The Prevalence Of Intestinal Parasitic Infection And Associated

Factors Among People Living In Wadajir District, Mogadisu-Somalia

A Research Proposal

Presented to JOBKEY University

Mogadishu-Somalia

In Graduation Fulfillment of the Requirements for the Degree

Bachelor of Medical Lab

Researchers ID

1. Abdinasir Mohamed Ali 11094

2. Mohamed Nur Ali 10543
3. Muna Mohamed Aden 11330
4. Khadija Tahlil Mohamud 10808

JANUARY 2024
 DECLARATION A
We hereby declare that this Proposal is our own work and effort and that it has not
been submitted to JOBKEY UNIVERSITY for any award. Where other sources of
information have been used, they have been acknowledged.

Name: Abdinasir Mohamed Ali

Signature ___________________________
Date: ___/ ___/ ________

Name: Mohamed Nur Ali

Signature ___________________________
Date: ___/ ___/ ________

Name: Muna Mohamed Aden

Signature ___________________________
Date: ___/ ___/ ________

Name: Khadija Tahlil Mohamud

Signature ___________________________
Date: ___/ ___/ ________

ii
 DECLARATION B

“I confirm that the work reported in this Proposal was carried out by the candidate(s)
under my/our supervision

Name and signature of Supervisor: ________________________________

Date: _______/______/_______________

iii
 APPROVAL SHEET
This thesis entitled “Assessment of Factors Influencing Medical Waste

Management in Benadir Hospital”. Prepared and submitted by Abdinasir Mohamed

Ali, Mohamed Nur Ali, Muna Mohamed Aden and Khadija Tahlil Mohamud in partial

fulfillment of requirements for the degree of Bachelor of Public Health has been examined

and approved by the panel on oral examination with a grade of _____________

____________________________

Name and Sig. of Chairman

____________________________ __________________________

Name and Sig. of Supervisor Name and Sig. of Panelist

____________________________ __________________________

Name and Sig. of Panelist Name and Sig. of Panelist

___________________________

Name and Sig. of Director, Undergraduates

___________________________

Name and Sig of Dean of Health Science

iv
 DEDICATION
We dedicate this work to our parents, who have served as our main sources of
motivation, courage, and success. Particularly my father, who acted as a motivator
for everything I have accomplished to now. My mum is also thankful for this
prosperity that we have today. Thank you, Mom and Dad.

ACKNOWLEDGEMENT

v
Praise is due to him, the master of the universe, in the name of Allah Most Merciful
and Almighty, who gave me the opportunity to conduct this research. This
project/Proposal magnitude is never merely my own work and mu ability, I deeply
appreciate and to thankful my supervisor Dr. Abdullahi Adane. I also like to send
special gratitude to my parent.

”.

vi
 LIST OF ABBREVIATION AND ACRONYMS

CDC: Centers for Disease Control and Prevention.

IPIs: Intestinal parasitic infections
MRI: Magnetic Resonance Imaging
WHO: World Health Organizations

vii
 TABLE OF CONTENTS

DECLARATION A....................................................................................................ii

DECLARATION B...................................................................................................iii

APPROVAL SHEET.................................................................................................iv

DEDICATION............................................................................................................v

ACKNOWLEDGEMENT........................................................................................vi

LIST OF ABBREVIATION AND ACRONYMS..................................................vii

TABLE OF CONTENTS........................................................................................viii

CHAPTER ONE.........................................................................................................1

INTRODUCTION......................................................................................................1

1.0 Introduction...........................................................................................................1

1.2. Background.......................................................................................................1

1.2 problem statement.............................................................................................5

1.3 significance of the study....................................................................................5

1.4 Objectives of the study......................................................................................6

1.4.1 General objectives........................................................................................6

1.4.2 Specific objectives........................................................................................6

1.5 Research questions............................................................................................6

1.6 Scope of the study..............................................................................................6

1.6.1Content scope................................................................................................6

1.6.2 Geographical scope......................................................................................6

1.6.3 Time scope...................................................................................................6

1.8 Definition of important terms..........................................................................7

CHAPTR TWO...........................................................................................................8

LITERATURE............................................................................................................8

2.0 INTRODUCTION.............................................................................................8

viii
 2.1 Effects of intestinal parasitic infection............................................................9

2.1.1 Amoebic dysentery.......................................................................................9

2.1.2 Iron deficiency anemia...............................................................................10

2.1.3 Intestinal Obstruction.................................................................................12

2.2 Associated factors of intestinal parasitic infections.....................................14

2.2.1 Personal hygienic factors............................................................................14

2.2.2 Socioeconomic factors...............................................................................15

2.2.3 Environmental factors................................................................................15

2.3 Laboratory Diagnosis.....................................................................................16

2.3.1Stool examination........................................................................................16

2.3.2 Blood test....................................................................................................16

2.3.3 Endoscopy/Colonoscopy............................................................................17

CHAPTER THREE..................................................................................................18

METHODS AND MATERIALS.............................................................................18

3.0 Study Area...........................................................................................................18

3.1 Study population.............................................................................................18

3.2 Criteria of the study........................................................................................18

3.3 Study design.....................................................................................................18

3.4 Sampling procedure........................................................................................18

3.6 Types of data. Qualitative vs quantitative....................................................19

3.7 Research instrument i.e .questionnaire, interview, observation.................19

3.8 Ethical issues in research................................................................................19

3.9 Limitations and Delimitations........................................................................20

APPENDIX (A).........................................................................................................25

QUESTIONAIRE.....................................................................................................25

ix
 CHAPTER ONE

INTRODUCTION

1.0 Introduction
This chapter consists of introduction, background of the study, problem statement, and
significance of the study, objectives of the study, research question, and scope of the study,
limitation and delimitation of the study, definition of important terms / Glossary and
conceptual frame work.

