DOI: https://doi.org/10.21203/rs.2.23962/v1
Introduction
Several epidemiological studies suggest that the prevalence of intestinal parasites is high, especially in developing countries, and are amongst the major public healthchallenges facing Sub-Saharan Africa.The aim of this study was to determine the prevalence of intestinal parasites and its associated factors among food handlers in Woreda Medebay Zana, Tigray, Ethiopia.
Methods
A cross-sectional study was conducted among 401 food handler individuals selected by systematic random sampling.Binary and multivariable logistic regression was used to determine the possible association between the independent variable and outcome variables. Statistical significance was declared at p- value <0.05 with 95% confidence interval.
Result
The prevalence of intestinal parasites was 33.2% within this sample.The dominant parasite were Entamoeba coli 50(37.4%), followed by Entamoeba histolytica/dispar 24(18%), Entamoeba hartmanni 18(13.5), Giardia lamblia 17(12.8%), Schistosoma mansoni 8(6%), Hymenolepis nana 7(5.3%), Enterviousvermicularies 6(4.5%) and Taenia species 3(2.5%).
Conclusion
This study revealed a high prevalence of intestinal parasites among food handlers for a range of intestinal parasites. The significant predictors weresource of water, washing hands before food preparation, washing hands with soap and water after visiting toilet, shower installation, washing body regularly, and eating raw vegetables.
Infection with intestinal parasites remains a major public health challenge in developing countries where poor environmental sanitation, poor personal hygiene, and low level of education are prominent[1]. Globally, about one third of the total population is estimated to be infected with intestinal parasites, the majority being people living in tropical and sub-tropical parts of the world [2]. The World Health Organization (WHO) estimated that at least one quarter of the world’s population is infected with soil-transmitted helminthes[3]. Worldwide, about 300 million people suffer from severe helminthic infections, leading to morbidity and over 150,000 deaths annually[4]. The reasons for the incidence of parasites include climatic conditions, local traditions, and the use of human and animal fertilizers in agriculture and vegetable planting[5]. Food sold in markets may be contaminated by hands that have not been washed after defecation or from flies that land on both food and feces, thereby increasing the risk of transmission of intestinal parasites for consumers[6].
Regarding the etiologies, about1.2 billion people were infected with Ascaris lumbricoides, 795 million people with Trichuris trichiura, 740 million people with hookworm, 500 million people with Entamoeba histolytica, and 2.8 million people with Giardia lamblia[7]. As in many developing countries, cases of intestinal parasites are highly abundant in Ethiopia. The country has the second highest burden of Ascariasis, the third highest burden of hookworm, and the fourth highest burden of Trichuriasisin Sub-Saharan Africa[8].
Industrialization, urbanization, and population growth have promoted people to migrate from rural to urban areas, forcing them to have their meals at any place at an affordable price. In urban areas, there is mushrooming of eating establishments due to increased demand with the concomitant. potential to spread of disease via food handlers in those eating establishments[9]. The epidemiology of intestinal parasitesremains complex because of the diversity of associated factors involved, with the complexities of control highly relevant to addressing this escalating challenge [10]. In Ethiopia, particularly in the study area, intestinal parasitosis is a steadily increasing public health concern [11, 12]. Therefore, this cross-sectional study was conducted to assess the prevalence and associated factors of intestinal parasites in food handlers in Woreda Medebay Zana Towns,Tigray, Ethiopia.
This cross-sectional, community based study was conducted among food handlers working in food service establishments in Medebay Zana Towns from January 2019 to February 2019. Medebay Zana districtis about 1040kms from Addis Ababa. In the district, therewerea total of 277 restaurants and hotels, 44 snack bars and 52 food bakeries. These estalishments can accommodate a total of 1850 people. In total, in the hotels, restaurants and snack bars found in the Woredathere are 1050food handlers.
All food handlers who were working in Woreda Medebay Zana Towns were the source population;randomly selected food handlers formed the study population. Food handlers who wereunder treatmentor who who finishedtreatmentfor parasites within two weeks prior to the study were excluded.
