a

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND

TECHNOLOGY, KUMASI

COLLEGE OF SCIENCE

DEPARTMENT OF THEORETICAL AND APPLIED BIOLOGY

PREVALENCE AND INTENSITY OF URINARY SCHISTOSOMIASIS IN WEWESO

(M/A) BASIC SCHOOL CHILDREN.

A DISSERTATION PRESENTED TO THE DEPARTMENT OF THEORETICAL AND

APPLIED BIOLOGY, COLLEGE OF SCIENCE, IN PARTIAL FULFILMENT OF THE

REQUIREMENT FOR THE AWARD OF B.Sc. (HONS) DEGREE IN BIOLOGICAL

SCIENCES

BY

AMOAH, Isaac Dennis

BOAKYE, Sandra

INKOOM, Patrick

APRIL, 2011

i

DECLARATION

We, Amoah Isaac Dennis, Boakye Sandra and Inkoom Patrick, declare that we have fully

undertaken the study reported herein under the supervision of Mr. Martin A. Arkoh and Dr. John

A. Larbi and that, except portions where references have been duly cited, this dissertation is the

outcome of our investigations.

............................................. .............................................

Date Amoah, Isaac Dennis

(Student)

............................................. ..............................................

Date Boakye, Sandra

..............................................

Date

(Student)

...................................................

Inkoom, Patrick

( Student)

............................................ ....................................................

Date Mr. Martin, A. Arkoh

(Supervisor)

.......................................... ...............................................

Date Dr. John A. Larbi

(Supervisor)

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ACKNOWLEDGEMENT

The first and foremost thanks go to the Almighty God for His protection, wisdom as well as

granting us travelling mercies to and from the project site.

We also want to extend our sincere thanks to our supervisors, Mr. Martin A. Arkoh and Dr. John

A. Larbi who in diverse ways gave us advice and took time off their busy schedules to be with us

throughout the entire period of the project and also gave us the needed guidance in executing this

project.

Our sincere gratitude is also extended to our parents, siblings, friends, etc. for their financial and

moral support. Your diverse encouragement and pieces of advice made this project a success.

Thanks.

Furthermore we will like to thank all persons who in diverse ways made this project possible and

also appreciate the cooperation of the heads; Victoria Catherine Osei (JHS) and Margaret Bertha

Mmieh (Primary), teachers, parents and children of Weweso M/A Basic School during the

present study. God richly bless you all.

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ABSTRAC

Urinary schistosomiasis infection is a major problem throughout the world. It comes second to

tuberculosis and malaria in infection of humans. Between November 2010 and March 2011, 200

urine samples were collected from randomly selected school children of the Weweso M/A Basic

School in the Ashanti Region of Ghana to determine the prevalence and intensity of urinary

schistosomiasis. The objectives of the study were to determine and estimate the prevalence and

intensity of urinary schistosomiasis in the school children using the microscopy and the urine

reagent strip, it was also to determine the various factors that expose the children to this

infection. The presence and number of eggs of the Schistosoma haematobium parasite was

determined by microscopy whilst the use of urine reagent strip was employed to determine the

presence of hematuria and proteinuria among the infected. 10.5% of the pupils sampled were

infected. 12.3% of the 105 males sampled were infected, whilst 8.92% of the ninety-five females

sampled were infected, the difference in prevalence between the sexes did not differ significantly

(p=0.3616). Generally the intensity was low and ranged from 5-20 eggs/10ml urine. Hematuria

and proteinuria among the infected children was 46% and 30% respectively. The study revealed

the persistence of the infection among the school children, which calls for a concerted effort

towards control of schistosomiasis particularly in the Weweso M/A Basic School.

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TABLE OF CONTENTS

Declaration i

Acknowledgement ii

Abstract iii

Table of contents iv

List of Tables v

List of Figures vi

List of Plates vii

CHAPTER ONE: Introduction

1.1 Schistosomiasis in Ghana 2

1.1.1 Sensitivity test in Ghana 3

1.2 Schistosoma species 3

1.2.1 S. haematobium 3

1.2.2 S. mansoni 4

1.2.3 S. japonicum 4

1.2.4 S. intercalatum 4

1.2.5 S. mekongi 5

1.3 Life cycle of Schistosoma spp. 5

1.4 Epidemiology 10

1.5 Pathogenesis 11

1.6 Diagnosis and control 12

1.7 Justification 15

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1.8 Objectives 16

CHAPTER TWO: Materials and methods 17

2.1 Target area 17

2.2 Target group 19

2.3 Sampling procedure 19

2.4 Laboratory analysis 20

2.5 Data analysis 22

CHAPTER THREE : Results 24

3.1 The overall prevalence of Urinary schistosomiasis 25

3.1.1 Sex related prevalence of urinary schistosomiasis 26

3.1.2 Prevalence of urinary schistosomiasis and age group 27

3.1.3 Prevalence of urinary schistosomiasis and contact with the river (Wewe) 28

3.2 The overall intensity of infection 30

3.2.1 Sex related intensity of infection 31

3.2.2 Intensity of infection and age group 32

3.3 Overall presence on Hematuria and Proteinuria 33

3.3.1 Sex related presence of hematuria and proteinuria 34

CHAPTER FOUR: Discussion 35

CHAPTER FIVE: Conclusion and Recommendation 39

5.1 Conclusion 39

5.2 Recommendation 39

REFERENCES 41

APPENDICES 45

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LIST OF TABLES, FIGURES AND PLATES

LIST OF TABLES

Table 1 Prevalence of urinary schistosomiasis in the school children 45

Table 2 prevalence of urinary schistosomiasis and sex 45

Table 3 prevalence of urinary schistosomiasis and age group 45

Table 4 prevalence of urinary schistosomiasis and contact with River Wewe 45

Table 5 Intensity of infection of urinary schistosomiasis 46

Table 6 Intensity of infection and sex 46

Table 7 Presence of hematuria and proteinuria 46

Table 8 Sex related presence of hematuria and proteinuria 47

Table 9 Chi-square analysis for prevalence of urinary schistosomiasis and sex 47

Table 10 Chi-square analysis for prevalence of urinary schistosomiasis and age group 47

