpugoeze 300 E Water source Rain Well Pipeborne Vendor Number in group Satchet Stream 0 TOWN 300 Community Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Foulton Ezeopi Edem F New Anglican Rd Site Road Ogurugu Margret Pipe type In-house Compound standpipe 300 G H Number in group Foulton Ezeopi Edem Akpugoeze Latrine type Bush Number in grouup Pit WC 0 Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Edem Ezeopi Foulton New Anglican Rd Site Road Ogurugu Margret WC type In-house Compound 300 Community I 300 Community J Number in group Cleaning material Water Number in group Wash hand? 0 Paper Tissue 0 Yes No Number in group Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoeze Community Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret K Washing material Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoeze Community Water only 0 Foulton Ezeopi Edem Akpugoeze Water and soap Community Fig. 11; The level of access to different types of facilities for water supply and sanitation as well as modes of hygiene practices of the respondents are shown in figure 11E-K.

64 63 In terms of access to toilet facilities, about 54% of respondents had access to water system (95% in-house connection and 5% within compound). The rest of the respondents were using pit latrine (24.4%) and indiscriminate defaecation in the bush (21.4%). Almost all respondents in Ezeopi, Fulton, Margaret Cartwright and New Anglican Road had in-house installed WC while those in Akpugoeze, Uvuru, Nkpunato and Nkpologu rely almost exclusively on either pit latrine or the bush (fig. 11G & H) Types of materials used for anal cleansing after toilet use also varied from one community to another. While nearly all respondents in Ezeopi, Foulton, Magaret Cartwright and New Anglican Road use tissue papers and wash hands with soap and water after using the toilet, those in Akpugoeze, Nkpunato, Uvuru and Nkpologu use other papers (e.g. news paper and notebook leaves and fresh leaves) and seldom wash hands with soap and water after using the toilet. However, a reasonable number of residents in all communities (19.30% - 100%) except Nkpologu (5.6%) admitted to washing hands after using the toilet though with water alone. Fig. 11 I, J and K Health Condition Ranking and Perception: According to the respondents, stomachache is the second most common health problem (27.6%) in the area after malaria (57.7%). However, these ill health conditions are ranked differently by the various communities. For instance, while malaria is ranked as the most common ill health condition in the urban communities of Ezeopi, Fulton, Margaret Cartwright and New Anglican Road, stomachache is more common to the rural dwellers in Akpugoeze, Nkpunato, Uvuru and Nkpologu. In peri-urban communities of Edem and Site Road, the ill-health conditions are fairly distributed.

65 L 100 M Number in group 100 Nkpologu Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoeze Health problem Fever Number in group Nkpologu Uvuru Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoez Stomachache cause Witchcraft Food poisoning Unw ashed vegetable Stomachache 20 Pilled groundnut 0 Others 0 Dirty hands Number in group 100 N Treatment Self Chemist Herbalis Number in group O Hospital distan 0 Hospital Far Nkpolog Uvuru New An Site Roa Ogurugu Nkpunat Margret Foulton Ezeopi Edem Akpugoe 0 Near Number in group 100 P Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Rate Often Number in group Nkpologu Uvuru New Ang Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoe Q Nkpologu Uvuru New Anglican R Site Road Ogurugu Nkpunato Margret Foulton Ezeopi Edem Akpugoeze Footwear often 0 Occation No Edem Akpugoeze Nkpologu 0 Yes 200 Number in group 100 Ezeopi Edem Akpugoeze R Uvuru New Anglican Rd Site Road Ogurugu Nkpunato Margret Foulton Footwear typ Open 0 Closed Fig. 11: Health Condition Ranking and perception according to the respondents in the studied population (Fig. 11 L-R)

66 65 In terms of perception, respondents in the urban and peri-urban communities said stomachache was caused by poor personal hygiene, while those in rural communities said it was caused by witchcraft and food poisoning (Fig 11L & M). Most respondents in the urban communities went to hospital when they feel unwell while those in the peri-urban and rural communities resorted to self medication, herbalist or chemist shops. Most respondents in urban and peri-urban communities said hospitals were close to their residences, while those in the rural communities said hospitals were far from their residences and explains why they seldom visit hospitals when they were sick (Fig. 11 N, O & P). This is probably why respondents in urban communities visit hospitals more often than their peri-urban and rural counterparts. On the habit of putting on footwears, most respondents in the urban and periurban (80-100%) communities said they wear slippers, sandals or shoes regularly while only a few (10-25%) do so in the rural communities. Among those that normally put on footwears, 46.3% said they normally wear open footwears while 53.7% said they wear closed footwears more often (Fig. 11 Q & R). 3.2 Prevalence and Intensity Patterns Prevalence and intensity of infection in communities Table 3.1 presents the summary of prevalence and intensity of hookworm infection and' ascariasis in the eleven communities investigated in Nsukka zone. Out of a total of 2055 persons examined in the eleven communities, 1085 (52.8%) were infected with hookworm and 1526 (74.3%) with ascariasis, suggesting that overall prevalence of ascariasis in the communities was about a third higher than that of hookworm. About 1034 (50.3%) persons were also found positive for both infections while 1577 (76.7%) persons were infected with either hookworm or ascariasis (i.e. at least one of the two worm infections). No other soil-transmitted helminth infection was encountered.

67 52 Table 3.1: Prevalence of single, double and either infections of hookworm and ascariasis in eleven communities in Nsukka zone, Enugu State, Nigeria, 2007 Community Hookworm Ascariasis Double Infection Either or both Infections Examin Prev (%) Infected Prev (%) Infected Prev (%) Infected Prev (%) ed Infected Akpugoeze Edem Ezeopi Fulton Margret Nkpunato Ogurugu Site Road New Anglican Uvuru Nkpologu χ 2 (df) 53.1(10) 57.1(10) 59.3(10) 60.0(10) p-value <1 1 <1 2 <1 <1 3 Total : χ 2 = 53.06, df= 10; 2: χ 2 = 57.63, df= 10; 3: χ 2 = 60.52, df= 10

68 53 Prevalence of both hookworm and ascariasis varied highly significantly (p< 1) among the eleven communities investigated. Hookworm prevalence ranged from 38.9% among 193 persons examined at Margaret Cartright to 64.7% of 187 persons examined at Nkpunato. In contrast, least prevalence of ascariasis (61.9%) was recorded among 194 persons examined at New Anglican Road, Nsukka while the highest prevalence of 82.6% was obtained among 190 persons examined at Ogurugu. Prevalence of double infection ranged from 38.9% at Margaret Cartright to 58.2% at Site Road Nsukka while that of at least a single infection ranged from 61.7% to 85.6% at Uvuru and Nkpunato, respectively. Further analysis showed that while most persons with hookworm infection also carried ascariasis, in Margaret Cartright, individuals either had a double infection or no infection at all. The overall mean intensity of hookworm infection was eggs per gramme (epg) of faeces while mean intensity of ascariasis was epg (Table 3.2). Thus, epg overall mean intensity of double infection was six times higher than mean hookworm intensity and nearly double that of ascariasis. Mean intensity of at least a single infection was about 150% and 50% higher than hookworm and roundworm infections, respectively.

