ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCE

SCHOOL OF ALLIED HEALTH SCIENCE
DEPARTMENT OF MEDICAL LABORATORY SCIENCE

Prevalence of Helicobacter pylori and intestinal parasite and their associated risk factors
among school children at Selam Fire Elementary School in Akaki Kality, Addis Ababa,
Ethiopia

By: Abebe Worku (BSc)

Advisors: Kassu Desta (MSc, PhD fellow)

Mistire Wolde (MSc, PhD)

A thesis submitted to Addis Ababa University, College of Health Sciences, Department

of Medical Laboratory Science, in partial fulfillment of the requirements for the degree
of master in Clinical Laboratory Science (Diagnostic and public health microbiology).

June /2017/

Addis Ababa, Ethiopia

I
 ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL OF ALLIED HEALTH SCIENCES

DEPARTMENT OF MEDICAL LABORATORY SCIENCES

This is to certify that the thesis prepared by Abebe Worku, entitled: Prevalence of
Helicobacter pylori and intestinal parasite and their associated risk factors among school
children at Selam Fire Elementary School in Akaki Kality, Addis Ababa, Ethiopia and
submitted in partial fulfillment of the requirements for the degree of Master of Science in
Clinical Laboratory Sciences (Diagnostic and Public Health Microbiology) complies with the
regulations of the University and meets the accepted standards with respect to originality and
quality.

BY: ABEBE WORKU (BSc)

Approved by the Examining Board

Chairman, Dep. Graduate Committee Signature

_________________________________ ________________

Advisors Signatures

_________________________________ ________________

_________________________________ ________________

Internal Examiner Signature Date

__________________ __________________ _______________

External Examiner Signature Date

__________________ __________________ _______________

1
Acknowledgment
Primarily my heartfelt thanks go to the Almighty God, And my all Families

Then my thanks go to Addis Ababa University, Department of Medical Laboratory Sciences

for arranging a program to conduct my MSc Thesis work.

I would like to express my sincere gratitude and deep appreciation to my advisors,

Kassu Desta (MSc, PhD fellow) and Dr Mistre Wolde (MSc, PhD) whose advice and support
made this work fruitful. Their guidance was very clear since the beginning of the process and
their input always valuable in term of giving direction and helps to solve problems in this
thesis.

Finally, my special thanks also go staffs working in Selam Fire Health Center Laboratory;
and Akaki kality Sub City education Bureau and to Selam Fire Elementary School director,
and all staffs, in which the research has been conducted, also the school children who
participated in this study.

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Table of Contents

Pages
Acknowledgment………………………………………………………………………...........II

Table of contents...…………………………………………………………………………...III

List of Tables…………………………………………………………………………...…….VI

List of Figures……………………………………………………………………………….VII

List of Abbreviation………………………………………………………………………..VIII

Operational definition………………………………………………………………………..IX

Abstract……………………………………………………………………………………….X

1.Introduction………………………………………………………………….........................1

1.1. Background……………………..………………………………………………………...1

1.2. Statement of the problem…………………………………………………………………3

1.3. Significance of the study………………………………………………………………….4

2.Literature review………….…………………………………………………………………5

2.1 Prevalence of H. Pylori………….......................................................................................5

2.2. Risk factor for H. pylori……………………………………………………………….….6

2.3. Prevalence of intestinal parasite ….....................................................................................8

2.4. Risk factors associated for intestinal parasite ….................................................................9

3. Objectives……………………………………………………………………….................10

3.1. General objective………………………………………………………………………...10

3.2. Specific objectives……………………………………………………………………….10

4. Materials and methods…………………………………………………………………….11

4.1. Study Design…………………………………………………………………………….11

4.2. Study Area……………………………………………………………………………….11

4.3. Study Duration…………………………………………………………………………..11

4.4. Population………………………………………………………………………………..11

4.4.1. Source population………………………………...……….…………………………...11

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4.4.2. Study population……………………………………………………………………….12
4.5. Inclusion and Exclusion criteria…………………………………………………………12

4.5.1. Inclusion criteria……………………………………………………………………….12

4.5.2. Exclusion criteria………………………………………………………………………12

4.6. Variables of the Study…………………………………………………………………...12

4.6.1. Independent variables…………………………………………………………...……..12

4.6.2. Dependent variable.........................................................................................................12
4.7. Sample size determination and sampling………………………………………………..12

4.7.1. Sample size determination……………………………………………………………..12

4.7.2. Sampling procedures…………………………………………………………………..13
4.8. Data collection tools and procedures…………………………………………………….15

4.8.1. Demographic characteristics and exposure to risk factors…………………………….15

4.8.2. Specimen collection and transportaion ……………………………………………….15
4.8.3. Laboratory tecquniqies ………………………………………………………………..15
4.8.3.1. Direct wet mount….....................................................................................................15

4.8.3.2. Formal Ether concentration techniques……….…………………………………….15

4.8.3.3. H. Pylori stool antigen test…….…………………………………………………….16

4.9. Data management and Quality control…………………………………………………..16

4.9.1. Pre-analytical phase……………………………………………………………………17

4.9.2. Analytical phase……………………………………………………………………….17
4.9.3. Post-analytical phase…………………………………………………………………..17
4.10. Data Processing and Analysis………………………………………………………….19

4.11. Ethical consideratios……………………………………………………………………19

5. Result………………………………………………………………………………………20

6. Discussion…………………………………………………………………………………27

7.Limitaion of the study………………………….…………………………………………..30

8.Conculusion and Recommendation ………………………………………………………..31

9. References…………………………………………………………………………………32

10. List of annexes……………………………………………………………………………37

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Annex I: English version of participant information sheet ………………………………….37

Annex II: Amharic version of participant information sheet………………………………...40

Annex III: English version informed consent form………………………………………….42

Annex IV: Amharic version informed consent form…………………………………………43

Annex V: English version informed assent form…………………………………………….44

Annex VI: Amharic version informed assent form…………………………………………..45

Annex VII: English version questionnaires…………………………………………………..46

Annex VIII : Amharic version questionnaires……………………………………………….49

Annex IX: laboratory standard operating producers…………………………………………52

1. For helicobacter pylori stool antigen test…………………………………………………52

2. For direct stool examination………..……………………………………………………..55

3. For stool sedimentation concentration technique…………………………………………56

Annex X: Data entry work sheet for participants’ laboratory test results…………………...58

Annex XI: Selection participants from various arms /grade……………………………...….59

Annex XII: Declaration………...…………………………………………………………….60

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List of tables Page
Table5.1. Socio demographic characteristic of Selam Fire Elementary School children...…20

Table5.2. Shows the distribution of the study population by household population

characteristics, and student’s behavioral characteristic in Selam Fire Elementary School
children…………………………………….………………………………………………....21

Table 5.3 Association between risk factors and H. Pylori infection at Selam Fire Elementary
School children .................................................................................................................…...22

Table5.4. Association between risk factors and Intestinal parasites infection at Selam Fire
Elementary School children ……….………………………………………………………...23

Table 5.5 The Co-infection of IPI with H. pylori at Selam Fire Elementary School
children…………………………………………….................................................................26

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List of figures Page
Fig.1. Conceptual framework………………………………………………………………….9

Fig.2. A diagrammatic representation of sampling procedures………………………………14

Fig.3. Work flow of the study………………………………………………………………..18

Fig.4.The distribution of intestinal parasite among study subjects…………………………..25

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List of abbreviations
Ag: Antigen

ENAO: Ethiopian National Accreditation Office

ELISA: Enzyme linked immune sorbent assay

FECT: Formal ether concentration technique

HP: Helicobacter pylori

HpSA: Helicobacter pylori stool antigen

ICT: Immune chromatographic test

IgG: immunoglobulin G

IPI: Intestinal parasitic infection

KG: Kindergarten

MALT: Mucosa-associated lymphoid tissue

MUAC: Mean Upper Arm Circumference

NaCl: Sodium Chloride

PTA: Parents Teachers Association

SOP: Standard operating producers

SPSS: Statistical package for social study

STH: Soil transmitted helminthes

UK: United Kingdom

WGO: World Gastroenterology Organization

WHO: World health organization

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Operational definitions
Helicobacter pylori stool Antigen test (HPSA): is a lateral flow chromatographic
immunoassay for the qualitative detection of H. pylori antigen in human faecal specimen.

Prevalence: is a measurement of all individuals affected by the disease at a particular time.

Co-infection: the simultaneous presence of two or more infections, which may increase the
severity and duration of one or both

Children: A person between birth and puberty.

School children: a child attending school.

A Primary school: is a school for children between the ages of 5 and 18.

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Abstract
Background: The prevalence of H. pylori infection mainly acquired during childhood and
may be persisting throughout life and it has been found high in developing countries; this
prevalence is related to low socioeconomic status, and Intestinal parasitic infections are
among the major public health problems in Sub-Saharan Africa. Their distribution is mainly
associated with poor personal hygiene, environmental sanitation and limited access to clean
water. There is limited information on the burden of the H. pylori and intestinal parasites in
Ethiopia and this research will address such gap.

Objectives: To assess the prevalence of Helicobacter pylori and intestinal parasite and their
associated risk among Elementary School Children.

Methods: A cross sectional study was conducted to determine the burden and risk factors
associated of H. pylori and intestinal parasite among in 422 school children. The study was
conducted between March to June 2017. Multiple sampling methods were used, to collect the
data. The stool samples were tested for intestinal parasite using direct wet mount and
concentration techniques and stool antigen test for H. pylori. Information from the laboratory
analysis and questionnaires were entered into SPSS version.20 for analysis.

Results: A total of (n=422) students have been participated in this study 55.2 %( n=233/422)
44.8% (n=189/418) were female and male respectively. Age of range (4-18) years, with mean
age of 11.16±SD years [95% CI 10.82-11.5], the mean weight of 30.99 ± SD Kg [95 % CI
29.9 -32.08], the mean height 1.36 ± SD m [95% CI 1.34-1.38], Helicobacter pylori antigens
were detected in 14.6% (n=61/422) ,and 6%(n=25/189) 8.6%(n=36/233) male and female
respectively. Intestinal parasite were detected in 23.7 %( n=100/422), 10.4 %( n=44/189)
13.3 %( n=56/422) male and female respectively. The co-infection for HP and IPI was
present in 4.5 %( n=19/422). The age of study subject, educational status/ monthly income
status of their family/guardians, overcrowding and some sanitary practice were a risk factor
for the development of intestinal parasite and H. pylori infection.

Conclusions: The prevalence of H. pylori infection is 14.6 %, and IPI is 23.7 %, this burden
of IPI among school children call mass de-worming which is going on in some schools.
Moreover further studies are required to understand the role of HP and IPI on the overall
growth of children and school performance.

Key words: H. pylori, intestinal parasite, School Children, Selam Fire Elementary School

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1. INTRODUCTION

1.1 Background

In the early 1980s, gastroenterologist Barry Marshal and his pathologist colleague,
Rober Warren, found spiral-shaped bacteria in about half of the routine biopsies,
obtained from patients attending the gastroenterology consultation, and their presence was
closely associated with mucosal inflammation[1].

