Effects of intestinal parasitic infections on nutritional status of primary children in Imo State Nigeria

Introduction A cross-sectional study was conducted between the months of April to October 2015, to determine the effects of intestinal parasitic infections (IPIs) on nutritional status of school age children in Owerri and Orlu geographical zones, in Imo State, Nigeria. Methods Faecal samples were examined using Kato Katz method and formol-ether concentration techniques, while blood samples were examined using cyamethahaemoglobin method. Anthropometric indices were used as indicators of nutritional status, children whose Height-for-Age, Weight-for-Age and Weight-for-Height were <-2 standard deviation (SD) were classified as stunted, wasted, and underweight respectively. Results Total prevalence rate of 16.6% was recorded in the study areas with Ascaris lumbricoides (4.0%), Trichuris trichiura (0.6%), Hookworm (1.0%) Taenia sp (0.3%), Entaomeba histolytica (5.3%), Entamoeba coli (2.7%) and Giardia lambia (2.7) Majority (73.4%) of the children had light intensity. Anthropometric study results showed that 79(31.3%) of the children were malnourished. The prevalence of stunting, under-weight and wasting were higher in uninfected (86.1%, 90.0% and 10%) respectively than in infected children (13.9%, 10.0% and 0.0%) respectively, although not significant at p = 0.857, 0.587 and 0.368 respectively. Prevalence of anaemia was 17.4%, anaemia was insignificantly (p = 0.09) higher in infected (21.1%) than in uninfected (16.5%) children. Children that had co-infection recorded higher prevalence (2.2%) of severe anaemia. There was an association (p = 0.002) between anaemia and intensity of helminth infection. Malnutrition was insignificantly (p = 0.319) higher in children with heavy (100.0%) and moderate (75.0%) intensity of helminth infection than children that had light intensity (41.7%) of helminth infection. Conclusion When compared with previous study, there were decline in the prevalence of intestinal parasitic infections and anaemia among school age children. Low intensity parasitemia with intestinal parasites had no significant effect on the malnutrition and haemoglobin profile of the children in the study areas. Therefore, improved sanitation and more deworming efforts should be intensified to ensure further decline in prevalence of intestinal parasitic infections.


Introduction
Intestinal parasitic infections (IPIs) have continued to pose serious medical and public health problem in developing countries, these infections constitute a global health burden causing clinical mortality in 450 million people, especially in children [1,2]. An estimation by WHO [3] showed that Ascaris lumbricoides, hookworm and Trichuris trichiura infect 1,450 million, 1,300 million and 1,050 million people worldwide, respectively, while intestinal schistosomiasis affects over 200 million people. Outside morbidity and mortality caused by these parasites, infections with intestinal parasites have been associated with stunting, physical weakness and low academic performance of schoolchildren [3]. Intestinal parasitic infections cause decreased intake in the body's nutrient requirement by their interface with absorptive surfaces, physical obstruction of intestinal lumen, production of proteolytic substances and consumption of nutrients intended for body [4,5]. The impact of intestinal parasitic infections is more on children due to their vulnerability to nutritional deficiencies [1,6]. The poor people in developing countries experience a cycle where under nutrition and repeated infections lead to excess morbidity that can continue from generation to generation [7].

