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Cathy Sun

 

Abstract

Objective: To assess the prevalence and associated risk factors of Intestinal Helminth infections among pre-school children (1 to 5 years old) in Internally Displaced Persons (IDPs) settlements.

Methods: A multistage cluster sampling, cross-sectional study was conducted in IDPs Settlements of Khartoum State, Sudan, in 2013. Questionnaires were collected from 662 preschool children and their stool samples were examined. The response rate for stool samples collection was 84.9%.

Results: 24.9% of the preschool children had Intestinal Helminth infections. Most of the infected children (98.6%) had one type of Intestinal Helminth (Hymenolepis nana or Taenia saginata) and only 1.4% of them had two parasites infections (Hymenolepis nana and Taenia saginata). Most of the Intestinal Helminth infections were due to Cestodes, such as Hymenolepis nana, which represented 95.7% of the all Intestinal Helminth infections, followed by Taenia saginata infection, which represented 2.9% of all infections, and 1.4% had both Hymenolepis nana and Taenia saginata infections. The infection increased among the age group 24-59 months (P-Value ˂ 0.001). There was an association between infection increase and toilet usage (P-Value = 0.001). There was also a relationship between infection and walking barefoot (P-Value = 0.023).

Conclusions: The rates of intestinal parasitosis infection in IDPs settlements of Khartoum State are very high. The highest proportion of infections was due to Hymenolepiasis nana. Most of the affected children were asymptomatic because they were infected with one Intestinal Helminth. We recommend application of regular mass deworming campaigns and comprehensive community interventions to ensure permanent control of Intestinal Helminth. This will only be feasible where chemotherapy is supplemented by improved water supplies and sanitation. Effective sanitation education programs for IDPs settlements should be provided to strengthen the deworming campaigns and interventional activity.

Introduction

Helminths or parasites, often called “worms” are widespread throughout the world. Nematodes (roundworms), Cestodes (tapeworms), and Trematodes (flatworms) are among the most common Helminths that inhabit the human gut. There are four species of Nematodes, also known as geohelminths and soil-transmitted Helminths: {Ascaris lumbricoides (roundworm), Trichiuris trichiuria (whipworm), Ancylostoma duodenale, and Necator americanicus (hookworms)}. 1,2  These Helminthic infections are most prevalent in tropical and subtropical regions of the developing world where there is commonly a lack of adequate water and sanitation facilities. 1,2  Adult Cestodes that infect humans include the following: Diphylllobothrium latum (found in Argentina, Europe, Japan, Siberia, Great Lakes area USA), Taenia species (found everywhere) and Hymenolepis nana (found everywhere). 3  Hymenolepiasis most frequently occurs in warm, dry regions of the developing world, where exposure to human faces results in hand-to-mouth infection. Direct person-to-person spread of Hymenolepis nana may occur.4 Taenia solium is virtually extinct in Europe and the Americas, while Taenia saginata is very common in developing countries where hygiene is poor and the inhabitants have a tendency to eat raw or insufficiently cooked meat. 5 Parasitic infections, caused by Intestinal Helminths, are among the most prevalent infections in humans in developing countries. They cause a significant morbidity and mortality in endemic countries. 4  Recent estimates suggest that A. lumbricoides can infect over a billion, T. trichiuria 795 million, and hookworms 740 million people. 6 Children aged between one and five years are particularly vulnerable to disease caused by Intestinal Helminth infections. 7 Children of this age group are less likely to harbor heavy infections (Fecal Egg Count per gram of feces, >20,000 for roundworm and >5000 for whipworm) 8 . However, because the sizes of their bodies are generally smaller, they are less able to handle the burden of the worms. Thus, they are put at a higher risk of suffering from anemia and malnutrition. 9 The World Health Organization strategy for control of Helminth infections is to control morbidity through the periodic treatment of at-risk people living in endemic areas. People at risk include preschool children. WHO recommends periodic drug treatment (deworming) without previous individual diagnosis to all at-risk people living in endemic areas (especially those involved in subsistence farming (commonly associated with hookworm infection), to those who have frequent contact with water (associated with schistosomiasis), to those who live in poor rural areas or urban slums, in area where households lacking safe water and sanitation are clustered, and to those who live in warm and moist climates that are hospitable to worms and parasites). 10 In addition: health and hygiene education reduces transmission and reinfection. Provision of adequate sanitation is also important but not always possible in resource-poor settings. Periodic deworming can be integrated with child health days or supplementation programs for preschool children, or integrated with school health programs. In 2009, over 300 million preschool and school-age children, or 35% of the children at risk, were dewormed in endemic countries. 11 Intestinal parasitic infections are major public health problems in developing countries. 12 In Sudan, data on Intestinal Helminth infections prevalence and treatment chemotherapy distribution program are limited. The objective of this study was to determine the prevalence of the Intestinal Helminths and associated risk factors among children in the age group between 1-5 years in Khartoum State, Sudan. Although this age group of children is considered as a target of deworming intervention by WHO, there were no regular intervention programs against Intestinal Helminth infections among this age group, because officials are unaware of the prevalence of the infections among children. 13 This study was conducted to help formulate evidence based policies and intervention programs. These interventions will improve the health situation of children and the health status of the population in all Internally Displaced Persons settlements in Khartoum State.

