DISTRIBUTION AND RISK FACTORS FOR GIARDIA LAMBLIA AMONG CHILDREN AT AMRAN GOVERNORATE, YEMEN

Objective: The widespread prevalence of Giardiasis is a public health problem worldwide, and it is also common among Yemeni children. Hence, this work aims to identify the prevalent Giardia lamblia infection and risk factors among children admitted to health care centers in Amran governorate in Yemen. Methods: Three hundred and thirty-four stool samples were collected from infected children between March and July 2019 and the parasite is identified by light-microscope according to standard parasitology methods. Also, relevant data was obtained using a designed questionnaire. Results: The results showed that 181 cases (54.2%) were infected with G. lamblia infection.Total 57.5% of the infected children were from urban areas, while 42.5% of the cases were from rural areas. The highest incidence of G. lamblia was 60.3% among males compared to 47.5% among females. The results for age, residents and male children aged 8-14 years in both urban and rural areas recorded the highest prevalence of G. lamblia infection while the lowest was among females between 1 and 7 years and 8-14 years old, respectively, in the rural and urban area. Conclusion: In conclusion, as described in this work, multisectoral efforts are needed that include hygiene practices, personal hygiene habits, the provision of safe drinking water and the provision of sanitation systems to efficiently reduce this infection from all governorates of Yemen.


INTRODUCTION
Giardia lamblia, a flagellate intestinal protozoan, is probably among the most common observed gastrointestinal parasites in the world. Globally, it is one of the most frequent that are diarrhea-causing among 200 million cases reported annually particularly in infants, young children, and young adults in developing countries 1,2 . The highest prevalence of G. lamblia was recorded in developing countries between 10% and 50% compared between 2 to 5% in developed countries 3, 4 . G. lamblia is transmitted by consumption of contaminated food or water with mature cysts. Also, parasites transmission between community can occur via direct fecal-oral contact between family members and homosexual men 5, 6 . Giardia prevalence in Yemen is associated to some factors that include inadequate hygienic practices, environmentally contaminated with fecal, lack of health awareness, and the lack of health infrastructure. These factors are resulting from the Saudi Emirati aggression started in March 2015 that destroyed the health system and increased the prevalence of infectious diseases especially among children suffering from severe malnutrition 7  Amran governorate lacks many epidemiological studies focusing on the prevalence and incidence of intestinal parasitic infections among the population. Hence, this work aims to identify the prevalent G. lamblia infection and risk factors among children admitted to health care centers in Amran governorate in Yemen.

MATERIALS AND METHODS Study Design and Area
This study is a cross-section study carried out in the medical laboratory at 22 May hospital in Amran City, Yemen, during the period from March to July 2019. This investigation was applied at Amran governorate in both of urban and rural areas; about 50 km north of Sana'a, the capital of Yemen.

Data Collection
Prior to specimen collection, the objectives of the study were explained briefly to all children. The data was collected in a structured questionnaire from the children's parents or adult guardians via face-to-face interview that includes data on social and demographic information (i.e. age, gender, parent education, and residence) and behavioral habits (i.e. hand washing after defecation and washing of fruits and vegetables), and environmental conditions such as type of water supply and presence of absence of a toilet. The age of participants in this study was categorized into two groups that were between 1-7 years and from 8 to 14 years.

Figure 1: The distribution of specimens among areas Sample Collection and Examination
A total of three hundred and thirty-four (334) stool specimens were collected from infected children in clean plastic containers (60 ml) and labeled. The collected samples were directly processed and analyzed by direct smear to identify the presence of Giardia parasites (cysts and/or trophozoites) from fresh stool. Also, the wet mount preparation was used after formalether sedimentation technique according to Cheesbrough 12 .

RESULTS
Three hundred and thirty-four (334) stool specimens were chosen of children from Amran governorate, 160(47.9%) specimens were from an urban area and 174(52.8%) specimens from a rural area ( Figure 1). The obtained results were revealed that 181 (54.2%) cases were infected with G. lamblia parasite. Meanwhile according to resident high rate of giardiasis 104(57.5%) were recorded in stool specimens belong the urban area compared to 77(42.5%) cases from the rural area are shown in Figure 2. Table 1 shows that the high frequency of G. lamblia infection by sex was 105 (60.3%) in males when compared to 76 (47.5%) of females with G. lamblia.

