Everything you need to know about Helminths – Well, almost everything

It had been such a warm day in Chennai and like everyone else I was also looking at the clear skies wondering how much hotter it could get. As I was thirsty and hungry, I went to a nearby street vendor selling some fruits which he had cut and laid out on display. Just as I was making my decision on what to buy, I overheard a conversation from other buyers who were talking about some kind of ‘worms’ that causes serious ‘illness’ in people. Being the curious type, I went ahead and joined in the conversation, while I continued to gulp down the pieces of mangoes which the vendor had wrapped in the previous day’s newspaper.

Here is the gist of the conversation from the alleged ‘worm expert’.

It turns out the worms the person was talking about are called Helminths. So what are Helminths? And how do they make people fall ill? Well, Helminths are basically worms that are widely present in areas which plagued by poor sanitation and where open defecation is widely practised. The Helminth worms are usually tape worm (Taenia solium), hook worm (Anclostoma duodenale and Necator americanus), round worm (Ascaris lumbricoides), whip worm (Trichuris trichiura) etc., I realised that the Helminths eggs and larvae are the agents that cause infection, and are usually discharged into the environment via faeces. The ‘Worm expert’ told me that the viable eggs will be infective when it develops as a larva and gets attached to a suitable host such as humans.

But, “Why is it important to know about Helminths?” I wanted to know. “Because it causes various kinds of illnesses in human beings,” he said, adding that these illnesses are commonly known as Helminthiases. Helminths are transmitted mainly through water and soil through the oral – faecal transmission pathway (popularly referred as the F-diagram). “Synergy between WASH and nutrition” – It’s complicated The worms are widely present in faeces, sewage, sludge and fecal sludge and crops. Consuming infected water or food, physical contact when handling infected soil and water, or even walking barefoot on contaminated soil, can lead to one getting infected. Wow! who would have thought of that, right?

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Relative sizes of Helminth eggs.                                                                             Source: http://ogimed.blogspot.in/2013/06/relative-sizes-of-helminth-eggs.html (dated Aug 4, 2017)

The worm expert told me, that worms come in sizes varying from 1 mm to several metres in length. The eggs range from 20 to 80 microns’ size, which means they cannot be seen by the naked eye. Interestingly, the eggs are also sticky in nature, and can stick to vessels, furniture, cash, food, water, door handles, stair cases rails, fingers and nails etc., thereby escalating the risk of infection without people even realising it.

The situation is so alarming that the World Health Organisation in 2015 called Helminthiases a major health concern. Helminths infections in human beings affect the nutritional status by causing poor absorption of nutrients, loss of appetite, bowel obstruction and increased blood loss. Long term and heavy infections can cause abdominal pain, diarrhoea, blood and protein loss, and slow down the physical and cognitive growth. Heavy infections with whipworm and roundworm can even impair growth in children. Hookworm infections are a major cause of anaemia in pregnant women and children.

Wow, not only had I learnt something about these ‘dangerous worms’ that makes people sick, but thanks to my newly established camaraderie with the ‘Worm expert’, I went on to ask him more questions:  How do we ensure that Helminths are eliminated from our surroundings? There are various ways, he said. But the most important one is to make sure that all those materials which consists of Helminths are treated before being released into the environment. In that way, we can minimise the risk of infection, if not completely eliminate it.

I realised that we have reached the end of our intense conversation. But there was one more question to which I needed an answer. How do we reduce the incidence of Helminths -related infections in our day-to-day activities, I wanted to know? “Well, the obvious yet often overlooked practice of hand washing, is one of the most effective ways to beat the infection cycle. In addition to that, thorough washing of vegetables and fruits before consumption should be compulsorily followed,” the worm-expert said. I thought of the delicious mangoes that I had just gulped down. I had not bothered to find out if the fruit had been washed properly, and how long ago it had been cut.

I thanked the worm-expert profusely for answering all my questions and bade him goodbye. As I left, he said: “Don’t underestimate the power of what you can’t see or smell.” I was strangely intrigued. So I decided to find out more. And what I found out included a wealth of information on the universe of microbial pathogens and their implication on public health, and how the very act of defecating in the open can lead to Helminth infection and what can be done to keep ourselves safe.
But more of that in the next part, where we will talk about Helminths infection and its very obvious relationship to open defecation.

