Acta Tropica 141 (2015) 322331

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Acta Tropica
journal homepage: www.elsevier.com/locate/actatropica

Multiparasitism and intensity of helminth infections in relation to

symptoms and nutritional status among children: A cross-sectional
study in southern Lao Peoples Democratic Republic
Somphou Sayasone a,b,c , Jrg Utzinger b,c , Kongsap Akkhavong a , Peter Odermatt b,c,
a
National Institute of Public Health, Ministry of Health, Vientiane, Lao Peoples Democratic Republic
b
Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box, CH-4002 Basel, Switzerland
c
University of Basel, P.O. Box, CH-4003 Basel, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: The occurrence and spatial distribution of intestinal helminth infection in children is fairly well under-
Available online 5 October 2014 stood. However, knowledge on how helminth infections govern intestinal morbidity is scarce. We
conducted a cross-sectional study to assess and quantify the relationship between single and multiple
Keywords: species helminth infection with clinical and self-reported morbidity indicators and nutritional status in
Soil-transmitted helminthiasis Champasack province, southern Lao Peoples Democratic Republic (Lao PDR). A random sample of 1313
Food-borne trematodiasis
children, aged 6 months to 12 years, from villages in nine rural districts were enrolled and examined
Nutrition
for helminth infection using duplicate Kato-Katz thick smears. Morbidity was assessed by self-reported
Anaemia
Symptoms
symptoms, coupled with clinical examination and appraisal of nutritional status and anaemia. Bivari-
Lao Peoples Democratic Republic ate and multivariate logistic regression was employed to study associations between helminth infection
and morbidity indicators and anaemia. We found considerable morbidity among the surveyed children,
including hepatomegaly (13.7%), pale conjunctiva (13.2%) and abdominal pain (10.4%). Anaemia was
recorded in 60.4% of the children, whilst signs of stunting and low body mass index (BMI) were observed
in 49.8% and 33.3% of the surveyed children, respectively. Hookworm and Opisthorchis viverrini were
the predominant helminth species with prevalences of 51.0% and 43.3%, respectively. The prevalence
of Schistosoma mekongi in the surveyed children was 5.6%. Multiple species helminth infections were
recorded in 40.4% of the study cohort. Morbidity was associated with specic helminth species infec-
tion (e.g. S. mekongi with hepatomegaly; adjusted odds ratio (aOR): 9.49, 95% condence interval (CI):
2.0743.51) and multiparasitism (e.g. two or more helminth species with abdominal pain; aOR: 2.40, 95%
CI: 1.463.93). Anaemia was associated with hookworm infection (aOR: 1.64, 95% CI: 1.162.34) and mul-
tiparasitism (aOR: 1.64, 95% CI: 1.182.29). Low BMI was associated with O. viverrini infection (aOR: 1.68,
95% CI: 1.142.49) and multiparasitism (aOR: 1.42, 95% CI: 1.012.00). The multiple strong associations
reported here between helminth infections (single or multiple species) and intestinal morbidity among
children in rural parts of southern Lao PDR call for concerted efforts to control helminth infections, which
in turn might improve childrens health and development.
2014 Elsevier B.V. All rights reserved.

1. Introduction et al., 2012b; Murray et al., 2012; Pullan et al., 2014). More than 5
billion people are at risk of helminthiases, an estimated 2 billion are
Parasitic worm infections, including soil-transmitted helminths infected and hundreds of millions suffer from some kind of mor-
(STHs), food-borne trematodes (FBTs) and Schistosoma spp., remain bidity (Hotez et al., 2008; Pullan and Brooker, 2012; Utzinger et al.,
important public health issues in low- and middle-income 2012). The occurrence of morbidity varies from individual to indi-
countries in the tropics and subtropics (Colley et al., 2014; Frst vidual and is related to the type, number and intensity of helminth
species and host factors (e.g. school-aged children and pregnant
women are of particular risk of morbidity) (Hall et al., 2008;
Corresponding author at: Department of Epidemiology and Public Health, Swiss
Quinnell, 2003). In children, chronic helminth infections may cause
Tropical and Public Health Institute, P.O. Box, CH-4002 Basel, Switzerland.
a number of negative health outcomes, such as impaired phys-
Tel.: +41 61 284 8214; fax: +41 61 284 8105. ical and cognitive development (Al-Mekhla et al., 2005; Bundy
E-mail address: [email protected] (P. Odermatt). et al., 2009; Frst et al., 2012a,b; Oninla et al., 2010). Additionally,

http://dx.doi.org/10.1016/j.actatropica.2014.09.015
0001-706X/ 2014 Elsevier B.V. All rights reserved.
 S. Sayasone et al. / Acta Tropica 141 (2015) 322331 323

