UNIVERSA MEDICINA

May-August, 2014 Vol.33- No.2

Footwear as a risk factor of hookworm infection

in elementary school students

Semuel Sandy*, Sri Sumarni**, and Soeyoko**

ABSTRACT

BACKGROUND *Papua Health and Biomedical

In Indonesia, there is still a high prevalence of hookworm infection, especially in Research and Development
poor areas with poor sanitation. The number of helminthic diseases in Keerom Institute, Ministry of Health
Regency was about 599 cases in 2010. This number is bound to increase due to **Department of Parasitology,
Faculty of Medicine,
the low sanitation, hygiene and socio-economic status of the people in the
Gadjah Mada University
regency. The children are a group at risk for contracting infections, especially
intestinal worms, which affect the child’s physical growth and intelligence. The Correspondence
objective of this study was to determine the risk factors of hookworm diseases Semuel Sandy, M.Sc, Apt
in elementary school students. Papua Health and Biomedical
Research and Development
METHODS Institute, Ministry of Health
A cross-sectional study was conducted on 224 elementary school students. (Balai Penelitian dan
Demographic data were obtained by questionnaire, comprising gender, parental Pengembangan Biomedis
socio-economic status, household sanitation, and personal hygiene. Body mass Papua)
index was calculated by measurement of body weight and height. And Jl. Kesehatan No.10 Dok II.
Jayapura
hemoglobin concentration was measured using a Quick Check Hb-meter. Stool
Phone: +62967-534539
samples were microscopically examined using the Kato-Katz method. We used
Fax: +62967-534697
chi-square and logistic regression to find predictors of hookworm infections, E-mail:
with level of significance at p<0.05. [email protected]

RESULTS Univ Med 2014;33:133-40

The number of hookworm infection was 6.7% and the risk factor of hookworm
infection among elementary school students was the habit of using footwear
outdoors [OR 5.3; 95% CI 1.7-17.7; p=0.004].

CONCLUSION
The use of footwear outdoors was a predictor of hookworm infections in
elementary school children. An effective and efficient intervention program is
needed to prevent and eradicate hookworm infection among primary school
children.

Key words: Hookworm, sanitation, hygiene, anemia, primary school children

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Sandy, Sumarni, Soeyoko Footwear a risk hookworm infection

Penggunaan alas kaki sebagai faktor risiko infeksi cacing tambang

pada murid sekolah dasar

ABSTRAK
LATAR BELAKANG
Prevalensi infeksi cacing tambang di Indonesia masih cukup tinggi terutama di daerah miskin yang memiliki sanitasi
lingkungan yang buruk. Jumlah kasus kecacingan di Kabupaten Keerom yaitu 599 kasus pada tahun 2010, dan
tentunya kasus ini akan bertambah mengingat sanitasi, higiene dan status sosial-ekonomi masyarakat rendah. Anak-
anak merupakan kelompok berisiko untuk tertular infeksi cacing yang berdampak pada pertumbuhan fisik dan
intelegensia anak. Penelitian ini bertujuan untuk menentukan prevalensi dan faktor risiko infeksi cacing tambang
pada murid sekolah dasar (SD)

METODE
Desain penelitian potong lintang (cross sectional) mengikut sertakan 224 murid SD. Pengambilan data demografi
menggunakan kuesioner meliputi jenis kelamin, status sosial ekonomi orang tua murid, sanitasi lingkungan rumah,
higiene murid pengukuran antropometri untuk mengukur status gizi dan kadar hemoglobin (Hb) menggunakan
Quick Chek Hb-meter. Spesimen tinja diperiksa menggunakan metode Kato-Katz. Analisis data menggunakan statistik
bivariat (Chi Square) dan regresi logistik untuk menentukan variabel prediktor.

HASIL
Jumlah infeksi cacing tambang sebesar 6,7% (n=224). Hasil analisis regresi logistik menunjukkan faktor prediktor
terjadinya infeksi cacing tambang adalah kebiasaan menggunakan alas kaki saat bermain di luar rumah dan sekolah
[OR 5,3; (95% KI 1,7-17,7); p=0,004].