H. pylori cause acute and chronic gastritis, and can cause duodenal and gastric ulcers. There
is strong epidemiological evidence to implicate H. pylori gastritis in marginal B cell
mucosal lymphomas. Although these significant diseases are typically found among adults,
there are clear parallels with gastro duodenal disease in children. In particular, Peptic
ulceration, abdominal pain in the absence of peptic ulceration and Gastro-esophageal
reflux diseases are pediatric disorders have been associated with H. pylori[2].

The natural history of H. pylori infection in children has not yet been extensively
studied, but there are several reports that affected children develop a chronic gastritis,
localized especially in gastric antrum, similar to adult. The majority of infected children
remain asymptomatic, but the inflammatory response may result in an ulcerogenic process,
also the prevalence of H .pylori associated peptic ulcer in children is not clearly known. It is
thought to be low, based on the studies of large pediatric endoscopy unit which report
an incidence of 5-9 new peptic ulcer, cases per year. H. pylori are crucial factor in the
pathogenesis of peptic ulcer, especially duodenal ulcer, since almost all children with the
disease were positive for the bacterium [3].

Intestinal Parasitic Infections (IPIs) constitute the greatest single worldwide cause of illness
and disease. 3.5 billion Individuals have been infected with intestinal parasites, of these 450
million individuals developed diseases Africa, more specifically Sub-Saharan Africa,
parasitic infections are the major public health problem and most of the victims are children
[4]. Parasites are one of the important casual agents of diarrhea, loss of weight, abdominal
pain, nausea, vomiting, lack of appetite, abdominal distention and Iron deficiency anemia [5].
Currently, the protozoan parasite (Entameoba histolitica and Giardia intestinalis) and the soil
transmitted helminthes (Ascaris lumbricoides, Trichuris trichiura, and Hookworm) are the
leading intestinal parasites which cause significant morbidity and mortality in the world [6].

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For instance, recent estimates indicated that approximately 1472, 1298 and 1049 million
people have round worm, hookworm and whip worm infection, respectively [7]. However,
the incidence and prevalence of intestinal parasitic infections varies within and across the
countries due to environmental, social and geographical factors [8].

In children, soil-transmitted helminthes is the cause of common health problems, in most

instances, associated with stunting of linear growth, physical weakness and low educational
achievement. These is due to their immune systems are not yet fully developed and they also
habitually play in faecally contaminated soil. Those problems are predominant in tropical
areas [9].

In Ethiopia, intestinal parasitic infection is sixth of the top ten causes of morbidity amongst
children. Different studies conducted in different regions depicted that the prevalence and
possible associated factors are different [10].

So far, guidelines for the management of Hp infection in children recommend endoscopy to

exclude other pathological causes for the child’s symptoms [11]. The reasoning behind this
recommendation is that no specific complex of clinical symptoms and signs has been
established for children. Cultures of gastric tissues have a specificity of 100%, but a relatively
low sensitivity of 38-80%. PCR testing in gastric tissue can detect genes associated with
virulence factors and antibiotic resistance. The 13C-urea breath test (UBT) and the
monoclonal stool test have been validated well in children older than 6 years for the detection
as well as the eradication control of Hp. Unfortunately these non-invasive tests have not
sufficiently been validated in younger children, below the age of 6 years[12].

The diagnosis of intestinal parasite is initially based on clinical signs and symptoms and
Confirmed by the presence of cysts, trophozoites, ova, and larva stage etc, in stool samples
[13]. The direct wet preparation is more useful for detection of characteristic motility of
trophozoite [14]. Diagnosis of intestinal parasite by conventional microscopic methods
following the application of fecal concentration techniques, especially Zinc sulphate
flotation and centrifugation remains a relatively reliable indicator of infection [15].
Enzyme immunoassay (ELISA) is highly sensitive and specific. For these reasons, in the last
years, Molecular techniques particularly polymerase chain reaction (PCR) based procedures
have greater sensitivity and specificity than the conventional diagnostic methods for
diagnosis of intestinal parasite [15].

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1.2 Statements of the problems
In various regions of sub-Saharan Africa, for example, 61–100% of the population may
harbor H. pylori infection; young children have the highest prevalence [16].
A lack of proper sanitation, safe drinking water, and basic hygiene, as well as poor diets and
overcrowding, play a role in determining the overall prevalence of H. pylori infection [17].
The greatest burden of soil-transmitted helminthes (STH) occurs among children in
developing countries, where there is poor hygiene and sanitation [18].

In severe cases the number of parasites may grow so large that the intestines become blocked.
Some infections cause specific complications: Amebiasis can affect the liver, lungs and brain;
parasites migrating through the lungs may cause difficulty in breathing; and
hookworm infection can cause anemia and malnutrition, which can affect growth and
development in children [19].

Multiple infections with several different parasites are common and their harmful aspects are
often aggravated by coexistent with malnutrition or micro environment [20].

In the absence of Clean, functioning and adequate toilets will result in children to defecate in
and around the school compound. In such situations the school and its surroundings are likely
to become infested with parasitic helminthes. In the absence of the availability of convenient
hand washing facilities Children dipping their unwashed hands into a shared drinking-water
supply are a typical route of contamination infectious diseases which can be spread via the
faecal-oral route [21].

To the best of our knowledge, there is no study conducted in this area in particular
and in Ethiopia in general, about H. pylori, and intestinal parasite infection among school
children, hence conducting this study and address this issue will be fill the existing gap.

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1.3 Significance of the study

This study would helpful to see which type of parasite is more prevalent and the prevalence
of H. pylori infection in school children and which type of predisposing risk factors
contribute more to existence of both infection or for each of infection.

This study would help us to design strategies that involve schools about school health
services, which provides invaluable support for schools in order to achieve the collective
goals of promoting healthier environments.

The findings of this study would help in strengthening the information available so far and
would be helped policy makers to design effective strategies to combat intestinal parasitic
infections and H. pylori in the study area.

This study provided the current prevalence of H. pylori infection and its associated risk
factors among the study subjects and used to plan intervention activities in the future. Lastly
the study served as base line data for the upcoming researchers in this area.

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2. LITERATURE REVIEW
2.1. Prevalence of H. pylori infection

The prevalence of H. pylori and associated diseases has been highly inconsistent worldwide.
In industrialized countries there is generally a low prevalence of H. pylori infection and yet a
relatively high prevalence of gastric cancer. On the other hand, some countries with high H.
pylori prevalence have low gastric cancer prevalence, particularly among the Asian countries.
Prevalence of H. pylori infection is high in less developed Asian countries like India,
Bangladesh, Pakistan, and Thailand, and is acquired at an early age than in the more
developed Asian countries like Japan and China. The frequency of gastric cancer, however, is
very low in India, Bangladesh, Pakistan and Thailand compared to that in Japan and China.
Similar enigma has been reported from Africa as compared to the West [22].

The search identified population-based studies reporting frequency of Helicobacter pylori

infection primarily from Asia and the Middle East. Several studies used stool antigen testing;
others used serologic testing, carbon-13 urea breath testing, or urine antigen testing [23].
Prevalence of infection with H. pylori varied between 7% in a study conducted among
asymptomatic children in the Czech Republic, 24 to 92% in Pakistani population [24].

A study was conducted in China on children and adults in two regions of China with both a
low and a high incidence of gastric cancer, reported that the prevalence of H. pylori was
significantly lower in 2006 when compared to the early 1990s, with a decrease in the
prevalence between 5 and 28%, depending on the population under study. Only one study
compared prevalence of H. pylori infection within the same population using different
diagnostic tests and reported no statistically significant difference in the prevalence of
infection when the stool antigen test was used, compared with serologic testing [25].

In a rural village of Linqu Country, Shandong Province, China, a study of 98 children

found that nearly 70% of those aged 5-6 years were infected with the organism, a
rate similar to that reported for adults in that area, suggesting that most infection takes
place early in childhood [26].

In developing countries, H. pylori infection is markedly more prevalent at younger ages than
in developed countries. According to World Gastroenterology Organization (WGO) 2010 the
Prevalence of H. Pylori in Ethiopia was 48% in age between 2-4, 80% at the age of 6 and
95% in adult’s population [17].

15
In developing countries, where majority of children are infected before the age of 10, the
prevalence in adults peaks to more than 80% before 50 years of age. In developed nations,
serologic evidence of H. pylori is rarely found before 10 years of age, but increases to 10% in
those between 18 and 30 years of age and to 50% in those older than 60 [27].

The increased prevalence of infection with age was initially thought to represent a continuing
rate of bacterial acquirement throughout one's lifetime. However, epidemiologic evidence
now indicates most infections are acquired during childhood even in developed countries.
Thus, the frequency of H. pylori infection for any age group in any locality reflects that
particular cohort's rate of bacterial acquisition during childhood years [28].

Infection with H. Pylori is relatively common in Africa, and the organism is the main cause
of at least 90% of duodenal ulcers and 70% of gastric ulcers. Studies conducted in various
parts of Africa have revealed high Sero-prevalence of infection (61-100%) which
differs from country to country and between different racial groups within each country
[29].

2.2. Risk factors for H. pylori

Several epidemiological studies have examined risk factors for H. pylori infection, with lower
socio-economic conditions being the most consistently identified. However, social
classifications by occupation, level of education or earning are merely markers for groups of
people sharing certain characteristics or practices and not a specific cause of infection.
Studies of adults have revealed a stronger association between H. pylori infection and
childhood living conditions than for current living conditions, thus supporting acquisition
early in life. The risk of introduced recall bias when adults and elderly were asked
about living conditions before the age of 5 years should not be ignored. However, studies
performed among children have confirmed the finding of an inverse association
between socio-economic conditions and H. pylori infection [30].

Ayse et al. reported from eastern Turkey a very high prevalence of H. pylori (64.4%)
among300 children. The risk factors for acquiring the infection were the low economic status
and larger sibling size of the family. However, no significant difference between children
whose parents were from different educational levels was found suggesting that the very high
prevalence of H. pylori in eastern Turkey depends on environmental factors [31].

16
Person-to-person transmission of H. pylori has been suggested in a number of studies
pointing at domestic overcrowding early in life as an important risk factor for infection [33].

A common exposure to infection could, however, not be excluded. Two studies from the UK
(Whitaker et al. 1993, Webb et al. 1994) identified childhood crowding, increasing number
of siblings and bed sharing as possible risk factors for transmission of the organism.
Although statistical analyses could not separate the relative importance of the three,
the findings indicated transmission via close personal contact early in life [32].

Several studies investigated putative risk factors for H. Pylori infection. Gender and age do
not seem to be associated with an increased risk of infection. Indeed, most studies reported no
significant difference of H. pylori infection between men and women, both in adults and in
children .No-significant association was found between infection and age in the adult
population. Moreover, several factors related to residence have been found to be associated
with the infection. Indeed, living in a rural area, in crowded homes, and having contaminated
sources of drinking water were risk factors for H. pylori infection [33].