1.2. Background
Intestinal parasitosis refers to a group of diseases caused by one or more species of
protozoa, cestodes, trematodes and nematodes. These parasites are responsible for the
major share of morbidity and mortality in communities where there is over-crowding, poor
environmental sanita- tion and personal hygienic practices, which make them a great
concern for the developing countries. Factors ranging from water, sanitation and hygiene to
weak health service delivery to populations at risk of infec- tions were major reasons for
persistence of these diseases in the community (Anteneh T, et al, 2008).

Intestinal parasitic infections (IPIs) are one of the most common diseases and resulted in
widespread morbidity starting from early times of human history. The eggs of cer- tain
intestinal worms were recovered from mummified feces of humans dating back thousands
of years. These days intestinal parasites, mostly of soil transmitted hel- minthiasis, affect
nearly a third of global population and se- verely affects underprivileged populations of
developing countries where poverty, undernutrition, inadequate sanita- tion and lack of
clean drinking water prevails [1, 4]. In 2010, an estimated 438.9 million people were
infected with Hookworms, 819.0 million with Ascaris lumbricoides,464.6 million with
Trichuris trichuria and these parasites inflicted nearly 5 million years lived with disability
in the world (Pullan RL, et al, 2014).

1
Parasitic infections are a major public health problem worldwide; particularly in the
developing countries and constituting the greatest cause of illness and disease. Current
assessments suggest that at least one third of the total population in the world is infected
with intestinal parasites. Indeed, it is estimated that about 3.5 billion people in the world
are infected with intestinal parasites, of whom 450 million are ill. The majority is living in
tropical and subtropical parts of the world. The prevalence of the intestinal parasitic
infections varied from one region to another and it also depends largely on the diagnostic
methods employed and the number of stool examinations done. Intestinal parasitic
infections are one of the biggest socioeconomic and medical problems. Epidemiological
studies show that parasitic infections are among the most common infections and one of
the biggest health problems of the society worldwide. Surveys on the prevalence of various
intestinal parasitic infections in different geographic regions are a prerequisite for
developing appropriate control strategies ( WHO, 2001).

The effect of this group of disease is mainly manifested as a chronic and insidious effect on
health and quality of life, while intense infection can result in developmental falter- ing,
poor growth and poor school performance [1]. Studies indicate that children with heavy
intestinal parasitic infec- tion have lower body mass index, lower hemoglobin levels and
are often stunted. Some studies also revealed that children with heavy parasitic infection to
have poor an- thropometric indices, growth retardation, poor cognitive development,
chronic inflammatory diseases and life threat- ening surgical conditions. Furthermore, the
chemothera- peutic treatment of the intestinal parasites resulted in improved physical,
motor and language development (Stoltzfus RJ. et al, 2001).

In Globally

According to the WHO report in 2014, more than 3.5 billion people were infected with
intestinal helminths mainly by Taenia saginata, S.stercoralis, H.nana, A. lumbricoides,
T.trichiura and hookworms. From helminthic infections that are grouped under geo-
helminthic; A. lumbricoides, T.trichuria and hook worm are widely distributed in sub-
Saharan Africa, the Americas, China and East Asia. Many studies showed that more than
two billion people were infected by geo-heminthic in worldwide. Two third (2/3) of
African countries had high risk areas with prevalence of more than 50% . On the other
hand, neglected intestinal protozoans like E. histolytica/dispar, G. lamblia and other

2
coccidian are triggering millions morbidity and mortality among children, pregnant women
and immune-compromised People (Speich B, et al. 2016).

In developed countries, protozoan parasites more commonly because gastrointestinal

infections compared to helminthes. Intestinal parasites cause a significant morbidity and
mortality in endemic countries. The intestinal parasites different whether protozoan or
worms ,parasites most prevalent in the world generally and the level of the third world in
particular, where its widespread to be affected the climatic and environmental conditions
such as heat and high humidity, in addition to economic conditions and social conditions
such as poverty, lack of clean water supply and the low level of health services increases
the incidence of intestinal parasites and reduce the chances of control or eradication of
diseases they cause intestinal parasites. Intestinal parasites cause significant morbidity and
mortality. Diseases caused by Enterobius vermicularis, Giardia lamblia, Ancylostoma
duodenale, Necator americanus, and Entamoebahistolytica occur in the United States. E.
vermicularis, or pinworm, causes irritation and sleep disturbances ( Kuchenmüller T. et al.
2013 ).

The effect of intestinal parasitic infection on health of infected children is found to depend
on the status of the children. Children with underlying nutritional problems and other
health conditions are more likely to suffer from the brunt of the diseases and develop
morbidities. According to WHO, three quarters of children with in- testinal worms
requiring chemotherapy are in South East Asia and African regions. In Africa only, nearly
three hun- dred million preschool age and school age children re- quire preventive
chemotherapy; this figure accounts for 30% of the global chemotherapy requirement
(WHO, 2012).