69 54 Table 3.2: Distribution of single, double and at least one infection of hookworm and/or ascariasis in eleven communities investigated in Nsukka zone ( ) Community Examined Hookworm Ascariasis Double Infection At least a single Infections Infected Mean intensity (epg) Infected Mean intensity (epg) Infected Mean intensity (epg) Infected Mean intensity (epg) Akpugoeze Edem Ezeopi Fulton Margret Nkpunato Ogurugu Site Road New Anglican Uvuru Nkpologu χ 2 (df) p-value Total

70 55 As was the case for prevalence, intensity of infection also varied significantly (p< 1) among the eleven communities investigated. The mean intensity of hookworm ranged from to epg at Fulton and Nkpunato communities, respectively. The corresponding values for ascariasis, double and at least a single infection are epg at Nkpologu epg at Nkpunato; epg at Fulton epg at Akpugoeze and epg at Fulton epg at Nkpunato, respectively Age and sex prevalence and intensity of infection: The pattern of distribution of prevalence and intensity of hookworm and ascariasis in relation to age and sex of subjects examined in the eleven communities are presented in Tables 3 and 4, respectively. Out of a total of 906 male and 1145 female examined, 453 (50%) and 632 (55.0%), respectively were infected with hookworm; while the corresponding prevalence of other infections were, roundworm (69.5%, 71.9); double.infection (47.5%, 34.5%) and at least one infection (72.1, 80.4%). For all infection combinations (i.e. single, double and at least one) prevalence was very significantly higher (p< 1) in females than males. For both hookworm and ascariasis and their combinations, peak prevalence was attained in the first decade of life (0-9years age group) in males and second decade (10-19 years) in females. That is, prevalence was attained earlier in males than females, and among males, decreased gradually from peak in the first decade of life to its lowest level in the oldest age. Among females, however, it increased gradually to a peak in the second decade of life before decreasing to lower levels in the subsequent age groups. Age-dependent infection patterns of all infections and combinations were also highly significantly (p< 1) different between males and females. Intensity of both hookworm and ascariasis infection and their combinations was higher in females than males but while this difference was significant (p< 0.01) for ascariasis, double and at least one infection, it was comparable for hookworm ( for males and

71 56 epg) (Table 3.3). Age dependent intensity patterns were highly significant (p< 1) in both males and females, but while in males peak intensity occurred in the 0-9 years age bracket, in females it occurred in the year age group. Comparing individual age groups between males and females, intensity of each infection and combination of infections was higher among females than males except in the age group 0-9 year old where boys were more heavily infected than girls. Tables 3.4 and 3.5 present the sex related distribution patterns of prevalence and intensity of hookworm and ascariasis in each of the eleven communities investigated. Although overall sex related prevalence of hookworm (50.0 % male, 55.0% female) and ascariasis (69.5% male, 78.0% female) were significantly distributed (p< 0.05), distribution of each of the two diseases by sex in the various communities was significant in three communities (Ezeopi, Margaret Cartwright and Ogurugu for hookworm; Fulton, Margaret Cartwright and Nkpunato for ascariasis). Thus, prevalence of both hookworm and ascariasis was comparable between males and females in the other communities. Intensity of infection followed a similar basic pattern though hookworm was significantly (p< 0.05) distributed in two rather than three communities and ascariasis in three communities. However, while the two communities with significant hookworm intensity variation between the sexes were those where prevalence also varied significantly, prevalence was comparable in one (Edem) of the three communities with significant variation in ascariasis intensity. Thus, as recorded for prevalence, females were significantly more heavily infected with hookworm in Margaret Cartwright and Ogurugu and with ascariasis in Margaret Cartwright and Nkpunato, while in Ezeopi and Fulton where prevalence of hookworm and ascariasis were respectively, significantly different between the sexes, intensity distribution was comparable.

72 57 Table 3.3: Age and sex patterns of mean intensity of hookworm and ascariasis among individuals with single, double and at least one infection in eleven communities investigated in Nsukka zone ( ) Community Examined Hookworm Ascariasis Double Infection Either or both Infections Infected Mean intensity (epg) Infected Mean intensity (epg) Infected Mean intensity (epg) Infected Mean intensity (epg) Male χ 2 (df) p-value <1 <1 <0.01 <1 Total Female χ 2 (df) p-value <1 <1 >0.05 <1 Total Both sexes combined χ 2 (df) p-value <1 <1 <0.05 <1 All age groups combined Male Female χ 2 (df) p-value >0.05 <1 <0.01 Overall Total

73 58 Table 3.4: Sex distribution of prevalence of hookworm and ascariasis in different communities examined in Nsukka zone, Enugu State, Nigeria ( ) Community Hookworm Ascariasis Male Female χ 2 -value (df= 1) P-value Male Female χ 2 -value (df= 1) P-value Examined Prev (%) Examined Prev (%) Examined Prev (%) Examined Prev (%) Akpugoeze 75 (41) (63) Ns 75 (50) (70) ns Edem 83 (48) (70) Ns 83 (63) (88) ns Ezeopi 81 (32) (58) < (59) (84) Ns Fulton 86 (37) (44) Ns 86 (54) (77) <0.05 Margret 77 (23) (52) < (38) (113) <1 Nkpunato 81 (50) (71) Ns 81 (59) (95) <0.01 Ogurugu 86 (38) (62) < (67) (90) ns Site Road 81 (47) (70) Ns 81 (65) (83) ns New 96 (56) (51) Ns 96 (60) (60) ns Anglican Uvuru 81 (41) (47) Ns 81 (54) (58) Ns Nkpologu 79 (40) (44) Ns 79 (61) (78) ns Total 906 (453) (632) < (630) (896) <1

74 59 Table 3.5: Sex distribution of mean and standard deviation of hookworm and ascariasis in different communities examined in Nsukka zone, Enugu State, Nigeria ( ) Community Hookworm Ascariasis Male Female t-value (df) P- Male Female t-value P- Exam Meansd Exam Meansd value Exam Meansd Exam ( Meansd value ( inf) (epg) ( inf) (epg) ( inf) (epg) inf) (epg) Akpugoeze 75 (41) (63) (174) Ns 75 (50) (70) ns (174) Edem 83 (48) (70) (190) Ns 83 (63) (88) <0.05 (190) Ezeopi 81 (32) (58) (184) Ns 81 (59) (84) ns (184) Fulton 86 (37) (44) (185) Ns 86 (54) (77) ns (185) Margaret 77 (23) (52) (191) < (38) (113) (191) < 1 Nkpunato 81 (50) (71) (185) Ns 81 (59) (95) <0.05 (185) Ogurugu 86 (38) (62) (188) < (67) (90) ns (188) Site Road 81 (47) (70) (187) Ns 81 (65) (83) ns (187) New 96 (56) (51) (192) Ns 96 (60) (60) ns Anglican (192) Uvuru 81 (41) (47) (181) Ns 81 (54) (58) ns (181) Nkpologu 79 (40) (44) (176) Ns 79 (61) (78) ns (176) Total 906 (453) (632) (2053) Ns 906 (630) (896) (2053) < 1

75 Prevalence and Intensity of Infection by educational background. Table 3.6: Prevalence and Intensity of single and double infections of hookworm and ascariasis among different educational background in eleven communities investigated in Nsukka Zone Enugu state Nigeria ( ). Hookworm Ascariasis Double Infection Educational No No Prev. Mean No Prev Mean No Prev. Mean Background Examined Infected (%) Intensity (epg) Infected (%) Intensity Infected (%) Intensity(epg) Primary Secondary Tertiary None P-value <0 0 <0 0 <0 3 Total