Several socioeconomic factors have been associated with H. pylori infection. In particular,
subjects with a low socioeconomic status, measured also as a low family income, had a
higher likelihood of carrying H. pylori infection. Furthermore, an inverse association between
educational level and H. pylori infection was found in the majority of the studies; indeed,
except for two cases, individuals with lower educational levels had a higher risk than those
with a higher education. The same association concerning the parents’ education was also
found in studies on children [34].

High prevalence of human infection seen in Africa and the world at large are an indication
that effective public-health interventions need to be developed; while the variations seen
in the prevalence of infection between and among populations may point to the fact that
parameters such as age, cultural back-ground, genetic predisposition, socio-economic
status and environmental factors all play a role in the acquisition and transmission of H.
pylori [35].

Within countries, there may be similarly wide variation in prevalence between the more
affluent urban populations and the resource-poor rural populations. A lack of proper
sensitization, good drinking water and poor diet seem to play a role in the high
prevalence of infection [36].

17
2.3. Prevalence of intestinal parasite

Intestinal parasitic infections which are caused either by protozoa or helminthes or both are
among the most widespread of human infections worldwide. It is estimated that as much as
60% of the World’s population is infected with intestinal parasites which may play a
significant role in morbidity due to intestinal infections [37].

The most common intestinal parasitic infections in the world are Ascaris
lumbricoide,Trichuris trichuria and Hook worms. [38] Also the study found, in India shows
that approximately two-third (63.94%) of the school children was infected with intestinal
parasitic infection. In another study performed in India showed a low prevalence (29.2%) of
intestinal parasitic infection when compared to the present study [39].

The prevalence of intestinal parasites was investigated in a primary school located in kubia
Junior, Saopaulo state Brazil, of 219 school children of which 123 (56.1%) were found to be
infected with one or more parasite species [40].

Study conducted at western city, turkey showed that about 456 stool specimen were collected
and 145(31.8%) were infected with one or more intestinal parasites, 29(6.4%) of the students
were infected with more than one parasites, 26(5.7%) with two parasites and about 3(0.7%)
infected with three parasites. The three most common parasites were E.vermicularis.
G.lamblia and E.coli intestinal parasites prevalence were higher in rural than urban area [41].

A cross sectional survey conducted in Ethiopian on intestinal infection in asymptomatic

children in south western Ethiopia in July 2005 showed that the overall prevalence rate of
intestinal helminthes was 57.4% with T.trichiura (31%) A.lumbricides (30.5%), H.nana
(14.3%) and hook worm (4%) [42].

Another study conducted in Jiren School, Jimma town, showed that the overall intestinal
parasite prevalence rate of 68.4% and A.lumbricoides was the most prevalent parasite which
accounted 52.2% and T.trichiura was the second parasite with 18.6% and S.mansoni was the
least intestinal parasite which was (0.3%) [43].

18
2.4. Risk factors for intestinal parasite

Most studies show that potential risk factors with the prevalence of intestinal parasites among
school children. Socio-demographic, Environmental, behavioral factors and different
sanitation facilities had a significant contribution for the presence of IPIs. Among the
potential risk factors, the unavailability of washing facilities constructed at home had also a
contributing effect for the presence of intestinal parasites. Home cleanness condition also had
contribution for the existence of IPIs [44].

They are closely associated with low household income, poor personal and environmental
sanitation, overcrowding conditions, and limited access to clean water, tropical climate and
low latitude [45].

Study conducted in, Delgi, School children in south Gondar of Ethiopia, the finding showed
school children who had no toilet with washing facilities in their home were more likely to
acquire the IPIs than those who had the facilities. However, the difference was not
statistically significant (p > 0.05). An open defecation system of latrine in the living
environment could have a significant contribution for the occurrences of IPIs (P < 0.05). The
highest prevalence of IPIs was also found in children who had no toilet at their vicinity
compared to those who had toilet at/around their home. This might have contribution due to
the absence washing facility and exposure of children to parasites in open defecation system
[46]. Based on the above literature review no data is available in Ethiopia context comprising
both H. pylori and IPI. Hence this study is required to fill the gap.

Figure 1: Conceptual framework:

Low Socio economic status Size of families

Environmental sanitary facilities

IPI
Residence behavioral factors
HP
Family educational level

I have adopted this framework from different literature this risk factor could be for either of
infection [reference, 32, 34, 35, and 44].

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3. OBJECTIVES
3.1 General objectives:

To assess the prevalence and risk factors associated with Helicobacter pylori, and intestinal
parasites among Selam Fire Elementary School Children form a duration of March to June
2017.

3.2 Specific objective:

 To determine the prevalence Helicobacter pylori among school children.

 To determine the prevalence intestinal parasite among school children.
 To assess the risk factors associated with H. pylori and intestinal parasite among
school children.

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4. MATERIALS AND METHODS
4.1. Study design

A cross-sectional, institutional-based study was conducted.

4.2. Study area

The study was conducted in Selam Fire Elementary School ( SFES)which is located in Akaki
Kality Sub City in wareda 3, Addis Ababa, Ethiopia, according to the Sub City educational
system (educational statistic annual abstracts, 2008 E.C) report the number of Elementary
school are around 68which are 20 governmental and 48 privates and others.

According to the SFES annual reports (statically data) the School was built in 2002E.c, by the
communities with the governments support; it is also governed under Addis Ababa city
education Bureau, the school located having an area of 15,274 square meters, organized with
58 teachers with different level of study and departments and 35 administrative staff, The
total number students enrolled in this school are 1,174.it has water facility, but has no hand
washing facility especially at toilet, it has seven toilets or dry toilet, it has eighteen (18) room
or teaching class each of them have 56 square meter Area , the school also has enough area
for playing and studying. The school has two set up, pre-school which has KG students with
total number of 184 from this there are 92 female and 92 male, And the primary school has
two cycle structure the first cycle is from grade 1-4 has 421students from this, there are 184
male, and 237 female, and the second cycle from grade (5-8) has 557 students from this, there
are 238 male, and 319 female, in all of these area the lower limit of age was 4 years and the
above limit it was reach up to 18 years.

4.3. Study duration

The study was conducted in the period from March to June, 2017.

4.4. Population

4.4.1. Source population

All of Selam Fire Elementary school students who were attending the classes during the study
period.

21
4.4.2. Study population

Selam Fire Elementary School students who have been involved in the study based on the
inclusion and exclusion criteria were the study population.

4.5Inclusion and exclusion criteria

4.5.1. Inclusion criteria

In the study documented all the school students who have been enrolled were included in the
study after consent with parents/guardians.
4.5.2. Exclusion criteria
Those students were taken. H. Pylori treatments for the last two week.

4.6 Variables of the study

4.6.1. Independent variables:
Age, sex, weight, pre-sample antibiotic history, Socio demographic factors, parents
educational status, parents income, hygiene practice like hand washing, environmental
conditions (latrine, water source etc.)
4.6.2. Dependent variables:

Burden of H. pylori infection, and intestinal parasites

4.7 Sample size determination and sampling

4.7.1. Sample size determination

Different studies in different parts of the country also reported different prevalence rates of
intestinal parasites in school children, also resa5rch has not been conducted the prevalence of
H. pylori in school children. So that to determine appropriates for the population sample
maximum value 50 % had been used.

N = Z2 P (1-P)
D2
Where Z= 95% confidence interval (1.96)
P = Estimated prevalence rate (50%), = (0.90)
D = Marginal of sampling error

N = minimum sample size

= (1.96)2.0.50(1-0.50) =3.8x.0.50 (0.50) = 384
0.052 0.0025

22
Therefore by adding 10% non-response rates, a total of 422 study subjects were participated
in the study.

4.7.2. Sampling procedures

Multiple sampling methods were used , such as a purposive sampling technique was used to
select these sub city, Akaki Kality, which is located at western parts from the center of Addis
Ababa, and comprises of 11 woarda, and 27 local kebele, the total population is around
2,739,551 (1,305,387 male, and 1,437,164 female).

Simple random sampling technique was used to include study participants who meet the
inclusion criteria until the achievement of the sample size, And to represent a proportional
distribution from the various arms /grade of classes. Each arm/grade of class was given an
equal chance of being selected. Selection of the various arms /grade were made by Simple
random sampling technique this is assured by about (422/1174) or 35 % chances were given
at each of classes, Consenting students in the class (es) selected was interviewed while stool
samples collected immediately after the interview from the respondents.

23
 Figure: 2 A diagrammatic representations of sampling procedures.

Addis Ababa City Administration

Ten sub- city

Purposive sample technique

Akaki Kality Sub City

11 worada
Purposive sample technique

Worada 3

Two governmental and one private Elementary School

Purposive sample technique

Selam Fire Elementary School

Simple random sampling technique
At primary school, 994 students
At Preschool, 184 students 1174 students
o
o

Simple random sampling

1Grd 2Grd 1ewe
3Grd 4Grd 5Grd 6Grd 7Grd 8Grd
1ewe

Simple random sampling

KG-1 KG-2 KG-3
Grade
o 41 38 39 e 42 57 44 51 46
1ewe 1ewe 1ewe
Simple random sampling
o o
o 1ewe 1ewe 1ewe
22 16 26
1ewe
o o o
1ewe 1ewe 1ewe
1ewe
o o o o o o o
1ewe 1ewe 1ewe
o
Note: Stu: students, Grd: grade, no = students
1ewe
number
1ewe 1ewe 1ewe 1ewe 1ewe 1ewe

1ewe

24
4.8 Data collection tools and procedures

4.8.1 Demographic characteristics and exposure to risk factors

Structured questionnaire was prepared with English version and translated to Amharic and
retranslated to English for data analysis and interpretation of results. Before the actual data
collection time, the questionnaire was pre-tested on 20 of the study subjects (5% of the
sample), in Aste Tewdrose Elementary school, which is located at worda 3 , in Akaki Kality
sub city to check for any missing options, ambiguity and clarity.

4.8.2 Specimen collection and transportation

Students were advised to pass the stool samples directly into a plastic cup with a tight fitting
lid. About 20-40 grams of formed stools or 5-6 spoonfuls for watery stools was collected. All
specimens were labeled with patient’s name, age, sex, and date of collection. The safety was
assured by using universal safety guide line, and National health and safety guideline, by
Wearing personal protective equipments and other personnel protective equipments. The
participant’s students were informed and well instructed by data collectors how handling the
sample and their safety to reduce the contamination, after toilet, and giving a sample the
participants were also informed to clean their hands with soap and clean water after the
collection of the sample.

4.8.3 Laboratory techniques

4.8.3.1. Direct wet mount:

A small sample of Faeces was placed on a glass slide and mixed with a drop of 0.9%
solutions of NaCl and the slide was covered with a glass cover slip and examined for the
presence of intestinal parasites at 10× and 40 × magnifications [47].

4.8.3.2 Formal ether concentration technique (FECT):

About 1 g of Faeces (pea-size) will be emulsified in 4 ml of 10% formal saline. 3-4 ml of

10% formal saline were added and mixed well by shaking. Then sieved in a beaker and
transferred to centrifuge tube. A 3- 4 ml of diethyl ether were added, stoppered and mixed for
1 minute. Then centrifuged at 750-1000 rpm for 1 minute, layers of faecal debris, ether and
formal saline were discarded by using plastic bulb pipette. The sediment were re-suspended,
mixed and transferred to slide, covered with cover glass, and then it was examined
microscopically using (10 xs, 40 xs) [48].

