UNIVERSITY OF GHANA, LEGON COLLEGE OF BASIC AND APPLIED SCIENCES DEPARTMENT OF ANIMAL BIOLOGY AND CONSERVATION SCIENCE IMPACT OF COVID-19 OUTBREAK ON THE PREVALENCE OF SOIL TRANSMITTED HELMINTHS AMONG SCHOOL CHILDREN IN THE VOLTA REGION OF GHANA. BY VORSAH ROBINSON YAW 10469852 THIS THESIS SUBMITTED TO UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PHILOSOPHY IN APPLIED PARASITOLOGY. DECEMBER, 2021 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I hereby declare that this thesis presented to the Department of Animal Biology and Conservation Science in partial fulfilment for the award of M. Phil. Degree, is a true account of my own work except for the references that have been duely acknowledged. Signature: ……………………………………… Date: ………………………… Name: ROBINSON YAW VORSAH (STUDENT) Signature: ……………………………………… Date: …………………………… Name: Dr. ISAAC FRIMPONG ABOAGYE (SUPERVISOR) Signature: Name: Dr. DANIEL ODURO (SUPERVISOR) Date: January 24, 2022 University of Ghana http://ugspace.ug.edu.gh ii DEDICATION I would want to dedicate this work first and foremost to the Almighty God, and secondly to my parents, Mr. and Mrs. Vorsah. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENTS My heartfelt gratitude goes to the Almighty God for his Grace, strength, mercies and wisdom during the duration of this effort. My sincere thanks go to my supervisors, Dr. Daniel Oduro and Dr. I. F Aboagye, for their time, insight, and encouragement during my research. I am extremely thankful to Dr. Benjamin Ofori-Yeboah and Jones Quartey for their invaluable assistance, guidance, patience, and criticism during my work. God bless you abundantly. My heartfelt thanks also go to the headmaster and all of the staff at Jim Bourton Memorial Agricultural SHS for allowing me to use their laboratory for the diagnostic work. I would want to express my gratitude finally to all of the lecturers, laboratory technicians and colleagues in the Department of Animal Biology and Conservation Science at the University of Ghana, Legon, who made this research a success. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION ..................................................................................................................................... i DEDICATION ........................................................................................................................................ ii ACKNOWLEDGEMENTS ....................................................................................................................iii TABLE OF CONTENTS ....................................................................................................................... iv LIST OF ABBREVIATIONS ................................................................................................................ ix ABSTRACT ............................................................................................................................................ x CHAPTER ONE ..................................................................................................................................... 1 1.0 INTRODUCTION ...................................................................................................................... 1 1.1 Background of the Study ............................................................................................................... 1 1.2 Problem and justification of the study .......................................................................................... 5 1.3 Objectives of the study .................................................................................................................. 6 1.3.1 General objective ....................................................................................................................... 6 1.3.2 Specific objectives ..................................................................................................................... 6 CHAPTER TWO .................................................................................................................................... 7 2.0 LITERATURE REVIEW ........................................................................................................... 7 2.1 Global Distribution of Soil Transmitted Helminthiasis ................................................................ 7 2.2 Conceptual framework of helminth infection ............................................................................... 8 2.3 Helminths Classification ............................................................................................................... 9 2.3.1 Nematodes ................................................................................................................................. 9 2.3.2 Trematodes ............................................................................................................................... 10 2.3.3 Cestodes ................................................................................................................................... 10 2.4 Hookworms (Ancylostoma duodenale and Necator americanus) ............................................... 10 2.4.1 Morphology of Hookworms..................................................................................................... 11 2.4.2 Life cycle of Hookworm .......................................................................................................... 12 2.4.3 Transmission of Hookworm ..................................................................................................... 13 2.4.4 Pathology associated with hookworm ...................................................................................... 14 2.4.5 Clinical Manifestation of hookworm ....................................................................................... 15 2.4.6 Diagnosis of hookworm ........................................................................................................... 15 2.5 Ascaris lumbricoides ................................................................................................................... 16 2.5.1 Morphology of Ascaris lumbricoides ...................................................................................... 16 2.5.2 Life cycle of Ascaris lumbricoides .......................................................................................... 17 2.5.3 Transmission of Ascaris lumbricoides ..................................................................................... 18 2.5.4 Pathology associated with A. lumbricoides .............................................................................. 19 University of Ghana http://ugspace.ug.edu.gh v 2.5.5 Clinical Manifestation of Ascaris lumbricoides ....................................................................... 19 2.5.6 Diagnosis of Ascaris lumbricoides .......................................................................................... 20 2.6 Trichuris trichiura……………………………………………………………………………20 2.6.1 Morphology of Trichuris trichiura .......................................................................................... 21 2.6.2 Life cycle of Trichuris trichiura .............................................................................................. 21 2.6.3 Transmission of Trichuris trichiura ......................................................................................... 22 2.6.4 Pathology associated with Trichuris trichiura ......................................................................... 22 2.6.5 Clinical Manifestation of Trichuris trichiura .......................................................................... 23 2.6.6 Diagnosis of Trichuris trichiura .............................................................................................. 23 2.7 Prevention and Control of intestinal parasites ............................................................................. 23 2.8 Risk Factors for Soil Transmitted Helminths .............................................................................. 25 2.9 Sanitation and STH infections .................................................................................................... 26 2.10 Hygiene and regular handwashing ............................................................................................ 27 2.11 Morbidities associated with soil-transmitted helminthiasis ...................................................... 28 2.12 Educational background associated STH infection ................................................................... 28 2.13 Climate, Water, Season and STH infection ............................................................................... 29 2.14 Effects of STH in preschool children ........................................................................................ 29 2.15 Diagnostic Method in Parasitological Laboratory ..................................................................... 30 2.15. 1 Concentration methods ......................................................................................................... 30 2.15.2 Kato-Katz technique............................................................................................................... 31 2.15.3 Baermann technique............................................................................................................... 31 2.15.4 Molecular diagnosis ............................................................................................................... 32 2.16 COVID 19 impact on STHs Programmes ................................................................................. 32 CHAPTER THREE ............................................................................................................................... 35 3.0 MATERIALS AND METHOD ...................................................................................................... 35 3.1 Ethical approval .......................................................................................................................... 37 3.2 Study design ................................................................................................................................ 38 3.4 Inclusion criteria ......................................................................................................................... 38 3.5 Exclusion criteria ........................................................................................................................ 38 3.6 Sample size determination and Sampling Technique ..................................................................... 39 3.7 Data and stool collection ............................................................................................................. 39 3.9 Laboratory Procedure .................................................................................................................. 39 3.10 Identification of Helminths Eggs .............................................................................................. 40 3.11 Data Processing ......................................................................................................................... 40 3.12 Data Analysis ............................................................................................................................ 41 CHAPTER FOUR ................................................................................................................................. 42 University of Ghana http://ugspace.ug.edu.gh vi 4.0 DESCRIPTION OF RESULTS ...................................................................................................... 42 CHAPTER FIVE ................................................................................................................................... 