Research ArticlePrevalence of Soil-Transmitted Helminthiases andSchistosomiasis in Preschool Age Children in Mwea DivisionKirinyaga South District Kirinyaga County and Their PotentialEffect on Physical Growth

Stephen SifunaWefwafwa Sakari1 Amos K Mbugua2 and Gerald M Mkoji3

1 Institute of TropicalMedicine and InfectiousDiseases (ITROMID) JomoKenyattaUniversity of Agriculture and Technology (JKUAT)PO Box 62000 Nairobi 00200 Kenya2College of Health Sciences Jomo Kenyatta University of Agriculture and Technology (JKUAT) PO Box 62000 Nairobi 00200 Kenya3Centre for Biotechnology Research and Development Kenya Medical Research Institute (KEMRI) PO Box 54840Nairobi 00200 Kenya

Correspondence should be addressed to Stephen Sifuna Wefwafwa Sakari sakaristephengmailcom

Received 14 February 2017 Accepted 21 June 2017 Published 23 August 2017

Academic Editor Jean-Paul J Gonzalez

Copyright copy 2017 Stephen Sifuna Wefwafwa Sakari et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Intestinal parasitic infections can significantly contribute to the burden of disease may cause nutritional and energetic stressand negatively impact the quality of life in low income countries of the world This cross-sectional study done in Mweairrigation scheme in Kirinyaga central Kenya assessed the public health significance of soil-transmitted helminthiases (STH)schistosomiasis and other intestinal parasitic infections among 361 preschool age children (PSAC) through fecal examinationby measuring anthropometric indices and through their parentsguardians by obtaining sociodemographic information Bothintestinal helminth and protozoan infections were detected and among the soil-transmitted helminth parasites there wereAscarislumbricoides (prevalence 3) Ancylostoma duodenale (lt1) and Trichuris trichiura (lt1) Other intestinal helminths wereHymenolepis nana (prevalence 36) and Enterobius vermicularis (lt1) Schistosoma mansoni occurred at a prevalence of 55Interestingly the protozoan Giardia lamblia (prevalence 147) was the most common among the PSAC Other protozoanswere Entamoeba coli (39) and Entamoeba histolytica (lt1) Anthropometric indices showed evidence of malnutrition Intestinalparasites were associated with hand washing behavior family size water purification and home location These findings suggestthat G lamblia infection and malnutrition may be significant causes of ill health among the PSAC in Mwea and therefore anintervention plan is needed

1 Introduction

Soil-transmitted helminthiases (STH) and schistosomiasisare listed among the many Neglected Tropical Diseases withan established association to chronic disabling and disfig-uring conditions occurring in settings of extreme povertyand even more so in rural poor and disadvantaged urbanpopulations characterized by poor sanitation [1ndash3] Theycontribute significantly to the burden of disease causingnutritional and energetic stress negatively impacting thequality of life and as such these parasitic infections have also

been associated with malnutrition which contributes to morethan one-third of all deaths of under-five children [2]

Estimates show that in sub-Saharan Africa (SSA) about198 million people are infected with hookworms [4] 192million with schistosomiasis infection [5] 173 million withascariasis infection [4] and 162 million with trichuriasisinfection [4] Based on the initial global percentage preva-lence determined over 60 years ago [6] it is believed that theprevalence of STH has remained relatively constant in sub-Saharan Africa [4] where between one-quarter and one-thirdof sub-Saharan Africarsquos population is affected by one or more

HindawiJournal of Tropical MedicineVolume 2017 Article ID 1013802 12 pageshttpsdoiorg10115520171013802

2 Journal of Tropical Medicine

STH infections [4] with preschool age children and schoolage children carrying the highest prevalence and intensities[7 8] Available data estimates over 270million preschool agechildren and over 600million school age children live in areascharacterized by intense transmission of intestinal parasites[9] These infections have also been strongly associatedwith malnutrition [10] which is known to contribute tomore than one-third of all deaths of under-five children[11]

In Kenya the National Multi Year Strategic Plan forthe Control of Neglected Tropical Diseases has prioritizedintestinal worms among other NTDs (Neglected TropicalDiseases) as diseases of great public health importancemostlyaffecting the poorest of the poor [12]

Recent studies in Kenya estimate that about 6 millionpeople are infected with schistosomiasis and even more areat risk [13] The prevalence is set to range from 5 to over65 in various communities in Kenya It is endemic in 56districts with the highest prevalence for Schistosomamansonioccurring in lower Eastern and Lake Regions of Kenyaand in irrigation schemes [14] The Kenya Demographicand Health survey has also shown that 353 of under-five children were stunted nationwide 67 were wastedand 163 were underweight suggesting the significance ofthe burden of malnutrition particularly in rural Kenya [15]To what extent the burden of malnutrition is contributedby intestinal parasites in particular helminth infectionsremains to be accurately determined [16]

The prevalence of intestinal schistosomiasis STH andother intestinal parasitic infections in preschool age children(PSAC) in the Mwea rice irrigation scheme of KirinyagaCounty in Central Kenya is not well documented butaccording to research done in an endemic community inWestern Kenya the prevalence in PSACwas demonstrated tobe up to 37 [17] indicating the significant risk of infectionin this age group in an endemic setup Although there isa national school deworming programme which to date isstill being implemented at the national level the control pro-gramme has no clear policy for inclusion of PSAC (le5 yearsold) in the mass treatment for STH and schistosomiasis Thisthus highlights the need for a baseline survey to determine theprevalence intensity and possible effects on nutritional statusof schistosomiasis and STH among other intestinal parasitesin PSAC

In view of the lack of information regarding the preschoolage children this study was undertaken to determine theprevalence of intestinal parasites in this age group the riskfactors favoring the spread of the parasites and subsequentlythe possible association between the parasitic infections andthe nutritional status

2 Materials and Methods

21 Study Area This study was conducted in the Mwea Divi-sion of Kirinyaga South district in Kirinyaga County centralKenya (00∘4010158405410158401015840S 037∘2010158403610158401015840E)This area is approximately110 km North East of Nairobi and the main agriculturalactivity is rice farming which is grown under flood irriga-tion Mwea is situated in the lower altitude zone (approx

1150mASL) of the district in an expansive flat land mainlycharacterized by black cotton and red volcanic soils MweaDivision has a land area of approximately 5428 sq KmMweaDivision has a population of 190512with an urban populationof 7625 (census 2009) The specific area (survey area) ofstudy was Thiba ward which comprises Nguka and Thibasublocations of Kirinyaga County which is approximately34 sq Km with a population of 31689 The nearest largetown and administrative centre for Thiba ward is WangrsquouruTown

The geography of the area is mainly flat at an altituderanging from 1150 to 1200mASL

The area is mainly known for its horticultural cropfarming where the main cash crop is rice grown under floodirrigation followed by maize

The setting for the study site was largely a rural and peri-urban population

22 Study Design The study was a comparative cross-sectional study carried out to collect both quantitative andqualitative data Based on the objectives the study designinvestigated the possible association between infections andintensities of STH and schistosomiasis among other intestinalhelminth infections on the one hand with indicators ofcurrent physical growth status on the other

23 Study Population The target population of the study wasgenerally preschool age children between ge2 and le5 yearsof age who have at least lived in the area under study forthe past 6 months Using a random sampling techniquethe study selected 13 schools within the study area Theschools included Kandongu Primary School Kiorugari Pri-mary School Mbui Njeru Primary School Mukou PrimarySchool Ngurubani Primary School AIPCA Primary SchoolRurumiNursery SchoolThiba Primary SchoolMidlandDayCare Sibling Day Care St Joseph Day CareThiba Glory DayCare and Vision Day Care centres Parents and guardians ofall eligible childrenwere invited to ameetingwhere out of 517parents in attendance 361 consented to allow their childrento participate in the study and 361 childrenwere enrolled intothe study

24 Data Collection For every child recruited a uniqueidentifier number was assigned and information regardingthe childinfantrsquos name sex and age and area of residence(ie rural or urban) was collected A questionnaire wasalso administered to consenting parents and guardian andwas used to collect socioeconomic information of the par-entsguardians and other behavioral information of the par-ticipating children considered to be relevant in contributingto the risk of infection

241 Questionnaire Following the acquisition of aninformed consent from the parents or guardians ques-tionnaires were administered to the parents of the enrolledchildren The questionnaires were provided in both Englishand Swahili The study also recruited translators in the locallanguage (Kikuyu) to help parents better understand thequestionnaire

Journal of Tropical Medicine 3

242 Anthropometry All children were examined by a qual-ified and registered community nursecommunity healthworker recruited by the study who carried out physical exam-ination andmeasurements to obtain their weight age heightand mid-upper arm circumference These parameters werecollected as per the guidelines in the National Health andNutrition Examination Surveyrsquos Anthropometry ProceduresManual developed by the United States Centre for DiseaseControl and Prevention (CDC) For purposes of accuracythe instruments were calibrated regularly and random repeatmeasurements were done as a quality control measure Fromthe measurements 119885-score values for height-for-age (HAZ)weight-for-age (WAZ) and weight-for-height (WHZ) werecalculated and used as indices for nutritional status