25
4.8.3.3 H. pylori antigen rapid test (H. pylori Ag rapid test):

The source of Hp, Wondfo was one of the earliest high tech. biological companies focusing
on rapid diagnostic in china: as described by manufacturer the use of rapid immune
chromatographic test (ICT): for the qualitative detection of H. pylori antigen in fresh fecal
samples. Instructions given by the manufacturer were followed. Stool collection device were
opened and using collection stick to pierce the stool sample, then the collection stick was
replaced to stool device and was shake vigorously. On the test device, 2 drops of the solution
was dispended into the sample well. Results may be read after 15 minutes of adding the
specimen, the performance of these test kit has been compared with H. pylori ELISA
detection kit , accordingly the fact given from manufactures it has (99.1% ,99.6%) , and
(99.2%, 96.6% ) sensitivity and specificity respectively [49].

4.9. Data management and quality control

Data was collected by pre tested questioner and clean sample collection material with leak
proof and a lid. Data collectors were identified, trained and informed to collect the data as per
the pre-structured questionnaire, and Interviews were conducted by two trained research
assistant’s that has more than a three years’ work experience. Also they were trained in how
to use the instrument and how they should introduce themselves and the research objectives
modestly to the students/parents/guardians during the interview. The daily analysis was
supervised by Personal investigator. For laboratory analysis Pre-analytical, analytical and
post-analytical stages of quality assurance that is incorporated in Standard operating
procedures (SOPs) was strictly followed. The purpose of the study as well as any related
harm and benefits were explained to the study participants accordingly. Demographic data
and potential risk factor of H. pylori, and intestinal parasitic infection, MUAC, weight, pre-
sample antibiotic history, parental /guardian per-individual monthly income was recorded.

26
4.9.1 Pre-analytical phase
First of all we were asked the parents/guardians verbally and by written consent/assent for
their willingness and then we were filled all the information on the preformed questioner, we
were also took, weigh, height, and MUAC measure, finally by labeling the stool
cup/container with participants identification number and information was informed them to
bring the sample. The specimen quality assured by stool specimen rejection criteria of the
health center laboratory which is indicated in SOP, following collection, specimens has been
transported with ice bag at about 20c o to the Selam Fire health center laboratory within 20-30
minutes. Which is situated about 100 meter away from the study area.

4.9.2 Analytical phase

The sample was analyzed at Selam Fire Health Center which is located at nearby the study
area, this Health center is still participated, and it has two Star levels ENAO assessment
program. The test was performed by the well experienced laboratory technicians/technologist
and continuously was supervised by principal investigator. A collected sample was tested
once for Stool Ag for H. pylori, and for intestine parasite. All materials, equipment and
Procedures have been adequately controlled. Stool Ag test reagents were evaluated using a
control band indicator on test kit. Standard operating procedures (SOPs) of the health center
laboratory for both tests (stool Ag test and stool examination) were strictly followed and the
results were checked by the supervisors.

4.9.3 Post-analytical phase

The results were recorded with identification number. In order to avoid the errors in the
results of the test, the reporting has been repeatedly checked and evaluated by the head of the
department and principal investigator. The laboratory result was given a free of charge for
parents/guardians at tested day or whenever they came with their identification number. For
students with positive for either of H. pylori and intestinal parasite or for co infection we
were linked to the health center, for medical treatments. Every laboratory test results were
interpreted based on the SOPs of SFHCL, AARL.

27
 Informed consent, Questionnaires was filled

Specimen container Labeling, Stool sampling,

Stool sample was transported to the laboratory

Stool sample for direct

Stool sample for Formal-ether microscopic examination for
sedimentation and microscopic ova/parasite
exam. For ova/parasite

Report No Report No Report

Report Ova Ova Ova/parasi
Ova/parasite /Parasite /Parasite te
seen seen
seen
Stool sample for H.pylori stool antigen test

Positive report Negative report

Figure 3: Work flow of stool sample for H. pylori stool antigen test, direct microscopic stool examination and
formol-ether sedimentation and microscopic examination for ova/parasite

28
4.10 Data processing and analysis
Data was coded and entry analysis were done using SPSS statistical software version 20. The
descriptive statistics were calculated & binary and multiple logistic regression analysis was
used to see the relation between dependent variable and independent variables. The
association was assessed by using chi-square test. Variables that was showed a significant
association were selected for further analysis. In all cases P-value less than 0.05 was
considered as statistically significant. The strength of the association was interpreted using an
odds ratio in a 95% confidence interval. Finally, the results were presented on words, charts,
graphs and tables.

4.11 Ethical considerations

This research project has been approved by department of ethical and review research
committee (DRCRC) of the Department of Medical Laboratory Sciences, CHS, and School of
Allied Health Science of AAU, and Addis Ababa public Health Research and emergency
management core processes, During the planning of the study, the researchers approached the
authority’s in-charge of the selected schools particularly the principals and the Local
Education District Officer in-charge of public schools with formal letters to obtain permission
to carry out the work in the schools and also explained the study objectives.

There was very minimal risk associated with the process of sampling and data collection. For
all confirmed H. pylori infection or intestinal parasite infection, we were linked to health
center by informing their parents/guardians to get treatment. We were provided a laboratory
results with free of charge. All the information contained within the study was kept
confidential.

29
5. RESULTS

5.1 Socio demographic characteristics of the study subjects

From 1174 students of Selam Fire Elementary School, only 422 students were selected.
About 55.2% (n=233/422) of student were female resulting male to female ratio of 1:1.3.
Children with age groups 10-15 years were the highest population 59.6% (n=249/422), Age
of range (4-18) years, with mean age of 11.16±SD years [95% CI 10.82-11.5] none of the
school children had severe malnutrition based on medium upper arm circumference (MUAC).
(Table 5.1)

Table5.1. Socio demographic characteristic of Selam Fire Elementary School children.

Variable Frequency Percent

Age
4-9 124 29.4
10-15 253 60.0
16-18 45 10.7
Sex
Male 189 44.8
Female 233 55.2
MUAC
Normal 268 63.5
Moderate 154 36.5
Residence
Urban 402 95.3
Rural 20 4.7
Family/guardians income
Low 396 93.8
Medium 26 6.2
Family/guardians level of education
Illiterate 175 41.5
Read and write 61 14.5
Primary school 72 17.1
Secondary school 69 16.4
Above secondary 45 10.7

30
In this study,97.9%(n=413/422) children live in house with bed room of 3 or low and
majority of the child live in a family size of 6 and above 54.5%(n=230/422), and 87.2 %(n=
368/422) did not had history of de-wormed. (Table 5.2)

Table5.2 Shows the distribution of the study population by household population

characteristics, and student’s behavioral characteristic in School children.

Variable Frequency Percent

No of bed room
<3 413 97.9
>3 9 2.1
No person do live in house
<6 192 45.5
>6 230 54.5
Abdominal pain
Yes 134 31.8
No 288 68.2
De-worm
Yes 54 12.2
No 368 87.8
Source of water
Tap/bono water 402 95.3
Bottled water 1 0.2
Mineral/ground water 19 4.5
Type of toilet
Pit latrine 389 92.2
Flush toilet 1 0.2
Open field 32 7.6
Hand washing after using toilet
Always 296 70.1
Some times 71 16.8
Not at all 55 13.0

31
5.2. Prevalence of H .pylori and associated of risk factors

Helicobacter pylori antigens were detected in children giving an overall prevalence of 14.6 %
(n=61/418), (95% CI 1.82-1.88), 8.6% (n=36/233) in female and 5.9 %( n=25/189) in male
children (x2 = 0.310, 95% CI=1.82-1.88). The prevalence of H .pylori among age group of 4-
9, 10-15, and 16-19 is 10(2.4%), 42(10.0%), and 9(2.2%) respectively. According to the Comment [u1]: Not clear

study subject the peak age was 10-15 year and prevalence was 10.0 % (X2 = 6.16, p value=
0.046). (Table5.3). In this study the high prevalence of H. pylori infection were in age group
of 10-15, in accounting 10%(n=42/249), and majority of these infection were occurred in
children whose their family/guardians low level of education, also majority of infection were
occurred in children with less than 3 bed room in the house. (Table 5.3)

Table 5.3 Association between risk factors and H. Pylori

Variables and categories N HP, Positive X2, 95%CI, OR P

(%) value
Age 6.16 0.046
4-9 124 10(2.4%)
10-15 253 42(10%)
16-18 45 9(2.2%)
Sex 0.42(0.48-1.45) 0.52
Male 189 25(5.9%)
Female 233 36(8.6%)
Family/guardians educational 10.53 0.03
Illiterate 171 29(6.9%)
Read and write 61 13(3.1%)
Primary school 72 12(2.8%)
Secondary school 69 6(1.4%)
Above secondary 45 1(0.4%)
Family/guardians income 4.7(0.8-0.88)0.85 0.03
low 396 61(14.6%)
Middle 26 0(0.0%)
No of bed room 0.08(0.17-11)1.4 0.77
<3 413 60(14.2%)
>3 9 1(0.4%)
No person do live in house 0.04(0.6-1.6)0.94 0.83
<6 192 27(6.4%)
>6 230 34(8.2%)
Total 2532 366(14.5%)

32
Table5.4.Association between risk factors and Intestinal parasites in school children

Variables and categories N IPI, Positive X2, 95%CI, OR P

(%) value
Age 11.33 0.003
4-9 124 16(3.8%)
10-15 253 71(16.8%)
16-18 45 13(3.1%)
Sex 0.033(0.6-1.5)0.96 0.86
Male 189 44(10.5%)
Female 233 56(13.3%)
Family/guardians education 9.6 0.04
Illiterate 175 48(11.4%)
Read and write 61 12(2.8%)
Primary school 72 23(5.5%)
Secondary school 69 11(2.6%)
Above secondary 45 6(1.4%)
Family/guardians income 3.93(0.9-17)3.95 0.04
low 396 98(23.2%)
Middle 26 2(0.5%)
No of bed room 2.19(0.1-1.4)0.38 0.14
<3 413 96(22.7%)
>3 9 4(1.0%)
No person do live in house 5.3(0.37-0.93)0.58 0.02
<6 192 36(8.6%)
>6 226 64(15.3%)
De-worm
Yes 54 11(2.6%) 0.38(0.39-1.61) 0.8 0.54
No 368 89(21.1%)
Source of water 12.6 0.002
Tap/bono water 402 89(21.1%)
Bottled water 1 1(0.2%)
Mineral water 19 10(2.4%)
Type of toilet 27.8 0.00
Pit latrine 389 80(19.0%)
Flush toilet 1 1(0.2%)
Open field 32 9(4.5%)
Hand washing after using a toilet 245.5 0.00
Always 296 14(3.3%)
Some times 71 32(7.6%)
Not at all 54 54(12.8%)
Total 4220 900(21.3%)

33
5.3. Prevalence of intestine parasite and associated risk factors

Intestinal parasite were detected in children giving an overall prevalence of 23.7%

(n=100/422) (95% CI 1.72-1.8), 13.3% % (n=44/233) in female and 10.5 %( 56/189) in male
children. (Table 5.3) The distribution of IPI in female children was, 1(0.2%) ova of Ascaris
Lumbricode, lowest prevent, and 40(9.6%) cyst of Giardia Lamblia, which is the most
prevalent. And in male the distribution the highest prevalence was 29(6.9%) cyst of Giardia
lamblia, and the lowest prevalence was 1 (0.2%) ova of Hookworm. In both gender the
occurrence of multiple infection in one individual was very minimum. (Fig 4)

The frequency of IPI colonization was not significantly different between females and males
p = 0.952, and the highest prevalence of IPI was seen among age group of 10-15 years 16.8
%( n=71/253) and in age group of 16-19 years 3.1 %( n= 13/45) had the lowest prevalence of
IPI (P value of 0.003), according to these study there were a significant association the Comment [u2]: DO NOT WRITE EVERYFINDINGS
IN TEXT ( WORDS) THE DETAIL SHOULD BE SHOWN
between the prevalence IPI with age. (Table 5.4) IN TABLES PLESAE FOLLOW FOR ALL YOUR RESULTS
!!!