Table 11 Chi-square analysis for prevalence of infection and contact with the river 48

LIST OF FIGURES

Fig. 1 Diagram showing life cycle of Schistosoma spp. 9

Fig.2 Map showing Weweso Basic School and its environs 18

Fig. 3 Prevalence of urinary schistosomiasis in the children 25

Fig.4 Correlation between prevalence and sex 26

Fig. 5 Association between prevalence and age group 27

Fig. 6 Association between prevalence and contact with the river 28

Fig. 7 Intensity of infection among infected school children 30

Fig. 8 Relationship between sex and intensity on infection 31

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Fig. 9 Association between age groups and intensity of infection 32

Fig. 10 Presence of hematuria and proteinuria among infected children 33

Fig. 11 Association between sex and hematuria and proteinuria 34

LIST OF PLATES

Plate 1 Schistosoma haematobium egg as seen under the microscope 24

Plate 2. Picture of a section of the River Wewe with children swimming in it. 29

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1

CHAPTER ONE

INTRODUCTION

Schistosomiasis is among the oldest known intestinal parasite infections of man, it is caused by a

trematode (Schistosoma spp) and the disease was named after the German. Theodor Bilharz, who

first described the cause of urinary schistosomiasis. Evidence of human infection with these

parasites dates back to the mummified remains from ancient Egypt and China (Geiges, 1934). It

comes second to tuberculosis and malaria in infection of humans worldwide (Talaro and Talaro,

2002). Human intestinal parasitic infections are of major public health importance in the tropics

and the subtropics of which this disease is of no exception.

Individuals from various societies and places play host to the worms during various stages of

their lives. Urinary schistosomiasis is mostly a prevalent infection with high morbidity and

mortality rate and historically has been a disease confined to the tropical rural poor (Gillespie

and Pearson, 2001). Its geographic distribution is determined by the distribution of the snail that

acts as the intermediate host (Gillespie and Pearson, 2001).

Schistosomiasis is endemic in 76 countries, most of which are in Africa. Other regions affected

are: the Americas (Brazil, Suriname, Venezuela, several Caribbean islands); the Eastern

Mediterranean (Iran, Iraq, Saudi Arabia, Syrian Arab Republic and Yemen); and eastern Asia

(Cambodia, China, Indonesia, Japan, and the Philippines (WHO, 2009). At least 600 million

people are at risk of infection and 200 million are infected with schistosomiasis. Of these, 20

million have severe disease and 120 million have symptoms. An estimated 80% of transmission

takes place in Sub-Saharan Africa. Water resource schemes for power generation and irrigation

have resulted in a tremendous increase in the transmission and outbreaks of schistosomiasis in

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several African countries (WHO, 2009). In Ghana, a large number of inhabitants living around

the Volta Lake have become infected with the disease since the construction of the Akosombo

dam.

1.1 SCHISTOSOMIASIS IN GHANA

Prevalence of schistosomiasis has been on the increase in Ghana since the creation of the Volta

Lake (Jones, 1999, Aryeetey et al, 1999). In some villages around the lake, about 90% of the

children were found to be affected by urinary schistosomiasis (WHO, 2009). In 1992–1993, an

epidemiological study on urinary schistosomiasis in eight communities in Southern Ghana.

Showed that the overall prevalence of infection ranged between 54.8% and 60.0%, indicating

that the disease continues to be a major problem in some parts of Ghana. The study also showed

that the rate of urinary schistosomiasis in the study area increased by age with a peak in 10–19

year old individuals and then decreased with age (Aryeetey et al, 1999). Snail sampling

conducted in the same study area revealed that Bulinus globosus was the intermediate host snail

for urinary schistosomiasis in Southern Ghana (Abdel-Salam, 1984).

Although both urinary and intestinal schistosomiasis are prevalent in Ghana, urinary

schistosomiasis is more prevalent with approximately 15-20% of the population being infected

(McCullough, 1965). Initial and frequent re-infection is associated with the common activities of

washing, bathing, and fishing in infected streams, ponds, and burrow pits (Lawson, 1975).

1.1.1 SENSITIVITY TESTS IN GHANA

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Artemis et al. (2008), worked on the sensitivities and specificities of diagnostic tests and

infection prevalence of Schistosomiasis haematobium in villages Northwest of Accra, using five

Schistosoma haematobium dipsticks. The dipsticks were found to be the most appropriate for the

detection of schistosomiasis infection. Microhematuria and proteinuria had significant lower

sensitivity than either microscopy or dipstick, though the MoAb dipstick was found to be more

sensitive than microscopy (Bosompem et al., 2004).

1.2 SCHISTOSOMA SPECIES

Schistosoma species belongs to the phylum Platyhelminthes, class Trematoda and the super

family Schistomatoidea. Flukes of this super family are peculiar because they have no second

intermediate host in their life cycles and they mature in the blood vascular system of their

definitive host (Schmidt and Roberts, 1996).

1.2.1 Schistosoma haematobium

Schistosoma haematobium causes urinary schistosomiasis. The species contains many strains

and it is transmitted mostly in Africa and the Middle East (Cheesbrough, 1987). It differs from

the others in that, the eggs are found in urine and sometimes in biopsies of the bladder and

rectum. The egg is large (112-170 μm by 40-70 μm), thin shelled and has a terminal spine. The

snail host belong to the genus Bolinus. In rare cases, eggs of S. haematobium are also found in

faeces (WHO, 1985).

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1.2.2 Schistosoma mansoni

Schistosoma mansoni causes intestinal schistosomiasis. In 1981, the minimum number of

persons infected with this disease was estimated to be about 57 million (Cheesbrough, 1987) and

is most common in Africa but occurs in the Americas as well. The egg is discharged in faeces

but typically in small numbers. The egg is large, has a relatively thin shell with a conspicuous

lateral spine. S. mansoni are also easily identified in Kato-Katz preparations due to their size and

presence of a lateral spine. The egg measures 114-175 μm by 45-70 μm and contains a larva

called the miracidium. Occasionally, the egg may be oriented in a way that hides the spine and

tapping the cover glass on the preparation will often reorient the egg and reveal the spine (WHO,

1985). The aquatic snail host belong to the genus Biomphalaria.

