Prevalence and Intensity of Urinary schistosomiasis in Weweso M/A Basic School-Kumasi Metropolis
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Transcript of Prevalence and Intensity of Urinary schistosomiasis in Weweso M/A Basic School-Kumasi Metropolis
a
KWAME NKRUMAH UNIVERSITY OF SCIENCE AND
TECHNOLOGY, KUMASI
COLLEGE OF SCIENCE
DEPARTMENT OF THEORETICAL AND APPLIED BIOLOGY
PREVALENCE AND INTENSITY OF URINARY SCHISTOSOMIASIS IN WEWESO
(M/A) BASIC SCHOOL CHILDREN.
A DISSERTATION PRESENTED TO THE DEPARTMENT OF THEORETICAL AND
APPLIED BIOLOGY, COLLEGE OF SCIENCE, IN PARTIAL FULFILMENT OF THE
REQUIREMENT FOR THE AWARD OF B.Sc. (HONS) DEGREE IN BIOLOGICAL
SCIENCES
BY
AMOAH, Isaac Dennis
BOAKYE, Sandra
INKOOM, Patrick
APRIL, 2011
i
DECLARATION
We, Amoah Isaac Dennis, Boakye Sandra and Inkoom Patrick, declare that we have fully
undertaken the study reported herein under the supervision of Mr. Martin A. Arkoh and Dr. John
A. Larbi and that, except portions where references have been duly cited, this dissertation is the
outcome of our investigations.
............................................. .............................................
Date Amoah, Isaac Dennis
(Student)
............................................. ..............................................
Date Boakye, Sandra
..............................................
Date
(Student)
...................................................
Inkoom, Patrick
( Student)
............................................ ....................................................
Date Mr. Martin, A. Arkoh
(Supervisor)
.......................................... ...............................................
Date Dr. John A. Larbi
(Supervisor)
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ACKNOWLEDGEMENT
The first and foremost thanks go to the Almighty God for His protection, wisdom as well as
granting us travelling mercies to and from the project site.
We also want to extend our sincere thanks to our supervisors, Mr. Martin A. Arkoh and Dr. John
A. Larbi who in diverse ways gave us advice and took time off their busy schedules to be with us
throughout the entire period of the project and also gave us the needed guidance in executing this
project.
Our sincere gratitude is also extended to our parents, siblings, friends, etc. for their financial and
moral support. Your diverse encouragement and pieces of advice made this project a success.
Thanks.
Furthermore we will like to thank all persons who in diverse ways made this project possible and
also appreciate the cooperation of the heads; Victoria Catherine Osei (JHS) and Margaret Bertha
Mmieh (Primary), teachers, parents and children of Weweso M/A Basic School during the
present study. God richly bless you all.
iii
ABSTRAC
Urinary schistosomiasis infection is a major problem throughout the world. It comes second to
tuberculosis and malaria in infection of humans. Between November 2010 and March 2011, 200
urine samples were collected from randomly selected school children of the Weweso M/A Basic
School in the Ashanti Region of Ghana to determine the prevalence and intensity of urinary
schistosomiasis. The objectives of the study were to determine and estimate the prevalence and
intensity of urinary schistosomiasis in the school children using the microscopy and the urine
reagent strip, it was also to determine the various factors that expose the children to this
infection. The presence and number of eggs of the Schistosoma haematobium parasite was
determined by microscopy whilst the use of urine reagent strip was employed to determine the
presence of hematuria and proteinuria among the infected. 10.5% of the pupils sampled were
infected. 12.3% of the 105 males sampled were infected, whilst 8.92% of the ninety-five females
sampled were infected, the difference in prevalence between the sexes did not differ significantly
(p=0.3616). Generally the intensity was low and ranged from 5-20 eggs/10ml urine. Hematuria
and proteinuria among the infected children was 46% and 30% respectively. The study revealed
the persistence of the infection among the school children, which calls for a concerted effort
towards control of schistosomiasis particularly in the Weweso M/A Basic School.
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TABLE OF CONTENTS
Declaration i
Acknowledgement ii
Abstract iii
Table of contents iv
List of Tables v
List of Figures vi
List of Plates vii
CHAPTER ONE: Introduction
1.1 Schistosomiasis in Ghana 2
1.1.1 Sensitivity test in Ghana 3
1.2 Schistosoma species 3
1.2.1 S. haematobium 3
1.2.2 S. mansoni 4
1.2.3 S. japonicum 4
1.2.4 S. intercalatum 4
1.2.5 S. mekongi 5
1.3 Life cycle of Schistosoma spp. 5
1.4 Epidemiology 10
1.5 Pathogenesis 11
1.6 Diagnosis and control 12
1.7 Justification 15
v
1.8 Objectives 16
CHAPTER TWO: Materials and methods 17
2.1 Target area 17
2.2 Target group 19
2.3 Sampling procedure 19
2.4 Laboratory analysis 20
2.5 Data analysis 22
CHAPTER THREE : Results 24
3.1 The overall prevalence of Urinary schistosomiasis 25
3.1.1 Sex related prevalence of urinary schistosomiasis 26
3.1.2 Prevalence of urinary schistosomiasis and age group 27
3.1.3 Prevalence of urinary schistosomiasis and contact with the river (Wewe) 28
3.2 The overall intensity of infection 30
3.2.1 Sex related intensity of infection 31
3.2.2 Intensity of infection and age group 32
3.3 Overall presence on Hematuria and Proteinuria 33
3.3.1 Sex related presence of hematuria and proteinuria 34
CHAPTER FOUR: Discussion 35
CHAPTER FIVE: Conclusion and Recommendation 39
5.1 Conclusion 39
5.2 Recommendation 39
REFERENCES 41
APPENDICES 45
vi
LIST OF TABLES, FIGURES AND PLATES
LIST OF TABLES
Table 1 Prevalence of urinary schistosomiasis in the school children 45
Table 2 prevalence of urinary schistosomiasis and sex 45
Table 3 prevalence of urinary schistosomiasis and age group 45
Table 4 prevalence of urinary schistosomiasis and contact with River Wewe 45
Table 5 Intensity of infection of urinary schistosomiasis 46
