Prevalence of Parasitic Infection and its Determinants Among Children Aged 6–13 Years in Rural Areas of Gorakhpur

Abstract

Background:

Parasitic infections are a significant public health concern in low-resource settings, particularly among children and adolescents. This study aims to determine the prevalence of parasitic infections and their association with various sociodemographic and environmental factors among asymptomatic children aged 6–13 years in rural India.

Methods:

This cross-sectional study was conducted at the rural field practice area of AIIMS, Gorakhpur, located in Uttar Pradesh, India. Data on sociodemographic factors, birth order, and hygiene practices were collected. Stool samples were examined microscopically. Anthropometric measurements followed standard guidelines.

Results:

The prevalence of parasitic infections among the children was 29.3%, with Blastocystis hominis (11.6%), Entamoeba histolytica (8.9%), and Giardia sp. (8.3%) being the most common pathogens. Younger children (6–9 years) had a higher infection rate (32.1%) compared to older children (10–13 years) at 23.9%. Males showed a slightly higher infection prevalence (31.5%) compared to females (27.6%). Higher birth order and living in pucca houses were associated with higher infection rates. Logistic regression analysis living in pucca houses was associated with increased infection risk (adjusted OR: 2.69, 95% CI: 1.07–4.00).

Conclusions:

The study reveals a significant burden of asymptomatic parasitic infections among children in rural India, with various socioeconomic and environmental factors influencing infection rates. These findings underscore the need for comprehensive public health interventions focusing on hygiene education, improved sanitation, and routine screening to mitigate the impact of these infections on child health.

INTRODUCTION

Parasitic infections are a critical public health challenge globally, particularly within low-resource rural settings, where they contribute significantly to morbidity and mortality among children.[1] According to the Global Burden of Disease (GBD) Study 2017, diarrheal diseases were responsible for approximately 446,000 deaths among children under 5 years old worldwide, with a significant proportion occurring in low- and middle-income countries.[2] These infections, caused by a variety of pathogens, including viruses, bacteria, and parasites, are especially prevalent in environments with inadequate sanitation, poor hygiene practices, and limited access to clean water. In India alone, it is estimated that over 100 million cases of diarrhea occur annually among children under 5 years.[3] Children in these setting are particularly vulnerable due to their heightened exposure to environmental pathogens and reduced immune systems response.[4]

The impact of asymptomatic parasitic infections is not well understood; studies have shown that these infections can be fivefold more prevalent than symptomatic cases.[5] Moreover, chronic, subclinical infections can subtly undermine nutritional status, leading to malnutrition and impaired physical and cognitive development. The GBD 2017 report highlighted that malnutrition was an underlying factor in nearly 45% of deaths among children under 5 years, further emphasizing the critical interplay between infection and nutrition.[2] This scenario underscores the need for more comprehensive surveillance and management strategies that include asymptomatic individuals, especially in high-risk populations.[6]

This study focuses on the prevalence of parasitic infections among asymptomatic children aged 6–13 years in rural India. Research in such demographics is crucial as they often do not receive the attention needed in public health initiatives. According to UNICEF, rural children in India are disproportionately affected by poor health outcomes due to limited healthcare access and resources.[7] This research aims to illuminate not only the rate of infection but also how these infections correlate with various sociodemographic and environmental determinants. Understanding the hidden burden of these diseases can provide valuable insights that could influence public health strategies aimed at reducing the incidence of parasitic infections.[8]

Rural settings, characterized by limited infrastructure, often result in poor living conditions and inadequate healthcare services, which exacerbate the spread of parasitic diseases. For instance, the World Health Organization (WHO) reports that only 32% of rural households in India have access to improved sanitation facilities, compared to 70% in urban areas.[9] Investigating the environmental and behavioral factors contributing to health disparities in these areas is crucial for developing effective public health interventions.[7] Such interventions are needed to address the underlying causes of health issues and improve overall health outcomes in these communities.[10]