76 61 60 Table 3.6 presents the summary of prevalence and intensity of infection of hookworm and ascariasis among people with different educational background in the; eleven communities investigated in Nsukka zone. Prevalence of hookworm ranged from 22.7% among persons with tertiary education to 84.8% among those with no formal education. Corresponding values for ascariasis were 61.5% and 87.9% and for double infection 21.1% and 84.8%. The prevalence of both diseases and their co-infection was highest among persons without formal education and least among those with tertiary education. Intensity of hookworm infection also followed the same pattern being highest among individuals with no formal education ( epg) and lowest among those with a tertiary education ( epg). On the other hand, while lowest intensity of ascariasis ( epg) and double infection ( epg) were also recorded among persons with a tertiary education, heaviest intensity of ascariasis ( epg) and double infection ( epg) occurred among individuals with only a primary education Prevalence and intensity of infection by seasons: Table 3.8 presents the summary of prevalence and intensity of single and double infection of hookworm and ascariasis by seasons in eleven communities investigated in Nsukka zone, Enugu state, Nigeria Prevalence of hookworm infection ranged from 48.7% in October-December season to 59.7% (308) in April-January season. This variation was very significantly different (P<0.01). Corresponding values for ascariasis infection varied very significantly from 71.1% in January-March to 79.5% April June (P<0.01). While double infection varied from 46.2% in October December, 56.6% in April June.

77 62 Table 3.7: Prevalence & Intensity of single and double infections of hookworm and ascariasis by seasons in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). Months Hookworm Ascariasis Double infection Examined Infected Prev (%) Infected Prev (%) Infection Prev (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Oct-Dec Jan-Mar Apr-Jun Jul-Sept X 2 (df) P value < < < Total

78 64 63 Intensity of hookworm infection was heaviest ( epg) in April - June and lowest ( epg) in October December, while those of ascariasis was heaviest ( epg) in April - June, and lowest ( epg) October December. The variations are very highly significant (P<). Intensity of double infection was heaviest ( epg) and lowest ( ,7 epg) in April June and October December respectively. The difference was however not significant (P>0.05)

79 Prevalence and intensity of infection by marital status Table 3.8 presents summary of prevalence and intensity of single and double infection of hookworm and ascariasis according to marital status in the eleven communities investigated in Nsukka zone, Enugu state, Nigeria. Prevalence of hookworm infection ranged from 36.3% (338) among married persons to 70.1% (693) among single persons and varied very significantly (P<O.OO). Prevalence of ascariasis, on the other hand, varied significantly (P<0.01) from 61.5% (24) among widowed/widowered to 81.4% (805) among unmarried persons. Double infection varied very significantly (P<0.01), from 34.2% (338) among married individuals to 67.0%(693) among single persons.

80 6561 Table 3.8 Prevalence & Intensity of single and double infections of hookworm and ascariasis according to marital status in Nsukka Zone, Enugu State Nigeria Marital Status Examined Hookworm Ascariasis Double infection Infected Prev Infected Prev (%) (%) Infection Mean intensity (epg) Mean intensity (epg) Prev (%) Mean intensity (epg) Single Married Divorced Separated Widowed/ Widower X 2 (df) P value `0.297 Total

81 66 Intensity of hookworm infection was heaviest ( epg) among single persons and lowest ( epg) among married individuals with very significant variation (P<). Corresponding values for intensity of ascariasis infection was epg among single persons to epg among widows/widower. Intensity of Double infection of the diseases was heaviest ( epg) among single persons and lowest ( epg) among divorced/separated individuals, but this was not significantly different (P>0.05) Prevalence and intensity of infection by latrine type. Table 3.9 presents the summary of the prevalence and intensity of hookworm and ascariasis according to access to different latrine types in eleven communities investigated in Nsukka zone Enugu state, Nigeria. Prevalence of hookworm infection varied significantly (P<0.05) according to access to different latrine facilities. It ranged from 48.9% to 62.1% (P<) among individuals with access to Water Cistern (WC) to those that defaecated openly in the bush, respectively. In contrast, prevalence of ascariasis was least among individuals defaecating openly in the bush (72.1%) and highest among those using pit latrine (76.1%). However, variation in the prevalence of ascariasis, was not significantly different (P>0.05).

82 67 Table 3.9: Prevalence & Intensity of single and double infections of hookworm and ascariasis according to access to different latrine type in eleven communities investigated in Nsukka Zone, Enugu State, Nigeria ( ). Latrine Type Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Bush Pit WC X 2 (df) P - value < (ns) 3 <0 0 Total ns = not significant

83 68 Intensity of both diseases and their co-infection varied significantly according to access to different latrine types. Hookworm intensity varied from, epg; among individuals with access to WC to epg among those using the bush. Intensity of ascariasis infection varied from epg to epg among people with access to pit latrine and the bush respectively. Intensity of double infection varied significantly from to epg among WC and bush users respectively Prevalence and intensity of infection according to cleaning habits after toilet use. Tables 3.10 and 3.11 present the summary of prevalence and intensity of hookworm and ascariasis infection according to cleaning habit of individuals investigated. About 48.9% and 74.4% of 1062 persons who use toilet tissues were infected with hookworm and ascariasis respectively while corresponding figures among 992 persons using any available paper material were 58.1% and 74.1, respectively (Table 12). Out of 1172 that said they wash hands regularly with water and soap after toilet use, 584 (49.5%) were infected with hookworm and 74.1% with ascariasis, while 56.8% and 74.4% of those that do not wash hands were similarly infected with the respective diseases (Table 3.11). Thus, while hookworm prevalence differed significantly with hand washing pattern, hand washing pattern, surprisingly, did not affect pattern of ascariasis. Intensity of hookworm infection varied significantly from to epg for those who wash hand with water and soap and those who do not, respectively. Corresponding values of ascariasis intensity are to epg, and double infection of the disease: epg to epg respectively.

84 69 Table 3.10: Prevalence & Intensity of single and double infections of hookworm and ascariasis cleaning materials used after toilet use investigated in eleven communities in Nsukka Zone, Enugu State Nigeria ( ). Cleaning Material Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Paper Tissue X 2 (df) P value < (ns) 0.482(ns) <0 8 Total ns = not significant

85 70 Table 3.11: Prevalence & Intensity of single and double infections of hookworm and ascariasis by hand washing habit of people investigated in eleven communities in Nsukka Zone, Enugu State Nigeria ( ). Hand wash Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Yes No X 2 (df) P value <1 0 >0.936(ns (ns) < (ns) Total

86 71 Table 3.12: Prevalence & Intensity of single and double infections of hookworm and ascariasis according to occupation of people in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). Occupation Hookworm Ascariasis Double infection Examined Infected Prev (%) Infected Prev (%) Infection Prev (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Civil service Student Trading Farming X 2 (df) P value <0 0 <0 0 <0 4 Total

