ORIGINAL

Niger J Paed 2012; 39 (3): 118 - 123

Risks of intestinal helminthiasis in

children living in orphanages in

Benin city, Nigeria

Nwaneri DU

Omuemu VO

DOI:http://dx.doi.org/10.4314/njp.v39i3.6

Accepted: 15th January 2012

helminths isolated.

aberrations were represented more

in infected subjects than the non-

Behavioural

Abstract Background: Risk factors

of intestinal helminthiasis include

poor personal hygiene/care, and

behavioural aberrations such as

finger sucking, nail biting and pica

which had been found to enhance

intestinal ova transmission.

Objectives: To determine risk fac-

tors of intestinal helminthiasis in

children living in orphanages in

Benin City, Nigeria.

Subjects and Methods: Fresh stool

samples from 140 children (0 – 17

years) living in 10 orphanages in

Benin City, were analyzed using the

Kato-Katz technique for the detec-

tion of ova of helminths between

January-April, 2011.

Results: Prevalence of intestinal

helminthiasis was 20.7%. Children

ages 12 – 17 years had highest

prevalence of intestinal helminths.

Ascaris lumbricoides and Trichuris

trichiura were the intestinal

(

)

Nwaneri DU

2

infected children (χ = 3.94, p =

Institute of Child Health,

Omuemu VO

Department of Community Health,

College of Medicine,

University of Benin,

PMB 1154 Benin City,

Edo State, Nigeria.

0

.047, O.R = 2.3). Nail biting and

use of common towel were the most

significant independent predictors

of intestinal helminthiasis (p =

0

.017 and 0.028 respectively). Hand

washing with water and soap after

defeacation was significantly asso-

ciated with decreased prevalence of

intestinal helminthiasis (p = 0.016).

Conclusion: Behavioural modifica-

tion, good personal hygiene and

provision of towels for each child

living in the orphanage should be

integral part of intestinal helminths

control in orphanages.

E-mail: damiannwaneri@yahoo.com

Tel: +2348056321577,

+

23480139172309

Key words: finger sucking,

helminthiasis, nail biting, pica, risk

5

-7

5

Introduction

those who do not possess them. Nwaneri et al and

6

Giacometti et al in their separate studies observed that

Intestinal helminthiasis is usually a problem of

encopresis and pica were respectively major predictors

of intestinal helminthiasis in children with chronic

neurological disorders (cerebral palsy, epilepsy and

mental retardation), while in healthy children, Herrstrom

1

,2

pre-school and school aged children worldwide. In

Nigeria, the prevalence of intestinal helminthic infec-

tions ranges from 14.4 – 71.1%, depending on th₂_-e₄ loca-

tion and the methodology employed in the study.

7

et al observed that finger sucking, nail biting and pica

were strongly associated with E. vermicularis . The au-

thors concluded that behavioural modification and im-

proved personal hygiene (such as nail trimming, hand

washing before and after meals, etc) should be integral

part of control program for intestinal helminthiasis espe-

cially in in₅s_-t₇itutionalized children and/or children in

orphanages.

Risk factors of intestinal helminthiasis include poor

personal hygiene/care, and behavioural aberrations such

as finger sucking, nail biting and pica which had been

found to encourage soil contamination by helminths ova

and intestinal helminths transmission from one individ-

ual to another especially among childr_-₇en who live in

3

closed communities or in institutions. Available data

showed that children who possess these behavioural

aberrations especially in communities with poor sanitary

practices and personal hygiene are at higher risk of

acquiring intestinal helminthiasis when compared to

There was an estimated 7,000,000 orphans in Nigeria in

2003 and an increase of 1,200,000 by end of 2010.

There is paucity of published data on the prevalence of

intestinal helminthiasis in children living in orphanages

8,9

1

19

1

0

in Nigeria. Ogbe et al observed a prevalence of 63.6%

in an orphanage in Isolo Lagos Nigeria over two decades

ago. Inadequate access to clean drinking water, health

care, and poor sanitation which characterize most or-

phanages in developing countries (including Nigeria)

were the major risk factors of this high prev₉a_,l₁e₀nce of

the researcher/assistants were at the orphanages in the

morning to collect the stool samples.

Stool sample collected in the mornings from each sub-

jects was examined the same day with the Kato-Katz

method to calculate the number of eggs per gram of

12

intestinal helminthiasis observed in the study.

There

feaces (WHO 1998) in Research Laboratory, Depart-

is need to identify and document the risk factors of in-

testinal helminthiasis in orphanages. This study there-

fore set to identify risk factors to intestinal helminthiasis

in children living in orphanages in Benin City, Nigeria.

