Journal of The Academy of Clinical Microbiologists

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 23  |  Issue : 1  |  Page : 29--33

Prevalence of intestinal parasites in the patients with suspected gastrointestinal infections


Upninder Kaur, Taruna Kaura, Sofia Rani, Rakesh Sehgal 
 Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Rakesh Sehgal
Department of Medical Parasitology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India

Abstract

BACKGROUND: Intestinal parasitic infections (IPIs) are considered a serious public health problem worldwide, particularly in developing countries. It is important to study the trend distribution of IPIs in a particular community. The prevalence rate of intestinal parasites in the present study was undertaken in patients who were reported with suspected gastrointestinal infections at PGIMER, Chandigarh, from May 2013 to April 2017. MATERIALS AND METHODS:A four-year study was conducted in which all the suspected patients having gastrointestinal infections attending both Nehru Hospital and Outpatient Department attached to Post-Graduate Institute of Medical Education and Research, Chandigarh, were analysed for IPIs at Department of Medical Parasitology, PGIMER, Chandigarh. Direct microscopic examination of stool samples was done using saline and iodine preparations. RESULTS: 1042/2404 samples were found to be positive for intestinal parasites. The predominant parasite isolated was Giardia lamblia with a prevalence rate of 68.9% followed by Entamoeba histolytica (14.9%). The present study showed preponderance of males (69.2%) than females (30.7%). The most affected age group varied with the type of IPI and maximum cases were observed in monsoon period. CONCLUSIONS: The epidemiological studies of these parasites are necessary for effective prevention and control strategies. More surveillance studies, therefore, should be planned to establish the exact proliferation and prevalence of intestinal parasites in a particular region.



How to cite this article:
Kaur U, Kaura T, Rani S, Sehgal R. Prevalence of intestinal parasites in the patients with suspected gastrointestinal infections.J Acad Clin Microbiol 2021;23:29-33


How to cite this URL:
Kaur U, Kaura T, Rani S, Sehgal R. Prevalence of intestinal parasites in the patients with suspected gastrointestinal infections. J Acad Clin Microbiol [serial online] 2021 [cited 2022 Jan 27 ];23:29-33
Available from: https://www.jacmjournal.org/text.asp?2021/23/1/29/326050


Full Text



 Introduction



Intestinal parasitic infections (IPIs) are ubiquitous in humans, both in urban and rural environments from tropical and subtropical countries.[1] The World Health Organisation (WHO) ranks diarrhoeal disease as the second most common cause of morbidity and mortality in children in the developing world.[2] Diarrhoeal disease is a major cause of morbidity and mortality worldwide, particularly in developing countries where poor sanitary and hygienic conditions exist.[3],[4],[5],[6] The common parasitic causes of acute diarrhoea are the intestinal protozoans of which Entamoeba histolytica, Giardia lamblia and Cryptosporidium species are considered the most important.[7]

Approximately 10% of the world population are infected by the closely related parasites: E. histolytica, Entamoeba dispar and Entamoeba moshkovskii. E. histolytica, an enteric protozoan parasite causing amoebiasis, is one of the major causes of morbidity and mortality and an important public health problem in developing countries.[8] It is an aetiological agent of amoebic dysentery and amoebic liver abscess,[9] whereas E. dispar and E. moshkovskii are non-pathogenic commensal species that are morphologically identical to E. histolytica.[10],[11] E. moshkovskii has been reported for the first time in India.[12] The WHO estimates that approximately 50 million people worldwide suffer from invasive amoebic infection each year, resulting in 40,000–100,000 deaths annually.[13],[14],[15] It is a worldwide infection that is commonly found in tropical and subtropical countries.[16],[17] Giardia intestinalis is the most common protozoan infection of the intestinal tract worldwide. G. lamblia is considered as one of the main non-viral causes of diarrhoea in developed countries.[18] Cryptosporidium, an important cause of diarrhoea, has been reported worldwide both in immunocompetent and immunocompromised individuals such as HIV patients[19],[20] and has emerged as a serious public health problem which can be associated with chronic, potentially life-threatening diarrhoea.[21] In developing countries, Cryptosporidium spp. infections occur mostly in children younger than five years of age, with a peak in children younger than two years of age.[22],[23] E. histolytica, G. intestinalis and Cryptosporidium spp. are not only three of the most important and common diarrhoea-causing parasitic protozoa, but they often have similar clinical presentations.[24]

Detection of trophozoites, cysts or oocysts in fresh or preserved stool specimens using microscopy (ova and parasite examination [O and P]) is the most common method of diagnosis particularly in resource-limited countries.

In the present study, a four-year study was planned so as to determine the prevalence of intestinal parasites in the patients with suspected gastrointestinal infections from May 2013 to April 2017 at PGIMER, Chandigarh.