The sample size was determined using the following assumptions (level of confidence of the population is taken to be 95% and Zα/2 = 1.96).A 5% margin of error (d = 0.05) and the prevalence of intestinal parasites among food handlers was based on a study done in Ethiopia, Tigray Mekelle Town at 49.3%[11]. Based on these assumptions, the actual sample size for the study is computed using one sample population proportion formula as indicated below.
Then, the sample size was, n ≈ 384 + 10% contingency = 422. A systematic random sampling technique was employed to select the study participants from the sampling frame.
Interviewers administered structured questionnaires adapted from different literatures to collect the data. The content of the questionnaire included socio-demographic characteristics, educational status, economic status, individual behavioral factors, and house characteristics as well as environmental related conditions.
Fecal specimens were obtained from the selected food handlers and transported to the laboratory based on the standard operating procedures for the collection and transportation of fecal specimens.In the laboratory the stool was immediately examinedby wet mount technique for motile parasites, helminth eggs,cysts, and oocysts of intestinal protozoa followed by Kato-Katz and formol ether concentration technique[13].
Dependent variable: Intestinal parasites status
Independent variable:Socio demographic variables, such asage, sex, monthly income, educational level, service in year; Individual factors, such as poor personal hygiene practice, using fresh vegetable salads and meat, irregular use of sanitizer and disinfectants, poor environmental sanitation, contact with water source, contact with animal, eating raw meat and vegetables; Economic factors, such aspoor quality of housing, poor isolation from work environment when sick, lack of supply of safe water, Lack of access to toilet facility, lack of medical check screening
To assure the data quality, the data collection instrument was pretested in nearby towns. Data collectors weretrained before the actual data collection by whom?. Furthermore, the collected data were reviewed and checked for completeness each day. Laboratory investigations were done as per the standard operating procedures for specimen collection, transportation, and analysis of the institution.
After checking for completeness, data were coded, cleaned, and enteredintoSPSS version 21.0 for analysis. Binary logistic regression was used to determine the possible associations between the independent variables and outcome variable.Those factors with p-value of 0.2 and below during the bivariate logistic regression analysis were considered for multivariate logistic regression to control the confounders. Finally, statistically significant was declared at p-value < 0.05 with 95% confidence interval.-
From the total of 422 study participants, 401 wereincluded in this research (95%), of which 377(94%) were females and the mean age of all study participants was 28.74 (± SD = 4.56).From the total participants, 21(5.2%) have completed college and above, 78(19.5%) completed secondary school, 273(68.1%) completed primary school, and the remaining 29(7.2%) were unable to read and write. The study also showed that212 (52.9%) participants had monthly incomes of between 500 and 900 birr and the remaining 189 (47.1%) participants earned ≥ 1000 birr monthly(Table 1).
