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      High Prevalence of Diarrhoegenic Intestinal Parasite Infections among Non-ART HIV Patients in Fitche Hospital, Ethiopia

      1 , * , 2 , 3

      PLoS ONE

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          Abstract

          Background

          HIV infection has been modifying both the epidemiology and outcome of parasite infections. Hence, this study was undertaken to determine the prevalence of Cryptosporidium and other intestinal parasite infections among HIV positives with and without Antiretroviral Treatment(ART) and its association with CD4+ T-cell count.

          Methods

          A cross-sectional study was conducted at Fitche hospital focusing on HIV positives who came to hospital for follow-ups. A total of 378 HIV positive persons with and without ART participated in the study. Data on socio-demographic factors and diarrhoea status were obtained by interviewing all 214 with ART and 164 without ART. Stool samples were collected from all patients and examined for intestinal parasites using direct, formol-ether and modified acid-fast staining techniques.

          Results

          The prevalence of intestinal parasite infections in this study was significantly higher among HIV positive persons not on ART. Specifically, the rate of infection with Cryptosporidium species, Blastocystis spp., Giardia lamblia, and Entamoeba histolytica/E. dispar were higher, particularly in those with CD4+ T-cell counts less than 200 cells/µL. Fifty seven percent of the study participants were on ART. Out of these 164/378 (43%) of the non-ART study participants were infected with at least one intestinal parasite species. Significant association was observed between lower CD4+ T-cell count (<200 cells/µL) and the prevalence of Cryptosporidium spp. and Blastocystis spp. The two parasites were significantly more prevalent in HIV positive non-ART patients.

          Conclusion

          HIV infection increased the risk of having Cryptosporidium and other intestinal parasites and diarrhoea. Therefore, raising HIV positive’s immune status and screening for intestinal parasites is important. This study showed that patients who are taking ART had a lower prevalence of diarrhoea causing parasites and Cryptosporidium suggesting that ART through improvement of immune status of the patients may have contributed to controlling diarrhoea-causing parasites in HIV positive patients.

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          Most cited references 20

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          Prevalence and Risk Factors of Intestinal Parasitism in Rural and Remote West Malaysia

