Gastrointestinal Parasitosis and Anemia Monitoring in the Child Population of Villa Clarín, Colombia

doi:10.21203/rs.3.rs-1101403/v1

Background

There is limited non-anecdotal literature on the effectiveness of health policies and the prevalence of childhood anemia in rural communities in the Colombian Caribbean region. The objective of the following study is to report a parasitological and hematological episode of 94 children belonging to the child population of Villa Clarín, Colombia, and reinforce the disposable literature of local care reports.

Case presentation

This article studies an event of intestinal parasitosis prevalence and anemia in 94 children between 1 and 11 years of age, grouped into three age ranges of 1 to 3 years, 4 to 6 years, and 7 to 11 years of age respectively, from the rural community of Villa Clarín, Colombia. Blood samples were obtained by venipuncture and processed through a complete blood count. The feces were collected by spontaneous evacuation and analyzed using a spontaneous sedimentation technique. The prevalence of intestinal parasitosis was 96.81%.

Conclusions

Eight of the 91 children in whom intestinal parasites were detected had anemia while 29 were above the normal levels of hemoglobin. An association was found with E. histolytica / dispar, but not with A. lumbricoides, T. trichiura, S. stercolaris, Uncinaria, Taenia sp, H. nana, H. diminuta, G. lamblia, T. hominis or B. hominis. The high prevalence of intestinal parasitosis and the anemia levels indicate deficiencies in environmental sanitation and hygienic-sanitary measures.

Health Policy

Nutrition & Dietetics

Anemia

intestinal parasites

Colombia

public health

Anemia is the reduction in the volume of red blood cells or the concentration of hemoglobin in the bloodstream (Barrera-Dussán, Fierro-Parra, Puentes-Fierro & Ramos-Castañeda, 2018). Hemoglobin is an iron-rich protein that helps red blood cells carry oxygen from the lungs to the rest of the body. Among the clinical manifestations caused by parasites in humans are prolonged infections and inflammations and chronic blood loss. According to the World Health Organization (Aguilar et al., 2021), parasitosis is one of the top five causes of human morbidity, especially in children.

The presence of intestinal parasites in children is related to unfavorable socioeconomic conditions, a consequence of family economic poverty that increases the viability and maturation of soil-transmitted helminth eggs. Parasites cause loss of appetite, increased metabolism, intestinal malabsorption, and lesions in the intestinal mucosa that generate protein malnutrition and iron deficiency anemia (Aguilar et al., 2021).

Among the parasites that can be transmitted by contaminated water with feces, are protozoa such as Entamoeba histolytica, Giardia intestinalis, Balantidium coli, Cryptosporidium spp, Cyclospora cayetanensis, Isospora belli, microsporidia, and helminths such as Ascaris spp, Trichuris spp, Trichuris spp, Trichuris spp, Ancylostoma spp, and Strongyloides spp. These infections can affect any individual regardless of age and are often followed by diarrhea, abdominal pain, and fever (Heredia Martínez, Tovar Meléndez, Gallego Jaramillo & Naranjo García, 2015).

The study population of Villa Clarin (Colombia) was selected due to the availability of participation of the individuals analyzed (previous oral authorization of their parents), and the availability of information supply on the sanitary conditions of drinking water supply and basic public services (sewerage, electric service, natural gas supply, latrine supply). This event study was based the reports by Cardona-Arias (2014) on the unfavorable nutritional and sanitary conditions of the observed population and the consequent episodes of anemia. The objective of this study is to relate anemia episodes in the observed population with gastrointestinal parasitosis using a spontaneous sedimentation technique.

According to the World Health Organization, intestinal parasitosis is part of the tropical diseases in which developing countries have economic difficulties in battling it (Aguilar et al., 2021). It has been recognized in low-income rural populations. Poor housing conditions, lack of access to drinking water, low income, low educational level, barriers to access to health services in general, and the poor sanitary conditions of the rural population are social determinants with which intestinal parasitosis is associated (Pan American Health Organization, 2021).