| Characters | Category | Frequency | Percent |
|---|---|---|---|
| Sex | Female Male | 377 24 | 94 6 |
| Age | < 21 21–30 31–40 > 40 | 28 254 110 9 | 7 63.3 27.4 2.2 |
| Religious | Orthodox Muslim | 398 3 | 99.3 0.7 |
| Educational level | College and above Secondary school Primary school Unable to read and write | 21 78 273 29 | 5.2 19.5 68.1 7.2 |
| Monthly income | 500–900 birr 1000–1500 birr | 212 189 | 52.9 47.1 |
| Service in year | 1–5 year 6–9 year | 332 69 | 82.8 17.2 |
Responses of the study participants showed that 306(76.3%) washed their hands before food preparation, 73(18.2%) washed their hands usually, and 22(5.5%) washed their hands sometimes. Out of the total participants,222(55.4%) washed their hands with soap and water after using the toilet, 378(94.3%) washed their hands after touching dirty materials and different body parts, 180(44.9%) washed their body regularly in their working area, and 284(70.8%) participants had renewed their medical certificate every three months(Table 2)
| Characters | Category | Frequency | Percent |
|---|---|---|---|
| How often do you wash your hands before food preparation? | Always Usually Sometimes | 306 73 22 | 76.3 18.2 5.5 |
| Do you wash your hands by soap and water after visiting toilet? | Always Usually Sometimes | 222 147 32 | 55.4 36.7 8 |
| Do you wash your hands after touching dirty materials and d/t body parts? | No Yes | 23 378 | 5.7 94.3 |
| Do you wash your body regularly in your working area? | No Yes | 221 180 | 55.1 44.9 |
| Do you have a medical certificate? | No Yes | 0 401 | 0 100 |
| How frequent do you come to health center for medical checkup? | Every three month Every six month Every nine month | 284 70 47 | 70.8 17.5 11.7 |
| Do you wear clean aprons during food preparation? | N0 Yes | 137 264 | 34.2 65.8 |
| Do you wear clean hair garment during food preparing? | No Yes | 122 279 | 30.4 69.5 |
| How frequent do you cut your fingernails? | Two times per week One times per week One times per two week | 29 75 295 | 7.2 18.2 74.1 |
From the total of 401study participants, 386 (96.3%) used private tap water, 349(87%) hada shower facility in their working area, 287(71.6%) had separate dressing rooms in their working area, 310(77.3%) used water and detergent to clean utensils and drinking cups, and 87(21.7%) cleaned the kitchen floor at least three times per day (Table 3)
| Variables | Category | Frequency | Percent |
|---|---|---|---|
| What is the source of water in your working area? | Private tap Public tap | 386 15 | 96.3 3.7 |
| Does your working area have shower facility? | No Yes | 52 349 | 13 87 |
| Does your working area have separate dressing room? | No Yes | 114 287 | 28.4 71.6 |
| What do you use to clean utensils and drinking cup? | Only water Water and detergent Hot water and detergent | 53 310 38 | 13.2 77.3 9.5 |
| How frequently is the kitchen floor cleaned? | One times per day Two times per day Three times per day | 115 199 87 | 28.7 49.6 21.7 |
| Do you have toilet facility in your working area? | No Yes | 0 401 | 0 100 |
Based on microscopic stool sample examinations, eight species of intestinal parasites were identified with an overall prevalence of 33.2%.From the total species of intestinal parasites detected the most prevalent wasprotozoan 109(81.7%) followed by helminths 24(18.3%) (Table 4).
| Parasites category | Number (%) | Total (%) | |||
|---|---|---|---|---|---|
| Protozoan | 109(81.7) | ||||
| Entamoeba coli | 50(37.4) | ||||
| Entamoeba histolytica/dispar | 24(18) | ||||
| Entamoeba hartmanni | 18(13.5) | ||||
| Giardia lamblia | 17(12.8) | ||||
| Helminths | 24(18.3) | ||||
| Schistosoma mansoni | 8(6) | ||||
| Hymenolepis nana | 7(5.3) | ||||
| Enterviousvermicularies | 6(4.5) | ||||
| Taenia species | 3(2.3) | ||||
| Total | 133(100%) | ||||
The findings from the bivariate analysis showed that 13 variables meet the criteria of p- value < 0.2 to be included for multivariate analysis. From the total of 13 variables that met the criteria only 7 variables were significantly and independently associated with the occurrence of intestinal parasites.