Method

Study Design

A cross-sectional study was conducted from January 2013 to June 2013 among preschool children of IDPs settlements in Khartoum State, Sudan. Data was collected using a structured questionnaire. The questionnaire was purposely designed and formulated for this research based on possible risk factors. The questionnaire was pretested in a fifty subjects similar to the study participants for validation. The participants’ caretakers were interviewed directly in order to collect health information on sociodemographic and economic factors of relevance to the households: factors associated with housing and lifestyle, personal hygiene, reception of chemotherapy treatment for Intestinal Helminth infections and receiving health education. The questionnaire (annex.2) was administered by trained data collectors and trained female/male Community Health Workers (nurses, midwives, medical assistants), who had experience as research assistants.

Study Area

Khartoum state (the capital of the Sudan) has six IDPs sites, with a combined population of 0.7 million inhabitants, with almost 20% being children. The first IDPs arrived in mid 1980s from Kordofan region and in late 1980s from the south region. 14 In the early 1990s; Non Governmental Organizations (NGOs) provided their support to these IDPs, particularly in the form of healthcare and nutrition. Some International NGOs withdrew their activities and handed them over to local NGOs. The government is implementing the process of re-planning of some camps and IDPs sites must move to new settlements. The IDPs residents live in cardboard or mud houses in poor hygiene condition. These IDPs settlements are lacking health facilities and correct sanitary conditions that could create a destabilization of health status. 14 Household mortality survey in displaced camps in the state of Khartoum indicates that crude mortality rate for children under 5 years is high, the main cause of death in all area being diarrhea, pneumonia, and measles. 13 Primary Health Care facility (PHC) coverage was 69%. 14 Health coverage with different routine immunization strategies was still under the recommended level (a goal was to reach a sustained DTP3 coverage of 90%); however, routine immunization coverage in IDPs was 63.7%, 70.4%, in 2007, 2008, respectively. 14

Study Population

The study population was comprised of all pre-school children (1 to 5 years old) who were living in Khartoum State IDPs settlements. The populations at risk for Intestinal Helminth infections were most likely to be found in these IDPs.

Sampling

The Khartoum State’s six IDPs settlements were all included in this study and were considered as the main sampling domains. A multistage sampling technique was used for this survey. The sample size was calculated using OpenEpi, entitled “OpenEpi for a Proportion for Cluster Surveys Version 04.06.08”. Single proportion formula was at 95% confidence interval (CI) level Z = 1.96, Population size (N) = 131919, 14 an expected prevalence of 50% ” the prevalence rate of the key indicator, (when selecting P = 0.5 this will yield the maximum sample size, since the overall prevalence rate (P) of the Intestinal Helminth infections was not known for the study area)”, 15 0.1 marginal error, and the design effect (for cluster surveys-DEFF) was = 1.5. The sample size was 575 and the total sample size was completed to 662 preschool children included in this study. Then the sample size was divided into 30 clusters (Lot Quality Assurance Sampling (LQAS) Community Survey) and so the number of preschool children per cluster was 22. Then 11 households were selected from each cluster expecting 2 preschool children in each household.