Methods
Study area: the study was conducted in two zones in Imo State Nigeria in 2015. Imo State is located in South Eastern part of Nigeria.
It lies within latitudes 4°45'N and 7°15'N, and longitudes 6°50'E and 7°25'E, with an area of about 5,100 km 2 . The average annual temperature is above 20°C (68.0°F) which creates an annual relative humidity of 75%, with humidity reaching 90% in the rainy season.
These areas experience dry season from December to March and Harmattan commences from late December to late January ( Figure 1). Ministry of Health. Ethical considerations were applied by issuing of results of laboratory analysis to parents. Samples and data from participants were identified with codes and participants were assured of the confidentiality of data collected. The objective of the study was explained to the teachers and parents/guardians of participants, and written informed consent was sought from parents or guardians of selected pupils before commencement.
Sample and sampling technique: the sample size was determined using Daniel [8] statistical formula for determination of sample size using prevalence population. One thousand two hundred pupils within the ages of 5-13 years were selected through a random process, (six hundred pupils from each zone) for determination of prevalence of anaemia. Simple random sampling method was also used to select three hundred (300) pupils (150 pupils from each zone) from the already selected 1200 pupils to determine the prevalence of intestinal parasitic infections and anthropometric studies. Pupils with history suggestive of common childhood chronic illness such as sickle cell anaemia, human immunodeficiency virus (HIV) were excluded from the study in accordance with the works of Saloojee and Cooper [9]. Anthropometric measurement: anthropometric measurements of the pupils were carried out by a method described by WHO [10]. The subjects were weighed barefooted and in light clothing on a bathroom scale accuracy of 0.1kg. The scale was standardized before use with 11kg weight. Height was measured to the nearest 1cm, with a paper stadiometer attached to a vertical wall. Subjects stood barefooted with their scapula, buttocks and heels' resting against a wall, the neck was held in a natural non-stretched position and the heels were touching each other. Nutritional status indicators were classified and standardized into Z-scores for height-for-age (HAZ), weight-forheight (WHZ) and weight-for-age (WAZ) in EPI Info (version 3.2), relative to the WHO reference curves recommended for international use WHO [10]. Nutritional assessment of children was evaluated using the World Health Organization [11] recommended HC -for-age specific z-score cut-off value. Moderate under nutrition: <-2 standard deviation (SD) z-score value while severe under nutrition: <-3 standard deviation (SD).
Data analysis: the quantitative data was analyzed using Statistical Package for Social Sciences (SPSS) version 15 software package. Data generated were sorted into categories and observations and analyzed by using simple frequency tables and percentages, analysis and Chisquare and at level of significance P< 0.05, were employed to test relationships and differences. Table 1 showed that the total prevalence of Intestinal parasitic infections in the study was 16.5%. A total of seven (7) intestinal parasites were reported in the study area. The most prevalent intestinal was E. histolytica(5.3%) followed by A.lumbricoides (4.0%), while the least prevalent was Taenia spp (0.3%). As shown in Table 2, light infection with intestinal helminthes predominated in the study areas, A. lumbricoides 75.0%, Trichuris trichiura 50.0% and Hookworm 66.7%. Heavy intensity was only recorded in a child infected with A. lumbricoides (8.3%) Table 3 shows prevalence of malnutrition in the 300 children used for anthropometric study. The prevalence of stunting (under-height) was 26.0%. Twelve (12) children (4.0%) were under-weight while 4(1.4%) had wasting. As shown in Table 4, the prevalence of severely under-height was higher in non-infected (86.1%) than in infected children (13.9%).

Results
Similarly, the prevalence of moderately under-height was higher  Table 5, the total prevalence of anaemia in infected and noninfected children was 17.4%. The prevalence of anaemia was higher (21.1%) in infected children than in non-infected children (16.5). At P = 0.098, there was no significant difference between anaemia in infected and non-infected children. Table 6 shows that out of 232 infected children, 49 (21.1%) had anaemia, 29 (12.5%) mild, 19(8.2%) moderate and 1 (0.4%) severe. Severe anaemia was only reported in children with double infection (2.2%). As shown in Table 7, the least prevalence (41.7%) of malnutrition was recorded among children with light intensity of intestinal helminth infection.
Only a child recorded heavy intensity and the child had poor nutrition.
However, at (p-value = 0.319) there was no association between prevalence of malnutrition and intestinal helminth infection.

Discussion
Many authorities have linked intestinal parasitic infections (mostly helminthes) with an increased risk for nutritional anaemia, proteinenergy malnutrition and growth deficits in children, low pregnancy weight gain and intrauterine growth retardation followed by low birth weight [6,12]. Mechanisms by which intestinal parasitic infections may cause malnutrition exist and these include; impaired nutrient absorption reduction of appetite and resulting infection [4]. In this study, the total prevalence of intestinal parasitic infections was 16.7%, which is low when compared with prevalence of 47.7% reported by Udensi et al. [13] in Imo State. In two States in Nigeria, Thomas et al. [14] and Orji [15] reported prevalence of 17.75% and 18.0% in Chikun, Kaduna State and Uli community in Anambra State, respectively. The low prevalence reported in this study could be due to the efforts of Imo State Government as the time of the study to reduce child mortality, through improved sanitation, free mass drug administration in different Health Centres, improved personal hygiene through construction of classrooms with modern toilets and sinking of bore-hole water in majority of the schools in urban areas of Imo State. Prevalence of malnutrition (31.3%) observed in the present study was in line with 24% prevalence reported by Amuta et al. [16] and 30.0% prevalence reported by Opara et al. hence, it is possible that most of the subjects had acute infection, which is less likely to affect weight and growth in children [20]. Low intensities of intestinal parasitic are known to cause minimal or no clinical impact [20]. Stephenson et al. [4] suggested that relationship between helminth infections and nutritional status of young children in a population should be over looked in communities where the prevalence is below 20%. This study suggested that reduction in growth (weight and height) was not associated with intestinal parasitic infection in the study area; it could be due to other health problems and poverty.
The total prevalence of anaemia among infected and non-infected children was 17.4%. Anaemia was insignificantly higher (P=0.098) in infected children than non-infected children. This was in conformity with the study conducted by Orji [15], in Uli, Ihiala Local government Area, Anambra State. The total prevalence of anaemia in infected children was 21.1%. This prevalence was lower when compared with 50% prevalence reported by Ehiaghe et al. [21], in infected children     Table 4: anthropometric measurement of infected and non-infected children Table 5: prevalence of anaemia in infected and non infected children Table 6: prevalence of anaemia in infected children with respect to number of parasites species Table 7: relationship between varying intensity of helminth iInfection, malnutrition and anaemia