INCIDENCE OF URINARY SCHISTOSOMIASIS AND THE CONTRIBUTORY RISK FACTORS AMONG SCHOOL CHILDREN IN AGULU

ABSTRACT

The purpose of this investigation was to determine the incidence and association of urinary Schistosomiasis among a cross section of two primary school (Agulu migrant and Umuowelle primary school) in Agulu,Anaocha Local Government Area of Anambra state.A cross sectional study was done with a total of 60 participants that provided urine samples to be examined for urinary Schistosomiasis.The schools were Agulu migrant and Umuowelle primary school.The urine samples were examined using the sedimentation and flotation techniques.The study was carried out during the months of November to December 2015.The data was analysed and the following result were obtained: 25(41.6%) out of the 60 samples examined were infected; with the infection occurring high within the age range of 8-10 years 11(55%). of the 30 pupils sampled in umuowelle primary school, 12(40%) were infected while 18(60%) were not infected. 13(43.3%) out of the pupils examined from Agulu migrant school were infected and 17(56.6%)were not infected.Hence,based on d findings,it is clear there is a prevalence of urinary Schistosomiasis among school children in Agulu and therefore intervention in the study area is needed.

KEY WORD: Haematuria, Eosinophiluria, Schistosomiasis, Schistosoma haematobium, S.mansoni, S.japonicum, S.intercalatum, Niclosamide, Achloronitrosali_cylanilide, Praziquantel

CHAPTER ONE

INTRODUCTION

Schistosomiasis is also known as bilharzia or “snail fever”. It is a parasitic disease carried by freshwater snail infected with one of the five varieties of the parasite schistosoma. Found predominantly in tropics and sub-tropical climates. (Chitsulo, 2000), schistosoma ranks second only to malaria as the most occurring parasitic disease in the tropics (chitsulo, 2000).

1.1    BACKGROUND OF THE STUDY

The schistosomes or blood flukes belong to the class trematoda of the phylum platyhelminthes. They are parasites of the blood stream of warm blooded vertebrates. The species which infect man are schistosoma haematobium, s mansoni, s intercalatum and s japonicum. They cause the disease known as schistosomiasis or bilharziasis (uyama, 2011).

Urinary schistosomiasis caused by fluke worm s haematobium is one of the most common tropical disease which poses serious health hazard due to its associated morbidities. Globally, over 153 million people are infected with this parasitic infection (WHO 1999). In Nigeria, a good number of foci infections have been documented in various parts of the country (Egwunyenga et al, 1994).

In developing countries, the true epidemiological picture appears difficult because of inadequate researches in this direction despite its relevance in planning and control in any locality. This problem is compounded by the poor habits of people in developing countries in visiting hospital, for treatment. Also, self medication is still practiced as manifested by anthelmintic abuse. This act is worsened by presence of inadequate health facilities. One of the consequences of the self-medication of the anthelmintics abuse includes the suppression of the egg laying capacity of the worms. The net effect is erroneous diagnosis using ova in urine in any locality. This may also become evident in sub clinical cases and period of immaturity of the worms when they are yet to commence egg laying. Another obvious difficulty occurs during the early stages of infections. Although the uses of serological diagnosis are available, poverty poses a serious impediment to the applications of serology in the epidemiological work in these countries.

The spined eggs are laid in water, the eggs hatch into ciliated miracidia which bore into the tissues of certain freshwater snails, the intermediate host. Within the snail, each miracidium forms a sporocyst which reproduces asexually to give rise to cercariae (Raven and Johnson, 1996 cercariae production may continue for several weeks, over 300 being produced each day from a single sporocyst. The cercariae leaves the snail and swim in the water. They gain entry into man, the final host, by penetrating the skin. once in the body system, the cercariae develop into the adult fluke where they cause schistosomiasis.

Characteristic /features

  1. They are dioecious i.e sexes are separate and there is sexual dimorphism
  2. The male and female always occur together and the larger male carries the slender female in it’s ventral groove or gynecophoral canal.
  3. They live in the blood stream of vertebrates.
  4. The eggs are not operculate and are usually armed with a spine.
  5. The furcocercous cercariae penetrates directly through the skin into the definitive host
  6. It is a waterborne disease with water snails as the intermediate host.
  7. There are two suckers, an oral and a ventral sucker (acetabulum).
  8. The alimentary canal consists only of intestinal caeca without an anus. (Uyaeme, 2011).

Habitat.

Schistosoma haematobium occurs in the veins of the vesical plexus surrounding the urinary bladder of man. it is found throughout Africa, middle East and India. the skin or integument is spined. The snail hosts are members of the genus Bulinus which are freshwater snail. it is the agent of haematuria and in renal schistosomiasis, the eggs are voided via urine (Uyaeme, 2011).