Stool examination for Parasitology

After completion of the baseline questionnaire, stool samples were collected from the respondents the next morning. The stool examination was carried out in Khartoum State Ministry of Health Public Health Reference Lab, which was specially set up for the study under the strict quality control program. Fresh stool samples were collected from respondents in clearly labeled (with the first name and serial numbers of the subjects) containers with a wide mouth and screw cap. Appropriate demonstrations on how to collect the stool samples were made to the caretakers to ensure standard collection of the stool samples at home. The caretakers were asked to put about 10 grams of stool in the containers the following morning. The collected stool samples were transported within two hours in suitable boxes for analysis at the stool processing section of the Khartoum State Ministry of Health Public Health Reference Lab. The stool samples were examined by Kato-Katz thick smear in order to determine presence of parasites and worm eggs in the stools. Hymenolepis nana was diagnosed by identifying the characteristic eggs in the stool sample. Taenia saginata was diagnosed by the recovery of the segments and or scolex, because the ova of T. solium and T. saginata are identical. Before starting the actual work, the quality of reagents and instruments was checked by experienced laboratory technicians. They record each serial number, quantity and the procedures of collection. Expert lab technicians did the standard microscopic examinations of the stool samples under a strict quality-control protocol. The technicians considered the stool sample as negative when there were no egg and or parasites. The technicians were not told about the health and other status of the study participants. In cases where the results were discordant, a second expert reader was used. The results of the second expert reader were considered the final result.

Ethical consideration

The ethical clearance was obtained from the Ethics Committee of Ministry of Health of Khartoum state, PHC directorate of Khartoum state and PHC directorates of the localities where IDPs settlements exist. Prior to any interview or any procedures, the participant’s caretaker was given an explanation on the purpose and nature of the study. Informed consent was taken from parents/guardians of the children and permission to participate in the study and to collect stool samples were obtained. Confidentiality on data and privacy were rigorously protected. Research team was trained adequately in this aspect. Access to the confidential data was limited to the researcher.

Data analysis and interpretation of results:

Data analysis was carried out using SPSS 16 (Statistical Package of Social Science program, version 16). The dependent variable for this study was Intestinal Helminths (Positive or negative). The independent variables were divided into sociodemographic, personal hygiene practice, treatment chemotherapy of Intestinal Helminths; and level of health education. Both the dependent and independent variables were further categorized into numerical, ordinal or continuous data. The distribution of the independent variables first were analyzed and described by using tables and figures. The association between each exposure and presence of infection was tested using chi-squared test. A p-value of less than 0.05 was considered statistically significant.

Results

Socio-demographic characteristics of the study population:

              The socio-demographic characteristics of the study population are shown in table (1). A total of 662 preschool children were included in this study. Almost equal percentage was distributed between male and female preschool children (49.7% and 50.3% respectively). The preschool children’s age ranged between 1 and 5 years. The mean age of preschool children was 2.5 years with Standard deviation of 1. Table 1: Shows frequency and percentage distribution of preschool children (1-5 years) by their sociodemographic characteristics in Khartoum State IDPs Settlements, 2013.