Table 6 Intensity of infection and sex 46
Table 7 Presence of hematuria and proteinuria 46
Table 8 Sex related presence of hematuria and proteinuria 47
Table 9 Chi-square analysis for prevalence of urinary schistosomiasis and sex 47
Table 10 Chi-square analysis for prevalence of urinary schistosomiasis and age group 47
Table 11 Chi-square analysis for prevalence of infection and contact with the river 48
LIST OF FIGURES
Fig. 1 Diagram showing life cycle of Schistosoma spp. 9
Fig.2 Map showing Weweso Basic School and its environs 18
Fig. 3 Prevalence of urinary schistosomiasis in the children 25
Fig.4 Correlation between prevalence and sex 26
Fig. 5 Association between prevalence and age group 27
Fig. 6 Association between prevalence and contact with the river 28
Fig. 7 Intensity of infection among infected school children 30
Fig. 8 Relationship between sex and intensity on infection 31
vii
Fig. 9 Association between age groups and intensity of infection 32
Fig. 10 Presence of hematuria and proteinuria among infected children 33
Fig. 11 Association between sex and hematuria and proteinuria 34
LIST OF PLATES
Plate 1 Schistosoma haematobium egg as seen under the microscope 24
Plate 2. Picture of a section of the River Wewe with children swimming in it. 29
viii
1
CHAPTER ONE
INTRODUCTION
Schistosomiasis is among the oldest known intestinal parasite infections of man, it is caused by a
trematode (Schistosoma spp) and the disease was named after the German. Theodor Bilharz, who
first described the cause of urinary schistosomiasis. Evidence of human infection with these
parasites dates back to the mummified remains from ancient Egypt and China (Geiges, 1934). It
comes second to tuberculosis and malaria in infection of humans worldwide (Talaro and Talaro,
2002). Human intestinal parasitic infections are of major public health importance in the tropics
and the subtropics of which this disease is of no exception.
Individuals from various societies and places play host to the worms during various stages of
their lives. Urinary schistosomiasis is mostly a prevalent infection with high morbidity and
mortality rate and historically has been a disease confined to the tropical rural poor (Gillespie
and Pearson, 2001). Its geographic distribution is determined by the distribution of the snail that
acts as the intermediate host (Gillespie and Pearson, 2001).
Schistosomiasis is endemic in 76 countries, most of which are in Africa. Other regions affected
are: the Americas (Brazil, Suriname, Venezuela, several Caribbean islands); the Eastern
Mediterranean (Iran, Iraq, Saudi Arabia, Syrian Arab Republic and Yemen); and eastern Asia
(Cambodia, China, Indonesia, Japan, and the Philippines (WHO, 2009). At least 600 million
people are at risk of infection and 200 million are infected with schistosomiasis. Of these, 20
million have severe disease and 120 million have symptoms. An estimated 80% of transmission
takes place in Sub-Saharan Africa. Water resource schemes for power generation and irrigation
have resulted in a tremendous increase in the transmission and outbreaks of schistosomiasis in
2
several African countries (WHO, 2009). In Ghana, a large number of inhabitants living around
the Volta Lake have become infected with the disease since the construction of the Akosombo
dam.
1.1 SCHISTOSOMIASIS IN GHANA
Prevalence of schistosomiasis has been on the increase in Ghana since the creation of the Volta
Lake (Jones, 1999, Aryeetey et al, 1999). In some villages around the lake, about 90% of the
children were found to be affected by urinary schistosomiasis (WHO, 2009). In 1992–1993, an
epidemiological study on urinary schistosomiasis in eight communities in Southern Ghana.
Showed that the overall prevalence of infection ranged between 54.8% and 60.0%, indicating
that the disease continues to be a major problem in some parts of Ghana. The study also showed
that the rate of urinary schistosomiasis in the study area increased by age with a peak in 10–19
year old individuals and then decreased with age (Aryeetey et al, 1999). Snail sampling
conducted in the same study area revealed that Bulinus globosus was the intermediate host snail
for urinary schistosomiasis in Southern Ghana (Abdel-Salam, 1984).
Although both urinary and intestinal schistosomiasis are prevalent in Ghana, urinary
schistosomiasis is more prevalent with approximately 15-20% of the population being infected
(McCullough, 1965). Initial and frequent re-infection is associated with the common activities of
washing, bathing, and fishing in infected streams, ponds, and burrow pits (Lawson, 1975).
1.1.1 SENSITIVITY TESTS IN GHANA
3
Artemis et al. (2008), worked on the sensitivities and specificities of diagnostic tests and
infection prevalence of Schistosomiasis haematobium in villages Northwest of Accra, using five
Schistosoma haematobium dipsticks. The dipsticks were found to be the most appropriate for the
detection of schistosomiasis infection. Microhematuria and proteinuria had significant lower
sensitivity than either microscopy or dipstick, though the MoAb dipstick was found to be more
sensitive than microscopy (Bosompem et al., 2004).
1.2 SCHISTOSOMA SPECIES
Schistosoma species belongs to the phylum Platyhelminthes, class Trematoda and the super
family Schistomatoidea. Flukes of this super family are peculiar because they have no second
intermediate host in their life cycles and they mature in the blood vascular system of their
definitive host (Schmidt and Roberts, 1996).
1.2.1 Schistosoma haematobium
Schistosoma haematobium causes urinary schistosomiasis. The species contains many strains
and it is transmitted mostly in Africa and the Middle East (Cheesbrough, 1987). It differs from
the others in that, the eggs are found in urine and sometimes in biopsies of the bladder and
rectum. The egg is large (112-170 μm by 40-70 μm), thin shelled and has a terminal spine. The
snail host belong to the genus Bolinus. In rare cases, eggs of S. haematobium are also found in
faeces (WHO, 1985).