helminth infections are aetiological factors of anaemia and protein- and extent of malnutrition in Champasack province are similar to
energy malnutrition, which account for half of child mortality in other rural parts of Lao PDR (Kamiya, 2011).
developing countries (Al-Mekhla et al., 2005; Oninla et al., 2010).
In Lao Peoples Democratic Republic (Lao PDR) helminthiasis 2.3. Study design and population
are highly endemic with distinct spatial patterns depending on
the helminth species. For example, STHs (i.e. Ascaris lumbricoides, Epidemiological data were collected during a cross-sectional,
hookworm and Trichuris trichiura) show highest prevalence rates in community-based survey carried out between January and May
the northern provinces (Rim et al., 2003), Opisthorchis viverrini and 2007 in Champasack province (Forrer et al., 2012). We employed a
other FBTs are particularly prevalent in the lowlands in the Mekong two-stage sampling method. In a rst step, 54 villages were ran-
River basin (Forrer et al., 2012; Phongluxa et al., 2013; Sayasone domly selected. Second, in each village 1520 households were
et al., 2007, 2011) and Schistosoma mekongi is restricted to the lower selected at random. All children of the selected household aged
Mekong River basin (Lao-Cambodian border) (Muth et al., 2010; between 6 months and 12 years were invited to participate.
Sayasone et al., 2011). In many provinces, the distributions of var-
ious helminth species are geographically overlapping, and hence, 2.4. Field and laboratory procedures
multiple species helminth infections are a common phenomenon
(Phongluxa et al., 2013; Sayasone et al., 2011). Multiparasitism is Data on behaviour (e.g. food consumption and hygiene) and
of concern, as multiple species helminth infections can exacer- medical history were obtained from each child with assistance
bate morbidity (Ezeamama et al., 2005; Steinmann et al., 2010). of parents or legal guardians using a pre-tested questionnaire.
However, data pertaining to morbidity associated with single and For children aged <6 years, only parents or legal guardians were
multiple species helminth infections and intensity are scarce in interviewed. Older children (up to 12 years) participated dur-
resource-constrained settings, including Lao PDR. ing the interviews with their parents or caregivers. A household
We conducted a cross-sectional parasitological, clinical and questionnaire was administered to heads of household to obtain
questionnaire survey focussing on children aged between 6 months socioeconomic data, such as access to clean water and sanitation,
and 12 years in nine rural districts of Champasack province in the house construction material, and ownership of household assets
southern part of Lao PDR where STHs, FBTs and S. mekongi co- and livestock.
exist. Our aim was to assess and quantify the relationship between Anthropometric data were collected from all enrolled children.
single and multiple species helminth infections with clinical and Exact child age was obtained from birth records and other of-
self-reported morbidity indicators and nutritional status. cial documents (e.g. vaccination card, vaccination book registry
and household registry book). Childrens weight was measured
using a digital scale (Tanita Corporation; Tokyo, Japan). A child
2. Materials and methods was weighed bare-foot wearing light clothes to the nearest 0.1 kg.
Height was measured using a measuring board to the nearest
2.1. Ethics statement 0.1 cm. Children aged below 2 years were measured in supine posi-
tion.
Ethical approval for the current study was obtained from the Study participants provided a single stool sample. Within 2 h of
Ministry of Health (MOH) of Lao PDR (reference no. 027/NECHR) stool collection, duplicate Kato-Katz thick smears, using 41.7 mg
and the ethics committee of Basel, Switzerland (EKBB; reference templates, were prepared, adhering to standard protocols (Katz
no. 255/06). Permission for eld and laboratory work was obtained et al., 1972; Yap et al., 2012). In brief, Kato-Katz thick smears were
from the MOH, the Provincial Health Ofce (PHO) and the District allowed to clear for 30 min before examination under a light micro-
Health Ofce (DHO). Village meetings were held and local author- scope by experienced laboratory technicians. Helminth eggs were
ities and inhabitants were given detailed explanations about the counted and recorded for each species separately. For quality con-
objectives, procedures and potential risks and benet of the study. trol, 10% of the Kato-Katz thick smears were re-examined by a
An information sheet in the local language was read aloud to par- senior technician. Helminth species-specic egg counts were com-
ents in the presence of their children and sufcient time was given pared with the original readings and, whenever discrepancies were
to pose any kind of questions related to the study. Parents were observed (i.e. negative versus positive result; helminth egg counts
asked for written informed consent and a local witness observing differing by more than 10%), the slides were read a third time and
this procedure also signed the consent form. Participation was vol- results discussed until agreement was reached.
untary, and hence, parents could withdraw their children from the A ngerpick blood sample was taken from each child and
study anytime without further obligations. Children found posi- assessed for haemoglobin (Hb), using a B-haemoglobin photometer
tive for any intestinal helminth infection were treated according to (Hemocue AB; Angelholm, Sweden). Morbidity data were obtained
national guidelines (MOH, 2004). from each participant by recall of symptoms within 2 weeks prior
to the survey (e.g. abdominal bloating, abdominal pain, bloody diar-
rhoea and watery diarrhoea) and by clinical examination (e.g. big
2.2. Study area belly, pale sub-conjunctiva, tenderness of abdomen, hepatomegaly
and splenomegaly). Clinical examinations were conducted by an
The study was carried out in Champasack, the largest province experienced physician. Hepatomegaly was determined by palpat-
of southern Lao PDR, covering an area of 15,415 km2 , stretching ing the left liver lobe along the xiphoid-umbilicus line in the supine
from 13 55 to 15 29 N latitude and from 105 11 to 106 46 E position. It was classied as absent or present when the left liver
longitude. According to the 2005 census, the total population of lobe was not palpable or palpable, accordingly (Biays et al., 1999).
Champasack province was 603,370 inhabitants (Census 2005, Lao Splenomegaly was classied using the Hackett score (Hackett,
Statistics Bureau, Vientiane; www.nsc.gov.la). The study was car- 1944).
ried out in all nine rural districts of Champasack province (i.e.
districts of Bachieng, Champasack, Khong, Mounlapamok, Paksong, 2.5. Statistical analysis
Pathoumphone, Phonthong, Sanasomboun and Soukhouma). Of
note, helminth infections, including multiparasitism (Chai et al., Survey data were double-entered and cross-checked using Epi-
2005; Eom et al., 2014; Sayasone et al., 2009) and the prevalence Data 3.1 (EpiData Association; Odense, Denmark). Only those
324 S. Sayasone et al. / Acta Tropica 141 (2015) 322331