34
Figure 4: the distribution of intestinal parasite infection among the gender of children

200
177
180

160
141 male
140 female

120

100

80

60
40
40 29

20
6 4
1 0 2 1 3 7 0 2 1 0 2 2
0
H.N H.W A.L G.L E.H TE.H A.L & G.L H.N & No o/p
G.L seen

Key:

H.N – Ova of H. Nana

H.W- Ova of Hookworm

A.L- Ova Ascaris Lumbricoid

G.L- Cyst of Giardia Lamblia

E.H- Cyst of Entambea Histolytical

TE.H- Trophozoite of Entambea Histolytical

35
Out of 422 study subjects co-infection was observed in 4.5 %( n=19/422), of children had HP
and IPI. (X2= 2.19 p=0.14), OR= 1.56, 95%CI= 0.86-2.84),in this study we had observed a
common risk factors which is significantly associated with both infection, like
Family/guardians educational level and their monthly income. (Table 5.5)

Table 5.5 The co infection of IPI with H. pylori among the study groups

H. pylori Total
Positive Negative
IPI Positive 19 81 100
Negative 42 280 322
Total 61 361 422
P= 0.14

36
6. DISCUSSION
6.1 The prevalence of Helicobacter pylori and risk factors

The overall prevalence rate of 14.6% obtained in this prospective cross sectional study is low
and suggests that H. pylori infection was not significant in the asymptomatic school children.
As compared to study conducted in Pakistani children was between 24 and 92%, and in China
on children in between 5 and 28%, however these prevalence was affected by test methods,
and variation from country to country [24, 25].

The prevalence of H. pylori 2.4 % in the age group 4-9, and increased to 10% in the age
group 10-15., and 2.2 % among age group of 16-18 and also majority of students number
was under 10-15 age categories. From study subjects the increased prevalence of infection
with age was initially thought to represent a continuing rate of bacterial acquirement
throughout one's lifetime, as previous study conducted in developing countries where Comment [u3]: Controvercial statement please
be consistant if the prevalence is low how it is
majority of children are infected before the age of 10 and the prevalence in adults peak up to significant.

80% (28)

The prevalence of H. pylori infection in age group of 4-9 years was very small; as compared
to study conducted WGO 2010 which was reported 80%, however. The reduced prevalence
of H. pylori in study were related to the study subjects were asymptomatic. The difference in
socio-economic factors, educational status of their family/ guardians and life style could also
contribute for their difference [17].

This study was strongly agreed with in studies showed that risk factors such as gender do not
seems to be associated risk factor and no significant association were founded among gender
from the general study population [33].

Ayse.et.al reported from eastern turkey, also shown, the high prevalence of H. pylori
infection not a significant different where parents were different education level. In contrast
to this study found a significant relationship between H. pylori prevalence, and
family/guardians educational status (p= 0.030.) [31].

Study conducted in eastern turkey has shown as large family size and overcrowding was risk
factors. This study also strongly agreed and a significant. (p= 0.03) in 3 bed room or less
14.2% (n=60/423) and also HP was higher in study subjects living more than six people in
the household 8.2 %( n=34/230) [31, 33]

37
In previous study, several socioeconomic factors have been associated with H. pylori
infection [33, 34]. In particular, subjects as a low family income had a higher likelihood of
carrying H. pylori infection. This study agreed and founded a significant Prevalence rates
were higher in children of low socioeconomic class compared with those of increased
socioeconomic class.

Study conducted in UK showed that, bed sharing, family size was possible risk factors.
However, According to this study the prevalence of H. pylori were almost not different, also
statistically insignificant in families with large number peoples do lives than less, although,
majority infection to this organism were occurred among who shared bed, but insignificant as
risk[32].

6.2 The prevalence of intestinal parasite and risk factors

Different studies which were conducted in different parts of the world showed that a different
prevalence rate, in India showed two third of 63-94% [38]. , in kubia Junior, Saopaulo state
Brazil, of 219 school children of which 123 (56.1%) [39]. in asymptomatic children in south
western Ethiopia in July 2005 showed that the overall prevalence rate of intestinal helminthes
was 57.4%, Another study conducted in Jiren School, Jimma town, showed that the overall
intestinal parasite prevalence rate of 68.4%.[42]. As compared to the above studies showed
that prevalence of IPI among study group was low, the overall prevalence of intestinal
parasite was 23.7 %( n= 100/422), and 20.4 %( n=86/422) for Protozoan, and 3.32 %(
n=14/422) for Protozoan Helminthes, and multiple infection 0.96 %( n=4/422).

In this the most prevalent intestinal parasite were cyst of Giardia Lamblia 17.1% (n=72/100),
and the least was ova of Hookworm 0.2 %( n= 1/100). As compared this study agreed with in
Study conducted at western city, turkey showed that the three most common parasites were
E.vermicularis. G.lamblia and E.coli intestinal parasites prevalence were higher in rural than
urban area [19]. And a cross sectional survey conducted in Ethiopian in July 2005 showed in
asymptomatic children with T.trichiura (31%) A.lumbricides (30.5%), H.nana (14.3%) and
hook worm (4%) [37, 38]

In our study showed that the prevalence of IPI in different age group significantly increased,
its prevalence with age was initially thought to represent a continuing rate of intestinal
parasite acquirement throughout one's lifetime. Also it’s the prevalence among the gender of
the children not significantly associated, however. Majority of these were significantly
detected in children with parents/guardians with low monthly income, and level of
38
educational status. As compared this study is agreed with studies conducted in that potential
risk factors with the prevalence of intestinal parasites among school children. Socio-
demographic, Environmental, behavioral factors and different sanitation facilities had a
significant contribution for the presence of IPIs [38, 43].

Overcrowding index such as family size and number of bed room in the house is risk factors.
[43]. in our study the prevalence of IPI among children were significantly increased in
families with large number people than less. However, majority of the IPI infection among
children were insignificantly occurred in families with sharing a bed room.

Different sanitary activity and facilities had a significant contribution for the prevalence of
IPI among school children [43, 44]. In our study not practicing hand washing after using
toilet was significant factors for observing a high prevalence of IPI among children, and,
majority of the prevalence IPI observed in study participants which used tap/bono water than
other; this could be due to contaminated and poor hygiene. Even though, majority of study
participants used a pit latrine and they had a significantly high prevalence of IPI among
children. according to this perspective study showed that the prevalence rate was in consisted
with the poor health practices were responsible ,especially the poor habits of hand washing
after using toilet, families/guardians awareness, educational status, and economic factors.

39
7. Limitation of the study

1. The limitation of this study was lack of quantitative confirmatory test. The test should
be confirmed by enzyme-linked immunosorbant assay (ELISA) stool Antigen test,
because the Linear Helicobacter Pylori Ag cassette is limited to the qualitative
detection of H. Pylori antigen in human fecal specimen.
2. This study done in one governmental elementary school and the data was collected
from those students who learned to this school during the data collection period. It
doesn’t include other elementary school in the city of Addis, as well as in this study
area in Akaki Kality sub City that may underestimate findings.

40
8. CONCLUSIONS AND RECOMMENDATIONS

8.1 Conclusion

The study concluded that IPI infection was high prevalent compared with H. pylori infection
in the study area, prevalence rates of with H. pylori and IPI were (14.6%), (26.7%)
respectively in subjects under study by using stool Ag test, and direct wet mount and
FECT respectively. Females were found to be more affected than males in infection by both
pathogens. The prevalence of IPI and H. pylori was higher in the age group 10-15 years
old than other age groups this is due to large number of study sample under this group.
The study concluded that of IPI and H. pylori is possibly a burden in asymptomatic study
area, due to social, economical, and environmental risk factors.

8.2 Recommendations

1. In this study educational status, monthly income status of their family/guardians was
positively associated with H. pylori prevalence. Overcrowding, educational, and
monthly income level of families/guardians, poor sanitary practice of the students,
water source positively associated with IPI. Thus, minimizing overcrowded condition,
and improving the living standard of the society, health education in the area is
mandatory.
2. Improvement of health measures such as personal hygiene, and water purification are
useful ways for elimination of the infection, and these should be done in the school.
3. Further studies with the aid of more advanced techniques such as PCR, ELISA are
recommended to assess the presence of IPI and H. Pylori.
4. The school de-worming program should be strengthened, to reduce and eliminated
intestinal parasitic infection.

41
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46
10. LIST OF ANNEXES

Annex I: English version of participant information sheet

I. English version of Participant information sheet
Department of Medical Laboratory Science, Collage of Allied Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia, 2017

Title of the Research Project: Prevalence of Helicobacter pylori and intestinal parasite and
their associated risk factors among school children at Selam Fire Elementary School in Akaki
Kality Sub City, March to June 2017, Addis Ababa, Ethiopia

Introduction: First of all I would like to thank you in advance for your cooperation and
consent in participation in this study. Please read or listen when it is read for you about the
general information of the study. If you have any question regarding the study please ask
freely.

Background information

Background: The prevalence of H. pylori infection mainly acquired during childhood and
may be persisting throughout life, it has been found high in developing countries; this high
prevalence is related to low socioeconomic status, Intestinal parasitic infections are among
the major public health problems in Sub-Saharan Africa. Their distribution is mainly
associated with poor personal hygiene, environmental sanitation and limited access to clean
water. There is limited information on the burden of the H. pylori and intestinal parasites in
Ethiopia and this research will be addressed such gap.

Aim of the study

The purpose of this study was determined the Prevalence of Helicobacter pylori with
intestinal parasite and their associated risk factors among school children; since most school
children are asymptomatic, besides these the study were focused on to evaluating their burden
and socio-demographic, lifestyle, and environmental hygiene conditions as associated
possible risk factor.

