The prevalence of schistosomiasis among school children in Zagazig district, Sharkyia Governorate, Egypt

Middle East Journal of Applied Sciences Volume : 05 Issue : 04 Oct.-Dec. 2015 Pages: 1267-1272 The prevalence of schistosomiasis among school children in Zagazig district, Sharkyia Governorate, Egypt 1 Mostafa M. Ahmady, 1 Saber A.M. El-Sayed, 2 Yasser F Ali, 3 Salah F. Alsayed and 4 Ahmed M. Baraka 1 Department of Pediatrics, National Research Center, Cairo, Egypt. 2 Department of Pediatrics, Faculty of Medicine, Zagazig University, Egypt. 3 Department of Internal Medicine, Faculty of Medicine, Zagazig University, Egypt. 4 Clinical & Chemical Pathology, Faculty of Medicine, Zagazig University, Egypt. ABSTRACT Background: Schistosomiasis is a common third tropical parasitic disease caused by trematodes of the genus Schistosoma. Next to malariasis and helminthiasis of intestinal tract, it constitutes a major source of morbidity and mortality for developing countries in Africa, South America, the Caribbean, the Middle East, and Asia (1). Schistosomiasis is due to immunologic reactions to Schistosoma eggs trapped in tissues. Antigens released from the egg stimulate a granulomatous reaction involving T cells, macrophages, and eosinophil that results in clinical disease. Symptoms and signs depend on the number and location of eggs trapped in the tissues. Initially, the inflammatory reaction is easy reversible. In the latter stages of the disease, the pathology is associated with collagen deposition and fibrosis, resulting in organ damage that may be only partially reversible. Objective this study aimed to study the prevalence of schistosomiasis in Sharkia, Egypt during the period of April 2013- April 2014 in children with age from 6 years - 18 years in school age children. Patients and Methods: 1500 school aged children from 6 y-18y were chosen from three primary, three preparatory schools and 3 high schools, they underwent to specific rules in the study including data about name, age, sex, family educations, sanitary disposal of housing, swimming in river, ethical approval was obtained from the local research ethics committee of the schools director in sharkia and parents of all children gave an informed written consent prior to the study Urine and stool samples were collected for laboratory investigation for schistosomiasis by microscopic examination Results: The rate of schistosomiasis among school children in Zagazig district, Sharkyia Governorate, Egypt was 0.7 %. All positive cases were of Schistosoma mansoni, but no Schistosoma haematobium was detected. A highly significant positive correlation was found between male sex and increasing prevalence of schistosomiasis (P<0.05) as 73% of positive cases were among males and 27% among females. Conclusion: The rate of schistosomiasis among school children in Zagazig district, Sharkia Governorate, Egypt is slightly high, raising an alarm that schistosomiasis remains a major public health problem among children in rural Egypt. There was a predominance of S. mansoni in the study area. The majority of positive cases were among males than females. Key words: Sharkia Egypt, school children, schistosomiasis, and prevalence. Introduction Schistosomiasis is a common third tropical parasitic disease caused by trematodes of the genus schistosoma. Next to malariasis and helminthiasis of intestinal tract, it constitutes a major source of morbidity and mortality for developing countries in Africa, South America, the Caribbean, the Middle East, and Asia (Zumla, 2009). An estimated 750 million peoples are at risk of infection in 76 countries where the disease is considered endemic in tropical and subtropical regions of Africa, Asia, South America, and the Caribbean, as their agricultural work, domestic chores, and recreational activities expose them to infested water. Schistosoma haematobium infection was common, whereas Schistosoma mansoni infection was rare in the Nile Delta, it was reported by Scott in 1937 during his study the prevalence of schistosomiasis in 100 Egyptian villages (Scott, 1973). Corresponding Author: Saber A.M. El-Sayed, Department of Pediatrics, National Research Center, Cairo, Egypt. E-mail: saber_196215@yahoo.com 1267

Zakaria et al. (1980) discussed that the change pattern of prevalence of schistosomiasis in Egypt S. mansoni infection increased and that of S. haematobium decreased because the hepatosplenic schistosomiasis caused by S. mansoni is more difficult to detect early and is associated with greater morbidity and mortality than the urinary schistosomiasis caused bys. haematobium. The prevalence and severity of schistosomal infections vary with age. Children and adolescents are infected most often and are infested most heavily. Infection rates and severity may vary with gender-specific activity at all ages. Congenital infection has been defined; Schistosomiasis has been detected in the placenta and newborns have been diagnosed with the disease, thus confirming congenital infection. Abdel-Kader et al. (2005), reported that in Egypt the prevalence of S. mansoni is