243 Stool Samples Collection andExamination Each partic-ipant was provided with a stool sample collection containerwith unique identifiers and with the help of activity coordi-nators approximately 4 grams (gm) of fresh stool sample wascollected using polypots from each participating child

From each sample collected Kato-Katz thick smears wereprepared for examination under a compound microscopeThe fecal smears were prepared in duplicate on glass micro-scope slides to improve detection levels The samples wereprocessed within an hour of collection time The Kato-Katz technique was mainly used to detect eggs and ovaof Schistosoma mansoni Ancylostoma duodenale Ascarislumbricoides and Trichuris trichiura Where infection wasdetected intensity of infection was also noted and graded aseither heavy moderate or low in accordance with the WHOproposed criteria [18 19]

Further diagnosis using the formol concentration tech-niquewas done to detect presence of other intestinal parasitesof public health significance thatmay have passed undetectedin the Kato-Katz technique Following diagnosis subjectswere divided into 3 groups uninfected infected with a singlespecies and infected with two or more species of intestinalhelminthes

25 Study Approval The study protocol was approved bythe Scientific and Ethics Review Unit of the Kenya MedicalResearch Institute Approval to carry out the study in thearea was also sought from administrative authorities in theschools the Mwea Division Health Administration and theKirinyaga County Health Administration Prior to enroll-ment of the study subjects a meeting with parentsguardiansof all eligible children was called with the help of theschoolsrsquo administration so that the study purpose objectivesand procedures to be used could be explained includingparticipantsrsquo rights if they both accept or decline to have theirchildren participate in the study Written informed consentwas obtained and the children were recruited into the studyThe parentsguardians were assured of the privacy and con-fidentiality of the information collected All children foundto be infected with intestinal parasitic infections receivedthe appropriate medication prescribed by a qualified andregistered clinician where albendazole (for soil-transmittedhelminthes) and praziquantel (for schistosomiasis) wereadministered in their recommended doses as per the WHO

recommendations [18] Other infections or conditions werereferred to the local health clinic

26 Statistical Analysis The data collected was first enteredand stored into Microsoft Excel 2010 The data was verifiedand crosschecked for errors A copy of the data was thenrecoded and exported into Statistical Package for SocialSciences (SPSS) Version 20 and baseline descriptive statisticswere drawn

Comparison of weight and height against infection statuswas done using independent 119879-test to assess significantdifferences in weight and height between the infected andthe noninfected ANOVA test was used to assess differencein height and weight between the noninfected infected andthose with multiple infections

Anthropometric data was exported toWHOAnthro [20]where WAZ HAZ and WHZ were derived and used todetermine nutritional status The anthropometric variableswhere applicable were reported as mean plusmn standard deviation(SD) 95 confidence interval

Based on the119885-score values obtained forWAZHAZ andWHZ the children were categorized as normal (le2 and geminus2119885-score) underweight (geminus3 and ltminus2 119885-score) or severelyunderweight (ltminus3 119885-score) stunted (geminus3 and ltminus2 119885-score)or severely stunted (ltminus3 119885-score) and wasted (geminus3 and ltminus2119885-score) or severely wasted (ltminus3 119885-score)

Binary variableswere compared using Studentrsquos 119905- test andChi-square test where applicable

Demographic and socioeconomic data were entered ascategorical variables and the frequencies and percentageswere calculated Later they were assessed using a binarylogistic regression model with the baseline category as theleast likely to result to an infection outcome

All statistical tests were evaluated for significance at 119875 lt005 95 CI (confidence interval)

3 Results

31 General Characteristics of the Study Group A total of 361children were recruited into the study of which 5040 weremale (119899 = 183) and 4960 female (119899 = 178) The meanage in months was 4662 plusmn 968 (4562ndash4762) 95 CI Meanheight was 10178 plusmn 657 cm (10110ndash10245) 95 CI andmeanweightwas 1471plusmn208 kg (1449ndash1492) 95CI Table 1gives an overall summary of the study group demographicswhile Table 2 provides an age group sex distribution of thepopulation

The same number of families participated in the ques-tionnaires determining behavioral trends and socioeconomicstatus and summary of the responses is tabulated on Table 3

32 Parasitological Investigations Out of the total 361 chil-dren enrolled in the study 108 children (299) were foundto be infected with an intestinal parasite of which 15 (39)had multiple parasite infections Prevalence of each parasiticinfection is shown in Table 4 The prevalence of Ancylostomaduodenalewas at 06Ascaris lumbricoides 33 Entamoebahistolytica 03 Enterobius vermicularis 083 Entamoebacoli 388 Giardia lamblia 1468 Hymenolepis nana 36

4 Journal of Tropical Medicine

Table 1 Summary of anthropometric descriptive statistics of the sampled study population

Mean Confidence intervalAge in monthsMale (119899 = 183) 4630 plusmn 1001 (4485ndash4775) 95 CIFemale (119899 = 179) 4693 plusmn 936 (4555ndash4830) 95 CITotal 361 4662 plusmn 968 (4562ndash4762) 95 CIHeight in cmMale (119899 = 183) 10134 plusmn 643 (10041ndash10227) 95 CIFemale (119899 = 178) 10223 plusmn 669 (10124ndash10321) 95 CITotal 361 10178 plusmn 657 (10110ndash10245) 95 CIWeight in kgMale (119899 = 183) 1480 plusmn 206 (1450ndash1510) 95 CIFemale (119899 = 178) 1461 plusmn 211 (1430ndash1492) 95 CITotal 361 1471 plusmn 208 (1449ndash1492) 95 CI119899 = total number of children

Table 2 Agesex distribution of the sampled study population (119899 = 361)

Age group Female Male TotalCount Count Count

lt25 years 14 388 20 554 34 94225ndash30 years 13 360 16 443 29 80330ndash35 years 24 665 22 609 46 127435ndash40 years 38 1053 39 1080 77 213340ndash45 years 44 1219 46 1274 90 2493gt45 years 45 1247 40 1108 85 2355Grand total 178 4931 183 5069 361 10000

Schistosoma mansoni 554 and Trichuris trichiura 111combining single and multiple infections It was noted thatprevalence for most infections showed a tendency to increasewith age as is illustrated in Table 5 There was a significantdifference in prevalence of Schistosoma mansoni infectionbetween boys and girls where boys showed a higher tendencyto be infected with schistosomiasis (119905 = 3308 119875 = 0030026ndash0119 at 95 CI) All other infections showed nostatistically significant difference between boys and girlsGenerally infection prevalence showed tendency to increasewith age Based on independent 119905-tests done to compareweights and heights of those infected versus the uninfectedthere was no statistically significant difference based on theoverall infection status (weight 119875 = 007482 119905 = 16520height 119875 = 02230 119905 = 16519) there was however statisticalsignificant difference in weight between those infected withGiardia lamblia and those not infected (119875 = 00362119905 = 18015) All other infections individually showed nosignificant difference in weight and height between thoseinfected and the noninfected

33 Nutritional Status

331 Weight and Height Based on the weight for height ofthe children the prevalence of malnutrition was determinedand is presented in Table 6 The mean weights of the

participants (119899 = 361) were 1471 kg (1449ndash1492) 95 CIand height was 10178 (10110ndash10245) 95 CI The meanheights and weights of the children showed no statisticaldifference between males and females

Prevalence of severe stunting severe underweight andsevere wasting were 06 (2) (minus02ndash13mdash95 CI) 17(6) (03ndash30mdash95 CI) and 36 (13) (21ndash62mdash95 CI)respectively

Seven boys and 8 girls were found to be severely wasted1 boy and 1 girl were severely stunted and 4 girls and 2boys were severely underweight The prevalence of wastingunderweight and stuntingwas also noted to increasewith ageThere was also significant difference in HAZ (119875 = 0036 119905 =2108 95 CI = minus06486ndashminus02251) and WHZ (119875 = 0022 119905 =2303 95 CI = 00372ndash04738) between boys and girls Theresults of height and weight and prevalence of malnutritionare shown in Tables 6 and 7

Based on the general status of infection of the childrenthere was a significant difference in WAZ (119875 = 0000 119905 =3675 95 CI = 02162ndash07175) and HAZ (119875 = 0001 119905 =3383 95 CI = 02438ndash09210) between the infected and thenoninfected for all parasitic infectionsWith regard to specificinfections children with Giardia lamblia infections showedsignificantly lower mean weights (1414 versus 1480 kg 119875 =0031 119905= 2171 95CI = 00626ndash12669)meanweight for age119885-scores (minus1275 versus minus0542 119875 = 0000 119905 = 4728 95 CI

Journal of Tropical Medicine 5

Table 3 Frequency distribution of socioeconomic characteristics of the sampled study population