Figure 2: Rate and distribution of child infected and non-infected
The current results related to gender and age showed that the highest prevalence of G. lamblia infection was reported among the age group of 8 to14 years (81.90%) in males followed by 61.9% was among the age group of 1-7 years in females recorded urban area. Similarly, the highest rate of G. lamblia was 55.8% and 40.5%, respectively, observed among each age group of 8 to14 years in males and females in rural area ( Figure 3). Present work showed the associations between the frequency of G. lamblia infection and several behavioral and environmental factors. The highest prevalence of G. lamblia infection was (73.8%) found between parents of children with the uneducated level of education, use untreated water sources for drinking water (71.9%), eating unwashed vegetables and fruits (69.2%) and (66.4%), respectively. Also, high prevalence was (81%) observed between children lived in houses without toilets and those who didn't wash their hands after defecation (74.5%) as summarized in Table 2.

DISCUSSION
The overall rate of G. lamblia infection was 54.2% recorded between children. This study revealed a high frequency of G. lamblia infection among children compared to other studies in other governorates' in Yemen where it ranged between 23.6% and 23.94% in Ibb 8,13 , 3% in Al-Mahweet 9 , 19.17% in Hadramowat 10 , and between 16.7% and 17.7% in Sana'a 11, 14 . The high frequency of Giardia infection between young children might be due to lower standards of personal hygienic practices and sanitary behaviors when compared to adults and older children 15, 16 . Amran governorate is a developing region in Yemen and the life of most people depended upon agriculture and live with domestic animals in the same house. They also suffer from severe water shortages and people tend to collect drinking water from unclean water sources such as streams, wells, tanks, rains, and and other natural or artificial sources. Moreover, they lack the basic constituents in the health and educational systems 17, 18 . In current work, the highest prevalence of G. lamblia was 57.5% reported in an urban area compared to 42.5% in the rural area. In agreement with the unexpected results, Al-Haddad and Baswaid 10 found that G. lamblia infection was (33.57%) more prevalent in the urban area than (32.06%) in the rural area. Furthermore, a study conducted in Taiz  It is difficult to explain the higher prevalence of Giardia parasite in urban area than rural area, but it may be due to some factors such as sociodemographic and socio-economic environmental of Amran city that does not differ in general than natural of habitats life in rural communities.  In addition, the Amran city lacks the piped-water supply and sewage disposal, as well as its population below the poverty line, are considered as factors that contribute to spreading the intestinal infection. In this study, it was revealed that the prevalence of Giardia for males was 60.3% higher compared to the female by 47.5%, and likewise, a high percentage of Giardia infection was recorded in previous studies among males in Yemen; it was between 17-17.6% in Sana'a 7, 11 and 32.1% in Ibb 8 . In contrast, Qasem et al., 13 noted that the high prevalence of Giardia was 64.4% among females. The higher prevalence of the Giardia infection among males in this work than females is due to the males in the study area are contributing to some works and they remain for a long time outside the home daily making them more susceptible to Giardia infection than females. Results from this work revealed that the highest infection rate (81.90%) was between the age group 8 to 14 years in males followed by (61.90%) among the age group of 1-7 years in females in the urban area. Whereas, the highest prevalence of Giardia infection was 55.80% among males aged 8-14 years and lowest 35.90% between males aged 1-7 years in a rural area. A similar study was investigated by Mekhlafi et al., 7 and showed that the high rate of G. lamblia. infection was (18.6%) recorded among less than 10 years. Qasem et al., 13 also reported that the age group of 9-12 years was 51.1% highly infected by G.
lamblia. Findings of the current work showed that the prevalence rates of Giardia infection were influenced by the educational level of parents and the type of water sources used for the drink. The high prevalence of Giardia infection was more between children of parents with a low level of education. Also, the children who used the untreated water were more exposed to infection than used treated water. Moreover, children who eating unwashed vegetables and fruits as well as not used the toilet and not washed hands after defecation were found to be highly infected with Giardia infection. These results were supported by studies conducted in Yemen found a significant association between Giardia infection and type of drinking water, methods of food preparation, and the statue of personal hygiene 9, 19 . Most people in the rural area depend entirely on dams and surface water such as rivers and springs as a major source of drinking water because this area lacks deep wells. These types of water sources are easily contaminated by intestinal parasites resulting from the human and animal sources during the rainy season and eventually, the people in the rural area consume this contaminated water 18 . However, it was reported that the contaminated hands play an important role in transmitting fecal-oral in developing countries and washing hands after defecation or before eating have been considered as a secondary barrier 19 .