Age group Frequency Percent
12-23 months 130 19.6
60-71 month 140 21.1
48-59 months 159 24.0
24-47 months 233 35.2
Total 662 100.0
Gender
Male 329 49.7
Female 333 50.3
Total 662 100.0
Mothers’ age
< 15 years 1 0.2
< 45 years 10 1.5
15 – 25 years 223 33.7
26-45 years 428 64.7
Total 662 100.0
Ethnic group
Arab 31 4.7
Fallata 31 4.7
Fur 109 16.5
Nuba 203 30.7
Others 288 43.5
Total 662 100.0
Family size
< 5 83 12.5
>10 90 13.6
5-10 489 73.9
Total 662 100.0
Family income
>1500 SDG 25 3.8
1000-1500 SDG 65 9.8
<500 SDG 215 32.5
500- < 1000 SDG 357 53.9
Total 662 100.0
Fathers’ education
University 43 6.5
Secondary 101 15.3
Primary 246 37.2
No formal education or illiterate 272 41.1
Total 662 100.0
Mothers’ education
University 17 2.6
Secondary 92 13.9
Primary 275 41.5
No formal education or illiterate 278 42.0
Total 662 100.0
Fathers’ occupation
Unemployed 21 3.2
Professional 31 4.7
Skilled worker 59 8.9
Unskilled worker 551 83.2
Total 662 100.0
Mothers’ occupation
Skilled worker 9 1.4
Professional 10 1.5
Unskilled worker 100 15.1
Housewife or unemployed 543 82.0
Total 662 100.0

Confirmation of the Intestinal Helminth infections among pre-school children by stool examination:

Almost all preschool children caretakers (662 individuals) agreed to give stool samples for examination in the next morning, but only 84.9% of them actually gave the samples. As shown in table (2), almost one quarter of the preschool children had Intestinal Helminths infections (24.9%); most of them were due to one parasite (24.5%) and only 0.4% of them had two parasites infections. Most of the Intestinal Helminths infections were due to Cestodes like Hymenolepis nana, which represented 95.7% of all the Intestinal Helminth infections, followed by 2.9% Taenia saginata infection. 1.4% of the preschool children had both Hymenolepis nana and Taenia saginata infection. There were no Nematode and or Trematodes parasites found among the study population in this study. Table 2: Shows frequency and percentage distribution of preschool children (1-5 years) by stool samples examination results in Khartoum State IDPs Settlements, 2013.

 Stool sample examination results Frequency Percent
Hymenolepis nana 134 23.8
Taenia Saginata 4 .7
Negative 422 75.1
H.nana and T. Saginata 2 .4
Total samples 562 100.0

 

Risk factors of the Intestinal Helminth infections among preschool Children in IDPs settlements of Khartoum state:

Concerning the association between the socio-demographic characteristics of the study population and the Intestinal Helminth, with α = 0.05 and a P value of < 0.05, there was evidence of a highly significant association (P-Value ˂ 0.001) between preschool children age and the presence of Intestinal Helminth infections, and the infection increased in the middle age groups 24-59 months. On the other hand, there was no evidence of significant association between preschool children’s gender, mothers’ age, ethnic group, family size, family income, fathers’ and mothers’ education or occupation and Intestinal Helminth infections. Other risk factors are shown in table (3). The Intestinal Helminth infections were found more prevalent among those walking barefoot (P-Value = 0.023) in the study area. This metric is used because some of the Intestinal Helminths are transmitted to humans from contaminated soil through the skin, usually due to walking barefoot. In this study, the prevalent Helminths were Cestodes, which mainly transmitted oro-faecally. So the association we found in this study between the Intestinal Helminth infection and walking barefoot may be due to poor personal hygiene attitude and behavior, which is usually found among those walking barefoot in the study area. On the other hand, there was no evidence of association between preschool children’s hand washing, vegetable washing and cleaning (peeling) before eating, place of cooking at the house, waste disposal method, presence of animals at house with the Intestinal Helminth infection. Table 3: Shows frequency and percentage distribution of preschool children (1-5 years) by Housing characteristics, Practice of personal hygiene and life style factors in Khartoum State IDPs Settlements, 2013.