4
1.2.2 Schistosoma mansoni
Schistosoma mansoni causes intestinal schistosomiasis. In 1981, the minimum number of
persons infected with this disease was estimated to be about 57 million (Cheesbrough, 1987) and
is most common in Africa but occurs in the Americas as well. The egg is discharged in faeces
but typically in small numbers. The egg is large, has a relatively thin shell with a conspicuous
lateral spine. S. mansoni are also easily identified in Kato-Katz preparations due to their size and
presence of a lateral spine. The egg measures 114-175 μm by 45-70 μm and contains a larva
called the miracidium. Occasionally, the egg may be oriented in a way that hides the spine and
tapping the cover glass on the preparation will often reorient the egg and reveal the spine (WHO,
1985). The aquatic snail host belong to the genus Biomphalaria.
1.2.3 Schistosoma japonicum
Schistosoma japonicum causes intestinal schistosomiasis and is transmitted in Asia. The egg
which is found in faeces measures 70-100 μm by 55-65 μm has a thin shell with an often
inconspicuous, small lateral spine. The egg contains a miracidium. The shell is sticky, causing
debris to adhere to the surface and making it more difficult to identify (WHO, 1985).
1.2.4 Schistosoma intercalatum
Schistosoma intercalatum is restricted in its geographic distribution to West and Central Africa.
The egg resembles that of S. haematobium in that it has a terminal spine and is found in faeces
rather than urine. It is very large, measuring 140-240 μm long has an equatorial bulge and
contains a miracidium (WHO, 1985).It causes intestinal schistosomiasis but compared with
5
S.japonicum and S. mekongi, it is less pathogenic (Cheesbrough, 1987). The Bolinus snails are
the intermediate hosts.
1.2.5 Schistosoma mekongi
Schistosoma mekongi is closely related to S. japonicum and is transmitted in areas of Laos,
Cambodia and Thailand. The egg is very similar to that of S. japonicum but is smaller, measuring
51-78 μm by 39-66 μm (WHO, 1985).
1.3 LIFE CYCLE OF Schistosoma spp.
1.3.1 Eggs and Miracidia stages
Humans are the principal definitive host for two of the species; (S. mansoni and S.
haematobium). Adult worms reproduce sexually in the definitive host (man) and pass
characteristically shaped eggs into the environment in urine or stool (WHO, 1985).
In fresh water, the eggs hatch to release ciliated, motile, short-lived, free swimming, sexually
distinct (male and female) miracidia. The miracidia in turn drill through the epithelium of the
appropriate snail’s foot to infect the intermediate host (Jourdane and The´ron, 1987) (Fig.1). The
parasite to snail interaction is highly specific, and only a few species of freshwater snails do
support the life-cycle of each specific schistosoma species (Sobhon and Suchart, 1990). Infection
with schistosomes does not normally affect the life span of the snails.
6
1.3.2 Stages in snail vector
Once inside the snails, the miracidium sheds its ciliated glycocalyx and reforms into a primary
sporocyst (Jourdane and The´ron, 1987). The primary sporocysts migrate into the snail’s
digestive gland or mature in its foot process. Germinal cells of the sporocysts replicate through
asexual multiplication and increasing parasite numbers.
The replicating cells mature and bud off as secondary sporocysts which then migrate to the snails
liver and mature. This process is repeated multiple times until the snail contains many maturing
sporocysts. The germinal cells mature into motile, forked-tailed, infective 0.4-0.6mm larval
forms called cercariae.
1.3.3 The Cercariae Stage
Cercariae are infective to the definitive host (man) and are shed by infected snails. The cercariae
leave the snail from the edge of the snail’s mantle and enter the surrounding water. The cercariae
have a discrete head and a bifurcated tail that allows locomotion. The head carries small oral and
ventral suckers, flame cells and a non-functional gut. Unicellular glands near the ventral suckers
secrete mucilage, which assists the parasite in attachment, other glands like the penetration gland
secretes digestive enzymes which aid in skin penetration. The parasite is able to migrate through
human epidermis in 5–10 minutes. Infected snails continue to shed cercariae for many weeks.
The total lifespan of a shed cercarium in fresh water is about 48 hours, but decreases
dramatically after about 4 hours. Death occurs due to exhaustion of the glycogen stores (Miller
and Wilson,1980).
7
1.3.4 Skin Penetration
During penetration, the cercaria leaves its tail on the dermis, The cercarial head penetrates into
deeper structures of the skin. The transformed cercaria is then called schistosomula.
Schistosomulae take up host antigens and attach them to their surface membranes. This prevents
host immune attack. In the first 48 hours, the schistosomula penetrate into subcutaneous tissues
and migrate through the dermis to gain access into the veins and lymphatics. During the next 5–
7 days, successful schistosomulae are transported through blood circulation via the heart to the
lungs (Miller and Wilson, 1980).
1.3.5 Somatic Migration
The schistosomulae migrate via the pulmonary capillaries to enter the left side of the heart and
systemic circulation (Miller and Wilson, 1980). Schistosomulae are carried with the arterial
blood flow to the mesenteric arteries, splanchnic arteries and portal veins and eventually reach
the appropriate venous plexus and mature. Repeated cycles through the systemic circulation may
be required. This process takes 10–20 days.
Each schistosomulum is either male or female. After migration to the appropriate peripheral
venous plexus, maturation takes place. Adult worms pair with the opposite sex and live out their
lifespan together. Migration in the veins is aided by the worm’s ventral and oral suckers, which
are used to attach to the endothelial wall. The worm pair migrates against the mesenteric or
vesical blood flow to lay their eggs. Different species tend to prefer different anatomical
locations for optimal growth and survival. Thus, S. haematobium prefers the vesical veins
(Elliott, 1996b).