Findings obtained from this study could be used to insti-

tute interventional programs to reduce the prevalence of

intestinal helminthiasis in orphanages.

ment of Child Health, University of Benin Teaching

Hospital, Benin City. In order to ensure proper identifi-

cation of hookworm ova, the preparation of each stool

slide was₁₂_-r₁e₄ad not later than 4-6 hours after taking the

samples.

All the slides were read by one medical

microbiologist specialized in parasitology and a second

reading of the slides were done by the same microbiolo-

gist to ensure consistency. Another reading was done

after 24 hours for search for ova₁₂o_,₁f₃ Schistosoma man-

soni by the same microbiologist.

Intensity of infec-

tions for each worm was defined according to the thresh-

olds proposed by the World H₁₃ealth Organization

(WHO) Expert Committee in 1987.

Subjects and Methods

This cross sectional, descriptive study was carried out

between January and April 2011 in 10 orphanages in

Benin City, Nigeria. There were 15 registered orphan-

ages in Benin City and all the orphanages are privately

owned by individuals or corporate bodies. As at the time

of this study, three of the orphanages were not func-

tional, one had no child as inmate during the period of

recruitment of the subjects and one of the orphanages

with 8 inmates was used for pre-testing and was ex-

cluded from the final analysis. Children with obvious

chronic neurological disorders such as cerebral palsy

Data Analysis

The data obtained was entered into spread sheet using

the Microsoft Excel 2007 and the analysis was done

using the Statistical Package for Scientific Solutions

(SPSS) versions 11.0 and 16.0 softwares (SPSS Inc Chi-

cago, Illinois, USA). The proportion of children who

had ova of helminths in stool was used to calculate the

prevalence of intestinal helminthiasis in this study.

Quantitative variables were summarized using means

and standard deviations. The significance of association

between variables was tested using chi-square and

fisher’s exact tests where appropriate for comparison of

proportions while student t -test was used for compari-

son of mean. Binary logistic regression was used to ob-

tain predictors of intestinal helminthiasis in children

seen at the orphanages using the obtained risk factors as

independent variables against whether or not the child

has positive ova of helminths in stool (infected and non-

infected) as dependent variable. The level of signifi-

cance of each test was set at p < 0.05.

(

CP) were also excluded. These children have obvious

behavioural aberrations such as pica, and encopressis

which put them at higher risk of inte₅s_,₆ti_,₁n₁al helminthiasis

when compared with other children.

The 10 orphan-

ages used for this study had a total of 165 inmates. Six

of the inmates were either 18 years or above; and an-

other six children had CP. Complete data and appropri-

ate stool samples for analysis for this study was obtained

from 140 children giving a response rate of 84.8%.

Preliminary meetings were held with the proprietors/

proprietresses of the selected orphanages where the out-

line of the programme was explained in details. An in-

formed written consent was signed by each proprietors/

proprietresses and an assent obtained from older chil-

dren within the orphanage for participating in the study.

Ethical approval was obtained from the Ethics and Re-

search Committee University of Benin Teaching Hospi-

tal, Benin City, Nigeria. In addition, a written permis-

sion was obtained from the Ministry of Women Affairs

and Social Development, Edo State Nigeria.

Results

The subjects consisted of 60 (42.9%) boys and 80

(57.1%) girls; mean age (±SD) was 7.1 ± 4.7 years, and

mean (±SD) years lived in the orphanage was 3.5 ± 3.4

years.

During recruitment of participants, the procedure of

stool collection with a wooden stick was clearly ex-

plained to the older children and the caregivers within

the orphanages. Each child within the orphanage was

given an identification number. Stool containers labeled

with each child’s identification number were given to

the caregivers within each orphanage previous₁₂day.

Morning stool samples were preferred for analysis, and

Prevalence of intestinal helminthiasis in children seen in

orphanages was 29/140 (20.7%). Age of infected sub-

jects (9.1 ± 4.5 years) was significantly higher than 6.6 ±

4.6 years observed in non-infected subjects (t = 2.69,

p = 0.01, 95% C.I = 0.63, 4.40). Prevalence of intestinal

helminthiasis was virtually the same among the age

groups 0 – 5 year and 6 – 11 years, thereafter, there was

marked increase in prevalence at ages 12 – 17 years

1

20

(

helminthic infection: 15/29 (51.7%) girls and 14/29

(

Figure 1). There was no significant gender difference in

(finger sucking, nail biting and pica) when compared

with 32/111(28.8%) observed among the non-infected

subjects (χ = 3.94, p = 0.047, O.R = 2.3).

2

48.3%) boys (χ = 0.44, p = 0.53, OR = 1.3).

Species of intestinal helminths isolated were A. lumbri-

coides in 26/29(89.7%) and T. trichiura in 3/29 (10.3%)

of subjects.