 Water supply source Frequency Percent
General water net 327 49.4
Protected dug well 332 50.2
Others 3 0.5
Total 662 100.0
 Method of water transfer
Tab water 108 16.3
From the pump 22 3.3
Cart 523 79.0
Others 9 1.5
Total 662 100.0
 Water treatment
Yes 5 0.8
No 657 99.2
Total 662 100.0
 Method of water treatment
Poiling 4 0.6
Filtration 1 0.2
Not applicable 657 99.2
Total 662 100.0
 Sanitation and toilet facilities
Traditional split latrine 469 70.8
Shared latrine 139 21.0
General latrine (Public) 27 4.1
Improve latrine with cement slab 15 2.3
Open defecation 11 1.7
Not applicable 1 0.2
Total 662 100.0
 Place of cooking
Kitchen 446 67.4
At room 98 14.8
At yard 97 14.7
Other 21 3.2
Total 662 100.0
 Animals at the home
Yes 256 38.7
No 406 61.3
Total 662 100.0
 Waste disposal method
Garbage collection car 55 8.3
Burning 241 36.4
Collections areas far from home 322 48.6
Burning and in the collection area far from home 33 5.0
Others 11 1.7
Total 662 100.0
 Use of toilet for defecation
Yes 312 47.1
No 350 52.9
Total 662 100.0
 Hand washing
Regular 539 81.4
Irregular 104 15.7
No hand wash 19 2.9
Total 662 100.0
 Time of hand washing
Before eating 19 2.9
After eating 10 1.5
After toilet use 18 2.7
After waste disposal 4 0.6
Not applicable 35 5.3
Before and after eating 229 34.6
Before and after eating and after use of toilet 347 52.4
Total 662 100.0
 What used for hand washing
Only water 263 39.7
Soap and water 366 55.3
Water and Ash (ramad) 3 0.5
Others 1 0.2
Not applicable 29 4.4
Total 662 100.0
 Walking barefoot habit most of time per day
Yes 479 72.4
No 183 27.6
Total 662 100.0
Vegetable washing and cleaning (peeling) before eating
Yes 639 96.5
No 23 3.5
Total 662 100.0

Discussion

In this study, the prevalence and associated risk factors of Intestinal Helminth infections was assessed among pre-school children (1 to 5 years), living in IDPs settlements of Khartoum state, Sudan. The prevalence of Intestinal Helminths was estimated to be 24.9%. Our report of the high findings in this study were compared with studies done in Mexico in 2006 (25%), 16 in Guyana (43.5%) and (21.2%) for detection of single parasite and multiple parasitic infections respectively, 17 and in Kilifi on the Kenyan coast (28.7%). 18 Higher prevalence of Intestinal Helminths in Sierra Leone among IDPs Camps at Parade Ground Camp 19 and in Ethiopia 20 were found (50% and 83.0% respectively). The similarity of high prevalence of Intestinal Helminth infections among the previously mentioned developing countries might be due to comparable environmental and climatic conditions such as high temperature, poor hygiene, and water supply and sanitation problems, which facilitate the spread of the parasitic infections. In our study, we noticed that only Cestodes Helminths were more prevalent in the study area, unlike Trematodes and Nematodes. This could be due to the dry and hot weather in addition to other risk factors, in the study area, which facilitates the spread of Cestodes rather than Trematodes and Nematodes, which favor high humidity and low temperatures. 4 The few cases of T. saginata that found in this study were very important signs especially when found among younger children, because T. saginata infections are more common in developing countries where hygiene is poor and the inhabitants have a tendency of eating raw or insufficiently cooked meat, 21 which we noticed during this survey. In this study we found that; there was no predilection for gender with Intestinal Helminth infections. This compared with the study done in Guyana which found that there was no predilection for gender with any of the parasites. 17 The Intestinal Helminth infections in the current study were found to be more prevalent among the older age groups of preschool children 24-59 months (P-Value < 0.001). This may be due to increase exposure of children in this age to the environments. Also most of the children after two years of age receive no assistance from their mothers during defecation, which makes them more vulnerable to contract infections with Intestinal Helminth. In this study, almost all of the preschool children had access to a clean water source (99.5%), but only 16.3% had tab water connected to their houses. The remaining transfer water to their houses using cart and other unhygienic methods render them more susceptible to parasitic infections, however no statistical significance was observed between source of water supply, method of water transfer and method of water treatment (P = 0.444, 0.329, 0.433 respectively).  This study showed evidence of significant association between preschool children use of toilet (P-Value = 0.001) and Intestinal Helminths infection, the infection increased among those using toilet. But this should not lessen the importance of using toilets, because preschool children who were using improve latrine were only 2.3% and most of them were using traditional split latrine (70.8%), shared latrine between more than one household (21%) and general or public latrine (4.1%). Health authorities have to ensure provision of services related to health promotion and use effective and attractive material of health education. Also they should promote safe transfer of drinking water to the houses and improvement of sanitation in order to control the Intestinal Helminth infections.