Raven and Johnson (1996) stated that the widespread, introduction of irrigation in the tropic has contributed greatly to the spread of this serious disease, by spreading habitats for the snails that carry the worms. The disease is an occupational hazard because people are infected due to the type of occupation (job they do). It is water borne, people that frequent stagnant water bodies like lakes, streams, ponds, dams e.t.c are at risk of being infected. The presence of the appropriate snail host in a habitat is also important in the disease transmission. Pollution of water with human faeces and urine due to bad sanitary habits or disposition of human wastes in water bodies is also important.

Economic importance

Schistosoma haematobium causes schistosomiasis also known as Bilharzia. Hosts of the parasites are humans and affect about 200 million people worldwide and is considered one of the most serious pathogenic infections today (chitsulo, 2000).

S haematobium is pathogenic to humans and causes spot of blood in the urine and sometimes in the stool, this leads to haematuria (Uyaeme, 2011).

S haematobium causes cough, fever, skin inflammation and tenderness of the liver because the spined eggs attach to vital organs and cause tissue degeneration. Later stages may cause swelling and damaging of the liver and other organs. the eggs of S haematobium can clog the bladder neck and cause infection chronic schistosomiasis raises the incidence of bladder cancer in many middle eastern countries (Roberts et al, 2000).

Calcified eggs embedded in the bladder wall increase the chances of blockage of the vessels. Although other species of schistosoma are also of medical importance.

S haematobium is the only species that affects human urinary system (Baschi, 1991).

Considering the high morbidity and mortality associated with Schistosoma infection in man, it is important that before any control measures can be attempted, a thorough knowledge of the disease pathogen, the epidemiology, the life cycle and the economic importance as well as the egg shape must be well understood.

1.2   Statement of Problem

There are reports of urinary schistosomiasis all over Nigeria, which constitute a public health problem particularly among children. (Sulyman et al, 2009). The distribution of the disease is focal, aggregated and usually related to water resources and development schemes such as irrigation projects, rice/fish farming and dams.(mafe et al, 2000). This disease is predominant in Agulu owing to the fact that this town is surrounded by a lake and the inhabitants frequents the lake, while some always get in contact with water because farming is their major occupation.

1.3 Significance of the study

The significance of this study is to determine the incidence of urinary schistosomiasis among the inhabitants of Agulu. The importance of this study extends to revealing the contributory risk factors of the disease in Agulu and to suggest ways to control or prevent the disease.

1.4 Objectives of the study

  1. Determining the incidence of urinary schistosomiasis among the inhabitants of Agulu.
  2. Determining the socio-economic and environmental factors that can lead to urinary schistosomiasis among the inhabitants of Agulu.

iii. Developing strategies to control the disease in the town.

1.5 Scope of the study

This research work has been limited within Agulu and its environs. There are many school but only three primary school has been used. With this perspective, the analysis of the incidence of urinary schistosomiasis among both male and females of different ages in Agulu must not be neglected for a better result.

1.6 Limitations of the study

As a result of inadequate information, coupled with time and financial constraints, the study was not an easy one. Most of the inhabitants had the impression that giving out their urine should be seen as exposing themselves to danger hence their refusal to give out the sample, few refused as a result of ignorance and formal education.

CHAPTER TWO

LITERATURE REVIEW

Records indicates that bloody urine was a well recognized disease symptom in Northern Africa in ancient times.

In about 1950 BC, an Egyptian Pharoah wrote of urinary bladder disturbances that were probably Schistosoma haematobium

The criteria used to denote the disease was a dripping penis. At least 50 reference to this condition have been found in surviving Egyptian papyri and calcified eggs of Schistosoma haematobium have been found in Egyptian mummies dated back to 1200bC (Roberts et al, 2010).

The first Europeans to record contact with S. haematobium was a surgeon with Napoleon’s army in Egypt (1799-1801). They reported that haematuria was prevalent among the troops, although this was unknown. Over 50 years later precisely 1851, a young German pathologist Theodor Bilharz discovered the parasite that caused it while working at Kasr El-Eini hospital in Cairo. It was discovered some years later that 30% to 40% of the population in Egypt have infection of Schistosoma haematobium.

In 1858, Weinland proposed the name Schistosoma but it was named Bilharzia by cobbold after the discovery by Theodor Bilharz. This name later became widely accepted throughout the world. However, the strict rules of zoological nomenclature decree prefers Schistosoma and is this an apt name, referring to the “split body” (gynecophoral canal) of the male.