The presence of intestinal parasitic infections may have multiple effects among children
including physical and mental developments. The presence of chronic and heavy intestinal
parasitic infection causes intestinal bleeding, malabsorption of nutrients, nutritional
deficiency, destruction of cells and tissues and other associated effects. The overall effect
of these results in growth retardation, reduced mental development, school absenteeism,
low academic performance, susceptible to malnutrition and

3
infection (Okyay P. et al, 2004).

In Africa Latest estimates indicate that more than 880 million children are in need of
treatment for these parasites. Populations at risk in the WHO African Region are estimated
at 350 million. High prevalence of intestinal parasitic infection were reported among
school children in Sub Saharan African countries including 27.7% to 95% in Ethiopia,
90% in Central Sudan 50.0% in Rwanda 48.7% inTanzania and 84.7% in Burkina Faso.
High prevalence of intestinal parasitic infection in the region is

associated with personal hygiene, socio economic status and educational level of the
community (Bishop J. et al, 2012).

In Somalia About 85% of the population of Somali communities harboured soil-

transmitted intestinal nematodes and/or protozoa. The commonest parasite (75% in the
Lafoole institution and 59% in the Afgoye institution) was Trichuris trichiura. Mixed
infections were common. The source of infection is contaminated fields around dwelling
quarters, because of indiscriminate defaecation. One of the factors responsible for the
higher incidence of hookworm in Lafoole (45%) compared with Afgoye (1.5%) may be the
different soil character of the surrounding fields. Intestinal parasitic infections are
historically common in Somalia. Although epidemiologic characteristics of these infections
have been studied in some populations (mostly children) in Somalia, a true and accurate
picture of the magnitude of the problem is still unclear and the challenge still remains
(Kuchenmüller T. et al, 2013).

In Somalia a considerable amount of human and animal wastes are discharged into the soil
daily leading to soil seepage with pathogenic organisms which include cysts, eggs and
larvae of these intestinal parasites. The distribution and prevalence of various species of
intestinal parasites differ from one region to another.ye (1·5%) may be the different soil
character of the surrounding fieldsparasitic infections are historically common in Somalia.
Although epidemiologic characteristics of these infections have been studied in some
populations (mostly children) in Somalia, a true and accurate picture of the magnitude of
the problem is still unclear and the challenge still remains. In Somalia a considerable

4
amount of human and animal wastes are discharged into the soil daily leading to soil
seepage with pathogenic organisms which include cysts, eggs and larvae of these intestinal
parasites ( WHO, 2001).

1.2 problem statement

Intestinal parasites are among the major contributors to the global disease burden but the
non- acute nature of the infections has contributed to the perception of intestinal parasitic
infections as being common but usually unimportant to the public health community.
Inadequate sanitation and unhygienic living conditions lead to fecal contamination of the
environment, lack of proper health education, insufficient and contaminated water supplies
contribute to more infection by intestinal parasites in many localities. The consumption of
street foods from food vendors and roadside hawkers of foods contaminated with eggs of
intestinal parasites contribute to the transmission of infection in WADAJIR district.

The most common effect of intestinal parasitic infection on the health of children affect the
normal physical development, resulting in children failing to achieve their genetic potential
for growth and having the clinical consequences of iron deficiency anemia and other
nutritional deficiencies. Although intestinal parasites are a significance problem in
Somalia, however, there are no sufficient studies related to the problem at hand. The study
will specifically examine the prevalence of intestinal parasitic infections and associated
factors among people in WADAJIR district.

1.3 significance of the study

The findings of the study will serve as guidance for the local authorities, civil society,
NGOs, health centers, ministry of health and the international community operating in
Somalia. The findings of the study will provide research based and up to date information
to future researchers and academicians about the prevalence of intestinal parasitic
infections and associated factors among people in WADAJIR district. The findings are also
more likely to inform the community about intestinal parasitic infections and also ways of
enhancing these intestinal parasiticinfections in the community.

5
1.4 Objectives of the study

1.4.1 General objectives

The general objective will be the prevalence of intestinal parasitic infections and associated
factors among people living in WADAJIR district.

1.4.2 Specific objectives

1. To assess the effects of intestinal parasitic infections among people living in WADAJIR
district.

2. To identify associated factors of intestinal parasitic infections among people living in

WADAJIR district.

3. To determine Laboratory diagnosis of intestinal parasitic infections among people living

in WADAJIR district.

1.5 Research questions

1. What is the prevalence of intestinal parasitic infections among people living in
WADAJIR district?

2. Describe associated factors of intestinal parasitic infections among people living in

WADAJIR district?

3. How to diagnose of intestinal parasitic infections among people living in WADAJIR

district.

1.6 Scope of the study

It is a description of the boundary of the study in terms of, content, geographical, and time.

1.6.1Content scope
This study focused on the prevalence of intestinal parasitic infections and associated
factors among people living in WADAJIR district.

1.6.2 Geographical scope

The study area will be in wadajir district

1.6.3 Time scope

The study will be conducted in Banadir hospital between 1 st March 2024 up to 30th
July 2024.