8
1.3.6 Further infection and subsequent egg shedding.
Throughout infection, the adult worm pair migrates up and down the veins. Laying of eggs is
dependent on the anatomical preference of the species; the S. haematobium eggs are mostly
found in the urine but occasionally, can be found in the stool (Elliott, 1996b; Zwingenberger,
1990). During migration, when the diameter of the venule becomes small enough to restrict
further movement, the female often leaves the male and continues to migrate to the farthest point
permitted by the worm’s diameter. This minimizes backflow of ova. Adult worms induce little
direct damage to the host unless they die. The eggs, however, are capable of boring through
tissue planes and generally cause micro perforations in the colon and urinary bladder. The ova
are then shed to the outside from the bladder (urine) and rectum (stool) and getting into contact
with suitable substrate (water), starts the whole cycle again.
In Ghana, the intermediate host of S. haematobium is the Bulinus truncates in the lower Volta
Basin, whereas in the other parts of Ghana, the host is Bulinus globosus.
9
SOURCE:CDCP(1993)
Fig. 1 Diagram showing life cycle of Schistosoma spp.
10
1.4 EPIDEMIOLOGY
1.4.1 Geographical Distribution
Urinary schistosomiasis caused by Schistosoma haematobium is reportedly endemic in 53
countries in the Middle East and the African continent. The most common way of getting
schistosomiasis in developing countries is by wading or swimming in lakes, ponds and other
bodies of water that are infested with the snails. These happen to be the natural reservoirs of the
Schistosoma pathogen.
Transmission of schistosomiasis depends on human contact with fresh water, the presence of a
specific snail species capable of completing the schistosome life-cycle, and contamination of
fresh water with human waste. In endemic areas, the highest prevalence and intensity of infection
occurs in adolescents; 10–16 years of age (Davis, 1985). Males generally have a much higher
prevalence and intensity than females, presumably through higher water contact. High
prevalence areas have a greater frequency of patients with heavy infections. In S. haematobium
endemic communities, there is often a sharp drop-off in the prevalence and intensity in adults
over 25 years of age (Jordan and Webbe, 1993). This is partially explained by decreased water
contact.
Age distribution with the highest peak in adolescence, is not seen, in some populations who
relocate to schistosomiasis endemic areas (Aryeetey et al. 1999). The intensity of infection,
however, often reaches its peak in the same 12– 16 year age range and then declines. This has
similar implications for the probable development of at least partial immunity to re-infection. In
one large longitudinal study from the Philippines, individuals previously infected and cured of a
11
schistosome infection appeared to acquire a second infection slower than age and sex-matched
controls living in the same village (Olveda et al., 1996).
1.5 PATHOGENESIS
Worms exhibit numerous adaptations to their host (Talaro and Talaro, 2002). Before developing
into adults most helminthes often migrate through various tissues and organs. Adult helminthes
eventually take up final habitations in the intestinal mucosa, blood vessel, lymphatic,
subcutaneous tissue, skin, lungs, muscles, brain or even the eyes (Talaro and Talaro, 2002).
Clinical manifestations of schistosomiasis are often divided into three phases: (I) the migratory
phase encompass the time from penetration until maturity and egg production. It is often
symptomless. Penetration of the cercariae may produce dermatitis if the patient’s immune system
has been sensitized by earlier experiences of cercariae penetration.
(II) Acute phase (Katayama fever) occurs when the schistosomes begin producing eggs, about 4-
10 weeks after initial infection. By this time, the body has had considerable exposure to various
schistosome antigens sufficient to mount humoral response. However, the advent of egg
production substantially increases the amount of antigen released. There is increased formation
of granulomas. The phase is marked by chills and fever, fatigue, headaches, malaise, muscle
aches, lymphadenopathy and gastrointestinal discomfort.
(III) During the chronic phase patients especially those in endemic areas are commonly
asymptomatic but with intestinal schistosomiasis, they may show mild, chronic bloody diarrhoea
with mild abdominal pain. Adults of S. haematobium live in the venules of the urinary bladder
and so the major symptoms are associated with the urinary bladder. Urinary schistosomiasis is
12
associated with high risk or increased risk of bladder cancer because of the progressive damage
to the bladder, uterus and kidney. It may cause obstructive uropathy in 60% of infected patients
(WHO, 2009). Due to its infection of the urinary bladder most symptoms of infection can be
seen in relation to its effect on the bladder. The damage to the bladder may lead to proteinuria,
were small molecules of proteins like albumin are able to pass through the glomerular filter into
the urine leading to a condition more often referred to as albuminuria. Also the ulcerations to the
bladder wall produce blood. The blood may also come from any part of the urinary tract. Blood
may also appear in the urine when a stone or gravel is present in the pelvis of the kidney setting
up irritation, especially after exercise. The blood may also originate from a bladder that is
inflamed or infected or which contains benign growths (papilloma) or malignant growths.
Inflammation or injury to the urethra can also cause hematuria; these conditions are common
with S. haematobium infections.
1.6 DIAGNOSIS AND CONTROL
1.6.1 Urine Diagnosis
The eggs of S. haematobium are passed in the urine with diurnal periodicity, with peak excretion
between mid-morning and mid-afternoon (Doehring et al., 1985). Urine collected during this
period may be concentrated by simple sedimentation or passing the urine through a cellulose
filter to concentrate the parasite eggs. The latter allows quantification of infection. Filtration
techniques that give quantitative assessment of egg excretion are replacing the simple
sedimentation or centrifugation techniques (Dazo and Biles, 1974).
13
1.6.1.1 Urine diagnosis by the use of reagent strips
Urine reagent strips are firm plastic/card strips to which several different reagents areas are
affixed, depending on the product being used urine reagent strips provide tests for glucose,
bilirubin, ketones, specific gravity, blood, pH, protein etc. Therefore these strips can be used to
detect the presence of hematuria and proteinuria in suspected patients, these results together with
other diagnostic tests gives an indication of infection and sometimes helps to determine the
severity of the infection.