Attribute Response Frequency frequency

Knowledge of disease transmission No 114 316Yes 247 684

Geophagy (soil eating) No 74 205Yes 287 795

Hand washing (child)Never 118 327

Sometimes 213 590Always 30 83

Shoe wearing Sometimes 325 900Always 36 100

Water source (domestic)Rivercanal 292 809Borehole 43 119Piped 26 72

River bathing child No 98 271Yes 263 729

Water purification method

None 71 197Filtration 115 319Boiling 79 219

Chlorination 96 266

Bathroom waste water disposal Open ground 275 762Latrine 86 238

Employment status (father) No 75 208Yes 286 792

Employment status (mother) No 236 654Yes 125 346

Home ownership Self-own 208 576Rental 153 424

Home location classification Rural 284 787Urban 77 213

Family with children above 5 yrs No 249 690Yes 112 310

House type

Rural 289 801Wooden 8 22Iron sheets 12 33Brickstone 52 144

= 04285ndash10387) and mean height for age119885-scores (minus07582versus 02776 119875 = 0000 119905 = 4728 95 CI = 06075ndash1464)when compared to the noninfected children

Based on the sex of the children with regard to wastingboth boys were affected with boys showing slightly higherdegree of severe wasting in contrast to girls who showslightly higher number of moderate wasting Comparison bya Studentrsquos t-test showed that the slight difference was ofno statistical significance Table 6 gives a summary of thepercentages of children affectedwithmalnutrition In Figure 1it further shows that the majority of girls although withinnormal limits that is 119885-score values within the normallimits of 2 standard deviations showed a tendency to deviatetowards the negative with a mean119885-score value of minus110This

is likely as a result of the many of the girls recording lowerweight to height 119885-score values although within the normalinterval On the other hand majority of boys within thenormal WHO confidence interval recorded 119885-score valuescloser to the WHO mean 119885-score value Figure 1 also drawsattention to the percentage of children falling outside the minus2Standard deviation mark indicating percentage of childrenwith wasting

With regard to height for age Figure 2 is indicative ofmore boys affected by stunting with 82 of the boys beingmoderately stunted compared to 34 of girls that is per-centage of children falling outside the minus2SD WHO standardinterval As for severe stunting boys again showed slightlyhigher percentage compared to girls This was confirmed

6 Journal of Tropical Medicine

Table 4 Prevalence of parasitic infections in sampled study population in Mwea Division

Row labels Frequency Percentage Boys Percentage Girls PercentageAncylostoma duodenale 2 055 1 053 1 058Ascaris lumbricoides 12 305 6 319 5 289E coli 7 (7)lowast 388 5 266 9 520E histolytica 1 028 0 000 1 058E vermicularis 3 083 1 053 2 116G lamblia 54 1468 29 1543 25 1387H nana 9 (4)lowast 360 4 213 9 520No infection 253 6648 123 6543 117 6763Schistosoma mansoni 18 (2)lowast 554 17 904 3 173Trichuris trichiura 2 (2)lowast 111 2 106 2 116Grand total 361 10000 188 10000 173 10000lowastOccurrence as multiple infections

Table 5 Frequency distribution of parasitic infections per age groups

Age Group S mansoni Hookworm A lumbricoides T trichiura G lamblia H nana Evermicularis E histolytica E colilt25 yrs 1 0 1 0 4 1 0 0 325ndash3 yrs 1 0 1 0 1 0 0 0 130ndash35 yrs 2 0 1 0 6 0 1 0 335ndash40 yrs 3 1 1 0 9 1 0 1 540ndash45 yrs 5 1 3 4 15 7 2 0 045ndash5 yrs 8 0 4 0 19 4 0 0 2Grand total 20 2 11 4 54 13 3 1 14

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

Weight-for-height Z-scores (boysgirls)

WHO standardsBoys (183)Girls (178)

Figure 1 A plot of weight for height 119885-scores by gender for thePSAC inMweaDivision against the recommendedWHO standards

by the Student t-test which showed a statistically significantdifference in HAZ (119875 = 0036 119905 = 2108 95 CI =minus06486ndashminus02251) between the boys and the girls

Theweight for age119885-score values show boys to be slightlymore affected by malnutrition with a percentage of 142compared to girls 118 The same trend is observed withsevere malnutrition as is shown in Table 6 As per Figure 3

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-scoreWHO standardsBoys (183)Girls (178)

Height-for-age Z-scores (boysgirls)

Figure 2 A plot of height for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

the boysrsquo curve shows some degree of skewness to the leftalthough it is centered towards the mean and the skewnesstranslates to the slightly higher percentage of boys affected bymalnutrition This is confirmed by Studentrsquos t-test showingstatistically significant difference in WHZ (119875 = 0022 119905= 2303 and 95 CI = 00372ndash04738) between boys andgirls As for the girlsrsquo curve there is tendency to slightly shift

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

Journal of Tropical Medicine 3

242 Anthropometry All children were examined by a qual-ified and registered community nursecommunity healthworker recruited by the study who carried out physical exam-ination andmeasurements to obtain their weight age heightand mid-upper arm circumference These parameters werecollected as per the guidelines in the National Health andNutrition Examination Surveyrsquos Anthropometry ProceduresManual developed by the United States Centre for DiseaseControl and Prevention (CDC) For purposes of accuracythe instruments were calibrated regularly and random repeatmeasurements were done as a quality control measure Fromthe measurements 119885-score values for height-for-age (HAZ)weight-for-age (WAZ) and weight-for-height (WHZ) werecalculated and used as indices for nutritional status

243 Stool Samples Collection andExamination Each partic-ipant was provided with a stool sample collection containerwith unique identifiers and with the help of activity coordi-nators approximately 4 grams (gm) of fresh stool sample wascollected using polypots from each participating child

From each sample collected Kato-Katz thick smears wereprepared for examination under a compound microscopeThe fecal smears were prepared in duplicate on glass micro-scope slides to improve detection levels The samples wereprocessed within an hour of collection time The Kato-Katz technique was mainly used to detect eggs and ovaof Schistosoma mansoni Ancylostoma duodenale Ascarislumbricoides and Trichuris trichiura Where infection wasdetected intensity of infection was also noted and graded aseither heavy moderate or low in accordance with the WHOproposed criteria [18 19]

Further diagnosis using the formol concentration tech-niquewas done to detect presence of other intestinal parasitesof public health significance thatmay have passed undetectedin the Kato-Katz technique Following diagnosis subjectswere divided into 3 groups uninfected infected with a singlespecies and infected with two or more species of intestinalhelminthes

25 Study Approval The study protocol was approved bythe Scientific and Ethics Review Unit of the Kenya MedicalResearch Institute Approval to carry out the study in thearea was also sought from administrative authorities in theschools the Mwea Division Health Administration and theKirinyaga County Health Administration Prior to enroll-ment of the study subjects a meeting with parentsguardiansof all eligible children was called with the help of theschoolsrsquo administration so that the study purpose objectivesand procedures to be used could be explained includingparticipantsrsquo rights if they both accept or decline to have theirchildren participate in the study Written informed consentwas obtained and the children were recruited into the studyThe parentsguardians were assured of the privacy and con-fidentiality of the information collected All children foundto be infected with intestinal parasitic infections receivedthe appropriate medication prescribed by a qualified andregistered clinician where albendazole (for soil-transmittedhelminthes) and praziquantel (for schistosomiasis) wereadministered in their recommended doses as per the WHO

recommendations [18] Other infections or conditions werereferred to the local health clinic

26 Statistical Analysis The data collected was first enteredand stored into Microsoft Excel 2010 The data was verifiedand crosschecked for errors A copy of the data was thenrecoded and exported into Statistical Package for SocialSciences (SPSS) Version 20 and baseline descriptive statisticswere drawn

Comparison of weight and height against infection statuswas done using independent 119879-test to assess significantdifferences in weight and height between the infected andthe noninfected ANOVA test was used to assess differencein height and weight between the noninfected infected andthose with multiple infections

Anthropometric data was exported toWHOAnthro [20]where WAZ HAZ and WHZ were derived and used todetermine nutritional status The anthropometric variableswhere applicable were reported as mean plusmn standard deviation(SD) 95 confidence interval

Based on the119885-score values obtained forWAZHAZ andWHZ the children were categorized as normal (le2 and geminus2119885-score) underweight (geminus3 and ltminus2 119885-score) or severelyunderweight (ltminus3 119885-score) stunted (geminus3 and ltminus2 119885-score)or severely stunted (ltminus3 119885-score) and wasted (geminus3 and ltminus2119885-score) or severely wasted (ltminus3 119885-score)

Binary variableswere compared using Studentrsquos 119905- test andChi-square test where applicable

Demographic and socioeconomic data were entered ascategorical variables and the frequencies and percentageswere calculated Later they were assessed using a binarylogistic regression model with the baseline category as theleast likely to result to an infection outcome

All statistical tests were evaluated for significance at 119875 lt005 95 CI (confidence interval)

3 Results

31 General Characteristics of the Study Group A total of 361children were recruited into the study of which 5040 weremale (119899 = 183) and 4960 female (119899 = 178) The meanage in months was 4662 plusmn 968 (4562ndash4762) 95 CI Meanheight was 10178 plusmn 657 cm (10110ndash10245) 95 CI andmeanweightwas 1471plusmn208 kg (1449ndash1492) 95CI Table 1gives an overall summary of the study group demographicswhile Table 2 provides an age group sex distribution of thepopulation

The same number of families participated in the ques-tionnaires determining behavioral trends and socioeconomicstatus and summary of the responses is tabulated on Table 3