Conclusion

This study reflects not only the prevalence of Intestinal Helminth infections among children, but also showed the health situation of IDPs and some of the problems facing the displaced population. Some of the main conclusions emerging from the survey findings include the following: The Intestinal Helminths that were prevalent in IDPs settlements were mainly Cestodes. There was no single case of Nematodes and or Trematodes infection, however, the low sensitivity of the Kato-Katz test may explain why no hookworm infections were detected. Detection of hookworm infection using this technique was considered as a limitation of this study. This limitation was described clearly in a study conducted by Tarafder MR, et al in Philippines, to estimate the sensitivity and specificity of the Kato-Katz technique to detect infection with hookworm. 22 Hymenolepis nana was the most prevalent intestinal Helminths. This may be because of the warm and dry environment of the IDPs settlements in the study area, which is favored by Hymenolepis nana. This also reflected that there was high exposure to human feces, which is a known cause of hand-to-mouth parasitic infection especially Hymenolepis nana infection. Few cases of Taenia saginata were found, which can reflect poor hygiene, presence of a tendency of eating raw or insufficiently cooked meat among the IDPs population. The study indicated that factors of age of Preschool Children, the use of a toilet and walking barefoot all strongly influenced the prevalence rate in IDPs settlements. Application of deworming program and comprehensive community interventions can ensure permanent control of the Helminth Infections. This will only be feasible where chemotherapy is supplemented by improved water supplies and sanitation, and strengthened by sanitation education directed to IDPs settlements preschool children and their families as the vulnerable groups. 9 In between these mass intervention programs, regular measures can be applied for prevention, early detection, and treatment of the infected children such as the equipment of PHC health units with necessary laboratory equipment’s for accurate diagnosis of the Helminth infections (e.g. Microscope for fresh stool and urine examination, Kato-Katz technique set, Sodium Acetate-acetic acid-Formalin solution (SAF) materials for stool examination and sedimentation materials for stool and urine examination), continuous supply of anti-Helminths drugs at the PHC settings, and making regular health education activities concerning the Helminths and parasitic infections prevention. Moreover, the health authorities should especially reach out to mothers in de-worming campaigns and educate them about hygienic practices in order to reduce exposure to human feces, which results in hand-to-mouth infection of Hymenolepiasis nana. We emphasize that the provision of free health services including drugs such as Praziquantel, Albendazole and Mebendazole to treat and reduce this high prevalence of intestinal parasitic infections in the IDPs settlements. Moreover, continuous efforts should be devoted to reduce poverty and improve the education in order to improve the health status of the IDPs settlements population and to remove intestinal parasitic infections from the community.

Acknowledgements

Author would like to express sincere gratitude and thanks to Dr. Abdel Rahman El-asha Hamadel Nile for his continuous, patient guidance, assistance, support and expert advices during this research. Great acknowledgement also extended to Ministry of Health, Khartoum State staff for their support and generous help during this survey. Thanks and appreciation to Eman A. Eljack (MA, Translation) who revised the language of this report. Also, great thanks to the people of IDPs settlements of Khartoum State for participating in this survey.

