Although the clinical consequences associated with the infection may not pose a major problem, the prevalence of the infection is still high, therefore it is still of public health concern in Malaysia. In addition, it is common in low-income communities including the aborigines, rural and poor Malay community, children in estates and squatter areas (Anuar et. al., 2014).
Development of
A cross-sectional study was performed by collecting of stool samples from the aboriginal community (n=473) residing at three aboriginal villages in Kuala Krau, Temerloh, Pahang during two seasons; wet season from October to November 2014 (n=256) and dry season in June 2015 (n=217). (Fig. 1). The seasons were identified based on the data obtained from Malaysian Meteorological Department from 2010 to 2013, recorded at Temerloh station. The sample size was calculated using Epi Info based on study by Anuar et al. (2021), with 95 % confidence level and an 80 % power. The minimum sample size required was 441.
The objectives and protocol of the study were explained briefly to the participants and family members. An adapted structured questionnaire in the Malay language was used and explained to the subjects through an oral interview (Anuar et al., 2014). The guardians or parents who signed the informed consent for their children were briefed on the details related to the study.
Risk factors for
Labeled stool containers were distributed to participants a day prior to stool collection. Approximately 10 grams of stool collected from the participants were subjected to preservation in polyvinyl alcohol (PVA). The preserved stool was filtered into a centrifuge tube. After centrifugation, the supernatant was decanted. Stool sample was then collected using a fine hair brush and smeared on a cover slip and air-dried, followed by Wheatley’s Trichrome staining (Salleh et al., 2012). The stained slides were examined with microscope using 100x magnification for
Data were entered into the Statistical Package for Social Sciences software for Windows (SPSS Version 23, Chicago, IL, USA). Prevalence of
Chi-square (χ2) analysis was used to determine the associations between the prevalence of
The study protocol was approved by Research and Ethical Committee, Faculty of Medicine, Universiti Kebangsaan Malaysia (FF-2014-219) prior to stool samples collection. Permission for fieldwork was granted from the Department of Orang Asli Development (JAKOA) (JAKOA/PP.30.032Jld29(04)). Prior to the study, informed consent was obtained from all participants and from the parent or guardian (for participants aged 16 years old and below)
Higher prevalence of
Prevalence and significant difference of
Wet season (n=256) | Dry season (n=217) | Significant difference between the two seasons | |||||
---|---|---|---|---|---|---|---|
Number of infections | Prevalence (%) | 95 % CI | Number of infections | Prevalence (%) | 95% CI | ||
142 | 55.5 | 49.2, 61.7 | 138 | 63.6 | 56.8, 70.0 | 1.792 | 0.073 |
Chi square (χ2) analysis revealed that low household income of RM500 and below [OR=1.511(1.294, 3.891),
Univariate analysis of the risk factors associated with
Variables | Wet season (n=256) | Dry season (n=217) | OR (95% Cl) | p-value | ||||
---|---|---|---|---|---|---|---|---|