Study Duration

The study was conducted in the period from March to June 2017.

47
Benefits for participants
Study participants were not having any financial incentives or other inducements from
participating on this study. However, based on the diagnosis result, we were linked to health
center by consenting to parent/guardians to get treatment. We were provided a laboratory
results with free of charge. Most importantly, the result of the study was beneficial to design
effective prevention and control measure for Elementary School children. Hence, you are
indirectly benefiting other children and the society in this respect.

Risks and complication

There are no anticipated risks to you and your child participation. Stool sample were taken
from the students once by clean sample container. During sample giving it was expect form
students, after toilet they should be washed their hands with plane water and soap.

Confidentiality

There is no sensitive issue that you were asked related with your social desirability but any
information that is obtained in connection with this study and that can be identified with you
and your child will remain confidential. Participants were not being prohibited to stop or
withdraw at any time from the study. Only interested participants can retrieve their own lab
result using their code number. The information collected about you and your child were
coded using numbers. No personal information was disclosed to third party or will not appear
in any report from this study.

Assurance of Principal Investigator

I put my signature below to confirm you that I take over the responsibility for the scientific
ethical and technical conduct of the research project and for provision of progress reports for
all stakeholders of the research project.

Abebe Worku (PI)

Signature: __________________ Date: __________________

Note: If you have any questions about this study, you should feel free to ask now or anytime
throughout the study by contacting

48
PI Address: Abebe Worku: Department of Medical Laboratory Sciences, Collage of Allied
Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia,2017

E-mail:[email protected],

Mobile/phone no: +251-912685504

Fax no:-

Po Box: - 36, Addis Ababa, Akaki, Ethiopia, 2017

Department Address: Department of Medical Laboratory Science, Collage of Allied Health

Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Phone no: +251-112-75-51-70

Fax no: +251-112-75-46-69

E-mail:- [email protected]

Po-Box: - 1176, Addis Ababa, Ethiopia, 2017

49
Annex II. Amharic version of the information sheet

ቅፅ 1 ፡ሇተሳታፊው በቂ መረጃ ሇመስጠት የተዘጋጀ ቅጽ (ትርጉም በአማርኛ) አዲስ አበባ

ዩኒቨርሲቲ የድህረ ምረቃ ትምህርት፡፡

የተመራማሪውስም፡አበበወርቁ

የድርጅቱ ስም፡ አዲስ አበባ ዩኒቨርሲቲ፡የጤና ሳይንስ ኮላጅ ፡የአሊይድ ጤና ሳይንስ ት/ት፡

ህክምና ሊቦራቶሪ ሳይንስ ክፍሌ

ርዕስ፡ የኤች ፓይልሪ ባክቴሪያ እና የሆድ ውስጥ ትሊትልች በአንዯኛ ዯርጃ ት/ቤት በሌጆች
ሊይ ስሊሇው ስርጭት ምክንያት እና መንሴዎችን ሇይቶ ሇማወቅ የሚሌ ነው፡፡

መግቢያ ፡ በመጀመሪያ ሇዚህ ጥናት ሇመሣተፎ እና ሇመተባበር ፍቃዯኛ በመሆኖ እጅግ

አመስግናሇሁ ፡፡ በመቀጠሌ ስሇጥናቱ አሊማ እና ሁኔታ ሇማወቅ እባኮ መጠየቁን ያንብቡት
ወይም እንዲነበብልት ይጠይቁ ፤ ማንኛውንም ጥያቄ ስሇ ጥናቱ ካልት እባኮ በነጻንት
ይጠይቁ፡፡

የጥናቱ ዋና አሊማ ፡ የጥናቱ አሊማ የተሇያዩ የጨጋራ ህመሞች ምክንያት የሆነውን የኤች
ፓይልሪ ባክቴሪያ እና የሆድ ውስጥ ትሊትልች በአንዯኛ ዯርጃ ት/ቤት በሌጆች ሊይ ስሊሇው
ስርጭትና ፡እና ምክንያትና መንሴዎችን ሇይቶ ሇማወቅ ነው፡፡ ይህም የሚረዳው እርሶዎ
በሚሠጡት መሌስ እና ከሌጆሆ በሚገኘው መረጃና የሊብራቶረ ውጤት ሊይ በመንተራስ
ሇኤች ፓይልሪ ባክቴሪያ እና ሇሆድ ውስጥ ትሊትልች ስርጭት ምክንያት የሆኑትን
መተሊሇፊያ መንገዶችን ሇመግታት እንዲየስችሌ ነው፡፡

የጥናቱ ጊዜ፡ ጥናቱ በሚካሄድበት ት/ቤት የተማሪዎች ብዛት የሚወስን ሲሆን 5ወር እና
ከዛም በሊይ ሉወስድ ይችሊሌ፡፡

የጥናቱ ሂዯት፡ ሇዚህ ጥናት እውን መሆን የእርሶዎን እና የተማሪውን ተሳትፎ እንፇሌጋሇን
በዚህ ጥናት ሇመሳተፍ ፇቃዯኛ ከሆኑ የስምምነት ቅጹን መረዳትና መፇረምይጠበቅቦዎታሌ
ከዛም ህብረተሰብ ነክ እና የህክምና መረጃዎች መጠይቁ ሊይ ይሞሊለ ወይም ስሇ ሌጁ
የልትን መረጃ በመጠየቁ ሊይ ይሞሊለ፡፡ናሙና የሚስበሰበው ከሌጆት ሠገራ ሊይ ነው
ምርመራውም ወዲየሁኑ ወይም በነጋታው በትምህርት ቤቱ አቅራቢያው ካሇው በስሊም ፍሬ
ጤና ጣቢያ ሊብራቶሪ ይከናወናሌ፡፡

50
ሉከሰት ስሇሚችለ ስጋቶችና ምቾት መንገዶች ፡ሇጥናቱ በሚወስዯው ችግር ስጋት
አይኖረውም ምክንያቱም የጥናቱ ናሙና አወሳስድ የተሇየ አይዯሇም ወይም ሌጆትን ምንም
አይነት ችግር አይፇጥረም ምክንያቱም ሇምርመራው የምንጠቀመው ስገራ በመሆኑ እና
ሇመስጠት አስቸጋሪ ስሊሌሆነ፡፡

የተሳታፊዎች ጥቅሞች፡ በዚህ ጥናት በመሣተፎ ምንም አይነት ገቢ አያስገኝም ነገር ግን

ባክቴሪያው እና የተሇያዩ የሆድ ትሊትልች ያሇባቸውን ተማሪዎችን የሊብራቶሪ
ውጤታቸውን ሇቤተስባቸው ወይም ሇአሳዳጊ እናሳውቃሇን፡፡ ከዚያም ከጤና ጣቢያ ገር
ግንኙነት በመፍጠር እንዲታከሙ ማመድርግ ነው፡፡

ሚስጥራዊነት፡ሇጥናቱ ተብሇው የተስባስቡ የግሌዎ እንዲውም የሌጆዎ መረጃ ሚስጢራዊነቱ

የተጠበቀ ነው ፡፡

ክፍያ፡ በዚህ ጥናት በመሳተፍዎ እርሶም ሆነ ሌጆትም የሚያገኙት ምንም ሌዩ ክፍያ የሇም፡

የተሳታፊውመብት፡ የእርሶም ሆነ የሌጆት ተሳትፎዎ ሙለ በሙለ በፇቃዯኙንት ሊይ

የተመስረት ነው፡፡ፇቃዯኛ ካሌሆኑ በዚህ ጥናት ያሇመሳተፍ መብትዎ የተጠበቀ ነው ፡፡

የጥናቱ ፇቃድ/ህጋዊነት፡- የዚህ ጥናት ህጋዊነት በዲፓርትመንታሌ ምርምር እና ስነምግባር

ቅኝት ኮሚቴ ፤ አዲስ አበባ ዩኒቨርሲቲ፤ ኮላጅ ኦፍ ሄሌዝ ሳይንስ ስኩሌ ኦፍ አሊይድ ጤና
ሳይንስ እና በአዲስ አበባ ጤና ቢሮ ፡ ፇቃድ ያገኘ ነው፡፡

መረጃ ስሇማግኘት ፡- ይህን ጥናት አስመሌክቶ ምንም አይነት ጥያቄ ወይም ማብራሪያ
ቢያስፇሌግዎት ፡

1. አዲስ አበባ ዩኒቨርሲቲ፡ የጤና ሳይንስ ኮላጅ፡የአሊይድ ጤና ሳይንስ ት/ት ፡ ህክምና

ሊቦራቶሪ ሳይንስ ዲፓርትመንት
ሰ.ቁ ፡ +251 -112-75-51-70 ፋክስ ፡ +251-112-75-46-69

ኢ-ሜሌ ፡ [email protected]ፒ.ኦ.ቦክስ ፡ 1176 ፡ አዲስ አበባ ፡ ኢትዮጵያ፣2017

2. የጥናቱ ተመራማሪ አበበወርቁ ( በአዲስ አበባ ዩኒቨርሲቲ የማስተር ተማሪ )

ሰ.ቁ፡ +251 912685504

ኢ-ሜሌ ፡ [email protected]

ፒ.ኦ.ቦክስ ፡ 36 ፡ አዲስ አበባ ፡ ኢትዮጵያ፣2017

51
Annex III. English version of Consent form

We are doing this research to find out more about the Prevalence of H. pylori, intestinal
parasite and associated risk factors among Elementary school children; the choice that you
have to take part in it is up to you. We would still take good care of you no matter what you
decide. We want you to ask us any questions that you have any time. If you decide to be in
the research, you may need a clean stool container for sample so we could test some of your
child stool sample. We would ask you to read questions on a piece of paper or listen when
read for you. Then you would mark your answers on the paper or tell your answer. A person
on the research team would ask you questions. Then you would say your answers out loud.
Some of the questions might be hard to answer. You can say ‘no’ to what we ask you to do
for the research at any time and we will stop. This research will not help you and you would
not be paid. But we hope it will help your child and other children. It is also OK to say yes
and change your mind later. You can stop being in the research at any time. If you want to
stop, please tell the researcher. Take the time you need to make your choice. If you want to
be in the research after we talk, please sign below.
We will write our name too. This shows we talked about the research and that you want to
take part. I ___________________________________ hereby give my consent for giving of
the requested information and allowing my child participation for this study.