Fig. 1. Childrens compliance of survey in nine districts of Champasack province, southern Lao PDR, 2007.

children with complete data records were included in the nal anal- We used 2 statistics to compare proportions. Associations
ysis. For summary statistics, children were classied into two age between morbidity indicators (outcome) and helminth infection
groups (i.e. 6 months to 5 years and >5 years to 12 years). status (predictor) were assessed by using (i) a bivariate logis-
Anaemia was determined according to age-specic Hb levels tic regressions and (ii) a multivariable logistic regression analysis
using World Health Organization (WHO) cut-offs (WHO, 2014). (stepwise backwards elimination), adjusted for sex, age-group,
Children aged <5 years were considered anaemic if their Hb lev- socioeconomic status, nutritional status and personal hygiene.
els were below 11.0 g/dl, whilst for older children up to 12 years of Crude odds ratio (cOR) and adjusted odds ratio (aOR) and corre-
age, the cut-off was 11.5 g/dl. sponding 95% condence intervals (CIs) were calculated. Variables
Helminth infection intensities were classied into light, mod- exhibiting an association at a signicance level of 0.15 were
erate and heavy, according to eggs per 1 g of stool (EPG) and included in multivariate logistic regression models. Multiple linear
thresholds put forward by Maleewong et al. (1992) and WHO regression models were used to associate helminth infections with
guidelines (WHO, 2005). In brief, light, moderate and heavy hook- mean Hb levels as previously performed (Degarege et al., 2014).
worm infections were 11999 EPG, 20003999 EPG and 4000 Statistical signicance was dened as P value <0.05.
EPG; whilst the respective cut-offs for A. lumbricoides were 14999
EPG, 500049,999 EPG and 50,000 EPG, those of T. trichiura and
3. Results
O. viverrini were 1999 EPG, 10009999 EPG and 10,000 EPG, and
S. mekongi intensity classes were 1100 EPG, 101399 EPG and
3.1. Compliance and population characteristics
400 EPG. Additionally, children were grouped into ve helminth
infection/intensity classes, as follows: (i) no infection; (ii) any sin-
A total of 1554 children aged between 6 months and 12 years
gle helminth species infection with light intensity; (iii) any single
were enrolled (Fig. 1). Among them, 241 (14.6%) failed to submit
helminth species infection with moderate or heavy intensity; (iv)
a stool sample, were absent during the clinical examination and
any multiparasitism with light intensity; and (v) any multipara-
questionnaire survey, or had extreme z-score values (too low or
sitism with moderate or heavy intensity.
high according to WHO denitions). The remaining 1313 children
Anthropometric data were calculated in STATA version 10.1
had completed all study procedures, and hence were retained for
(Stata Corporation; College Station, TX, USA) using a readily avail-
the nal analysis. There were 649 (49.4%) girls and 664 (50.6%) boys.
able macro-statistical package developed by a technical group of
In terms of age, 464 (35.3%) of the children were below 5 years,
WHO (2007). The WHO child growth standards 2007 for under-ve
whilst the remaining 849 children were older, up to 12 years.
children and children aged 519 years (merged data NCHS/WHO)
were used as references (de Onis et al., 2007). The following
four anthropometric indicators were considered (i) weight-for- 3.2. Helminth infections
height (wasting); (ii) height-for-age (stunting); (iii) weight-for-age
(underweight); and (iv) body mass index (BMI) for age. A child was Table 1 summarises childrens helminth infection status, strat-
dened as being undernourished when z-score measurement of ied by sex and two age groups. Hookworm was the predominant
these indicators were below 2 standard deviations (SDs) of the species (51.0%), followed by O. viverrini (43.3%), A. lumbricoides
population reference (Alom et al., 2012; de Onis et al., 2007). (16.8%), T. trichiura (10.7%), S. mekongi (5.6%) and Taenia spp.
House construction material and ownership of household assets (1.2%). 307 children were free of any helminth infection (23.4%),
and livestock were used to build an asset-based socioeconomic 476 children (36.2%) harboured a single helminth species and the
index, using principal component analysis (PCA). This approach has remaining 530 children (40.4%) were infected with at least two and
been widely and successfully used to construct household socioeco- up to ve helminth species concurrently. The following helminth
nomic status (see, for example, Forrer et al., 2012). Households were infection intensities proles were observed: single infection with
classied in ve wealth quintiles, the rst quintile corresponding light infection intensities (27.5%), single infection with moderate
to the poorest and the fth to the least poor population group. and heavy infection intensities (8.8%), multiparasitism with light
 S. Sayasone et al. / Acta Tropica 141 (2015) 322331 325

Table 1
Situation of helminth infections among 1313 children of Champasack province, southern Lao PDR in 2007, stratied by sex and age group.