1.6.2 Stool Diagnosis
Where the eggs are found in the stool as in the case of Schistosoma mansoni and occasionally
Schistosoma haematobium, diagnosis may be done with stool analysis. Various methods can be
used; normal saline, formol–ether, etc. The most common method for the detection of eggs in
stool is the Kato–Katz thick smear technique. It allows quantification of the intensity of
infection. Standard wet mounts do not contain a large enough sample to reliably find
schistosome eggs. Flotation methods of concentration should not be used if schistosomiasis is
suspected, because schistosome eggs do not float on the usual solvents because of their weight. It
is therefore, imperative that the laboratory be notified about the possible diagnosis of
schistosomiasis.
The Kato–Katz thick smear preparation is an inexpensive, non-invasive, highly specific test with
an acceptable sensitivity. Low-level infection may not be diagnosed by the standard triplicate
Kato–Katz thick smear using a single stool specimen. Sensitivity is improved if multiple stool
14
samples are examined (Katz et al., 1970). A quick Kato technique has been developed for this
purpose that can be read in two hours.
1.6.3 Current Approach
Since most people infected with schistosomiasis are asymptomatic, a high index of suspicion is
required to clinically identify infection, especially in geographic areas where infection is
uncommon. The diagnosis should be considered in any patient with a possible exposure history
who presents with fever, eosinophilia, hepatosplenomegaly, anaemia, hematuria, obstructive
uropathy, recurrent urinary tract infection (especially with Salmonella), glomerulonephritis,
seizures, etc. In order to increase the diagnostic utility of the reagent strip test of hematuria,
additional measurement of proteinuria and leukocyturia have been suggested (Kaiser et al.,
1992).
1.6.4 CONTROL
The development of a vaccine will ultimately be the best control method or measure, but until
then, schistosomiasis could be better controlled worldwide given existing drugs and control
strategies. The development of a national control programme in developing countries is under
competition from other diseases like HIV, malaria and tuberculosis (Gillespie and Pearson, 2001)
For the effective control of schistosomiasis, the following preventive control measures can be
undertaken to prevent and control the infection;
1. Avoiding contact with water known to contain cercariae by providing safe water supplies
in villages, construction of footbridges across infested rivers and streams and providing
safe recreational bathing sites, especially for children.
15
2. Minimizing the risk of infection from new water conservation and irrigation schemes and
hydroelectric developments by treating workers when necessary, sitting settlements away
from canals, drains and irrigation channels and providing latrines and sufficient safe
water for domestic use.
3. Destroying snail intermediate hosts, mainly by using molluscides where it is affordable
and feasible and would not adversely affect important plant and animal life.
These measures among other things would effectively control the spread of schistosomiasis.
In cases of chemotherapy control the first drug of choice is praziquantel.
1.7 JUSTIFICATION
There have been numerous studies conducted on schistosomiasis worldwide especially in the
intermediate host (of worm), geographical distribution, endemic regions, morbidity rate, motility
rate and its prevalence. Such studies have generally been concentrated in tropical poor areas of
Asian countries (China, Indonesia, Philippines, and Thailand), the Middle East and several
African countries spanning from Angola, Botswana, Burundi, Cameroun, even in Ghana etc.
Although enough works have been done on schistosomiasis in Ghana there is the need to
ascertain the current status of the infection due to environmental changes which have the
potential of affecting the habitat of the snail intermediate host. Most especially in school children
who have contact with reservoirs (rivers, streams, ponds) of the snail intermediate host.
16
1.8 OBJECTIVES
The main aim of the study was to determine the prevalence and intensity of urinary
schistosomiasis and the presence of hematuria in the school children at Weweso.
1.8.1 SPECIFIC OBJECTIVES: To determine the;
Prevalence of urinary schistosomiasis in the school children.
Intensity of the infection.
Various factors that expose the children to infection.
Presence of hematuria in the infected children.
Presence of proteinuria in the infected children.
17
CHAPTER TWO
MATERIALS AND METHODS
The study is a school-based survey at Kentinkrono to determine the prevalence of urinary
schistosomiasis infections in the Weweso Basic School children. Two diagnostic methods were
used to determine the prevalence and to ascertain the most sensitive method.
2.1 Study area
The study was carried out at Kentinkrono in the Atwima District of the Ashanti Region in Ghana
between November, 2010 and March, 2011. The school is located about 1.5 miles
(approximately 2.4 km) from the university junction. The vegetation within the Weweso Primary
and JHS school compound is dominated by grasses with few trees. The soil is of the sandy type
as a result of the Wewe River that flows through it.
The River Wewe which flows near the school takes its source from a mountain near Nkwanta on
latitude 6 48’N and longitude 1 32’W. (Fig. 2).It is densely populated by aquatic weeds which
pollute it, with its debris making it appear as almost stagnant. One of its largest tributaries is the
Boha River. The river flows for about 13 miles South-West through Abirem, Weweso and the
Kwame Nkrumah University of Science and Technology before joining River Sisai at Ahinsan.
The school children occasionally swim in the river and it is also used for irrigational purposes by
the community.
18
Fig. 2 Map showing Weweso Basic School and environs.
19
2.2 Target group
The study group consisted of primary and junior high school children of the Weweso Basic
School and they were visited twice a week for a period of a month (four weeks).
2.3 Sampling procedure
The systematic random sampling technique was used. In a class of less than 30 pupils, a one of
three samples was chosen whiles a one of five samples was taken in a class of 30 or more pupils.
This was carried out by instructing the children to form a separate queue of male and females,
with the shortest in front. The first 3 or 5 pupils from both queues were asked to pick folded
sheets, numbered 1-3 or 1-5 depending of the class size. All those who selected number 1 or 5
were first chosen and using them as a start point, subsequent pupils were selected.
2.3.1 Questionnaire administration
Appropriate questionnaires were formulated and administered to the school children. The
consent of the school authorities was sought before the questionnaires were administered. The
questionnaires were given to the children (pupils) to answer. With those in the lower primary, the
questions were read to them and their answers written on the questionnaires, each questionnaire
had a serial number.