Intestinal parasites are single or multicellular living beings that feed on their host, which are mainly children, causing a series of repercussions on their health. Infections by intestinal parasites are determined by economic and social development processes, having a high prevalence in low-income countries affecting individuals of all ages. Despite its high morbidity, its low mortality has hindered recognition as an important problem, resulting in underestimation of its severity; In addition, in specific cases such as helminthiasis, the problem is aggravated by its endemicity and chronicity.

The presence, persistence and dissemination of intestinal parasites are related to various factors that negatively affects natural socioeconomic and environmental conditions. The first refers to family economic poverty and malnutrition, fecal contamination of soil and food, drinking water, inadequate hygienic habits, low education, and lack of environmental sanitation. The natural environmental aspects refer to change in temperature, humidity, and soil conditions, which increase the viability and maturation of geohelminth eggs. In addition to the above, the parasites produce loss of appetite, increased metabolism, intestinal malabsorption, and lesions in the intestinal mucous membrane, all of which contribute to protein-energy malnutrition, iron deficiency anemia and learning problems.

The exposed situation has a greater impact on children, due to their susceptibility to infections; In addition, it is a group in which iron deficiency and nutritional anemias lead to functional disorders, increase mortality and retard growth and psychomotor development (Pan American Health Organization, 2021).

According to the World Health Organization, in Latin America and the Caribbean, more than 18 million people still practice open-air defecation, a condition that expands fecal-oral contamination and the transmission of intestinal parasites (Quizhpe, San Sebastián, Hurtig & Llamas, 2003, Ministry of Health, 2020).

The same entity establishes that anemia affects 27.7% of selected population groups including, preschool-age children, pregnant women, and women of reproductive age. The integrated care strategy for diseases prevalent in childhood, promoted by the World Health Organization, the Pan American Health Organization, and the United Nations in Colombia, highlights the seasonal proliferation symptoms that could be associated with intestinal parasitosis in minors from rural populations (Cardona-Arias et al., 2017).

Parasitic diseases that can be transmitted by water contaminated with soil or feces, are protozoa, such as: Entamoeba histolytica, Giardia intestinalis, Balantidium coli, Cryptosporidium spp., Cyclospora cayetanensis, Isospora belli, microsporidia, and helminths such as Ascaris, Ancylostoma, and Strongyloides.

These infections can affect any individual regardless of their immune status, age or socioeconomic condition and are usually accompanied by diarrhea, abdominal pain, and fever, in some cases (Heredia Martínez, Tovar Meléndez, Gallego Jaramillo & Naranjo García, 2015).

On the other hand, anemia is defined as a reduction in erythrocyte volume or hemoglobin concentration below the values registered for age (Behrman et al., 2004). It is the decrease in oxygen transported by erythrocytes towards the tissues, due to different factors, causing clinical manifestations according to the severity. In children 6 months to 6 years, there is anemia when hemoglobin is less than 10.5 g/dl, and in children 7 to 12 years, when it is less than 11g/dl. Although this is the most frequent factor, it should not be forgotten that other factors that need to be explored and treated according to the epidemiological situation present in the affected population can coexist, such as the presence of hematophagous parasites (Necator americanus and Ancylostoma duodenale), malaria, genetic diseases such as sickle cell anemia due to a type of abnormal hemoglobin (HbS), chronic inflammatory diseases and malignant diseases, mainly.

According to Quizhpe, San Sebastián, Hurtig & Llamas (2003), anemia is a global health problem that mainly affects developing countries. The causes of anemia can be multifactorial and often coincidental, but the main one is the low intake of food with adequate sources of iron in quantity and quality. It is assumed that 50% of the causes of anemia are due to iron deficiency.

The National Survey of Intestinal Parasitism in School Population in Colombia from 2012 to 2014, identified the oceanic island territories of the Colombian Caribbean biogeographic province as the highest prevalence of childhood anemia due to intestinal parasites (45.1% of the school population), followed by the Belt provinces Árido Pericaribeño and Orinoquía, both with prevalences of 30%, Amazonia province (29.6%), Guayana (25.1%), Chocó - Magdalena (24.6%), Sierra Nevada de Santa Marta (18.1%) and Norandina province (3.5%).

