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UNIVERSITI PUTRA MALAYSIA
PREVALENCE OF AND FACTORS AFFECTING ACQUISITION OF INTESTINAL CRYPTOSPORIDIOSIS IN MALAYSIAN CHILDREN WITH MALIGNANCIES AT ONCOLOGY WARD, INSTITUTE OF PEDIATRICS,
HOSPITAL KUALA LUMPUR, MALAYSIA
LUBNA MOHAMED ELBESHTI
FPSK(m) 2011 42
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PREVALENCE OF AND FACTORS AFFECTING ACQUISITION OF INTESTINAL
CRYPTOSPORIDIOSIS IN MALAYSIAN CHILDREN WITH MALIGNANCIES AT
ONCOLOGY WARD, INSTITUTE OF PEDIATRICS, HOSPITAL KUALA LUMPUR,
MALAYSIA
By
LUBNA MOHAMED ELBESHTI
Thesis Submitted to the School of Graduate Students, University Putra Malaysia, in Fulfillment
of the Requirements for the Degree of Master of Science
June 2011
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Abstract of thesis presented to the Senate of Universiti Putra Malaysia in fulfillment of the
requirement for the degree of Master of Science
PREVALENCE OF AND FACTORS AFFECTING ACQUISITION OF INTESTINAL
CRYPTOSPORIDIOSIS IN MALAYSIAN CHILDREN WITH MALIGNANCIES AT
ONCOLOGY WARD, INSTITUTE OF PAEDIATRICS, HOSPITAL KUALA LUMPUR,
MALAYSIA
By
LUBNA MOHAMED ELBESHTI
June 2011
Supervisor: Rukman Awang Hamat, PhD
Faculty Medicine and Health Sciences
Cryptosporidium parvum is an opportunistic parasitic agent that has a world-wide distribution.
The disease caused by this parasite can be severe and very difficult to manage in
immunocompromised patients especially in children with malignancies. However, data on
immunocompromised children in Malaysia is very much lacking. The aim of this study was to
estimate the prevalence of cryptosporidiosis in children with different types of malignancies and
to study factors that might contribute to acquisition of cryptosporidiosis.
A cross-sectional study was conducted over 10 months from November 2009 until August 2010
in Institute of Pediatrics, Hospital Kuala Lumpur. A self-administered questionnaire was used
and medical records were obtained. Stool samples were examined for the Cryptosporidium
oocyst by using two different techniques i.e. modified Ziehl-Neelsen stain and
Immunochromatographic (ICT) assays (RIDA-Quick Cryptosporidium R-Biopharm, Germany).
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One hundred and ten stool samples were collected from children (56 boys, 49 girls) with
different types of malignancies between the ages of 3 months and 17 years (mean age: 2 years).
The majority of those children were the Malays (75.2%), followed by the Chinese (11.4%),
Indians (8.6%) and others (4.8%) The most common type of lympho-hematopoietic malignancies
was acute lymphoblastic leukemia (38.1%), followed by acute myeloid leukemia (8.6%),
suspected leukemia (8.6%), lymphoma (7.6%), and chronic myeloid leukemia (1.9%). Whereas,
among non-lympho-hematopoietic malignancies, brain tumor represented 11.4% of cases,
followed by retinoblastoma (5.7%), hepatoblastoma (3.8%), Wilm‟s tumor (2.9%),
pleuropulmonary blastoma (1.9%) and right adrenal cortical tumor (0.9%). Fever was presented
in (83.8%) of those patients, followed by diarrhea (54.3%). All stool samples were negative for
Cryptosporidium oocysts by two different techniques. (33.3%) from those patients had history of
admission to other wards, (29.5%) had history of animal contact, (24.8%) had history of
swimming in the swimming pool. In terms of precautionary measures practiced, (80.9%) and
(75.2%) washed their hands before and after eating, or after going to the toilet respectively. In
addition, preventive measures that were also observed: (16.2%) had history of admission to day-
care center, (2.9%) had history of drinking tap water, and (0.9%) had history of travel.
In this present study, we documented a zero prevalence rate of cryptosporidiosis amongst
children with malignancies despite higher prevalence rates being reported in other developing
countries. Our results may suggest that the children with malignancies are at low risk of
acquiring cryptosporidiosis because of good personal hygiene, good infection control and
practices in the hospital, and improve water supply system. Screening for Cryptosporidium
oocysts may not be necessary in those patients. Our findings suggest that routine screening of
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stools for Cryptosporidium might not be necessary for our patients. However, we believe large
multicenter studies throughout Malaysia are needed to establish the true prevalence and
characteristics of cryptosporidiosis among children with malignancies.