32 Parasitological Investigations Out of the total 361 chil-dren enrolled in the study 108 children (299) were foundto be infected with an intestinal parasite of which 15 (39)had multiple parasite infections Prevalence of each parasiticinfection is shown in Table 4 The prevalence of Ancylostomaduodenalewas at 06Ascaris lumbricoides 33 Entamoebahistolytica 03 Enterobius vermicularis 083 Entamoebacoli 388 Giardia lamblia 1468 Hymenolepis nana 36

4 Journal of Tropical Medicine

Table 1 Summary of anthropometric descriptive statistics of the sampled study population

Mean Confidence intervalAge in monthsMale (119899 = 183) 4630 plusmn 1001 (4485ndash4775) 95 CIFemale (119899 = 179) 4693 plusmn 936 (4555ndash4830) 95 CITotal 361 4662 plusmn 968 (4562ndash4762) 95 CIHeight in cmMale (119899 = 183) 10134 plusmn 643 (10041ndash10227) 95 CIFemale (119899 = 178) 10223 plusmn 669 (10124ndash10321) 95 CITotal 361 10178 plusmn 657 (10110ndash10245) 95 CIWeight in kgMale (119899 = 183) 1480 plusmn 206 (1450ndash1510) 95 CIFemale (119899 = 178) 1461 plusmn 211 (1430ndash1492) 95 CITotal 361 1471 plusmn 208 (1449ndash1492) 95 CI119899 = total number of children

Table 2 Agesex distribution of the sampled study population (119899 = 361)

Age group Female Male TotalCount Count Count

lt25 years 14 388 20 554 34 94225ndash30 years 13 360 16 443 29 80330ndash35 years 24 665 22 609 46 127435ndash40 years 38 1053 39 1080 77 213340ndash45 years 44 1219 46 1274 90 2493gt45 years 45 1247 40 1108 85 2355Grand total 178 4931 183 5069 361 10000

Schistosoma mansoni 554 and Trichuris trichiura 111combining single and multiple infections It was noted thatprevalence for most infections showed a tendency to increasewith age as is illustrated in Table 5 There was a significantdifference in prevalence of Schistosoma mansoni infectionbetween boys and girls where boys showed a higher tendencyto be infected with schistosomiasis (119905 = 3308 119875 = 0030026ndash0119 at 95 CI) All other infections showed nostatistically significant difference between boys and girlsGenerally infection prevalence showed tendency to increasewith age Based on independent 119905-tests done to compareweights and heights of those infected versus the uninfectedthere was no statistically significant difference based on theoverall infection status (weight 119875 = 007482 119905 = 16520height 119875 = 02230 119905 = 16519) there was however statisticalsignificant difference in weight between those infected withGiardia lamblia and those not infected (119875 = 00362119905 = 18015) All other infections individually showed nosignificant difference in weight and height between thoseinfected and the noninfected

33 Nutritional Status

331 Weight and Height Based on the weight for height ofthe children the prevalence of malnutrition was determinedand is presented in Table 6 The mean weights of the

participants (119899 = 361) were 1471 kg (1449ndash1492) 95 CIand height was 10178 (10110ndash10245) 95 CI The meanheights and weights of the children showed no statisticaldifference between males and females

Prevalence of severe stunting severe underweight andsevere wasting were 06 (2) (minus02ndash13mdash95 CI) 17(6) (03ndash30mdash95 CI) and 36 (13) (21ndash62mdash95 CI)respectively

Seven boys and 8 girls were found to be severely wasted1 boy and 1 girl were severely stunted and 4 girls and 2boys were severely underweight The prevalence of wastingunderweight and stuntingwas also noted to increasewith ageThere was also significant difference in HAZ (119875 = 0036 119905 =2108 95 CI = minus06486ndashminus02251) and WHZ (119875 = 0022 119905 =2303 95 CI = 00372ndash04738) between boys and girls Theresults of height and weight and prevalence of malnutritionare shown in Tables 6 and 7

Based on the general status of infection of the childrenthere was a significant difference in WAZ (119875 = 0000 119905 =3675 95 CI = 02162ndash07175) and HAZ (119875 = 0001 119905 =3383 95 CI = 02438ndash09210) between the infected and thenoninfected for all parasitic infectionsWith regard to specificinfections children with Giardia lamblia infections showedsignificantly lower mean weights (1414 versus 1480 kg 119875 =0031 119905= 2171 95CI = 00626ndash12669)meanweight for age119885-scores (minus1275 versus minus0542 119875 = 0000 119905 = 4728 95 CI

Journal of Tropical Medicine 5

Table 3 Frequency distribution of socioeconomic characteristics of the sampled study population

Attribute Response Frequency frequency

Knowledge of disease transmission No 114 316Yes 247 684

Geophagy (soil eating) No 74 205Yes 287 795

Hand washing (child)Never 118 327

Sometimes 213 590Always 30 83

Shoe wearing Sometimes 325 900Always 36 100

Water source (domestic)Rivercanal 292 809Borehole 43 119Piped 26 72

River bathing child No 98 271Yes 263 729

Water purification method

None 71 197Filtration 115 319Boiling 79 219

Chlorination 96 266

Bathroom waste water disposal Open ground 275 762Latrine 86 238

Employment status (father) No 75 208Yes 286 792

Employment status (mother) No 236 654Yes 125 346

Home ownership Self-own 208 576Rental 153 424

Home location classification Rural 284 787Urban 77 213

Family with children above 5 yrs No 249 690Yes 112 310

House type

Rural 289 801Wooden 8 22Iron sheets 12 33Brickstone 52 144

= 04285ndash10387) and mean height for age119885-scores (minus07582versus 02776 119875 = 0000 119905 = 4728 95 CI = 06075ndash1464)when compared to the noninfected children

Based on the sex of the children with regard to wastingboth boys were affected with boys showing slightly higherdegree of severe wasting in contrast to girls who showslightly higher number of moderate wasting Comparison bya Studentrsquos t-test showed that the slight difference was ofno statistical significance Table 6 gives a summary of thepercentages of children affectedwithmalnutrition In Figure 1it further shows that the majority of girls although withinnormal limits that is 119885-score values within the normallimits of 2 standard deviations showed a tendency to deviatetowards the negative with a mean119885-score value of minus110This

is likely as a result of the many of the girls recording lowerweight to height 119885-score values although within the normalinterval On the other hand majority of boys within thenormal WHO confidence interval recorded 119885-score valuescloser to the WHO mean 119885-score value Figure 1 also drawsattention to the percentage of children falling outside the minus2Standard deviation mark indicating percentage of childrenwith wasting

With regard to height for age Figure 2 is indicative ofmore boys affected by stunting with 82 of the boys beingmoderately stunted compared to 34 of girls that is per-centage of children falling outside the minus2SD WHO standardinterval As for severe stunting boys again showed slightlyhigher percentage compared to girls This was confirmed

6 Journal of Tropical Medicine

Table 4 Prevalence of parasitic infections in sampled study population in Mwea Division

Row labels Frequency Percentage Boys Percentage Girls PercentageAncylostoma duodenale 2 055 1 053 1 058Ascaris lumbricoides 12 305 6 319 5 289E coli 7 (7)lowast 388 5 266 9 520E histolytica 1 028 0 000 1 058E vermicularis 3 083 1 053 2 116G lamblia 54 1468 29 1543 25 1387H nana 9 (4)lowast 360 4 213 9 520No infection 253 6648 123 6543 117 6763Schistosoma mansoni 18 (2)lowast 554 17 904 3 173Trichuris trichiura 2 (2)lowast 111 2 106 2 116Grand total 361 10000 188 10000 173 10000lowastOccurrence as multiple infections

Table 5 Frequency distribution of parasitic infections per age groups

Age Group S mansoni Hookworm A lumbricoides T trichiura G lamblia H nana Evermicularis E histolytica E colilt25 yrs 1 0 1 0 4 1 0 0 325ndash3 yrs 1 0 1 0 1 0 0 0 130ndash35 yrs 2 0 1 0 6 0 1 0 335ndash40 yrs 3 1 1 0 9 1 0 1 540ndash45 yrs 5 1 3 4 15 7 2 0 045ndash5 yrs 8 0 4 0 19 4 0 0 2Grand total 20 2 11 4 54 13 3 1 14

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

Weight-for-height Z-scores (boysgirls)

WHO standardsBoys (183)Girls (178)

Figure 1 A plot of weight for height 119885-scores by gender for thePSAC inMweaDivision against the recommendedWHO standards

by the Student t-test which showed a statistically significantdifference in HAZ (119875 = 0036 119905 = 2108 95 CI =minus06486ndashminus02251) between the boys and the girls

Theweight for age119885-score values show boys to be slightlymore affected by malnutrition with a percentage of 142compared to girls 118 The same trend is observed withsevere malnutrition as is shown in Table 6 As per Figure 3

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-scoreWHO standardsBoys (183)Girls (178)

Height-for-age Z-scores (boysgirls)

Figure 2 A plot of height for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

the boysrsquo curve shows some degree of skewness to the leftalthough it is centered towards the mean and the skewnesstranslates to the slightly higher percentage of boys affected bymalnutrition This is confirmed by Studentrsquos t-test showingstatistically significant difference in WHZ (119875 = 0022 119905= 2303 and 95 CI = 00372ndash04738) between boys andgirls As for the girlsrsquo curve there is tendency to slightly shift