6
1.8 Definition of important terms
I. Helminths are parasitic worms that feed on a living host to gain nourishment and

protection, while causing poor nutrient absorption, weakness and disease in the host.

II. Parasite: is an organism that lives on or in a host. Organism gets its food from its host.

III. Infection: is the invasion and growth of germs in the body.

IV. Protozoa: A parasitic single-celled organism that can divide only within a host
organism.

7
 CHAPTR TWO

LITERATURE
2.0 INTRODUCTION
Intestinal parasitic infections (IPIs) are regarded as one of the main public health problems
and socio-economic issues adversely affecting the health of millions of people worldwide
particularly poor individuals in developing countries Frequently, IPIs are due to
Entamoeba histolytica, Giardia lamblia, Ascaris lumbricoides, Trichuris trichiura,
Hookworms, Hymenolepis species, Taenia species and Schistosoma mansoni where the
majority of them are transmitted directly by fecal-oral route and others may be transmitted
via skin penetration of humans. IPIs are common cause of anemia such as iron, folate, and
vitamin B12 deficiencies among low- income populations and are associated with
micronutrient deficiencies such as low plasma vitamin A, loss of weight, diarrhea, chronic
blood loss, and stunted growth among children . Socio-demographic factors such as age,
low-income, gender, family size, and education levels of parents, which have significantly
associated with the increased prevalence of these parasites (Shumbej T. et al, 2015).

International studies showed that a significant percentage of IPIs were observed among
schoolchildren. A prevalence rate of 19.6% in Zambia’ in Khartoum, Sudan 30.0% and in
Riyadh, Saudi Arabia with 17.7% children under the age of five as they are more
vulnerable to soil-transmitted helminthic infections than adults. Nutritional disorders
caused by the parasites may lead to iron deficiency anemia, malnutrition and they may
have a negative impact on growth and cognitive development of a child ( Zewdneh S. et al.,
2011).

Despite all the medical and pharmaceutical advance as well as progress in sanitary
engineering, intestinal parasitic infections remain the most prevalent in the world,
especially in developing countries struggling with water scarcity, poor hygiene and lack of
adequate health care services. Furthermore, it is difficult to control intestinal parasitoses in
these regions due to the high cost of infrastructure improvements and lack of educational
projects offered to the population (Speich et al., 2016; Ostan et al., 2007; Mehraj et al.,
2008). Water is essential to life, but it is also an important vehicle for pathogen
dissemination, and many invasive helminth eggs and larvae, and protozoan cysts are
distributed via water in the environment. Protozoa such as Giardia lamblia and
Cryptosporidium spp. Are recognized as important waterborne pathogens, causing in some

8
cases severe gastrointestinal disease (Baldursson & Karanis, 2011; Kumar et al., 2014). It
has been well documented that the conventional treatment of drinking and waste water is
not always sufficient for a complete destruction of protozoan oocysts and helminth eggs
(Jejaw A. et al., 2015).

2.1 Effects of intestinal parasitic infection

A person with intestinal worms may also experience dysentery. Dysentery is when an
intestinal infection causes diarrhea with blood and mucus in the stool. Intestinal worms can
also cause a rash or itching around the rectum or vulva. In some cases, you will pass a
worm in your stool during a bowel movement.(healthline) (Hailu T. et al., 2018).

2.1.1 Amoebic dysentery

Amoebic dysentery is caused by the protozoan parasite Entamoeba histolytica. Invasive
intestinal parasitic infection can result in symptoms of fulminant dysentery, such as fever,
chills, bloody or mucous diarrhoea, and abdominal discomfort. The dysentery can
alternate, with periods of constipation or remission. This review focuses on amoebic
dysentery only, and includes populations with both suspected and documented disease in
endemic areas where levels of infection do not exhibit wide fluctuations through time. The
term amoebic dysentery encompasses people described as having symptomatic intestinal
amoebiasis, amoebic colitis, amoebic diarrhoea, or invasive intestinal amoebiasis. Extra-
intestinal amoebiasis (e.g. amoebic liver abscess) and asymptomatic amoebiasis are not
covered (Hailegebriel T. et al., 2017).

Amoebic dysentery may progress to amoeboma, fulminant colitis, toxic megacolon and
colonic ulcers, and may lead to perforation. Amoeboma may be mistaken for colonic
carcinoma or pyogenic abscess. Amoebic dysentery may also result in chronic carriage and
the chronic passing of amoebic cysts. Fulminant amoebic dysentery is reported to have 55-
88% mortality. It is estimated that more than 500 million people are infected with E
histolytica worldwide. Between 40 000 and 100 000 will die each year, placing this
infection second to malaria in mortality caused by protozoan parasites Amoebic dysentery
is transmitted in areas where poor sanitation allows contamination of drinking water and
food with faeces. In these areas, up to 40% of people with diarrhoea may have amoebic
dysentery. Fulminant amoebic dysentery is often fatal. Other complications include

9
perforation of the colon, colonic ulcers, amoeboma, or chronic carriage ( Workneh T. et al.,
2018).

