The Prevalence of Intestinal Parasitic Infections …applications.emro.who.int/imemrf/Saudi_J_Med_Med_Sci/Saudi_J_Med...The Prevalence of Intestinal Parasitic Infections Among Foreign

Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 2 | May 2015 | 112-117112

The Prevalence of Intestinal Parasitic Infections Among Foreign Workers in Madinah, Kingdom of Saudi Arabia

Naglaa F.A. Imam, Zakeya B. Abdulbaqi1, Rawan A. Fahad2

Medical Laboratories Technology Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Kingdom of Saudi Arabia and Faculty of Medicine, Cairo University, Egypt, 1College of Medicine, 2Medical Laboratories Technology Department, Taibah University, Madinah, Kingdom of Saudi Arabia

Correspondence: Dr. Naglaa Fouad Abbas Imam, Faculty of Applied Medical Sciences, Taibah University, Madinah, Kingdom of Saudi Arabia. E-mail: [email protected]

INTRODUCTION

Intestinal parasites (IPs) are the most prevalent infections causing significant morbidity and mortality in developing and tropical countries. Moreover, IPs are the most common infections that contribute significantly to enteric diseases in both normal and immunocompromised

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DOI:10.4103/1658-631X.156414

A B S T R A C T

Background: The Kingdom of Saudi Arabia has a high number of foreign workers, especially those coming from endemic areas with intestinal parasites.

Objective: The aim of this study was to determine the prevalence of parasitic infection among foreign workers in Madina, Kingdom of Saudi Arabia.

Materials and Methods: There was direct microscopic examination of stool samples by wet smears for parasitic stages. This was followed by the formalin-ethyl acetate concentration technique to confirm and detect parasites not recovered by the wet mount.

Results: The total number of foreign workers was 120, 47.5% of whom were males and 52.5% females. They were within the age group of 20-60 years. A total of 53 cases (44.2 %) were infected with IPs. Some samples had double or triple infections, with a total of 69 parasitic infections detected (57.5%). These included Entamoeba histolytica (27.5%), Giardia lamblia (18.8%), hookworm (14.5%), Ascaris lumbricoides (11.6%), Entamoeba coli (7.2%), Trichuris trichiura (5.8%), Strongyloides stercoralis (5.8%) and Hymenolepis nana (4.3%). Furthermore, 1.4% each of Enterobius vermicularis, Schistosoma mansoni and Taenia eggs were found.

Conclusion: Foreign workers newly arrived from Asia and Africa carry high rates of IPs infection. It is necessary to increase awareness about occupational health, and the risks of parasite transmission to the local population. Moreover, strict adherence to infection prevention policies is recommended.

Key words: Community health, foreign workers, intestinal parasites, Madinah, Saudi Arabia

ملخص البحث :هدفت هذه الدراسة المقطعية لتحديد معدل انتشار الطفيليات المعوية لدى العمال االجانب في المدينة المنورة بالمملكة العربية السعودية. وقد تم الفحص المجهري للبراز والذي بين أن %44.2 من العمال مصابون بالطفيليات المعوية. شملت أنواع الطفيليات األميبا )%27.5(, الجارديا

)%18( الدودة الخطافية )%14.5( دودة االسكارس )%11.6( أي كوالي )%7.21( ، الترايكيورس )%5.80( خلصت الدراسة إلى أن العمال الجدد من قارتي أسيا وأفريقيا مصابون بالطفيليات المعوية بمعدالت عالية، لذا يصبح من الضروري رفع الوعي الصحي بمخاطر انتقال الطفيليات

إلى السكان المحليين لتفادي انتقال العدوى لهم مع الحرص على تطبيق التدابير الوقائية.

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Imam, et al.: Prevalence of intestinal parasitic infections

113Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 2 | May 2015

patients worldwide. The high rates of prevalence in some communities are usually attributed to inadequate hygiene, environmental contamination and occupational risks. The prevalence rate of infections correlates directly with the level of sanitation and adherence to infection prevention and control standards.[1]

The World Health Organization (WHO) estimated that more than 2 billion people are infected with schistosomiasis and soil-transmitted helminthes (STH) worldwide, of which more than 300 million suffer from associated severe morbidity. STH infections are widely distributed in tropical and subtropical areas, especially in poor populations and these constitute the major source of foreign workers (FW) who come to the Kingdom of Saudi Arabia (KSA).[2]

It is noteworthy that with the rapid socioeconomic development in recent years and the improved standards of living in KSA, there has been a large influx of FW with high rates of IPs from developing countries. This influx evidently brings with it the risks of disease transmission to the public.[3]