The WHO and UNICEF Joint Monitoring Program (JMP) for Water Supply and Sanitation reported that in 2017, 163 million people in rural India still practiced open defecation, a major risk factor for parasitic infections.[9] The Government of India has initiated several programs to improve rural health, but these efforts often fall short due to inadequate implementation and coverage. For example, the Swachh Bharat Mission aims to eliminate open defecation by constructing toilets, but challenges in behavior change and maintenance remain.[11] This study is set within the context of the Health and Demographic Surveillance Site of AIIMS, Gorakhpur, which provides a comprehensive database for examining health trends in rural populations.

The prevalence of asymptomatic parasitic infections among children in rural India has not been extensively studied. Most existing research focuses on symptomatic cases, particularly those resulting in diarrhea and other severe health outcomes. A study by Garzón M et al. (2018) found that subclinical infections in infants were associated with growth faltering, highlighting the importance of addressing these silent infections.[8] Environmental factors such as the type of water supply, availability of sanitation facilities, and personal hygiene practices play a crucial role in the transmission of parasitic infections. For instance, a 2010 study by Cairncross et al.[12] found that improved water and sanitation could reduce the incidence of diarrhea by up to 37%. The use of handpumps and open defecation are common in rural India, contributing to the spread of pathogens. Behavioral factors, including handwashing practices and nail hygiene, also significantly affect infection rates.[13]

Sociodemographic factors, including parental education and occupation, influence health outcomes by affecting household income and access to health services. Children from lower socioeconomic backgrounds are more likely to be exposed to conditions that foster the spread of parasitic infections. According to the GBD 2017, socioeconomic disparities are a major determinant of health outcomes, with children from the poorest quintiles experiencing higher rates of infectious diseases.[14] This study examines these factors to identify key determinants of infection and malnutrition among rural children.

This quantifies the burden of disease and enhances understanding of how various vulnerabilities—biological, environmental, and socioeconomic—intersect to impact health. The findings would be vital for designing targeted health interventions that effectively address the root causes of parasitic infections and mitigate their impact on young populations in similar settings globally.[15] Comprehensive health surveillance and targeted treatment programs are essential to prevent the long-term health consequences associated with chronic parasitic infections.[16] Thus, this study aimed to determine the prevalence of parasitic infections and their association with various sociodemographic and environmental factors among asymptomatic children aged 6–13 years in rural India.

MATERIALS AND METHODS

Study design and setting

This cross-sectional study was conducted at the rural field practice area (RFPA) of AIIMS, Gorakhpur, located in Uttar Pradesh, India. The RFPA covers a population of approximately 16,000 individuals living in rural settings and is 24 km far from AIIMS Gorakhpur. This region was chosen due to its representative demographic and environmental characteristics typical of rural northern India, where infrastructural and healthcare challenges are prevalent.

Study population

The study population consisted of children aged 6–13 years residing in the RFPA. Eligible participants were identified from the RFPA database, which maintains comprehensive records of demographic and health-related information. Inclusion criteria included being a permanent resident of the RFPA and being asymptomatic for parasitic infections, which include fever, abdominal pain, and diarrhea for the past 2 weeks since the time of the survey. Exclusion criteria included recent antibiotic use (within the last 2 weeks) and the presence of chronic diseases.

Sample size and sampling technique

The sample size for this study was calculated using OpenEpi 3.4.4, with a prevalence rate of 24.09% for parasitic infections in children[17] and an absolute allowable error of 5%. The initial calculation indicated a sample size of 280.9. To account for a 10% non-response rate, the sample size was increased to 312, resulting in a final sample size of 320. Participants were selected using simple random sampling from the list of eligible children in the RFPA database. The random selection was performed using a computer-generated random number sequence of RFPA database to ensure unbiased sampling. Same number of participants (consent declined, not available even after three visit, stool sample not provided) were replaced by repeated random selection method.