Villa Clarín is a neighborhood in Palermo, part of the Colombian Caribbean, whose socioeconomic and sanitary conditions are risk factors for the acquisition of intestinal parasitosis and anemia in children. This community reflects the situation of many rural areas in the northern territory of Colombia (Barrera-Dussán, Fierro-Parra, Puentes-Fierro & Ramos-Castañeda, 2018).

A cross-sectional study was carried out in the rural community of Villa Clarín, located in the Colombian Caribbean region. Ninety-four minors between 1 and 11 years of age participated in the study, grouped in the following age ranges. 1) 1 to 3 years, 2) 4 to 6 years, and 3) 7 to 11 years. Informed consent was obtained from the parents or responsible guardians.

Participants' feces were collected by spontaneous evacuation, which was analyzed using a spontaneous sedimentation technique. The density of the intestinal parasites was analyzed by counting the parasitic forms per microscopic field. Blood samples were obtained by venipuncture of the forearm using disposable syringes and processed through a hemogram.

The condition of anemia was found when hemoglobin levels were less than two standard deviations (-2 SD) from the mean hemoglobin distribution. Univariate analysis of the data obtained in the samples analyzed using contingency tables and crossed tabulation was applied with the variables intestinal parasitosis and hemoglobin levels. Pearson's Chi-square (χ2) was applied to analyze the independence between the variables.

The contingency coefficient was also used to measure the association between intestinal parasitism species and hemoglobin levels, a sign test to estimate the association between anemia and parasite densities, an estimate of the population means with the following hematological parameters: 1) hemoglobin, 2) hematocrit and 3) erythrocytes. A density relationship was also applied to relate each parasite to anemia. The densities ++ (h) in Ascaris lumbricoides, ++ (q) in Entamoeba histolytica / dispar, ++ (t) in Entamoeba coli, Blastocystis hominis and ++ (q) in Endolimax nana, are a reliable indicator in the estimation risk of developing anemia. The study hypotheses are the following: 1) the presence of protozoa and metazoan makes intestinal parasitosis prevail. 2) The younger population is more exposed to anemia (Table 1).

Table 1

Parasite density.
Observed parasites	Way to express
1 or 2	The name of the agent and its developmental stage was written
2 to 5	One cross (+)
6 to 10	Two crosses (++)
> 10	Three crosses (+++)

It was found a high presence of protozoa (57.14%) and metazoa (42.86%) in the population studied. The prevalence of intestinal parasitism was 96% in females and 98% in males, indicating similar eating habits in both groups (polyparasitism = 61.7%; monoparasitism = 35.11%).

Hemoglobin ranged between 9 and 14.5 g / dl. The prevalence of anemia by gender was slightly higher in males (11.11%) than in females (6.12%). The group from 1 to 3 years of age (13.33%) had a greater presence of anemia compared to those from 7 to 11 (8.82%) and from 4 to 6 years (3.33%) respectively.

Of the 91 participants in whom intestinal parasites were detected (96.81%), eight had anemia (8.51%), 54 showed a normal level of hemoglobin (57.45%) and 29 were above the normal (30.85%). The analysis of contingency coefficients found an association between hemoglobin levels and the species E. histolytica / dispar. The samples did not associate the species A. lumbricoides, T. trichiura, S. stercolaris, Uncinaria, Taenia sp, H. nana, H. diminuta, G. lamblia, T. hominis, B. hominis with hemoglobin levels. The chi-square test result was 1.67 with a P-value of 0.43 (see Table 2, 3, 4, 5, 6, 7).