20
2.3.2 Sample collection
One sterile bottle was provided for each selected student for urine collection. The specimen
bottles were appropriately labeled with serial numbers of the individuals as on the questionnaires
before giving it out to the children and specimens collected were placed in a cold box
immediately after collection.
Each sample collected was then divided into two fractions. About 10ml of each urine sample
(fraction A) was investigated for the presence of S. haematobium ova using microscopy. The
remaining 10ml (fraction B) was investigated using the urine reagent strip.
2.4 Laboratory analysis
Two laboratory methods were applied in the analysis of the samples. They were the use of the
urine reagent strip to determine proteinuria and hematuria and the use of microscopy to detect
the ova of the parasite.
2.4.1 Urine reagent strip
The test tubes were labeled with grease pencils respective to the labels on the specimen bottles.
A single strip was completely immersed in the test tube containing well-mixed urine, the strip
was removed quickly to avoid dissolving the reagent areas. Excess urine was removed by
21
touching the side of the strip against the rim of the test tube or by the use of tissue paper. Results
were obtained by direct color chart comparison at specific times.
2.4.2 Preparation of sample for microscopy
The centrifuge method was employed where 10ml centrifuge tubes were labeled using a grease
pencil. Urine sample was stirred and poured into the centrifuge tubes about half full of specimen.
The colour and appearance was observed, and then the tubes were placed in the centrifuge.
Spinning was done at 3000rpm for three to five minutes, supernatant was decanted, and the
deposits re-suspended in the residual fluid. A glass slide was labeled and a drop of urine was
deposited on it. The cover slip was applied gently on it. The preparation was then placed under
the microscope, and viewed using low power objective lens and low light intensity. High power
(X40) lens was used for clarity.
The characteristic ovum showed oval shape, was pale yellow-brown and had a sub-terminal
spine (Cheesbrough, 1987). Some urine samples were left to stand for six to twelve hours. The
supernatant was decanted, and leaving the sediments to remain at the bottom. A plastic bulb
pipette was used to mix the sediment, and then transferred onto a slide. It was carefully covered
with a cover slip and examined microscopically for S. haematobium eggs as evidence of
infection. This procedure was used when there was a power shortage.
22
2.5 DATA ANALYSIS
2.5.1 DETERMINATION OF INFECTION PREVALENCE
Prevalence is the ratio of the number of individuals of a host species affected by a particular
disease to a number of such host examined. It is usually expressed as a percentage;
Prevalence (%) = A/B*100
Where A = Number of positive cases
B = Number of children examined
2.5.2 DETERMINATION OF GROUP PREVALENCE
This is determined by
Infection Rate (%) = C/D * 100
Where C = Number of positive cases in a particular age group
D = Number of children in that age group
2.5.3 DETERMINATION OF MEAN INTENSITY
This is determined by
Intensity= E/F
Where E= total number of eggs and F= total number of infected individuals.
23
2.5.4 STATISTICAL ANALYSIS
A mathematical proportion, Microsoft Office Excel and Chi- Square test of proportion and were
used to analyze and correlate the results obtained respectively.
24
CHAPTER THREE
RESULTS
3.1 The Overall Prevalence of Urinary Schistosomiasis
A total number of 200 school children were sampled and examined from the Weweso M/A Basic
School. Twenty-one (21) of the 200 children were infected with the Schistosoma haematobium
representing 10.5%, whilst the remaining 179 (89.5%) were uninfected.
INFECTED
UNINFECTED
Fig. 3: Prevalence of urinary schistosomiasis in the children.
89.5%
10.5%
25
3.1.1 Sex Related Prevalence of Urinary Schistosomiasis
Out of the 200 school children examined 105 were males and 95 females, with thirteen (13)
males infected representing 12.38%, whiles eight (8) females were infected representing 8.42%
of the total females sampled. The difference was not significant at p> 0.05 (p= 0.3616).
Fig. 4: : Association between Prevalence and sex.
26
3.1.2 Prevalence of Urinary Schistosomiasis and age group
Amongst the sampled children, the youngest age was seven years and the oldest nineteen years.
Ninety-three (93) children were within the age group 7 to 11 years, ninety-eight (98) between 12
to 15 years and nine between 16 to 19 years. The highest prevalence was within the age 12 to 15
years with 11.2 % of them having the infection, followed children within the age group 7 to 11
years with 8.6 % of them being infected. The difference between these categories was not
significant at 95% confidence (p= 0.4216).
Fig. 5: Association between infection and age.
27
3.1.3 Prevalence of Urinary Schistosomiasis and contact with the river.
The prevalence of infection was high in children who had contact with the river for various
purposes, with a prevalence of 14.44% compared to those who did not have contact, this
category of children had a prevalence of 7.27%. The difference in infection prevalence between
these two groups of children was not significant (p=0.0998).
Fig. 6: Association between prevalence and contact with the river.
28
PLATE 1: A section of the River Wewe with children bathing in it.
29
3.2 THE OVERALL INTENSITY OF INFECTION
Out of the total twenty-one (21) children infected with the Schistosoma haematobium, eight (8)
representing 35.10% of them had between 1 to 5 eggs per 10ml of their urine, seven (33.33%) had
between 6 to 10 eggs, four (19.05%) had between 11 to 15 eggs and two representing 9.52% had
between 16 to 20 eggs per 10ml of urine.
Fig.7. Intensity of infection among infected school children
30
3.2.1 Sex Related Intensity of Infection
The intensity of infection for both sexes indicated that four males had between 1 to 5 eggs per 10ml
this representing 30.77% of infected males, four females also had the same number representing 50%
of infected females. Five males had between 6 to 10 eggs representing 38.47% and three females had
this number representing 37.5%. Between 11 to 15 eggs only two males had such intensity (15.38%),
whiles only one lady had this number of eggs. For the highest category of intensity, thus between 16
to 20 eggs also two males had such an infection with no female recording that number of eggs.
Fig.8. Relationship between sex and intensity of infection.
