Water Sanitation and Hygiene Role in Childhood Intestinal Parasitic Infection and Reinfection in Rural Dire Dawa Eastern Ethiopia
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Date
2025-09-01
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Addis Ababa University
Abstract
Background: Numerous infectious disorders brought on by parasitic worms, such as Schistosoma and soil-transmitted helminths, or pathogenic intestinal protozoa, have been grouped as neglected tropical diseases (NTDs). Parasitic illnesses still pose a serious and challenging threat to public health in developing countries. Worldwide, intestinal parasite infections (IPIs) affect about 3 billion individuals. Sanitation and hygiene are crucial to avoid intestinal parasite infections. Children are particularly vulnerable due to their frequent exposure to unhygienic environment and inability to keep adequate personal hygine. Inadequate water quantity limites basic hygienic practices such as hand hygiene and also poor water quality favours the direct transmission of IPIs. Pathogens transmitted through drinking water are mainly of fecal origin and are called enteric pathogens. Eventhough substantial progress has been made in Ethiopia in expanding access to safe drinking water, a significant challenge remains. Approximately 56.7% of the population faced a shortage of clean water. In rural areas, open defecation practices were common, and there was frequent sharing of water sources with animals. All these conditions facilitate fecal contamination of water and poor hygienic practices that favours IPI transmition. Children living in unsanitary and unhygienic environments are often trapped in a vicious cycle of infection and reinfection with intestinal parasites. This recurrent exposure can lead to chronic health issues like malnutrition, stunted growth, impaired cognitive development, and reduced school performance. Moreover, the burden of parasitic infections can persist across generations, reinforcing a cycle of poverty and poor health. In light of this, the present study evaluates the associations between water quality, sanitation, hygiene (WASH) practices, and the occurrence and recurrence of intestinal parasitic infections among children. Objectives: The objectives of this study are to assess the prevalence of intestinal parasitic infections (IPIs) among children aged 1–14 years and to identify associated risk factors related to sanitation and hygiene practices at the community level. In addition, the study examines the microbial quality of point-of-use drinking water in households with children and evaluates its association with the prevalence of IPIs. Furthermore, to determine the six-month reinfection rate of IPIs among previously treated children and to assess the relationship between their sanitation and hygiene practices and the likelihood of reinfection. Methods: From April to May 2021, a community-based cross-sectional study was carried out. Nine rural kebeles were randomly selected by the lottery method from a total of 38 kebeles. A total of 778 children aged 1-14 years participated in the survey. Data were collected using a pretested structured questionnaire administered through interviews to the participants parent or caregiver. Stool samples were taken for analysis using the direct wet mount method in the field and theformol-ether concentration technique at the institution, respectivly. Descriptive statistics and logistic regression analysis were performed using the Statistical Package for the Social Sciences (SPSS) version 23 to addres the first specific objective.
For objective II, a nested case-control study design was used. From April to May 2021, children with positive stool results for IPIs were identified as cases, while those with negative results were selected as controls based on direct wet mount method and formol-ethe concentration technique. A total of 352 water samples were collected 176 from case households and 176 from control households using sterile water sample collection bottles. For each household, 500 ml point of use water was collected from the actual point where water is consumed (cup or jug) by trained water lab staffs, following the standard procedures for water sample collection. In addition to collecting water samples for microbiological analysis, mothers and other caregivers of children were asked to complete pretested structured questionnaires. Data were entered into Epi Info, and exported to SPSS version 23 for analysis to examine the relationship between IPIs and point-of-use microbiological water quality. For objective III a case-control study design was employed. Data were collected from 75 IP reinfected cases and 147 unmatched controls. Fecal specimens were examined for parasities using both the direct smear and formol ether methods. Data entery was performed using EpiInfo, and statistical analysis was conducted using SPSS. Logistic regration analysis was used to identify associations between variables, with statistically significant set at P < 0.05.