Table 2

Changes in hemoglobin, hematocrit, and erythrocytes.
Males and females
Ages		1 a 1.99	2 a 4.99	5 a 7.99	8 a 11.99
Hemoglobin (g/dl)	Average	12.3	12.4	12.5	12.8
Hemoglobin (g/dl)	-2SD	10.7	10.7	10.9	11.0
Hematocrit (%)	Average	35.9	36.3	37.2	38.4
Hematocrit (%)	-2SD	32	32	33	34
erythrocytes (10⁶/mm³)	Average	4.34	4.34	4.41	4.52
erythrocytes (10⁶/mm³)	-2SD	3.8	3.7	3.1	3.8

Table 3

hemoglobin and hematocrit values.
Height in meters	Hemoglobin (g/dl)	Hematocrit (%)
<1.000	0	0
1.000	+ 0.2	+0.5
1.500	+ 0.5	+1.5
2.000	+ 0.8	+2.5
2.500	+1.3	+4.0
3.000	+2.7	+6.0
3.500	+1.9	+8.5
4.000	+3.5	+11.0
4.500	+4.5	+14.0

Table 4

Anemia by hemoglobin or hematocrit levels.
Levels	Anemia (%)
Severe	> ó = 40
Moderate	20.0 – 39.9
Mild	5.0 – 19.9
Low	< ó = 4.9

Table 5

Intestinal parasites found.
Test results	n	%
Pathogenic metazoa
Ascaris lumbricoides	41	25.47%
Trichuris trichiura	17	10.56%
Hymenolepis nana	5	3.11%
Strongyloides stercolaris	2	1.24%
Taenia sp	2	1.24%
Hookworm	1	0.62%
Tiny hymenolepis	1	0.62%
Subtotal	69	42.86%
Pathogenic protozoa
Entamoeba histolytica / dispar	21	13.04%
Giardia lamblia	2	1.24%
Subtotal	23	14.28%
Non-pathogenic protozoa
Endolimax nana	12	7.45%
Trichomonas hominis	10	6.21%
Blastocystis hominis	9	5.59%
Entamoeba coli	38	23.6%
Subtotal	69	42.86%
Total	161	100%

Table 6

Significance test of the contingency coefficient.
Intestinal parasites and Hemoglobin levels	Population		Study sample
	0 ≤ C ≤ 1		P < 0.05
	No association	Association	Relation
	C value	Association	P―value	Relation
Metazoan pathogens
Ascaris lumbricoides	0.2	Yes	0.14	No
Trichuris trichiurids	0.14	Yes	0.38	No
Hymenolepis nana	0.11	Yes	0.57	No
Strongyloides stercolaris	0.12	Yes	0.48	No
Taenia sp	0.21	Yes	0.12	No
Hookworm	0.15	Yes	0.36	No
Hymenolepis diminuta	0.15	Yes	0.36	No
Protozoos pathogens
Entamoeba histolytica/dispar	0.28	Yes	0.02	Yes
Giardia lamblia	0.22	Yes	0.09	No
Protozoos (non-pathogens)
Trichomonas hominis	0.24	Yes	0.06	No
Blastocystis hominis	0.2	Yes	0.15	No

Table 7

Estimation of the association by means of the signs´ test.
No association <0.05< Association
Species	Density	P―value	Association
Pathogens
Ascaris lumbricoides	++(h) and anemia	P = 0.07	Yes
Entamoeba histolytica/dispar	+(q) and anemia	P = 0.5	Yes
	++(q) and anemia	P = 0.36	Yes
	++(t) and anemia	P = 0.27	Yes
Non-pathogens			Yes
Entamoeba coli	++(t) and anemia	P = 0.62	Yes
Blastocystis hominis	++(t) and anemia	P = 0.6	Yes
Endolimax nana	++(q) and anemia	P = 0.5	Yes
Trichomonas hominis	++(t) and anemia	P = 0.27	Yes

Monitoring of the presence of parasitosis, protozoa, and metazoan in the population studied from previous reports (Cardona-Arias, 2017) generates an alarm about the hygienic-sanitary conditions in which the population studied is found, thus confirming the first hypotheses. The consumption of untreated water, inadequate environmental sanitation, and deficient hygienic-sanitary measures are the main triggers for the results found in this case report.