 Materials and Methods



The present study was planned to study all the suspected patients having gastrointestinal infections attending both Nehru Hospital and Outpatient Department (OPD) attached to Post-Graduate Institute of Medical Education and Research, Chandigarh, being sent for screening at Department of Medical Parasitology, PGIMER, Chandigarh. The study has been approved by the Institutional Ethics Committee of the Institute.

Subjects and sample collection

Hospital based

Stool samples from 2404 patients suspected to have gastrointestinal infections attending both Nehru Hospital and Gastroenterology OPD at Post-Graduate Institute of Medical Education and Research, Chandigarh, were received in the Department of Medical Parasitology for routine diagnosis.

Sample collection

Collection of samples was done in sterile containers, carefully labelled and sent to the Routine Diagnostic Laboratory of the Department. Specimens were identified.

Macroscopic examination

Samples were initially examined for colour, consistency, the presence of mucous and blood and any adult worms.

Direct examination

Stool samples were examined by normal saline and the protozoan parasites were detected by using iodine.

Informed written consent was also obtained from all the subjects.

Processing

Direct examination by microscopy

The collected stool samples were examined for the presence of cyst and/or trophozoite of Entamoeba species, G. intestinalis and Cryptosporidium parvum by the following methods, respectively:

Wet smear examination and concentration technique[25]Antigen detection for differentiation of E. histolytica and E. disparModified acid-fast stain also known as Modified Ziehl − Neelsen technique[26] for Cryptosporidium oocysts.

For the negative samples, two subsequent stool samples from each patient were taken.

Analysis of data

The data were analysed yearly for IPIs. Parasite prevalence was studied per year, season, sex and age wise.

 Results



A total of 2404 individuals participated in the present study. Participants were stratified by age and gender. The study population was characterised predominantly by adults. Overall, 1042 (43.3%) participants out of 2404 [Figure 1]a were infected with at least one enteric parasite. Among the total parasites, the predominant intestinal parasite was G. lamblia (68.9%) followed by E. histolytica (14.9%), Entamoeba coli (3.5%), Iodamoeba butschlii and Strongyloides stercoralis (2.9%), Microsporidia (2.8%), Cryptosporidium (1.9%), Hymenolepsis nana (0.9%) and Iodamoeba belli and Enterobius ova (0.1%), as depicted in [Figure 1]b. Only five patients with double parasite infestation were recorded. Out of five, two patients had E. histolytica + I. butschlii infection and single patient each had E. histolytica + E. coli, E. coli + I. butschlii and G. lamblia + Cryptosporidium, respectively [Figure 1]b.{Figure 1}

When the year wise distribution of different intestinal parasites was studied, Giardia was found to be the most prevalent during all years of the study period [Figure 2]. The prevalence of parasites in males and females was also calculated. The result showed that males harboured more proportion of infections as compared to females [Figure 3]a. Overall, 69.2% of males were infected as compared to 30.7% of females. E. histolytica showed 69.2% in males, whereas in females, it showed 31%, followed by G. lamblia (71%), E. coli (62.1%), aI. butschlii (58%), S. stercoralis (48.3%), Microsporidium (73.3%) and Cryptosporidium (65%) in males, whereas in females, less number of cases were reported as E. histolytica (31%), G. lamblia (29.2%), E. coli (37.8%), I. butschlii (42%), S. stercoralis (51.6%), Microsporidium (26.6%) and Cryptosporidium (35%).{Figure 2}{Figure 3}

In addition to this, the age prevalence profile of the intestinal parasites was also studied. In the present study, the most common intestinal parasite G. lamblia was found to be more prevalent in children and teenagers with 0–5 and 6–10 age groups, while it showed decreasing profile in old age group 46–50 to >60. The second dominant parasite E. histolytica was higher in 21–25 and 26–30 age groups. The parasites E. coli, I. butschlii and Cryptosporidium were found aggregated in all age groups [Figure 3]b. E. ova was completely absent in all the other age groups except in middle age groups, namely 36–40 and 41–45 years, whereas H. nana was found completely absent from above 30 years age group. S. stercoralis was recorded in almost all age groups with slight dominance in 0–5 age group, while no case of Microsporidia was recorded in children/teenagers.