The analysis from the multivariate logistic regression showed that those that use public tap water were11.5 times more likely to be positive for intestinal parasitescompared with those that used private tap [AOR = 11.59, 95% CI = 1.73–77.45], food handlers who washed their hands sometimes before food preparationwere 3.25 times more likely to be positive for intestinal parasitescompared to those who washed always[AOR = 3.25,95% CI = 1.33–7.92]. Those food handlers who washed their hands sometimes by soap and water after visiting toilet were 3.54 times more likely to be positive for intestinal parasites compared to those washedtheir hands always[AOR = 3.54,95% CI = 1.72–7.31]. Similarly, food handlers who have no shower facility in their working area were 3.84 times more likely to be positive for intestinal parasites compared to those who have shower facility [AOR = 3.84, 95% CI = 1.47–10.26]. Food handlers who have habit of eating raw vegetables and meats were 31.9times more likely to be positive for intestinal parasites compared to their counterparts[AOR = 31.92, 95% CI = 10.01–101.80]. (Table 5)
| Variables | Category | Intestinal parasite | COR(CI) | AOR(CI) | |
|---|---|---|---|---|---|
| No (%) | Yes (%) | ||||
| What is the source of water in your working area? | Public tap Private tap | 4(26.7%) 264(68.4%) | 11(73.3%) 122(31.6%) | 5.95(1.86-19.065) 1 | 11.59(1.73–77.45)* 1 |
| How often you wash your hands before food preparation? | Sometimes Usually Always | 8(36.4%) 34(46.6%) 226(73.9%) | 14(63.6%) 39(53.4%) 80(26.1%) | 5.95(1.91–5.482) 4.95(1.99–12.22) 1 | 3.25(1.33–7.92)* 4.12(1.13–15.05)* 1 |
| Do you wash your hands by soap and water after visiting toilet? | Sometimes Usually Always | 6(18.8%) 74(50.3%) 188(84.7%) | 26(81.2%) 73(49.7%) 74(15.3%) | 5.45(3.34–8.88) 23.96(9.17–62.57) 1 | 3.54(1.72–7.31)* 6.05(1.67–21.92)* 1 |
| Have you use your sick leave properly to obtain Rx? | No Yes | 56(47.9%) 212(74.6%) | 61(52.1%) 72(25.4%) | 3.21(2.04–5.03) 1 | |
| Does your working area have shower facility? | No Yes | 18(34.6%) 250(71.6%) | 34(65.4%) 99(28.4%) | 4.77(2.57–8.84) 1 | 3.84(1.47–10.26)* 1 |
| Do you wash your body regularly in your working area? | No Yes | 116(52.4%) 152(84.4%) | 105(47.5%) 28(15.6%) | 4.91(3.03–7.95) 1 | 2.48(1.09–5.61)* 1 |
| Do you have habit to eat raw vegetables &meat? | Yes No | 6(12.8%) 264(74% | 41(87.2%) 92(26%) | 19.46(7.99–47.34) 1 | 31.92(10.01–101.80)* 1 |
| Does your working area have separate dressing room? | No Yes | 55(48.2%) 213(74.2%) | 59(51.8%) 74(25.8%) | 3.08(1.96–4.85) 1 | |
| Do you wear clean aprons when you preparing food? | No Yes | 63(46%) 205(77.7%) | 74(54%) 59(22.3%) | 4.08(2.61–6.36) 1 | |
| Variables | Category | Intestinal parasites | COR(CI) | AOR(CI) | |
| No (%) | Yes (%) | ||||
| Do you wear hair garments during preparing food? | No Yes | 59948.4%) 209(74.9%) | 63(51.6%) 70(25.1%) | 3.18(2.04–4.98) 1 | |
| How frequent you cut your fingernails? (per week) | One times One times Two times | 184(62%) 62(82.7%) 22(75.9%) | 113(38%) 13(17.3%) 7(24.1%) | 1.93(0.79–4.664) 0.65(0.23–1.864) 1 | |
| How frequently the kitchen floor cleaned? (per day) | One times Two times Three times | 35(30.4%) 152(76.4%) 81(93.1% | 80(69.6%) 47(23.6%) 6(6.9%) | 30.85(12.30-77.38) 4.17(1.71–10.18) 1 | 13.73(4.21–44.77)* 2.51(0.85–7.39) 1 |
| Monthly income (birr) | 500–900 1000–1500 | 119(56.1%) 149(78.8%) | 93(43.9%) 40(21.2%) | 2.91(1.87–4.52) 1 | |
| Note: CI = Confidence interval AOR = Adjusted odds ratio COR = Crude odds ratio * =Significant associated factors | |||||