References

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Annexes

Annex.1: The questionnaire Questionnaire among pre-school children in Khartoum State to determine the prevalence and risk factors of Intestinal Helminth infections Directions: – To fill out this questionnaire with a mother who has children aged between one year to less than 6 years (12-59 months) – Explain to the child’s caretaker the title of the research and the importance of participating in it, to help us know the health status of pre-school children and the prevalence of Intestinal Helminth infections in the IDPs. – Explain to the child’s caretaker that the research contains a questionnaire about the family and the child. A stool sample will be taken from the child in the next early morning to be examined for Intestinal Helminths. – Explain to the child that the research is under supervision of the Ministry of Health and we will be back to treat the child if the sample is found positive. The child’s caretaker can inquire about the test result on the telephone 798745 from the researcher Dr. Ibrahim Awad Eljack, after a month from now. – Mother approval to engage in the research and sampling: 1. Yes     2. No – If the answer is yes, type the number 1 in the box above. Thank the mother and Start the questionnaire.

Annex.2. Questionnaire: Coding
Region name Camp name………..Squire No…
Data collector team No (a, b)
Cluster No
Questionnaire date: Day…Month… Year………
Data collector name:
Respondent name (Optional):
Serial Number:
1. Child date of Birth (check the birth certificate if possible) Day…Month……… Year…
2. Child age (months / years): Year…………..Months…………
3. Gender: 2=Female.               1= Male
4. Mother age in years: 1=Less than 15 years.  2=15-25 years.  3=26-45 years. 4=Greater than 45 years
5. Ethnicity: 1=Arabs. 2= Four. 3=Nuba. 4. Fallatah. 5= Other (specify……………….)
6. No of family members: ………………..Individuals
7. Household’s monthly income (in Sudanese pound): ………………… Sudanese pound
8. Educational level of the father 1=Illiterate/ None formal education. 2= Primary/Basic. 3= Secondary. 4= University/Postgraduate.
9. Educational level of the mother 1=Illiterate/ None formal education. 2= Primary/Basic. 3= Secondary. 4= University/Postgraduate.
10. Father’s occupation 1=Unemployed. 2=Unskilled worker. 3= skilled labor. 4=Professional worker.
11. Mother’s occupation 1=Housewife. 2=Unskilled worker. 3= skilled labor. 4= Professional worker.
12. Source of drinking water 1=River or canals. 2=Public network. 3= protected Well. 4= Other (specify)……………
If the answer is a public network or well what are the means of water transport? 1=Pipes network. 2= Directly from the pump. 3= From the cart.   4= Other (specify)………..          9= Not applicable
Do you treat water? 1=Yes.       2=No
If the answer is yes, what are the means of water treatment? 1= Poiling. 2=Filtration. 3= Other (specify)………………. 9=Not applicable.
13. Sanitation and toilet facilities 1=split latrine. 2= share latrine with other families. 3=Public latrine. 4= Improve latrine with cement slab. 5= Open defecation. 6= Not applicable
14. Place of cooking 1=At the Kitchen 2=At room 3= At yard     4= Other (specify)…         
15. Do you have animals at the home? 1=Yes.       2=No
16.  Hand washing 1=Regular 2=Irregular 3=No hand wash
At what time you wash your child’s hands? ………………………………….
What used for hand washing? …………………………………..
17. Waste disposal method 1= Garbage collection car. 2= Burning. 3= Collections areas far from home. 4= Burning and in the collection area far from home. 5= Others specify………
18. Walking barefoot habit most of time per day 1= Yes.     2= No
19. Vegetable washing and cleaning (peeling) before eating 1= Yes.     2= No
20. Did you receive health education about hygiene, hand washing and Intestinal Helminths infections prevention in the previous year? 1= Yes.     2= No
21. Did you receive anti-helminthic drugs for the treatment of Intestinal Helminths infections? * 1= Yes.     2= No
22. Investigations:
Prepare the mother/caretaker to take the stool sample in the early morning 1=Agree to give the sample. 2=Do not agree to give the sample.
Give the sample container to the mother and explain to her how to take the sample (Make sure to write the serial number in the container and the name of the child** (
23 Did you receive the stool sample from the mother/caretaker? 1= Yes.     2= No
At the end of the questionnaire thank the mother/caretaker and take her telephone number to return back for any inquiry: Telephone number……………………………….