87 Prevalence and Intensity of Infection in relation to Occupation. Table 3.12 presents the summary of single and double infections of hookworm and ascariasis according to occupation in eleven communities investigated in Nsukka zone, Enugu State, Nigeria. Prevalence of hookworm varied from 22.1% among civil servants to 79.2% among school children. Corresponding values, for ascariasis and double infection were 61.1 to 85.8 and 20.4 to 75.9 respectively among civil servants and school children. All infection patterns were highly significantly different (P<001). Intensity of infection also varied significantly among the occupational groups. Hookworm intensity ranged from to epg among civil servants and farmers respectively, ascariasis: among civil servants and school children respectively while those of co-infection were epg among civil servants and epg among the farmers. Thus, while the lowest prevalence and intensity of all infections occurred among civil servants, the highest prevalence occurred among school children while the heaviest intensity occurred either among school children (ascariasis) or the farmers (hookworm and co-infection) Prevalence and intensity of infection by dry season water source ( ) Table 3.13, presents the summary of the prevalence and intensity of single and double infection of hookworm and ascariasis in eleven communities investigated in Nsukka zone, Enugu state. Prevalence of hookworm ranged from 38.1% among persons who use sachet water to 59.8% among those who use vendor. Corresponding values for ascariasis were 76.2% and 79.7% and for double infection 37.3% and 56.6%. The prevalence of the diseases and their co-infection was highest among persons who use vendor water during dry season and least among persons who use sachet water during dry season. The diseases were not significant. P>0.05.

88 78 73 Intensity of hookworm infection was highest among individuals who use vendor ( epg) and lowest among those that use sachet ( epg). Lowest intensity of ascariasis was ( epg), double infection was ( epg) among persons who use pipe borne water, heaviest ( epg) was recorded among persons who use sachet water while intensity of double infection ( epg) occurred among those who use other sources of water during dry season, and were not significant except for mean intensity of hookworm infection Prevalence and intensity of infection by water source during the rainy season Table 3.14 presents the summary of prevalence and intensity of single and double infection of hookworm and ascariasis by source of water during the rainy season in eleven communities investigated in Nsukka zone, Enugu state. Prevalence of hookworm ranged from 41.3% among persons who use sachet waters as their primary source of drinking water during the rainy season to 67.5% among those that rely on well water. Corresponding values for ascariasis were 66.3% and 79.7% and for double infection 38.0% and 63.4% among the same groups respectively. The prevalence of both diseases and their co-infection was highest among persons who use well water and least among individuals that use sachet water. The prevalence of ascariasis was highly significant including the mean intensity of hookworm infection

89 Prevalence and intensity of infection according to footwear and footwear type ( ) Table 3.15 represents the summary of prevalence and intensity of single and double infection of hookworm and ascariasis according to whether people wear foot-wears or not in eleven communities investigated in Nsukka zone of Enugu State, Nigeria. Higher prevalence of hookworm (57.2%) ascariasis (74.9%) and double infection (55.0%) occurred among people that normally do not wear foot -wears but while the difference with those that normally wear foot-wears was significant for hookworm and double infection, it was comparable for ascariasis. Further comparison on the basis of nature of foot wears, revealed that prevalence of both diseases and their co-infections independent of whether the foot-wear is open or closed (table 3.16). The diseases were highly significant P<1 except for mean intensity of ascariasis (p>0.05)

90 81 75 Table 3.15: Prevalence and intensity of single and double infection of hookworm and ascariasis of footwear in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Footwear Hookworm Ascariasis Double infection Examined Infected Prev (%) Infected Prev (%) Infection Prev (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) No Yes X 2 (df) P-value Total=

91 82 76 Table 3.16 : Prevalence and intensity of single and double infection of hookworm and ascariasis according to footwear-type used by people investigated in eleven communities investigated in Nsukka zone, Enugu state Nigeria ( ). Footwear type Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean inte+nsity (epg) Mean intensity (epg) None Open Closed X 2 (df) P-value <0 < 0 < 0 >0.112(ns) < 0 <0 Total =

92 83 77 Intensity of both hookworm, ascariasis and their co-infection followed the same pattern as prevalence, being higher among individuals who do not normally put on footwears ( epg, and epg, epg respectively) and lower among persons who normally put on footwear ( epg, epg; respectively). However, unlike the situation observed for prevalence, all differences in intensity of infection was significant (P <0.01). Intensity was also independent of whether footwears are open or closed also people that normally wear footwears generally have lower intensity Knowledge of the people concerning the infection of hookworm and ascariasis diseases ( ). Table: 3.17 presents the summary of prevalence and intensity of single and double infections of hookworm and ascariasis according to the knowledge of the people concerning the causes of the diseases in eleven communities investigated in Nsukka zone, Enugu state, Nigeria. Prevalence of hookworm infection ranged from 34.2% among those who said that peeled groundnut caused the disease to 59.9% among those who said that witchcraft causes the disease. Corresponding values for ascariasis ranged from 56.7% among persons who said that unwashed eggs, carrots etc cause the disease to 85.7% among those who have no idea of the causes of disease, while double infection ranged from 34.2% among persons who said that peeled groundnuts was the cause of diseases and 53.2% among those who said that witchcraft was the cause. Prevalence of hookworm infection, ascariasis and double infection of both diseases were not significant (P>0.05). However, mean intensity was highly significant (P<0) among the respondents.

93 78 84 Table 3.17: Prevalence and intensity of single and double infection of hookworm and ascariasis according to people's belief on the causes of the diseases in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Causes Hookworm Ascariasis Double infection Examined Infected Prev (%) Infected Prev (%) Infection Prev (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) None Witchcraft Food poisoning Unwashed vegetables Unwashed eggs, carrot, etc Pilled groundnuts Dirty hands X 2 (df) P-value 0.162(ns) 0 < (ns) 0 Total=

94 89 79 Intensity of hookworm infection followed the same pattern it being highest ( epg) among those who said that dirty hands were the cause of the disease and lowest ( epg) among those who have no knowledge of the cause of the disease and varied very significantly (P<) corresponding values for ascariasis infection ranked highest ( epg) among those that said the cause of disease was eating pilled groundnuts and lowest ( epg) occurred among persons who eat unwashed eggs, carrots etc, while double infection was heaviest ( epg) among persons who said that eating pilled groundnuts caused the disease and lowest ( epg) among persons who said that the cause of the disease and co-infection was witchcraft. And varied very significantly (P<) Prevalence and intensity of infection according to treatment method. Table 3.18 present the summary of prevalence and intensity of single and double infection of hookworm and ascariasis according to treatment method in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Prevalence of hookworm infection ranged 51.6% among persons who do not use herbal or orthodox treatment method to 56.5% among persons who use herbal treatment method. Corresponding values for ascariasis infection ranged from 73.7% among those who do not use herbal or orthodox method to 75.7% among persons who use herbal treatment method, while double infection ranged from 49.1% among persons who do not use other treatment method to 53.8% among persons who use herbal treatment method. Intensity for hookworm infection was heaviest ( epg) among people who go to herbalist for treatment and lowest ( epg) among persons who visit hospital for treatment. Intensity of ascariasis followed the same pattern, heaviest ( epg) among persons who go to herbalist for treatment and lowest ( epg) for people who go for hospital treatment, while the co-infection and the diseases was heaviest ( epg)

95 90 80 among persons who go to herbalist for treatment and lowest ( epg) occurred among people who visit hospital for treatment and was very highly significant (P<).