Infections Overall Sex Age group

Females Males 2 P-value 6 months5 years 512 years 2 P-value

All infections
Opisthorchis viverrini 569 (43.3) 277 (42.7) 292 (44.0) 0.22 0.636 117 (25.2) 452 (53.2) 95.95 <0.001
Schistosoma mekongi 74 (5.6) 41 (6.3) 33 (5.0) 1.12 0.290 21 (4.5) 53 (6.2) 1.66 0.197
Hookworm 670 (51.0) 323 (49.8) 347 (52.3) 0.81 0.367 194 (41.8) 476 (56.1) 24.40 <0.001
Ascaris lumbricoides 221 (16.8) 109 (16.8) 112 (16.8) 0.01 0.970 90 (19.4) 131 (15.4) 3.37 0.066
Trichuris trichiura 140 (10.7) 71 (10.9) 69 (10.4) 0.10 0.748 37 (8.0) 103 (12.1) 5.44 0.020
Taenia spp. 16 (1.2) 9 (1.4) 7 (1.1) 0.30 0.583 2 (0.4) 14 (1.7) 3.70 0.054

Individual infection
Negative 307 (23.4) 155 (23.9) 152 (22.9) 173 (37.3) 134 (15.8)
Only Opisthorchis viverrini 209 (15.9) 106 (16.4) 103 (15.5) 54 (11.6) 154 (18.3)
Only Schistosoma mekongi 9 (0.7) 6 (0.9) 3 (0.5) 5 (1.1) 4 (0.5)
Only hookworm 193 (14.7) 103 (15.9) 90 (13.6) 79 (17.0) 114 (13.4)
Only Ascaris lumbricoides 58 (4.5) 25 (3.9) 33 (5.0) 24 (5.2) 34 (4.0)
Only Trichuris trichiura 7 (0.5) 2 (0.3) 5 (0.8) 3 (0.7) 4 (0.5)
Any multiparasitism 530 (40.4) 252 (41.9) 278 (38.8) 5.75 0.452 126 (27.2) 404 (47.6) 103.5 <0.001

Number of helminth species

Single species 476 (36.3) 242 (37.3) 234 (35.2) 165 (35.6) 311 (36.6)
Two species 393 (29.9) 179 (27.6) 213 (32.1) 87 (18.8) 305 (35.9)
Three or more species 138 (10.5) 73 (11.3) 65 (9.8) 3.61 0.307 39 (8.4) 99 (11.7) 92.40 <0.001

Intensity of infections
Any single helminth species with light 331 (25.2) 176 (27.1) 155 (23.3) 108 (23.3) 223 (26.3)
Any single helminth species with moderate+ 145 (11.0) 66 (10.2) 79 (11.9) 57 (12.3) 88 (10.4)
Any multiparasitism with light 219 (16.7) 98 (15.1) 121 (18.2) 26 (5.6) 193 (22.7)
Any multiparasitism with moderate+ 311 (23.7) 154 (23.7) 157 (23.6) 4.99 0.288 100 (21.6) 211 (24.9) 113.61 <0.001

P-value calculated from 2 test

infection intensities (16.6%) and multiparasitism with moderate 54.8% versus 35.3%, P = 0.001; low BMI for age: 44.8% versus 12.3%,
and heavy infection intensities (23.7%). P < 0.001). The opposite trend was observed for wasting (9.5%
versus 13.6%, P = 0.025).

3.3. Clinical assessments

3.5. Predictors of clinical outcomes
Table 2 shows the frequency of reported symptoms, stratied
by sex and age group. The most frequently reported symptom Stepwise multiple logistic regression analysis revealed that
was abdominal pain (10.4%). Abdominal bloating and watery diar- helminth infections (e.g. single and multiple species infection and
rhoea were reported by 4.0% of the children each, whilst bloody different infection intensity proles) were signicant predictors
diarrhoea was reported by 1.2% of the children. There was no for different morbidity indicators. Table 4 summarises identied
signicant sex difference in self-reported morbidity indicators. associations between helminth infection and morbidity indicators.
Abdominal bloating and watery diarrhoea were reported signi- Of particular note is that S. mekongi infection showed signi-
cantly more often in children aged 6 months to 5 years compared cant associations with palpable hepatomegaly (aOR: 9.49, 95%
to their older counterparts (both P < 0.001). Hepatomegaly (13.7%) CI: 2.0743.51), splenomegaly (aOR: 53.7, 95% CI: 6.44448.79),
was the most frequent clinical sign diagnosed in the physical self-reported bloody diarrhoea (aOR: 23.33, 95% CI: 4.04134.66)
examination, followed by pale sub-conjunctiva (13.2%), big belly and pale sub-conjunctiva (aOR: 6.13, 95% CI: 1.4426.19). Sim-
(6.9%), splenomegaly (4.3%) and tenderness of abdomen upon pal- ilarly, multiple species helminth infection was associated with
pation (1.0%). Big bellies were signicantly more often diagnosed hepatomegaly and splenomegaly with a trend for higher aORs
in the younger age group compared to children aged above 5 the higher the intensity of multiple species helminth infec-
years. tions.
None of the other single species helminth infection was signif-
icantly associated with morbidity indicators, except for a positive
3.4. Anaemia and nutritional status association between hookworm infection and pale sub-conjunctiva
(aOR: 1.91, 95% CI: 1.213.01). Multiple species helminth infec-
Overall, 793 children (60.4%) were found anaemic with no tion showed strong associations with morbidity (e.g. any multiple
signicant difference by sex (males: 62.1% versus females: 58.7%, species helminth infection with moderate and high infection inten-
P = 0.216) and age group (6 month to 5 years: 60.3% versus 512 sity was signicantly associated with reported watery diarrhoea
years: 60.4%, P = 0.978). Table 3 summarises the nutritional status (aOR: 2.35, 95% CI: 1.264.39), abdominal bloating (aOR: 2.00, 95%
of children examined, stratied by sex and age group. Overall, high CI: 1.093.67) and abdominal pain (aOR: 1.84, 95% CI: 1.262.67).
prevalences of stunting (49.4%), underweight (47.9%) and low BMI The presence of palpable hepatomegaly in children showed a
for age (33.3%) were observed. Wasting was determined in 10.7% strong association with any multiple species helminth infection
of children surveyed. We did not observe any signicant difference (aOR: 3.67, 95% CI: 2.495.40). The association was particularly
between boys and girls. However, children aged 512 years had a strong between any multiple species helminth infection with mod-
signicantly lower nutritional status than their younger counter- erate and heavy infection intensity (aOR: 7.91, 95% CI: 5.4011.60).
parts (e.g. stunting: 51.1% versus 46.3%, P = 0.048; underweight: The presence of palpable splenomegaly was strongly associated
326 S. Sayasone et al. / Acta Tropica 141 (2015) 322331

Table 2
Frequency of clinical outcomes obtained from physical examination of children in Champasack province, southern Lao PDR in 2007, stratied by sex and age group (n = 1313).