Table 1 shows the distribution of the behavioural aberra-

tion among the infected and non-infected subjects. Sub-

jects with nail biting significantly were infected with

intestinal helminthiasis (p = 0.04) and were about 2

times more likely to acquire the disease (Table 2). Pro-

portion of children with nail biting increases with in-

crease in age as against finger sucking and pica which

were more common among the pre-school and school

ages (less than 12 years old).

Among the 140 subjects, 46 (32.9%) had one or more

behavioural aberration such as nail biting, finger sucking

and pica. Nail biting was the most frequent behavioural

aberration observed in 37/140 (26.4%) of the subjects,

finger sucking 8/140 (5.7%) and then pica, one (0.7).

Fourteen (48.3%) of the 29 infected subjects possess

significantly one or more of the behavioural aberration

Table 1: Behavioural aberration among infected and non-infected subjects

Behavioural

Aberration

Infected

Non-infected p –value

O.R

95%C.I

n=29 (%) n = 111 (%)

Nail biting present

No nail biting

12 (41.4) 25 (22.5)

17 (58.6) 86 (77.5)

0.04

2.40

1.02, 5.76

Finger sucking present 2 (6.9)

6 (5.4)

27 (93.1) 105 (94.6)

1 (3.4) 0 (0.0)

0.76*

0.21*

1.30 0.24, 6.79

No finger sucking

Pica present

7.90 0.47, 296.03

No pica

28 (96.6) 111 (100.0)

O.R = Odds Ratio; C.I = Confidence Interval; *Fisher’s Exact test

Eighty-eight (62.9%) of the children use common towel

to clean their body after bathing. These towels were

washed usually once every week. One quarter of these

8

8 that use common towel had intestinal helminths.

Another behavioural risk factors of intestinal helminthi-

asis observed was wearing of dirty long nails in 99/140

(

70.7%). Binary logistic regression model using pres-

ence of ova of intestinal helminths (infected and non-

infected) as dependent variable and behavioural risk

factors (nail biting, finger sucking, and pica) and per-

sonal hygiene (use of common towel, wearing of long

and/or dirty finger nails, frequency of body bath per day,

hand wash practices before and after meals and regular

use of footwears) as independent variable showed that

nail biting and use of common towel independently were

the significant predictors of intestinal helminthiasis in

this study (Table 2).

Infected

subjects

AGE (YEARS)

Each orphanage had a borehole which serves as source

of drinking water for all inmates. There was presence of

at least one toilet (water cistern) in each orphanage for

the inmates and another toilet (water cistern) for the staff

of the orphanage. Each toilet had flowing water from the

borehole and always had at least a tablet of toilet soap

for hand washing.

Fig 1: Age distribution of infected subjects

Eighty-four (60.0%) of the 140 subjects clean them-

1

21

selves after defeacation while 56 (40.0%) were being

cleaned by care-givers. Seventeen (12.1%) of the 140

subjects do not wash their hands after defeacation; while

in 123 (87.9%) subjects, hand washing practices were

observed by both subjects and/or their care-givers.

Prevalence of intestinal helminthiasis (47.1%) was

significantly higher among subjects (or their caregivers)

who do not wash their hands after defeacation when

compared with 17.1% observed among those who wash

2

their hands with water and soap (χ = 8.28, df = 2, p =

0

.016).

Table 2: Binary logistic regression models of predictors of intestinal helminthic infections in subjects

Behavioural

risk factors

Infected

Non-infected

β

t

O.R

p-value

Behavioural aberration

Nail biting

Finger sucking

Pica

(n = 37) 12 (32.4)

(n = 8) 2 (25.0)

(n = 1) 1 (100.0)

25 (67.6)

6 (75.0)

0 (0.0)

1.20

5.71

0.03

0.00

2.40

1.30

0.017

0.865

1.000

-0.20

24.19

11.74

Hand wash and meals

Before meals- Yes (n = 98) 23 (23.5)

No (n = 42) 6 (14.3)

After meals- Yes (n = 123) 27 (22.0)

No (n = 17) 2 (11.8)

75 (76.5)

36 (85.7)

96 (78.0)

15 (88.2)

1.06

2.51

0.08

1.84

2.11

0.113

0.780

-0.27

Use of common towel

Yes

No

Dirty finger nails

Yes

No

Finger nails trimmed

Yes

No

(n = 88) 22 (25.0)

(n = 52) 7 (13.5)

66 (75.0)

45 (86.5)

1.19

-0.40

-0.23

4.85

0.56

0.19

2.14

0.74

1.04

0.028

0.454

0.651

(n = 99) 19 (19.2)

(n = 41) 10 (24.4)

80 (80.8)

31 (75.6)

(n = 76) 16 (21.1)

(n = 64) 13 (20.3)

60 (78.9)

51 (79.7)

Number of bathing times per day

Twice daily- Yes (n = 127) 25 (19.7)

No (n = 13) 4 (30.8)

Once daily- Yes (n = 13) 4 (30.8)