Wet season | Dry season | Wet | Dry | |||||
Prevalence | (95% Cl) | Prevalence | (95% Cl) | |||||
<15 | 58; 22.7 % | 17.7, 28.3 | 53; 24.4 % | 18.9, 30.7 | 1.690 (1.420,2.135) | 1.496(1.283, 3.869) | ||
>15 | 84; 32.8 % | 27.1,38.9 | 85; 39.2 % | 32.6, 46.0 | 1 | 1 | 0.143 | 0.014* |
Female | 77; 30.1 % | 24.5, 36.1 | 63; 29.0 % | 23.1,35.6 | 1.994(1.606,2.630) | 0.703 (0.404, 1.225) | ||
Male | 65; 25.4 % | 20.2,31.2 | 75; 34.6 % | 28.3,41.3 | 1 | 1 | 0.980 | 0.213 |
>8 | 93; 36.3 % | 30.4, 42.6 | 78; 35.9 % | 29.6, 42.7 | 1.967(1.544, 3.718) | 1.722 (1.412,2.265) | ||
<8 | 49; 19.1 % | 14.5, 24.5 | 60;27.7 % | 21.8, 34.1 | 1 | 1 | 0.909 | 0.255 |
≤ RM500 | 90; 35.2 % | 29.3,41.4 | 88; 40.6 % | 34.0, 47.4 | 1.511 (1.294, 3.891) | 1.021 (1.575, 1.813) | ||
> RM500 | 52; 20.3 % | 15.6, 25.8 | 50; 23.0 % | 17.6, 29.2 | 1 | 1 | 0.017* | 0.944 |
No formal education | ||||||||
Primary and secondary education | 37; 14.5% 105; 41.0% | 10.4, 19.4 34.9, 47.3 | 40; 18.4% 98; 45.2 % | 13.5, 24.2 38.4, 52.0 | 1.451 (1.266, 5.764) 1 | 1.935(1.511,2.712) 1 | 0.003** | 0.828 |
Rubber tapper, farmer | 140; 54.7 % | 48.4, 60.9 | 97; 44.7 % | 38.0,51.6 | 3.889 (1.770,9.648) | 1.788(1.005, 3.180) | 0.078 | 0.047* |
Professional, factory | 2; 0.8 % | 0.1, 2.8 | 41; 18.9% | 13.9, 24.8 | 1 | 1 | ||
Untreated tap water | 101; 39.5% | 33.4, 45.7 | 95; 43.8 % | 37.1,50.7 | 1.857(1.105, 3.120) | 2.154(1.219, 3.807) | ||
from river and wells | 0.019* | 0.008** | ||||||
Governmental tap water | 41; 16.0% | 11.8,21.1 | 43; 19.8% | 14.7, 25.8 | 1 | 1 | ||
Yes | 75; 29.3 % | 23.8, 35.3 | 60; 27.7 % | 21.8, 34.1 | 1.539(1.937,2.530) | 1.072 (1.613, 1.876) | ||
No | 67; 26.2 % | 20.9, 32.0 | 78; 35.9 % | 29.6, 42.7 | 1 | 1 | 0.088 | 0.807 |
No latrine system, river | 140; 54.7 % | 48.4, 60.9 | 135; 62.2 % | 55.4, 68.7 | 1.892 (1.311, 11.519) | 1.022 (0.997, 1.048) | ||
Flush toilet and pit latrine | 2; 0.8 % | 0.1, 2.8 | 3; 1.4% | 0.3, 4.0 | 1 | 1 | 0.482 | 0.187 |
No | 16; 6.3% | 3.6, 10.0 | 9; 4.2 % | 1.9, 7.7 | 0.907 (0.423, 1.947) | 0.543 (0.206, 1.430) | ||
Yes | 126; 49.2 % | 42.9, 55.5 | 129; 59.4% | 52.6, 66.0 | 1 | 1 | 0.802 | 0.211 |
No | 7; 2.7 % | 1.1, 5.6 | 5; 2.3 % | 0.8, 5.3 | 1.687 (1.241, 1.955) | 0.705 (0.184,2.705) | ||
Yes | 135; 52.7 % | 46.4, 59.0 | 133; 61.3% | 54.5, 67.8 | 1 | 1 | 0.480 | 0.609 |
River, bushes | 66; 25.8 % | 20.5,31.6 | 67; 30.9 % | 24.8, 37.5 | 1.737 (1.043,2.893) | 2.120 (1.203, 3.736) | ||
Flush toilet and pit latrine | 76; 29.7 % | 24.2, 35.7 | 71; 32.7% | 26.5, 39.4 | 1 | 1 | 0.033* | 0.009** |
Yes | 89; 34.8 % | 28.9,41.0 | 81; 37.3% | 30.9, 44.1 | 1.621 (1.983,2.674) | 1.968(1.551,2.698) | 0.908 | |
No | 53; 20.7 % | 15.9, 26.2 | 57; 26.3 % | 20.5, 32.7 | 1 | 1 | 0.058 | |
No formal education | 67; 26.2 % | 20.9, 32.0 | 41; 18.9% | 13.9, 24.8 | 1.591 (0.960,2.635) | 1.862 (1.475,2.561) | ||
Primary and secondary education | 75; 29.3 % | 23.8, 35.3 | 97; 44.7 % | 38.0,51.6 | 1 | 1 | 0.071 | 0.623 |
No formal education | 62; 24.2 % | 19.1,29.9 | 39; 18.0 % | 13.1,23.7 | 1.434(1.863,2.383) | 1.021 (0.551, 1.890) | ||
Primary and secondary education | 80; 31.3% | 25.6, 37.3 | 99; 45.6 % | 38.9, 52.5 | 1 | 1 | 0.164 | 0.948 |