Regarding seasonal prevalence, the cases were compared in pre-monsoon, monsoon and post-monsoon period. In three years (2014–2016), more cases were recorded in monsoon period (from May to September) followed by pre-monsoon period as compared to post-monsoon period [Figure 4].{Figure 4}

 Discussion



IPIs are among the major public health problems in developing countries. It has been observed that distribution and prevalence of the various intestinal parasites species depend on the social, geographical, economical and inhabitant customs. IPIs are linked to the sanitary habits, and moreover, there is no availability to safe potable water and poor hygiene conditions.[27] In the present study, out of 2404 stools examined, 1042 were found to be positive for intestinal parasites. They attended the OPD and Nehru Hospital, PGIMER, Chandigarh, and were referred from there to the Department of Medical Parasitology for routine stool examination for detection of ova, cysts and adult forms of several parasites. Out of the 1042 cases, 1037 cases were found to be positive for one parasite and five patients had dual parasitic infections. The rate of infection was found to be higher in males (69.2%) as compared to female (30.7%) patients. In a study in a tertiary hospital located in Central India, 1004 (13.9%) samples out of total 7215 were found to be positive for one parasite, and moreover, the rate of infection was found to be higher in males (15.6%) as compared to females (12%).[28] Similarly, in a two-year retrospective study in a hospital at Bihar, majority of infections were because of single parasite as compared to dual and triple infections.[29] Here also, more males (59.4%) than females (40.5%) were found to be infected. E. histolytica was predominant of all cases followed by G. lamblia 216 (25.99%).

In the present study, 1042 confirmed cases were recorded with ten different parasites. G. lamblia (68.9%) was found to be predominant parasite followed by E. histolytica (14.9%). In a five-year trend prevalence carried out at Poly Health Center Gondar, Northwest Ethiopia, out of 13,329/5510 (41.3%) stool samples were found to confirmed cases for intestinal parasites.[30] From ten different parasites recorded E. histolytica/dispar (16.8%) was recorded as dominant parasite followed by G. lamblia (11.4%). Here, both males (49%) and females (51%) were found to be equally affected (P = 0.14).

In another study carried out in the Department of Microbiology, AIIMS, Jodhpur, India, from September 2014 to April 2016, a total of 968 stool samples were collected.[31] Out of 968 cases, 158 (16.3%) were found to be infected with either a parasite or a commensal or both. The most common protozoa isolated was E. histolytica (37.57%) followed by G. lamblia (23.12%). It is studied that the rate of IPIs was more in females than males (0.38%). This is so because females are more prone to the infective stages because of the nature of the household works they perform.[27]

The most affected age group in the present study varied with the type of parasitic infection. The dominant intestinal parasite G. lamblia was found to be more prevalent in children with 0–5 and teenagers with 6–10 age group, while the second prevalent parasite E. histolytica was higher in 21–25 and 26–30 age groups. Similar findings were reported in which the overall prevalence of IPIs was 48% (49/102), while the predominant parasites were G. lamblia at 37% (37/102) and the infection rate was highest in children less than four-year-old.[32] In another study in district Anantnag of Kashmir Valley, the prevalence rate was significantly higher in case of male children (10.4%) as compared to females (6.29%).[33] The most affected age group was 5–8 years (13.7%) and least 13–15 years age group (3.88%). Similarly, it was also found all age groups to be affected, but the highest and the lowest prevalences were reported from age groups of 20 − 29 years to 40 − 49 years, respectively.[34] Maximum E. histolytica cases in age groups of 31–40 years positively correlated with our present findings. In another study, prevalence and seasonal variation of human intestinal parasites was carried out in patients attending hospital with abdominal symptoms in Northern Jordan.[34] A total of 21,906 stool samples were collected in a study of four years, out of which 9611 samples tested positive for parasitic infection (44%). G. lamblia was the most prevalent parasite (41%), followed by E. histolytica (31%) and E. coli. The prevalence of different parasites varied in different seasons: on average, the summer months (June–September) showed the highest incidence of parasitic infection (62%), with a peak in September, compared with the winter months (November–February) (16%). In the present study, IPI and seasonality relationship was evaluated. In our results also, maximum cases of IPIs were observed in monsoon period i.e. from June to September. There was less prevalence of infection in winter season. The reason for the more prevalence of infection in summer season is attributed to the number of factors such as temperature and humidity which affect the transmission of parasitic infections.[27]

 Conclusions



Prevalence of IPIs is low in the present study. This depicts that living conditions and hygiene practices are improved. Due to improvements in epidemiological surveillance and the systematic management of populations, the prevalence of parasitic infections is currently very low. This is because of the efforts of the healthcare authorities in the region. The most common intestinal parasite found was Giardia. Rate of infection is higher in males as compared to the females. There was high prevalence of infection in monsoon period as compared to post-monsoon period. Therefore, in addition to drink and food safety, health education related to hygiene education targeting both primary group (household, children, women, men etc.) and secondary group (people involved in control programme) should be imparted to inculcate the awareness among society. Epidemiological surveillance is must keeping in mind the consequences and health burden due to infections related to parasites.

Acknowledgement

We duly acknowledge SERB (DST), New Delhi, for providing financial assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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