53 5.0 DISCUSSION ................................................................................................................................. 53 5.1 Limitation of the study ............................................................................................................ 59 CHAPTER SIX ..................................................................................................................................... 60 6.0 CONCLUSION AND RECOMMENDATIONS............................................................................ 60 6.1 Conclusion .................................................................................................................................. 60 6.2 Recommendations ....................................................................................................................... 60 REFERENCES ..................................................................................................................................... 61 APPENDICES ...................................................................................................................................... 85 University of Ghana http://ugspace.ug.edu.gh vii LIST OF TABLES Table 4.1: Sociodemographic characteristics of parents and school children .......................... 41 Table 4.2 Comparison of (STH) infections in school-aged pupils of Afadjato South and Ho West district during COVID-19 outbreak ................................................................................ 42 Table 4.3: Prevalence of soil-transmitted helminths infections among age and sex of school children .................................................................................................................................... 44 Table 4.4: Prevalence and univariate analysis of factors associated with STH infection by simple logistic regression for Ho West District ....................................................................... 47 Table 4.5: Prevalence and univariate analysis of factors associated with STH infection by simple logistic regression for Afadjato South .......................................................................... 48 Table 4.6: Administration of anti-helminthic drugs to school children before and during COVID-19 outbreak (responses of parents) ............................................................................ 50 Table 4.7: Administration of anti-helminthic drugs and soil-transmitted helminth (STH) infections in school-aged pupils during COVID-19 outbreak ................................................. 51 University of Ghana http://ugspace.ug.edu.gh viii LIST OF FIGURES Figure 2.1: Conceptual framework of helminths infestation among school-going children. ..... 8 Figure 2.2 : Life cycle of Hookworm (Source: www.cdc.gov) ................................................ 13 Figure 2.3: Life cycle of Ascaris lumbricoides (Source: www.cdc.gov) ................................. 18 Figure 2.4: Life cycle of Trichuris trichiuria (Source: www.cdc.gov).................................... 22 Figure 3.1: Study area showing selected areas for the study ................................................... 36 Figure 4.1: Prevalence of soil transmitted helminths among school children in the Ho West and Afadjato South districts ............................................................................................................ 43 Figure 4.2: Respondents’ place of going to toilet .................................................................... 45 Figure 4.3: Respondents’ last time of taking anthelminthic drugs .......................................... 46 University of Ghana http://ugspace.ug.edu.gh ix LIST OF ABBREVIATIONS CDC Centre for Disease Control DALYs Disability adjusted life years GIT Gastro-intestinal tract GBD Global Burden of Disease GSS Ghana Statistical Service MDA Mass Drug Administration NTD Neglected Tropical Disease SSA sub-Saharan Africa STH Soil-transmitted helminth WHO World Health Organization FAO Food and Agriculture Organization PCR Polymerase Chain Reaction SD Standard deviation SPSS Statistical Product and Service Solutions RPM Revolutions per minute YLLs Years of life lost MRCP Magnetic Resonance Cholangiopancreatography OR Odd ratio University of Ghana http://ugspace.ug.edu.gh x ABSTRACT Soil-transmitted helminths (STHs) continue to pose a substantial health risk to humans, particularly children, all over the world, with the majority of cases occurring in underdeveloped countries. This study, carried out from March to April 2021, investigated the impact of the COVID 19 pandemic on STH infections among primary school children in the Ho West and Afadjato South Districts in the Volta Region of Ghana using stool examination, microscopic techniques and administered questionnaire. The parasitological examination of 347 stool samples showed that 144 (41.5 %) were positive for STHs: hookworm (Necator americanus and Ancylostoma duodenale) (21.9%), Trichuris trichiura (10.4%) and Ascaris lumbricoides (9.2%). The risk of STH infection among females was observed to be higher compared to males (OR = 3.69; 95% CI =1.48-9.20; p = 0.005) In the Ho West district, school children who used blade to cut their nails are less likely at risk to helminth infection than those who bite their nails in Ho West district (OR= 0.26; CI = 0.93- 0.70; p= 0.008 but there was no significant association between potential risk factors and STH infections in the Afadjato South District. More parents reported anthelminthic drug administration to their children before COVID- 19 outbreak compared to during COVID-19 outbreak (χ² (df) =31.04(1), p <0.0001). Eighty- one of school children in both districts (84%) were positive for Trichuris infection, there was a significant difference between parent’s response and Trichuris infection among those who administered anthelminthic drug before and during COVID-19 (p <0.0001). The high prevalence of STHs infections among primary school children calls for education on the proper hygiene habits and regular deworming exercise among residents in the study area. University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background of the Study More than 1 billion people living in underdeveloped countries are estimated to be infected with at least one species of soil-transmitted helminths (STHs) globally (WHO, 2017). The common STHs that infect individuals are Ascaris lumbricoides, Trichuris trichiura, and hookworm species (Necator americanus and Ancylostoma duodenale) (WHO, 2018). Ascaris lumbricoides cases recorded are about 800 to 1000 million, 500 million reported Trichuris trichiura cases, 700 to 900 million hookworms cases reported (Wekesa et al., 2014). Due to their high prevalence, chronic, and debilitating characteristics (Njenga et al., 2011), these diseases presently are classified as Neglected Tropical Diseases (NTDs) by the World Health Organization (WHO, 2002). Heavy helminth infection affects around 300 million individuals globally, causing severe morbidity and mortality in the range of 10,000 to 135,000 persons each year (Lustigman et al., 2012). The helminthic parasites N. americanus and A. duodenale cause human hookworm infestation, with an estimated 1.3 billion cases worldwide and 65,000 deaths annually and is the most common chronic infection (Mehraj et al., 2008). Hookworm infections are characterized by blood loss, iron deficiency and anaemia. Ascariasis is caused by A. lumbricoides, which is linked to a high risk of morbidity due to medical and surgical difficulties, as well as allergic reactions (Abera & Nibret, 2014). A. lumbricoides is projected to cause 1.471 billion cases of illness and 65,000 deaths worldwide. Trichuris trichiura lives in the colon and rectum and is as common as Ascaris. In people with a high infestation of Trichuris, the inflammatory alterations have been linked to rectal prolapse, chronic dysentery, and poor growth. 1 University of Ghana http://ugspace.ug.edu.gh 2 In children, STHs are not only considered to be a major cause of morbidity, but also, they are disproportionately impacted by STH, and afflicted children are typically underweight and anaemic as a result of the nutritional consequences. In Ghana, anaemia in children is a public health concern. Anaemia affects 76% of children in Ghana under age five, 73% aged between 2 to 10 years, and 63% of schoolchildren between ages 5 to 12 years (Egbi et al., 2014). Intestinal helminthiasis is believed to aggravate pre-existent anaemia by lowering appetite and, as a result, food and iron consumption (Baidoo et al., 2010; Bondevik et al., 2000). Epidemiologically, it is widely documented that while worms may be found in people of all age groups, children in rural regions have the highest rates of infections (Bethony et al., 2006). Children behaviour is also a major risk factor for STHs infection. Children are typically highly energetic, playing unsupervised in soil and other things in their surroundings. Helminth control programs is an excellent target among school children and schools provide an ideal setting for control program execution since children are at a higher risk of helminth infection (Ojurongbe et al., 2014). Poor personal hygiene and environmental factors like pollution of environment and water bodies with human faeces as well as the use of night soil as fertilizer all contribute to the transmission of parasitic infection to people via the faecal-oral route (Gungoren et al., 2007). Furthermore, they are mostly spread by contaminated fingernails and flies (Nyarango et al., 2008). They are particularly common in areas with warm, humid weather, as well as poor sanitation and hygiene. Human health and the socioeconomic conditions of impacted populations are both affected by soil-transmitted helminths. In endemic populations, STH infections tend to follow an "over scattered" pattern, with significant worm loads in a few people and little or absence of infection. Children with high University of Ghana http://ugspace.ug.edu.gh 3 worm load prefer to congregate in families or homes (Bethony et al., 2006; Dold and Holland, 2011). Each of these nematode species has a direct life cycle and is soil-transmitted, meaning that the eggs or larvae responsible for transmission become infective after a required period of development in the soil. Due to the similarity in transmission and geographical spread of such helminths, many people get single, double, or triple infections. The maintenance of a continuous life cycle needs the presence of soil and eggs must embryonate in the soil to become infective in humid and wet conditions, and the embryonation duration varies per helminth species. The eggs of hookworm species, for example, can take up to 14 days to embryonate. Trichuris trichiura eggs need between 20 and 100 days to become viable, while Ascaris lumbricoides eggs take between 8 and 37 days. Suitable moisture and a warm temperature are required for larval growth in the soil, and climate is a major driver of infection transmission. Poverty, as well as insufficient water and sanitation, are significant factors. STH species are frequently co-endemic in such environments (Nguhiu et al., 2009). University of Ghana http://ugspace.ug.edu.gh 4 COVID-19 outbreak has implications for health systems and initiatives, mainly in inhabitants where neglected tropical diseases such as STH infections are endemic. In areas where soil- transmitted helminths are endemic, the COVID-19 pandemic will have an impact on health systems and initiatives. Neglected Tropical Diseases (NTDs), such as STH surveys, detection of active cases, and mass drug administration programs suspended, according to WHO advise, but diagnosis, treatment, and critical control of vector must carry on when practicable (WHO, 2020). The COVID-19 pandemic, with its severe public health impact, is without a doubt deserving attention. However, in