quite high especialy in Nile Delta and it is replacing S. haematobium. The causative agent is a blood fluke of the genus Schistosoma, human beings become infected with schistosomiasis when larval forms of the parasite, released by freshwater snails, penetrate their skin during contact with infested water. In the body, the larvae develop into adult schistosomes. Adult worms live in the blood vessels, where the females release eggs. Some of the eggs are passed out of the body in the feces or urine to continue the parasite life cycle. Others become trapped in body tissues, causing an immune reaction and progressive damage to organs. Two major forms of schistosomiasis exist: intestinal and urogenital. These are caused by 5 main species S. haematobium, S. mansoni, Schistosoma mekongi, and Schistosoma intercalatum, Schistosoma japonicum, (Zumla, 2009; WHO, 1985). Keiser et al.(2006) documented that An individual can become infected by prolonged contact with fresh water containing free-swimming cercariae, the infective stage of the parasite, which then enters the subcutaneous tissues, the blood stream, migrates to the lungs, then to the liver, and finally to the mesenteric and perivesical venous plexuses. The parasite is excreted from the body through urine and feces into fresh water and the miracidia eventually infects its intermediate hosts, the fresh water snails, where they develop into cercariae and the vicious cycle starts again. Bauol et al. (2002) reported that the most common symptom of Schistosomiasis is tiredness also it is asymptomatic in up to 80% of those infected. WHO Expert Committee and Hammar et al.(11,12) stated that the disease has an effect on the growth and development of school-age children, causing anemia, malnutrition, stunted growth, reduced physical activity, and impaired cognitive function. Dickman et al. (2005) recorded that in about 90% of infected persons, the egg-associated inflammation recedes, resulting in intestinal schistosomiasis. In contrast, 10% of infected individuals present with severe hepatic and periportal fibrosis, and portal hypertension. (WHO, 1985) First report of a WHO expert committee recorded that the most common and seriously fatal complication of fibrotic hepatic schistosomiasis is bleeding from gastroesophageal varices. Freeman, et al. (1993) documented that the most serious complication of urinary schistosomiasis is an increase in squamous cell carcinoma of the urinary bladder, Behrmman, (2002) discussed basis for diagnosis of the disease by detecting the eggs in stool and urine by microscopic detection, also Gryseels et al. (2006) and Polderman et al. (2000) ( had been proposed to overcome some of the limitations with parasitological methods of Immunodiagnosis of schistosomiasis, so the prognosis of the disease when discovered early disease usually improves with treatment. Surprisingly, patients with hepatic and urinary disease, even with fibrosis, may improve significantly over months or years following therapy. Renal and intestinal pathology also improves with treatment, as, usually, do brain lesions (depending on their location and size). Hepatosplenic schistosomiasis carries a relatively good prognosis because hepatic function is preserved until the end of the disease (unless variceal bleeding occurs). Although treatment is indicated for patients with end-stage complications of portal hypertension and severe pulmonary hypertension, these patients are much less likely to benefit from it. Indeed, cor pulmonale usually does not improve significantly with treatment. Spinal cord schistosomiasis carries a guarded prognosis. Praziquantel should be administered as soon as possible. Praziquantel can safely be given to pregnant and lactating women; it decreases the disease burden and improves pregnancy and fetal outcomes. Programs targeting women during reproductive years will improve their reproductive life and well-being.co-infection of schistosomiasis along with hepatitis, HIV, and malaria can raise the risk of hepatocellular carcinoma and increase the risk of mortality.patients with heavier worm burdens are less likely to improve and are more likely to require re-treatment. 1268

Patients and methods Ethical approval was obtained from the local research ethics committee of the school children responsible in Zagazig district, Sharkia Governorate and parents of all children gave an informed written consent prior to the study In this study, a multistage random sample of 1500 child of school age (6-18 years) was selected randomly from and 3 high schools in a rural area in Egypt (Zagazig district, Sharkia Governorate). Data were collected through a predesigned questionnaire including data on name, age, sex, parents' education, housing sanitation, and some special habits such as swimming at river. Urine and stool samples were collected for laboratory investigation for schistosomiasis by microscopic examination. Results Table 1: among the studied group, 825 children were males (55%) and 675 were females (45%). The results showed that 540 (36%) of children were 6-11 years old and 960 (64%)of children were 12-18 years old. Table 1: Age number and gender relationship Age of children in years Number and percentage 6y-11y 12y-18y 540 ( 36 % ) 960 ( 64 % ) Sex Male 825 ( 55 % ) Female 675 ( 45 % ) 64 % of studied children age were from 12y 18y and 36 % were from 6y 11y 55 % of the studied group were males and 45 % of them were females. Table 2: he results showed that 11children were infected (0.7%); all of them were infected with S. mansoni and no S. haematobium was detected among the studied group. Table 2: The prevalence of Schistosoma mansoni and haematobium among our studied group. Items S. mansoni percentage S. haematobium percentage Positive stool for Schistosoma 11 patients 0.73 % O 0 % Negative stool for Schistosoma 1489 99.27 % 1500 100 % Total children 1500 100 % 1500 100% The prevalence of Schistosoma mansoni is 0.7 % Table 3: 8 males (73%) and 3 female (27%) were infected, and the difference was statistically significant at a P-value of 0.01 (<0.05). The results showed that there was a nonsignificant difference relation between age group and schistosoma infection in the studied group (P > 0.05). There was a significant difference between fathers' occupation as farmers and nonfarmers in terms of schistosoma infection among the studied group (P < 0.05) as the results showed that 5 of all infected children had fathers who were farmers, whereas 6 child had a father who was not a farmer. There was a nonsignificant difference between those with pure water supply and those with nonpure water supply in terms of schistosoma infection among the studied group (P > 0.05). There was a significant difference between those with sanitary sewage disposable and those with nonsanitary sewage disposable in terms of schistosoma infection among the studied group (P < 0.05) as the results showed that the homes of 3 of all infected children had sanitary sewage disposable, whereas 8 child had nonsanitary sewage disposable. There was a nonsignificant difference between anemia and schistosoma infection among the studied group (P > 0.05). 1269

Table 3: Factors affecting the prevalence of schistosomiasis among school age children in our study and anaemia. Factors affecting prevalence Positive stool for Negative stool for Total group P- value of schistosomiasis Schistosoma n% Schistosoma n % n % Age 6y-11y 4 (0.74%) 536 ( 99.3% ) 540 ( 36% ) 0.18 12y-18y 7 (0.73%) 953 ( 99.3% ) 960 ( 64% ) Sex Males 8 (73%) 817 ( 99% ) 825 ( 55% ) 0.01 Females 3 27%) 672 (99.5%) 675 ( 45% ) Anaemia Hemoglobin 10mg 8 (0.96%) 817 (99% ) 825 (55% ) 0.3 Hemoglobin 10mg 3 (0.44%) 672 (99.5%) 675 (45% ) Occupation farmers 5 (1.3% ) 371 (98.6%) 376 ( 25% ) 0.01 Of father Non farmers 6 0.5% ) 1118 (99.5%) 1124 ( 75% ) Water pure 5 0.74%) 670 (99.3%) 675 (45% ) 0.1 Housing states Supply Non pure 6 0.73%) 819 (99.3%) 825 (55% ) Discussion Sewage disposal Sanitary 3 (0.36%) 822 (99.6%) 825 ( 55% ) 0.02 Non sanitary 8 (1.2% ) 667 (98.8%) 675 ( 45% ) This study aimed to study the prevalence of schistosomiasis in Sharkia, Egypt during the period of April 2013- April 2014 in children with age from 6 years - 18 years in school age children. Ethical approval was obtained from the local research ethics committee of the school children responsible in Zagazig district, Sharkyia Governorate and parents of all children gave an informed written consent prior to the study In this study, a multistage random sample of 1500 child of school age (6-18 years) was selected randomly from and 3 high schools in a rural area in Egypt ( Zagazig district, Sharkyia Governorate).Data were collected through a predesigned questionnaire including data on name, age, sex, parents' education, housing sanitation, and some special habits such as swimming at river. Urine and stool samples were collected for laboratory investigation for schistosomiasis by microscopic examination. There was a nonsignificant difference between age group and schistosoma infection P 0.05. Prevalence of schistosomiasis is significantly higher among males than females P 0.05. There was a nonsignificant difference between anaemia and schistosoma infection among children in our study P 0.05, There was a significant difference between occupation of the fathers farmers and non farmers P 0.05. There was a nonsignificant difference between children with pure water supply and children with non pure water supply P 0.05.There was a significant difference between children with sanitary sewage disposal and children with non sanitary sewage disposal in the prevalence of schistosoma infections P 0.05. In this study, the prevalence of schistosomiasis in the studied group was 0.7%, which is higher than that reported by MOHP in 2009, which was 0.6% in Sharkyia and 0.6% in Egypt. El Shafie et al, (2011) reported that the prevalence of S. mansoni infection was estimated to have decreased from ~15% in 1993 to 3% in 2002, decreasing to 1.5% in 2006, and the prevalence of S. haematobium infection decreased from 7% in 1993 to 2% in 2002 and then to 1% in 2006. Smith et al.