There are at least six species of parasites in the Entamoeba group but symptoms are most
common with the Entamoeba histolytica parasite. The amoebae are found in water, soil and
other damp environments. They also live in the intestines of infected people and can be
passed out in the stools of infected people, leading to contamination of drinking water or
food supplies in countries with poor sanitation. The majority of infected people develop no
symptoms. In those 10% who do develop symptoms, diarrhoea is most common. Other
symptoms may include abdominal pain and bloody diarrhoea, but sometimes a severe
colitis can occur that can result in bowel perforation. People affected may also develop
anaemia due to loss of blood (Tulu B. et al., 2014).

Amoebic dysentery is often confused with ‘traveller’s diarrhoea’ because of its prevalence
in developing nations. In fact, most traveller’s diarrhoea is bacterial or viral in origin. It is
estimated that more than 500 million people are infected with E. histolytica worldwide.
Between 40,000 and 100,000 will die each year, placing this infection second only to
malaria in mortality caused by protozoan parasites. Those most at risk are travellers to
areas where amoebic dysentery is common, usually in countries with poor sanitation.
Amoebiasis occurs worldwide but is particularly common in tropical areas of Central and
South America, western and southern Africa, and South Asia (Nute A. et al., 2018).

2.1.2 Iron deficiency anemia

Iron deficiency anemia is the most common type of anemia, and it occurs when your body
doesn't have enough of the mineral iron. Your body needs iron to make hemoglobin. When
there isn't enough iron in your blood stream, the rest of your body can't get the amount of
oxygen it needs (healthline)

The main parasites causing blood loss in man and leading to direct iron-deficiency anemia
are the common worm infections. These include hookworm infection (Necator americanus
and Ancylostoma duodenale); whipworm infection (Trichuris trichiura); and
schistosomiasis (Schistosoma mansoni, S. haematobium, and S. japonicum). Radioisotope
studies with chromium 51-tagged red blood cells have shown that patients with heavy

10
hookworm infection can lose up to 250 ml, or a quarter of a liter of blood, daily, and up to
29 mg of iron in the gastrointestinal tract, thus leading to direct iron-deficiency anemia
(Feleke D. et al., 2017).

Workers from South America and East Africa have shown that each Necator americanus
worm can cause a daily blood loss of 0.03 ml, which means that patients infected with
approximately 1,000 worms can lose up to 30 ml of blood daily. More recent work from
London and Egypt has shown that the Old World hookworm, Ancylostoma duodenale, can
cause a daily blood loss of 0.2 ml, approximately 10 times more than the American
hookworm, Necator americanus. Layrisse and his colleagues (24– 27), using 51Cr-tagged
red cells, measured the blood loss caused by T. trichiura in heavily infected children and
showed that the daily blood loss can reach up to 8.6 ml. These workers concluded that
infection of over 800 parasites can lead to anemia. Using 51Cr-isotopes, Farid (10–15) and
his colleagues measured the blood loss in patients with chronic Schistosoma mansoni
polyp formation of the colon and showed that these patients can lose up to 12.5 ml of blood
daily. Using 59Fe-isotopes, these workers also measured the blood loss in the urine in
patients infected with Schistosoma haematobium and demonstrated that these patients can
lose up to 120 ml of blood daily. Blood loss in schistosomiasis, however, is intermittent
and not constant and though it may be severe for a few days it usually ceases for prolonged
periods (Tadege B. et al., 2017).

It has been shown by 51Cr and body surface counting of radioactivity that the large spleen
in chronic schistosomiasis, leishmaniasis, and malaria, can destroy the red blood cells and
lead to anemia secondary to hypersplenism. Recent work has also shown that a
malabsorption syndrome leading to poor absorption of essential nutrients may occur in
patients heavily infected with hookworms, Strongyloides stecoralis and Giardia
lamblia.Destruction of red blood cells leading to a hemolytic anemia has been shown to
occur in malaria, and vitamin B12 megaloblastic anemia has been demonstrated to occur in
patients infected with the intestinal fish worm, Diphyllobothrium latum(American Society
for Nutrition (ASN) Hookworm infection is one of the common parasitic infestations in
developing countries (Alemu G. et al., 2018).

11
They are mainly causing iron deficiency anemia in exposed patients. This activity reviews
the evaluation and management of hookworm infections and highlights interprofessional
team members' role in collaborating to provide well-coordinated care and enhance patient
outcomes. Hookworms are nematode parasites that usually get transmitted through infested
soil. They usually affect the poorest individuals in tropical and subtropical areas. Two
species are mainly responsible for human infections, Ancylostoma duodenale and Necator
americanus. They can cause chronic infection of the intestinal tract, suck their host blood,
leading to iron deficiency anemia in most cases. Blood loss in heavily infected persons
could reach up to 9.0 mL/day and occurs by two mechanisms. The first is through
consumption of the parasite, which accounts for a small portion of blood loss ( Gyorkos T. et
al., 2013).

The second and the main loss occurs through the attachment site by leakage around it. Iron
deficiency anemia occurs when the host becomes unable to compensate for blood loss,
especially in heavy infections and nutritionally deprived individuals. Simultaneous protein
loss might occur and result in symptomatic hypoalbuminemia and hypoproteinemia,
leading to anasarca and worsen malnutrition. Parasites can last for years in the host, and
accordingly, it had to develop multiple strategies to ensure survival. The parasite uses
broad-spectrum protease inhibitors to neutralize the effect of the host's immune defenses.
While it helps the parasite protect itself from proteolytic enzymes, it worsens the host's
malnutrition by interfering with absorption.( Gebreyohanns A. et al., 2018).