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

4 Journal of Tropical Medicine

Table 1 Summary of anthropometric descriptive statistics of the sampled study population

Mean Confidence intervalAge in monthsMale (119899 = 183) 4630 plusmn 1001 (4485ndash4775) 95 CIFemale (119899 = 179) 4693 plusmn 936 (4555ndash4830) 95 CITotal 361 4662 plusmn 968 (4562ndash4762) 95 CIHeight in cmMale (119899 = 183) 10134 plusmn 643 (10041ndash10227) 95 CIFemale (119899 = 178) 10223 plusmn 669 (10124ndash10321) 95 CITotal 361 10178 plusmn 657 (10110ndash10245) 95 CIWeight in kgMale (119899 = 183) 1480 plusmn 206 (1450ndash1510) 95 CIFemale (119899 = 178) 1461 plusmn 211 (1430ndash1492) 95 CITotal 361 1471 plusmn 208 (1449ndash1492) 95 CI119899 = total number of children

Table 2 Agesex distribution of the sampled study population (119899 = 361)

Age group Female Male TotalCount Count Count

lt25 years 14 388 20 554 34 94225ndash30 years 13 360 16 443 29 80330ndash35 years 24 665 22 609 46 127435ndash40 years 38 1053 39 1080 77 213340ndash45 years 44 1219 46 1274 90 2493gt45 years 45 1247 40 1108 85 2355Grand total 178 4931 183 5069 361 10000

Schistosoma mansoni 554 and Trichuris trichiura 111combining single and multiple infections It was noted thatprevalence for most infections showed a tendency to increasewith age as is illustrated in Table 5 There was a significantdifference in prevalence of Schistosoma mansoni infectionbetween boys and girls where boys showed a higher tendencyto be infected with schistosomiasis (119905 = 3308 119875 = 0030026ndash0119 at 95 CI) All other infections showed nostatistically significant difference between boys and girlsGenerally infection prevalence showed tendency to increasewith age Based on independent 119905-tests done to compareweights and heights of those infected versus the uninfectedthere was no statistically significant difference based on theoverall infection status (weight 119875 = 007482 119905 = 16520height 119875 = 02230 119905 = 16519) there was however statisticalsignificant difference in weight between those infected withGiardia lamblia and those not infected (119875 = 00362119905 = 18015) All other infections individually showed nosignificant difference in weight and height between thoseinfected and the noninfected

33 Nutritional Status

331 Weight and Height Based on the weight for height ofthe children the prevalence of malnutrition was determinedand is presented in Table 6 The mean weights of the

participants (119899 = 361) were 1471 kg (1449ndash1492) 95 CIand height was 10178 (10110ndash10245) 95 CI The meanheights and weights of the children showed no statisticaldifference between males and females

Prevalence of severe stunting severe underweight andsevere wasting were 06 (2) (minus02ndash13mdash95 CI) 17(6) (03ndash30mdash95 CI) and 36 (13) (21ndash62mdash95 CI)respectively

Seven boys and 8 girls were found to be severely wasted1 boy and 1 girl were severely stunted and 4 girls and 2boys were severely underweight The prevalence of wastingunderweight and stuntingwas also noted to increasewith ageThere was also significant difference in HAZ (119875 = 0036 119905 =2108 95 CI = minus06486ndashminus02251) and WHZ (119875 = 0022 119905 =2303 95 CI = 00372ndash04738) between boys and girls Theresults of height and weight and prevalence of malnutritionare shown in Tables 6 and 7

Based on the general status of infection of the childrenthere was a significant difference in WAZ (119875 = 0000 119905 =3675 95 CI = 02162ndash07175) and HAZ (119875 = 0001 119905 =3383 95 CI = 02438ndash09210) between the infected and thenoninfected for all parasitic infectionsWith regard to specificinfections children with Giardia lamblia infections showedsignificantly lower mean weights (1414 versus 1480 kg 119875 =0031 119905= 2171 95CI = 00626ndash12669)meanweight for age119885-scores (minus1275 versus minus0542 119875 = 0000 119905 = 4728 95 CI

Journal of Tropical Medicine 5

Table 3 Frequency distribution of socioeconomic characteristics of the sampled study population

Attribute Response Frequency frequency

Knowledge of disease transmission No 114 316Yes 247 684

Geophagy (soil eating) No 74 205Yes 287 795

Hand washing (child)Never 118 327

Sometimes 213 590Always 30 83

Shoe wearing Sometimes 325 900Always 36 100

Water source (domestic)Rivercanal 292 809Borehole 43 119Piped 26 72

River bathing child No 98 271Yes 263 729

Water purification method

None 71 197Filtration 115 319Boiling 79 219

Chlorination 96 266

Bathroom waste water disposal Open ground 275 762Latrine 86 238

Employment status (father) No 75 208Yes 286 792

Employment status (mother) No 236 654Yes 125 346

Home ownership Self-own 208 576Rental 153 424

Home location classification Rural 284 787Urban 77 213

Family with children above 5 yrs No 249 690Yes 112 310

House type

Rural 289 801Wooden 8 22Iron sheets 12 33Brickstone 52 144

= 04285ndash10387) and mean height for age119885-scores (minus07582versus 02776 119875 = 0000 119905 = 4728 95 CI = 06075ndash1464)when compared to the noninfected children

Based on the sex of the children with regard to wastingboth boys were affected with boys showing slightly higherdegree of severe wasting in contrast to girls who showslightly higher number of moderate wasting Comparison bya Studentrsquos t-test showed that the slight difference was ofno statistical significance Table 6 gives a summary of thepercentages of children affectedwithmalnutrition In Figure 1it further shows that the majority of girls although withinnormal limits that is 119885-score values within the normallimits of 2 standard deviations showed a tendency to deviatetowards the negative with a mean119885-score value of minus110This

is likely as a result of the many of the girls recording lowerweight to height 119885-score values although within the normalinterval On the other hand majority of boys within thenormal WHO confidence interval recorded 119885-score valuescloser to the WHO mean 119885-score value Figure 1 also drawsattention to the percentage of children falling outside the minus2Standard deviation mark indicating percentage of childrenwith wasting

With regard to height for age Figure 2 is indicative ofmore boys affected by stunting with 82 of the boys beingmoderately stunted compared to 34 of girls that is per-centage of children falling outside the minus2SD WHO standardinterval As for severe stunting boys again showed slightlyhigher percentage compared to girls This was confirmed

6 Journal of Tropical Medicine

Table 4 Prevalence of parasitic infections in sampled study population in Mwea Division

Row labels Frequency Percentage Boys Percentage Girls PercentageAncylostoma duodenale 2 055 1 053 1 058Ascaris lumbricoides 12 305 6 319 5 289E coli 7 (7)lowast 388 5 266 9 520E histolytica 1 028 0 000 1 058E vermicularis 3 083 1 053 2 116G lamblia 54 1468 29 1543 25 1387H nana 9 (4)lowast 360 4 213 9 520No infection 253 6648 123 6543 117 6763Schistosoma mansoni 18 (2)lowast 554 17 904 3 173Trichuris trichiura 2 (2)lowast 111 2 106 2 116Grand total 361 10000 188 10000 173 10000lowastOccurrence as multiple infections

Table 5 Frequency distribution of parasitic infections per age groups

Age Group S mansoni Hookworm A lumbricoides T trichiura G lamblia H nana Evermicularis E histolytica E colilt25 yrs 1 0 1 0 4 1 0 0 325ndash3 yrs 1 0 1 0 1 0 0 0 130ndash35 yrs 2 0 1 0 6 0 1 0 335ndash40 yrs 3 1 1 0 9 1 0 1 540ndash45 yrs 5 1 3 4 15 7 2 0 045ndash5 yrs 8 0 4 0 19 4 0 0 2Grand total 20 2 11 4 54 13 3 1 14

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

Weight-for-height Z-scores (boysgirls)

WHO standardsBoys (183)Girls (178)

Figure 1 A plot of weight for height 119885-scores by gender for thePSAC inMweaDivision against the recommendedWHO standards

by the Student t-test which showed a statistically significantdifference in HAZ (119875 = 0036 119905 = 2108 95 CI =minus06486ndashminus02251) between the boys and the girls

Theweight for age119885-score values show boys to be slightlymore affected by malnutrition with a percentage of 142compared to girls 118 The same trend is observed withsevere malnutrition as is shown in Table 6 As per Figure 3

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-scoreWHO standardsBoys (183)Girls (178)

Height-for-age Z-scores (boysgirls)

Figure 2 A plot of height for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

the boysrsquo curve shows some degree of skewness to the leftalthough it is centered towards the mean and the skewnesstranslates to the slightly higher percentage of boys affected bymalnutrition This is confirmed by Studentrsquos t-test showingstatistically significant difference in WHZ (119875 = 0022 119905= 2303 and 95 CI = 00372ndash04738) between boys andgirls As for the girlsrsquo curve there is tendency to slightly shift

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

Journal of Tropical Medicine 5

Table 3 Frequency distribution of socioeconomic characteristics of the sampled study population