**significant at p<0.05
** significant at p<0.01
Multivariate analysis confirmed that low household income of RM500 and below [OR=1.545(1.304, 3.979),
Multivariate analysis of the risk factors of
Variables | OR (95% CI) | |||
---|---|---|---|---|
Wet season | Dry season | Wet | Dry | |
NA | 1.317 (1.396, 4.381) | NA | 0.653 | |
≤15 | ||||
≤ RM500 | 1.545 (1.304, 3.979) | NA | 0.042* | NA |
No formal education | 1.440 (1.195, 2.997) | NA | 0.049* | NA |
Rubber tapper, farmer | NA | 1.435 (1.768, 2.683) | NA | 0.258 |
1.362 (1.030, 4.414) | 2.253(1.996, 5.095) | 0.426 | 0.049* | |
Untreated tap water from river | ||||
and wells | ||||
River, bushes | 2.740 (1.184, 6.339) | 1.513 (1.474, 4.834) | 0.019* | 0.485 |
* Significant at
Gastrointestinal symptoms including abdominal pain, diarrhea, flatulence and nausea were not associated with
Besides
Other intestinal parasites detected among the aboriginal community during wet and dry seasons.
Intestinal parasites | Number of infection (%) | Association with |
||||
---|---|---|---|---|---|---|
Wet season (N=256) | Dry season (N=217) | Wet season (N=256) | Dry season (N=217) | |||
χ2 | χ2 | |||||
81 (31.6 %) | 54 (24.9 %) | 32.460 | <0.001** | 22.882 | <0.001** | |
59 (23.0 %) | 73 (33.6 %) | 23.614 | <0.001** | 27.544 | <0.001** | |
53 (20.7 %) | 18 (8.3 %) | 3.430 | 0.064 | 8.069 | 0.005** | |
56 (21.9 %) | 53 (24.4 %) | 2.412 | 0.120 | 2.267 | 0.132 | |
55 (21.5 %) | 38 (17.5 %) | 1.940 | 0.164 | 0.162 | 0.688 | |
2 (0.8 %) | 1 (0.5 %) | 1.618 | 0.203 | 0.575 | 0.448 | |
2 (0.8 %) | 0 (0.0 %) | 2.511 | 0.113 | NA | NA | |
21 (8.2 %) | 7 (3.2 %) | 2.359 | 0.125 | 1.529 | 0.216 | |
10 (3.9 %) | 5 (2.3 %) | 2.535 | 0.111 | 0.595 | 0.441 | |
11 (4.3 %) | 7 (3.2 %) | 0.004 | 0.950 | 1.529 | 0.216 |
** Significant at
NA Not applicable
Soil-transmitted helminth (STH) infections are important neglected tropical diseases which cause diarrhea, growth retardation, iron deficiency anemia and cognitive impairment. In Malaysia, among all the STH, infection with
A higher prevalence of trichuriasis during the dry season might be due to heavy rainfall during wet season, which may wash away most of the
STH infection is endemic in many parts of the world, particularly in low-income communities (Ediriweera et al., 2019). Low income has been reported to be a strong predictor of various diseases, including intestinal parasitic infections; people with low income significantly had a higher risk to be infected with intestinal parasites (Dai et al., 2019). In this study, a monthly household income of less than RM500 was found to be the significant risk factor for the aborigines to acquire trichuriasis during the wet season with the odds of 1.545. A strong association between low income and health was reported where there is a higher risk of health problems for the low-income groups in comparison with middle to higher income groups (Stronks et al., 1997). Our study found the same association; low income is associated with a higher risk to contract trichuriasis during the wet season. Most of the aborigines could not get their usual earnings during the wet season due to restrictions in movement particularly heavy rainfall and flood. Low income leads to poor medical care, poor nutrition thus increasing the exposure to harmful agents (Syme & Berkman, 1976).