2.1.3 Intestinal Obstruction

Intestinal blockage. Intestinal blockage occurs when a mass of worms blocks your
intestines, causing severe pain and vomiting. Intestinal blockage is considered a medical
emergency and requires treatment right away.( healthline) Ascariasis is an infection of the
small intestine caused by Ascaris lumbricoides, which is a species of roundworm.
Roundworms are a type of parasitic worm. Infections caused by roundworms are fairly
common. Ascariasis is the most common roundworm infection. About 10 percentTrusted
Source of the developing world is infected with intestinal worms, according to the World
Health Organization (WHO). Ascaris lumbricoides is a parasitic nematode and one of the
most common parasites in the world. Infection can manifest with vomiting,
malnourishment, pneumonitis, growth impairment and abdominal pain. If a severe

12
infestation occurs, it can produce, cholangitis, pancreatitis, appendicitis or even masses
with intestinal obstruction (De Benitez T. et al., 2011).

Ascariasis is a roundworm infestation that affects as many as 1.5 billion people around the
globe . The Ascaris parasite life cycle begins with the ova in human feces, which is then
ingested by the fecal to oral route. The larvae first hatch in the intestine, and then burrow
into the mucosa, entering the portal circulation. The larvae then move to the lungs, where
they mature for about 2 weeks, make their way to the bronchi and thence to the
oropharynx, where they are again swallowed. The worms then make their final home in the
small intestine, where they remain and lay eggs to be excreted in the feces. As such,
roundworm infestation can result in small bowel obstruction and segmental intestinal
volvulus. Although this is a less common cause of intestinal obstruction in the developed
world than adhesive bands or stricture from previous surgery, we describe here a case of
proximal small bowel obstruction from ascariasis in the setting of a concurrent anastomotic
stricture from prior laparotomy. Ascaris lumbricoides infection is extremely common in
the developing world and in endemic areas As the adult form of A. lumbricoides resides in
the small intestine, large masses of roundworms may persist in the intestinal lumen and
cause obstruction; this is in fact a common etiologiy for small bowel obstruction in the
developing world (Chimdessa A. et al., 2018).

The most common complication of intestinal ascariasis is small bowel obstruction, which
is typically due to a physical obstruction caused by a large number of entangled worms.
Other mechanisms of small bowel obstruction due to a worm bolus include volvulus and
intussusception, which may lead to bowel ischemia or infarction. These mechanisms of
small bowel obstruction are typically seen in children with large worm burdens. The
mortality rate among children with complicated intestinal obstruction may be as high as
24%; this high rate is attributable to delay in presentation. Intestinal obstruction has been
reported to occur in adults infected with only a few adult roundworms. Intestinal
obstruction may be caused by adherence of intestinal loops to an inflamed segment of the
small bowel, which is what we believe was the reason for our patient's partial small bowel
obstruction . A single ascaride may stimulate an inflammatory reaction in a segment of
bowel through production of toxins or by causing a small perforation. (Woan J. et al., 2013).

13
2.2 Associated factors of intestinal parasitic infections

2.2.1 Personal hygienic factors

In hand washing practices, 272 (79.1%) food handlers had a habit of handwashing after
toilet, while 226 (83.1%) food handlers had the habit of handwashing with soap and water
after toilet. Almost all food handlers (342 (99.4%)) had a habit of handwashing before
having contact with food items. Majority of the study participants (food handlers) (222
(64.5%)) have had no medical checkup previously, including stool examination. All food
handlers working at the prison center were not certified. 148 (43.0%) food handlers
trimmed their fingernails well, 112 (32.6%) trimmed their fingernails partially, and the rest
(84 (24.4%)) did not trim their fingernails (Table 1). Sanitary facility of study participants
working in the entire four prison centers had a latrine at the workplace but none of them
had handwashing facility inside the latrine. Majority of participants (282 (81.9%)) had pipe
water access, and 160 (46.5%) used burning solid disposal Various epidemiological studies
indicate that the prevalence of intestinal parasites is high in developing countries and those
parasites are major public health importance in Sub-Saharan Africa. Their distribution is
mainly associated with poor personal hygiene, environmental sanitation and lack of access
to clean water. Food-borne diseases are the commonest types of infectious diseases among
the global burdens of diseases in human beings especially in developing countries. Food
handlers can play a vital role in the transmission of these parasitic infections ( Habtamu D. et
al., 2013).

Though there are so many sources of food and drinking contamination methods, food
handlers serve as the main ones. If food handlers practice poor hygienic behavior, they
could be carriers of pathogens. According to World Health Organization (WHO) estimate,
nearly one- third of the population in developed countries is affected by intestinal parasitic
infections; whereas in developing countries the estimate is around five times higher. In
Ethiopia, intestinal parasitic infections (IPIs) are usually related to so many factors that are
associated with poverty, including poor socioeconomic condition, poor hygiene and
sanitation practice, lack of safe and adequate water supply and climate change ( Islam F. et
al., 2014).