Clinical Overall Sex Age group (years)

outcomes
n (%) Girls, n (%) Boys, n (%) 2 P-value <5, n (%) 512, n (%) 2 P-value

Symptoms in past two weeks

Abdominal pain 137 (10.4) 69 (10.6) 68 (10.2) 0.05 0.817 57 (12.3) 80 (9.4) 2.63 0.105
Abdominal bloating 52 (4.0) 26 (4.1) 26 (3.9) 0.01 0.933 30 (6.5) 22 (2.6) 11.84 0.001
Watery diarrhoea 52 (4.0) 22 (3.5) 30 (4.5) 1.10 0.295 31 (6.7) 21 (2.5) 13.96 <0.001
Bloody diarrhoea 16 (1.2) 9 (1.4) 7 (1.1) 0.30 0.583 8 (1.7) 8 (0.9) 1.52 0.217

Physical examinations
Hepatomegaly 180 (13.7) 88 (13.6) 92 (13.9) 0.02 0.876 64 (13.8) 116 (13.7) 0.01 0.948
Pale sub-conjunctiva 173 (13.2) 74 (11.4) 99 (14.9) 3.55 0.060 72 (15.5) 101 (11.9) 3.44 0.064
Big belly 90 (6.9) 50 (7.5) 40 (6.2) 0.96 0.327 56 (12.1) 34 (4.00) 30.56 <0.001
Splenomegaly* 57 (4.3) 31 (4.3) 26 (3.9) 0.59 0.444 17 (3.7) 40 (4.7) 0.79 0.373
Tenderness of abdomen 13 (1.0) 6 (0.9) 7 (1.1) 0.06 0.812 2 (0.4) 11 (1.3) 2.29 0.130

P-value obtained from x2 test.

*
Splenomegaly: Hackett score 2.

with multiple species helminth infection (aOR: 14.13, 95% CI: to 0.07; Fig. 2a). Regarding helminth infection intensity proles,
3.3958.86) and any multiple species helminth infection with mod- the linear regression model revealed a lower mean Hb level in chil-
erate or heavy infection intensity (aOR: 10.41, 95% CI: 4.7322.92). dren who had positive stool examination compared to non-infected
children (Fig. 2b). Single infections with moderate or heavy infec-
tion intensities were signicantly associated with a lower mean Hb
3.6. Predictors of nutritional status and anaemia
level (coefcient: 0.32, 95% CI: 0.60 to 0.04; Fig. 2b).

Table 5 summarises the main associations between helminth

infection and nutritional indicators, readily adjusted for potential 4. Discussion
predictors, such as sex, age group, personal hygiene, socioeconomic
status and recent history of illness, as obtained from stepwise mul- In Lao PDR, helminthiases remain issues of considerable pub-
tivariable logistic regression analysis. The presence of anaemia lic health relevance, at local, provincial and national level. Single
showed a strong association with helminth infection. For exam- and multiple species helminth infections and associated morbidity
ple, S. mekongi infection (aOR: 1.52, 95% CI: 1.082.15), hookworm patterns are governed by social-ecological systems. Over the past
infection (aOR: 1.64, 95% CI: 1.162.34) and multiple species 15 years, data have been accumulated regarding peoples infection
helminth infection (two helminth species infection, aOR: 1.65, 95% status with individual helminth species and their spatial distribu-
CI: 1.242.20; three or more helminth species infections, aOR: 1.53, tion at different scales (Eom et al., 2014; Forrer et al., 2012; Rim
95% CI: 1.152.04) were signicantly associated with anaemia. et al., 2003; Sayasone et al., 2011). However, the current knowledge
With regard to malnutrition, low BMI for age was signicantly on morbidities due to specic helminth infections, and particularly
associated with multiple species helminth infection (two helminth concurrent infections with multiple helminth species in the same
species infection, aOR: 1.40, 95% CI: 1.011.94; three or more host, is scarce. In a previous study, we have reported on hepato-
helminth species, aOR: 1.45, 95% CI, 1.032.04) and helminth infec- biliary excess morbidity associated with concurrent S. mekongi
tion intensity (any multiparasitism with light infections, aOR: 1.42, O. viverrini infection in adults in southern Lao PDR (Sayasone et al.,
95% CI: 1.012.00). 2012). Here, we further this line of scientic inquiry, as we report
Other nutritional indicators such as stunting and wasting were on the association of single and multiple species helminth infec-
not associated with any of the helminth infection intensity pro- tion with intestinal morbidity among children aged 6 months to 12
les. The presence of stunting in a child was signicantly associated years.
with low socioeconomic status and wasting was associated with We carried out a large cross-sectional survey in all nine rural dis-
self-reported watery diarrhoea (aOR: 2.58, 95% CI: 1.075.84) and tricts of Champasack province, situated in the southern part of Lao
bloody diarrhoea (aOR: 3.99, 95% CI: 1.1014.50). PDR. Our aim was to deepen the understanding of how helminth
Linear regression analysis, adjusted for age group, sex, weight infections, multiparasitism and different infection intensity proles
and height, showed that the mean Hb level was signicantly lower inuence childrens health and nutritional status. We employed
in children who harboured a single helminth species compared to the widely used Kato-Katz technique for the diagnosis of helminth
non-infected children (i.e. for S. mekongi, coefcient: 1.42, 95% CI: infections (Bergquist et al., 2009; Speich et al., 2010). Addition-
2.35 to 0.48; for hookworm, coefcient: 0.33, 95% CI: 0.58 ally, children were interviewed for a recent history of illness and