Low education level has been previously suggested by various studies to be associated with soil-transmitted helminth infections (Pham-Duc et al., 2013). Rural communities in Ghana with low education levels had a higher prevalence of soil-transmitted helminths infection in comparison to those with a high level of education (Adu-Gyasi et al., 2018). In agreement with that, our study indicated that aborigines with low education levels had a higher risk to contract
Open defecation is a common practice among the aborigines. In our study, we found that this practice is very common since many of the aborigines still hold on their cultural belief to perform such practice. Among the aboriginal community in this study, those who perform open defecation had a higher risk to acquire trichuriasis during the wet season with the odds of 2.740 as compared to the aborigines who defecate in a latrine. Such practice increases their chances to be exposed to many sources of infection in the environment. Besides, aborigines who perform open defecation may not practice proper handwashing after defecation. Open defecation practices among rural community in Ghana as a result of lack of toilet facilities leads to high prevalence of soil-transmitted helminths infection (Adu-Gyasi et al., 2013). A study in India found that although sanitation has been improved, however low usage of latrine among the community leads to no reduction in soil-transmitted helminths infection (Clasen et al., 2014; Patil et al., 2014). Soil moisture and relative humidity are among the factors which influence the survival of viable ova of soil-transmitted helminths (Gyawali, 2018). In our study, open defecation practice during the wet season may have spread the ova to a wider area. With optimum soil moisture and humidity, this may have contributed to infection among the aborigines during the wet season.
Utilisation of untreated water was the major risk factor that increased the transmission of intestinal parasitic infection among the aboriginal community (Chin et. al., 2016). In line with that, Moktar et al., (1998) reported usage of untreated water sources from well water was the risk factor for trichuriasis among aboriginal children. The present study identified usage of untreated tap water supply which originated from rivers and wells for domestic activities as a significant risk factor to acquire
Activities such as washing, bathing and others at the river bench may introduce the infective ova into the river water. Natural water bodies especially river water are one of the most important sources of water used for daily activities within the community. As described previously, untreated tap water from the river was used daily and the river water was collected and stored in the houses by the most of the aborigines although several houses located at the downstream of the river are equipped with treated water supply (Noradilah et al., 2017). Water contaminated with helminth ova pose significant public health risks where people may be infected by exposure to the contaminated water such as wastewater and sludge (Gyawali, 2018). In our study, river water contaminated with fecal materials serves as an important source of infection to the aboriginal community. Using tap water originating from the contaminated river through various activities such as cooking preparations, washing, bathing and others and consuming untreated tap water via food or drinking water put the aborigines at higher risk to contract trichuriasis during the dry season.
This study also identified an association between
This study highlighted that low socioeconomic status contributes to high prevalence of trichuriasis in the aborigines living in Kuala Krau, Temerloh, Pahang especially during the wet season. In addition, unhygienic lifestyle and behavior play important roles in the acquisition of trichuriasis. Unsafe water supply used for daily activities during the dry season puts the aborigines at high risk to contract trichuriasis. Provision of treated water supplies, health education, access to sanitation facilities and promotion of good health behavior such as high usage of a proper latrine for defecation are hoped to reduce the prevalence of trichuriasis among the aboriginal community.