14
2.2.2 Socioeconomic factors
The burden of diseases associated with intestinal parasitic infections is enormous. About
two billion people are affected worldwide, of whom 300 million suffer from associated
severe morbidity. Indirect morbidity is particularly important in children with parasitic
infections, ranging from malnutrition, anaemia, growth retardation, irritability and
cognitive impairment to increased susceptibility to other infections and acute
complications. Epidemiological studies carried out in different countries have shown that
the socio-economic level of the society may affect the incidence of intestinal parasites;
control strategies of local managements involving improved infra-structure for both
drinking water and sewage system, education of the society to improve personal hygiene
and sanitation have been related to reduced incidence of intestinal parasites ( Cumber S. et
al., 2016).

2.2.3 Environmental factors

The free-living stages of gastro-intestinal nematodes on pasture (i.e. eggs, developing and
infective larvae) are often overlooked and not considered by producers. The factors that
influence the development, survival, distribution, or migratory behavior of the free-living
larvae seen on pasture are primarily weather related. The deposition of helminth eggs in
feces is the starting point for the contamination of the pasture and the subsequent
development of the parasites. The cumulative numbers of eggs can be considerable by the
end of the grazing season. Environmental factors will influence both development and
survival of the larvae on pasture, as well as their distribution onto the herbage. It is
difficult to evaluate the effects of temperature without considering moisture. Moisture must
be present to prevent desiccation and death of the developing larvae. Moisture has an effect
on the movement and motility of the larvae. As the fecal pat dries out the larvae may
desiccate and die. If the environment is dry, movement onto surrounding herbage would
probably not be possible, thus forcing movement or migration into the soil beneath the
fecal pat (Mekonnen B. et al., 2014).

15
2.3 Laboratory Diagnosis
Many kinds of lab tests are available to diagnose parasitic diseases. The kind of test(s) the
health care provider will order will be based on the signs and symptoms, any other medical
condition. Diagnosis may be difficult, so health care provider may order more than one
kind of test (Kheir A. et al., 2017).

2.3.1Stool examination
You collect a fresh stool sample in a clean container provided by the laboratory or your
healthcare practitioner. The stool sample should not be contaminated with urine or water.
Once it has been collected, your stool should either be taken to the laboratory within two
hours after collection or transferred into special transport vials containing preservative
solutions.

Often, multiple samples are collected and tested. These should be collected at different
times on different days because parasites are shed periodically and may not be in your
stool at all times. Multiple samples can increase the likelihood that parasites will be
detected. This test is used to find parasites that cause diarrhea, loose or watery stools,
cramping, flatulence (gas) and other abdominal illness. This test looks for ova (eggs) or the
parasite (Baldo ET. Et al., 2004).

2.3.2 Blood test

Your blood can be tested for the presence of an increased number of a certain type of white
blood cell, called eosinophils. Ascariasis can elevate your eosinophils, but so can other
types of health problems. You can have high levels of eosinophils in your blood (blood
eosinophilia) or in tissues at the site of an infection or inflammation (tissue eosinophilia).
Tissue eosinophilia may be found in samples taken during an exploratory procedure or in
samples of certain fluids, such as mucus released from nasal tissues. If you have tissue
eosinophilia, the level of eosinophils in your bloodstream is likely normal. Blood
eosinophilia may be detected with a blood test, usually as part of a complete blood count.
A count of more than 500 eosinophils per microliter of blood is generally considered
eosinophilia in adults. A count of more than 1,500 eosinophils per microliter of blood that
lasts for several months is called hyper eosinophilia (.mayoclinic) Serology This test is
used to look for antibodies or for parasite antigens produced when the body is infected
with a parasite and the immune system is trying to fight off the invader.This test is done by

16
your health care provider taking a blood sample and sending it to a lab ( Lakew A. et al.,
2015).

2.3.3 Endoscopy/Colonoscopy
Endoscopy is used to find parasites that cause diarrhea, loose or watery stools, cramping,
flatulence (gas) and other abdominal illness.This test is used when stool exams do not
reveal the cause of your diarrhea.This test is a procedure in which a tube is inserted into the
mouth (endoscopy) or rectum (colonoscopy) so that the doctor, usually a
gastroenterologist, can examine the intestine.This test looks for the parasite or other
abnormalities that may be causing your signs and symptoms.(CDC) (Samuel F. et al., 2017).

2.3.4 Imaging test

X-ray, Magnetic Resonance Imaging (MRI) scan, Computerized Axial Tomography scan
(CAT)These tests are used to look for some parasitic diseases that may cause lesions in the
organs.

X-rays. If you're infested with worms, the mass of worms may be visible in an X-ray of the
abdomen. In some cases, a chest X-ray can reveal the larvae in the lungs.

Ultrasound. An ultrasound may show worms in the pancreas or liver. This technology uses
sound waves to create images of internal organs (De Benitez T. et al., 2011).

17
 CHAPTER THREE

METHODS AND MATERIALS

This chapter highlights the methodology and materials appropriate to the study. This
includes the following

3.0 Study Area

The study area will be in Wadajir district Mogadishu Somalia.

3.1 Study population

Target population of this study will be people living in wadajir district Mogadishu somalia
and the target population is 70.