Data collection

Data on sociodemographic variables (e.g., age, gender, parental education, and occupation), birth order, and environmental factors (e.g., type of housing, water supply, and sanitation facilities) were collected through structured interviews with parents or guardians. Drinking water supply was categorized based on the JMP.[18] These interviews were conducted by trained field workers using a standardized questionnaire. Information on hygiene practices (e.g., handwashing and nail trimming), defecation habits, and behaviors such as playing in soil and wearing shoes was also gathered through interviews.

Anthropometric measurements, including height and weight, were taken for all participants according to WHO standard protocols.[19] Height was measured using a stadiometer, and weight was measured using a digital scale. Body mass index (BMI) was calculated and interpreted according to WHO growth standards. Malnutrition was classified based on BMI-for-age Z-scores calculated using WHO Anthroplus software.[20]

Stool sample collection and laboratory analysis

After completion of the interview, pre-labeled screw-capped plastic containers were given to participants’ mothers. They were instructed to collect around 10 g of the morning stool sample using a wooden spoon in the sample container. The collected stool samples were brought within 2 h to the Department of Microbiology, AIIMS Gorakhpur, for their examination. On receiving the samples, they were preserved using formalin. All the stool samples were concentrated using the formol ether sedimentation technique.[21] Microscopy was performed by preparing saline and iodine mount from the sediment recovered in the concentration technique. The saline and iodine mount were observed under detection of parasites, and the finding were tabulated.

Data analysis

Data were entered into a database and analyzed using STATA version 18 and R software. Descriptive statistics, including frequencies and percentages, were calculated for categorical variables. To identify factors associated with parasitic infection, logistic regression analysis was performed. Both unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Variables included in the regression model were selected based on their significance in bivariate analysis and their relevance to the study objectives. Adjustments were made for potential confounders such as age, gender, parental education, and hygiene practices.

Ethical considerations

The study was approved by the Institutional Ethics Committee of AIIMS, Gorakhpur (IEC number: IHEC/AIIMS-GKP/BMR/76/2022. Informed consent was obtained from the parents or guardians of all participants, and assent was obtained from children aged 7 years and older. Confidentiality and anonymity of the participants were strictly maintained throughout the study. To ensure data quality, field workers received extensive training in data collection procedures. Regular supervisory visits were conducted to monitor data collection and address any issues. Laboratory analyses were conducted by experienced technicians, and all measurements were taken in duplicate to ensure accuracy.

RESULTS

The study included 327 children aged 6–13 years, with a median age of 8 years. Among the participants, 55% were male. The distribution of parasitic infections showed that 32.1% of children aged 6–9 years were infected compared to 23.9% in the 10–13 years age group [Table 1]. Gender-wise, 27.6% of females and 31.5% of males were found to be infected, indicating a higher prevalence among boys [Figure 1].

Table 1.

Demographic and environmental characteristics of young children and early adolescents aged 6–13 in rural Gorakhpur