31
3.2.2 Intensity of Infection and Age Group
Mean intensity of infection for the various age groups indicated that children within the age group of
12-15 years had the highest mean intensity of nine (9) eggs, followed by those between 16 to 19 years
with seven eggs and then those between ages 7 to 11 had a mean intensity of five eggs per 10ml of
urine.
Fig.9. Association between age groups and intensity.
32
Plate 2 :Schistosoma haematobium egg as viewed under the light microscope, X400
33
3.3 OVERALL PRESENCE OF HEMATURIA AND PROTEINURIA
Out of the twenty-one children who had the infection, a sub-sample of thirteen children was chosen,
thus children having between six to twenty eggs per 10ml. Out of these four had traces of protein in
their blood (30.76%), six had hematuria (46.16%) and three had both hematuria and proteinuria
(23.08%). So in general there were seven proteinuria cases and nine hematuria cases.
Fig.10. Presence of hematuria and proteinuria in infected children
34
3.3.1 SEX RELATED PRESENCE OF HEMATURIA AND PROTEINURIA
Out of the thirteen children chosen, nine were males and four were females. The total of seven who
had proteinuria, there were five males (71.43%) and two females (28.57%) and also out of the nine
who had hematuria, there were six males (66.67%) and three (33.33%) females.
Fig. 11. Association between sex and hematuria and proteinuria
35
CHAPTER FOUR
DISCUSSION
Infections of urinary schistosomiasis are increasingly gaining prominence among the research
community, both locally and internationally. This is due to the challenges posed on victims of the
disease in relation to their health and socio-economic status.
The survey gave an infection prevalence of 10.5% (i.e. 21 out of the 200 children examined). The
result supports several other studies which has shown consistently that infection with Schistosoma
haematobium in southern Ghana is currently of low prevalence (Bosompem et al, 2004). This may be
attributed to improved sanitation, access to portable water, education etc. A similar research
conducted for the prevalence of infant schistosomiasis in a community in the Ewutu-Efutu Senya
District of the Central region of Ghana, showed a prevalence of 11.2% through microscopy and 30%
through MoAb-dipstick examination from a total of 75 subjects (Bosompem et al, 2004).These results
were confirmed by the findings in the present study.
From the questionnaires administered, it was revealed that ignorance of the effects of schistosomiasis,
poor living conditions, poor parental control, inadequate sanitation and water supplies, deplorable
personal and environmental hygiene and more importantly lack of supervision while in school, was
the prime reasons for the infection. Lack of control during school hours was the chief predisposing
factor because, inferring from the questionnaires most of the children are not residents of the Weweso
community, but rather from surrounding communities where the river does not pass through, so these
children only had contact with the river during breaks, before and after school hours.
36
Males had a higher prevalence (12.3%), than that of the females (8.92%) and this could be attributed
to the fact that most males are actively involved in activities that make them susceptible to the
infection than females, i.e. activities like swimming (which we saw whiles undertaking the study),
wadding through and fetching the water for various purposes. The difference in prevalence between
the sexes was not statistically significant within a confidence interval of 95%, the p-value as
calculated by Chi-square analysis was 0.3616, thus greater than 0.05 hence not significant. This
means that the reasons given for the difference are valid because a smaller p-value would have meant
the assumption that males had a higher prevalence due to increased contact with the river was not
true.
Prevalence due to contact was also high (14.44%) among the children who use the water (for purpose
as listed above) than those who did not have contact (7.27%), again we suspect some of the children
were not sincere in answering the questionnaires, probably due to fear of being punished by school
authorities. Again statistically the difference in prevalence was not significant at confidence level of
95%, the p-value was 0.0998 determined by chi-square analysis. Therefore we conclude that the
difference was due to contact only.
Children within the age group of 12-15 years had the highest prevalence with eleven of them out of a
total of ninety-eight children examined being infected (11.2%). This information conforms to the
facts already established by researchers that, in endemic areas the highest prevalence and intensity
occurs in adolescents, between the ages of 10-16 (Davies, 1985). This may be as a result of the fact
that as they (children) progress in age their contact with the reservoirs of infection (rivers, streams,
lakes etc) reduces, thereby reducing their risk of being infected among other reasons. A p-value of
0.4216 was determined by chi-square analysis, this means at confidence level of 95% the difference
in prevalence by age group was not significant.
37
Intensity of infection as established by number of eggs per 10ml of urine indicated that most of the
children infected had between 1-5 eggs (38.10%), the highest number of eggs recorded was between
16-20 (9.25%). These figures show a low intensity of infection among the children, this may be due
to the same factors listed above that contributed to the low prevalence and may be also due to access
to medications either traditional or orthodox as confirmed by some of the children as they answered
the questionnaires.
Sex related intensity showed that most males had between 6-10 eggs (38.47%), unlike the females
who had more of them having between 1-5 eggs (50%). This collaborates with earlier information
that most males are actively involved in activities that predisposes them to infection. Again only
males had between 16-20 eggs which were the highest range of egg intensity found in the children.
Mean egg intensity by age groups showed that children between the ages of 12-15 had the highest of
nine eggs which is not different from the results acquired by other investigators, as stated earlier on
prevalence and intensity peaks during that age group. This we assume is due to reduced contact with
the water or probably the development of immunity.
Hematuria and proteinuria prevalence as determined among the thirteen children with an egg intensity
between six and twenty, showed that the number of infected children with blood in their urine was
more (9 out of13) than those who had protein in their urine (7 out of 13). This may be due to the fact
that the intensity of infection was low as a result of several factors, like improved sanitation, access to
medication, education etc. A higher incidence of hematuria was recorded than proteinuria because the
former turned to occur in patients with lesser egg intensity than the latter. Also, it is possible to have
hematuria in certain cases of malaria (black water fever) due to heamolysis and, also in the urine of
menstruating females.
38
The prevalence of both hematuria and proteinuria was high in males (66.67% and 71.43%) than in
females (33.33% and 28.57%) respectively. Per the intensity of infection discussed earlier on, males
turn to have a higher intensity than females and the occurrence of both hematuria and proteinuria due
to urinary schistosomiasis were dependent on severity of infection, this therefore explains the results
recorded. Also as mentioned earlier menstruating females might have given positive reaction to
hematuria.