Participant code_______________Signature__________________date________________

52
Annex IV. Amharic version of the consent form

ቅፅ1 የፍቃዯኝነት መጠየቂያ

ይህ ጥናት በኤች ፓይልሪ ባክቴሪያ እና በሆድ ውስጥ ትሊትልች ህመምን በአንዯኛ ዯርጃ
ት/ቤት በለ ሌጆች ሊይ ያሇው ስርጭት ሇማየትና የዳሰሳ ጥናት ሇማካሄድ የሚገሇጽ ሲሆን
መሳተፍ ከፇሇግህ/ሽ ምርጫው ባንተ/ች የሚወሰን በማንኛውም ሰአት ማንኛውንም ጥያቄ
መጠየቅ ትችሊሇህ/ሽ፡፡በጥናቱ ሇመሳተፍ ከወሰነክ/ሽ ሇምርመራ ጥቂት የስገራ ናሙና ከሌጆ
ይወሰዳሌ ወይም መስጠት ይጠይቃሌ፡፡ወረቀቱ ሊይ ሇሰፇሩት ጥያቄዎች አንብበህ/ሽ
ተገቢውን ምሊሽ ወረቀቱ ሊይ ሙሊ/ይ ወይም እንዲነበብ በመጠየቅ ተገቢውን ምሊሽ
መስጠት ይጠበቅቦታሌ ከጥናት ቡድኑ አባሌ ሇሚጠይቅህ/ሽ ድምፅህን/ሽን ከፍ አድርገህ/ሽ
መሌስ ስጥ በማንኛውም ሰአት በጥናቱ አሌሳተፍም የማሇት መብት አሇህ/ሽ፡፡በዚህ ጥናት
ምንም አይነት የገንዘብ ክፍያና የተሇየ ጥቅም አታገኝም/ኚም ሆኖም ግን በዚህ የጥናት
ዉጤት ሌጆትን እና ላልች በዚህ እድሜ ክሌሌ ሊለ ሌጆች ይጠቅማሌ፡፡

በማንኛውም ሰአት ጥናቱን ማቆም ትችሊሇህ/ያሇሽ፡፡ምርጫህን/ሽን ሇማሳወቅ ጊዜ ወስዯህ/ሽ

አስብበት፡፡በመጨረሻም ሇመሳተፍ ከወሰንክ/ሺ ስምና ፊርማህን/ሽን ከታች ባሇው ክፍት ቦታ
ሊይ አስፍር/ሪ፡፡

እኔ ----------------------------------- የተባሌኩ ግሇሰብ ይህን ሁለ በመገንዘብ በምርምሩ ሊይ

መረጃና የሌጄ የስገራ ናሙና እንዲወሰድ ተስማምቻሇሁ፡፡

ፊርማ-------------------- ቀን-------------------

53
Annex V. English version of Assent form

I have been informed about the research which will be conducted in Addis Ababa, in Akaki
Kality Sub City in Selam Fire Elementary School which plans to determine the Prevalence of
H. pylori, intestinal parasite, and Associated Risk factor of among Elementary school
children. The objective and the application of the study were briefly explained to me.
Moreover, I have been well informed of my right to refuse information, decline to cooperate
and drop out of the study if I want. It is therefore with full understanding of the situation that
I agreed to give the informed assent voluntarily to the researcher for my child to give stool
sample for the mentioned study. I agreed that the specimen will be tested for H. pylori stool
antigen test and intestinal parasite. I have had the opportunity to ask questions about the
project and received clarification to my satisfaction in a language I understand. I have been
also informed that results for the analysis of stool will be given with free of charge whenever
I came with unique code number, to those with a positive finding they will be liked to health
center for treatment.

I ___________________________________ hereby give my assent for giving of the

requested information and my child’s stool for this study.

Participant code: __________________ Signature: _____________ Date: _______________

54
Annex VI. Amharic version of the Assent form

ቅጽ 2 የፇቃዯኝነት ማረጋገጫ (ሇቤተሰብ/አሳዳጊ)

በአዲስ አበባ ከተማ በአቃቂ ቃሉቲ ክፍሇ ከተማ በስሊም ፍሬ አንዯኛ ዯረጃ ት/ቤት ሊይ
የኤች ፓይልሪ ባክቴሪያና የሆድ ውስጥ ትሊትልች ህመምን ስርጭትና የበሽታው አጋሊጭ
ሁኔታዎችን ሇማጥናት በሚሌ ርእስ ሊይ በሚዯረገው ጥናት ሊይ ሇመሳተፍ ሲሆን፤
የጥናቱ አሊማና ጥቅም በሚገባ ተገሌፆሌኛሌ፡፡በመጠይቁ ሊይ የሚሞሊው የኔ ሙለ መረጃም
በሚስጥር እንዯሚያዝ ተነግሮኛሌ፡፡

በተጨማሪም በጥናቱ ውስጥ ሌጄን አሇማሳተፍ መብቴ እንዯሆነና በማንኛውም ጊዜ ከጥናቱ

በራሴ ውሳኔ መውጣት እንዯምችሌ በሚገባ ተረድቻሇሁ፡፡

ስሇሆነም ሁኔታውን በሚገባ በማጤን በፍቃዯኝነት ሌጄን በምርምሩ ሊይ ሇማሳተፍ

ሇተመራማሪው ፍቃዯኝነቴን ሰጥቻሇሁ፡፡በተጨማሪም ሌጄ የሚሰጠው የስገራ ናሙና
ሇተጠቀሰው ጥናት ብቻ እንዯሚውሌ ተነግሮኝ ተስማምቻሇው፡፡ማንኛውም ያሌገባኝን ነገር
የመጠየቅ እድሌ ተሰጥቶኝ በሚገባኝ ቋንቋ መሌስ አግኝቻሇሁ፡፡

በተጨማሪም የሊብራቶሪ ምርመራ ውጤት ምንም አይነት ክፍያ ሣሌጠየቅ በነጳ

እንዯሚስጠኝና ነገር ግን ከእኔ የሚጠበቀው በወቅቱ መሇያ ቁጥር ይዞ መቅረብ ብቻ
እንዯሆነ ተነግሮኛሌ፡፡ከዚያም የጨጋራ ባክቴሪያ እና የሆድ ውስጥ ትሊትልች ሊሇባቸው
ሌጆችን ከጤና ጣቢያ ገር ግንኙነት በመፍጠር እንዲታከሙ እንዯሚያዯርጉ ነው፡፡

እኔ ----------------------------------- የተባሌኩ ግሇሰብ ይህን ሁለ በመገንዘብ በምርምሩ ሊይ

ስሇሌጄ መረጃና የስገራ ናሙና እንዲወሰድ/እንዲስጥ ተስማምቻሇሁ፡፡

55
Annex VII . English version of Questionnaire

Addis Ababa University Collage of Health Sciences, School of Allied Health Science
Department of Medical Laboratory Science.

Questionnaires: for the demographic characteristics, assessment of risk factors for H. pylori,
intestinal parasitic for students, who were learning at Elementary School:

Participant Identification

School name ________________ Year __________ Participant code no: _______________

Participants address (Sub city) ________ Telephone ____________ signature__________

Grade ___________________________Block___________

Data collector name _________________________date ____________signature__________

Demography of the child

Part one: - For Children from KG level to grade eight

1. Age in yr. ____________

2. Weight in kg.__________
3. Height. _____________
4. MUAC_____________
5. Sex? 1. Male 2. Female

6. Residence of the children?

1. Rural 2. Urban

7. Shoe wearing habit?

1. Sometimes 2. Always 3. Not at all

8. Does the child have a habit of washing hands after using toilet?
1. Sometimes 2. Always 3. Not at all

56
Part two: - For Family/Guardian
1. Age in yr. ____________
2. Sex?

1. Male 2. Female

3. Residence of family /guardians?

1. Rural 2. Urban

4. Does the child report abdominal pain more than 3 times per week?

1. Yes 2. No

5. Does the students have taken / given a de-worming before the last six weeks?

1. Yes 2. No

6. How much family /guardian monthly income?

1. <1000
2. 1000-1500
3. 2000-2500
4. 3000-3500
5. > 4000

7. How many bedrooms do you have in the house?

1. 1-2

2. 3-5

3. ≥ 5 above

8. How many persons do live in the house?

1. < 4
2. 4-6
3. >6

57
9. What is family or guardian level of education?
1. Illiterate
2. Read and write
3. Primary school
4. Secondary school
5. above secondary school
10. What is your family/home drinking water Source?
1. Tap/ bono water
2. Bottled water
3. Boiled tap water
4. Mineral water
11. Do you have a Toilet in your house?

1. Yes 2. No
12. What type of toilet used in your house?
1. Pit latrine
2. Flush toilet
3. Open field

58
Annex VIII: Amharic version of Questionnaire

የጨጓራ ህመምች ምክንያት የሆነውን የኤች ፓይልሪ ባክቴሪያ እና የሆድ ውስጥ

ትሊትልች በአንዯኛ ዯርጃ ት/ቤት በሌጆች ሊይ ስሊሇው ስርጭትና፡ አጋሊጭ ምክንየትና
መንሴዎችን ሇይቶ ሇማወቅ ሇማጥናት የተዘጋጀ ቃሇ መጠየቅ ፡፡

የተሳትፎመሇያ

የት/ቤቱ ስም________________ዓ/ም__________መሊያ ቁጥር : _______________

አድራሻ (ክፊሇ ከተማ ) ________ ስሌክ ቁጥር ____________ ፊርማ__________

የት/ ዯርጃ ___________________________ህንፃ ቁጥር _________

የመርጃ ስብሳቢ ስም __________________ቀን ____________ ፊርማ__________

ክፍሌ አንድ ፡- ከ KG – 8 ኛ ክፇሌ ሊለ ተማሪዎች

መሠረታዊመረጃ

1. እድሜ -------------------
2. ክብዯት ------------------
3. ቁመት -------------------
4. የክንድ መጠን ሌኬት -----------------
5. ፆታ 1. ወንድ 2. ሴት
6. መኖሪያቦታ?
1. ገጠር
2. ከተማ
7. ጫማየማድረግሌምድአሇው/ አሊት?

1. አንዳንዴ 2. ሁሌጊዜ 3. አይ የሊትም/ውም

8. መጸዳጃ ቤት ከተጠቀመ/ቸ በዋሊእጅየመታጠብሌምድአሇው/አሊት?

1. አንዳንዴ 2. ሁሌጊዜ 3. አይ የሊትም/ውም

59
ክፍሌ ሁሇት፡- ሇቤተሠብ/ ሇአሳዳጊዎች ;

1. እድሜ -------------------
2. ፆታ 1. ወንድ 2. ሴት

3. መኖሪያቦታ?

1. ገጠር
2. ከተማ
4. ሌጆት በሳምንት ከ ሶስት ጊዜ በሊይ የሆድ ህመም ስሜት ይስማዋሌ?

1. አዎ ይስማዋሌ 2. አይ አይስማውም

5. በት/ቤቱ የፀር ሆድ ትሊትሌመድሀኒትተስጥቶየውቃሌ?

1. አዎ ያውቃሌ 2. አይ አያውቅም

6. የቤተሠብ/ የአሳዳጊ ወርሀዊ ገቢ?

1. <1000
2. 1000-1500
3. 2000-2500
4. 3000-3500
5. > 4000

7. ስንት መኝታ ክፍሌ ቤት አሇዎት ?

1. 1-2
2. 3-5
3. ከ 5 በሊይ
8. ምን ያህሌ ስው በቤት ውስጥ ይኖራሌ?

1. < 4

2. 4-6

3. > 6

60
9. የአሳዳጊው /የወሊጅ የትምህርት ዯረጃ?