1.2.3 Schistosoma japonicum

Schistosoma japonicum causes intestinal schistosomiasis and is transmitted in Asia. The egg

which is found in faeces measures 70-100 μm by 55-65 μm has a thin shell with an often

inconspicuous, small lateral spine. The egg contains a miracidium. The shell is sticky, causing

debris to adhere to the surface and making it more difficult to identify (WHO, 1985).

1.2.4 Schistosoma intercalatum

Schistosoma intercalatum is restricted in its geographic distribution to West and Central Africa.

The egg resembles that of S. haematobium in that it has a terminal spine and is found in faeces

rather than urine. It is very large, measuring 140-240 μm long has an equatorial bulge and

contains a miracidium (WHO, 1985).It causes intestinal schistosomiasis but compared with

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S.japonicum and S. mekongi, it is less pathogenic (Cheesbrough, 1987). The Bolinus snails are

the intermediate hosts.

1.2.5 Schistosoma mekongi

Schistosoma mekongi is closely related to S. japonicum and is transmitted in areas of Laos,

Cambodia and Thailand. The egg is very similar to that of S. japonicum but is smaller, measuring

51-78 μm by 39-66 μm (WHO, 1985).

1.3 LIFE CYCLE OF Schistosoma spp.

1.3.1 Eggs and Miracidia stages

Humans are the principal definitive host for two of the species; (S. mansoni and S.

haematobium). Adult worms reproduce sexually in the definitive host (man) and pass

characteristically shaped eggs into the environment in urine or stool (WHO, 1985).

In fresh water, the eggs hatch to release ciliated, motile, short-lived, free swimming, sexually

distinct (male and female) miracidia. The miracidia in turn drill through the epithelium of the

appropriate snail’s foot to infect the intermediate host (Jourdane and The´ron, 1987) (Fig.1). The

parasite to snail interaction is highly specific, and only a few species of freshwater snails do

support the life-cycle of each specific schistosoma species (Sobhon and Suchart, 1990). Infection

with schistosomes does not normally affect the life span of the snails.

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1.3.2 Stages in snail vector

Once inside the snails, the miracidium sheds its ciliated glycocalyx and reforms into a primary

sporocyst (Jourdane and The´ron, 1987). The primary sporocysts migrate into the snail’s

digestive gland or mature in its foot process. Germinal cells of the sporocysts replicate through

asexual multiplication and increasing parasite numbers.

The replicating cells mature and bud off as secondary sporocysts which then migrate to the snails

liver and mature. This process is repeated multiple times until the snail contains many maturing

sporocysts. The germinal cells mature into motile, forked-tailed, infective 0.4-0.6mm larval

forms called cercariae.

1.3.3 The Cercariae Stage

Cercariae are infective to the definitive host (man) and are shed by infected snails. The cercariae

leave the snail from the edge of the snail’s mantle and enter the surrounding water. The cercariae

have a discrete head and a bifurcated tail that allows locomotion. The head carries small oral and

ventral suckers, flame cells and a non-functional gut. Unicellular glands near the ventral suckers

secrete mucilage, which assists the parasite in attachment, other glands like the penetration gland

secretes digestive enzymes which aid in skin penetration. The parasite is able to migrate through

human epidermis in 5–10 minutes. Infected snails continue to shed cercariae for many weeks.

The total lifespan of a shed cercarium in fresh water is about 48 hours, but decreases

dramatically after about 4 hours. Death occurs due to exhaustion of the glycogen stores (Miller

and Wilson,1980).

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1.3.4 Skin Penetration

During penetration, the cercaria leaves its tail on the dermis, The cercarial head penetrates into

deeper structures of the skin. The transformed cercaria is then called schistosomula.

Schistosomulae take up host antigens and attach them to their surface membranes. This prevents

host immune attack. In the first 48 hours, the schistosomula penetrate into subcutaneous tissues

and migrate through the dermis to gain access into the veins and lymphatics. During the next 5–

7 days, successful schistosomulae are transported through blood circulation via the heart to the

lungs (Miller and Wilson, 1980).

1.3.5 Somatic Migration

The schistosomulae migrate via the pulmonary capillaries to enter the left side of the heart and

systemic circulation (Miller and Wilson, 1980). Schistosomulae are carried with the arterial

blood flow to the mesenteric arteries, splanchnic arteries and portal veins and eventually reach

the appropriate venous plexus and mature. Repeated cycles through the systemic circulation may

be required. This process takes 10–20 days.

Each schistosomulum is either male or female. After migration to the appropriate peripheral

venous plexus, maturation takes place. Adult worms pair with the opposite sex and live out their

lifespan together. Migration in the veins is aided by the worm’s ventral and oral suckers, which

are used to attach to the endothelial wall. The worm pair migrates against the mesenteric or

vesical blood flow to lay their eggs. Different species tend to prefer different anatomical

locations for optimal growth and survival. Thus, S. haematobium prefers the vesical veins

(Elliott, 1996b).

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1.3.6 Further infection and subsequent egg shedding.

Throughout infection, the adult worm pair migrates up and down the veins. Laying of eggs is

dependent on the anatomical preference of the species; the S. haematobium eggs are mostly

found in the urine but occasionally, can be found in the stool (Elliott, 1996b; Zwingenberger,

1990). During migration, when the diameter of the venule becomes small enough to restrict

further movement, the female often leaves the male and continues to migrate to the farthest point

permitted by the worm’s diameter. This minimizes backflow of ova. Adult worms induce little

direct damage to the host unless they die. The eggs, however, are capable of boring through

tissue planes and generally cause micro perforations in the colon and urinary bladder. The ova

are then shed to the outside from the bladder (urine) and rectum (stool) and getting into contact

with suitable substrate (water), starts the whole cycle again.