current times, the diagnostic and therapeutic prerequisites for STH must not be overlooked, since many more people are living with them. The government of Ghana's initiatives under the ministry of health has concentrated on deworming mainly in schools to decrease the morbidity related to STH infections for school children primarily living in endemic areas. STH transmission in preschool children has been reduced as a result of deworming through school programs (Obala et al., 2013). Improved water sanitation and hygiene appear to be a long- term sustainable control strategy for soil-transmitted helminths. Despite efforts being made to increase hygiene and access to clean water, the WHO control strategy for STH focuses on (MDA) to control and eventually eliminate STHs (Strunz et al., 2014). The Ministry of Health's current deworming program is only for school-aged children; therefore, occupational children who are not in school may continue to be the bases of infection all over the year (Humphries et al., 2011). University of Ghana http://ugspace.ug.edu.gh 5 1.2 Problem and justification of the study STH prevalence is about 30% in sub-Saharan Africa and is reported to be 50% in North-eastern part of Ghana (Humphries et al., 2011). Heavy infections of STHs are linked to iron deficiency anaemia, stunted growth, cognitive impairment and malnourishment in school-aged children and immune-compromised individuals (Teklemariam et al., 2014). The current global priority is to prevent people from becoming infected with coronavirus and to treat those who have been infected. This has disrupted other health-related activities, such as NTD control and elimination programs, resulting in postponement of mass drug administration campaigns around the world. The COVID-19 pandemic has disrupted NTD programs in the year in which celebrating achievements towards 2020 goals should be achieved (WHO, 2020). The global economic, social, and health effects of the COVID-19 pandemic will be felt for a long time. In the case of STHs, it may result in reinfections as a result of delayed treatment. The effects of this disturbance, along with the epidemic, will reverberate for years. However, the administration of anthelmintic drugs and the impact of COVID-19 outbreak on these helminth infestations in school children and associated risk factors has not been reported in Ghana. Helminth infestation such as STHs is regarded as neglected tropical disease that receives less study and funding worldwide, including Ghana. STHs have been linked to stunted development, malnutrition, and cognitive impairment in children in Sub-Saharan Africa, according to many studies (Ojha et al., 2014). All of these factors have an impact on children's health and, as a result, their academic performance in school in the countries. University of Ghana http://ugspace.ug.edu.gh 6 COVID-19 outbreak will place an extra burden on healthcare systems and programs in areas where soil-transmitted helminths are endemic. 87% of student population in the world is affected by the pandemic leading to closure of schools and over 1.5 billion students in 195 countries are affected by COVID-19 outbreak reported by UNESCO (2020b). STH surveys and MDA activities has been suspended as advised by (WHO) while diagnosis, prompt treatment and control of vector should continue where necessary at areas where STHs are endemic (WHO, 2020). Diagnostic and treatments for STHs must not be overlooked during the outbreak, since a lot of lives are likely to be affected and lost through neglect. This study will investigate Soil-Transmitted Helminths infection in school children in this era of COVID- 19 outbreak and the use of anthelmintic drug administration. 1.3 Objectives of the study 1.3.1 General objective: To determine the impact of COVID-19 outbreak on the prevalence of Soil-Transmitted Helminths in school children the Ho West and Afadjato South of the Volta Region. 1.3.2 Specific objectives: 1. To determine the prevalence of STH infections during COVID-19 outbreak in Ho West and Afadjato South of the Volta Region. 2. To determine associated risk factors with STH among school children in (2) two districts in the Volta Region. 3. To assess the impact of COVID-19 outbreak on the administration of anti-helminthic drugs to school children. University of Ghana http://ugspace.ug.edu.gh 7 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Global Distribution of Soil Transmitted Helminthiasis In the Americas and high-income Asian countries, there has been a significant decrease in the prevalence of STH infections, this trend is until now to commence in sub-Saharan Africa (Chammartin et al., 2013; De Silva et al., 2003). Warm temperatures and moisture in the soil are critical for the development of infective larvae (Bethony et al., 2006), which explains why tropical and sub-tropical locations have such a high prevalence. Inadequate water supply, sanitation, and poor hygiene are all major socioeconomic factors (Strunz et al., 2014; Dunn et al., 2016) that influence the spread of STH infections. Poverty is also a significant factor in STH infections (Ngui et al., 2011; Ngui et al., 2012). STHs affect an estimated 4.5 billion people globally; 2 billion are infected, 135,000 people lose their lives annually (De Silva et al., 2003). About a third of the world's populace is infected with roughly 20 major helminth diseases (Awasthi et al., 2003). A total of 875 million school children are likely to be at risk of STH infection, with 30% of them being pre-schoolers and 70% being school children (Barry et al., 2013). It is estimated that it has cost the globe at least 6.4 million (Disability Adjusted Life Years), with 1.7 million in sub-Saharan Africa, however, the disease burden has become increasingly concentrated in countries with low income as a result of this reduction, which is mostly concentrated in upper-middle-income countries (Stolk et al., 2016). According to estimates, 117.9 million, 117.7 million, and 100.8 million persons in sub-Saharan Africa are infected with A. lumbricoides, hookworms, and T. trichiura, respectively (Pullan et al., 2014). Togo and Sierra Leone have the most hookworm infections, whereas Gabon and Rwanda have the most T. trichiura and A. lumbricoides infections (Karagiannis-Voules et al., 2015). University of Ghana http://ugspace.ug.edu.gh 8 Hookworm prevalence in sub-Saharan Africa ranges from 30% to 50% (De Silva et al., 2003); in the Ghana's middle belt the prevalence of helminth infection is quite comparable, at 45%. Infection with other helminths infections such as Hymenolepis nana, and Taenia solium is seen in 3% of people (Humphries et al., 2011). 2.2 Conceptual framework of helminth infection Figure 2.1: Conceptual framework of helminths infestation among school-going children. The framework in Figure 1.1 tackles the different factors that might lead to an infection of STH among schoolchildren. Children frequently play in soil, which is home to these parasites. If Educational level Access to toilet facility Handwashing after visiting the toilet Occupation of parent Soil transmitted helminths infection Cultural Factors Socio economic factors Wearing of footwear Age Regular cutting of finger nails Place of residence University of Ghana http://ugspace.ug.edu.gh 9 fingernails are not correctly trimmed and handwashing is not done immediately after playing in the soil, children will be exposed to these soil-transmitted helminths. Children's residential location has more to do with their family's poverty, which might have an impact on their helminth infection because these parasites thrive in poor and congested environments. Also, because hookworm is most commonly spread by going barefooted, children who do so are at risk of contracting parasitic infection. 2.3 Helminths Classification Helminths are invertebrates characterized by flat and elongated bodies. They are classified based of the place of habitat in the host organ, in the case of tapeworm and roundworms which reside in the intestine of the host (Mehraj V et al., 2008). The Digenean Flukes (Trematode), Roundworms (Nematodes) and Tapeworms (Cestodes), are the three types of helminths which have humans as their primary host. 2.3.1 Nematodes One of the major phyla harbouring parasites is Nemata. The general features of nematodes include bilateral symmetry and cylindrical form with tapering ends, lack of segmentation, circular coating, sexual dimorphism, and dioecy, however there are a few exceptions (Roberts and Janovy, 2009). Roundworms, often known as nematodes, may be divided into two categories. Tissue nematodes and intestine nematodes are two types of nematodes. Enterobius vermicularis (threadworm), Ascaris lumbricoides (roundworm), hookworm (Ancylostoma duodenale and Necator americanus) and Trichuris trichiura (whipworm) are among the intestinal nematodes (Cheesbrough, 2006). Nematodes are characterized by a smooth, spined, or ridged cuticle and a body cavity. Some species' adults are extremely long. University of Ghana http://ugspace.ug.edu.gh 10 2.3.2 Trematodes Trematodes (flukes) have small flat leaf-like bodies with no have a body cavity and are dorsoventrally flattened with bilateral symmetry. Most species are hermaphroditic, meaning they have both male and female reproductive organs with the exception of blood flukes. Before reaching the adult stage flukes go through several larval stages. Most flukes’ infections in human are caused by Schistosoma species, liver flukes such as Fasciola hepatica. 2.3.3 Cestodes Cestodes, often known as tapeworms, are flat, "segmented" worms that suck nutrition straight from the intestines of their hosts. A scolex, which adheres to the intestinal mucosa of its host, a neck, and strobila make up the tapeworm's body (Roberts and Janovy, 2009). Cestodes have an elongated, regular ribbon-like body with a distinct scolex and several segments. The absence of an alimentary canal is a distinguishing trait of adult tapeworms, which is fascinating given that all of these adult worms reside in the small intestine. According to estimates, the group has more over 20,000 described species, which is likely still a small percentage of the actual number of species (Caira and Littlewood, 2001). 2.4 Hookworms (Ancylostoma duodenale and Necator americanus) Hookworm, like any parasitic worms, takes their name from the hook-like appendages that surround their mouths (Stephenson et al., 2009). In 2015, over 428 million individuals were afflicted with hookworms, according to the Global Burden of Disease report (GBD, 2015). Necator americanus and Ancylostoma duodenale are the main hookworm species that infect people (Olaniran et al., 2015). Adult A. duodenale worms are greyish white or pink in color, and have a slightly twisted head. They have two sets of teeth and a well-formed mouth. Females University of Ghana http://ugspace.ug.edu.gh 11 are longer and stouter than males, measuring about 1 centimeter by 0.5 millimeters. N. americanus has been discovered to be more common than A. duodenale around the world (Jiraanankul et al., 2011). N. americanus is the most common hookworm in sub-Saharan Africa, Southeast Asia, and the Americas, while A. duodenale is found only in China and India. Anaemia is a common symptom of hookworm disease (Brooker et al., 2004). Anaemia is dangerous especially in children and those that are who are also malnourished (Brooker et al., 2004). Chronic infection in people who are not malnourished, can induce a drop in haemoglobin levels (Santos et al., 2013). Eosinophilia is produced in large quantities by hookworm infections. However, adult parasite attaches itself to the small intestine's mucosa and submucosa, causing voracious blood sucking, is a major pathophysiology of hookworm infection. Delay in puberty, dry skin and oedema, are all symptoms of severe protein deficiency in children (Wang et al., 2012). Men have a higher prevalence of hookworm than females (Santos et al., 2013), males participate in activities that endanger them at increased risk of infection. 