Therefore, in order to avoid disease transmission, the Saudi Ministry of Health and the Ministry of Interior require that FWs must be infection-free and physically fit. This is because most of the workers are housemaids, food-handlers, cooks and housekeepers in various private and governmental sectors. All FWs should be screened within 90 days of arrival and followed annually in order to renew their residency permits. This is done through free medical check-ups and screening for infectious diseases, including IPs. The screening techniques for IPs involve laboratory tests, using fresh saline and iodine stool preparations.[4]

Diagnosis of IPs is confirmed by microscopic recovery of protozoan trophozoites and cysts, helminthes eggs and larvae in the clinical parasitology laboratory. Due to the possibility of the low density of parasites in stool samples, direct microscopy is basically useful for the observation of motile trophozoites, but is not recommended solely for the detection of other stages. Needless to say, it is essential to increase the probability of finding the parasites by the concentration method to obtain an accurate diagnosis.[5,6]

MATERIALS AND METHODS

Prospective data collection on stool samples of FW from Asia and Africa was done at the central lab of the Medical Check-up and Report Center in Madinah, KSA. This was performed over a period of 2 months by students of the College of Applied Medical Sciences, Taibah University,

in the second semester of the academic year 2012. The study was approved by the College Research Ethical Board. Consent of the participants was also obtained.

A total number of 120 samples were collected and examined. Microscopic examination of wet mount preparations was carried out,[7] followed by the formalin-ethyl acetate concentration method. This made possible the detection of small numbers of organisms missed using a direct wet smear.[6]

RESULTS

In the present study, there were 57 (47.5%) males and 63 (52.5%) females whose ages ranged between 20 and 55 years, with a mean age of 36 years ±5.23 for the males, and 29 years ±3.47 for the females. The participating FW were from a variety of countries such as Kenya, Chad, Nepal, Egypt, Sudan, Morocco, among others. They were mostly housemaids and drivers [Table 1].

Eleven species of IPs (eight helminthes and three protozoa) were identified, with an overall prevalence of 53 (44.2%), out of 120 FW. The predominant parasite

Table 1: Sociodemographic characteristics of studied casesCharacteristics n (%)Sex

Male 57 (47.5)Female 63 (52.5)

NationalityEgyptian 13 (10.8)Sudanese 12 (10)Indonesian 4 (3.3)Pakistani 7 (5.8)Ethiopian 46 (38.3)Indian 22 (18.3)Sri Lankan 10 (8.3)Kenyan 3 (2.5)Chadian 1 (0.8)Nepali 1 (0.8)Moroccan 1 (0.8)

Type of workDriver 32 (26.6)Housemaid 62 (51.6)Drover 11 (9.1)Farmer 11 (9.1)Others 4 (3.3)

Mean ageMale 36Female 29



Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 2 | May 2015 114

was Entamoeba histolytica, which was observed in 19 samples (27.5%), followed by Giardia lamblia in 13 samples (18.8%), 10 for hookworm (14.5%), eight for Ascaris lumbricoides (11.6%), 5 for Entamoeba coli (7.2%), 4 (5.8%) for each of Trichuris trichiura and Strongyloides stercoralis, 3 for Hymenolepis nana (4.3%) and 1 (1.4%) for each of Enterobius vermicularis, Schistosoma mansoni and Taenia [Figure 1].

Of the study subjects, 39 (32.5%) had a single infection, 12 (10%) had double, and two (1.7%) had triple infections [Table 2]. Of the 53 positive cases, the majority of mixed infections were in the females (13 cases, 24.5%), compared to males (1 case, 1.9%) [Table 3]. This was found to be statistically significant P < 0.05.

As for double and triple infections [Table 4], each of these combinations: (Hookworm and S. stercoralis) and (hookworm and E. coli), was found in two subjects. The remaining patterns of mixed infections were each detected in a single participant.

In this study, 38 (55.1%) of IPs were found in FWs from Ethiopia [Table 5]. These were followed by 14 (20.3%) from India, five, (7.2%) from Sri Lanka, four (5.8%) from Sudan, three (4.3%) from Egypt and two (2.9%) from Pakistan. Indonesian subjects were parasite free.

Finally, Figures 2 and 3 show microscopic pictures of some parasitic stages detected and photographed in the study.