* The common anti-helminthic drugs in Sudan like: Praziquantel, Albendazole and Mebendazole. **Stool sample collection technique:

  • Must be larger enough (at least 5 grams (and to be clean and not mixed with the soil.
  • If the sample is diarrhea, you should increase the quantity so that it fills half of the container.
  • If the stool contains mucus and/or blood, it is preferred to take the blood and/or mucus area and then complete the required amount of sample. In the absence of mucus and/or blood, it is preferred to take the sample from the peripheries of the stool.
  • Advice the mother to maintain the serial number labeled in the container and not to delete, also advise her not to mix up the containers and to take the sample in the container in which the child’s exact name is written.
  • When collecting the sample in the early morning, you must make sure that all the above steps were followed by the mother/caretaker.

Annex.2: Results: Figure.1: Shows percentage distribution of preschool children (1-5 years) who had Intestinal Helminths infection by type of Helminths in the samples in Khartoum State IDPs Settlements, 2013. (N = 140) Most of preschool children with Intestinal Helminths infection had Hymenolepis nana (95.7%), 2.9% had Taenia saginata infection, and 1.4% of them had both Hymenolepis nana and Taenia saginata infection. Table 4: Chi-Square test showing the association between preschool children age group and Intestinal Helminths infection in Khartoum State IDPs Settlements, 2013

Age group  Intestinal Helminths infection Total
Positive Negative
12-23 months Count 6 101 107
% Within dependent variable 4.3% 23.9% 19.0%
24-47 months Count 45 148 193
% Within dependent variable 32.1% 35.1% 34.3%
48-59 months Count 59 84 143
% Within dependent variable 42.1% 19.9% 25.4%
60-71 month Count 30 89 119
% Within dependent variable 21.4% 21.1% 21.2%
 Total Count 140 422 562
% Within dependent variable 100.0% 100.0% 100.0%

P-Value ˂ 0.001 With α = 0.05 and a P value of < 0.05, there was evidence of a high significant association between the presence of Intestinal Helminths in preschool children stool and their age, the infection increase in the middle age groups 24-59 months. Table 5: Chi-Square test showing the association between preschool children use of toilet and Intestinal Helminths infection in Khartoum State IDPs Settlements, 2013

Use of toilet Intestinal Helminths infection Total
Positive Negative
Yes Count 84 182 266
% Within dependent variable 60.0% 43.1% 47.3%
No Count 56 240 296
% Within dependent variable 40.0% 56.9% 52.7%
Total Count 140 422 562
% Within dependent variable 100.0% 100.0% 100.0%

P-Value = 0.001 With α = 0.05 and a p value of < 0.05, there was evidence of high significant association between preschool children’s use of toilet (high among those using toilet) and the presence of Intestinal Helminths in their stool. Table 6: Chi-Square test showing the association between preschool children walking barefoot habit and Intestinal Helminths infection in Khartoum State IDPs Settlements, 2013

Walking barefoot habit Intestinal Helminths infection Total
Positive Negative
Yes Count 112 296 408
% Within if positive or negative parasite 80.0% 70.1% 72.6%
No Count 28 126 154
% Within if positive or negative parasite 20.0% 29.9% 27.4%
Total Count 140 422 562
% Within if positive or negative parasite 100.0% 100.0% 100.0%

P- Value = 0.023 With α = 0.05 and a P value of < 0.05, there was an evidence of significant association between preschool children’s Walking barefoot habit (more common among those who had the habit of walking barefoot) and the presence of intestinal Helminths in their stool.