In Ghana, the intermediate host of S. haematobium is the Bulinus truncates in the lower Volta

Basin, whereas in the other parts of Ghana, the host is Bulinus globosus.

9

SOURCE:CDCP(1993)

Fig. 1 Diagram showing life cycle of Schistosoma spp.

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1.4 EPIDEMIOLOGY

1.4.1 Geographical Distribution

Urinary schistosomiasis caused by Schistosoma haematobium is reportedly endemic in 53

countries in the Middle East and the African continent. The most common way of getting

schistosomiasis in developing countries is by wading or swimming in lakes, ponds and other

bodies of water that are infested with the snails. These happen to be the natural reservoirs of the

Schistosoma pathogen.

Transmission of schistosomiasis depends on human contact with fresh water, the presence of a

specific snail species capable of completing the schistosome life-cycle, and contamination of

fresh water with human waste. In endemic areas, the highest prevalence and intensity of infection

occurs in adolescents; 10–16 years of age (Davis, 1985). Males generally have a much higher

prevalence and intensity than females, presumably through higher water contact. High

prevalence areas have a greater frequency of patients with heavy infections. In S. haematobium

endemic communities, there is often a sharp drop-off in the prevalence and intensity in adults

over 25 years of age (Jordan and Webbe, 1993). This is partially explained by decreased water

contact.

Age distribution with the highest peak in adolescence, is not seen, in some populations who

relocate to schistosomiasis endemic areas (Aryeetey et al. 1999). The intensity of infection,

however, often reaches its peak in the same 12– 16 year age range and then declines. This has

similar implications for the probable development of at least partial immunity to re-infection. In

one large longitudinal study from the Philippines, individuals previously infected and cured of a

11

schistosome infection appeared to acquire a second infection slower than age and sex-matched

controls living in the same village (Olveda et al., 1996).

1.5 PATHOGENESIS

Worms exhibit numerous adaptations to their host (Talaro and Talaro, 2002). Before developing

into adults most helminthes often migrate through various tissues and organs. Adult helminthes

eventually take up final habitations in the intestinal mucosa, blood vessel, lymphatic,

subcutaneous tissue, skin, lungs, muscles, brain or even the eyes (Talaro and Talaro, 2002).

Clinical manifestations of schistosomiasis are often divided into three phases: (I) the migratory

phase encompass the time from penetration until maturity and egg production. It is often

symptomless. Penetration of the cercariae may produce dermatitis if the patient’s immune system

has been sensitized by earlier experiences of cercariae penetration.

(II) Acute phase (Katayama fever) occurs when the schistosomes begin producing eggs, about 4-

10 weeks after initial infection. By this time, the body has had considerable exposure to various

schistosome antigens sufficient to mount humoral response. However, the advent of egg

production substantially increases the amount of antigen released. There is increased formation

of granulomas. The phase is marked by chills and fever, fatigue, headaches, malaise, muscle

aches, lymphadenopathy and gastrointestinal discomfort.

(III) During the chronic phase patients especially those in endemic areas are commonly

asymptomatic but with intestinal schistosomiasis, they may show mild, chronic bloody diarrhoea

with mild abdominal pain. Adults of S. haematobium live in the venules of the urinary bladder

and so the major symptoms are associated with the urinary bladder. Urinary schistosomiasis is

12

associated with high risk or increased risk of bladder cancer because of the progressive damage

to the bladder, uterus and kidney. It may cause obstructive uropathy in 60% of infected patients

(WHO, 2009). Due to its infection of the urinary bladder most symptoms of infection can be

seen in relation to its effect on the bladder. The damage to the bladder may lead to proteinuria,

were small molecules of proteins like albumin are able to pass through the glomerular filter into

the urine leading to a condition more often referred to as albuminuria. Also the ulcerations to the

bladder wall produce blood. The blood may also come from any part of the urinary tract. Blood

may also appear in the urine when a stone or gravel is present in the pelvis of the kidney setting

up irritation, especially after exercise. The blood may also originate from a bladder that is

inflamed or infected or which contains benign growths (papilloma) or malignant growths.

Inflammation or injury to the urethra can also cause hematuria; these conditions are common

with S. haematobium infections.

1.6 DIAGNOSIS AND CONTROL

1.6.1 Urine Diagnosis

The eggs of S. haematobium are passed in the urine with diurnal periodicity, with peak excretion

between mid-morning and mid-afternoon (Doehring et al., 1985). Urine collected during this

period may be concentrated by simple sedimentation or passing the urine through a cellulose

filter to concentrate the parasite eggs. The latter allows quantification of infection. Filtration

techniques that give quantitative assessment of egg excretion are replacing the simple

sedimentation or centrifugation techniques (Dazo and Biles, 1974).

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1.6.1.1 Urine diagnosis by the use of reagent strips

Urine reagent strips are firm plastic/card strips to which several different reagents areas are

affixed, depending on the product being used urine reagent strips provide tests for glucose,

bilirubin, ketones, specific gravity, blood, pH, protein etc. Therefore these strips can be used to

detect the presence of hematuria and proteinuria in suspected patients, these results together with

other diagnostic tests gives an indication of infection and sometimes helps to determine the

severity of the infection.

1.6.2 Stool Diagnosis

Where the eggs are found in the stool as in the case of Schistosoma mansoni and occasionally

Schistosoma haematobium, diagnosis may be done with stool analysis. Various methods can be

used; normal saline, formol–ether, etc. The most common method for the detection of eggs in

stool is the Kato–Katz thick smear technique. It allows quantification of the intensity of

infection. Standard wet mounts do not contain a large enough sample to reliably find

schistosome eggs. Flotation methods of concentration should not be used if schistosomiasis is

suspected, because schistosome eggs do not float on the usual solvents because of their weight. It

is therefore, imperative that the laboratory be notified about the possible diagnosis of

schistosomiasis.