KESIMPULAN
Kebiasaan menggunakan alas kaki saat diluar rumah merupakan faktor risiko infeksi cacing tambang pada murid
SD di Kabupaten Keerom. Diperlukan suatu intervensi yang efektif dan efisien untuk mencegah dan memberantas
infeksi cacing tambang

Kata kunci: Cacing tambang, sanitasi, higiene, anemia, murid Sekolah Dasar

INTRODUCTION helminthiasis because it needs soil in the growth

process of the worm larva to become infective
Infection by soil transmitted helminths (filariform larva). (3) Man is the sole host for
(STH) is a neglected tropical disease caused by hookworm (A. duodenale and N. americanus),
worms of the species Ascaris lumbricoides, since these worms do not have an intermediate
Ancylostoma duodenale, and Trichuris host. The hookworm infection is known as
trichiura. Soil transmitted helminth infection ancylostomiasis (for infection with A.
depends on socio-economic conditions and is duodenale) and as necatoriasis (for infection
frequently found among children in developing with N. americanus). Hookworm infection is a
countries. A high prevalence of STH infection symptomless chronic infection that can cause
is found in poor village areas, with poor sanitation microcytic hypochromic anemia.(4)
and hygiene, where there are no toilets, allowing Hookworms infect humans by way of
pollution of the soil with infective worms.(1,2) infective (filariform) larvae which penetrate the
Hookworm infection is a soil transmitted skin (through the sides of toes and the skin pores

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of legs and hands).(3) Children and gardeners with high rainfall, annual average temperatures
are at risk of hookworm infection, because of 30.50C - 35.10C, 80-89% humidity, consisting
children like to play with soil and frequently do for 99.9% of soft soils and 0.42% peaty soils,
not use footwear when outdoors, and gardeners with soil pH values between 5.0 – 8.3.(10) The
are exposed to filariform larvae if they do not geographic condition and physical environment
wear boots or gloves when working in the substantially supports the spread of hookworm
garden.(2) infection through soil. (3,11) The number of
Soil transmitted helminth infection occurs helminths found in the Regency in 2011 was about
in almost all parts of the world. It is estimated 1.2%.(9) The prevalence of hookworm infection
that about 2 billion people are infected by these has a high probability of increasing, based on the
parasitic worms. Generally, this disease is found traditional lifestyle of the local farmer community,
among poor people with poor environmental poor environmental sanitation, and the existence
sanitation. The World Health Organization of people who still defecate in gardens or near
(WHO) estimates that 250 million people are their homes. The aim of this study was to estimate
infected by ascariasis, 151 million by hook- the prevalence of hookworm infection among
worm, 100 million by strongyloidasis and 45.4 elementary school students and identify the risk
million by trichuriasis.(5) School-age children are factors affecting this infection.
at high risk of becoming infected by this
contagious disease.(6) The factors of poverty, METHODS
environmental sanitation, and immunity also
contribute to infection by these worms through Research design
soil. The detrimental effects of these parasitic The present study used a cross-sectional
and contagious worms can be various and analytic observational design and was conducted
harmful, such as impeding physical growth of in the Arso District, Keerom Regency, Papua
the children, disturbing their activities, and Province, from September until December 2012.
decreasing their ability to receive lessons at
school. The chronicity of these infections can Research subjects
decrease the quality of human resources.(7) The research subjects were third- and
In Indonesia, soil transmitted helminthic sixth-grade elementary school students meeting
infections pose health problems in urban and the inclusion and exclusion criteria, and having
semi-urban areas with low socio-economic level, signed a statement agreeing to join the research
poor environmental sanitation, and poor hygiene. (informed consent). The three largest
Generally, the data on the prevalence of worm elementary schools in the area were selected
infections in Indonesia depend on geography, for the study, comprising Inpres Elementary
climate, human behavior, level of education, and School 01 Arso I, Inpres Elementary School 02
personal hygiene. The tropical climate of Arso I and Inpres Elementary School PIR I. The
Indonesia substantially supports the growth of sample size for this study was calculated by
the hookworm, as the high humidity, light using the single proportion formula at 95%
intensity, and rainfall influence the process of confidence interval (CI) level (Z (1-α/2) = 1.96),
the eggs maturing to become infective larvae.(8) an expected prevalence of 19.4 % and 5%
Keerom Regency is a region in the Papua marginal error.(12) The calculated total sample
Province of Indonesia with a surface area of 9.365 size was 241 students. However, the total
km2. Its geographic location is between longitude number of students joining the research, filling
1400 15’ 00’’ - 1400 0’ 0’’ E and latitude 20 37’ the questionnaire and delivering their stool
00’’ - 40 00’ 00’’ S.(9) It also has a tropical climate samples for examination, was 224.