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Abstrak projek yang dikemukakan kepada Senat Universiti Putra Malaysia
Sebagai memenuhi keperluan untuk ljazah Master Sains
PREVALENS DAN FAKTOR YANG MEMPENGARUHI KEJADIAN
KRIPTOSPORIDIOSIS USU PADA KANAK-KANAK MALAYSIA YANG
MENGHIDAPI MALIGNANSI DI WAD ONKOLOGI , INSTITUT PEDIATRIK,
HOSPITAL KUALA LUMPUR , MALAYSIA
Oleh
LUBNA MOHAMED ELBESHTI
Jun 2011
Pengerusi: Rukman Awang Hamat, PhD
Fakulti Perubatan dan Sains Kesihatan
Cryptosporidium parvum adalah sejenis agen parasit oportunistik yang mempunyai taburan di
serata dunia. Penyakit yang di sebabkan oleh parasit ini boleh menjadi parah dan ia sangat sukar
untuk di kawal pada pesakit terimunokompromi terutamanya kanak-kanak malignansi. Namun
begitu, data pesakit terimunokompromi di Malaysia tidak mencukupi. Tujuan penyelidikan ini di
jalankan adalah untuk menganggarkan prevalen cryptosporidiosis pada kanak-kanak yang
mempunyai malignansi berlainan dan mengkaji factor-faktor jangkitan cryptosporidiosis.
Satu kajian keratan rentas telah di jalankan selama 10 bulan dari November 2009 sehingga Ogos
2010 di Institut Pediatrik, Hospital Kuala Lumpur. Soal selidik yang di jalankan sendiri di
gunakan dan rekod perubatan di perolehi. Sampel tinja telah di periksa untuk kehadiran oosista
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Cryptosporidium menggunakan 2 teknik berlainan iaitu pewarna Ziehl-Neelsen terubahsuai dan
asai imunokromatografi (ICT) (RIDA-Quick Cryptosporidium R-Biopharm, Germany).
Seratus dan sepuluh sampel tinja telah di kumpul dari kanak-kanak (56 lelaki, 49 perempuan)
dengan malignansi yang berlainan, yang berumur di antara 3 bulan dan 17 tahun (min umur: 2
tahun). Sebahagian besar daripada kanak-kanak tersebut adalah Melayu (75.2%), diikuti dengan
Cina (11.4%), India (8.6%) dan lain-lain (4.8%). Malignansi berjenis hematopoetik limfa yang
paling umum adalah leukemia limfoblastik akut (38.1%), di ikuti dengan leukemia mieloid akut
(8.6%), pesakit yang disyaki leukemia (8.6%), limfoma (7.6%), leukemia mieloid kronik (1.9%).
Manakala di kalangan malignansi yang bukan berjenis hematopoetik limfa, kes tumor otak
mewakili 11.4%, diikuti dengan retinoblastoma (5.7%), hepatoblastoma (3.8%), tumor Wilm
(2.9%), blastoma pleuropulmonari (1.9%) dan tumor korteks adrenal kanan (0.9%). Lapan puluh
tiga perpuluhan lapan peratus pesakit mengalami demam, diikuti dengan cirit-birit (54.3%).
Semua sampel tinja di dapati negatif untuk oosista Cyrptosporidium berdasarkan 2 teknik
berbeza. Tiga puluh tiga dan tiga peratus daripada pesakit tersebut mempunyai sejarah
kemasukan ke wad berlainan, (29.5%) mempunyai sejarah menyentuh binatang, (24.8%)
mempunyai sejarah berenang di dalam kolam air. Berdasarkan langkah berjaga-jaga yang di
amalkan (80.9%) dan (75.2%) mencuci tangan sebelum dan selepas makan, serta selepas
mengunakan tandas. Di samping itu, langkah berjaga-jaga tersebut telah di patuhi: (16.2%)
mempunyai sejarah menghadiri pusat asuhan kanak-kanak, (2.9%) mempunyai sejarah minum
air paip, dan (0.9%) mempunyai sejarah perjalanan.