For further reference

https://www.unicef.org/media/files/IntegratingWASHandNut_WHO_UNICEF_USAID_Nov2015.pdf (accessed on April 24, 2017)

http://atm.eisai.co.jp/english/ntd/helminthiasis.html (accessed on April 25, 2017)

B.E. Jimenez-Cisneros and C. Maya-Rendon (2007) “Helminths and Sanitation”, Communicating Current Research and Educational Topics and Trends in Applied Microbiology

Suneethi

 

 

 

Suneethi Sundar
Specialist, TNUSSP

A loo that is usable too!

In the winter of 1999, when I was a post graduate student of social work in Mumbai, we were taken to a remote village in Banaskantha District, Gujarat. The objective of this visit was to understand the rural way of life, their customs and practices, the formal and informal institutions at work and so on. As young 20 somethings, we all were very excited about the trip but for one aspect. There were no toilets!! We were all told that we would have to use the open fields just like all the other women in the village did. At some point or the other in our growing up years, we would have definitely relieved ourselves in public; either while travelling by bus, or while visiting our native village or sometimes even within the city while going from point A to point B where public conveniences were either absent or open defecation (OD) was better than using these toilets.

Pics for blog
Photo Courtesy: Nitin Kumar Gupta/NavShrishti NGO

However, in our early twenties, defecating in the open seemed quite an uncomfortable task to do especially when you had to choose between early morning or late night. During the course of those ten days, while some of us got adjusted to the open toilets, few others had severe gastrointestinal problems on our return back to Mumbai. Of course there were a fair share of humorous incidents such as the one where after an “evening visit” to the anointed spot, as we were collecting the “lotas” to leave, we suddenly saw a huge black thing move right next to us. To our utter alarm, we realized we had been blissfully unaware of the camel sitting right next to us while we defecated under the star-lit sky!

Our experience with inadequate toilets didn’t quite end in the village. As we waited in Ahmedabad for our train to Mumbai, we were forced to use the toilets in a movie hall which repulsed us to the core.   Badly maintained, with no running water, poor electricity and broken doors, it made us want to run back to the open fields in the villages. When I look back at this episode in light of the recent attention to sanitation and OD, I am able to relate to all the reasons people gave for not cultivating the toilet-using habit. Despite having built toilets, poor maintenance, lack of water and hygiene were the main reasons which made several women in the villages to prefer open fields to toilets, risking their safety, privacy and convenience.

So, why is that though there are several schemes and programmes for toilet construction, OD is still a major concern in India? The answer, I believe, lies in the usability of the toilets constructed. By usability, I don’t mean only the cleanliness and maintenance of the facility. Usability comprises of several other factors: availability of the toilet, followed by the distance to the facility, accessibility i.e is there sufficient lighting, are there ramps for the disabled and senior citizens, are the toilet pans appropriate for different age groups such as children? Is there privacy and safety for adolescent girls, and so on. The sanitation infrastructure in India lacks the human life-cycle thinking. The recognition that different people have different sanitation requirements at different stages in their life which affects the way they use toilets is neglected in toilet design and construction. Although a handful of organisations working at the grassroots have incorporated some aspects of this life-cycle thinking by making smaller pans for children, open dwarf-walled cubicles where children can see their mothers or defecate under the mothers’ supervision and so on, these modifications in design are exceptions and not the norm.

With rampant construction of toilets under the SBM and attention to behavior change where people are encouraged to use toilets, it might be worthwhile to conduct rapid assessments of the different needs of toilet users in order to reorient the current toilet designs. With several players getting involved in sanitation construction and campaigns targeting behavior change, we need to mainstream studies on usability to bring about a shift in the guidelines on toilet specifications. For our multi-crore schemes to be effective and reach the target audience, it is time to pause and pay attention to the needs of the end user. Achieving universal access to sanitation is a good thing, but let us ensure people can use it too.

Harini Pic for website

Sriharini Narayanan
Senior Specialist, TNUSSP

Is your child’s shit affecting your health?

It was September 2008. It took me almost two-and-a-half hours to reach G-plot, one of the remotest islands among the deltoid labyrinth of Sundarbans. My colleague – a native to G-plot was waiting to receive me at the jetty. We got on a van fitted with a motorcycle engine, popularly known as Vano in this part of the world. Assaulting our eardrums with more than 85 decibels and leaving behind a deep dark trail of fume, the Vano set out for Satyadaspur, one of our intervention villages in G-plot.  Reaching the destination, we immediately jumped into action and rushed to meet the beneficiaries who had built their household toilets under the Total Sanitation Campaign Programme.