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Sandy, Sumarni, Soeyoko Footwear a risk hookworm infection

Data collection could be examined. (14) Stool analysis was

A structured questionnaire was distributed performed using the Kato-Katz technique by
among the participating pupils for the collection malachite green staining to detect hookworm
of demographic information, such as age, eggs. We used microscopic analysis for
gender, socio-economic status of their parents, identification of hookworm eggs. The results
household sanitation, and personal hygiene. The were categorized as positive if the Kato-Katz
items on parental socio-economic status were slide contained hookworm eggs. For the
educational level, occupation, and income of the determination of the hemoglobin concentration
parents. On the subject of sanitation, the of the pupils, finger-prick blood samples of the
questions asked were type of toilets, location of pupils were collected and the hemoglobin
toilets, and main water source of household. concentration measured with a rapid test Quick
Personal hygiene questions comprised habitual Check Hb meter, using capillary tubes containing
use of footwear when playing, using soil as 20 µL of finger prick blood. Subjects were
medium for playing, the habit of washing hands categorized as having anemia if the hemoglobin
before eating, and the habit of washing hands concentration was <11.5 g/dL.
after defecating. Body weight (kg) was
measured to the nearest 0.1 kg using Omron Ethical clearance
digital scale and height body (cm) was measured Ethical clearance for this research was
to the nearest 0.1 cm using a microtoise. The issued by the Medical and Health Research
children were measured wearing light uniforms, Ethics Committee, Faculty of Medicine, Gadjah
without shoes, belts, caps or any other material Mada University.
that could interfere with their actual height and
weight. Subjects were categorized as having Statistical analysis
wasting and normal anthropometric nutritional The data analysis was by descriptive
indices. Wasting was defined as < -2 Weight statistics, and differences between two variables
for Age Z-score [WAZ score].(3) were tested by bivariate statistics (chi square
and Fisher’s test). Statistical significance was
Collection of stool samples and laboratory considered to be achieved at p<0.05. Logistic
testing regression was performed to identify the
The pupils were educated on the causes predictor factors of hookworm infections.
of intestinal helminthic infections among school-
age children and they were convinced that every RESULTS
child should be free from such infections, thus
the necessity of participating in the research The distribution of hookworm infection in
work was appreciated by them. Thereafter, wide elementary school students of Arso District on
mouthed corked sterile containers were given the basis of gender can be seen in Table 1. The
to the pupils for the collection of their stool number of hookworm cases was found to be
samples at home. The pupils were taught how greater in male students (7.8%) than in female
to collect the stool samples, with the aid of their students (5.8%).
teachers. The stool samples received from the There was a significant relationship
children were properly labelled and transported between hookworm infection and the habit of
in a cold box to the laboratory of the Papua using footwear while playing or being outside
Health and Biomedical Research and the house (p<0.05). There was a risk of
Development Institute, Ministry of Health. The hookworm infection in elementary school
samples that could not be analyzed immediately students who did not use footwear when playing
were preserved using 10% formalin until they outdoors. The result of the logistic regression

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Table 1. Distribution of risk factors of hookworm infection in elementary school students