The Kato–Katz thick smear preparation is an inexpensive, non-invasive, highly specific test with

an acceptable sensitivity. Low-level infection may not be diagnosed by the standard triplicate

Kato–Katz thick smear using a single stool specimen. Sensitivity is improved if multiple stool

14

samples are examined (Katz et al., 1970). A quick Kato technique has been developed for this

purpose that can be read in two hours.

1.6.3 Current Approach

Since most people infected with schistosomiasis are asymptomatic, a high index of suspicion is

required to clinically identify infection, especially in geographic areas where infection is

uncommon. The diagnosis should be considered in any patient with a possible exposure history

who presents with fever, eosinophilia, hepatosplenomegaly, anaemia, hematuria, obstructive

uropathy, recurrent urinary tract infection (especially with Salmonella), glomerulonephritis,

seizures, etc. In order to increase the diagnostic utility of the reagent strip test of hematuria,

additional measurement of proteinuria and leukocyturia have been suggested (Kaiser et al.,

1992).

1.6.4 CONTROL

The development of a vaccine will ultimately be the best control method or measure, but until

then, schistosomiasis could be better controlled worldwide given existing drugs and control

strategies. The development of a national control programme in developing countries is under

competition from other diseases like HIV, malaria and tuberculosis (Gillespie and Pearson, 2001)

For the effective control of schistosomiasis, the following preventive control measures can be

undertaken to prevent and control the infection;

1. Avoiding contact with water known to contain cercariae by providing safe water supplies

in villages, construction of footbridges across infested rivers and streams and providing

safe recreational bathing sites, especially for children.

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2. Minimizing the risk of infection from new water conservation and irrigation schemes and

hydroelectric developments by treating workers when necessary, sitting settlements away

from canals, drains and irrigation channels and providing latrines and sufficient safe

water for domestic use.

3. Destroying snail intermediate hosts, mainly by using molluscides where it is affordable

and feasible and would not adversely affect important plant and animal life.

These measures among other things would effectively control the spread of schistosomiasis.

In cases of chemotherapy control the first drug of choice is praziquantel.

1.7 JUSTIFICATION

There have been numerous studies conducted on schistosomiasis worldwide especially in the

intermediate host (of worm), geographical distribution, endemic regions, morbidity rate, motility

rate and its prevalence. Such studies have generally been concentrated in tropical poor areas of

Asian countries (China, Indonesia, Philippines, and Thailand), the Middle East and several

African countries spanning from Angola, Botswana, Burundi, Cameroun, even in Ghana etc.

Although enough works have been done on schistosomiasis in Ghana there is the need to

ascertain the current status of the infection due to environmental changes which have the

potential of affecting the habitat of the snail intermediate host. Most especially in school children

who have contact with reservoirs (rivers, streams, ponds) of the snail intermediate host.

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1.8 OBJECTIVES

The main aim of the study was to determine the prevalence and intensity of urinary

schistosomiasis and the presence of hematuria in the school children at Weweso.

1.8.1 SPECIFIC OBJECTIVES: To determine the;

Prevalence of urinary schistosomiasis in the school children.

Intensity of the infection.

Various factors that expose the children to infection.

Presence of hematuria in the infected children.

Presence of proteinuria in the infected children.

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CHAPTER TWO

MATERIALS AND METHODS

The study is a school-based survey at Kentinkrono to determine the prevalence of urinary

schistosomiasis infections in the Weweso Basic School children. Two diagnostic methods were

used to determine the prevalence and to ascertain the most sensitive method.

2.1 Study area

The study was carried out at Kentinkrono in the Atwima District of the Ashanti Region in Ghana

between November, 2010 and March, 2011. The school is located about 1.5 miles

(approximately 2.4 km) from the university junction. The vegetation within the Weweso Primary

and JHS school compound is dominated by grasses with few trees. The soil is of the sandy type

as a result of the Wewe River that flows through it.

The River Wewe which flows near the school takes its source from a mountain near Nkwanta on

latitude 6 48’N and longitude 1 32’W. (Fig. 2).It is densely populated by aquatic weeds which

pollute it, with its debris making it appear as almost stagnant. One of its largest tributaries is the

Boha River. The river flows for about 13 miles South-West through Abirem, Weweso and the

Kwame Nkrumah University of Science and Technology before joining River Sisai at Ahinsan.

The school children occasionally swim in the river and it is also used for irrigational purposes by

the community.

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Fig. 2 Map showing Weweso Basic School and environs.

19

2.2 Target group

The study group consisted of primary and junior high school children of the Weweso Basic

School and they were visited twice a week for a period of a month (four weeks).

2.3 Sampling procedure

The systematic random sampling technique was used. In a class of less than 30 pupils, a one of

three samples was chosen whiles a one of five samples was taken in a class of 30 or more pupils.

This was carried out by instructing the children to form a separate queue of male and females,

with the shortest in front. The first 3 or 5 pupils from both queues were asked to pick folded

sheets, numbered 1-3 or 1-5 depending of the class size. All those who selected number 1 or 5

were first chosen and using them as a start point, subsequent pupils were selected.

2.3.1 Questionnaire administration

Appropriate questionnaires were formulated and administered to the school children. The

consent of the school authorities was sought before the questionnaires were administered. The

questionnaires were given to the children (pupils) to answer. With those in the lower primary, the

questions were read to them and their answers written on the questionnaires, each questionnaire

had a serial number.

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2.3.2 Sample collection

One sterile bottle was provided for each selected student for urine collection. The specimen

bottles were appropriately labeled with serial numbers of the individuals as on the questionnaires

before giving it out to the children and specimens collected were placed in a cold box

immediately after collection.

Each sample collected was then divided into two fractions. About 10ml of each urine sample

(fraction A) was investigated for the presence of S. haematobium ova using microscopy. The

remaining 10ml (fraction B) was investigated using the urine reagent strip.

2.4 Laboratory analysis

Two laboratory methods were applied in the analysis of the samples. They were the use of the

urine reagent strip to determine proteinuria and hematuria and the use of microscopy to detect

the ova of the parasite.