          Introduction Globally, the neglected intestinal parasitic infections (IPIs) such as soil-transmitted helminth (STH) and protozoa infections have been recognized as one of the most significant causes of illnesses and diseases especially among disadvantaged communities. With an average prevalence rate of 50% in developed world, and almost 95% in developing countries, it is estimated that IPIs result in 450 million illnesses [1], [2], [3]. These infections are ubiquitous with high prevalence among the poor and socioeconomically deprived communities where overcrowding, poor environmental sanitation, low level of education and lack of access to safe water are prevalent [4], trapping them in a perennial cycle of poverty and destitution [5]. These parasitic diseases contribute to economic instability and social marginalization; and the poor people of under developed nations experience a vicious cycle of under nutrition and repeated infections leading to excess morbidity with children being the worst affected [2], [6]. Of these illnesses, infections by STH have been increasingly recognized as an important public health problem and most prevalent of IPIs [7]. STH infections caused by Ascaris lumbricoides, Trichuris trichiura and hookworm (Necator americanus and Ancylostoma duodenale) are most significant in the bottom billion of the world's poorest people (i.e., RM 500 54668 45627 83.540.0 7.60 (5.30–11.13)1 <0.001 Water supply status*Untreated (river, well, rain water)Treated pipe water 317399 275249 86.862.4 2.84 (2.08–3.86)1 <0.001 Presence of proper latrine systemNoYes 212504 181343 85.468.1 2.19 (1.54–3.10)1 <0.001 Type of toilet facilityNonePour flush toilet 538178 44678 82.943.8 3.29 (2.62–4.12)1 <0.001 Defecation places status*Others (Bush, River)Pour flush toilet 550166 45668 82.941.0 3.45 (2.76–4.32)1 <0.001 Close contact with pets/livestockYesNo 65165 47252 72.580.0 0.73 (0.44–1.20)1 0.193 Garbage disposalIndiscriminatelyCollected 198518 168356 84.868.7 2.06 (1.45–2.94)1 <0.001 Iron supplementNoYes 412304 303221 73.572.7 1.03 (0.81–1.32)1 0.801 Anthelminthic drugNoYes 374342 286238 76.569.6 1.29 (1.01-1.65)1 0.038 N: Number examined; no: Number positive. Reference group marked as OR = 1; CI: Confidence interval. Significant association (p<0.05). * Variables were confirmed by multivariate analysis as significant predictors of IPIs. Discussion As shown by the results of the present study, intestinal parasitic infections (IPIs) are still a major public health problem (i.e., overall prevalence of 73.2%) among the impoverished and underprivileged communities in rural and remote West Malaysia. However, this study also observed some very encouraging trends. In Sungai Layau village where each family was provided with a concrete house and basic amenities like treated water supply, prevalence of IPIs was shown to be significantly lower (4.5%). This proved that proper provision of basic infrastructure and education are effective tools to reduce the prevalence of these infections. On the contrary, in Betau, Kuala Betis, Sungai Bumbun, Sungai Perah, Gurney, Pos Iskandar and Bukit Serok villages where some villagers still lived in traditional-built houses and using water from wells or rivers, prevalence of IPIs were very high. This was evident in the present findings whereby Betau village which was less provided or developed had the highest rate of infection (97.8%). Results also showed that STH infections (73.2%) were more common compared to protozoa infections (20.1%). T. trichiura infection is the most common (66.8%) followed by A. lumbricoides (38.5%) and hookworm (12.8%). These findings were in agreement with other previous local studies where T. trichiura infection was found to be the most prevalent (range: 26.0% to 98.2%), followed by A. lumbricoides infections (range: 19.0% to 67.8%) and lastly hookworm infections (range: 3.0% to 37.0%) [17], [18], [19], [20], [21]. However, global data has indicated that A. lumbricoides infections were the most prevalent among the three STH infections. The higher rate of T. trichiura infection has been reported to be due to the ineffective dosage and choice of anthelminthic used. Currently, the recommended treatment regime for STH infection is broad spectrum anthelminthics such as albendazole and mebendazole. Important therapeutic differences do exist between these drugs which affect their uses in clinical practice [22]. Both drugs are effective against ascariasis in single dose, whereas single doses of either albendazole or mebendazole have been found to be ineffective in many cases of trichuriasis [22]. Furthermore, potential resistance of T. trichiura to anthelminthic drugs has been highlighted in two intervention studies in Malaysian communities [23], [24]. It has been noted that unscheduled deworming without proper monitoring system was common among the children of these communities. Since the mass deworming program of schoolchildren has been discontinued in 1983 [25], some of the children received anthelminthic drug during visits to health clinic or from their school medical health team. Some parents have also bought anthelminthic drug for their children without following the recommended treatment intervals (i.e., periodic deworming) and this could have resulted in the inefficacy of the drug and subsequently lead to drug resistance [24]. Another important problem encountered in treatment is the high rate of re-infection especially in highly endemic areas. Local studies among rural communities have found that re-infection can occur as early as 2 months post treatment, by 4 months almost half of the treated population had been re-infected [24] and by 6 months the intensity of infections had returned to pre-treatment levels [26]. Similar findings have also been reported in other parts of the world indicating that by 6 months, the intensity of infections of T. trichiura and A. lumbricoides were similar to pre-treatment levels [27]. WHO has recommended that mass deworming programme should be carried out in communities when the cumulative STH prevalence is more than 50% or the cumulative percentage of moderately or heavily infected individuals is more than 10% [28]. As the present findings have indicated that the overall prevalence was 73.2%, it is strongly recommended that mass deworming programmes are restored and a systematic evaluation of treatment regime must be put in place to reduce the rates of re-infection. As for protozoa infections, the overall prevalence was 21.4%. However, in contrast with the latest local study in rural area, Noor Azian and colleagues reported very high rates of protozoa infection (72.3%) [29]. The present study found that G. duodenalis (10.4%) was the most predominant protozoa, followed by E. histolytica/dispar (10.2%) and lastly Cryptosporidium sp. (2.1%). In Malaysia, the prevalence of G. duodenalis infections varied from 2.0% to 29.2% while the prevalence of E. histolytica/dispar infections was reported to range from 1.0% to 18.5% among rural community [23], [29]. Although amoebic liver abscess (65% of 34) has been documented in patients admitted to an urban hospital in Malaysia [30], information from rural communities is not available as this infection can only be confirmed in a hospital setup. Two previous studies have indicated that Cryptosporidium sp. infections in rural areas ranged from 5.5% to 20.1% [31], [32]. The present study also reported 2 cases (0.3%) of Fasciolopsis/Fasciola sp. infection in Gurney village. This infection is most probably spurious due to consumption of infected animal liver. To date, there has not been any published data on intestinal fluke infection in West Malaysia, however, a case report of fasciolopsiasis by Fasciolopsis buski has been reported among rural community in East Malaysia [33]. In addition, two reported cases of food-borne diphyllobothriasis after consuming sushi and sashimi have also been reported in urban West Malaysia [34], [35]. Previous local studies indicated that there was a web of risk factors associated with the high prevalence of IPIs which included age, low family income, inadequate sanitation, presence and close contact with livestock or pets, untreated water supply, low level of parental education, poor geographical and personal hygiene [17], [22], [23]. Using multivariate analysis, the present study confirmed that children, low household income, untreated water supply, indiscriminate defecation were significant risk predictors of IPIs. This finding is further confirmed with the significantly lower prevalence in Sungai Layau village where household incomes are much higher and basic amenities provided by the government are fully utilized by the villagers. Conclusion Intestinal parasitic infections are highly prevalent and are major public health concerns among the poor and socioeconomically deprived rural and remote communities in West Malaysia. Given that IPIs are intimately associated with poverty, poor environmental sanitation and lack of clean water supply, it is crucial that these factors are addressed effectively. Improvement of socioeconomic status, sanitation, health education to promote awareness about health and hygiene together with periodic mass deworming are better strategies to control these infections. With effective control measures in place, these communities (especially children) will have a greater opportunity for a better future in terms of health and educational achievement. Supporting Information Checklist S1 STROBE checklist. (0.08 MB DOC) Click here for additional data file.
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            Prevalence of intestinal parasitic infections in patients with acquired immunodeficiency syndrome in Brazil.