Hookworm infection Odds Confidence

Risk factor Positive Negative ratio interval p value
n (%) n (%) (OR) (CI)
Gender
Male 8 (7.8) 95 (92.2) 0.729 0.255-2.084 0.554
Female 7 (5.8) 114 (94.2)
Anemia
Anemia (>11.5 g/dL) 3 (10.7) 25 (89.3) 0.543 0.143-2.060 0.410
Normal (<11.5 g/dL) 12 (6.1) 184 (93.9)
Nutritional status
Wasting ( <- 2 SD ) 11 (6.2) 167 (93.8) 1.446 0.438-4.769 0.517
Normal ( >-2 SD) 4 (8.7) 42 (91.3)
Type of toilet
Toilet without septic tank 4 (5.7) 66 (94.3) 1.269 0.390-4.134 0.781
Toilet with septic tank 11 (7.1) 143 (92.9)
Loca tion of toilet
Outside the house 17 (17.7) 79 (82.3) 1.749 0.911-3.358 0.091
Inside the house 35 (27.3) 93 (72.7)
Main water source
Untreated water (well water, river 12 (8.4) 131 (91.6) 0.420 0.155-1.534 0.177
water, rain water)
Treated water (piped water from PAM 3 (3.7) 78 (96.3)
/ bottled water)
Type of house floor
Noncemented floor (soil, board, 5 (5.0) 95 (95.0) 1.667 0.511-5.045 0.362
bamboo)
Cemented/ceramic tile floor 10 (8.1) 114 (91.9)
Parents’ educational level
Low (elementary school, junior high 11 (6.4) 160 (93.6) 1.187 0.362-3.896 0.777
school, senior high school)
High (D3, S1, S2, S3) 4 (7.5) 49 (92.5)
Parents’ job
Non-employe e (farmer, trader) 7 (5.4) 122 (94.6) 1.603 0.560-4.584 0.376
Employee (employee of private firm, 8 (8.4) 87 (91.6)
civil servant)
Parents’ income
Low (<Rp 3,000,000) 13 (6.7) 182 (93.3) 1.037 0.222-4.850 1.000
High (> Rp 3,000,000) 2 (6.9) 27 (93.1)
Habit of using footwear when playing
Yes 9 (4.6) 185 (95.4) 0.195 0.064-0.595 0.007*
No 6 (20.0) 24 (80.0)
Using soil as medium for playing
Yes 5 (9.8) 46 (90.2) 0.564 0.184-1.734 0.341
No 10 (5.8) 163 (94.2)
Habit of washing hands before eating
Using water 2 (4.2) 46 (95.8) 1.834 0.399-8.423 0.744
Using water and soap 13 (7.4) 163 (92.6)
Habit of washing hands after defecating
Using only water 4 (8.9) 41 (91.1) 0.671 0.203-2.215 0.509
Using water and soap 11 (6.1) 168 (93.9)

*chi square test (significant if p<0.05); PAM = water purification plant; D3, S1, S2,S3 = tertiary degrees, equivalent to
undegraduate diploma, bachelor, master, PhD

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Sandy, Sumarni, Soeyoko Footwear a risk hookworm infection

was that the predictor of hookworm infection in status with soil-transmitted helminth infection.(19)
this study was the habit of using footwear when There is the possibility of finding symptoms of
playing outdoors [OR 5.3; 95% CI 1.7-17.7; malnutrition in round worm infection of children,
p=0.004 ] (data not shown). while anemia is probably found in children
infected by malaria and hookworm.(11,20) That
DISCUSSION there is no significant relationship between
hookworm infection and anemia may be because
Examination for hookworm eggs was done generally the number of infected children is
by means of the Kato-Katz method, which is a smaller, and there are other causative factors
widely used diagnostic stool providing estimates of anemia in children, such as nutritional intake.
of population prevalence and infection intensity. The finding on anemia in our study is also in
The accuracy of the Kato-Katz method to detect agreement with that obtained in Turkey of no
hookworm eggs was reported by Knopp et al.(15) association between anemia and parasitic worm
to be higher than that of the FLOTAC infections.(21)
technique. Another study on the accuracy of the Environmental sanitation has an important
Kato-Katz technigue for hookworm eggs was role in worm infections that are transmitted
done by Funk et al.,(16) who showed that the through the soil, especially hookworm
prevalence of hookworm infection in elementary infection,(22) where poor sanitation increases the
school students was 6.7%. Similar results were risk of this infection. The bivariate statistical test
obtained in an Indian study, which found the results of risk factors in environmental sanitation
prevalence hookworm infections to be about found no significant relationship with hookworm
6.3%. (17) In the present study, male children infection. This is presumably because of the
were more infected than females. This is small number of hookworm infection cases in
presumably caused by the different playing this study, whereas a large number of cases are
habits of male and female children, such as needed to find relationships at population level.
walking on the ground without footwear, using Another study showed that water source and
soil as medium for playing, playing with balls, the habit of handwashing with soap were
jump ropes, and marbles. The children also have significantly associated with hookworm
the habit of taking off the footwear (shoes) when infection.(7)
going home.(1,2,7) This is in agreement with the The present study found no significant
results of a study conducted by Unike et al.(13) relationship between socio-economic status of
in Nigeria, where male children were more the parents and hookworm infection. High
infected than females, although the difference educational level of parents does not guarantee
in infection rate was not significant. However, that their children are free from hookworm
contrasting results were obtained in a Malaysian infection. Although parents with high educational
study showing that hookworms were more level, income, and job status are different from
frequent in female children.(18) the lower classes of the community, generally
There was no significant relationship of all community members have gardening as a side
hookworm infection effects with nutritional status job. Therefore members of the higher class also
and anemia. The finding for anemia is similar to have direct contact with the soil and their children
that obtained in the Satak Malaysian study, can be exposed to hookworm infection, because
showing no significant association between after school they help their parents in the
anemia and hookworm infection.(2) In addition, garden. (1,13,14)
the finding for nutritional status in our study is The risk factor of personal hygiene plays
similar to the results obtained in Pahang, an important role in hookworm infection
Malaysia, showing no association of nutritional transmission. The bivariate analysis results show