2.4.1 Morphology of Hookworms Hookworms are grouped together since they are both found all over the world and have overlapping geographic distributions; eggs of both species are similar and are not distinguishable under a microscope (Hall et al., 2008). As a result, they have been referred to as hookworm in the past and treated as one and the same (WHO, 2002b). Although Necator americanus and A. duodenale have many physical similarities, N. americanus is generally smaller than A. duodenale, females measure around 1 centimeter and males measuring about 5 to 9 millimeters. In addition, the hook form in N. americanus is significantly more defined compared to A. duodenale (Markell et al., 2006). Adult Ancylostoma duodenale worms are cylindrical, elongated, and thin. They are greyish-white in colour but when freshly passed out University of Ghana http://ugspace.ug.edu.gh 12 from the body, the worms appear reddish brown due to ingested blood. Hookworms get their name from the fact that their anterior end is somewhat twisted dorsally. Ancylostoma duodenale males and females are different and show sexual dimorphism. Females are bigger than males. The female has a narrower caudal end due to the existence of bursa copulatrix, whereas the male has a broader caudal end due to the presence of bursa copulatrix (copulatory bursa). The form, buccal capsule, and amle bursa are the main physical distinctions between the species. Anterior to the vulva is the vulva. 2.4.2 Life cycle of Hookworm Ancylostoma duodenale and Necator americanus are the most common human hookworm infections (Brooker et al., 2004), with the latter accounting for more than 85 percent of all hookworm infections (Tang et al., 2014). The larvae develop in 1 to 2 days if the eggs are passed in the faeces and the circumstances are favourable, shade, moisture and warmth. After 5 to 10 days, rhabditiform larvae are releases and they develop in the faeces or dirt. They molt twice more before becoming infective third-stage larvae (IL3). The female hookworms mate and generate to about 10,000 eggs daily, and they depart the body of the host in the faeces which may pollute the soil and water if released. The egg hatches in the soil, releasing a larva that passes through many stages before infecting a new host. Hookworm enters a human through the skin, grows and develops, and prefers to reside in the duodenum. The larvae enter the skin when they come into touch with a human host (Logan, 2009) and later transported through the blood arteries and moves to the heart and subsequently to the lungs. They enter the pulmonary alveoli after skin penetration, move to the pharynx through the bronchial tree, and reside in the small intestines, where they mature into adults. University of Ghana http://ugspace.ug.edu.gh 13 Figure 2.2: Life cycle of Hookworm (Source: www.cdc.gov) 2.4.3 Transmission of Hookworm Since hookworm infection is spread by hookworm eggs contaminating the environment, risk of infections is likely to include poor hygiene (Traub et al., 2004; Gunawardena et al., 2005 and Asaolu and Ofoezie, 2003;), low level of education (Mihrshahi et al., 2009; Liabsuetrakul et al., 2009) and sanitation levels around the environment (Ensink et al., 2005) which are the main drivers for the transmission of hookworm. Hookworm transmission is highest along the world's coasts, infective third-stage larvae may readily move areas where temperature and moisture are ideal for larval survival in the soil (Mabaso et al., 2003). Infectious larval stages (third stage larvae or L3) residing in the soil enter through the epidermis of the skin (Haas et al., 2005) in the case of N. americanus and A. duodenale but ingestion of hookworm larvae only occurs in A. duodenale (Zeehaida et al., 2011; Brooker et al., 2004; Olsen et al., 2009). Children are realtively active and they usually University of Ghana http://ugspace.ug.edu.gh http://www.cdc.gov/ 14 play in the soil with their bare hands, hence they are at a high risk of becoming infected with hookworm (Jiraanankul et al., 2011). Hook worm larvae that have penetrated the human skin produce severe itching and irritation. Skin lesions in the form of papules and blisters develop as a result of this disease. Hookworm is more frequent in agricultural households, involving the extensive use of faeces as a night soil fertilizer, as well as among vegetable producers and farmers. Oral transmission can occur when food is consumed that has been inadequately cleaned or has been exposed to faecal contaminated soil. Transmission between a mother and her foetus or infant can also happen (rarely) through contaminated placental or mammary tissue. 2.4.4 Pathology associated with hookworm Since adult worms are hematophagous, the most common complication of these infections are intestinal blood loss, which can result in iron deficiency anaemia. Although blood loss appears to be reduced in N. americanus infections, as predicted, 40 mature worms can decrease haemoglobin levels to below 11 g/dL (Bethony et al., 2006). By causing intestinal bleeding, adult hookworms induce morbidity in their hosts (Hotez et al., 2004). Matured hookworms consume a large proportion of blood, break erythrocytes, and destroy haemoglobin (Williamson et al., 2003). Hookworm infection can affect people of all ages, although children, adolescents and pregnant women are especially vulnerable to hookworm morbidity due to their high physiological needs for iron (Dobardzic et al., 2002). Severe anaemia in pregnant women can put the mother's life, the foetus’s life, and the neonate's life at jeopardy (Bethony et al., 2006; Brooker et al., 2008; Gyorkos et al., 2011a; Brentlinger et al., 2003). Since hookworms cannot reproduce in humans, patients with huge numbers of adult parasites have the highest hookworm morbidity. University of Ghana http://ugspace.ug.edu.gh 15 Quantitative faecal egg counts are commonly used to estimate the severity of hookworm infection. 2.4.5 Clinical Manifestation of hookworm A mild hookworm infection typically causes no symptoms, but a moderate or severe hookworm load can cause tiredness, recurring stomach discomfort, and iron deficiency anaemia. Repeated skin contact with hookworm L3 can produce a cutaneous condition known as "ground itch" (Brooker et al., 2004), which can cause sleep disruption due to severe itching (Jackson et al., 2006). Clinical characteristics are thought to correspond to the parasite's life cycle and the severity of infection (Strickland, 2000). The first symptom is a burning, stringing, or grinding itch feeling caused by larvae penetrating the skin. Pruritis and a papulo vascular rash appear, which lasts for 1 to 2 weeks. Hypoproteinemia and anasarca severe widespread edema (Bethony et al., 2006; Hotez et al., 2004), stunted development, and causes a delay in puberty are other significant clinical signs of these diseases. 2.4.6 Diagnosis of hookworm Hookworm infection and diagnosis are mostly overlooked because patients are usually presented with non-specific gastrointestinal complaints. Since the eggs of both Ancylostoma and Necator appear identical, they are grown in the laboratory to allow larvae to hatch out in order to identify the genus (Markell et al., 2006). PCR tests are usually used to diagnose hookworm in the faeces using a molecular method since eggs of hookworm are often indistinguishable from other parasite eggs (Yong et al., 2007; Gasser et al., 2009). The larvae of hookworm eggs would hatch out if stool samples containing the eggs are left for more than a day under favourable conditions (Markell et al, 2006). University of Ghana http://ugspace.ug.edu.gh 16 The Kato-Katz thick smear, ether concentration method, sodium acetate-acetic acid-formalin solution, FLOTAC technique, and PCR are all used in the identification of hookworm eggs. The development of DNA-based methods for infection detection, precise hookworm identification, and the study of genetic variability within hookworm populations has been a focus in recent research (Gasser et al., 2009). 2.5 Ascaris lumbricoides Ascaris lumbricoides, is morphologically similar to earthworm. The global prevalence of ascariasis is estimated to be more than 1.3 billion people with over 250 million people suffering from related morbidity (Crompton and Savioli, 2007). Years of life lost (YLLs) owing to A. lumbricoides infections alone total 204,111 throughout the world (Lozano et al. 2012). The most often afflicted children are those aged 2 to 10 years, with the frequency decreasing beyond the age of 15. It has direct lifecycle and it’s the most important parasite of human and animals (Urquhart et al., 2003). Ascaris lumbricoides, is in the family Ascarididae and is closely linked to the Ascaris suum (swine parasite) (Roberts and Janovy, 2009a). It is found all throughout the world, and it is common in the tropical zones of Asia particularly India and China and in Africa. Adult worms generally live in the jejunum, although they are also found throughout the small intestine, especially in high numbers (Bethony et al., 2006). 2.5.1 Morphology of Ascaris lumbricoides Males of Ascaris lumbricoides measure 2–4 mm in diameter and 15–31 cm in length (Roberts et al., 2009). The male's tail is bluntly pointed and his posterior end is curved ventrally. Females University of Ghana http://ugspace.ug.edu.gh 17 have a width of 3–6 mm and a length of 20–49 cm (Roberts and Janovy, 2009). The vulva is found around the front end, makes up about a third of its total length. Fertilized eggs have a thick shell and are round to oval in form, measuring 44-74 micrometres long and 30-45 micrometres broad, but unfertilized eggs are 87-93 micrometres long and 43 micrometres wide (Roberts et al., 2009). 2.5.2 Life cycle of Ascaris lumbricoides Humans become infected with Ascaris through a faecal-oral pathway and larvae grow in the parenteral tissue of the host when infective eggs are ingested and hatched (Dold and Holland, 2011). Infection occurs when human consumes contaminated food or drink that has fertilized eggs. The eggs are digested in the small intestine by digestive juices, releasing the already developed larvae (Mwinzi et al., 2012). The larva enters the lungs, grows, and travels down the bronchial tree, causing throat pain. About 240,000 eggs are laid by a female Ascaris worm daily, which are then transmitted through the faeces. In the external environment, the larva grows in the egg and hatches after egg is consumed by a host. After 19 days to several weeks’ viable eggs become infective depending on environmental circumstances such as optimal warm and moisture in the soil (Ziegelbauer et al., 2012). After swallowing infective eggs, larvae hatch, penetrate intestinal mucosa, goes through lungs via the portal and systemic circulation. The larvae enter the lungs through the air sacs and migrate to the trachea, where they are coughed up and ingested. Adult female must wait 2 to 3 months after ingesting the infective eggs before oviposition occurs. Adult worms have a lifespan of one to two years. (CDC, 2015). University of Ghana http://ugspace.ug.edu.gh 18 Figure 2.3: Life cycle of Ascaris lumbricoides (Source: www.cdc.gov) 2.5.3 Transmission of Ascaris lumbricoides The most common mode of transmission of Ascaris is the faecal-oral route. Infected people's faeces contain eggs, which must be exposed to a warm, wet soil environment to grow and become infectious. Embryonation of freshly discharged eggs takes 9-40 days before they become infective. Contaminated hands can transport eggs from the soil/water to the mouth, or eggs can be eaten with meals (uncooked vegetables and unwashed fruits). University of Ghana http://ugspace.ug.edu.gh 19 2.5.4 Pathology associated with A. lumbricoides Ascariasis pathology is diverse. However, it may be broadly divided into organ damage and host-sensitive responses caused by migratory larvae, as well as the adult worm's huge size and activity. During larval development, A. lumbricoides produces significant host-tissue inflammation. Adult worms in the small intestine cause little or no symptoms, depending on the host's health history, infection severity, and duration (OLorcain & Holland, 2000). A. lumbricoides infections is linked to severe malnutrition, particularly in children (Bethony et al., 2006; Stephenson et al., 2011). 