            To evaluate the prevalence of intestinal parasitic infections and to investigate the possible associations of clinical status and laboratory findings with the different parasites found in stool samples. Each patient was provided with one standard fecal collection vial containing 10% formalin for detecting ova, larvae, and cysts. To detect Cryptosporidium parvum and Isospora belli, the acid-fast Kinyoun stain and fluorescent auramine-rhodamine stain were used. A total of 200 patients with acquired immunodeficiency syndrome participated in this study; 40% were infected with at least one pathogenic species. The total prevalence of parasites was 16% for Giardia lamblia, 13% for Entamoeba coli, 7% for Cryptosporidium parvum, 3.5% for Endolimax nana, 2.5% for Ascaris lumbricoides, 2.5% for Strongyloides stercoralis, 2% for Isospora belli, and 0.5% for Blastocystis hominis. Results showed that diarrhea was significantly associated with cryptosporidiosis, giardiasis, and isosporiasis. However, no association was observed between the CD4+ cell counts and the manifestation of any particular parasite. The data support the value of standard fecal examinations in human immunodeficiency virus-infected patients, even in the absence of diarrhea, since these examinations easily can be performed, with low costs, and frequently disclose treatable conditions.
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              Intestinal parasitic infections in relation to HIV/AIDS status, diarrhea and CD4 T-cell count

              Background HIV infection has been modifying both the epidemiology and outcome of parasitic infections. Hence, this study was undertaken to determine the prevalence of intestinal parasitic infection among people with and without HIV infection and its association with diarrhea and CD4 T-cell count. Methods A cross-sectional study was conducted at Hawassa Teaching and Referral Hospital focusing on HIV positive individuals, who gave blood for CD4 T-cell count at their first enrolment and clients tested HIV negative from November, 2008 to March, 2009. Data on socio-demographic factors and diarrhea status were obtained by interviewing 378 consecutive participants (214 HIV positive and 164 HIV negative). Stool samples were collected from all study subjects and examined for parasites using direct, formol-ether and modified acid fast stain techniques. Results The prevalence of any intestinal parasitic infection was significantly higher among HIV positive participants. Specifically, rate of infection with Cryptosporidium, I. belli, and S. stercoralis were higher, particularly in those with CD4 count less than 200 cells/μL. Diarrhea was more frequent also at the same lower CD4 T-cell counts. Conclusion Immunodeficiency increased the risk of having opportunistic parasites and diarrhea. Therefore; raising patient immune status and screening at least for those treatable parasites is important.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2013
                26 August 2013
                : 8
                : 8
                Affiliations
                [1 ]Department of Biology, Addis Ababa University, Addis Ababa, Ethiopia
                [2 ]Tropical and Infectious Diseases, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
                [3 ]Department of Microbial, Cellular and Molecular Biology, College of Natural Sciences, Addis Ababa University, Addis Ababa, Ethiopia
                Tulane University School of Public Health and Tropical Medicine, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: HA BP. Performed the experiments: HA TW. Analyzed the data: HA BP. Contributed reagents/materials/analysis tools: HA BP TW. Wrote the paper: HA BP.

                Article
                PONE-D-12-35373
                10.1371/journal.pone.0072634
                3753330
                23991132

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 5
                Funding
                This work was supported by the School of Graduate Studies, Addis Ababa University. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology
                Microbiology
                Parasitology
                Parasite Groups
                Quantitative Parasitology
                Protozoology
                Parastic Protozoans
                Emerging Infectious Diseases
                Medical Microbiology
                Medicine
                Infectious Diseases
                Viral Diseases
                HIV
                HIV epidemiology
                HIV opportunistic infections

                Uncategorized

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