Attribute Response Frequency frequency

Knowledge of disease transmission No 114 316Yes 247 684

Geophagy (soil eating) No 74 205Yes 287 795

Hand washing (child)Never 118 327

Sometimes 213 590Always 30 83

Shoe wearing Sometimes 325 900Always 36 100

Water source (domestic)Rivercanal 292 809Borehole 43 119Piped 26 72

River bathing child No 98 271Yes 263 729

Water purification method

None 71 197Filtration 115 319Boiling 79 219

Chlorination 96 266

Bathroom waste water disposal Open ground 275 762Latrine 86 238

Employment status (father) No 75 208Yes 286 792

Employment status (mother) No 236 654Yes 125 346

Home ownership Self-own 208 576Rental 153 424

Home location classification Rural 284 787Urban 77 213

Family with children above 5 yrs No 249 690Yes 112 310

House type

Rural 289 801Wooden 8 22Iron sheets 12 33Brickstone 52 144

= 04285ndash10387) and mean height for age119885-scores (minus07582versus 02776 119875 = 0000 119905 = 4728 95 CI = 06075ndash1464)when compared to the noninfected children

Based on the sex of the children with regard to wastingboth boys were affected with boys showing slightly higherdegree of severe wasting in contrast to girls who showslightly higher number of moderate wasting Comparison bya Studentrsquos t-test showed that the slight difference was ofno statistical significance Table 6 gives a summary of thepercentages of children affectedwithmalnutrition In Figure 1it further shows that the majority of girls although withinnormal limits that is 119885-score values within the normallimits of 2 standard deviations showed a tendency to deviatetowards the negative with a mean119885-score value of minus110This

is likely as a result of the many of the girls recording lowerweight to height 119885-score values although within the normalinterval On the other hand majority of boys within thenormal WHO confidence interval recorded 119885-score valuescloser to the WHO mean 119885-score value Figure 1 also drawsattention to the percentage of children falling outside the minus2Standard deviation mark indicating percentage of childrenwith wasting

With regard to height for age Figure 2 is indicative ofmore boys affected by stunting with 82 of the boys beingmoderately stunted compared to 34 of girls that is per-centage of children falling outside the minus2SD WHO standardinterval As for severe stunting boys again showed slightlyhigher percentage compared to girls This was confirmed

6 Journal of Tropical Medicine

Table 4 Prevalence of parasitic infections in sampled study population in Mwea Division

Row labels Frequency Percentage Boys Percentage Girls PercentageAncylostoma duodenale 2 055 1 053 1 058Ascaris lumbricoides 12 305 6 319 5 289E coli 7 (7)lowast 388 5 266 9 520E histolytica 1 028 0 000 1 058E vermicularis 3 083 1 053 2 116G lamblia 54 1468 29 1543 25 1387H nana 9 (4)lowast 360 4 213 9 520No infection 253 6648 123 6543 117 6763Schistosoma mansoni 18 (2)lowast 554 17 904 3 173Trichuris trichiura 2 (2)lowast 111 2 106 2 116Grand total 361 10000 188 10000 173 10000lowastOccurrence as multiple infections

Table 5 Frequency distribution of parasitic infections per age groups

Age Group S mansoni Hookworm A lumbricoides T trichiura G lamblia H nana Evermicularis E histolytica E colilt25 yrs 1 0 1 0 4 1 0 0 325ndash3 yrs 1 0 1 0 1 0 0 0 130ndash35 yrs 2 0 1 0 6 0 1 0 335ndash40 yrs 3 1 1 0 9 1 0 1 540ndash45 yrs 5 1 3 4 15 7 2 0 045ndash5 yrs 8 0 4 0 19 4 0 0 2Grand total 20 2 11 4 54 13 3 1 14

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

Weight-for-height Z-scores (boysgirls)

WHO standardsBoys (183)Girls (178)

Figure 1 A plot of weight for height 119885-scores by gender for thePSAC inMweaDivision against the recommendedWHO standards

by the Student t-test which showed a statistically significantdifference in HAZ (119875 = 0036 119905 = 2108 95 CI =minus06486ndashminus02251) between the boys and the girls

Theweight for age119885-score values show boys to be slightlymore affected by malnutrition with a percentage of 142compared to girls 118 The same trend is observed withsevere malnutrition as is shown in Table 6 As per Figure 3

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-scoreWHO standardsBoys (183)Girls (178)

Height-for-age Z-scores (boysgirls)

Figure 2 A plot of height for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

the boysrsquo curve shows some degree of skewness to the leftalthough it is centered towards the mean and the skewnesstranslates to the slightly higher percentage of boys affected bymalnutrition This is confirmed by Studentrsquos t-test showingstatistically significant difference in WHZ (119875 = 0022 119905= 2303 and 95 CI = 00372ndash04738) between boys andgirls As for the girlsrsquo curve there is tendency to slightly shift

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

6 Journal of Tropical Medicine

Table 4 Prevalence of parasitic infections in sampled study population in Mwea Division

Row labels Frequency Percentage Boys Percentage Girls PercentageAncylostoma duodenale 2 055 1 053 1 058Ascaris lumbricoides 12 305 6 319 5 289E coli 7 (7)lowast 388 5 266 9 520E histolytica 1 028 0 000 1 058E vermicularis 3 083 1 053 2 116G lamblia 54 1468 29 1543 25 1387H nana 9 (4)lowast 360 4 213 9 520No infection 253 6648 123 6543 117 6763Schistosoma mansoni 18 (2)lowast 554 17 904 3 173Trichuris trichiura 2 (2)lowast 111 2 106 2 116Grand total 361 10000 188 10000 173 10000lowastOccurrence as multiple infections

Table 5 Frequency distribution of parasitic infections per age groups

Age Group S mansoni Hookworm A lumbricoides T trichiura G lamblia H nana Evermicularis E histolytica E colilt25 yrs 1 0 1 0 4 1 0 0 325ndash3 yrs 1 0 1 0 1 0 0 0 130ndash35 yrs 2 0 1 0 6 0 1 0 335ndash40 yrs 3 1 1 0 9 1 0 1 540ndash45 yrs 5 1 3 4 15 7 2 0 045ndash5 yrs 8 0 4 0 19 4 0 0 2Grand total 20 2 11 4 54 13 3 1 14

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

Weight-for-height Z-scores (boysgirls)

WHO standardsBoys (183)Girls (178)

Figure 1 A plot of weight for height 119885-scores by gender for thePSAC inMweaDivision against the recommendedWHO standards

by the Student t-test which showed a statistically significantdifference in HAZ (119875 = 0036 119905 = 2108 95 CI =minus06486ndashminus02251) between the boys and the girls

Theweight for age119885-score values show boys to be slightlymore affected by malnutrition with a percentage of 142compared to girls 118 The same trend is observed withsevere malnutrition as is shown in Table 6 As per Figure 3

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-scoreWHO standardsBoys (183)Girls (178)

Height-for-age Z-scores (boysgirls)

Figure 2 A plot of height for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

the boysrsquo curve shows some degree of skewness to the leftalthough it is centered towards the mean and the skewnesstranslates to the slightly higher percentage of boys affected bymalnutrition This is confirmed by Studentrsquos t-test showingstatistically significant difference in WHZ (119875 = 0022 119905= 2303 and 95 CI = 00372ndash04738) between boys andgirls As for the girlsrsquo curve there is tendency to slightly shift

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

Journal of Tropical Medicine 7

Table 6 Prevalence of malnutrition in PSAC in Mwea Division based on the childrenrsquos 119885-scores

Mean 119885-score values 95 confidenceinterval

of moderatelymalnourished children

of severelymalnourished children

WAZ

Male (119899 = 183) minus066 plusmn 108 (minus082ndashminus051)95 CI

142 underweight(ltminus2119911)

22 severe underweight(ltminus3119911)

Female (119899 = 178) minus064 plusmn 107 (minus079ndashminus048)95 CI

118 underweight(ltminus2119911)

11 severe underweight(ltminus3119911)

HAZ

Male (119899 = 183) minus011 plusmn 137 (minus031ndash009)95 CI 82 stunted (ltminus2119911) 05 severe stunted

(ltminus3119911)

Female (119899 = 178) 015 plusmn 125 (minus004ndash033)95 CI 34 stunted (ltminus2119911) 016 severe stunted

(ltminus3119911)WHZ

Male (119899 = 183) minus090 plusmn 112 (minus107ndashminus074)95 CI

208 wasted (ltminus2119911)00 obese (gt2119911)

38 severe wasted(ltminus3119911)

Female (119899 = 178) minus110 plusmn 104 (minus125ndashminus095)95 CI

202 wasted (ltminus2119911)00 obese (gt2119911)

34 severe wasted(ltminus3119911)

CI = confidence interval 119899 = total number of children and 119911 = 119885-score

Table 7 Factors associated with the general prevalence of infection in preschool age children in Mwea division a binary logistic regressionmodel

Variable OR (119875 value) 95 CIKnowledge of diseasetransmission 862 635 629 2137

Geophagy 975 947 459 2072Hand washing

Never 6478 010lowast 1553 27015Sometimes 3401 093 817 14167

Shoe wearing 405 155 117 1406Water source

Borehole 621 566 122 3167Rivercanal 194 088 029 1278

Water purification methodNone 3602 008lowast 1397 9288Filtration 778 537 351 1725Boiling 1272 572 552 2932