2.5.5 Clinical Manifestation of Ascaris lumbricoides Ascariasis is a parasitic infection that mostly affects children, causing malnutrition, stunted growth and difficulties in learning (Hagel and Giusti, 2010). In more than 85% of instances, infections are asymptomatic, especially in persons with a modest worm load. Symptoms vary in intensity depending on the worm load leading to difficulties breathing and fever accompanied by diarrhoea, abdominal pain and abdominal swelling (Dold and Holland, 2011). Children's cognitive development may be harmed by moderate and severe illnesses (Jukes et al., 2007). Severe stomach discomfort, tiredness, vomiting, weight loss, worms in stool are all symptoms. Ascaris worms in large numbers in the small intestine induce abdominal distension and discomfort, which can progress to partial or total blockage, intestinal perforation, and deadly peritonitis (Farrar et al., 2013). Adult worms cause chronic ascariasis symptoms (which appear six to eight weeks after egg intake and last for up to 18 months following infection). Abdominal pain, anorexia, nausea, vomiting, and diarrhoea are examples of non-specific symptoms. University of Ghana http://ugspace.ug.edu.gh 20 2.5.6 Diagnosis of Ascaris lumbricoides Eggs in the faeces are diagnostic methods for identifying Ascaris eggs. The numerous eggs are detected in the direct cover glass mount. If the results of the direct test are negative, the concentration technique may be used (Cheesbrough, 2006). For imaging Ascaris worms in the biliary tree, abdominal ultrasonography is the method of choice (Sherman & Weber, 2005). During the inspection, worms may be solitary, numerous, in bundles, and moving. When abdominal ultrasonography is not possible, as it is in certain pregnant women, magnetic resonance cholangiopancreatography (MRCP) provides an option (Arya et al., 2005). 2.6 Trichuris trichiura Trichuris trichiura is a round worm which infects the large intestines of humans and causes trichuriasis. The term whipworm is due to the worm's body form, which is whip-like with wider "handles" towards its back (Hayes et al., 2010). It spreads by the faecal-oral route, with a high incidence in places with tropical temperatures and inadequate sanitation (Bethony et al., 2006). Trichuris trichiura is found all over the world, with an estimated 500 million human infections (Hunter and Mckay, 2004). It is, however, mostly tropical, particularly in Asia, South America and Africa (Hunter and Mckay, 2004). In less developed countries, Trichuris trichiura is more frequent. Trichuris trichiura affects nearly a quarter of the world's population (Donkor, 2009). Adult worms can be seen in the large intestine, particularly in the cecum. Trichuris, unlike Ascaris, lives on the intestinal mucosa rather than in the intestinal lumen. In most cases, their lifespan is 1.5 to 2 years (Bethony et al., 2006); nevertheless, infections have been reported to extend up to 8 years (Bogitsh et al., 2012; Shiff, 2007). University of Ghana http://ugspace.ug.edu.gh 21 2.6.1 Morphology of Trichuris trichiura Matured female worms measures 35–50 mm and relatively longer than males, with males measuring about 30–45 mm. Females have a rounded posterior end and its blunt, with males having a coiled posterior end. Eggs measure 25-35µm in width, 50-70µm in length and are barrel-shaped and brown they also have two distinct mucoid polar plugs (CDC, 2015). Eggs contain an un-segmented ovum when it leaves the human hosts. The adult worms attach themselves to the walls of the host’s intestines and due to that they are rarely recovered from the stool (Garcia, 2007; Heelan, 2004). 2.6.2 Life cycle of Trichuris trichiura In a single day, female T. trichiura produces 4,000–10,000 unembryonated eggs. Eggs are realease in the soil from human faeces, embryonate in 2–3 weeks, and then enter the “infectious” stage. Newly discharged eggs require sometime to mature in the soil (2 - 4 weeks at 22 o C in humid soil) before embryonating and producing a first-stage larva (L1), which is the infective stage for humans (Bogitsh et al., 2012; Nejsum et al., 2012; Hotez et al., 2003). The eggs are transmitted by contaminated hands or drinking water contaminated. The cycle history of an egg begins when it is consumed in any of these ways. The eggs hatch in the small intestine after being ingested by soil-contaminated hands or food, releasing larvae that develops into adults. The caecum and ascending colon are where the adult worms reside. Copulation occurs between the sexes, and eggs produced by the female emerge in the faeces of the host 70 to 90 days after the eggs are consumed. Trichuris eggs can last up to 6 years in the soil under ideal conditions, but desiccation and high temperatures are harmful (Asaolu et al., 2002c). University of Ghana http://ugspace.ug.edu.gh 22 Figure 2.4: Life cycle of Trichuris trichiuria (Source: www.cdc.gov) 2.6.3 Transmission of Trichuris trichiura Infectious eggs from contaminated soils, hands, food, or water are consumed and spread through ingestion. In order for eggs to become infective, they must spend at least 15 to 30 days in warm, moist soil. Anthropogenic activities, as well as wind, water, and insects, spread eggs in the environment (houseflies can act as mechanical vectors). 2.6.4 Pathology associated with Trichuris trichiura The majority of morbidity symptoms are caused by the host's inflammatory response to the worms' hold on the mucosa's epithelial tunnels (Stephenson et al., 2011). Trichuris dysentery syndrome caused by heavy and moderate infection of T. trichiura worm can result in diarrhoea, University of Ghana http://ugspace.ug.edu.gh 23 rectal bleeding and anaemia but light T. trichiura infections are mostly asymptomatic (WHO, 2002). 2.6.5 Clinical Manifestation of Trichuris trichiura The most severe form of trichuriasis is Trichuris dysentery syndrome (TDS) which primarily affects children, however it has been documented in adults as well (Hotez et al., 2003; Khuroo, 2010). Many mild infections are asymptomatic at first, but serious symptoms such as persistent bloody diarrhoea with copious mucus, loss of weight anaemia, and rectal prolapse in children can occur (Albonico et al., 2008; Stephenson et al., 2000). Several epidemiological investigations have demonstrated high worm load can result in morbidity, even at modest infection intensities (Bieri, 2013). 2.6.6 Diagnosis of Trichuris trichiura Microscopically detecting whipworm eggs in a stool sample is the usual approach for diagnosing the presence of whipworm. A concentration method is employed since eggs in mild infections eggs might be difficult to identify. Clinically, trichuriasis is difficult to distinguish from infections with other intestinal worms. When Trichuris trichiura eggs are found in faeces, trichuriasis can be diagnosed (Levinson, 2008). Unembryonated eggs with bipolar plugs and a smooth shell will seem barrel-shaped. 2.7 Prevention and Control of intestinal parasites For long-term prevention and control of STH and other enteric infection, access to water, sanitation, and hygiene (WASH) is essential (Campbell et al., 2014; Strunz et al., 2014). The most essential component in maintaining helminth control programs in schools is the support of the children's parents and families, as well as the community at large. Significant University of Ghana http://ugspace.ug.edu.gh 24 support for these programs will develop with the help of additional proponents (ministries of health, education, and non-governmental organizations) (Montresor et al., 2002). For and effective and stable management and control of STH, understanding the mode of transmission and risk factors functioning in endemic populations are significant (Lustigman et al., 2012; Weaver et al., 2010). Preventive treatment has been found to significantly reduce STH infection morbidity (Strunz et al., 2014), although re-infection is common in endemic regions (Jia et al., 2012). It is predicted that treating only school children in high prevalence populations can avoid 70% of the overall burden caused by soil transmitted helminths (Asaolu and Ofoezie, 2003). Periodic deworming with benzimidazoles (albendazole and mebendazole) to uninfected at-risk persons on a regular basis, supported by health education, is the most cost-effective technique for decreasing the morbidity associated with STH infections. (WHO, 2002; Albonico et al., 2006; Savioli et al., 2002). The health benefits of deworming have gotten a lot of attention, but the research isn't always reliable. Regular deworming has minimal effect on children, according to a recent longitudinal research from India (Awasthi et al., 2013). Taylor Robinson and co-workers (2007) did a meta- analysis to assess the efficacy of deworming on child development and school performance, and found that study data is insufficient to suggest deworming medicines in targeted populations (Taylor-Robinson et al., 2007). Health and hygiene promotion reduces transmission and reinfection through improving health education and generating awareness (Aiello et al., 2008; Asaolu and Ofoezie, 2003; Ekpo et al., 2008; Fewtrell et al., 2005; WHO, 2006). University of Ghana http://ugspace.ug.edu.gh 25 Periodic deworming, on the other hand, is seen as a less complicated and inexpensive approach to STH control (Albonico et al., 2008; Molyneux et al., 2005; Crompton et al., 2003; Montresor et al., 2011; WHO, 2012). Clean water supply, food hygiene, improved sanitation and health education, in combination with treatment of a sick person, reduce the transmission of parasite in the long run. (Ngonjo et al., 2012). In a research to investigate the prevalence of STH in Cameroon (Richardson et al., 2011), revealed that intestinal parasite infections were lower in Bawa village (7.1%) due to improved sanitation than in Nloh village (15.7%), which had poor sanitation. Access to potable water reduces STH infections mostly mainly to increased hygiene; for example, handwashing is linked to decreased ascariasis transmission (Bartram and Cairncross, 2010; Fung and Cairncross, 2009). Since faecal contamination is the most common mode of STH transmission, maintaining excellent hygiene and washing hands with soap on a regular basis is suggested as a preventative strategy (Montresor et al., 2011). Handwashing before eating and after defecating is linked to a reduced risk of A. lumbricoides infections of 0.38 (95% CI 0.26–0.55) and 0.45 (95% CI 0.35–0.58), respectively (Strunz et al., 2014). Handwashing was also found to be a protective factor against STH infections in a handful of cross-sectional investigations done with Ethiopian students (Alemayehu, 2008; Alemu et al., 2011). Diarrhoea can be avoided to a significant degree by disrupting the faecal-oral transmission pathway by sanitary treatments such as improved personal cleanliness, waste disposal, and proper food preparation (Kümmerle, 2014). 