Table 3
Frequency of nutritional status among 1313 children from Champasack province, southern Lao PDR in 2007, stratied by sex and age groups.

Nutritional Overall Sex Age group (years)

indicators
Girls Boys  2
P-value <5 512 2 P-value

Stunting (z-score 2) 649 (49.4) 312 (48.1) 337 (50.8) 0.94 0.332 215 (46.3) 434 (51.1) 3.71 0.048
Underweight (z-score 2) 629 (47.9) 310 (47.8) 319 (48.0) 0.01 0.920 164 (35.3) 465 (54.8) 45.37 0.001
Wasting (z-score 2) 144 (10.7) 71 (10.9) 73 (11.0) 0.01 0.975 63 (13.6) 81 (9.5) 5.01 0.025
Low BMI for age (z-score 2) 437 (33.3) 202 (31.1) 235 (35.4) 2.69 0.101 57 (12.3) 380 (44.8) 142.50 <0.001

P-value calculated from x2 test.

 S. Sayasone et al. / Acta Tropica 141 (2015) 322331 327

Table 4
Association between helminth infections and outcomes of clinical examination among 1313 children from Champasack province, southern Lao PDR in 2007, using stepwise
multiple logistic regression (backwards elimination).

Morbidity indicators Signicant associations cOR (95% CI) aOR (95% CI)

Symptoms in past two weeks

Watery diarrhoea Multiple helminth species infections
No infection 1.00 1.00
Any multiparasitism 1.17 (0.592.31) 2.35 (1.264.39)
Helminth infection intensity
No infection 1.00 1.00
Any multiparasitism with moderate+ 1.64 (0.803.33) 2.40 (1.344.32)
Bloody diarrhoea Single helminth species
No infection 1.00 1.00
Only S. mekongi 14.33 (2.4583.90) 23.33 (4.04134.66)
Abdominal bloating Helminth Infection intensity
No infection 1.00 1.00
Any multiparasitism with moderate+ 1.18 (0.602.35) 2.00 (1.093.67)
Abdominal pain Multiple helminth species infections
No infection 1.00 1.00
Two helminth species 1.34 (0.812.22) 1.62 (1.132.32)
Three or more helminth species 2.52 (1.424.49) 2.40 (1.463.93)
Helminth infection intensity
No infection 1.00 1.00
Any multiparasitism with moderate+ 1.99 (1.213.27) 1.84 (1.262.67)
Physical examinations
Pale sub-conjunctiva Single helminth species infection
No infection 1.00 1.00
Only hookworm 1.84 (1.103.08) 1.91 (1.213.01)
Only S. mekongi 4.15 (0.9917.39) 6.13 (1.4426.19)
Helminth infection intensity
No infection 1.00 1.00
Any multiparasitism with light 1.74 (1.052.88) 1.62 (1.072.46)
Tenderness of abdomen Multiple helminth species infections
No infection 1.00 1.00
Three or more helminth species 3.02 (0.6713.70) 3.64 (1.1012.12)
Hepatomegaly Single helminth species infection
No infection 1.00 1.00
Only S. mekongi 6.81 (1.5929.18) 9.49 (2.0743.51)
Multiparasitism
No infection 1.00 1.00
Two helminth species 3.06 (1.845.11) 2.49 (1.723.61)
Three or more helminth species 6.37 (3.6111.27) 5.36 (3.378.52)
Any multiparasitism 3.82 (2.346.22) 3.67 (2.495.40)
Helminth infection intensity
No infection 1.00 1.00
Any single helminth species with moderate+ 2.84 (1.535.26) 3.02 (1.785.11)
Any multiparasitism with moderate+ 6.65 (4.0210.98) 7.91 (5.4011.60)
Splenomegaly Single helminth species infection
No infection 1.00 1.00
Only S. mekongi 43.57 (5.34355.20) 53.75 (6.44448.79)
Multiparasitism
No infection 1.00 1.00
Two helminth species 10.39 (2.4444.21) 20.70 (2.5245.75)
Three or more helminth species 22.88 (5.23100.09) 25.12 (5.71110.45)
Any multiparasitism 13.47 (3.2455.98) 14.13 (3.3958.86)
Helminth infection intensity
No infection 1.00 1.00
Any single helminth species moderate+ 6.58 (1.3133.03) 3.41 (1.1610.02)
Any multiparasitism with light 6.53 (1.4030.55) 3.46 (1.329.12)
Any multiparasitism with moderate+ 18.72 (4.4678.63) 10.41 (4.7322.92)

cOR: crude odds ratio; aOR: adjusted odds ratio.

aOR obtained from stepwise multiple logistic regression (backwards elimination), adjusted for sex, age group, socioeconomic status, nutritional status and personal hygiene.