While information was accumulating on the biology of S. haematobium, some people began to doubt whether it was a single specie or two or even more. This problem was more complicated by the observation in some patients of eggs with lateral spines and others with terminal spine in both urine and faeces.

In 1905, Sir Patrick Manson decided that intestinal and vesicular (urinary bladder) Schistosomiasis were different disease caused by different species of worms. He derived his conclusion after examining a man from West Indies who had never been to Africa, and who passed laterally spined eggs in his urine (Robert et al, 2010).

Human contact with the infection arise from four basic needs: Occupational, recreational, domestic and socio-cultural activities. The demands of occupation, life fishing and rice farming in which many in the rural areas are engaged, bring them into close contact with water. Obviously, such people are constantly exposed to infection (Ukoli, 1990). Ritual ablutions by muslims before prayer and their custom of washing the anus after defecation, which ordinarily should deserve commendation as an act of cleanliness are ironically act which tends to increase the risk of infection. This is because the water used for this purpose may be infected, in fact some of the ablution basins at the mosques happens to be good habitat for snail (Ukoli, 1990).

GEOGRAPHICAL DISTRIBUTION

       Schistosomiasis is estimated to occur world-wide infecting over 200 million people and endemic in 74 developing countries while leaving over 600 million people at risk. (Chitsulo et al, 2000). WHO (2000) estimate suggests that 85% of all schistosomiasis is endemic in 54 African countries and that the Eastern Mediterranean harbor it most. It is also in Iran, Saudi Arabia, Syria, Arab republic, Yemen in Maharashtra state in India and in several India ocean Islands including Mauritius, Recombina, Zanzibar and some smaller Island off the East African coast (cheesbrough 2003).

Schistosoma mansoni the causative agent of intestinal schistosomiasis is prevalent in 52 countries, Madagascar, and parts of middle east, south America (especially Brazil), and the west Indies. S. Mansoni occurs with S. haematobium in 41 countries of Africa and the eastern Mediterranean. (cheesbrough, 2003)

Schistosoma japonicum is widely distributed in mainland china, parts of the philippines and western Indonesia.

schistosoma intercalatum is limited in it’s distribution mainly to west and central Africa, that is Zaire, gabon and cameroun. Republic of Sao Tome (island off west Africa) recently recorded infection of S. intercalatum.

Cheesbrough (2003) noted that the development of irrigation channel and dams for hydroelectric power and flood control have altered the distribution of schistosomiasis in several countries, example Aswan lower dam in the United Arab Republic[Egypt],Akosombo dam in Ghana,the Sennar dam in Sudan, kainji dam in Nigeria, and the kariba dam in Zimbabwe.

In Nigeria, a good number of infection have been documented in various parts of the country. In the northern region, S. haematobium is marked particularly by heavy infection rates. These include the territory extending from Katsina, Kano,Zaria and Kaduna to the Western frontier, in the region of Birnin kebbi, argungu, kankiya area (Nmorsi et al, 2005). In these areas, schistosomiasis associated with haematuria, infection rate of up to 60% to 95% have been recorded (Onwe, 2005).

Several works by Ekejindu et al, (2002), Uneke et al (2007), Uwaezuoke et al (2008), Mbata et al (2009), all indicates high prevalence in the southern parts of Nigeria.

MORPHOLOGY.

Schistosoma specie are generally similar structurally with slight differences as listed below:

S. haematobium S mansoni S. japonicum.
Male: size; 10-15mm 10-15mm 12-20mm.

 

Width: 08-1.0mm 0.8-1.0mm 0.5-0.55mm
Female:lenghth:20mm 20mm 26mm
Width: 25mm 25mm 0.3mm

 

S. haematobium S mansoni   S. japonisum.
No of testes: 4-5 6-9 7
Position of ovary: near mid body. In anterior half Positerior to mid body.
Uterus: with 20-100 eggs at a time. Short, few eggs at one time Long, contain 300 eggs

 

(Roberts et al, 2010).They have narrow elongated bodies and have separate sexes (Ochei et al, 2000). Considerable sexual dimorphism exists in the genus, males being shorter and stouter than the females.

An investigation into the relationship between S haematobium infection and urinary tract infection among children in south eastern Nigeria by Eyong et al (2008) showed that the prevalence of urinary schistosomiasis was (51.0%). one hundred and seventy five (77.48) of those infected had mild intensity of infection (< 49 ova/10ml). significant bacteriuria was found in 2 ( 0.9%) of the 226 children with urinary schistosomiasis and in 4 (1.8%) of the 217 children without urinary schistosomiasis. (Eyong et al, 2008).