2.4.1 Urine reagent strip

The test tubes were labeled with grease pencils respective to the labels on the specimen bottles.

A single strip was completely immersed in the test tube containing well-mixed urine, the strip

was removed quickly to avoid dissolving the reagent areas. Excess urine was removed by

21

touching the side of the strip against the rim of the test tube or by the use of tissue paper. Results

were obtained by direct color chart comparison at specific times.

2.4.2 Preparation of sample for microscopy

The centrifuge method was employed where 10ml centrifuge tubes were labeled using a grease

pencil. Urine sample was stirred and poured into the centrifuge tubes about half full of specimen.

The colour and appearance was observed, and then the tubes were placed in the centrifuge.

Spinning was done at 3000rpm for three to five minutes, supernatant was decanted, and the

deposits re-suspended in the residual fluid. A glass slide was labeled and a drop of urine was

deposited on it. The cover slip was applied gently on it. The preparation was then placed under

the microscope, and viewed using low power objective lens and low light intensity. High power

(X40) lens was used for clarity.

The characteristic ovum showed oval shape, was pale yellow-brown and had a sub-terminal

spine (Cheesbrough, 1987). Some urine samples were left to stand for six to twelve hours. The

supernatant was decanted, and leaving the sediments to remain at the bottom. A plastic bulb

pipette was used to mix the sediment, and then transferred onto a slide. It was carefully covered

with a cover slip and examined microscopically for S. haematobium eggs as evidence of

infection. This procedure was used when there was a power shortage.

22

2.5 DATA ANALYSIS

2.5.1 DETERMINATION OF INFECTION PREVALENCE

Prevalence is the ratio of the number of individuals of a host species affected by a particular

disease to a number of such host examined. It is usually expressed as a percentage;

Prevalence (%) = A/B*100

Where A = Number of positive cases

B = Number of children examined

2.5.2 DETERMINATION OF GROUP PREVALENCE

This is determined by

Infection Rate (%) = C/D * 100

Where C = Number of positive cases in a particular age group

D = Number of children in that age group

2.5.3 DETERMINATION OF MEAN INTENSITY

This is determined by

Intensity= E/F

Where E= total number of eggs and F= total number of infected individuals.

23

2.5.4 STATISTICAL ANALYSIS

A mathematical proportion, Microsoft Office Excel and Chi- Square test of proportion and were

used to analyze and correlate the results obtained respectively.

24

CHAPTER THREE

RESULTS

3.1 The Overall Prevalence of Urinary Schistosomiasis

A total number of 200 school children were sampled and examined from the Weweso M/A Basic

School. Twenty-one (21) of the 200 children were infected with the Schistosoma haematobium

representing 10.5%, whilst the remaining 179 (89.5%) were uninfected.

INFECTED

UNINFECTED

Fig. 3: Prevalence of urinary schistosomiasis in the children.

89.5%

10.5%

25

3.1.1 Sex Related Prevalence of Urinary Schistosomiasis

Out of the 200 school children examined 105 were males and 95 females, with thirteen (13)

males infected representing 12.38%, whiles eight (8) females were infected representing 8.42%

of the total females sampled. The difference was not significant at p> 0.05 (p= 0.3616).

Fig. 4: : Association between Prevalence and sex.

26

3.1.2 Prevalence of Urinary Schistosomiasis and age group

Amongst the sampled children, the youngest age was seven years and the oldest nineteen years.

Ninety-three (93) children were within the age group 7 to 11 years, ninety-eight (98) between 12

to 15 years and nine between 16 to 19 years. The highest prevalence was within the age 12 to 15

years with 11.2 % of them having the infection, followed children within the age group 7 to 11

years with 8.6 % of them being infected. The difference between these categories was not

significant at 95% confidence (p= 0.4216).

Fig. 5: Association between infection and age.

27

3.1.3 Prevalence of Urinary Schistosomiasis and contact with the river.

The prevalence of infection was high in children who had contact with the river for various

purposes, with a prevalence of 14.44% compared to those who did not have contact, this

category of children had a prevalence of 7.27%. The difference in infection prevalence between

these two groups of children was not significant (p=0.0998).

Fig. 6: Association between prevalence and contact with the river.

28

PLATE 1: A section of the River Wewe with children bathing in it.

29

3.2 THE OVERALL INTENSITY OF INFECTION

Out of the total twenty-one (21) children infected with the Schistosoma haematobium, eight (8)

representing 35.10% of them had between 1 to 5 eggs per 10ml of their urine, seven (33.33%) had

between 6 to 10 eggs, four (19.05%) had between 11 to 15 eggs and two representing 9.52% had

between 16 to 20 eggs per 10ml of urine.

Fig.7. Intensity of infection among infected school children

30

3.2.1 Sex Related Intensity of Infection

The intensity of infection for both sexes indicated that four males had between 1 to 5 eggs per 10ml

this representing 30.77% of infected males, four females also had the same number representing 50%

of infected females. Five males had between 6 to 10 eggs representing 38.47% and three females had

this number representing 37.5%. Between 11 to 15 eggs only two males had such intensity (15.38%),

whiles only one lady had this number of eggs. For the highest category of intensity, thus between 16

to 20 eggs also two males had such an infection with no female recording that number of eggs.

Fig.8. Relationship between sex and intensity of infection.

31

3.2.2 Intensity of Infection and Age Group

Mean intensity of infection for the various age groups indicated that children within the age group of

12-15 years had the highest mean intensity of nine (9) eggs, followed by those between 16 to 19 years

with seven eggs and then those between ages 7 to 11 had a mean intensity of five eggs per 10ml of

urine.

Fig.9. Association between age groups and intensity.

32

Plate 2 :Schistosoma haematobium egg as viewed under the light microscope, X400

33

3.3 OVERALL PRESENCE OF HEMATURIA AND PROTEINURIA

Out of the twenty-one children who had the infection, a sub-sample of thirteen children was chosen,

thus children having between six to twenty eggs per 10ml. Out of these four had traces of protein in

their blood (30.76%), six had hematuria (46.16%) and three had both hematuria and proteinuria

(23.08%). So in general there were seven proteinuria cases and nine hematuria cases.