DISCUSSION

Foreign workers, mainly Asians and Africans, come from areas where IPs are a major health problem. Consequently, they may pose a potential public health threat.[8]

Figure 1: Prevalence of parasites detected in the study cases

Table 2: Patterns of infection of study casesPatterns of infection Infected cases n (%)Single infection 39 (32.5)Double infection 12 (10)Triple infection 2 (1.7)Total number of infected cases 53 (44.2)Total sample 120 (100)

Table 3: Patterns of combined infections according to genderGender Single Double TripleFemale 18 11 2Male 21 1 0

Table 4: Common patterns of parasitic infections among study casesPatterns of infection

Detected parasites Number of patients

Double infection

Hookworm+S. stercoralis 2Hookworm+E. coli 2A. lumbricoides+E. histolytica 1E. histolytica+hookworm 1Hookworm+E. vermicularis 1Hookworm+G. lamblia 1G. lamblia+H. nana 1T. trichiura+S. stercoralis 1E. histolytica+G. lamblia 1A. lumbricoides+S. mansoni 1

Total positive double infection

12

Triple infection Hookworm+T. trichiura+A. lumbricoides 1T. trichiura+E. histolytica+G. lamblia 1

Total positive triple infection

2

T. trichiura – Trichuris trichiura; A. lumbricoides – Ascaris lumbricoides; E. vermicularis – Enterobius vermicularis; S. stercoralis – Strongyloides stercoralis; S. mansoni – Schistosoma mansoni; H. nana – Hymenolepis nana; G. lamblia – Giardia lamblia; E. histolytica – Entamoeba histolytica; E. coli – Entamoeba coli

Previous studies carried out on FW in KSA reported different prevalence rates of IPs. These were up to 55.7% in Riyadh,[9] 40.3% in Jeddah[10] and 46.5% in Abha.[11] Generally speaking, the prevalence of parasitic infections among expatriates was found to be higher than in Saudi patients.[9,10] As for Madinah, a study done on food-handlers reported a 14% prevalence of IPs.[12]

In this study, the number of infected individuals was 53, including double or triple infections, in the same person. Hence, the total number of parasitic infections detected amounted to 69 in the enrolled FW. It was found that infection was more prevalent in the younger age group, (between 25 and 29 years). This is in agreement with a




study in India, which reported that the highest rate of Ascaris and hookworm infections were in those aged 26-30 years.[13]

Infection rates were higher among females than males (31 out of 63: 49.2% and 22 out of 57: 42.1%, respectively). Previously, a study reported an IPs infection

rate of 92.3% among female subjects.[14] This may imply that females are more exposed to parasitic infective stages, due to the nature of the chores they perform in the house and their lifestyle.

Apart from direct wet smear, a sedimentation concentration technique was used to increase the chances of not missing

Table 5: Distribution of parasites according to nationalitiesParasite Nationaliy Total

Egyptian Sudanese Indonesian Pakistani Ethiopian Indian Sri Lankan OthersHookworm 0 0 0 0 6 2 1 1 10Taenia 0 0 0 0 1 0 0 0 1T. trichiura 0 0 0 0 1 0 2 1 4A. lumbricoides 0 0 0 1 3 3 1 0 8E. vermicularis 0 0 0 0 1 0 0 0 1S. stercoralis 0 0 0 0 2 1 1 0 4S. mansoni 0 0 0 0 1 0 0 0 1H. nana 0 1 0 0 1 1 0 0 3G. lamblia 2 1 0 0 6 4 0 0 13E. histolytica 1 2 0 1 11 3 0 1 19E. coli 0 0 0 0 5 0 0 0 5Total number for each nationality 3 4 0 2 38 14 5 3 69Percentages 4.3 5.8 0 2.9 55.1 20.3 7.2 4.3 100T. trichiura – Trichuris trichiura; A. lumbricoides – Ascaris lumbricoides; E. vermicularis – Enterobius vermicularis; S. stercoralis – Strongyloides stercoralis; S. mansoni – Schistosoma mansoni; H. nana – Hymenolepis nana; G. lamblia – Giardia lamblia; E. histolytica – Entamoeba histolytica; E. coli – Entamoeba coli

Figure 3: Parasitic stages detected in the study (a) Taenia egg (b) Strongyloides stercorlais larva (c) Hymenolepis nana egg (d) Giardia lamblia cyst (e) Entamoeba coli cyst (f) Entamoeba histolytica cyst pictures of helminthesæ ova (×100), while that of protozoa (×400).

a b

e f

c d

Figure 2: Parasitic stages detected in the study (a) Ascaris lumbricoides egg (b) Enterobius vermicularis egg (c) Ancylostoma duodenale egg (d) Trichuris trichiura egg (e) Schistosoma mansoni egg.

a b

e

c d



Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 2 | May 2015 116

any parasitic stages in the examined samples.[15,16] Indeed, the value of concentration techniques, especially for the detection of protozoa, was underpinned by the results of this study. By wet mounts, the total number of detected helminths and protozoa was 57. However, using the concentration method the number increased to 69, because 12 more infections with protozoa were detected.