Family with children above 5years 390 007lowast 1293 5088

Constant 6206 216OR = odds ratio CI = confidence interval and lowast = variables with statistical significance

towards the left which is indicative of the girls being centredtowards the negative side of the WHOmean

With regard to socioeconomic and demographic factorsthe mean weight of the children was found to be significantlylower among those whose parents had other children abovethe age of 5 years (weight 15021 kg Vs 1396Kg 95 CI =05931ndash151168 119905 = 4507 119875 = 0000) A look at the summaryof the socioeconomic and behavioral characteristics of thestudy population (see Table 3) focusing on factors that mayhave an influence on the infection and nutritional statusof the target study group showed that 684 percent of thesampled population proved to be aware of the ways to prevent

transmission of intestinal parasites However a vast majorityfall short of applying preventive measures most of who lackthe means to implement such measures

A binary logistic regressionmodel performed to ascertainthe effects of demographic behavioral and socioeconomicstatus of the population on the childrenrsquos infection status wasstatistically significant 1205942 = 1044 119875 = 0000 It explained356 (Nagelkerke 1198772) of the variance in infection andcorrectly classified 781 of the casesThemodel revealed thatthe infection status of childrenwas significantly influenced bytheir handwashing behavior theirwater purificationmethodclassification of home location and whether the family had

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

8 Journal of Tropical Medicine

minus4 minus3 minus2 minus1 0 1 2 3 4 5

Z-score

5

10

15

20

25

30

35

40

45

o

f chi

ldre

n

WHO standardsBoys (183)Girls (178)

Weight-for-age Z-scores (boysgirls)

Figure 3 A plot of weight for age 119885-scores by gender for the PSACin Mwea Division against the WHO recommended standards

other children above the age of 5 Children who reportednever washing hands on the key recommended times were64 times likely to be infected (odds ratio (OR) 64119875 = 001095 CI) children in families with siblings above 5 years were26 times more likely to be infected with a parasitic infection(OR 2565 119875 = 007 95 CI) and those families thatreported not using any water purification methods were 36timesmore likely to be infected (OR 3602119875 = 008 and 95CI) while children living in the rural areas were at a 81 times(OR 8051 119875 lt 0001 and 95 CI) higher risk of infectionwith a parasitic infection

4 Discussion

Parasitic infections are well known for their burden of diseasemainly attributed to their chronic and insidious impact on thehealth nutrition and quality of life of those infected ratherthan to the mortality they cause [21] The study showed that299 of the children were infected with various parasiticinfections The prevalence of specific parasitic infectionswas generally low with prevalence of below 6 Howevera prevalence of 15 for Giardia lamblia a parasite oftenassociated with diarrhea and acquired through drinkingcontaminated water and consumption of contaminated soilor food [22] was interesting but not surprising This findingsuggests that this parasite is most likely common in this areaand a cause of ill health among children of 5 years of ageor less in this area Since there were no previous studies toinvestigate their prevalence this study served as a baselinesurvey providing information on the status of infection inPSACThe studywas also able to demonstrate that 36 17and 06 of the children were severely wasted underweightand stunted Based on the general infection status there wasa significant difference in WAZ (119875 = 0000 119905 = 3675 95CI = 02162ndash07175) and HAZ (119875 = 0001 119905 = 3383 95 CI= 02438ndash09210) between the infected and the noninfectedThe study demonstrated a significant lower mean weights

mean weight for age and mean height for age for childreninfected with Giardia lamblia infection a clear indication ofthe impact of Giardia lamblia on the nutritional status ofchildren [22] Other studies have also documented similarfindings with regard to the effects of Giardia lamblia onweight and height of children [22] where chronic infectionswith giardia lamblia have been associated with clinicalmanifestation of malnutrition The study however could notdemonstrate statistically significant association linking otherspecific parasitic infections to malnutrition This could beattributed to the low prevalence of these infectionsThis studyhas also shown that hand washing behavior water sourcefor drinking water purification methods and classificationof home location and family size were strongly associatedwith the general status of infection Similar studies have alsodemonstrated association between soil-transmitted helminthinfection with water supply source hand washing behaviorand family size [23]

The results of the binary logistic regression in Table 7show that the transmission of Schistosoma spp STH amongother parasitic infections have been strongly associated withsanitation and hygiene and the lack of clean and safe watersupply Most of these conditions have mostly been linkedto poverty as the root cause and as such have been linkedto malnutrition and many other health problems includingparasitic infections [2 16] Of the total number of infections935 (101 children) occurred in the rural setting and only65 (7 children) occurring in the urban setting Also fromthe regression analysis the odds of a child living in ruralareas is up to 81 times higher (See Table 7) compared to thechildren in urban settlementThis presents a clear associationof infection with the rural setting which is well known to beassociated with poverty and lack of access to clean and safewater [23 24]

The study findings of the study have also demonstratedan association between malnutrition and family size wherefamilies with more than 3 children above the age of 5 hada lower mean weight compared to families with lt3 chil-dren Other studies have demonstrated this to be especiallycommon in rural and poor socioeconomic communities dueto inadequate distribution of food among family members[2] Also to note is the association between families wherechildren have siblings above the age of 5 had a higher riskof infection which presents a likelihood of infection beingtransmitted from older siblings to younger ones

Regardless of infection status the study populationsshowed high prevalence of malnutrition with prevalence andseverity showing tendency to increasewith age as is illustratedin Table 8 This observation is consistent with findings fromother studies [2] that demonstrated significant increase of riskof malnutrition with increase in age for children under 5These observations could as well be attributed to poverty andother health problems which do not exclude other parasiticinfections beyond the scope of this study Figures 1 2 and 3provide a graphical representation of the nutritional status ofthe preschool age children in Mwea Division

The deviation observed for WHZ scores showing skew-ness to the left (negatively skewed) and a shift to the left(see Figure 1) is indicative that many of the children deviate

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

Journal of Tropical Medicine 9

Table8Prevalence

ofmalnu

trition

byageg

roup

sinPS

ACin

Mwea

Division

Age

(mon

ths)

Total

number

Severe

wastin

g(ltminus3119911-score)

Mod

eratew

astin

g(geminus3andltminus2119911-score)

Severe

underw

eight

(ltminus3119911-score)

Und

erweight

(geminus3andltminus2119911-score)

Severe

stunted

(ltminus3119911-score)

Mod

erates

tunted

(geminus3andltminus2119911-score)

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

Num

ber

6ndash

1718ndash29

341

29

5147

000

000

000

000

30ndash4

171

342

8113

114

442

114

228

42ndash53

163

425

31190

625

40202

106

1486

54ndash59

935

54

17183

111

12118

000

654

Total

361

1336

61169

822

56155

208

22155

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

10 Journal of Tropical Medicine

negatively from theWHOstandardWHZmeans Lowweightfor height119885-scores is known to result from recent nutritionaldeficiency which has been associated with availability of foodand disease prevalence

In comparison to the WHO standards the sampledpopulation HAZ distribution is platykurtic with lower andbroader central peaks (see Figure 2) This is indicative ofthe population mean not being centered around the WHOrecommended standards Height for age 119885-scores (HAZ) isan indicator for stunting represented by low HAZ and hasbeen demonstrated to result from prolonged periods of eitherinadequate food intake poor diet quality of morbidity fromdisease or a combination of the same Figure 2 shows distinctdeviation from the WHO standard which may be indicativeof either one or a combination of factors [2] In this instanceboys have been shown to be more affected compared to girls

Weight for age being an indicator of underweight isusually a composite of both WHZ and HAZ This thereforealso serves as an indicator of malnutrition which among themany causes chronic parasitism cannot be ruled out

The study also showed that the number of boys affectedby malnutrition was slightly higher compared to that ofgirls affected by malnutrition (see Table 6) In generalprevalence of malnutrition stood at 277 for wasting 177for underweight and 694 for stunting with a majority ofthese cases occurring in the rural areas This is a reflectionof the 2008-2009 Kenya Demographic Health Survey forchildren under 5 years which showed that nationwide 35367 and 163 of the children were stunted wasted andunderweight respectively and further suggested the greatestburden of malnutrition was in rural areas [2 15]

The synergistic relationship between nutrition and infec-tion can be attributed to the observed findings whereby eitherexposure to infectionsmay be the cause of themalnutrition orthemalnutrition predisposed the childrenmaking themmoresusceptible to infection This is but a hypothetical deductionbased on the study finding and thus further study is neededto ascertain the underlying cause of the observations made inthis population

5 Conclusion

In conclusion this study has demonstrated that the preva-lence of STH and schistosomiasis in Mwea division inKirinyaga County Central Kenya is relatively low with atendency to increase with age While children in this agegroup were found to be infected with both S mansoni andSTH prevalencewas generally low (lt6) therefore not likelyto have a major public health impact in this age groupNevertheless regular intervention will be necessary A highprevalence of Giardia lamblia infections (15) while inter-esting was not surprising as this infection is fairly commonin environments where hygiene is poor This finding inparticular suggests the G lamblia is likely to be a majorpublic health concern among children aged 5 years or less inMwea as they are at a high risk It is therefore importantto consider establishing an intervention program targetingthis particular age groupThe study further suggests the needfor further investigations into other parasitic infections that

cause ill health in this age group in the study area While theprevalence of schistosomiasis and STH may have been lowthese are likely to increase in prevalence given the conduciveenvironment for transmission of these parasites in the area