(2011) denoted that Studies from 2006 indicated approximately seven million cases of schistosomiasis in Egypt. Savioli et,al discussed as in this study, the diagnosis of S. mansoni was made on the basis of the microscopic detection of eggs in urine and stool samples, respectively, as it remains the gold standard for the diagnosis of schistosomiasis, in agreement with Feldmeier and Poggensee. In this study, S. mansoni was more predominant than S. haematobium as all positive cases included S. mansoni. Smith et al. (2011) over the last 5 years, however, these numbers have decreased, with S. haematobium infection almost eliminated and S. mansoni infections remaining only in what are described as 'hot spots' in the Nile Delta-irrigated area in the northern part of the country. The major interventions responsible for this situation include the building of the Aswan High Dam in 1960, which changed irrigation patterns in the Nile Delta, leading to an improved habitat for Biomphalaria spp. snails as opposed to Bulinus spp. snails, and therefore a reduction in the prevalence of S. haematobium, as well as implementation of mass treatments initially with tartar emetic and subsequently with praziquantel. Poggensee et al.(1993) reported like in this study, a significant positive association was found between male sex and increasing prevalence of schistosomiasis (P < 0.05) as 73% of positive cases were among males and 27% among females; this 1270

is in agreement with Samuels et al.(2005) who reported that the predominance of male sex is because of socioeconomic and cultural factors. The prevalence and severity of schistosomal infections vary with age. Children and adolescents are infected most often and are infested most heavily. Infection rates and severity may vary with gender-specific activity at all ages. Congenital infection has been defined; Schistosomiasis has been detected in the placenta and newborns have been diagnosed with the disease, thus confirming congenital infection. Abdel-Kader et al. (2005), reported that in Egypt the prevalence of S. mansoni is quite high especially in Nile Delta and it is replacing S. haematobium. The causative agent is a blood fluke of the genus Schistosoma, human beings become infected with schistosomiasis when larval forms of the parasite, released by freshwater snails, penetrate their skin during contact with infested water. There was a nonsignificant difference between age group and schistosoma infection P 0.05. Prevalence of schistosomiasis is significantly higher among males than females P 0.05. There was a nonsignificant difference between anaemia and schistosoma infection among children in our study P 0.05, there was a significant difference between occupation of the fathers farmers and non farmers P 0.05. There was a nonsignificant difference between children with pure water supply and children with non pure water supply P 0.05.There was a significant difference between children with sanitary sewage disposal and children with non sanitary sewage disposal in the prevalence of schistosoma infections P 0.05. References Abdel-Kader, A., W.M. Lotfy, R.J. Dejong, E.S. Loker, 2005. A molecular survey of biomphalaria in Egypt: is B. glabrata present? Am J Trop Med. Hyg, 73: 131-139. Bauol, J., S. Verma, K. Berry, 2002. Urinary schistosomiasis. Emerg Med J., 19: 483-484. Behrmman, A.J., 2002. Schistosomiasis of the bladder. Med Instant Access, 2: 133-148. Bergquist, N.R., 1995. Schistosomiasis vaccine development: approaches and prospects. Mem Inst Oswaldo Cruz., 90: 221-227. Capron, A., G.J. Riveau, P.B. Bartley, D.P. McManus, 2002. Prospects for a schistosome vaccine. Curr Drug Targets Immune Endocr Metabol Disord., 2: 281-290. Cioli, D., L. Pica-Mattoccia, S. Archer, 1993. Drug resistance in schistosomes. Parasitol Today, 9: 162-166. Dickman, K., C.H. King, D.J. Tisch, 2005. Reassessment of the cost of chronic helminthic infection: a meta-analysis of disability-related outcomes in endemic schistosomiasis. Lancet, 365: 1561-1569. El Shafie, A.M., M.H. Bahbah, 2011. Study of schistosomiasis among basic school children in Menoufia governorate, Quesna district. Freeman, G.L.J., G.S. Henderson, N.A. Nix, M.A. Montesano, D. Gold, T.L. McCurley, et al. 1993. Two distinct pathological syndromes in male CBA/J inbred mice with chronic Schistosoma mansoni infections. Am J Pathol 1993; 142 :703-714. Gryseels, B., K. Polman, J. Clerinx, L. Kestens, 2006. Human schistosomiasis. Lancet, 368: 1106-1118. Keiser, J., P. Steinmann, R. Bos, M. Tanner, J. Utzinger, 2006. Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet Infect Dis 2006; 6 :411-425. Poggensee, G., H. Feldmeier, 1993. Diagnostic techniques in schistosomiasis control. A review. Acta Trop., 52: 205-220. Polderman, A.M., L. Van Lieshout, A.M. Deelder, 2000. Immunodiagnosis of schistosomiasis by determination of the circulating antigens CAA and CCA, in particular in individuals with recent or light infections. Acta Trop., 77: 69-80. Samuels, R., T. Jemal, E. Murray, A. Ward, A.C. Tiwari, E. Ghafoor, et al. 2005. Cancer statistics. CA Cancer J Clin., 5: 10-30. 1271

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