96 Self - Treatment Method Table 3.19: Prevalence & Intensity of single and double infections of hookworm and ascariasis of self-treatment method type in eleven communities investigated in Nsukka Zone, Enugu State Nigeria ( ). Selftreatment Method Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) OO Herbal Orthodox X 2 (df) P value 0.829(ns) (ns) 3 0 Total

97 87 82 Intensity of hookworm and ascariasis infection varied very significantly (P<) and followed the same pattern being heaviest ( epg) among person who use herbal treatment method and lowest ( epg) among persons who use orthodox treatment method, while ascariasis was heaviest ( epg) occurred among persons who use herbal method, and lowest ( epg) occurred among persons who use orthodox treatment method. On the other hand, double infection was heaviest ( epg) was recorded among persons who use herbal treatment method and lowest ( epg) occurred among persons who do not use herbal orthodox treatment method. And very significant (P<) Prevalence and intensity in relation to knowledge of common signs and symptoms Table 3.20 presents the summary of prevalence and intensity of hookworm and ascariasis infection according to the people's idea of common symptoms of hookworm and ascariasis in Nsukka zone, Enugu state. Prevalence of hookworm infection ranged from 41.7% among people who said that the common symptom of the disease was stomach ulcer to 75.0% among persons who had no idea of the common symptoms of the disease. Corresponding values of ascariasis infection ranged from 68.4% among persons who said that the common symptom was stomach ulcer to 100% among persons who had no idea of the symptoms of the disease, while double infection ranged from 40.1% among persons who said that stomach ulcer was a symptom of hookworm and ascariasis infection to 75.0% among persons who had no idea of the symptoms of the disease.

98 8388 Table 3.20: Prevalence and intensity of single and double infection of hookworm and ascariasis according to people s idea of common symptoms of stomach problem in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Stomach problem Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) None Acute Abdomen Constipation Diarrhoea Stomach Ulcer Others X 2 (df) P-value 0.78(ns) 0 < (ns) 1 Total=

99 84 88 Intensity of hookworm infection followed the same pattern, it being heaviest ( epg) among persons who have other symptoms aside the listed and lowest ( epg) among those who said that the common symptom of the disease was stomach ulcer. Corresponding values for ascariasis infection was heaviest ( epg) among persons who have no idea of the common symptoms and lowest ( epg) among persons who said that the symptom of the diseases was stomach ulcer, while double infection was heaviest ( epg) among persons who said that the symptom of the disease was acute abdomen and the lowest ( epg) was recorded among persons who said that stomach ulcer was the symptom of the co-infection. The intensity of the diseases varied very significantly (P<).

100 Prevalence and intensity of infection according to hospital visit and rate in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Table 3.21: Prevalence and intensity of single and double infection of hookworm and ascariasis according to hospital visit and rate in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Hospital Visit & Rate Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infected (%) Mean intensity (epg) Mean Intensity (epg) Mean intensity (epg) No Yes X 2 (df) P-value 0.399(ns) 0.130(ns) 0.534(ns) 0.035(ns) 0.297(ns) 0 Total=

101 86 91 Table 3.21 presents the summary of prevalence and intensity of single and double infection of hookworm and ascariasis according to hospital visit and rate in eleven communities investigated in Nsukka zone, Enugu state. Prevalence of hookworm ranged from (623) 53.7% among persons who said that they do not visit hospital to 38.5% according to those who said that they visit hospital. Corresponding values for ascariasis ranged from 74.7% among those that do not visit hospital to 62.8% among those who said that they visit hospital. While double infection of both diseases ranged from 62.8% to 51.2% among persons who visit hospital. Prevalence and intensity of single double infection of hookworm ranged from (80/140) 57.1% among persons who said that they visited hospital once within the period of investigation to 58.1% among persons who said that they visited hospital twice. Corresponding values for ascariasis ranged from 73.2% among persons who visited hospital once and 74.3% among those who said that they visited hospital twice. The rate of hospital visit for hookworm infection and ascariasis were not significant (P>0.05). While double infection of both diseases ranged from 49.2% among persons who visited hospital once or twice to 51.2% among persons who do not visit hospital within the period of investigation, was also not significant (P>0.05).

102 95 87 Table 3.22: Prevalence and intensity of single and double infection of hookworm and ascariasis of hospital distance in eleven communities investigated in Nsukka zone, Enugu state, Nigeria ( ). Hospital distance Examined Hookworm Ascariasis Double infection Prev Prev Prev Infected (%) Infected (%) Infection (%) Mean intensity (epg) Mean intensity (epg) Mean intensity (epg) Far Near X 2 (df) P-value 0.240(ns) 0.020(ns) 0.792(ns) 0.090(ns) 0.297(ns) 0 Total=

103 9388 Prevalence of hookworm ranges from (698) 51.8% to (387) 54.7% according to the persons who said that hospital distance was near and far respectively, while that of ascariasis infection ranged from (522)73.8% to (1003) 74.5% according to persons who said that hospital distance was far and near respectively. Double infection ranged from (368)49.4 to (666) 52.1% according to persons who said that hospital distance was near and far respectively.table 3.23 Intensity of hookworm infection was heaviest ( epg) among persons who said that hospital distance was far and lowest ( epg) among persons who said that hospital distance was near in the eleven communities investigated in Nsukka zone and varied significantly (P<0.02). Corresponding values for ascariasis infection was heaviest ( epg) among persons who said that hospital distance was far and lowest epg among persons who said that hospital distance was near, while double infection was heaviest ( epg) was recorded among people who said that hospital distance was far and lowest ( epg) occurred among persons who said that hospital distance was near and varied very highly significant (<).

104 95 89 Prevalence of hookworm ranges from (698) 51.8% to (387) 54.7% according to the persons who said that hospital distance was near and far respectively, while that of ascariasis infection ranged from (522)73.8% to (1003) 74.5% according to persons who said that hospital distance was far and near respectively. Double infection ranged from (368)49.4 to (666) 52.1% according to persons who said that hospital distance was near and far respectively.table 3.23 Intensity of hookworm infection was heaviest ( epg) among persons who said that hospital distance was far and lowest ( epg) among persons who said that hospital distance was near in the eleven communities investigated in Nsukka zone and varied significantly (P<0.02). Corresponding values for ascariasis infection was heaviest ( epg) among persons who said that hospital distance was far and lowest epg among persons who said that hospital distance was near, while double infection was heaviest ( epg) was recorded among people who said that hospital distance was far and lowest ( epg) occurred among persons who said that hospital distance was near and varied very highly significant (<).

105 Environmental Characteristics Soils Physical Properties Table 3.24 presents the summary of physical properties of the soils in the eleven communities investigated in Nsukka zone, Enugu State, Nigeria. Silt ranged from % at Uvuru Nkpunato and Ogurugu to ( ) at Edem and Margaret Cartwright, clay from at Edem, Ezeopi and Margarete Cartwright to at New Anglican road, total sand from at New Anglican Road to at Edem, Margaret Cartwright and Ezeopi and texture from at Akpugoeze, Nkpunato and Uvuru to at Edem, Ezeopi, Margaret Cartwright Ogurugu and site Road. Also moisture content ranged from at Uvuru to at Margaret Cartwright while bulk density ranged from at Ezeopi to at Ogurugu Road. Conductivity ranged from at Nkpunato to at Fulton. Total porosity ranged from at Ezeopi to at Nkpologu, macro-porosity from at Edem to at Nkpunato and microporosity from at Nkpunato to at Edem. Mean soil temperature ( 0 C) was at Ogurugu Road and at Ezeopi, Nkpunato and Uvuru. Statistical analysis showed that silt, clay, texture, moisture, conductivity, total porosity, macro and micro porosity and soil temperature were highly significantly (p< 1) distributed, while distribution of total sand, fine sand, coarse and bulk density were comparable at 5% level of significance.