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Berdasarkan kajian yang telah dijalankan, kami telah mendokumenkan kadar prevalens sifar
cryptosporidiosis di kalangan kanak-kanak malignansi walaupun negara membangun lain telah
melaporkan kadar prevalen yang tinggi. Keputusan kami mungkin menunjukkan bahawa kanak-
kanak malignansi mempunyai risiko yang rendah untuk di jangkiti cryptosporidiosis kerana
kebersihan diri yang terjaga, kawalan dan penjagaan infeksi yang baik di hospital serta sumber
air yang bertambah baik. Saringan terhadap oosista Cyptosporidium mungkin tidak diperlukan
bagi pesakit kita. Walau bagaimanapun, kami percaya yang keputusan kami mewajarkan kajian
lanjut seperti kajian prospektif longitudinal kawalan kes di masa hadapan. Kajian ini mungkin
dapat menolong kami menentukan status imunologi kanak-kanak yang menghidap cancer sama
ada mereka lebih cenderung mendapat cyrptosporidiosis.
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ACKNOWLEDGEMENTS
By the Name of Allah, Most Gracious, Most Merciful, all praise and thanks are due to Allah, and
peace and blessings be upon His Messenger. I would like to express the sincerest appreciation to
those who made this work possible: Advisory members, Friends and Family.
I would like to convey my deepest and grateful thanks to my supervisor, Dr. Rukman Awang
Hamat for providing me the opportunity to complete my study under his valuable guidance, for
the many useful advice and discussions, for his constant encouragement and guidance. I would
like to thank all the co-supervisors, Dr. Amal .R. Nimir, Dr. Ngah Zasmy Unyah. I am grateful
for their willingness to serve on my supervisory committee, constant encouragement, helpful
advice and many fruitful discussions. In addition, I would like to thank Dr. Malina Osman for
her help in the statistical analysis of the data.
Special thanks go to the staffs in Oncology Ward, Pediatric Institute, Hospital Kuala Lumpur,
who had given me a lot of helping hands during data collection. I would also thank Staffs at
Laboratory of Parasitology, UKM, especially Encik Ismail Hj Mohd Ghauth for his assistance
for doing the stain technique. Laboratory assistants of mainly Cik Nurhanim Kamaruddin and
Encik Mohd Nawawi Daud from Parasitology Laboratory, Faculty of Medicine and Health
Sciences, UPM.
I would also like to give all my respect and appreciation for all respondents of this study for
their cooperation all along the data collection.
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The People‟s Bureau of the Great Socialist People Libyan Arab Jamahiriya is gratefully
acknowledged for providing the financial support. Trust Account no: 6381600. .
Last but not least, very special thanks to my husband, his love, support and encouragements are
behind my success.
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APPROVAL SHEET
I certify that an Examination Committee has met on (14 June) to conduct the final examination
of Lubna Mohamed Elbeshti in her thesis entitled " Prevalence of and Factors Affecting
Acquisition of Intestinal Cryptosporidiosis in Malaysian Children with Malignancies at
Oncology Ward, Institute of Pediatrics, Hospital Kuala Lumpur, Malaysia " in accordance with
Universities and University Colleges Act 1971 and the Constitution of the Universiti Putra
Malaysia [P.U.(A) 106] 15 March 1998. The committee recommends that the student be awarded
the degree of Master of Science.
Members of the Thesis Examination Committee were as follows:
Zamberi Sekawi, PhD
Associate Professor
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Chairman)
Wan Omar bin Abdullah, PhD
Professor
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Internal Examiner)
Malina binti Osman, PhD
Lecturer
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Internal Examiner)
Zeehaida Mohamed, PhD
Lecturer
School of Medical and Health Sciences
Universiti Sains Malaysia
Malaysia
(External Examiner)
__________________________________
NORITAH OMAR, PhD
Associate Professor and Deputy Dean
School of Graduate Studies
Universiti Putra Malaysia
Date: 26 July 2011
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This thesis submitted to the Senate of Universiti Putra Malaysia and has been accepted as
fulfillment on the requirement for the degree of Master Sciences. The members of the
supervisory committee were as follows:
Rukman Awang Hamat
Lecturer
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Chairman)
Amal R. Nimir, PhD
Senior Lecturer
Faculty of Medicine
Cyberjaya University
(Member)
Ngah Zasmy A/L Unyah
Senior Lecturer
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Member)
__________________________________
HASANAH MOHD GHAZALI, PhD
Professor and Dean
School of Graduate Studies
Universiti Putra Malaysia
Date:
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DECLARATION
I declare that the thesis is my original work except for quotations and citations, which have been
duly acknowledged. I also declare that it has not been previously and is not concurrently,
submitted for any other degree at Universiti Putra Malaysia or at any other institutions.