In this cross-sectional study, the overall prevalence of intestinal parasites among food handlers was 33.2% in Medebay Zana District, North West Tigray. The prevalence of intestinal parasites in this study was relatively higher than the studies reported in Ethiopia, Aksum Town at 14.5%[14], Gondar, Northwest Ethiopiaat 29.1%[15],North East India at 29.33% [16],Saudi Arabiaat 23%[17],Accra, Ghanaat 21.6%[18], Kenyaat23.7%[19],Omdurman, Sudan at 6.9%[20], Turkeyat 8.8%[21], and Sari and Northern Iranat 15.5%[22]. The prevalence of intestinal parasite in this current study among the food handlers was lower than study done in South West Ethiopia 44.1%[23], Bahr Dar Town 41.1%[24], Jima Town 48.2%[25], Tigray Mekelle Town 49.3%[26], and India Tertiary Care Hospital 40.5%[27].The prevalence of intestinal parasites in the current study wasconsistent with the studiesconducted in Southern, Ethiopia which was 36% [28] and study conducted in Qatar reporting 33.9% prevalence[29].
The variability from our current prevalence may reflect differences in socioeconomic status, climatic conditions, poverty, personal and community hygiene, and period of the study. Differences in the study time might have also contributed as our study was conducted during the time when irrigation movement was high; hence,the entire data set was collected during dry months which may contribute to raising the prevalence of schistosomiasis and other helminths. In many arid or semi-arid habitats, some protozoan parasites are common toward the end of the rainy season [20]. The cultural habit of eating raw meat in some areas may contribute to increasing presence ofhelminths[5].
In the present study, many intestinal parasitic infections were found with S.mansoni being the predominant parasite from helminths followed by Hymenolepis nana. This finding was relatively consistent with a similar study conducted in Aksum Town, Ethiopia[14].E.coliwas the most predominant parasite from protozoan parasites followed by E.histolytica/dispar which resembled findings from a similar study conducted in Southern Ethiopia, reporting the prevalence of (36%) [28].
Poor personal and environmental hygiene, including using public tap water and eating raw vegetables and meat among food handlers is a common practice that contributes to food and water borne as well as skin transmitted diseases[26]. Parasite eggs in the environment can contaminate vegetables and water source, then hands and subsequently foods,hence directly enter into the mouthas can ingested by eating raw vegetables and by scratching skins[22]. Hence, in this study,the untrimmed source of water, washing hands before food preparation, washing hands with soap and water after visiting toilet, shower facilities in the workplace, regular washing of one’s body, habit to eat raw vegetables & meat and kitchen floor cleaned were identified as determinant factors for intestinal parasites among food handlers.
In conclusion, this study revealed a high prevalence of intestinal parasite among food handlers who tested positive for different intestinal parasites.Sourceof water, hand washing after visiting the toilet and before food preparation, shower facilities, washing one’s body regularly, practices related to eating raw vegetables & meat, and kitchen floor cleanedwere the identified factors affecting food handlers risk of acquiring intestinal parasite in the study area.
Ethics approval and consent to participate: Ethical clearance was obtained from the Ethical Review Board, Institute of Biomedical Science Mekelle University. The respondents were informed about the objective and purpose of the study and written consent was obtained from each respondent. Confidentiality of the information was assured.
Consent for publication: Not applicable
Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Competing interests: We, the authors, declare no conflict of interests
Funding: This work was not funded by any external funding agent. Mekelle University College of Health Sciences supported the process of data collection.
Authors’ contribution: KR, KT, GB& MT: Conceived and designed the proposal, analyzed the data and wrote the initial version of the manuscript; HG, GG& MT, Wrote the final version of the manuscript. All authors read and approved the final version of the manuscript.
Acknowledgement
We would like to acknowledge the study participants for their willingness to participate in the current study
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