There was a close relationship between the nationality and the type of parasites detected. Helminthes, especially STH, were found to be more prevalent among Ethiopians, followed by Indians and Sri Lankans. For instance, hookworms were found in 15.8% of the Ethiopians. This was similar to the study done in Ethiopia, where the prevalence of infection with hookworm was 17.5%. Also, in that study, the rate of Trichuris infection was 60% and Ascaris 40.9% of the patients.[17] However, in this study, much lower rates of 0.3% and 7.9% were found, respectively, for the two last parasites in Ethiopians. This may be related to demographic differences in the tested subjects.

Of helminthic infections in Indian participants, 21.4% were positive for Ascaris, 14.2% for hookworm and 7.14% for H. nana. This result differed from those of the study done in India that found the following infection rates: Ascaris; 2.5%, hookworms; 2.4% and H. nana 9%.[18] As previously stated, a higher prevalence rate of H. nana is associated with poor personal hygiene. Furthermore, eating street food leads to more infections with such parasites as A. lumbricoides and T. trichiura.[19] Indeed, the positive cases found in this study came from areas where there is little practice of hygiene , and people often consumed food prepared by street sellers.

Regarding protozoal infections in this study, they were found to be more prevalent among Ethiopians, followed by Indians, Sudanese and Egyptians. G. lamblia and E. histolytica were the most common protozoa infections found in all of these nationalities. Among Indians in this study, G. lamblia was found in 28.5% subjects, while the positive rate for E. histolytica was 21.4%. This was not in accordance with a study done in India, which had the following rates: E. histolytica; 10.5% and G. lamblia; 3.9%.[18]

The study indicated again that in Egyptians two parasites were most prevalent; positivity rate for G. lamblia was 66.6% and 33.3% for E. histolytica. This was also in contrast with the Egyptian study that reported rates of 17.6% for G. lamblia and 24.6% for E. histolytica.[20]

In contrast to positive rates in Egyptians, the Sudanese subjects had fewer G. lamblia infections with a rate of

24%, while half of them were infected with E. histolytica. However, this was in contrast to a study done in Sudan that reported very low infection rates of 7.5% for G. lamblia and only 2% for E. histolytica.[21]

Evidently, the differences in the positive rates and findings of this study, compared to others done on selected population samples in the above mentioned countries, are most likely to be due to sociodemographic variations, the used diagnostic techniques and sample size.

Among the Ethiopians, the infection rate of E. histolytica was 28.9%, whereas the rate of G. lamblia detected was 15.7%. Different results were detected in an Ethiopian study, which indicated a rate of 10.3% for G. lamblia and 14% for E. histolytica 14.0%. Generally speaking, giardiasis is reported as being not as widespread as amoebiasis in Ethiopia. [17,22] Actually, E. histolytica is one of the most commonly reported parasitic infections in Ethiopia found in up to 16% of highland migrant farm workers, especially females.[19]

CONCLUSION

Given these positive rates among different nationalities enrolled in this study, it is clear that FW, particularly those who come for domestic work or as child minders may pose a hazard to public health as a source of IPs transmission. Careful examination of such laborers, especially those who have parasites transmitted by autoinfection, is mandatory to reduce the negative impact they may have on their employers or other contacts.

RECOMMENDATION

In view of the low cost of the laboratory tests required, a risk assessment study is recommended, along with a mass screening project for IPs in all FW, before and after receiving treatment. This aims at achieving a high rate of eradication of IPs in order to minimize the risk of transmission to the community.

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How to cite this article: Imam NF, Abdulbaqi ZB, Fahad RA. The prevalence of intestinal parasitic infections among foreign workers in Madinah, Kingdom of Saudi Arabia. Saudi J Med Med Sci 2015;3:112-7.

Source of Support: Nil, Conflict of Interest: None declared.


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The Prevalence of Intestinal Parasitic Infections …applications.emro.who.int/imemrf/Saudi_J_Med_Med_Sci/Saudi_J_Med...The Prevalence of Intestinal Parasitic Infections Among Foreign