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a significant relationship for the risk factor of activities which may increase their care about
hygiene, i.e. the habit of using footwear outdoors. the importance of health information and
The latter habit is very important to avoid education.(21)
exposure to soil polluted by infective (filariform)
larvae. The behavior of children of using sandy CONCLUSION
soil as playing medium has a high risk of this
worm infection.(7,23) This is in contrast with the The prevalence of hookworm infection
results of a study conducted by Nasr et al.(24) among elementary school students was 6.7%.
and Kattula et al.,(17) where use of footwear and The habit of using footwear was a risk factor in
shoes outdoors was not associated with transmission of hookworm infection to these
hookworm infection. elementary school students.
There are several limitations of this study
as potential sources of bias. One source may ACKNOWLEDGEMENT
have been the administration of the socio-
economic survey forms. The children answered The researchers thank the Head of the
questions about their personal, household, and Department of Parasitology, Medical Faculty,
health behavior characteristics on their own, Gadjah Mada University, Prof. dr. Supargiyono,
while the same information was collected about DTM&H, SU, Sp.Par.K, Ph.D, the Head of the
children by asking their parents. Since only a Institute of Health Biomedical Research and
single stool sample per child was collected in Development Papua dr. Lidwina Salim, M.Si, the
this study, using the Kato-Katz preparation to headmasters of Inpres Elementary School Arso
determine infection status, there is presumably 01, Arso 02, and Inpres Elementary School PIR
a significant underestimation of the infection. I, and the Chief of National Unity, Politics and
This is because a single sample may miss Public Protection Board Papua, Keerom
infection in an individual as a result of the Regency (LIMNAS Kabupaten Keerom).
temporal variation in egg excretion over hours
and days.(25) The cross-sectional study did not REFERENCES
describe the effects of socio-economic factors
on the children’s nutritional and parasitic status. 1. Ahmed A, Al-Mekhlafi HM, Choy SH, Ithoi I, Al-
A longitudinal cohort study would be necessary Adhroey A, Abdulsalam AM, et al. The burden
of moderate-to-heavy soil transmitted helminth
to provide information about a community’s
infections among rural Malaysian aborigines: an
social, educational, economic and behavioral urgent need for an integrated control programme.
characteristics.(21) Parasites Vectors 2011;4:242-9. doi:10.1186/1756-
Our study shows that hookworm infections 3305-4-242.
still pose a significant health challenge to children 2. Ahmed A, Al-Mekhlafi HM, Choy SH, Ithoi I, Al-
Adhroey A, Abdulsalam AM, et al. The nutritional
in the poor rural areas of Papua. Intestinal
impacts of soil-transmitted helminth infections
parasitic infections have detrimental effects on among Orang Asli schoolchildren in rural
survival, appetite, growth and physical fitness Malaysia. Parasites Vectors 2012;5:119-28.
of children. We hope that this study may doi:10.1186/1756-3305-5-119.
motivate the government to the deworming of 3. Loukas A, Constan SL, Bethony JM. Immunology
of hookworm infection. FEMS Immunol Med
soil transmitted helminths in school-age children
Microbiol 2005;43:115-24.
and provide educational information for 4. Soedarto. The textbooks of medical parasitology.
preventing soil transmitted helminth and other Sagung Seto, Jakarta, 2011.
intestinal parasite infections. When supporting 5. World Health Organization. Helminth control in
school health programs, hopefully parents may school-age children: a guide for managers of
control programmes. 2nd ed. Geneva: World Health
become involved in deworming and dietary
Organization; 2011