2.8 Risk Factors for Soil Transmitted Helminths Personal cleanliness, use of toilet facilities, wearing shoes, handwashing and consuming raw food are behavioural risk factors. Farming and other occupations that have a lot of soil contact raise the risk of STHs infection (Balen et al., 2011). In endemic areas, the primary cause of University of Ghana http://ugspace.ug.edu.gh 26 STH transmission is improper disposal of human excreta (Strunz et al., 2014). Higher education and socioeconomic status, on the other hand, have been proven to be favourable indicators of enhanced cleanliness, which protects against STH infections (Ohta and Waikagul, 2007). In Kenya, Ascaris spp infections were linked to a drop in the weight of six-month-old children (LaBeaud et al., 2015). Poverty, poor sanitation, large densities of domestic animals (Hayes et al., 2003), large family sizes (Traub et al., 2004, 2009), children under age 15 especially males are mostly at risk for STH infections (Mohammed Mahdy et al., 2008). The availability and use of toilets is another risk factor. Cysts are usaully washed down to water bodies or transported by flies that serves as mechanical and contaminate food or water supplies when individuals defecate in the open (Cheesebrough, 2005). Children have a considerably higher frequency of diarrhoea and higher egg counts for STH than adults, according to systematic studies, as a result, children stool offers a larger health risk than adult stool (Crompton et al., 2003). In Ghana, 19% of children under the age of five are stunted, 11% are underweight, and 5% are wasting (GSS, 2015). In Ghana, rural regions account for 22% of stunting, whereas urban areas account for 15%. Similarly, underweight children in rural regions are 13% more as compared to those in the urban areas of about 9% (GSS, 2015). Improper faeces disposal might account for the spread of helminths infections. 2.9 Sanitation and STH infections Improved sanitation aims to limit transmission by decreasing pollution in the soil and water. Sanitation is the only permanent solution for eradicating STH infections, but it must reach a large proportion of the population to be successful (Hotez et al., 2006). In areas where open defecation is practiced, the concentration of STHs eggs in soil can be quite high. The eggs of STH are excreted in the faeces. When faeces are disposed of in such a way University of Ghana http://ugspace.ug.edu.gh 27 that they come into touch with soil, the ova find a suitable habitat in which to develop and mature into infective forms. Anecdotal data suggests that open defecation is linked to a greater risk of hookworm infection (Schmidlin et al., 2013). In Kenya, it was discovered that toilet facilities located outside homes had a substantially greater incidence of STH infection than those located within the household premises (Worrell et al., 2013). Sanitation is linked to a lower risk of STH infection and is an important component of integrated STH management efforts (Bartram and Cairncross, 2010; Ziegelbauer et al.; 2012 Mara et al., 2010). A comprehensive analysis published in 2012, Zeigelbauer et al., discovered that the provision of sanitary facilities provided substantial protection against STH with an odds ratio of 0.46-0.58. Periodic deworming will not provide a sustained decrease in transmission without a change in defecation behaviours (Hotez et al., 2006). The reuse of wastewater and sludge has been linked to an increased risk of infection. In endemic regions, wastewater can hold about 3500 eggs per litre (Kamizoulis, 2008; Mara and Sleigh, 2010). 2.10 Hygiene and regular handwashing Handwashing using soap at suitable times, such as before food preparation, after coming into contact with animals, after urinating and visiting the toilet and after touch with rubbish, is the most essential component of personal hygiene. Fewtrell, Prüss-Üstün, and Bos 2007 reported that it is quite usual for a student in Africa to be infected with STHs which is prevalent in children a result of inadequate hand washing with soap and water. Evidence shows that cleanliness plays an essential part in the prevention of parasite illnesses caused by soil- transmitted helminths (Bieri, 2013; Kümmerle, 2014). Hand washing with soap and water after being implemented in primary schools, show a 30% reduction in diarrhoea incidence (Ejemot -Nwadiaro et al., 2009). University of Ghana http://ugspace.ug.edu.gh 28 2.11 Morbidities associated with soil-transmitted helminthiasis Regardless of near-ubiquity of STH worldwide, it is difficult to estimate the real impact of these infections due to the paucity of study on the morbidities associated with them (Utzinger and de Savigny 2006; Nagpal et al., 2013). The number of worms a host harbors is significantly associated with morbidity, and persons with multiparasitism are likely to have higher morbidities than people with single species infections (Brooker, 2010). Ascaris infection can lead to vitamin A deficiency, acute intestinal blockage (which kills over 10,000 people each year), and hepatobiliary and pancreatic ascariasis (Hotez et al., 2003). Anaemia, protein malnutrition, low birth weight and death in infants, are all linked to heavy hookworm infection (Loukas et al., 2016). Stunting (low height-for-age), wasting (low body mass index-for-age), and anaemia are frequent markers of malnutrition utilized for such assessments in areas where food resources are short (FAO 2012). Helminths have been shown to have a negative impact on the health of humans (Hailegebriel, 2018; Njaanake et al., 2015) by impairing nutritional digestion and absorption, resulting in undernutrition, anaemia and stunting growth (Casmo et al., 2014; Kinung’hi et al., 2017; Hailegebriel, 2018; Njaanake et al., 2015). It has also been proven that helminth infection is associated with a decrease in the host's cognitive skills (Kvalsvig et al., 2002). As previously stated, morbidity induced by STH causes absenteeism in children leading to poor academic performance and, poor pregnancy outcomes and low productivity at workplace in adults (Guyatt, 2000). 2.12 Educational background associated STH infection Nematian et al. (2010), reported that mothers' educational level lowers the parasite infection rate in children. Low incidence has been recorded among educated and skilled employees, as well as those with a good quality of life (Ugbomoiko and Ofoezie, 2007). Enlightenment via University of Ghana http://ugspace.ug.edu.gh 29 public health education is thought to be able to help individuals alter or at least adjust some of their habits and beliefs for the better (Nock et al., 2007). 2.13 Climate, Water, Season and STH infection Climate events such as high temperatures and rain have an influence on the infective forms of STH's soil habitat and, as a result, on their prevalence. Transmission of worm is promoted in their pre-parasitic stages mostly in wet seasons in an environment that favours transmission. This contrasts with dry season circumstances, which kills infective larvae deposited on the soil, lowering transmission dynamics (Weaver et al., 2010). Although Necator americanus is the most common hookworm globally (Hotez et al., 2004), a change in temperature may ultimately favour Ancylostoma duodenale since it can withstand developmental arrest as larvae in human tissues as a means to survive extreme conditions (Hotez et al., 2004, Brooker et al., 2006). Increased temperature shortens the time to embryonation and infectivity in Ascaris and Trichuris, although it is linked with the mortality of the ova above critical levels. It's been hypothesized that overall rainfall and its seasonal distribution in a given location might help explain observed infection patterns: wetter environments are generally linked with higher transmission of all three main soil transmitted helminth diseases (Brooker and Michael, 2000). 2.14 Effects of STH in preschool children A. lumbricoides, T. trichiura, and hookworm are the most frequent species, which infect children and cause substantial physical, cognitive, and economic impairments (Brooker et al., 2006). Children are the most vulnerable for STH infections. The immune system of the younger generation is less developed, and they have higher dietary needs (Brooker et al., 2006). The University of Ghana http://ugspace.ug.edu.gh 30 presence of 26 mature Ascaris lumbricoides worms in a kid has been demonstrated to deplete a child's entire protein supply to about one tenth (Bundy and Drake, 2004). Nutritional problems and STH infections are commonly seen together in impoverished nations, according to several research. Stunting was found to be prevalent in 48 percent to 56 percent of children in Ghana, Tanzania, Vietnam, India, and Indonesia, whereas underweight was found to be prevalent in 34 percent to 62 percent of children (Christiana et al., 2014). According to epidemiological statistics, infection starts around age one and two, and the severity and prevalence increases with age (Horiuchi, 2013). Hookworm infection that is severe and persistent during a child's development has ramifications on their cognitive performance and eventually, their academics (Jinabhai et al., 2001). 2.15 Diagnostic Method in Parasitological Laboratory The choice of a diagnostic method for STH infections influenced by its sensitivity, affordability and simplicity (WHO, 2002). Diagnosis of soil-transmitted helminths can be done by finding worm eggs or adult worms in faeces (Akujobi et al., 2005). The accuracy of various faeces testing procedures is highly dependent on adequate sample collection and storage practices. 2.15. 1 Concentration methods Sedimentation or flotation procedures can be employed for concentration, with the latter being the most commonly utilized for diagnosis (Knopp et al., 2011a; Mahon et al., 2007). In sedimentation, eggs of the parasite form a sink at the bottom of the liquid, for flotation eggs of the parasite suspends in a liquid with a high specific density making them buoyant and float to the surface. High sensitivity is associated with concentration techniques. It enables the identification of eggs and organisms in low-infection situations that would otherwise be missed by other approaches, particularly the direct wet method. The concentration approach has the University of Ghana http://ugspace.ug.edu.gh 31 added benefit of permitting transportation and storage of faeces once they have been preserved in formalin (Oguama and Ekwunife, 2007). Concentration by floatation uses a liquid suspending medium that is heavier than the parasite eggs allowing them to float and be collected from the film (Cheesbrough, 2005). 2.15.2 Kato-Katz technique. This technique is currently a WHO-recommended “Gold standard” for identifying STH and Schistosoma eggs, particularly when egg quantification is needed. In Kato Katz, large particles are eliminated by sieving faeces through a mesh. Sample is moved onto a slide through a template with a hole that contains a defined amount of faecal material (for example, a 9 mm hole on a 1 mm thick template holds roughly 50 mg of faeces). The template is removed, remaining sample is covered with cellophane soaked in glycerol-methylene blue solution. To clean the faeces, slides should be maintained at room temperature or in a 40°C incubator (except for hookworms). Despite the broad acceptance of Kato-Katz, several writers have pointed out that using the technique as suggested by WHO results in limited sensitivity in cases of mild infections, especially after deworming. Despite the fact that Kato–Katz is cheap and straightforward to use, samples with low infection intensity makes detection of several STH challenging (Garcia et al., 2018). 2.15.3 Baermann technique The Baermann technique is centred on the idea that active larvae will move out of a faecal specimen put on a wire mesh coated with many layers of gauze (Garcia, 2001). This is the most commonly used in parasitological field surveys because it does not require any complex University of Ghana http://ugspace.ug.edu.gh 32 laboratory materials and culturing or immunological procedures takes a lesser time (Knopp et al., 2008; Olsen et al., 2009). 2.15.4 Molecular diagnosis These high-tech methods are specific and sensitive, allowing for the differentiation of parasite species that are morphologically identical, however, in underdeveloped nations, they are frequently too expensive (Hotez et al., 2006). Molecular diagnostic methods like (PCR) with primers generated from various genetic markers are helpful. The method is useful for distinguishing between two species that are morphologically identical, such as Ancylostoma duodenale and Necator americanus (de Gruijter et al., 2005). Ayana et al., (2019) examined preservation techniques and four DNA extraction for molecular identification and quantification of STH in faeces and discovered substantial variations in DNA recovery. However, since PCR techniques are based on group specific gene or species gene sequence, they are more particular than morphological approaches. However, sensitivity was low due to the delay in DNA extraction if the samples were retained in the preservatives, making it acceptable for analysing samples with preservatives in a distant laboratory collected from remote areas (Ayana et al., 2019). PCR techniques have proved to be more sensitive as compared to microscopy-based methods in identifying parasite eggs in low quantities, notwithstanding their limitations (Oliveira et al., 2010; Guy et al., 2003). 2.16 COVID - 19 impact on STHs Programmes The COVID-19 pandemic was caused by the SARS-CoV-2 Virus (Coronaviridae). The virus spread quickly after the first cases were discovered in Wuhan, China, on November 17, 2019, and was designated a pandemic on March 11, 2020. The WHO suggested that MDAs, detection of active University of Ghana http://ugspace.ug.edu.gh 33 cases, and surveys in and around the community for STHs be postponed until April 2020 (WHO, 2020). The decision to stop administering PCs during COVID 19 is not a firm one. Delays in Mass Drug Administration (MDA) rounds would result in a higher number of infections in communities, since both existing infections and opportunistic infections will go untreated. This means that some of the benefits (prevalence decreases) made in prior rounds of MDA will be lost. Mathematical modelling, conducted by the NTD Modelling Consortium, can give quantitative insights into how delays may affect NTD programs (Gyapong et al., 2018). COVID-19 is expected to make the lives of millions of people living with STHs even more precarious, and the chances of maintaining STH prevention, control, and elimination gains slim, with disease resurgences expected since money and human resources will be diverted to combat the pandemic (Ehrenberg et al., 2020). (Bradbury et al., 2020) emphasized the possibility of adverse interactions between COVID-19 and helminths infection severity in areas where helminth infections are endemic, as well as the fact that helminth infection-related changes in gut microbiota appear to have systemic immunomodulatory effects. As noted by Huang et al., 2021 on resource tracking for STHs, measuring the economic impact, cost, and cost-effectiveness of integrated STHs programs would assist decision-making in nations seeking to improve domestic finance for sustainable STH management and eradication. Efforts to eradicate soil-transmitted infection during the COVID 19 pandemic has been disturbed. Ghana, as a tropical country, bears a double burden. For example, the management of COVID-19, which has made no major progress to date, along with the prevalence of NTDs, will continue to be a public-health issue. Efforts to minimize the spread of COVID-19 globally and University of Ghana http://ugspace.ug.edu.gh 34 locally has a direct influence on the preventive and control programs for soil-transmitted diseases (STDs), which are one of the neglected tropical diseases. Although a stop in STD prevention treatment would only have a temporary impact on progress toward the WHO 2030 objective, programs must be resumed as quickly as feasible to avoid morbidity (Malizia et al., 2021). Ehrenberg et al., 2020 pointed out relevant strategies that can support the control of STH, focusing on the virus's zoonotic origins and demonstrating how collaborations can be used to minimise STH infections during the pandemic. Given the mitigation techniques recommended by national NTD programs as preventative measures (increased handwashing and physical separation measures), the start of NTD programs will offer little danger of viral spread. Several of the strategies used preventing and controlling STHs, such as regular handwashing, sanitation, hygiene, and health education, are also being used to prevent COVID- 19 spread. However, if COVID-19 is reduced following a corresponding decrease in STHs infections, the suggested strategies and long-term modifications have proven inadequate. University of Ghana http://ugspace.ug.edu.gh 35 CHAPTER THREE 3.0 MATERIALS AND METHOD 3.1 Study design A cross-sectional study was conducted among school children in Afadjato South District and Ho West District in Ghana from March 2021 to April 2021. Stool samples were collected from children in primary one to JHS three in the (2) two districts and were examined for helminth eggs. Socio-demographic characteristics of the school children and their parents, including age, sex, risk factors for parasitic infections were recorded using structured questionnaires. Their status with respect to whether they have taken anti helminths drugs before and during COVID- 19 was also documented. 3.2 Study area This study was conducted in the Ho West and Afadjato South Districts of the Volta Region of Ghana. The Volta region is one of the sixteen regions in Ghana and is located between latitudes 50∘ 45‟N and 80∘ 45‟N in the South-eastern part of the country, bounded by Togo on the east and Lake Volta on the west. Afadjato South District and Ho West District are close in proximity and have common boundaries. Afadjato South District is one of Ghana's twenty-five (25) Municipalities and Districts. It was formed in 2012 when the Hohoe Municipal District was dissolved. Golokwati is the district's administrative capital. The District is bordered to the north by Hohoe Municipal, to the west by Kpando Municipal, to the east by the Republic of Togo, and to the south by Ho West District and South Dayi District. The district is located in Ghana's wet semi- equatorial climatic zone, with annual rainfall ranging University of Ghana http://ugspace.ug.edu.gh 36 from 1,016 mm to 1,210 mm. The area experiences an average of four to five months of dry season. Temperatures are hot all year, ranging from 26∘C in the coolest months to around 32 ∘C in the hottest months. The Ho West District is bounded on the south by the Adaklu District, on the north by the Afadjato South District, on the east by the Ho Municipality and the Republic of Togo, and on the west by the South Dayi District. It is located between latitudes 6.33∘ 32" N and 6.93∘ 63" N and longitudes 0.17∘ 45" E and 0.53∘ 39" E with a total land area of 1,002.79 square kilometers and a population density of 94.3 based on a population of 94,600 people (Ghana Statistical Service, 2014). The Ho West district is also constrained by two major vegetation zones: damp deciduous forest, which frequently shrouds the area's hills, and savannah woodland (Ghana Statistical Service, 2014). University of Ghana http://ugspace.ug.edu.gh 37 Figure 3.1: Study area showing selected areas for the study 3.3 Ethical approval Permission was obtained from the Ghana Education Service, the Afadjato South District, and the Ho West District. Before visiting the schools in this study, the district public health authorities, district education authorities, and the school administrators were educated on the aims and benefits of the research. The study focused on school-aged children from 6 to 17 years of age, covering from basic one to JHS three. Children younger than 12 years consented verbally and children between 12-17 years of age signed their assent forms and were informed about the objectives and benefits of University of Ghana http://ugspace.ug.edu.gh 38 the research. Each student was issued a distinctive ID number when they registered. All parasitological and survey data was coded and treated confidentially. 3.4 Inclusion criteria Participant of the research included school children within Afadjato South District and Ho West District and their guardians who agreed and signed the consent forms. 3.5 Exclusion criteria These included school children who did not want to participate in the research for one or two reasons and those whose parents or guardians did not want them to participate. 3.6 Sample size determination and Sampling Technique Children attending primary schools in Afadjato South District and Ho West District were selected systematically through random sampling. Study subjects were randomly sampled, first student in the school’s register was chosen, followed by the third student in the register for each class from Primary to JHS. The sample size was estimated by taking the prevalence as 50 %. Sample size was calculated using the formula (Naing et al., 2007). n = Z 2 P (1-P) d 2 Where, n= sample size Z= 95% confidence interval (1.96) P = prevalence of disease (50%) d= precision (0.05) Thus, n= (1.96)2 (.5) (1-0.5)/ (0.05)2 University of Ghana http://ugspace.ug.edu.gh 39 Giving a total of 384 But only 347 samples were collected 3.7 Data and stool collection 347 stool samples in total were collected from school children in the (2) two districts. In total seven (7) schools were sampled. Four (4) from Afadjato south and three (3) from Ho West. A structured questionnaire that probed into sociodemographic and environmental factors were collected through interviews. Each participant was given an already labelled (ID) stool collection container, applicator sticks, and instructions on how to collect and hand over the sample and were advised to bring the stool samples the next morning. Filled containers with stool samples were collected from 7 am and 9 am and were later transported to the Jim Bourton Memorial Agricultural SHS for helminths identification the same day. 3.8 Study adherence School children that took part in the study, completed the study questionnaire and provided stool samples were 347. Parents that also completed the study questionnaire were 318, but only 270 school children had corresponding stool sample and completed questionnaire with corresponding parent’s questionnaire. 3.9 Laboratory Procedure Formalin-Ethyl Acetate Sedimentation Concentration was used to examine fresh human faecal samples. One gram of stool sample was mixed with 10 mL of 10% formalin solution into a beaker and homogenized until all faecal material was suspended and sieved using a molded University of Ghana http://ugspace.ug.edu.gh 40 plastic strainer with pores not greater than 0.5mm x 0.5mm whose sieve opening size allow parasite eggs to pass through the strainer into a 15ml conical centrifuge tube while excess faecal debris was retained. 10% formalin was added through the strainer to bring the volume to 15 ml. The mixture was centrifuged at 3000 revolutions per minute for 3 minutes. The upper layer was thrown out, and the sediment was re-suspended with 10 ml of a 10% formalin solution and was thoroughly vortexed using a wooden applicator. After adding 4 mL of ethyl acetate, the solution was vigorously shaken for 30 seconds before being centrifuged at 3000 revolutions per minute for 3 minutes. The upper layers of the supernatant comprising ethyl-acetate, debris, and formalin were decanted after the debris block at the top of the tube was released. A cotton- tipped applicator was used to remove any remaining material from the tube's side. A few drops of normal saline was added to suspend the residue. On a clean slide, one drop of the suspension was placed and covered with a cover slip. For more details, the slide was examined under a compound light microscope with an x10 objective and then switched to high power. 