The worrying results may be due to unfavorable socioeconomic conditions, being this a rural community of extreme poverty. Regarding hematological findings, a higher prevalence of anemia is reported in the population under six years of age, followed by the population between 10 and 13 years of age. The youngest group had iron deficiency anemia, while the preschoolers showed normal values in the blood tests performed, thus confirming the second hypotheses. The low presence of anemia in older populations may be due to the consumption of foods subsidized by the Colombian government.

Anemia was found in eight participants associated with protozoan Entamoeba histolytica / dispar, which is the only species of intestinal amoebae that present pathogenic activity in humans. Its presence is a comorbidity factor in malnutrition and anemia in individuals under 6 years of age (Schneider et al., 2010). Inadequate excreta elimination allows cysts to spread into water and food sources which, in turn, are sources of infection when ingested, passing from the stomach to the large intestine where the cyst gives rise to the trophozoite and invading the intestinal mucosa. It is estimated that 90% of intestinal infections by this parasite are asymptomatic (Schneider et al., 2010). The chi-square test indicated independence between the variables of intestinal parasites and hemoglobin levels.

It should be borne in mind that routine treatment with deworming medications should be considered in each region or a particular country, according to their cost-effectiveness, the prevalence of infestations analyzed, and the impact that would generate on physical growth and cognitive functions in children (Schneider et al., 2010) since most of deworming programs assume that it is not necessary to diagnose the specific infestation, and consider that the common use of benzimidazole is sufficient for the eradication of common species of parasites, regardless of the difficulty this presents for the evaluation of the results of clinical trials, as the parasite species profoundly influence the risk of occurrence of anemia (Ugbomoiko, Dalumo, Danladi, Heukelbach & Ofoezie, 2012; World Health Organisation, 2020; Behrman et al., 2004; World Health Oeganisation, 2020).

This monitoring report contributes to a more in-depth understanding of the behavior of hemoglobin, hematocrit, and red blood cell levels, and their relationship with anemia in populations between one and three years of age in rural populations of developing countries.

Iron deficiency anemia is a condition that affects the health and well-being of the child population of our country, especially in rural areas of extreme poverty. Although this event report does not show an association between the presence of various intestinal parasites and the development of anemia, it does indicate deficiencies in environmental sanitation and the hygienic-sanitary measures of the observed community. The high prevalence of intestinal parasites in the children studied is a cause for alarm for regional authorities. It is necessary to create educational-sanitary intervention programs that prevent parasitic infections in infants. The results obtained in this territory can be assumed as a reflection of other rural communities with similar economic and sanitary conditions. More studies with larger samples are necessary to determine the prevalence of anemia due to intestinal parasites in children.

SPP: Species.

HbS: Hemoglobin S.

SD: Standard Deviation.

Ethics approval and consent to participate

The Education For All Online organization approved the ethical procedures and certified the consent of the target population to participate based on their parents' permission.

Consent for publication

All authors consent to the publication of this research article.

Availability of data and materials

The availability of data is based on its request to the corresponding author Mario de la Puente ([email protected]).

Competing interests

The authors declare no conflict of interest.

Funding

This research received no external funding.

Statement on ethics approval and consent

The participants in this case report verbally consented to the approval of the case report. This was verified by the Education For All Online Organization on January 14th, 2019 under file 212.21.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors declare no conflict of interest.