We reached a house located near the centre of the village. Stepping into the yard, I noticed a small child defecating on the other side of the premises near a bush. We knocked on the door and a lady in her mid-twenties came out. My colleague introduced me and told her the purpose of our visit. The lady welcomed us indoors, offered us a glass of water with sugar candy and started answering my questions. I was curious to know whether all members of her family were using the toilet. She answered in the affirmative. I pointed to the toddler and asked if he was using the toilet. With a chuckle she replied that the toddler could not sit on toilet. There was a danger of his falling down and injuring himself. The lady then took a mug of water and got busy cleaning the child. Once she had finished washing the child, she wiped her hand with her saree and continued talking to us. The shit was lying unattended.

“Don’t you use soap after going to the toilet?” I could not resist asking. “Of course we do. In fact, after using the toilet the women bathe in the village pond and only then get into the kitchen.”  Seeing me staring at the child who had just finished defecating in the open, she said. “Öh, him? He is not even three, his stool is not harmful at all.”

June 2014 – Odisha: While entering a large slum called Bapuji Nagar Railway Basti right in the heart of Bhubaneswar, a familiar sight of a small child defecating on a newspaper caught my eye. After some time, an aged woman, probably the child’s grandmother picked up the shit, wrapped it in the newspaper and threw it on the nearby railway tracks.

Unlike in the earlier case, none of the families in Bapuji Nagar Railway Basti had their own toilets. Adults used the railway track in the wee hours of the morning or late at night. Since it was not safe for children to use the tracks, an alternative arrangement was made using the toilet.

February 2017 – Tamil Nadu: We arrived at a small town to do an assessment of a community toilet. The toilet block was full of faeces indicating a high prevalence of open defecation.  A little probing showed that while adults from the neighbouring slums were using the community toilet, children were using the toilet premises itself.

These three instances from different parts of the country indicate a widespread perception about children’s faeces not being harmful.  According to the NFHS 3 (2005-2006) data, stools of around 79 percent children in India are disposed of unsafely. Two subsequent studies in rural Odisha and West Bengal show that the prevalence is around 81 percent (Majorin et al, 2014) and 72 percent (Preeti PS et al, 2016), respectively.  The commonly held belief that faeces of infants and young children is not harmful is untrue. There is evidence that children’s faeces could be more harmful than that of adults due to higher prevalence of diarrhoea, Hepatitis A, Rotavirus and E Coli in children (Feachem R G et al, 1983).

Often impact of poor sanitation and hygiene is measured by the effect it has on children, either in terms of infant mortality or morbidity due to diarrhoeal diseases, loss of intellectual capacity due to stunting or worm infestation. However, most sanitation and hygiene interventions target adults. According to JMP[1] 2015,  globally 68% population have access to improved toilets[2].  These estimates are based on the households’ primary sanitation facility and may have overlooked the disposal practices of faeces of young children. In many cases children might have access to improved toilets, but are not able to use it because of their age, stage of their physical development or just because of safety concerns of their caregiver.

In 2015, the Water and Sanitation Programme of World Bank released a research brief on management of child faeces. In this paper, the methods of disposal of children’s faeces from 26 locations across Africa, East Asia and Pacific, Latin America and South Asia were presented (see charts).  The key findings from the research showed that faeces of children under the age of three was less likely to be safely disposed of than that of the adult population, across the three study sites.  Not surprisingly, there was a higher rate of unsafe disposal of child faeces in populations practicing open defecation. Households with access to improved toilets have also reported exhibiting unsafe disposal traits when it comes to child faeces. This clearly shows that the belief that child faeces is less harmful is equally prevalent in many parts of the globe.

Chart

Poor management of child faeces can result in substantial health impacts on children, including a higher prevalence of diarrheal disease, intestinal worms, enteropathy, malnutrition, and death. A series of empirical studies across different countries (Baltazar J. C., et al, 1989; Curtis, Valerie, et al. 2011, Aulia, H. et al, 1994; Mihrete, T.,2014; Bawankule R, 2017) have proved the strong association between unsafe disposal of child’s faeces and clinically diagnosed diarrhoea among young children.  Based on the findings of several studies, The Child Health Epidemiology Reference Group (CHERG) has concluded that safe stool disposal has protection effect.