106 3.24 Physical properties of soils collected from selected sites in eleven communities investigated in Nsukka zone, Enugu State, Nigeria LOCATION Silt Clay Total sand Fine sand Coarse sand Texture Moisture content Bulk density Cond. Total porosity Macroporosity Microporosity Soil temp. Egg counts(epg of Soil Ascaris Hookw Akpugoeze Edem Ezeopi Fulton 3.80 Margaret Cartwright Nkpunato Ogurugu Site New Anglican Road Uvuru Nkpologu F-value (df= 10) p-value orm

107 Chemical Properties of Soils Table 3.25 presents the summary of the chemical properties of the soils in the eleven communities selected in Nsukka zone, Enugu state, Nigeria. The ph in H 2 0 ranged from at Nkpologu, Uvuru and Nkpunato to at Ogurugu, while ph in KCl ranged from at Akpugoeze to 6.33 at Edem Road suggesting that soil of the area are in low to high acidity range. Concentration of Na ranged from at Akpugoeze to at New Anglican Road, Site Road, Ogurugu Road, Margaret Cartwright, Ezeopi and Edem Road, K from + at Edem Road, Ezeopi, M. Cartwright, Ogurugu, Site Road and New Anglican Road to at Nkpunato, Ca from at New Anglican Road, Site Road, Ogurugu Road, M. Cartwright, Edem, Ezeopi to 0.9 +, Mg from at Edem, Ezeopi, Ogurugu, Site Road to at Nkpologu, Al from + at Edem, Ezeopi, M. Cartwright, Ogurugu and Site Road to at Akpugoeze, Nkpunato, Uvuru and Nkpologu and H from at Nkpunato to at Edem Road. Also organic content (OC) ranged from at Nkpologu, Uvuru, Akpugoeze, Ezeopi, Fulton, Nkpunato and Site Road to at Edem Road, OM from at New Anglican Road to at Ogurugu Road while total N concentration was about in all sites. Base saturation ranged from at Nkplogu to at Fulton while available phosphorous (P) ranged from at Ogurugu Road, Nkpunato, Edem Road and Akpugoeze to at Fulton. Statistical analysis revealed that chemical properties of the soils have little or no significant difference in characters/properties. For instance, Edem Road, Ezeopi C rescent, Fulton and M/Cartwright have slightly acidic sandy soil. Nkpologu, Uvuru and Ogurugu Road have moderately acidic sandy loam soil while site road, Akpugo Eze have a soil textural class of slightly to moderately acidic loamy sand. However, soils with micro porosity <1, bulk density o.678, B.S of 0.550, Organic matter of 0.467, Al (0.445) or clay composition show significant support for the development and survival of hookworm. In addition to the above, roundworm ova is also favoured by the presence of Na (-0.528) and BS (-0.547).

108 3.25 Chemical properties of soils collected from selected sites in eleven communities investigated in Nsukka zone, Enugu State, Nigeria LOCATION ph in ph in KCl Na K Ca Mg Al H OC OM Total N Base Sat Aval. P H 2 O Akpugoeze Edem Ezeopi Fulton Cartwright Nkpunato Ogurugu Site New Anglican Uvuru Nkpologu Total

109 Summary of Helminth Egg Concentration in soil Table 3.26 presents the summary of intensity of helminth eggs recovered from soils collected from eleven communities investigated, while table 3.27 presents the summary in various sites in the communities (dump sites, play grounds and markets). As was observed for human infection, only hookworm and Ascaris eggs were found in soils at intensities varying from one community to another. Hookworm egg intensity in soil ranged from at Fulton and M. Cartwright to egs/g soil at Uvuru while those of Ascaris ranged from at Fulton to at Uvuru. The eggs were also seasonally distributed, Ascaris intensity varying from eggs/g soil in January-March (late dry season) to peak epg in April-June (rainy season) (Table 3.26). Corresponding values for hookworm intensity per grame of soil sample was least ( epg) during late dry season (January to March) and peak ( epg) in the late rainy season (July to September). Statistical analysis showed seasonal distribution of eggs of both parasites in soil was significant at 1% level. Table 3.26: Summary of helminth egg concentration in soil in eleven communities investigated in Nsukka zone, Enugu State, Nigeria Months Ascaris Mean + S.D of egg count/ g soil Hookworm Jan-Mar Apr-Jun Jul-Sept Oct-Dec F- Value P- Value 9 3 Total

110 3.27 Summary of Helminth Egg Concentration in soil from sites Table 3.27 presents the summary of helminth egg concentration in soil from sites (dump site, playground and market). As was observed for soil from different communities, only hookworm and Ascaris eggs were found in sites at intensities varying from one site and another. Ascaris egg intensity ranged from at dump site and playground to at market, while those of hookworm ranged from at dump site and playground to at market. The eggs were also distributed according to sites, Ascaris intensity varying from epg of soil from dump site and at playground to at market. Corresponding values for hookworm intensity per gramme of soil sample from dump site was at the market least ( ) and highest ( ) at dump site. Statistical analysis showed that site distribution of eggs of both parasites in soil was significant at 0.3% level. Table 3.27: Summary of Helminth Egg Contamihation in Various Sites. (Dump sites, play grounds & markets). Mean +Standard Deviation of Egg Count per gram of soil. Helminth egg Dump site Play ground Markets P-Value Ascaris egg Hookworm egg Ascaris egg Hookworm egg Ascaris egg Hookworm egg Ascaris egg Hookworm egg Total Ascaris egg , Total Hookworm egg

111 3.3.4 Relationship between soil characteristics and geohelminthes contamination: Table 3.28 presents the summary of the relationship between geohelminthes identified and soil properties in the eleven communities selected in Nsukka zone, Enugu State, Nigeria from Out of a total of 26 soil parameters investigated, hookworm egg intensity correlated negatively with 15 and positively with 11 while Ascaris correlated negatively with 11 and positively with 15. Fifteen of the correlations between hookworm and soil properties were significant (p< 0.05) while only 13 of the correlations with Ascaris were significant (p<0.05).