3.2 Criteria of the study

a) Inclusion criteria

This study will be related the people living in Wadajir district Mogadishu Somalia.

b) Exclusion criteria

This study will not relate the people living other districts in Mogadishu Somalia.

3.3 Study design

The cross-sectional study of design will be used in this study. The researcher will be used
quantitative methods, which means that the sample will be taken from the population and
the information, will obtain at the same time on a particular point in time. Cross-sectional
studies are less expensive and more expedient to conduct compared with analytic studies.
Cross sectional survey also seeks to obtain information that describes existing phenomenon
by asking individuals about their perceptions, attitudes, behaviors or values with the aim of
the prevalence of intestinal parasitic infection and associated factors of among people in
wadajir district Mogadishu Somalia

3.4 Sampling procedure

The sampling procedure of this study will be used probability sampling procedure
particularly; simple sample stratified will use to select sample.

18
3.5 sample size

This is an important issue. Numerical techniques for determining complications will be

described later, but suffice it to say that the larger the sample size is, the more accurate we
can expect the sample estimates to be.

The sample size of the study will identify using Slovene’s formula

n= N / (1 + (N*e^2))

Where

N= Population size

n= Sample size

e= Margin of error of 5%

n =70/ (1+ (70*0.0025)) = 60

3.6 Types of data. Qualitative vs quantitative

3.7 Research instrument i.e .questionnaire, interview, observation.

Research instrument use to collect the data is questionnaire. The sample procedure, which
will use for this study is Random selection sampling; because it allows us to decide whom
to include in the sample and to collect focused information and the selection of typical and
useful cases and saves time and cost.

3.8 Ethical issues in research

The research team thought about the ethical issued during research project, and kept the
privacy and, confidentiality of the respondents from the public. The research team
acknowledged the authors mentioned in this study through citations and referencing, also
the respondents of this study had the freedom to ignore items that they do not wish to
respond. The identity of the respondents kept on secret as well as the private information
stayed confidential. To consider ethical issue, the research team requested the
organizations to permit the distribution of the questionnaire. In addition, the information of
the respondents was used only for academic purpose. Privacy, retreat and secrecy of the
hidden information were the main alarm of this study.

19
3.9 Limitations and Delimitations
1. time will be The very limited to carry out the study
2. Ignorance of some respondents to fill the questionnaire
3. Difficulties finding relevant respondents in our study because the topic is so
difficult.
4. Financial limitation
5. Transportation and internet fee
6. Research objectives
7. Research question
8. Target population
9. Statistical analysis techniques

20
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 APPENDIX (A)

QUESTIONAIRE
Dear respondents, we are currently pursuing bachelor degree of public health at
Jobkey University, as partial fulfillment towards the completion of our undergraduate
degree the purpose of this survey to find out the prevalence of intestinal Parasitic
infections and associated factors among people living in Wadajir district. you
have been selected randomly to participate in this study. The information received
will be treated with strict confidentiality and shall not be used for any other purpose
except for this study. Your responses are highly appreciated, so kindly request to
spare your precious time to answer the following questions.

SECTION A:
1. How old are you?
1. 15-25
2. 26-35
3. above 36
2. What is your gender?
1. Male
2. Female
3. What is your marital status?
1. Single
2. Married
4. What is your educational level?
1. Primary level
2. Secondary level
3. University level
4. Non formal education
5. What is your occupational level?
1. Housewife
2. Unemployed
3. Self employed

25
SECTION B: Effects of intestinal parasitic infection
6. Effects of intestinal parasitic infection include dysentery, intestinal blockage
and iron
Deficiency anemia
1. YES
2. NO
7. Amoebic dysentery is caused by the protozoa parasite called Entamoeba
histolytica
1. YES
2. NO
8. Iron deficiency anemia is the most common type of anemia, and it occurs
when your body doesn't have enough of the mineral iron.
1. YES
2. NO
9. The main parasite that cause blood loss is Hookworm.
1. YES
2. NO
10. Ascariasis is the most common roundworm infection that can cause
intestinal obstruction
1. YES
2. NO
SECTION C: Associated factors of intestinal parasitic infections
11. Epidemiological studies indicate that the prevalence of intestinal parasites is
high in developing countries.
1. YES
2. NO
12. Indirect morbidity is particularly important in children with parasitic
infections, ranging from malnutrition, anemia, growth retardation, irritability
1. YES
2. NO
13. The incidence intestinal parasitic infection may reduce good personal
hygiene, clean water drinking
1. YES
2. NO

26
14. The factors that influence the development, survival, distribution, or
migratory behavior of the free-living larvae seen on pasture are primarily
weather related.
1. YES
2. NO
15. the most common routes of intestinal parasites can transmitted is fecal oral
route
1. YES
2. NO

SECTION D: laboratory diagnosis of intestinal parasitic infection

16. the most common diagnostic tests of intestinal parasitic infection are stool
and blood test?
1. YES
2. NO
17. Can a blood test detect intestinal worms?
1. YES
2. NO
18. The Wet mount method has been chosen as a routine diagnosis of intestinal
parasitic Infection ?
1. YES
2. NO
19. Increasing number of eosinophils in wbc indicates the presence of intestinal
parasites ?
1. YES
2. NO
20. Endoscopy is used when stool exams do not reveal the cause of your
diarrhea?
1. YES
2. NO

27