Authors' contributions

Rubén Darío Macías Vásquez and Darling María Guzmán; methodology, Rubén Darío Macías Vásquez and Darling María Guzmán; validation, Rubén Darío Macías, Vásquez and Darling María Guzmán.; formal analysis, María Ripoll Rivaldo; investigation, Rubén Darío Macías Vásquez, Darling María Guzmán and Darling María Guzmán; resources, Rubén Darío Macías Vásquez, Darling María Guzmán and Darling María Guzmán; data curation, Elkyn Rafael Lugo Arias and José Luis Lugo Arias; writing—original draft preparation, Rubén Darío Macías Vásquez, Darling María Guzmán and Darling María Guzmán; writing—review and editing, Mario de la Puente Pacheco; visualization, Mario de la Puente; supervision, Mario de la Puente; project administration, Rubén Darío Macías Vásquez, Darling María Guzmán and Darling María Guzmán; funding acquisition, Rubén Darío Macías Vásquez, Darling María Guzmán and Darling María Guzmán. All authors have read and agreed to the published version of the manuscript.

Acknowledgments

The authors thank the observed individuals for participating in the study.

Barrera-Dussán N, Fierro-Parra E, Puentes-Fierro L, Ramos-Castañeda J. Prevalencia y determinantes sociales de malnutrición en menores de 5 años afiliados al Sistema de Selección de Beneficiarios para Programas Sociales (SISBEN) del área urbana del municipio de Palermo en Colombia, 2017. Universidad y Salud. 2018;20(3):236.
[Internet]. Bvs.hn. 2020 [cited 13 December 2020]. Available from: http://www.bvs.hn/Honduras/pdf/Parasitismo.Intestinal.y.Anemia.en.ninos/pdf/Parasitismo.Intestinal.y.Anemia.en.ninos.pdf
Heredia Martínez H, Tovar Meléndez M, Gallego Jaramillo L, Naranjo García M. Capacidad Resolutiva de la atención Materna en el municipio Juan Germán Roscio de Guárico, Venezuela. Revista Facultad de Ciencias de la Salud UDES. 2015;1(1):8.
Cardona-Arias J. Determinantes sociales del parasitismo intestinal, la desnutrición y la anemia: revisión sistemática. Revista Panamericana de Salud Pública. 2017;41:1-9.
Pan American Health Organization. 2020 [cited 13 December 2020]. Available from: http://www.paho.org/hq/index.php?option=com_content&view=article&id=2470%3A2010-data-statistics&catid=1900%3Ahome&Itemid=2003&lang=en
Quizhpe E, San Sebastián M, Hurtig A, Llamas A. Prevalencia de anemia en escolares de la zona amazónica de Ecuador. Revista Panamericana de Salud Pública. 2003;13(6).
[Internet]. Minsalud.gov.co. 2020 [cited 13 December 2020]. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/ET/encuesta-nacional-de-parasitismo-2012-2014.pdf
Schneider M, Aguilera X, Barbosa da Silva J, Ault S, Najera P, Martinez J et al. Elimination of neglected diseases in Latin America and the Caribbean: A mapping of selected diseases. International Journal of Infectious Diseases. 2010;14:e284.
Schneider M, Aguilera X, Barbosa da Silva J, Ault S, Najera P, Martinez J et al. Elimination of neglected diseases in Latin America and the Caribbean: A mapping of selected diseases. International Journal of Infectious Diseases. 2010;14:e284.
Ugbomoiko U, Dalumo V, Danladi Y, Heukelbach J, Ofoezie I. Concurrent urinary and intestinal schistosomiasis and intestinal helminthic infections in schoolchildren in Ilobu, South-western Nigeria. Acta Tropica. 2012;123(1):16-21.
Helmintiasis transmitidas por el suelo [Internet]. int. 2020 [cited 13 December 2020]. Available from: http://www.who.int/mediacentre/factsheets/fs366/es/
Behrman R, Kliegman R, Jenson H. Nelson tratado de pediatria. Madrid: Elsevier; 2004.
World Health Organization. 2020 [cited 13 December 2020]. Available from: http://apps.who.int/iris/bitstream/10665/152781/1/9789241564861_eng.pdf?ua=1

Gastrointestinal Parasitosis and Anemia Monitoring in the Child Population of Villa Clarín, Colombia

Status:

Version 1

Abstract

Case Presentation

Background

Research Method

Results

Discussion and conclusions

Abbreviations

Declarations

References

Status:

Version 1