The current switch from yearly mass deworming of school children to every two years is not helping,
and is a reflection of current outcome of this study. It gives room for self medication (if any at all)
which might not be enough to treat an infection, and may lead to other complications, this policy can
also be one of the factors contributing to the current status of infection in the school.
39
CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
5.1 CONCLUSION
This present study has shown that the prevalence and intensity of urinary schistosomiasis in the
school children was relatively high, though, the results were similar to that of other
investigations that suggested that the infection in Southern Ghana is reducing. Factors such as
lack of sanitary conditions, lack of proper parental control, lack of adequate education and more
importantly inadequate control of children during school hours were identified as the pre-
disposing factors to the infection.
5.2 RECOMMENDATIONS
The results obtained indicated that, school children who either swim or wade through the Wewe
River were at a higher risk of getting an infection. Therefore to control and possibly prevent
infection, these recommendations are therefore made.
There should be a survey in the area to determine the presence of the intermediate host and
vector control measure undertaken.
40
Mass treatment with praziquantel should be carried out in schools found to have this infection,
since the conventional dewormers normally used have been proven not to be effective against the
Schistosoma worm.
A public health education programme should be organized in the school for both teachers and
school children and, if possible, parents should be involved, to make them aware of the need to
control or prevent infection by reducing contact of the children with the river.
Basic school amenities, sanitation facilities and potable drinking water should be provided in the
school, to prevent the children from fetching water from the river.
The portion of the river facing the school compound should be fenced to prevent children from
playing in the water during school hours.
The bi-annual deworming policy should be reversed to the earlier annual policy (preferably with
praziquantel), this would help in preventing the spread of the disease.
In the absence of the fence (until it is provided), the school authorities should do more to prevent
the children from having frequent access to the water.
41
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45
APPENDICES
APPENDIX I
Table 1: Prevalence of urinary schistosomiasis in the children.
NUMBER EXAMINED INFECTED PREVALENCE (%)
200 21 10.5
Table 2: Prevalence of urinary schistosomiasis and sex.
NUMBEREXAMINED
NUMBERINFECTED
PREVALENCE (%)
MALES 105 13 12.3
FEMALES 95 8 8.92
Table 3: Prevalence of urinary schistosomiasis and age group.
AGE GROUPS EXAMINED INFECTED PREVALENCE(%)
7-11 93 8 8.6
12-15 98 11 11.2
16-19 9 2 22.2
Table 4: Prevalence of urinary schistosomiasis and contact with the River Wewe
EXAMINED INFECTED PREVALENCE(%)
CONTACT 90 13 14.44
NO CONTACT 110 8 7.27
46
Table 5: Intensity of infection of urinary schistosomiasis
NUMBER OF EGGS PER10ML
NUMBER OF CHILDRENINFECTED
PERCENTAGE
1-5 8 38.10
6-10 7 33.33
11-15 4 19.05
16-20 2 9.52
Table 6: Intensity of infection and sex
MALES FEMALES
NUMBER OF EGGS INFECTED/PERCENTAGE INFECTED/PERCENTAGE
1-5 4 30.77 4 50
6-10 5 38.47 3 37.5
11-15 2 15.38 1 12.5
16-20 2 15.38 0 0
Table 7: Presence of hematuria and proteinuria
INFECTED PERCENTAGE
HEMATURIA 6 46.16
PROTEINURIA 4 30.76
BOTH 3 23.08
47
Table 8: Sex related presence of hematuria and proteinuria.
MALES FEMALES
INFECTED/PERCENTAGE INFECTED/PERCENTAGE
HEMATURIA 6 66.67 3 33.33
PROTEINURIA 5 71.43 2 28.57
Table 9: Chi-square analysis for prevalence of urinary schistosomiasis and sex.
TABLE ANALYZED DATA 1
Chi-square, df 0.8322,1
P value 0.3616
P value summary Ns
One-or two-sided Two sided
Statistically significant? (alpha<0.05) No.
Table 10: Chi-square analysis for prevalence of urinary schistosomiasis and age group.
TABLE ANALYZED DATA 1
Chi-square, df 1.727,2
P value 0.4216
P value summary Ns
One-or two-sided NA
Statistically significant? (alpha<0.05) NO
48
Table 11: Chi-square analysis for prevalence of urinary schistosomiasis and contact with RiverWewe.
TABLE ANALYZED DATA 1
Chi-square, df 2.709,1
P value 0.0998
P value summary Ns
One-or two-sided Two sided
Statistically significant? (alpha<0.05) No
49
APPENDIX II. MATERIALS USED
1. Light microscope
2. Plastic container
3. Small specimen bottles
4. Test tubes
5. Plastic bulb pipette
6. Centrifuge
7. Cork stopper
REAGENTS USED
1. Urine reagent test strip.
50
APPENDIX III. SAMPLE QUESTIONNAIRE:.
Prevalence and intensity of Urinary Schistosomiasis in Weweso Basic Sch. Children.
A. Name .............................................. Code No. ..........................
Age: .................... Sex: Male Female
Do you stay at Weweso? YES NO
If no specify........................................................
Do you stay with both of your parents ? YES NO
.
If no who do you live with?Mother
Father
Relative
Other.............
If not with both parents, reasons:
Separated
Deceased
Other..............
51
B. Do you have a main source of potable water? YES NO
If yes specify...................................
If no specify..............................................
Do you have any contact with the Weweso river? YES NO
If yes for what purpose?
Swimming
Fishing
Washing
Other..................................
C. How many times in a day or in a week do you have contact with theriver?............................................
D. Have you visited any health facility reently? YES NO
E. How recent?...............................................................................
F. Have you recieved any other form of medication? YES NO
G. If yes what type of medication....................................................
H. Comments..............................................................................................................................................................................................................................................................................................................................................................................................................................