Despite such empirical evidence, sanitation for children has been a neglected area of research, policy and programme. There are significant knowledge gaps in this domain, and it is evident that we are trying to estimate the magnitude of the problem by referring to pretty outdated data. Nevertheless, to reach the proposed Sustainable Development Goal of universal coverage or end of Open Defecation by 2030, we must ensure that children’s faeces is disposed of safely. The World Bank report is undoubtedly indicating that India is far behind its neighbouring countries like Pakistan, Afghanistan and many countries from Africa, East Asia and Pacific in terms of safe disposal.

However, we are already witnessing an increased international acknowledgement of the importance of monitoring the practice. The Joint Monitoring Programme on Sanitation has recommended that the “percentage of children under five whose stools are hygienically disposed of” as a sub-indicator under the eliminating open defecation target.  Our own Swachh Bharat Mission also has laid “effective disposal of child faeces” as an essential indicator for obtaining an Open Defecation Free certificate.

References:

  1. International Institute for Population Sciences. National Family Health Survey (NFHS-3), 2005-06: India; 2007. Available from: http://dhsprogram.com/pubs/pdf/FRIND3/ FRIND3-Vol1andVol2.pdf.
  2. Ministry of Urban Development (India). Guidelines for Swachh Bharat Mission (Gramin); 2014 [cited 2016 Sep 26]. Available from: http://phed.bih.nic.in/Docs/Guidelines-Swachh-BharatAbhiyan.pdf.
  3. Majorin, F., Freeman, M. C., Barnard, S., Routry, P., Boisson, S., & Clasen, T. (2014). Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLOS One, 9(2). doi:10.1371/journal.pone.0089551
  4. Unsafe Disposal of Child Faeces: A Community-based Study in a Rural Block in West Bengal, India. (2016, September 8). Journal of Preventive Medicine and Public Health, 323-328. doi:https://doi.org/10.3961/jpmph.16.020
  5. Feachem, R. G., Bardley, D. J., Garelick, H., & Mara, D. D. (1983). Sanitation and Disease Health Aspects of Excreta and Wastewater Management. John Wiley & Sons.
  6. Baltazar J. C., and F. S. Solon. 1989. “Disposal of Faeces of Children under Two Years Old and Diarrhoea Incidence: A Case-Control Study.” International Journal of Epidemiology 18(4 Suppl 2):S16–S19
  7. Curtis, Valerie, et al. 2011. “Hygiene: New Hopes, New Horizons.” The Lancet Infectious Diseases 11(4):312–321; Curtis, Valerie, et al. 1995. “Potties, Pits and Pipes: Explaining Hygiene Behaviour in Burkina Faso.” Social Science & Medicine 41(3):383–393
  8. Aulia, H., S. C. Surapaty, E. Bahar, et al. 1994. “Personal and Domestic Hygiene and Its Relationship to the Incidence of Diarrhea in South Sumatera.” Journal of Diarrheal Diseases Research 12(1):42–48.
  9. Mihrete, T., G. Alemie, and A. Teferra. 2014. “Determinants of Childhood Diarrhea among Underfive Children in Benishangul Gumuz Regional State, North West Ethiopia.” BMC Pediatrics 14:102. http://www.biomedcentral.com/1471-2431/14/102
  10. Bawankule, R., Singh, A., Kumar, K., & Pedgaonkar, S. (2017). Disposal of children’s stools and its association with childhood diarrhea in India. Biomed Central Public Health, 3. doi: 10.1186/s12889-016-3948-2
  11. UNICEF and WHO, WASH Targets and Indicators Post-2015: Recommendations from International Consultations. Comprehensive Recommendations – Updated April 2014. 2014. 5
  12. Government of India MoUD. Swachh Bharat Mission; 2015. Available at http://www.swachhbharaturban.in/sbm/home/#/SBM. Accessed 21 May 2015.

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Niladri Chakraborti
Senior Specialist, TNUSSP

[1] Joint Monitoring Program by WHO/UNICF

[2] The JMP standardized definition for an improved sanitation facility is one that hygienically separates human excreta from human contact.