Variable	Category	Absent (n, %)	Present (n, %)	P
Age	6–9 years	148 (67.9%)	70 (32.1%)	0.157
	10–13 years	83 (76.1%)	26 (23.9%)
Sex	Female	131 (72.4%)	50 (27.6%)	0.519
	Male	100 (68.5%)	46 (31.5%)
Birth order	Lower	184 (69.2%)	82 (30.8%)	0.288
	Higher	47 (77.0%)	14 (23.0%)
Type of house	Kaccha	30 (62.5%)	18 (37.5%)	0.242
	Pucca	201 (72.1%)	78 (27.9%)
Father’s education	Lower	135 (70.7%)	56 (29.3%)	1
	Higher	96 (70.6%)	40 (29.4%)
Open-field defecation	Yes	33 (75%)	11 (25%)	0.521
	No	195 (68.9%)	88 (31.1%)
Nail hygiene	Trimmed	213 (71.0%)	87 (29.0%)	0.8
	Not trimmed	18 (66.7%)	9 (33.3%)
Plays in soil and dirt	Yes	38 (77.6%)	11 (22.4%)	0.326
	No	193 (69.4%)	85 (30.6%)
Helps in field work	Yes	25 (75.8%)	8 (24.2%)	0.632
	No	206 (70.1%)	88 (29.9%)
Wears shoes	Never	18 (69.2%)	8 (30.8%)	1
	Always	213 (70.8%)	88 (29.2%)
Handwashing	Improved	109 (76.7%)	34 (23.7%)	0.188
	Unimproved	127 (69.0%)	57 (31.0%)
Water source	Improved	229 (70.7%)	95 (29.3%)	1
	Unimproved	2 (66.7%)	1 (33.3%)
Malnutrition	Yes	36 (73.5%)	13 (26.5%)	1
	No	205 (73.7%)	73 (26.4%)
Pallor	Yes	56 (71.7%)	22 (28.2%)	0.909
	No	175 (70.3%)	74 (29.7%)

Figure 1.

Distribution of various parasitic infections in the studied population

The socioeconomic background and environmental conditions of the participants significantly influenced the prevalence of parasitic infections. Children from households with a higher birth order (two or more) had a lower infection rate (23.0%) compared to those with a lower birth order (30.8%). The type of housing also played a crucial role; children living in katcha houses had a higher infection rate (37.5%) compared to those in pucca houses (27.9%) [Table 1]. This suggests that certain factors associated with better housing, such as crowded living conditions or different sanitary practices, might contribute to higher infection rates.

Parental education, particularly the father’s, did not show a significant difference in infection rates, with children from families of lower and higher educational backgrounds showing similar infection rates (29.3% and 29.4%, respectively). However, children whose families practiced open-field defecation had a marginally lower infection rate (25.0%) than those who did not (30.1%) [Table 1]. This counterintuitive finding may be due to other confounding factors not directly addressed in the study, such as variations in hygiene practices or community sanitation initiatives.

Nail hygiene, playing in soil and dirt, wearing shoes, and handwashing practices were assessed for their impact on infection rates. Although good nail hygiene, reduced exposure to soil, regular shoe-wearing, and consistent handwashing practices were associated with lower infection rates, these factors did not show statistically significant differences [Table 1]. These behaviors are critical in mitigating infection risks but might be influenced by other underlying socioeconomic and environmental conditions.

Among malnourished children, 26.5% had parasitic infections compared to 29.8% of non-malnourished children, indicating a slight but notable correlation between malnutrition and infection rates. Similarly, children with pallor had a slightly higher infection rate (33.3%) compared to those without pallor (29.3%) [Figure 2]. These health indicators suggest that while parasitic infections contribute to malnutrition and anemia, the presence of these conditions might also predispose children to higher infection risks.

Figure 2.

Forest plot showing predictors of parasitic infections

Figure 2 illustrates the frequency distribution of various parasitic infections among a studied population. Each segment of the donut chart represents the proportion of individuals infected with a specific parasite. Ascaris (30%) and Blastocystis hominis (25%) appear to have the highest prevalence, indicating these infections are more common within the population. In contrast, infections such as Ancylostoma duodenale (5%) and Trichuris trichiura (7%) have lower frequencies. Other infections include Entamoeba histolytica (15%), Giardia sp. (10%), Entamoeba coli (4%), and Hymenolepis nana (4%). The high prevalence of Blastocystis hominis and Entamoeba histolytica highlights the significant burden of protozoal infections in rural areas, which can lead to various gastrointestinal symptoms and complications if not addressed timely.

Logistic regression analysis provided a deeper understanding of the factors associated with infections [Table 2]. Higher age groups had lower odds of the outcome, with an adjusted odds ratio (OR) of 0.644 (95% CI: 0.372–1.12), though this association was not statistically significant. Similarly, sex did not significantly influence the outcome, with males having an adjusted OR of 1.183 (95% CI: 0.723–1.94) compared to females. Birth order also showed no significant effect, with higher birth order having an adjusted OR of 0.674 (95% CI: 0.344–1.32).