Fig.10. Presence of hematuria and proteinuria in infected children

34

3.3.1 SEX RELATED PRESENCE OF HEMATURIA AND PROTEINURIA

Out of the thirteen children chosen, nine were males and four were females. The total of seven who

had proteinuria, there were five males (71.43%) and two females (28.57%) and also out of the nine

who had hematuria, there were six males (66.67%) and three (33.33%) females.

Fig. 11. Association between sex and hematuria and proteinuria

35

CHAPTER FOUR

DISCUSSION

Infections of urinary schistosomiasis are increasingly gaining prominence among the research

community, both locally and internationally. This is due to the challenges posed on victims of the

disease in relation to their health and socio-economic status.

The survey gave an infection prevalence of 10.5% (i.e. 21 out of the 200 children examined). The

result supports several other studies which has shown consistently that infection with Schistosoma

haematobium in southern Ghana is currently of low prevalence (Bosompem et al, 2004). This may be

attributed to improved sanitation, access to portable water, education etc. A similar research

conducted for the prevalence of infant schistosomiasis in a community in the Ewutu-Efutu Senya

District of the Central region of Ghana, showed a prevalence of 11.2% through microscopy and 30%

through MoAb-dipstick examination from a total of 75 subjects (Bosompem et al, 2004).These results

were confirmed by the findings in the present study.

From the questionnaires administered, it was revealed that ignorance of the effects of schistosomiasis,

poor living conditions, poor parental control, inadequate sanitation and water supplies, deplorable

personal and environmental hygiene and more importantly lack of supervision while in school, was

the prime reasons for the infection. Lack of control during school hours was the chief predisposing

factor because, inferring from the questionnaires most of the children are not residents of the Weweso

community, but rather from surrounding communities where the river does not pass through, so these

children only had contact with the river during breaks, before and after school hours.

36

Males had a higher prevalence (12.3%), than that of the females (8.92%) and this could be attributed

to the fact that most males are actively involved in activities that make them susceptible to the

infection than females, i.e. activities like swimming (which we saw whiles undertaking the study),

wadding through and fetching the water for various purposes. The difference in prevalence between

the sexes was not statistically significant within a confidence interval of 95%, the p-value as

calculated by Chi-square analysis was 0.3616, thus greater than 0.05 hence not significant. This

means that the reasons given for the difference are valid because a smaller p-value would have meant

the assumption that males had a higher prevalence due to increased contact with the river was not

true.

Prevalence due to contact was also high (14.44%) among the children who use the water (for purpose

as listed above) than those who did not have contact (7.27%), again we suspect some of the children

were not sincere in answering the questionnaires, probably due to fear of being punished by school

authorities. Again statistically the difference in prevalence was not significant at confidence level of

95%, the p-value was 0.0998 determined by chi-square analysis. Therefore we conclude that the

difference was due to contact only.

Children within the age group of 12-15 years had the highest prevalence with eleven of them out of a

total of ninety-eight children examined being infected (11.2%). This information conforms to the

facts already established by researchers that, in endemic areas the highest prevalence and intensity

occurs in adolescents, between the ages of 10-16 (Davies, 1985). This may be as a result of the fact

that as they (children) progress in age their contact with the reservoirs of infection (rivers, streams,

lakes etc) reduces, thereby reducing their risk of being infected among other reasons. A p-value of

0.4216 was determined by chi-square analysis, this means at confidence level of 95% the difference

in prevalence by age group was not significant.

37

Intensity of infection as established by number of eggs per 10ml of urine indicated that most of the

children infected had between 1-5 eggs (38.10%), the highest number of eggs recorded was between

16-20 (9.25%). These figures show a low intensity of infection among the children, this may be due

to the same factors listed above that contributed to the low prevalence and may be also due to access

to medications either traditional or orthodox as confirmed by some of the children as they answered

the questionnaires.

Sex related intensity showed that most males had between 6-10 eggs (38.47%), unlike the females

who had more of them having between 1-5 eggs (50%). This collaborates with earlier information

that most males are actively involved in activities that predisposes them to infection. Again only

males had between 16-20 eggs which were the highest range of egg intensity found in the children.

Mean egg intensity by age groups showed that children between the ages of 12-15 had the highest of

nine eggs which is not different from the results acquired by other investigators, as stated earlier on

prevalence and intensity peaks during that age group. This we assume is due to reduced contact with

the water or probably the development of immunity.

Hematuria and proteinuria prevalence as determined among the thirteen children with an egg intensity

between six and twenty, showed that the number of infected children with blood in their urine was

more (9 out of13) than those who had protein in their urine (7 out of 13). This may be due to the fact

that the intensity of infection was low as a result of several factors, like improved sanitation, access to

medication, education etc. A higher incidence of hematuria was recorded than proteinuria because the

former turned to occur in patients with lesser egg intensity than the latter. Also, it is possible to have

hematuria in certain cases of malaria (black water fever) due to heamolysis and, also in the urine of

menstruating females.

38

The prevalence of both hematuria and proteinuria was high in males (66.67% and 71.43%) than in

females (33.33% and 28.57%) respectively. Per the intensity of infection discussed earlier on, males

turn to have a higher intensity than females and the occurrence of both hematuria and proteinuria due

to urinary schistosomiasis were dependent on severity of infection, this therefore explains the results

recorded. Also as mentioned earlier menstruating females might have given positive reaction to

hematuria.

The current switch from yearly mass deworming of school children to every two years is not helping,

and is a reflection of current outcome of this study. It gives room for self medication (if any at all)

which might not be enough to treat an infection, and may lead to other complications, this policy can

also be one of the factors contributing to the current status of infection in the school.