In a study carried out by Bala et al, (2008) of the prevalence and intensity of infection with S. haematobium amongst primary school children of Taga Tanzania East Africa showed S. haematobium infection in four urban and four rural primary schools in the area. Out of the 2270 children examined 38.4% were found infected. In urban school, 2311% of 1411 children were infected compared to 63.6% of 859 children in rural school. Prevalence was higher in rural school children than in urban school children. This probably is due to the level of exposure of urban and rural children. The urban children were not very much exposed to fetching water from streams like the rural children except in situation where the tap water is not available.(Bala et al, 2001).

A study of prevalence and intensity of urinary schistosomiasis were carried out in two communities of Toro local government of Bauchi state between march and September 1991 by Elekeh(1994).Of the1,089 urine examined, 256 (23.6%) had infection. infection rate was significantly high (41.1%) at Bariga than Toro (13.6%). Prevalence (24.9%) and intensity of infection (21 eggs / 10ml of urine) were high among children under 15 years of age than among older people. males had higher infection rate than females. the difference was not statistically significant. prevalence varied among various occupational group (Elekeh 1994).

Investigation of urinary schistosomiasis among children by Adebayo and Ogunkune,( 2002) in a metropolitan city south west Nigeria showed a high prevalence rate of urinary schistosomiasis among school children in Ibadan especially those between 12-13 years of age. This observation is similar to those made in Gambia, Zimbabwe and some parts of Northern states of Nigeria. These results are not unexpected as the children in this age bracket are very active and adventurous and were observed during the course of this study to be wading through water and also swimming-playing in the adjacent stream to their schools. The infections were more in males than in females due to the fact that males are found always in the stream swimming, wading, playing e.t.c. (Adebayo and Ogunkunle, 2002)

A study by Nmorsi et al in Ikpeshi, a rural community of Edo state showed that 195 (65%) out of 300 volunteers harboured schistosoma haematobium ova in their urine. Eosinophiluria was markedly significant >5 eosinophilic leukocyturia/hpf and reported among 250 (83.3%) inhabitants of these, ova were absent in 55 (22.0%) of urine samples but had other associated urinary symptoms namely; proteinuria or haematuria or both. Eosinophiluria among the inhabitants with light infection as described by <50 ova/10ml was 15.83 (+- 15.98×10 9/L) while heavy infections (> 50 ova/10ml of urine ) was 107 (+- 76.20×10 9/L). in all, the eosinophiluria showed a positive correlation with the S haematobium ova excreted in their urine (R = 0.40046,p<0.05). The sensitivities of the urinary symptoms are eosinophiluria, (100%), proteinuria (56.0%), haematuria (80.0%), specific gravity (84.0%) and turbidity (76.0%). The eosinophiluria with a relatively highest sensitivity can complement the use of ova in urine as a diagnostic marker especially in sub clinical cases and other periods when egg laying capacity of this fluke are suppressed or absent. (Nmorsi et al 2004).

In a study carried out Nmorsi et al, 2000 assessing the ova of S. haematobium in the urine of 138 volunteers in thieve Ogben Edo state revealed 43 positive result (31.2%) with children having higher prevalence of urinary schistosomiasis 30 (41.1%) than their adult counterparts. this was attributed to high exposure factor among the children as had been previously reported by Egwunyenga et al (1994). (Nmorsi et al, 2000)

A study of the prevalence of urinary schistosomiasis in Ogbadibo local government area of Benue state showed that out of 657 urine samples examined, 300 (46.6%) showed the presence of S. haematobium. Of the 300 positive samples 152 (23.13%) were from males and 148 (22.52%) were from females. (Egwunyenga et al,1994)

In a survey of S. haematobium among school children in Ohaukwu and Onicha local government area of Ebonyi state by Uneke et al,( 2007) indicates that out of a total of 876 pupil examined, 235 (26.8%) were infected with S. haematobium, a total of 129 (27.01%) were males while 106 (26.6%) were females. This goes on to show that males are more infected than the female counterpart. This was equally supported by the study conducted by Okwelugo et al, (2012). This may be attributed to high exposure of the males who are mostly involved in recreational activities of swimming and agricultural endeavours. (Uneke et al, 2007)

An investigation on the prevalence and severity of infection with S. haematobium amongst inhabitants of Ebonyi/Benue river valley, south eastern Nigerian between August 2000 and June 2001 by Anosike et al 2003 showed that of 3296 subjects examined, 776 (23.5%) were excreting the eggs of S. haematobium in their urine. The prevalence and severity of infection increased with age from 6 to 25 years. This was attributed to the presence of infect snail host in the stagnant ponds of which many snail species were recorded including Bulinus globosus and Bulinus truncatus. (Anosike et al, 2003)