__________________________________
LUBNA MOHAMED ELBESHTI
Date: 14 June 2011
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TABLE OF CONTENTS
Page
CHAPTER
1
2
GENERAL INTRODUCTION
1.1Objectives
1.1.1General Objectives
1.1.2 Specific Objectives
LITERATURE REVIEW
2.1 Taxonomy and Life cycle
2.1.1 Taxonomic Classification
2.1.2 Life Cycle
2.2 Medically Importance Cryptosporidium Species
in Human
2.3 Routs of Transmission
2.3.1 Waterborne Transmission
2.3.2 Food borne Transmission
2.3.3 Person to Person Transmission
2.3.4 Zoonosis and Other Routes of
Transmission
2.4 Immune Response and Pathophysiology of
Cryptosporidiosis
2.4.1 Immune Response to Cryptosporidium
2.4.2 Pathophysiology
2.5 Cryptosporidiosis in Immunocompetent
Children
2.5.1 Epidemiology
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ABSTRACT
ABSTRAK
ACKNOWLEDGEMENTS
APPROVAL
DECLARATION
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS
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2.5.2 Clinical Manifestations of
Cryptosporidiosis
2.5.3 Disease Outcomes
2.6 Cryptosporidiosis in Immunocompromised
Children
2.6.1 Epidemiology
2.6.2 Clinical Manifestations and Disease
Outcomes
2.7 Methods of Detection
2.7.1 Concentration Techniques
2.7.2 Staining Techniques
2.7.3 Immunological- Based Methods
2.7.4 Molecular Techniques
2.8 Therapy and Preventive Measures
2.8.1 Antimicrobial Therapy
2.8.2 Prevention and Control
METHODOLOGY
3.1 Study Site
3.2 Study Design
3.3 Study Duration
3.4 Study Population and Subject Selection
3.4.1Study Population
3.4.2 Sample Population
3.4.2.1 Inclusion Criteria
3.4.2.2 Exclusion Criteria
3.5 Sample Method
3.6 Sample Size
3.7 Data Collection
3.7.1 Questionnaire
3.7.2 Medical Record
3.7.3 Stool Samples Collection
3.7.4 Stool Samples Transportation
3.8 Samples Processing
3.8.1 Immunochromatographic (ICT) assays
RIDA-Quick ( R-Biopharm , Germany )
Procedure
3.8.2 Concentration Technique (Formalin-Ether)
3.8.3 Modified Ziehl- Neelsen Technique
3.8.4 Direct Fecal Smear Technique
3.8.5 Disposal of the Stool Samples
3.9 Study Ethics
3.10 Variables
3.10.1 Dependent Variables
3.10.2 Independent Variables
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3.11 Statistical Methods
3.12 Definition of Terms
3.12.1 Fever
3.12.2 Diarrhea
3.12.3 Anemia
3.12.4 Leucopenia
3.12.5 Neutropenia
3.12.6 Febrile Neutropenia
3.13.7 Risk Factors
3.13 Limitations
3.13.1 Difficult to get the approval from
Ministry of Health (MOH)
3.13.2 Missing of Some Questionnaires
3.13.3 Inadequacy of Some Medical Record
3.13.4 Difficult to Get Stool Samples From the
Patients
3.13.5 Insufficient the Volume of Some Stool
Samples
3.13.6 Time
3.14 Bias
3.13.1 Recall Bias
3.13.2 Information Bias
RESULTS
4.1 Detection of Intestinal Parasites in Stool
Samples Collected from Children with
Malignancies
4.2 Socio-demographic Characteristics of Children
with Malignancies
4.3 Clinical Characteristics and Laboratory of
Children with Malignancies
4.4 Type of Malignancies Diagnosed in Children
in Oncology Ward
4.5 Factors that Might Influence the Acquisition of
Cryptosporidiosis in Children with
Malignancies
DISCUSSION
CONCLUSION AND RECOMMENDATION
REFERENCES
APPENDICES
APPENDIX A: QUESTINNAIRE
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