Table 2.

Logistic regression showing associations between environmental, behavioral, and sociodemographic factors and parasitic infections

Variable	Category	Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Age	Lower	Reference	Reference
	Higher	0.662 (0.392, 1.119)	0.644 (0.3720, 1.12)
Sex	Female	Reference	Reference
	Male	1.205 (0.748, 1.943)	1.183 (0.723, 1.94)
Birth order	Lower	Reference	Reference
	Higher	0.668 (0.349, 1.282)	0.674 (0.344, 1.32)
Type of house	Kaccha	Reference	Reference
	Pucca	2.304 (1.0351, 5.127)	2.616 (1.03, 4.00)
Father’s education	Lower	Reference	Reference
	Higher	1.004 (0.620, 1.628)	0.975 (0.58, 1.64)
Open-field defecation	No	Reference	Reference
	Yes	0.776 (0.375, 1.608)	1.253 (0.51, 3.03)
Nail hygiene	Poor	Reference	Reference
	Good	0.817 (0.353, 1.89)	0.827 (0.317, 2.12)
Plays in soil and dirt	No	Reference	Reference
	Yes	0.657 (0.321, 1.348)	0.646 (0.29, 1.44)
Wears shoes	Never	Reference	Reference
	Always	0.930 (0.390, 2.22)	0.740 (0.2820, 1.92)
Helps in field work	No	Reference	Reference
	Yes	0.749 (0.325, 1.725)	0.959 (0.384, 2.39)
Handwashing with soap before food handling	No	Reference	Reference
	Yes	0.836 (0.516, 1.354)	0.825 (0.496, 1.37)
Water source	Unimproved	Reference	Reference
	Improved	1.205 (0.108, 13.451)	0.840 (0.0619,2.00)
Malnutrition (Yes vs. No)	No	Reference	Reference
	Yes	0.848 (0.428, 1.682)	0.871 (0.428, 1.78)
Pallor (Yes vs. No)	No	Reference	Reference
	Yes	1.883 (0.683, 2.048)	1.116 (0.622, 2)

One significant finding is the type of house, where living in a pucca house was associated with significantly higher odds of the outcome, with an adjusted OR of 2.616 (95% CI: 1.03–4.00). Father’s education, open-field defecation, and nail hygiene did not show significant associations, with adjusted ORs close to 1 and wide confidence intervals. Similarly, playing in soil and dirt, wearing shoes, and helping in fieldwork did not significantly affect the outcome. Handwashing practices and the source of water also showed no significant associations, with adjusted ORs of 0.825 (95% CI: 0.496–1.37) and 0.840 (95% CI: 0.0619–2.00), respectively. Malnutrition and pallor did not significantly influence the outcome, with adjusted ORs of 0.871 (95% CI: 0.428–1.78) and 1.116 (95% CI: 0.622–2), respectively.

The forest plot presents the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for various sociodemographic, environmental, and behavioral factors associated with parasitic infections among children in rural India. The key findings indicate that living in pucca houses significantly increased the risk of parasitic infections (adjusted OR: 2.69, 95% CI: 1.03–4.00). Other variables, such as age, sex, birth order, father’s education, open-field defecation, nail hygiene, playing in soil, wearing shoes, helping in fieldwork, and handwashing, did not show statistically significant associations with the risk of infection.

DISCUSSION

The present study underscores the significant burden of parasitic infections among asymptomatic children in rural India, highlighting critical associations with various socioeconomic, environmental, and health factors. The prevalence of these infections poses a substantial public health challenge, requiring targeted interventions and policy measures to mitigate their impact.