112 Relationship between soil characteristics and Geohelminthes contamination Soil property Parasite N Correlation coefficient Significance Silt Hookworm Roundworm Clay Hookworm Roundworm Total sand Hookworm Roundworm Fine sand Hookworm Roundworm Coarse sand Hookworm Roundworm Texture Hookworm Roundworm Ph in H 2 O Hookworm Roundworm Ph in KCl Hookworm Roundworm Na Hookworm Roundworm K Hookworm Roundworm Ca Hookworm Roundworm Mg Hookworm Roundworm Al Hookworm Roundworm H Hookworm Roundworm OC Hookworm Roundworm OM Hookworm Roundworm Total N Hookworm Roundworm BS Hookworm Roundworm Avail. P Hookworm Roundworm Soil temp. Hookworm Roundworm Moisture Hookworm Roundworm Bulk density Hookworm Roundworm Hydrocarbon Hookworm Roundworm Total porosity Hookworm Roundworm Macro-porosity Hookworm Roundworm Micro-porosity Hookworm Roundworm Hookworm Hookworm Roundworm Roundworm Hookworm Roundworm

113 CHAPTER FOUR DISCUSSION AND CONCLUSION 4.1 DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS This investigation revealed hookworm and ascariasis as the two most common soil transmitted helminthes infections in Nsukka zone. It also showed that the two infections were widespread infected people of all socioeconomic standards, age, educational backgrounds and occupation, though at varying levels of prevalence and intensity. Out of the eleven communities investigated, three (Ezeopi, Fulton and Magaret Cartwright) are located within and around the University, and could be classified as urban based on relative provisions of water supply, sanitation facilities and other basic amenities (see Table 4.1). Table 4.1 Prevalence and Intensity of Hookworm and Roundworm infection in the University community, Nsukka Urban and Rural area University (566) Nsukka Urban (766) Rural (724) X 2 (df=2)/fvalue P value Hookworm (prevalence) Ascariasis (prevalence) Hookworm (intensity) Ascariasis (intensity) Table 4.2 Hookworm (prevalence.) Ascariasis (prev.) Hookworm (intensity) Ascariasis (intensity) < Ns < <0.05 Soil Contamination in University community, Nsukka Urban and Rural area University Nsukka Urban Rural X 2 (df=2)/fvalue P value (n= 13) (n= 16) (n= 15) < Ns < <0.01

114 Another four, namely Edem Road, Site Road, New Anglican Road and Ogurugu Road are Semi Urban while the remaining four (Uvuru, Nkpunato, Nkpologu and Akpugoeze) are rural communities. Majority of people in the places classified as urban had tertiary education and less people in the semi-urban had tertiary education.. The rural places had more of the people that had little or no formal education. The urban and semi-urban places about 81% were either civil servants or students while in the rural places most of them were formers. The people in these urban places had more access to pipe borne water than people in the rural places that rely mainly on shallow wells, stream and rivers. Most people in the urban places were using water system (95% compound). The people in the semi-urban were using either water system or pit-latrine. Pit latrine (24.4%), other forms of local toilet and indiscriminate defaecation in the bush (21.4%) were common in the rural places. Proper cleansing after toilet was common in the urban places. People there used tissue papers and washed hands with soap and water after using the toilet. Most people in the rural places resorted to using dirty materials like waste papers and fresh leaves for cleaning after toilet and may not wash their hands. Though the people were not diagnosed, but from their response the common ill- health was malaria (57.7%) in the urban, which stomach ache was the most common in the rural places. This suggested poor habit of feeding and symptoms of these infections. The poor life conditions contributed to the high prevalence of the infections in the rural places. Most people in the urban places went to the hospital when they fall sick and those in the rural communities resorted to self medication,and herbalist. Reoccurrences of the infections were more common in the rural places and these might be related to their treatment method. In most of these rural places hospitals were found to be far, that might hinder their frequent visit of hospitals when sick.

115 About 100% of the people in the urban places wore foot- wears. The mode of transmission of one of the infection is through skin penetrating. Moving bare-foot might lead to easy infection, which was more common in the rural places. The findings of this investigation show that although both hookworm and ascariasis were prevalent in all communities, prevalence and intensity were clearly reflective of the varying levels of urbanization in the communities investigated (Table 4.1). The findings of this investigation, therefore, provided the clearest evidence that risk of infection depended on individual exposure to specific risk factors. For instance, both prevalence and intensity of hookworm were higher among individuals that did not usually put on foot wears, while those of ascariasis were higher among individuals that did not use proper anal cleansing materials and did not wash their hands with soap and water after toilet use. These findings were clearly in accordance with classical knowledge on the mode of transmission of these diseases. Hookworm is transmitted by direct skin exposure to soil containing infective larvae while ascariasis is transmitted by the oral route (i.e. ingestion of infective egg with water or food). Thus, people who exposed their feet to soil stand a greater risk of hookworm infection while others that did not wash hands with soap and water had a greater tendency to ingest helminthes eggs. According to Crompton (1998) and Asaolu and Ofoezie (2003) proper use of anal cleansing materials, washing hands with soap and water after toilet use and wearing foot wears regularly depended on several factors including educational background, occupation, socioeconomic status and knowledge of mode of disease transmission. Many of these factors also favoured the urban residents more than their rural counterparts. Thus, urban dwellers were commonly more educated, majority are civil servants, live in better houses and are better aware of the basic mode of transmission of these diseases. These factors also influenced the ability of people to seek treatment. The findings of this study that the urban dwellers visit hospitals more

116 regularly might, therefore, explain the relative low intensity which was a clear manifestation of morbidity comfort. In spite of these clear cut differences between the urban and rural communities, multiple comparison tests using the Scheffe revealed that intensity of both hookworm and ascariasis were not significantly different between rural and Nsukka urban communities, while intensity level in both the rural and Nsukka urban communities were significantly different with that of the University communities. These findings were in agreement with the threshold saturation theory propounded by Shuval et al. (1981). The theory states that there is a threshold value below which investment on facilities for water supply and sanitation does not significantly affect the pattern of parasitic diseases infection in a community. While this threshold is not clearly defined, it appears that in the present study area, access to better and safer facilities for water supply and sanitation were closer to the threshold levels in the University communities than in the urban communities having used the rural communities as reference. Observations during the investigation actually revealed that though facilities for safe water supply (e.g. in-house pipe network) and sanitation (e.g. water cistern) were available in most urban households, these were not often used due to lack of regular water supply. In contrast, water run more frequently in the University communities. According to Okun (1988), where installed facilities are not used, significant changes in health status may not be expected. This probably explained the comparable situations in the rural and urban communities. 4.2 Prevalence and intensity patterns of the infections. The infection rate was very low in the urban places most especially in Margret and Fulton and in the rural places especially Mkpunato and Akpugoeze. The prevalence of the infections were equally found to be high in the semi urban places like site road (61.9%) when compared with those of the places in the rural places like Nkpologu (47.2%) these might be related to the fact that most people of these rural places were constantly de-wormed.

117 In all the places investigated ascariasis infection was higher than hookworm infection like in Fulton:hookworm (43.3%) and ascariasis (70.1%). Double infection was equally observed and found to be common in the rural places. The concentration of the egg in the faces was found to be highest in the rural areas for hookworm and for ascariasis. These supported that the rate of the infection was urbanization dependent. In all the communities the ascariasis infection was more common. The pattern of distribution of prevalence and intensity of hookworm and ascariasis infections were found to be age and sex dependent. More female were infected: hookworm (55%), ascariasis (71.9%) and less male were infected: hookworm (50%) and ascariasis (69.5). The margins were not much. These could be explained on the ground that females were more engaged in domestic and petty farm work hence more vulnerable to the infection. The peak prevalence of all the infection was attained in the first decade of life in males and second decade of life in females. The prevalence peak was attained earlier in males and decreased gradually in the subsequent ages. The age dependent was significantly high (p< 1). Male children are earlier used for farm work, other field involving projects and play a lot in the playground which might lead to earlier encounter of the infection than the female children. From the findings, children were more affected. They have tender skin, and larvae penetration might be easier. Children play more than the adults and such play involved direct contact with the soil. Then eating habit was equally poor and these factors contributed to rapid rate of infection. As these kids are growing their life will change and these contributed to the decline in the inflection rate as observed. The peak of the prevalence of the infections in females was years. This was the age female early engagement in farm work and other field project was highest and they have sound knowledge of hygiene and could easily be infected.