This study has also shown that hand washing practiceswater purification methods rural homes and families withsiblings above 5 years to are associated with infection in thisage group It is thus important to provide health educationprogrammes for disease prevention improved access to cleanand safe water for domestic use and appropriate sanitation

Although the study was not able to establish a firmassociation between infection and malnutrition the moder-ate prevalence of malnutrition in this age group cannot beignored and the contribution of parasitic infections to themalnutrition cannot be entirely ruled out It therefore callsfor further investigations into the nutritional status of thisage group to identify the underlying cause(s) Inclusion ofnutrition in education is also recommended with a focus onfamilies with preschool age children

Abbreviations

ANOVA Analysis of varianceCBRD Centre for Biotechnology and Research

DevelopmentCDC Centre for Disease ControlCI Confidence intervalHAZ Height for Age 119885-scoresITROMID Institute of Tropical Medicine and

Infectious DiseasesJKUAT Jomo Kenyatta University of Agriculture

and TechnologyKEMRI Kenya Medical Research InstituteMDA Mass drug administrationNACOSTI National Commission of Science

Technology and InnovationNTDs Neglected Tropical DiseasesPSAC Preschool age childrenSERU Scientific and Ethics Review UnitSPSS Statistical Package for Social SciencesSTH Soil-transmitted helminthes (simiases)SSA Sub-Saharan AfricaWAZ Weight for age 119885-scoresWHO World Health OrganizationWHZ Weight for height 119885-scores

Ethical Approval

The study protocol was approved by SERU (Scientific andEthics Review Unit) of KEMRI (Kenya Medical ResearchInstitute) Approval to carry out the study in the area wasalso sought from Administrative Authority in the schoolstheMweaDivisionHealth Administration and the KirinyagaCounty Health Administration Prior to enrollment a meet-ing with parentsguardians of all eligible children was calledwith the help of the schools administration A clear explana-tion was given describing the aims of the study the data to becollected procedures to be carried out and their rights if theyeither agree or decline to have their children participate in

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

Journal of Tropical Medicine 11

the study The parentsguardians were assured of the privacyand confidentiality of the information collected Treatmentof those infected was done by a qualified clinician wherealbendazole and praziquantel were administered in theirrecommended doses as per the WHO recommendations Noanimals were involved in this study

Consent

Written informed consent was obtained and the childrenwere recruited into the study

Conflicts of Interest

The coauthors declared having no conflicts of interest

Authorsrsquo Contributions

Gerald M Mkoji and Amos Mbugua were involved in thestudy design data collection analysis and preparation ofthe manuscript Stephen Sakari interpreted the results anddeveloped the final draft of this manuscript All authorsapproved the final draft of the manuscript

Acknowledgments

This study was undertaken as a Masterrsquos degree project forSSWS and was supported by the Kenya Medical ResearchInstitute (KEMRI) AstraZeneca Research Trust grant (Activ-ity no 319302) to Stephen Sakari in support of this researchstudy in data collection analysis publication and thesispreparation and Kenyarsquos National Commission of ScienceTechnology and Innovation (NACOSTI) through researchgrant referenced NACOSTIRCDSTampI 5th CALL MSc222to Stephen Sakari in support of the research study in pre-liminary survey of the study area preparation of study pro-posal and initial field study setup The authors acknowledgethe support of the County Government of Kirinyaga theteachers parents and children of the study schools in MweaDivision Special thanks are due to the Director Centre forBiotechnology Research and Development of KEMRI forlaboratory and logistical support andMessrs JosephKinuthiaandMainaGeoffrey for their technical expertise and theHeadTechnologist Mr Muigai Njoroge of Kimbimbi Sub-DistrictHospital and Ruth Machuru for their help and supportduring field collection of data This research is publishedwith the approval of the Director Kenya Medical ResearchInstitute (KEMRI)

References

[1] P J Hotez D H Molyneux A Fenwick et al ldquoControlof neglected tropical diseasesrdquo The New England Journal ofMedicine vol 357 no 10 pp 1018ndash1027 2007

[2] B Olack H Burke L Cosmas et al ldquoNutritional status ofunder-five children living in an informal urban settlement inNairobi Kenyardquo Journal of Health Population and Nutritionvol 29 no 4 pp 357ndash363 2011

[3] N Rujeni D Morona E Ruberanziza and H D MazigoldquoSchistosomiasis and soil-transmitted helminthiasis in Rwandaan update on their epidemiology and controlrdquo Infectious Dis-eases of Poverty vol 6 no 1 2017

[4] D H Molyneux P J Hotez and A Fenwick ldquoldquoRapid-impact interventionsrdquo how a policy of integrated control forAfricarsquos neglected tropical diseases could benefit the poorrdquo PLoSMedicine vol 2 no 11 2005

[5] P Steinmann J Keiser R Bos M Tanner and J UtzingerldquoSchistosomiasis and water resources development systematicreview meta-analysis and estimates of people at riskrdquo TheLancet Infectious Diseases vol 6 no 7 pp 411ndash425 2006

[6] N R Stoll ldquoThis wormy worldrdquoThe Journal of parasitology vol85 no 3 pp 392ndash396 1999

[7] World Health Organization ldquoSoil-transmitted helminth infec-tionsrdquo httpwwwwhointmediacentrefactsheetsfs366en

[8] A Alemu Y Tegegne D Damte and M Melku ldquoSchistosomamansoni and soil-transmitted helminths among preschool-aged children in Chuahit Dembia district Northwest EthiopiaPrevalence intensity of infection and associated risk factorsrdquoBMC Public Health vol 16 no 1 2016

[9] P J Hotez and A Kamath ldquoNeglected tropical diseases in sub-Saharan Africa review of their prevalence distribution anddisease burdenrdquo PLoS Neglected Tropical Diseases vol 3 no 82009

[10] D W T Crompton and M C Nesheim ldquoNutritional impactof intestinal helminthiasis during the human life cyclerdquo AnnualReview of Nutrition vol 22 pp 35ndash59 2002

[11] United Nations Childrenrsquos Fund (UNICEF) The state of theworldrsquo s children 2009 Special edition celebrating 20 years ofthe convention on the rights of the childWorldHealth 200992

[12] MOPHS ldquoNational Multi-year Strategic Plan for the Controlof Neglected Tropical Diseases Ministry of Public Health andSanitation (MOPHS) 2011rdquo

[13] L Chitsulo D Engels A Montresor and L Savioli ldquoThe globalstatus of schistosomiasis and its controlrdquo Acta Tropica vol 77no 1 pp 41ndash51 2000

[14] PMwinzi and SMontgomery ldquoIntegrated community-directedintervention for schistosomiasis and soil transmitted helminthsin western Kenya-a pilot studyrdquo Parasites amp vectors vol 5 no182 2012

[15] Kenya National Bureau of Statistics (KNBS) and ICF Macro2010 Kenya Demographic and Health Survey 2008-2009Calverton maryland 2009

[16] B De Gier M C Ponce M Van De Bor C M Doak and KPolman ldquoHelminth infections and micronutrients in school-age children a systematic review and meta-analysisrdquo AmericanJournal of Clinical Nutrition vol 99 no 6 pp 1499ndash1509 2014

[17] J R Verani B Abudho S P Montgomery et al ldquoSchistoso-miasis among young children in Usoma KenyardquoThe AmericanJournal of Tropical Medicine and Hygiene vol 84 no 5 pp 787ndash791 2011

[18] WHO Preventive chemotherapy in human helminthiasis Useof Anthelminthic Drugs in Control 200662

[19] A-F Gabrielli A Montresor L Chitsulo D Engels and LSavioli ldquoPreventive chemotherapy in human helminthiasistheoretical and operational aspectsrdquo Transactions of the RoyalSociety of Tropical Medicine and Hygiene vol 105 no 12 pp683ndash693 2011

[20] World Health Organization WHO Anthro (version 322 Jan-uary 2011)

12 Journal of Tropical Medicine

[21] World Health Organization Accelerating work to overcomethe global impact of neglected tropical diseases-A roadmap forimplementation 2012

[22] H M Al-Mekhlafi M T Al-Maktari R Jani et al ldquoBurden ofgiardia duodenalis infection and its adverse effects on growthof school children in rural Malaysiardquo PLoS Neglected TropicalDiseases vol 7 no 10 Article ID e2516 pp 1ndash12 2013

[23] J E Siza G M Kaatano J-Y Chai et al ldquoPrevalence of schisto-somes and soil-transmitted helminths among schoolchildren inlake Victoria basin TanzaniardquoThe Korean Journal of Parasitol-ogy vol 53 no 5 pp 515ndash524 2015

[24] J Bethony S Brooker M Albonico et al ldquoSoil-transmittedhelminth infections ascariasis trichuriasis and hookwormrdquoThe Lancet vol 367 no 9521 pp 1521ndash1532 2006

Submit your manuscripts athttpswwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Submit your manuscripts athttpswwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom