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      Towards an effective control programme of soil-transmitted helminth infections among Orang Asli in rural Malaysia. Part 2: Knowledge, attitude, and practices


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          In the first part of this study, we investigated the prevalence and associated key factors of soil-transmitted helminth (STH) infections among Orang Asli children in rural Malaysia; an alarming high prevalence and five key factors significantly associated with infections were reported. Part 2 of this study aims to evaluate the knowledge, attitude and practices (KAP) on STH infections among Orang Asli in Peninsular Malaysia.


          A cross-sectional study was carried out among 215 households from 13 villages in Lipis district, Pahang, Malaysia. Demographic and socioeconomic information of the participants and their KAP on STH were collected by using a pre-tested questionnaire.


          Overall, 61.4% of the participants had prior knowledge about intestinal helminths with a lack of knowledge on the transmission (28.8%), signs and symptoms (29.3%) as well as the prevention (16.3%). Half of the respondents considered STH as harmful, while their practices to prevent infections were still inadequate. Significant associations between the KAP and age, gender, educational and employment status, family size, and household monthly income were reported. Moreover, significantly lower prevalence of STH infections was reported among children of respondents who wear shoes/slippers when outside the house (72.8%; 95% CI= 62.6, 80.5 vs 87.0%; 95% CI= 81.4, 91.1), wash their hands before eating (32.4%; 95% CI= 24.3, 42.2 vs 51.4%; 95% CI= 44.7, 60.1), and wash their hands after defecation (47.8%; 95% CI= 35.7, 57.1 vs 69.2%; 95% CI= 63.7, 78.7) as compared to their counterparts. Multiple logistic regression analysis indicated that the educational level of the respondents was the most important factor significantly associated with the KAP on STH among this population.


          This study reveals inadequate knowledge, attitude and practices on STH infections among Orang Asli in rural Malaysia. Hence, there is a great need for a proper health education programme and community mobilisation to enhance prevention and instil better knowledge on STH transmission and prevention. This is crucial for an effective and sustainable STH control programme to save the lives and future of the most vulnerable children in rural Malaysia.

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          Disease and Development: Evidence from Hookworm Eradication in the American South.

          This study evaluates the economic consequences of the successful eradication of hookworm disease from the American South. The hookworm-eradication campaign (c. 1910) began soon after (i) the discovery that a variety of health problems among Southerners could be attributed to the disease and (ii) the donation by John D. Rockefeller of a substantial sum to the effort. The Rockefeller Sanitary Commission (RSC) surveyed infection rates in the affected areas (eleven southern states) and found that an average of forty percent of school-aged children were infected with hookworm. The RSC then sponsored treatment and education campaigns across the region. Follow-up studies indicate that this campaign substantially reduced hookworm disease almost immediately. The sudden introduction of this treatment combines with the cross-area differences in pre-treatment infection rates to form the basis of the identification strategy. Areas with higher levels of hookworm infection prior to the RSC experienced greater increases in school enrollment, attendance, and literacy after the intervention. This result is robust to controlling for a variety of alternative factors, including differential trends across areas, changing crop prices, shifts in certain educational and health policies, and the effect of malaria eradication. No significant contemporaneous results are found for adults, who should have benefited less from the intervention owing to their substantially lower (prior) infection rates. A long-term follow-up of affected cohorts indicates a substantial gain in income that coincided with exposure to hookworm eradication. I also find evidence that eradication increased the return to schooling.
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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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              Hookworms, malaria and vitamin A deficiency contribute to anemia and iron deficiency among pregnant women in the plains of Nepal.

              Anemia and iron deficiency during pregnancy are prevalent in developing countries, but their causes are not always known. We assessed the prevalence and severity of anemia and iron deficiency and their association with helminths, malaria and vitamin A deficiency in a community-based sample of 336 pregnant women in the plains of Nepal. Hemoglobin, erythrocyte protoporphyrin (EP) and serum ferritin were assessed in venous blood samples. Overall, 72.6% of women were anemic (hemoglobin 70 micromol/mol heme or serum ferritin < 10 microg/L). Eighty-eight percent of cases of anemia were associated with iron deficiency. More than half of the women (54.2%) had a low serum retinol concentration (<1.05 micromol/L), 74.2% were infected with hookworms and 19.8% had Plasmodium vivax malaria parasitemia. Hemoglobin, EP and serum ferritin concentrations were significantly worse and the prevalence of anemia, elevated EP and low serum ferritin was increased with increasing intensity of hookworm infection. Hookworm infection intensity was the strongest predictor of iron status, especially of depleted iron stores. Low serum retinol was most strongly associated with mild anemia, whereas P. vivax malaria and hookworm infection intensity were stronger predictors of moderate to severe anemia. These findings reinforce the need for programs to consider reducing the prevalence of hookworm, malaria infection and vitamin A deficiency where indicated, in addition to providing iron supplements to effectively control anemia.

                Author and article information

                Parasit Vectors
                Parasit Vectors
                Parasites & Vectors
                BioMed Central
                28 January 2013
                : 6
                : 28
                [1 ]Department of Parasitology, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia
                [2 ]Department of Biology, Faculty of Natural and Applied Sciences, Umaru Musa Yar’adua University, Katsina, Katsina State, Nigeria
                [3 ]Julius Centre University of Malaya, Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia
                [4 ]Department of Parasitology, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen
                Copyright ©2013 Nasr et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


                attitude,knowledge,malaysia,practice,soil-transmitted helminths
                attitude, knowledge, malaysia, practice, soil-transmitted helminths


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