Results: The prevalence of 5 intestinal parasites was 33.7% (95% CI = 30.4%-37%). Giardia intestinalis (15.2%) and Hymenolepis nana (11.6%) had the highest prevalence. The odds of IPIs among children of illiterate mothers were 13.1 times higher when compared with children of mothers with secondary education (aOR=13.1, P=.02), and the odds of IPIs among children from households that have unclean latrines were 1.8 times higher when compared with children from
households that have clean latrines. (aOR=1.8, P=.03). Children from households that discard solid waste in open fields had 1.7 times higher odds of having a positive result than children from households that burn their waste (aOR=1.7, P=.03). However, children who didn’t swim in accumulated water (naturally or for irrigation purpose) were 0.4 times less likely to test positive for intestinal parasitic infection compared to those who did. Also, children who were asymptomatic for IPIs at the time of the survey were 0.3 times less likely to be diagnosed with intestinal parasitic infection.
Overall, total coliform was detected from 298 point-of-use water samples (94.3% from cases and 75% from the control group), and E. coli was detected totally from 249 (96.6% from cases and 44.9% from the control group) point-of-use water at the household level. The positivity for IPIs was 12.6 times higher among the study subjects from households with point-of-use water detected with total coliform than their counterparts (P=0.001, 95% CI: 3.8-41). Also, IPIs were 14 times more likely to occur among children from households with point-of-use water detected with E. coli than the reference group. This relation has statistical significance (P=0.001, 95% CI: 6.6-30.2). Among microbial risk categories, water with E. coli counts in the low-risk range (1–10 CFU/100ml) showed a significantly increased infection risk (AOR = 15.3; p = 0.004), suggesting that even low risk contamination levels may pose substantial health threats in vulnerable populations. However, intermediate and high contamination levels did not retain significance after adjustment. Subjects from households that consum water ≥25 l/c/day had lower odds of infection (P=0.029, CI: 0.3–0.9), indicating a protective effect of adequate water consumption The overall IP reinfection rate within 24 weeks after treatment was 33.8% (75/222), with a 95% CI = 27.7%–40.5%. The frequency of intestinal protozoa was 18%, and for helminths, it was 15.8%. Children who swam in polluted water had 3.7 times greater odds of IP reinfection than children who did not swim (P = 0.01, 95% CI: 1.4–10.0). Children who regularly bathed in streams and children who bathed both at home and in streams were found to have 12.6 times and 5.8 times higher odds of IP reinfection than children who bathed regularly at home (P = 0.002, 95% CI: 2.5–64.8) and (P = 0.042, 95% CI: 1.1–31.3), respectively. Children from households that owned domestic animals had 4.2 times higher odds of IP reinfection compared to children from housholds without domestic animals (P = 0.013, 95% CI: 1.3–12.5). Conclusions: The multifaceted nature of intestinal parasite infections and reinfections in children is highlighted in this study, with particular attention paid to the important roles played by environmental exposures, sanitation, hygiene practices, maternal education, and water quality and quantity. Children of illiterate mothers, those living in households with unclean latrines or poor waste management practices, and those exposed to contaminated water sources were more likely to be infected. Additionally, behaviors such as swimming or bathing in contaminated surface waters and close contact with domestic animals were strongly associated with reinfection. These findings are consistent with both local and international studies, reinforcing the urgent need for integrated, community-based interventions that combine health education, improved water and sanitation services, behavioral change communication, and targeted environmental health strategies to reduce the burden of parasitic diseases among vulnerable populations. Recommendations: To effectively reduce childhood intestinal parasitic infections and reinfections in rural Dire Dawa, a comprehensive approach focusing on water, sanitation, and hygiene (WASH) is essential. To lessen the burden of intestinal parasite infections and reinfections in children, a number of important recommendations are put out in light of the study's findings. First, enhancing community-based health education is essential for promoting safe water management, illness prevention, and better hygiene habits, especially for illiterate mothers. Prioritizing access to clean and sufficient water (≥25 liters per person per day) should be achieved through better infrastructure and encouragement of water treatment and storage at the household level. Community-led total sanitation (CLTS) strategies must discourage openfield waste disposal and encourage routine latrine cleaning in order to improve sanitation and hygiene initiatives. Particularly in high-risk rural areas, it is important to discourage risky activities like swimming and bathing in contaminated surface waters and to encourage safe alternatives. Public health initiatives should also incorporate appropriate domestic animal management, emphasizing the safe disposal of animal waste and minimizing interaction between children and animals. To effectively address the multifactorial causes of intestinal parasitic infections (IPIs), it is essential to establish strong coordination between the health, education, and water sectors
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Keywords
Intestinal Parasitic Infections, Intestinal Parasitic Reinfection, Risk Factors, Water, Sanitation, Hygiene, Ethiopia