underwent a clinical examination for appraisal of current diseases. two or more helminth species concurrently. Interestingly, most of
Anthropometric data (i.e. height and weight) were determined and the children diagnosed with single helminth species were charac-
anaemia was assessed by means of a ngerprick sample tested for terised by light infection intensity proles (25.2%), whilst children
Hb level. with multiple species helminth infections showed moderate and
Our data conrm that helminth infections are highly preva- heavy infection intensity proles (23.7%). Helminth infections
lent in Champasack province. Indeed, microscopic examination of (either single or multiple species and particularly those of moderate
duplicate Kato-Katz thick smears showed that over three-quarter and heavy intensities) were signicantly associated with clinical
of the children were infected with at least one helminth species. morbidity, anaemia and malnutrition. Hence, ndings reported
Hookworm was the predominant species with slightly more than here are of relevance to further clarify whether and to what extent
half of the children infected (51.0%). Given the high marginal preva- helminth infections impact on childrens health, nutritional status
lence of various helminth species, multiparasitism was common; and overall development (Hall et al., 2008; Taylor-Robinson et al.,
two out of ve children with complete data records harboured 2012).
328 S. Sayasone et al. / Acta Tropica 141 (2015) 322331

Table 5
Predictors of nutritional status of 1313 children, Champasack province, southern Lao PDR in 2007, using stepwise multiple logistic regression (backwards elimination).

Morbidity indicators Signicant associations cOR (95%, CI) aOR (95%, CI)

Anaemia Single helminth species infection

No infection 1.00 1.00
Only S. mekongi 1.33 (0.971.82) 1.52 (1.082.15)
Only hookworm 1.51 (1.092.09) 1.64 (1.162.34)
Multiple helminth species infections
Two helminth species 1.48 (1.092.02) 1.65 (1.242.20)
Three or more helminth species 1.48 (1.092.02) 1.53 (1.152.04)
Helminth infection intensity
No infection 1.00 1.00
Any multiparasitism with light 1.60 (1.132.38) 1.64 (1.182.29)
Stunting Household socioeconomic status
Richest 1.00 1.00
Poor 1.17 (0.821.67) 1.63 (1.092.44)
Very poor 1.65 (1.172.32) 2.42 (1.623.62)
Poorest 1.38 (0.981.94) 1.93 (1.292.87)
Wasting Watery diarrhoea in past two weeks 1.05 (1.696.07) 2.58 (1.075.84)
Bloody diarrhoea in past two weeks 3.79 (1.3011.06) 3.99 (1.1014.50)
Low BMI for age Single helminth species
(z-score 2) No infection 1.00 1.00
Only O. viverrini 1.68 (1.162.45) 1.68 (1.142.49)
Multiple helminth species infections
No infection 1.00 1.00
Two helminth species 1.40 (1.021.91) 1.40 (1.011.94)
Three or more helminth species 1.41 (1.041.91) 1.45 (1.032.04)
Intensity of infections
No infection 1.00 1.00
Any multiparasitism with light 1.59 (1.102.31) 1.42 (1.012.00)
Household socioeconomic status
Richest 1.00 1.00
Poorest 1.49 (1.042.14) 1.58 (1.122.21)
Raw vegetables 1.36 (1.051.76) 1.38 (1.021.86)

SN: small number; cOR: crude odds ratio; aOR: adjusted odds ratio.
aOR obtained from stepwise multiple logistic regression (backwards elimination), adjusted for sex, age group, personal hygiene, household socioeconomic status and recent
history of illness.

Fig. 2. (a) Differences in mean haemoglobin levels among infected compared to non-infected children (n = 1313), adjusted for age group, sex, weight and height. * P = 0.003
(95% CI: 2.35 to 0.48); ** P = 0.012 (95% CI: 0.58 to 0.07). (b) Coefcients of association between infection intensity and haemoglobin levels among infected compared
to non-infected children (n = 1313), adjusted for age group, sex, weight and height. * P = 0.027 (95% CI: 0.60 to 0.04).

4.1. Strengths and limitations abdominal pain, bloody diarrhoea and watery diarrhoea), clini-
cal morbidities (e.g. big belly, pale sub-conjunctiva, tenderness
Our study has several strengths and limitations that are offered of abdomen, hepatomegaly and splenomegaly), quantication of
for discussion. A major strength is the rigorous appraisal of mor- Hb levels for assessment of anaemia and examination of malnu-
bidity, including self-reported morbidities (e.g. abdominal bloating, trition. An additional strength is the analytical approach taken
 S. Sayasone et al. / Acta Tropica 141 (2015) 322331 329