39

CHAPTER FIVE

CONCLUSION AND RECOMMENDATION

5.1 CONCLUSION

This present study has shown that the prevalence and intensity of urinary schistosomiasis in the

school children was relatively high, though, the results were similar to that of other

investigations that suggested that the infection in Southern Ghana is reducing. Factors such as

lack of sanitary conditions, lack of proper parental control, lack of adequate education and more

importantly inadequate control of children during school hours were identified as the pre-

disposing factors to the infection.

5.2 RECOMMENDATIONS

The results obtained indicated that, school children who either swim or wade through the Wewe

River were at a higher risk of getting an infection. Therefore to control and possibly prevent

infection, these recommendations are therefore made.

There should be a survey in the area to determine the presence of the intermediate host and

vector control measure undertaken.

40

Mass treatment with praziquantel should be carried out in schools found to have this infection,

since the conventional dewormers normally used have been proven not to be effective against the

Schistosoma worm.

A public health education programme should be organized in the school for both teachers and

school children and, if possible, parents should be involved, to make them aware of the need to

control or prevent infection by reducing contact of the children with the river.

Basic school amenities, sanitation facilities and potable drinking water should be provided in the

school, to prevent the children from fetching water from the river.

The portion of the river facing the school compound should be fenced to prevent children from

playing in the water during school hours.

The bi-annual deworming policy should be reversed to the earlier annual policy (preferably with

praziquantel), this would help in preventing the spread of the disease.

In the absence of the fence (until it is provided), the school authorities should do more to prevent

the children from having frequent access to the water.

41

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Control of Disease in Warm Climate Countries, 2nd edn. Edinburgh.

Dazo, B.C, Biles, J.E, (1974). Two new field techniques for detection and counting of

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Doehring, E, Rester, U, Ehrich, J.H.H. (1985). Circadian variation of ova excretion,

proteinuria, haematuria and leucocyturia in urinary schistosomiasis. Kidney Int 27: 667–71.

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investigation of periportal fibrosis in children with Schistosoma mansoni infection: reversibility

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409–15.

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Simpson AJG (eds), The Biology of Schistosomes from Genes to Latrines. London: Academic

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45

APPENDICES

APPENDIX I

Table 1: Prevalence of urinary schistosomiasis in the children.

NUMBER EXAMINED INFECTED PREVALENCE (%)

200 21 10.5

Table 2: Prevalence of urinary schistosomiasis and sex.

NUMBEREXAMINED

NUMBERINFECTED

PREVALENCE (%)

MALES 105 13 12.3

FEMALES 95 8 8.92

Table 3: Prevalence of urinary schistosomiasis and age group.

AGE GROUPS EXAMINED INFECTED PREVALENCE(%)

7-11 93 8 8.6

12-15 98 11 11.2

16-19 9 2 22.2

Table 4: Prevalence of urinary schistosomiasis and contact with the River Wewe

EXAMINED INFECTED PREVALENCE(%)

CONTACT 90 13 14.44

NO CONTACT 110 8 7.27

46

Table 5: Intensity of infection of urinary schistosomiasis

NUMBER OF EGGS PER10ML

NUMBER OF CHILDRENINFECTED

PERCENTAGE

1-5 8 38.10

6-10 7 33.33

11-15 4 19.05

16-20 2 9.52

Table 6: Intensity of infection and sex

MALES FEMALES

NUMBER OF EGGS INFECTED/PERCENTAGE INFECTED/PERCENTAGE

1-5 4 30.77 4 50

6-10 5 38.47 3 37.5

11-15 2 15.38 1 12.5

16-20 2 15.38 0 0

Table 7: Presence of hematuria and proteinuria

INFECTED PERCENTAGE

HEMATURIA 6 46.16

PROTEINURIA 4 30.76

BOTH 3 23.08

47

Table 8: Sex related presence of hematuria and proteinuria.

MALES FEMALES

INFECTED/PERCENTAGE INFECTED/PERCENTAGE

HEMATURIA 6 66.67 3 33.33

PROTEINURIA 5 71.43 2 28.57

Table 9: Chi-square analysis for prevalence of urinary schistosomiasis and sex.

TABLE ANALYZED DATA 1

Chi-square, df 0.8322,1

P value 0.3616

P value summary Ns

One-or two-sided Two sided

Statistically significant? (alpha<0.05) No.

Table 10: Chi-square analysis for prevalence of urinary schistosomiasis and age group.

TABLE ANALYZED DATA 1

Chi-square, df 1.727,2

P value 0.4216

P value summary Ns

One-or two-sided NA

Statistically significant? (alpha<0.05) NO

48

Table 11: Chi-square analysis for prevalence of urinary schistosomiasis and contact with RiverWewe.

TABLE ANALYZED DATA 1

Chi-square, df 2.709,1

P value 0.0998

P value summary Ns

One-or two-sided Two sided

Statistically significant? (alpha<0.05) No

49

APPENDIX II. MATERIALS USED

1. Light microscope

2. Plastic container

3. Small specimen bottles

4. Test tubes

5. Plastic bulb pipette

6. Centrifuge

7. Cork stopper

REAGENTS USED

1. Urine reagent test strip.

50

APPENDIX III. SAMPLE QUESTIONNAIRE:.

Prevalence and intensity of Urinary Schistosomiasis in Weweso Basic Sch. Children.

A. Name .............................................. Code No. ..........................

Age: .................... Sex: Male Female

Do you stay at Weweso? YES NO

If no specify........................................................

Do you stay with both of your parents ? YES NO

.

If no who do you live with?Mother

Father

Relative

Other.............

If not with both parents, reasons:

Separated

Deceased

Other..............

51

B. Do you have a main source of potable water? YES NO

If yes specify...................................

If no specify..............................................

Do you have any contact with the Weweso river? YES NO

If yes for what purpose?

Swimming

Fishing

Washing

Other..................................

C. How many times in a day or in a week do you have contact with theriver?............................................

D. Have you visited any health facility reently? YES NO

E. How recent?...............................................................................

F. Have you recieved any other form of medication? YES NO

G. If yes what type of medication....................................................

H. Comments..............................................................................................................................................................................................................................................................................................................................................................................................................................