No (n = 127) 25 (19.7)

102 (80.3)

9 (69.2)

-0.73

1.04

0.55

0.307

102 (80.3)

Regular Use of foot wears

Yes (n = 97) 18 (22.8)

No (n = 43) 11 (25.6)

79 (77.2)

32 (74.4)

-0.37

0.51

0.66

0.475

β = measure of how strongly each predictor variable influences the dependent variables, O.R = odds ratio, p-value

non-infected ones. These children were about two times

more likely to acquire intestinal helminthiasis compared

to children who do not posses these behavioural aberra-

Discussion

tions. This finding corroborated with those of some au-

thors who observed that behavioural aberrations are sig-

Behavioural aberration such as nail biting, finger suck-

nificant risk factors of i₅n_-₇testinal helminthiasis in chil-

ing, encopresis, and pica observed in some children have

dren who possess them. The consensus by these au-

been postulated as important risk factors that may en-

thors was that children who are in communities with

courage soil contamination by helminths ova and intesti-

poor sanitary practices and who possess these behav-

nal helminths transmission from one individual to an-

ioural aberrations as observed in this study are at higher

other especially_-c₇hildren living in closed communities or

risk of acquiring intestinal helminthia₅s_-i₇s when compared

5

in institutions. This study showed that behavioural

to those who do not possess them. Majority of the

aberrations (nail biting, finger sucking and pica) were

children had long and dirty finger nails. The helminths

significantly observed among the infected subjects than

1

22

ova can lodge under the finger nails and can then be

transmitted faeco-orally during finger sucking or nail

biting.

children living in orphanages in Benin City as well as

compare the prevalence and risks of intestinal helminthi-

asis in children living in orphanages and that of age /sex

matched children living with their parents.

Towels used by individuals are good illustration of

fomites and could be a sou₅rce of disease transmission

Limitation of study: Exclusion of Enterobius vermicu-

laris in this study due to inability to procure cellulose

tape necessary to capture the ova of the helminths for

analysis.

1

from one person to another. Majority of the children in

the orphanages use common towel to clean their body

after bathing. These towels can serve as formites since

ova of helminths can lodge into these towels and then

serve as sources for environmental contamination and

transfer of ova from one person to another. It has been

documented that disinfection of fomites in hospitals and

closed comm₆unities is an effective infection transmis-

1

sion control. Therefore, each child in the orphanages

Conclusion

should be provided with at least one towel and there

should be regular washing of these towels which could

serve as means of reducing intestinal helminths trans-

mission in the orphanages.

Use of common towel and nail biting among the chil-

dren living within the orphanages are significant risk

factors of intestinal helminthiasis. Provision of towels

for each child and regular cutting of finger nails of chil-

dren living in orphanages should be part of intestinal

helminths control in orphanages.

Highest prevalence of intestinal helminths was ob-

served in the adolescent age group. The caregivers may

have paid more attention to the younger children within

the orphanages than to the older children. Some authors

have observed that poor personal hygiene is a maj₁o₇r risk

factor of intestinal helminthiasis in this age group. Nail

biting which was observed in about one third of these

age group and poor personal hygiene in these children

could have proffered the reason for high prevalence of

intestinal helminthiasis among this age group.

Authors Contributions

Nwaneri DU: Conception and design ,collection of data,

manuscript drafting

Omuemu VO: Data analysis and Revising the

manuscript for intellectual content

Regular hand washing with soap is a u₁n₈_,i₁v₉ersal precau-

Conflict of Interest: None

Funding: None

tion that prevents disease transmission.

Hand wash-

ing after defaecation has been identified as an e_,f₅fective

3

preventive measure for intestinal helminthiasis. Lower

prevalence of intestinal helminthiasis has been observed

in children who washed their hands with water and soap

(

let. The findings observed in children who washed

their hands with soap and water in this study is in conso-

or _,t₅hose whose care-givers do so) after using the toi-

3

Acknowledgment

3

nance with those observed by Wagbatsoma et al in

2

008 among primary school children in Egor District,

The authors wish to thank Mr and Mrs Onuigbo Testi-

mony who participated in sample collections. Special

thanks to Mr. Oladipo, the laboratory scientist in Depart-

ment of Child Health Research Laboratory, University

of Benin Teaching Hospital, Benin City for his assis-

tance in stool analysis for ova of helminths.

Edo Nigeria. The above assertions perhaps attest to the

efficacy of soap as an important agent in₁₉hand washing

practices against intestinal helminths ova.

Ascaris lumbricoides and Trichuris trichiura were the

intestinal helminths isolated in this study. Absence of

hookworm could be attributed to regular use of foot-

wears to school or in the play ground within the orphan-

ages. Studies have shown that children who do not wear

footwears regularly to school, playgrou₂n_,₃d_,₄_,o₂₀r farm are at

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