A study was conducted to determine the prevalence and intensity of urinary schistosomiasis in Alabama district of Gusau local government area of Zamfara state, collected and analyzed for the eggs of S. haematobium using the standard filtrate technique out of which 296 (74.0%) were found to be infected. The mean egg intensity of infection was 77.63 eggs/10ml of urine. The infection rate was higher among males (81.7%) than the females 968.6%) although the difference was not statistically significant (p>0,005). The males had higher mean egg intensity of 139.36 eggs/10ml urine compared to the females with 38.16% eggs/10ml of urine. The highest infection was recorded in the age group 10-19 years, with 86.8% and egg mean intensity of 102.7 eggs/10ml of urine while the least infection 50-59 years age groups, with 55.0 and 50.0 eggs/10ml of urine respectively indicating infection to be age specific (p<0.05).Statistical analysis indicated the infection to be higher in lower age group (p<0.05) with respect to occupation, students were the highest infected (87.65%), followed by farmers (85.7%), traders (75.0%) wives (58.7%) and civil servants (12.5%). Prolonged contact with water was a factor aiding infection as the people engaged in farming had the highest mean intensity of 112.18 eggs/10ml of urine, while the least mean egg intensity occurred among those that engaged in swimming with 32.13 eggs/10ml of urine. these findings indicate that the area is endemic to urinary schistosomiasis and therefore prompt intervention in the study area is needed.

A preliminary parasitological and malacological survey Bala et al, (2001) was affected in rural communities of some local government area in plateau state, Nigeria by (Akufongwe et al, 1996) to estimate the prevalence of urinary schistosomiasis and identify active transmission foci out of 2888 persons examined in six LGA’s 1381 (47.82%) were excreting eggs of S. haematobium in their urine. Prevalence rates did not vary significantly (p>0.05) between the LGA’s: Pankshin (62.4%), Shendam (40.2%),qua’an-pan (22.9%), langtang south (45.4%), langtang north (58.8%) and Wase (50.0%). Infection rates were significantly different (p<0.001) between the sexes. Many water bodies in the study communities were colonized by infected Bulinus snails. Snail infection rates varied significantly (p<0.001) between the dry and wet seasons. A positive correlation was observed between snail infection rates and the prevalence of S. haematobium. (Akufongwe et al, 1996).

In an investigation on the prevalence, intensity and clinical symptoms/signs of urinary schistosomiasis by Okoli et al,( 2004) in Imo state, Nigeria, urine samples were assayed for urinary schistosomiasis in four local government area (LGA) of Imo state, Nigeria, between may 1998 and September 2000. A total of 3504 persons were sampled with 880 (25.1%) being positive for urinary schistosomiasis based on records of eggs of S. haematobium. The prevalence of S. haematobium Oguta (38.9%) and owerri-west (10.4%) showing the highest and the lowest values, respectively. Prevalence was higher in males (67.4%) than in females (32.6%) and in subjects 11-20 years of age (31.5%) while prevalence varied among different occupational groups, with farmers ranking the highest (41.6%). Visible haematuria was the predominant symptom (p<0.05). Of 880 persons positive for eggs of S. haematobium, 452 (51.4%) had visible haematuria, followed by suprapubic pains 214 (24.3) and painful micturition 97 (11.0%). although 367 (10.5%) of the sample subjects with eggs of S. haematobium showed no visible haematuria, 513 (14.6%) clearly demonstrated haematuria. (Okoli et al, 2004).

In a study on the incidence of schistosomiasis in primary school pupils with particular reference to S. haematobium in Maiduguri by (Musa et al) showed that the total of 744 urine samples collected within three weeks in the month of September 2004 in sterile universal containers from pupils from 10 different primary schools in Maiduguri metropolitan council, 110 (14.5%) was the overall incidence of S. haematobium. 115 (15.5%) had haematuria but had no schistosomiasis. The incidence of S. haematobium infections with negative haematuria (no blood in urine) was 21 (2.8%) the maimalari, shehu sanda I and Maiduguri primary schools recorded the highest number of schistosomiasis incidence. Incidence according to sex was higher in the males (517) than females (227), which were 85 (16.4%) and 25 (11%) positive respectively, and gave a difference of 60. Incidence according to age was 40 (15.0%) and highest within the group 12-15 years with total number 267. The result of this study agrees with the work of Robert and Cirillo, (2002). Musa et al, (2010)

Urine samples can be examined qualitatively after centrifuging. Eggs are not shed at a steady rate during day, they are shed/excreted around midday and microscopic examination of a centrifuged urine specimen collected at this time usually reveals ova in light infections, examination of increased quantities of urine is sometime required (AMY, 2002).