3.10 Identification of Helminths Eggs A parasitological atlas was used in the identification of eggs and larvae in stool samples (Cheesbrough, 2006). Identification was based on morphological characteristics of parasitic articles as follows. Hookworm eggs had grey cells or were dark-brown in colour and measured between 50 and 60m in length. T. Trichiura eggs measured about 50-53μm by 22-23μm in size were barrel-shaped plug at each pole. Eggs of Ascaris were oval in shape. 3.11 Data Processing The questionnaires that were given to school children in order to collect data were coded. University of Ghana http://ugspace.ug.edu.gh 41 Identification of eggs present or absent were presented in tables. Questionnaires, and all other data were entered into the Microsoft Excel and imported into SPSS for analysis. 3.12 Data Analysis Descriptive statistics was used to calculate for the data of 347 children. School children with infections for hookworm, Ascaris lumbricoides and Trichuris trichiura, were calculated using cumulative frequencies. A Chi-square test was performed to compare districts and schools with intestinal parasitic infections. P values < 0.05 were considered statistically significant. Logistic regression with 95% confidence interval (CI) was used to determine the association between potential risk factors and infections. University of Ghana http://ugspace.ug.edu.gh 42 CHAPTER FOUR 4.0 DESCRIPTION OF RESULTS 4.1 Study population 347 school-age children in total were examined for soil-transmitted helminths in seven schools in the Afadjato South District and Ho West District between March and April 2021. 318 parents were also interviewed from the ages range between 30 to 50 years. Majority of parents’ interviewed were farmers as shown in Table 4.1 Table 4.1: Sociodemographic characteristics of parents and school children Parameter Frequency Percentage (%) CHILDREN (N=347) Sex Male Female 171 176 49 51 Age group 6 -8 9 -11 12 -14 15-17 PARENTS (N=318) Sex Male Female Age group 15 60 174 98 147 171 4.3 17.3 50.1 28.3 46 54 30- 35 36-40 41-45 46-50 Occupation Farmer Trader Civil Servant 82 96 58 82 179 121 18 25.8 30.2 18.2 25.8 56 38 6 University of Ghana http://ugspace.ug.edu.gh 43 Table 4.2: Comparison of (STH) infections in school-aged pupils of Afadjato South and Ho West district during COVID-19 outbreak Parasites Ho West N=120 (%) Afadjato South N=227 (%) Total N=347 (%) χ² (df); p- value** Ascaris lumbricoides *NPS 105 (87.5) 210 (92.5) 315 (90.8) Positive cases 15 (12.5) 17 (7.5) 32 (9.2) 2.35 (1); 0.125 Hookworm *NPS 88 (73.3) 183 (80.6) 271 (78.1) Positive cases 32 (26.7) 44 (19.4) 76 (21.9) 2.43 (1); 0.119 Trichuris trichiura *NPS 109 (90.8) 202 (89.0) 311 (89.6) Positive cases 11 (9.2) 25 (11.0) 36 (10.4) 0.29 (1); 0.592 *NPS: no parasite seen; **p-values of parasite prevalence comparisons Table 4.2 shows the relationship between prevalence of parasites and districts. The overall prevalence of Ascaris was 9.2%. In Ho West and Afadjato South district the prevalence of Ascaris was 12.5% and 7.5% respectively. However, the prevalence of Ascaris was not significantly related to the districts (p>0.125) as shown in Table 4.2. The overall prevalence of hookworm was 21.9%. The prevalence of hookworm was 26.7% and 19.4% in Ho West and Afadjato South districts respectively. However, the prevalence of hookworm was not significantly related to the districts (p>0.119) as shown in Table 4.2. The overall prevalence of Trichuris was 10.4%. The prevalence of Trichuris was 9.2% and 11.0% in Ho West and Afadjato South districts respectively. However, the prevalence of Trichuris was not significantly related to the districts (p>0.592) as shown in Table 4.2. University of Ghana http://ugspace.ug.edu.gh 44 25 21.9% 20 15 10.4% 10 9.2% Ascaris Hookworm Trichuris Figure 4.1 shows the prevalence of each infection. Hookworm had the highest overall prevalence of 21.9%, followed by Trichuris (10.4%). Ascaris had the least overall prevalence (9.2%) among the sampled school children in the Volta Region. Figure 4.1: Prevalence of soil transmitted helminths among school children in the Ho West and Afadjato South districts. P e rc e n t University of Ghana http://ugspace.ug.edu.gh 45 Table 4.3 presents the prevalence among age groups and sex of school children. Prevalence of STH infections was higher in females (45.4%) than males (37.4%). Also, Hookworm infection was higher within sex groups, followed by Trichuris and Ascaris. Establishing the significance level or the p-value at 5% (0.05). For all there STH infections there was no significant difference (P>0.05). With respect to age groups, children between 6-8 years old recorded the highest prevalence of soil-transmitted helminths infections, while those between 12-14 years old recorded the least prevalence of all three STH infection of 38.5%. Prevalence among all age groups insignificant (P>0.05). Table 4.3: Prevalence of soil-transmitted helminths infections among age and sex of school children Parameter Measurement (n) Ascaris (%) Hookworm (%) Trichuris (%) Sex Male (171) 16 (9.4) 30 (17.5) 18 (10.5) Female (176) 16 (9.1) 46 (26.1) 18 (10.2) P-value 0.932 0.053 0.927 Age 6-8 (15) 3 (0.9) 4 (1.2) 1 (0.3) 9-11 (60) 10 (2.9) 13 (3.7) 6 (1.7) 12-14 (174) 13 (3.7) 36 (10.4) 18 (5.2) 15-17 (98) 6 (1.7) 23 (6.6) 11 (3.2) P-value 0.050 0.921 0.959 University of Ghana http://ugspace.ug.edu.gh 46 Figure 4.2: Respondents’ place of going to toilet About 36.3% of school children sample for the study go to toilet at home (figure 4.2). Those who go to public toilets were 26.2% while 19.6% go to the bush. The rest of the respondents rotate or combine these three places. 40 36.3% 35 30 26.2% 25 20 19.6% 15 10 5 8.9% 5.8% 3.2% 0 public toilet bush at home home and home and public toilet Place of Toilet Facility bush bush and public toilet P er c en t University of Ghana http://ugspace.ug.edu.gh 47 Figure 4.3: Respondents’ last time of taking anthelminthic drugs Figure 4.3 also presents the last time school children took anthelmintic drugs. Majority of the sampled school children (68.0%), the last time they took the anthelminthic drug was about a year (12 months) or more. Only 10.7% of the children had taken an anthelminthic drug in the last three months. The rest are distributed between 4 -11 months. 80 70 68.0% 60 50 40 30 20 10.7% 10 6.9% 6.9% 7.5% 0 1-3 months 4-6 months 7-9 months 10-12 months more than 12 months Last time of taking antihelminthic drugs P er ce n t University of Ghana http://ugspace.ug.edu.gh 48 Table 4.4: Prevalence and univariate analysis of factors associated with STH infection by simple logistic regression for Ho West District Parameters N=120 STH Infections p-value** (n*)% OR (95% CI) Sex Male 66 20 (39.2) 1 Female 54 31(60.8) 3.69(1.48-9.20) 0.005** Age category 6 – 8 5 3 (5.9) 1 9 – 11 12-14 15-17 27 60 28 7 (13.7) 26 (51.0) 15 (29.4) 0.18(0.16-1.97) 0.57(0.58-5.50) 1.23(0.13-13.48) 0.158 0.624 0.864 Handwashing before food Yes 68 29 (56.9) 1 No Sometimes 23 29 9 (17.6) 13(25.5) 0.44(0.11-1.78) 0.96(0.31-2.92) 0.252 0.940 Has toilet at home Yes 75 29 (56.9) 1 No 45 22(43.1) 1.36(0.56-3.32) 0.501 Always wear shoes Yes 63 26 (51.0) 1 No 57 25(49.0) 1.67(0.64-4.36) 0.292 Has taken anthelminthic drugs Yes 60 25 (49.0) 1 No 60 26 (51.0) 0.71(0.27-1.87) 0.493 Handwashing after toilet Yes 56 26 (51.0) 1 No Sometimes 17 47 6 (11.8) 19(37.2) 0.47(0.11-1.97) 1.18(0.44-3.19) 0.302 0.733 Handwashing method Yes No 31 89 14(27.5) 37(72.5) 1 0.62(0.22-1.73) 0.361 Nail cutting behaviour Bite nails 45 25 (49.0) 1 Use blade 75 26 (51.0) 0.26(0.09-0.70) 0.008** n* Number of hookworm positive cases in each category **Indicate variables with P < 0.05. University of Ghana http://ugspace.ug.edu.gh 49 Table 4.5: Prevalence and univariate analysis of factors associated with STH infection by simple logistic regression for Afadjato South Parameters N=227 STH Infections p-value** (n*)% OR (95% CI) Sex Male 105 35 (44.5) 1 Female 112 43 (55.1) 0.99(0.54-1.79) 0.998 Age category 6 – 8 10 4 (5.1) 1 9 – 11 12-14 15-17 33 114 70 16 (20.5) 35(44.9) 23(29.5) 1.50(0.35-6.41) 0.75(0.19-2.92) 0.82(0.21-3.28) 0.586 0.682 0.782 Handwashing before food Yes 138 48 (61.5) 1 No Sometimes 9 80 3 (3.8) 27(34.6) 0.92(0.18- 4.66) 1.00(0.53-1.90) 0.919 0.996 Has toilet at home Yes 120 40 (51.3) 1 No 107 38 (48.7) 1.12(0.61-2.05) 0.725 Always wear shoes Yes 111 38 (48.7) 1 No 116 40 (51.3) 0.99(0.56-1.74) 0.960 Has taken anthelminthic drugs Yes 167 56 (71.8) 1 No 60 22 (28.2) 1.14(0.60-2.30) 0.688 Handwashing after toilet Yes 151 53 (67.9) 1 No Sometimes 11 65 5 (6.4) 20 (25.6) 1.45(0.53-5.95) 0.83(0.41-1.65) 0.606 0.588 Handwashing method Yes No 37 190 11(14.1) 67(85.9) 1 1.22(0.55-2.71) 0.632 Nail cutting behavior Bite nails 66 24 (30.8) 1 Use blade 161 54 (69.2) 0.84(0.44-1.60) 0.585 n* Number of hookworm positive cases in each category **Indicate variables with P < 0.05. University of Ghana http://ugspace.ug.edu.gh 50 The risk of STH infection among females was observed to be higher compared to males (OR = 3.69; 95% CI =1.48-9.20; p = 0.005) school children in the Ho West district, Volta Region as shown in Table 4.4. Also nail cutting behaviour in the Ho West district was significant (OR= 0.26; CI = 0.93-0.70; p= 0.008). The association of STH infection among other variables in both districts are shown in Tables 4.4 and 4.5. Administration of Anthelminthic drugs and prevalence of soil-transmitted helminth infections. The results reveal that 179 respondents, representing (56%) had administered anthelminthic drug to their children before COVID-19, whereas 139 respondents (44%) did not administer anthelminthic drugs to their children before COVID-19. Prevalence among respondents who gave dewormers to their children during COVID-19 period were computed. The result (Table 4.6) shows that out of the 318 parents, 208 did not administered anthelmintic drugs to their children. However, the responses of parents who did not administered anthelminthic drugs during COVID-19 and before COVID-19 were highly statistically significantly p<0.0001 as shown in Table 4.5. Also, the responses of parents who administered anthelminthic drugs before COVID-19 and those who during COVID-19 were statistically significantly p<0.0001. University of Ghana http://ugspace.ug.edu.gh 51 Table 4.6: Administration of anti-helminthic drugs to school children before and during COVID-19 outbreak (responses of parents) Anti-helminthic drugs administration Frequency of responses (percentage) N=318 Difference in percentage frequency (95%CI) χ² (df); p-value Before Covid-19 Administered 179 (56) 22 (14.32 - 29.32) 31.04(1), <0.0001* Not administered 139 (44) During Covid-19 Administered 109 (34) Not administered 208 (66) 22 (14.32 - 29.32) 31.04(1), <0.0001** *p-value of parent responses comparing anti-helminthic drugs administered and not administered (**) before and during Covid-19 outbreak. University of Ghana http://ugspace.ug.edu.gh 52 Table 4.7: Administration of anti-helminthic drugs and soil-transmitted helminth (STH) infections in school-aged pupils during COVID-19 outbreak Dewormer during COVID-19 Characteristics Not Administered N=174 (%) Administered N=96 (%) % difference of cases χ² (df); p- value** Ascaris lumbricoides *NPS 158 (90.80) 90 (93.75) Positive cases 16 (9.20) 6 (6.25) 0.72 0.72 (1); 0.397 Hookworm *NPS 129 (74.14) 75 (78.13) Positive cases 45 (25.86) 21 (21.88) 0.53 0.53 (1); 0.466 Trichuris trichiura *NPS 159 (91.38) 15 (15.63) Positive cases 15 (8.62) 81(84.38) 75.76 154.39 (1); <0.0001** *NPS: no parasite seen; **p-values of parasite prevalence comparisons Table 4.7 shows the relationship between prevalence of parasites and the use of anthelminthic drug during COVID-19 based on parental