Our findings revealed a higher prevalence of parasitic infections among younger children (32.1% in the 5–9 years age group) compared to older children (23.9% in the 10–13 years age group). This aligns with previous studies that report younger children being more susceptible to infections due to their developing immune systems and greater exposure to environmental pathogens.[22,23] The slight male predominance in infection rates (31.5% for males vs. 27.6% for females) has also been observed in other studies, potentially due to behavioral differences in hygiene practices and outdoor activities.[24,25]

Housing type emerged as a significant factor, with children living in pucca houses having higher infection rates than those in kaccha houses. This is contrary to the assumption that better housing conditions necessarily lead to lower infection rates and suggests that other factors, such as overcrowding and sanitation practices, play a crucial role.[26] The practice of open-field defecation, surprisingly, was associated with a marginally lower infection rate. This counterintuitive finding might reflect variations in sanitation behaviors and community-led total sanitation initiatives that are not captured by simple measures of open defecation.[27,28]

The association between parasitic infections and malnutrition (26.5% among malnourished children vs. 29.8% among non-malnourished children) highlights the bidirectional relationship between infections and nutritional status. Parasitic infections can lead to malabsorption and nutrient loss, exacerbating malnutrition, while malnourished children are more susceptible to infections due to compromised immune function.[29,30] Similarly, the presence of pallor, a marker for anemia, was slightly higher among infected children, indicating the broader health impacts of these infections.[31]

Blastocystis hominis, Entamoeba histolytica, and Giardia sp. were the most prevalent pathogens, which aligns with other studies in similar settings that report high rates of protozoal infections.[32,33] The high prevalence of these pathogens underscores the need for regular screening and effective treatment strategies to address the asymptomatic burden of disease and prevent long-term health complications.[34]

The findings underscore the necessity for comprehensive public health strategies that address the multifaceted determinants of parasitic infections. Improving maternal education and promoting hygiene practices are critical components of such strategies. Community-based health education programs that target mothers and caregivers can significantly reduce infection rates by enhancing knowledge and practices related to hygiene and sanitation.[35,36]

Sanitation infrastructure improvements, particularly in rural areas, are crucial. Despite the paradoxical finding regarding housing type, efforts to provide adequate sanitation facilities and eliminate open defecation remain essential. The Swachh Bharat Mission, aimed at improving rural sanitation, should focus on behavior change communication and maintenance of sanitation facilities to ensure sustainable improvements.[37]

Further research is needed to explore the nuanced relationships between housing conditions, sanitation practices, and infection rates. Longitudinal studies that track changes in infection prevalence in response to sanitation interventions can provide valuable insights into effective strategies. Additionally, qualitative studies that explore community perceptions and behaviors related to sanitation and hygiene can inform culturally appropriate interventions.[12,38]

CONCLUSION

The study highlights the substantial burden of asymptomatic parasitic infections among children in rural India, with significant associations with socioeconomic, environmental, and health factors. Addressing this hidden burden requires a multifaceted approach that includes enhancing maternal education, improving sanitation infrastructure, and promoting hygiene practices. Comprehensive public health strategies, informed by robust research, can significantly reduce the prevalence of these infections and improve child health outcomes in similar settings globally.

Author contributions’ statement (CRedIT statement)

• Conceptualization: Dr. Anand Mohan Dixit

• Data Curation: Dr. Vivek Hada, Dr. Rama Shankar Rath

• Formal Analysis: Dr. Sridevi Gnanasekaran, Dr. Rama Shankar Rath

• Investigation: Dr. Anil Ramesh Koparkar

• Methodology: Dr. Hari Shanker Joshi

• Writing – Original Draft: Dr. Anand Mohan Dixit, Dr. Sridevi Gnanasekaran

• Writing – Review and Editing: All authors.

Consent to participate

Informed consent was obtained from all participants’ guardians.

Ethical approval

The study was approved by the Institutional Ethics Committee of AIIMS Gorakhpur (IEC number: IHEC/AIIMS-GKP/BMR/76/2022).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.