118 The prevalence and intensity of the infections were found to be educational back ground dependent. Prevalence of hookworm ranged from 22.7% among persons with tertiary education to 84.8% among those with no formal education and those for ascariasis were 61.5% and respectively. The concentration of the egg in the faces followed similar pattern (table 3.6).people that had formal education were less infected. Education is a pivot to civilization and special means of disease prevention and management. The prevalence and intensity of the infection were more in the people that were single. This findings supported that the rate of infection was age dependent, and more in children that constituted more of the single persons. Married, divoiced, separated widows and widower, constitute the older age and were less infected. The people infected were more in the rainy season (April to September) and less in the dry season (tables 3.7). The intensities of the infection follow the same pattern. The infection rate was found to be very high in rural areas where indiscriminate defaecation in the bush was rampant. It was less common in places using water system (urban places) and fair in places using pit-latrine. These indicate that toilet habit had influence on the infections rate. Occupation was found to be affecting the rate of the infection. The infection was most common among farmers and their children. The farmers farm around their houses and keep animals. Most of the animals were found not controlled and as such littered faeces here and there. Most of the farmers use animal waste as manure. These factors will increase the level of contamination of the soil, which can lead to increase in the rate of infection. In Nsukka, during dry season people source their water from different sources. It was found that people that drank sachet water were less infected followed by people that drank pipe borne water. The people that drank water from the water vendors were more infected followed by those that drank water from either stored rain or well. These indicated that the major causes of high prevalence of the infections in Nsukka zone was poor water supply. In the rainy season,

119 people that drank well and vendor water had the highest prevalence of the infections and people that drank sachet water still maintained the least prevalence. From tables 3.17, it was found that the people with high rate of infection were people that ate unwashed vegetables, garden eggs, carrot and peeled groundnuts. The people that ate with unwashed hands were infected more, so these conditions favour the prevalence of the infections. From the results there were so many treatment methods for the infections which included self treatment and hospital consultations. Hospital consultations were found to be more effective than self treatment. In self treatment herbal and orthodox medicine were used. Orthodox medicine was found to be more effective (table 3.20). People infected were found to have stomach ache, constipation and ulcer, which are common symptoms of the infections. The prevalence of these symptoms varied. Majority of the infected persons in the rural areas resorted to herbal medicine on self medication bases (tables 3.20). From table 3.23, the prevalence and intensity of the infections in relation to number of hospital visits were not significant (P>0.05).The number of hospital visits was not significant ( p>0.05) had no roles to play in this study. People living nearer hospitals were less infected than people living far from hospitals (tables 3.23). 4.3 Environmental factors that influence the infections. Soil characteristics may also have played vital roles in helminth egg contamination, hence disease transmission. According to W.H.O. (1967), hookworm and Ascaris eggs were less likely to survive in sandy soils than in other types of soils, and generally, rate of survival increased with increasing clay content up to a level not clearly defined. Thus, the findings of this investigation agree with classical knowledge of the relationship between soil characteristics and survival of helminth eggs in the soil. The study showed that the properties of soils from the University communities were more sandy, porous and relatively hotter, thus less favorable to egg survival. On the other hand, the loamy,

120 cooler and less porous soils in the rural and some Nsukka urban communities were more favourable to egg survival (Crompton, 1985). From tables 3.26, the soil samples from Edem, Ezeopi, Fulton, and Margaret Cartwright had high sand content and low clay content and low egg concentration ( epg) for hookworm and for (Ascaris egg). The moisture content was low and the soil temperature was high. These conditions did not favour the survival of Ascaris and hookworm egg. There by making the infections less common. The soil samples with high clay, and moisture contents and low sand, and low soil temperature had high egg concentrations ( for Ascaris egg and for hookworm). The above conditions favour the egg survival in the soil thereby encouraged the infections. The places included Akpugoeze, Edem, Nkpunato, Ogurugu, Uvuru and Nkpologu. Places like New Anglican Road had moderate. compositions of the parameters, then moderate soil egg concentration ( for Ascaris and for hookworm). Total porosity and other factors are related in one way or the other to the three major factors used (clay, moisture and sand content). However, soils with micro porosity <1,bulk density 0.678,B.S of 0.556,Organic matter of 0.467,Al (0.445) or clay composition show significant support for the development and survival of hookworm. In addition to the above, roundworm ova are also favoured by the presence of Na (-0.528) and BS (-0.547). The soil with high sand content had high porosity and the egg concentration was low. Soil contamination with helminth eggs was also higher in rural than urban communities suggested a higher potential for transmission. These findings were in agreement with those of several previous findings in other parts of Nigeria (Ugbomoiko and Ofoezie, 2007; Ugbomoiko et al., 2009). However, the findings of this investigation probably provided the first clear evidence linking level of prevalence and intensity in human population with egg intensity in the soil. The study also showed that the higher level of contamination in the rural areas might be explained by several factors including personal hygiene and access to

121 facilities for safe water supply and sanitation. According to Crompton and Pawlowski (1985) and Asaolu and Ofoezie (2003), personal hygiene is a major factor in the transmission of soil transmitted diseases. The ph values of all the soil samples tested were below 7.0, indicating acdic soil. The soil samples from Akpugoeze, Nkpunato, Uvuru and Nkpologu were more acidic (ph around 4.20) while the soil samples from Edem, Ezeopi, Fulton, Cartwright, and New Anglican road had ph around 6.6. This indicated that the readiness of a soil to retain mineral depends on the porosity. In Nsukka zone, soil samples with high clay and moisture content and less sand had lower ph values and high soil egg concentrations. The soil samples that gave low soil egg concentrations had high ph values. The mineral contents which included sodium, calcium, magnesium, Aluminum were more in soil samples with low ph values (around 4.20). There were no significant differences in the organic matter and total nitrogen contents of the soil samples, in the various localities From table 3.26, there were significant seasonal distributions of Ascaris and hookworm egg concentrations in the soil samples. It was found in rainy season that the soil egg concentration was highest for Ascaris and hookworm indicated in the date of July September ( for Ascaris and for hookworm. Rainy season favoured the infection because of high moisture content of the soil 4.4 Conclusion and Recommendations. Many factors have contributed to the high prevalence of hookworm and ascariasis infections in the eleven communities studied in Nsukka, which included dirty environment, lack of good water, educational background, poor life style, Occupation, and nature of soil. Some of these factors could be controlled. The people need good social amenities that include good water. Since these infections are common in the areas, there should be means of making the people understand the mode of transmission, and methods of prevention of the infections. Constant and

122 adequate de-worming is equally recommended. Cheap water treatment could easily be taught to the people, encouraging boiling their drinking water before use. Indiscriminate defecating should be discouraged. The farmer should be encouraged to wear boots and hand gloves during farm work. More hospitals could to be built nearer the people. The people need adequate information on the infection and the needs of the prevention methods for proper management of the infections.

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132 Fig. 13: Scanned from Arora and Arora (2006)

133 Fig. 14: Scanned from Arora and Arora (2006)

134 Fig. 15: Scanned from Arora and Arora (2006)

135 Fig. 16: Trichuris trichuira