139
Sandy, Sumarni, Soeyoko Footwear a risk hookworm infection

6. Avad SB, Hiware CJ. Soil transmitted helminthiasis 18. Al-Mekhlafi MSH, Azlin M, Aini UN, Shaikh A,
among school age children in Aurangabad Fatmah MS, Ismail MG, et al. Prevalence and
district, Maharashtra State, India. DAMA distribution of soil transmitted helminthiases
Internasional 2012;1:31-3. among orang asli children living peripheral
7. Alemu A, Atnafu A, Addis Z, Shiferaw Y, Teklu T, Selangor, Malaysia. Southeast Asian J Trop Med
Mathewos B, et al. Soil transmitted helminths and Public Health 2006;37:40-7.
Schistosoma mansoni infections among school 19. Al-Mekhlafi MH, Atiya AS, Mahdy AMK, Ariffin
children in Zarima Town, Northwest Ethiopia. AW, Abdullah H C, Surin J. Pattern and predictors
BMC Infect Dis 2011;11:189-96. of soil transmitted helminths reinfections among
8. Natadisastra D, Ridad A. Medical parasitology: orang asli (aborigine) schoolchildren in Malaysia.
viewed from the infected body organs. Jakarta: Acta Trop 2008;107:200-4. doi: 10.1016/j.
EGC;2009. actatropica.2008.05.022.
9. Keerom Regency Health Office. The health profile 20. Koukonari A, Estambela BBA, Njagi JK, Cundill
of Keerom regency in 2011. The Government of B, Anjaga A, Crudder C, et al. Relationship
Keerom Regency, Papua; 2012. between anaemia and parasitic infections in
10. The Government of Keerom Regency. The profile Kenyan schoolchildren: a Bayesian hierarchical
of local government of Keerom regency. Papua; modeling approach. Int J Parasitol 2008;38:1663-
2012. 71.
11. Nematian J, Nematian E, Gholamrezannezhab A, 21. Ulukanligil M, Seyrek A. Demographic and socio-
Asgari AA. Prevalence of intestinal parasitic economic factors affecting the physical
infections and their relation with socio-economic development, haemoglobin and parasitic infection
factors and hygiene habits in Tehran primary status of schoolchildren in Sanliurfa province,
school students. Acta Trop 2004;92:179-86. Turkey. Public Health 2004;118:151-8.
12. Chadha VK. Sample size determination in health 22. Ziegelbauer K, Speich B, Mäusezahl D, Bos R,
studies. NTI Bull 2006,42:55-62. Keiser J, Utzinger J. Effect of sanitation on soil-
13. Yap P, Wei-Du Z, Chen R, Zhang L, Wang J, Wang transmitted helminth infection: systematic review
X, et al. Soil transmitted helminth infections and and meta-analysis. PloS Med 2012;9:e1001162.
physical fitness in school-aged Bulang children doi:10.1371/journal.pmed.1001162.
in Southwest China; results from cross sectional 23. Ratnayaka RMKT, Wang ZJ. Prevalence and
survey. Parasites Vectors 2012;5:50. doi: 10.1186/ effect of personal hygiene on transmission of
1756-3305-5-50. helminth infection among primary schoolchildren
14. Unike CJ, Oze KO, Oyibo PG, Azu NC, Ali E. Soil living in slums. Int J Multidisciplinary Res 2012;2:
transmitted helminth infection in school children 1-12.
in south-eastern Nigeria: the public health 24. Nasr NA, Al-Mekhlafi HM, Ahmed A, Roslan MA,
implication. Internet J Third World Medicine Bulgiba A. Towards an effective control
2012;4:1 doi:10.5580/3f7 programme of soil-transmitted helminth
15. Knopp S, Speich B, Hattendorf J, Rinaldi L, infections among Orang Asli in rural Malaysia.
Mohammed KA, Khamis IS, et al. Diagnostic Part 2: Knowledge, attitude, and practices.
accuracy of Kato-Katz and FLOTAC for Parasites Vectors 2013; 6:28. doi: 10:1186/1756-
assessing anthelmentic drug efficacy. PloS Negl 3305-5-119.
Trop Dis 2011;5: e1036. doi:10.1371/journal.pntd. 25. Wang X, Zhang L, Luo R, Wang G, Chen Y,
0001036. Medina A, et al. Soil transmitted helminth
16. Funk AL, Boisson S, Clasen T, Ensink JHJ. infections and correlated risk factors in preschool
Comparison of Kato-Katz, ethyl-acetate and school aged children in rural Southwest
sedimentation, and Midi Parasep in the diagnosis China. PLoS ONE 2012;7: e45939. doi:10.1371/
of hook worm, Ascaris and Trichuris infections journal.pone.0045939.
in the context of an evaluation of rural sanitation
in India. Acta Tropica 2013; 126:265-8.
17. Kattula D, Sarkar R, Swarna S, Ajjampur R, Minz
S, Levecke B, et al. Prevalence & risk factors for
soil transmitted helminth infection among school
children in south India. Indian J Med Res 2014;139:
76-82.

140