(i.e. multi-variate analysis), which allowed for adjustment of episodes, pale sub-conjunctiva, hepatomegaly and splenomegaly
potential confounders, such as demographic, socioeconomic and obtained from clinical examination. Furthermore, our models
personal behavioural data. revealed the signicantly lower mean of Hb among children, who
In terms of limitations, the following issues must be emphasised. had hookworm, O. viverrini and S. mekongi infection, compared to
First, we employed a cross-sectional study design, and hence we non-infected children. These ndings are in agreement with pre-
cannot infer causality. Second, our diagnostic approach consisted vious reports published elsewhere (Degarege et al., 2014; Righetti
of the collection of a single stool sample per child that was sub- et al., 2013). Indeed, hookworm infection and schistosomiasis cause
jected to duplicate Kato-Katz thick smear examination. Clearly, chronic intestine inammation with continued intestinal blood
collection of multiple consecutive stool samples (instead of single loss (Gyorkos et al., 2011; Larocque et al., 2005; Ngui et al., 2012;
specimens), examination of triplicate or quadruplicate Kato-Katz Righetti et al., 2013) and are thus drivers of anaemia (Chen et al.,
thick smears per sample (instead of duplicate Kato-Katz thick 2012; Ngui et al., 2012; Pasricha et al., 2008).
smears) and use of multiple diagnostic methods (e.g. Kato-Katz plus Third, multiparasitism has previously been shown to be a poten-
ether-concentration techniques instead of Kato-Katz only) would tial cause for child anaemia and malnutrition. Even with light
have resulted in higher diagnostic accuracy (Knopp et al., 2008; infection intensity, the impact on health is considerable (Bustinduy
Lovis et al., 2012; Steinmann et al., 2008). Third, we did not assess et al., 2013; Degarege et al., 2014). In this study, the results conrm
childrens daily food consumption patterns. However, such pat- that multiple helminth infections concurrently were signicant
terns play an important role in childrens malnutrition, because predictors for occurrence of clinical morbidities such as watery
consumption of a diverse diet including animal meat products diarrhoeal episodes, abdominal discomforts, hepatomegaly and
are associated with lower odds of stunting and underweight, as splenomegaly. Moreover, they were also signicantly associated
shown in neighbouring Cambodia (Darapheak et al., 2013). Fourth, with anaemia and a low BMI for age among the study children.
anaemia is the consequence of multiple causes, which interact with However, no statistically positive association between helminth
each other in a complex manner. Among these factors are the inher- infections and stunting, underweight as well as wasting has been
ited haemoglobinopathies of primary importance in Lao settings found in this study. Similar ndings of not statistically association
(Savongsy et al., 2008; Tritipsombut et al., 2012). It must be noted between helminth infections and malnutrition have been previ-
that using a haemoglobin photometer for Hb measurement, the ously observed elsewhere in Nigeria (Oninla et al., 2010) and in
identication of the exact type of anaemia and the fraction of iron- Kenya (Bustinduy et al., 2013). It is widely acknowledged that in
deciency anaemia is not possible. Only the latter is associated developing countries, malnutrition is multi-factorial and it is dif-
with helminth infections (Brooker et al., 2008; Ngui et al., 2012). cult to establish its causal link (Bustinduy et al., 2013; Oninla et al.,
Fifth, we made no attempts to diagnose for other concurrent infec- 2010). In the present study, we found that the socioeconomic status
tions, such as Plasmodium spp. (the causative agent for malaria), of family predicted signicantly a childs stunting and the occur-
bacteria and viruses. Yet, infections with these pathogens and co- rence of watery and bloody diarrhoeal episodes were predictors of
infection with helminths could have affected childrens nutritional wasting.
status, self-reported morbidity and general health (Becker et al.,
2013; Manning et al., 2012; Mondal et al., 2012). However, given
5. Conclusion
the large number of children examined and limited human and
nancial resources for the current study, it was operationally not
We conclude that helminth infections and malnutrition are
feasible to diagnose all these infections.
highly prevalent among children living in the rural districts of
Champasack province, and most likely elsewhere in Lao PDR.
4.2. Policy implications
Helminth infections and multiparasitism are signicantly associ-
ated with observed morbidities. We believe that these morbidities
Our ndings have important bearings on policy. First, the high
can be resolved if adequate control measures are in place such
rates of specic helminth infections (i.e. hookworm and O. viver-
as health education, coupled with periodic de-worming, micronu-
rini) and the extent of multiparasitism at the time this study was
trient supplementation, improving access to clean water and
carried out in the southern part of Lao PDR is alarming. Our ndings
sanitation.
are in line with previous reports (Chai et al., 2007; Eom et al., 2014;
Sayasone et al., 2009, 2011), which call for urgent public health
measures to remedy this situation. Our observations and results Author contributions
reported by other investigators before provide a strong rationale for
scaling-up helminthiases control measures in Lao PDR and Cham- SS and PO conceived and developed the study; SS analysed the
pasack province in particular. In fact, the deworming programmes data and interpreted results together with PO; SS and PO drafted
targeting school-aged children and more recently preschool-aged the manuscript; JU and KA assisted with manuscript revision; all
children were initiated in 2005, but Champasack province was only authors read and approved the nal submitted manuscript; SS and
included in the late 2007, hence, just after the launch of the current PO are guarantors of the paper.
study (Phommasack et al., 2008). In the meantime, the deworming
programme has gone to scale (Lao PDR, 2014; Phommasack et al.,
2008). It will be interesting to reassess the helminthiasis situation Acknowledgements
nowadays. Repeated rounds of deworming might have improved
childrens health status, particularly in children under the age of We are grateful for the contributions of the population in
5 years, who are at highest risk of morbidity (Bryce et al., 2005). the districts of Sanasomboun, Phonthong, Bachieng, Champasack,
In addition, most recently, several pilot interventions focussing on Soukhouma, Pathoumphone, Paksong, Mounlapamok and Khong,
multiple parasitic infections and using ecohealth approaches were and the support of the curative and preventive health authorities
implemented. The results of their evaluation will contribute to the of the various locations. We acknowledge the support of technical
wider discussion how multi-parasitic infection is best addressed. staffs from the Centre for Malariology, Parasitology and Entomol-
Second, our ndings showed that a single helminth species ogy, the Department of Parasitology, University of Health Sciences,
infection negatively affects the health of children. S. mekongi infec- the Ministry of Health, Vientiane and the Champasack Provincial
tion was signicantly associated with reported bloody diarrhoeal Malaria station who helped with the stool sample examinations.
330 S. Sayasone et al. / Acta Tropica 141 (2015) 322331

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