1. ያሌተማረ

2. ማንበብና መጻፍ

3. አንዯኛ ዯርጃ ትምህርት

4. ሁሇተኛ ዯርጃ ትምህርት

5. ከሁሇተኛ ዯርጃ ትምህረት በሊይ

10. ቤተሠቡ ሇመጠጥ የሚጠቀመው ውሃ አይነት?

1. የቧንቧውሃ
2. የታሸገ የፕሊስቲ
3. የፇሊ የቧንቧ ውሃ
4. የጉድጋድ /የከርስ ምድር ውሃ
11. በቤት ውስጥ የመጸዳጃ ቤት አልት?

1. አዎ አሇኝ 2. አይ የሇኝ

12. ቤተሠብ የሚጠቀመው የመጸዳጃ ቤት አይነት?

1. ባሇ ጉድጎድ ሽንት ቤት
2. ውሃ መሌቀቂያ ያሇው ሽንት ቤት
3. ሜዳ ሊይ መጸዳዳት

61
Annex IX: Standard operational Procedure for Laboratory investigation

Well-trained laboratory technologist/technician was collected stool in order to ensure that

appropriate stool specimen is obtained and quality control for H. pylori stool antigen
test and intestinal parasite.

1. Standard operational procedures (SOP) for Helicobacter pylori Stool Antigen test

1.1 Purpose

The H. pylori Ag Rapid test is a lateral flow chromatographic immunoassay for the
qualitative detection of H. pylori antigen in human faecal specimen. It is intended to be used
by professionals as a screening test and as an aid in the diagnosis of infection with H. pylori.
Any reactive specimen with the H. pylori Ag Rapid test must be confirmed with alternative
testing method(s).

The H. pylori Ag Rapid test uses a colloid gold conjugated monoclonal anti-H.Pylori
antibody and another monoclonal anti-H. pylori antibody to specifically detect H. pylori
antigen present in the faecal specimen of an infected patient. The test is user friendly,
accurate, and the result is available within 15 minutes.

1.2 Test Principle

The H .pylori Ag Rapid test is a sandwich lateral flow chromatographic immunoassay. The
test strip consists of: a burgundy colored conjugate pad containing monoclonal anti- H.
pylori antibody conjugated with colloid gold (anti-H.P conjugates) and a nitrocellulose
membrane strip containing a test band (T band) and a control band (C band). The T
band is pre-coated with another monoclonal anti-H.P antibody, and the C band is pre-coated
with goat anti-mouse IgG antibody. When an adequate volume of extracted faecal specimen
is dispensed into the sample well of the test cassette, the specimen migrates by capillary
action across the cassette. H. pylori antigens if present in the specimen was bind to
the anti-H. Pylori conjugate. The immune complex is then captured on the membrane
by the pre-coated antibody, forming a burgundy colored T band, indicating an H. pylori
positive test result. Absence of the T band suggests that the concentration of H. pylori
antigens in the specimen is below the detectable level, indicating an H. pylori negative test
result.

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Reagents and Materials Provided

1. Individually sealed foil pouches containing:

 One cassette test device.

 One desiccant.

2. Sample extraction tubes, each containing 2ml of extraction buffer.

3. Plastic droppers for transferring watery stool.

4. One package inserts (instruction for use).

1.3 Test Procedure

1. Bring the specimen and test components to room temperature if refrigerated or frozen.
Mix the specimen well prior to assay once thawed

2. When ready to test, open the pouch at the notch and remove the test strip. Place the strip
on a clean, flat surface.

3. Fill the plastic dropper with the specimen. Holding the dropper vertically, dispense 1 drop
(about 30-45 µL) of specimen into the sample pad making sure that there are no air bubbles.
Then add 1 drop (about 35 – 50 µL) of Sample Diluents immediately and wait for 15 minutes

4. Set up timer

5. Results read within 15 minutes.

1.4 Test Quality Control

The test contains an internal control (C band) which should exhibit a burgundy colored band
of the immune complex of goat anti-mouse IgG/mouse IgG-gold conjugate regardless of the
color development on the T band. If the C band does not develop, the test result is
invalid and the specimen must be retested with another device.

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Interpretation of Assay Result of H. pylori test

1. Negative Result: If only the C band is developed, the test indicates that no detectable H.
pylori antigen is present in the specimen. The result is negative.

2. Positive Result: If both C and T bands are developed, the test indicates the
presence of H. pylori antigen in the specimen. The result is positive.

3. Invalid: If no C band is developed, the assay is invalid regardless of any color

development on the T band as indicated below. Repeat the assay with a new test device.
Excess faecal specimen can lead to invalid test results; if this is the cause, re-sample
and re-test (see instructions for collection of specimen).

Safety precaution

Consider any materials of human origin as infectious and handle them using standard
bio-safety procedures.

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2. SOP for Direct stool examination

2.1 Purpose of the test

For detection and identification of parasites in wet mount preparation of stool.

2.2 Principle of the test

The value of wet preparations lies in the fact that certain protozoa trophozoites retain their
motility which may aid in their identification. Definitive identification however may not be
possible, especially for amoeba, since the nuclei of trophozoites and cysts are often not
clearly visible. Wet preparations on fresh unpreserved liquid stool should be performed
and examined as soon as possible (within 30 minutes of passage) and on soft/formed
stool within 60 minutes of passage provided that prior arrangements have been made with
the lab.

2.3 Test Procedure

1. Place a drop of fresh physiological saline on one a slide, to avoid contaminating the
fingers and stage of the microscope, do not use too large a drop of saline

2. Using a wire loop or piece of stick, mix a small amount of specimen, about 2 mg,
(matchstick head amount) with the saline .Make smooth thin preparations. Cover preparation
with a cover glass. Sample from different areas in and on the specimen or preferably mix the
faeces before sampling to distribute evenly any parasites in the specimen. Do not use too
much specimen otherwise the preparations will be too thick, making it difficult to detect and
identify parasites.

3. Examine systematically the entire saline preparation for larvae, ciliates, helminthes eggs,
cysts, and oocysts. Use the 10x objective with the condenser iris closed sufficiently to
give good contrast. Use the 40x objective to assist in the detection and identification of eggs,
cysts, and oocysts. Always examine several microscope fields with this objective before
reporting ‘No parasites found’.

4. Report the number of larvae and each species of egg found in the entire saline preparation.

65
3. SOP for Stool Sedimentation Concentration technique

3.1 Purpose of the test

Sedimentation methods (using centrifugation) lead to the recovery of all protozoa, oocysts,
spores, eggs, and larvae present; however, the preparation contains more debris. If one
technique is selected for routine use, the sedimentation procedure is recommended as
being the easiest to perform and least subject to technical error.

3.2 Principle

By centrifugation, this concentration procedure leads to the recovery of all protozoa,

eggs, and larvae present; however, the preparation contains more debris than is found
with the flotation procedure. Ethyl acetate is used as an extractor of debris and fat
from the feces and leaves the parasites at the bottom of the suspension.

The formol ether sedimentation concentration is recommended as being the easiest to

perform, allows recovery of the broadest range of organisms, and is least subject to technical
error.

3.3 Test Procedures

1. Using a rod or stick, emulsify an estimated 1g (pea size) of faeces in about 4 ml of 10%
formol water contained in a screw cap bottle or tube from the surface and several
places in the specimen.

2. Add a further 3–4 ml of 10% v/v formol water, cap the bottle, and mix well by shaking.

3. Sieve the emulsified faeces, collecting the sieved suspension in a beaker.

4. Transfer the suspension to a conical (centrifuge) tube made of strong glass,

copolymer, or polypropylene. Add 3–4 ml of diethyl ether or ethyl acetate.

5. Stopper the tube and mix for 1 minute. If using a Vortex mixer leave the tube unstoppered
and mix for about 15 seconds (it is best to use a boiling tube). * Do not use a rubber bung or a
cap with a rubber liner because ether attacks rubber.

66
6. With a tissue or piece of cloth wrapped around the top of the tube, loosen the
stopper (considerable pressure will have built up inside the tube).

7. Centrifuge immediately at 750–1 000 g (approx. 3000 rpm) for 1 minute. After
centrifuging, the parasites will have sedimented to the bottom of the tube and the faecal
debris will have collected in a layer between the ether and formol water

8. Using a stick or the stem of a plastic bulb pipette, loosen the layer of faecal debris from
the side of the tube and invert the tube to discard the ether, faecal debris, and formol water.

9. Return the tube to its upright position and allow the fluid from the side of the tube to drain
to the bottom. Tap the bottom of the tube to re-suspend and mix the sediment. Transfer
the sediment to a slide, and cover with a cover glass.

10. Examine the preparation microscopically using the 10objective with the condenser iris
closed sufficiently to give good contrast. Use the 40 objective to examine small cysts and
eggs. To assist in the identification of cysts, run a small drop of iodine under the cover glass

3.4 Microscopic result interpretation

1. No ova of parasite seen, if there is no finding.

2. Examine systematically the entire saline preparation for larvae, ciliates, helminthes eggs,
cysts, and oocysts.

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Annex X: Data entry work sheet for participants’ laboratory test results

Helicobacter Intestinal parasites

stool Ag test
Weight

MUAC
Height
Ro: no

Formol-ether Direct
Grade

Age

Sex

Negative
concentration microscopy
Positive

methods
(wet method)

001

002

003

004

005

006

007

008

009

010

011

012

013

014

68
Annex XI: Selection participants from various arms /grade would made by balloting/lottery
method as described in the above. As summarized as follow:

Level of School Total number of Chance of students Total number of participant

students enrolled to be selected is 35% /students from each grade

Pre-school Male Female Male Female

KG -1 30 36 10 12 22
KG -2 24 20 8 8 16
KG -3 38 36 13. 13 26
Total 92 92 31 32 64
pary school Male Female Male Female
Grade 1A 23 26 9 10 19
Grade 1B 15 36 8 13 21
Grade 2A 20 32 8 11 19
Grade 2B 21 28 8 10 18
Grade 3A 24 34 8 12 20
Grade 3B 24 31 8 12 20
Grade 4A 24 35 9 12 21
Grade 4B 33 25 12 9 21
Grade 5A 35 45 12 16 28
Grade 5B 37 43 13 15 28
Grade 6A 26 37 9 13 22
Grade 6B 30 34 10 12 22
Grade 7A 30 42 10 16 26
Grade 7B 30 45 10 16 26
Grade 8A 17 25 6 11 17
Grade 8B 17 25 6 10 16
Grade 8C 18 23 6 8 14
516 658 186 289 422
Sum Total

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Annex XII: Declaration
As thesis advisor, I hereby certify that I have read and evaluated this thesis prepared under
my guidance, by Abebe Worku ; entitled: ‘Prevalence of Helicobacter pylori and intestinal
parasite and their associated risk factors among school children at Selam Fire Elementary
School in Akaki Kality, March to June 2017, Addis Ababa, Ethiopia

Abebe Worku (BSc) __________________ _______________

Principal investigator Signature Date

I recommend it to be submitted as fulfilling the thesis requirement.

Advisor Signature Date

Kassu Desta (MSc, PhD fellow ________________ __________

Mistire Wolde (MSc PhD) _________________ __________

70