Prevalence of Enteroparasites Among Non-Saudis in Bahrah, Saudi Arabia

Background Enteroparasitic infections in tropical and subtropical regions of the world are among the most common diseases. The majority of the cases may show no symptoms; however, many untreated cases may experience severe complications. The recent substantial economic development in Saudi Arabia has resulted in an inflow of millions of workers with intestinal parasitic infection, from highly endemic countries, mainly from Asia and Africa. Objective This cross-sectional study aimed to assess for the first time the prevalence and associated factors of intestinal parasitic infestation among non-Saudi residents in Bahrah, western region, Saudi Arabia. Materials and methods A total of 355 stool samples were collected from participants included in this study for several examinations of intestinal parasites. In addition, questionnaires including personal data, sociodemographic data, personal hygiene, health habits and other factors were used. Results The prevalence of intestinal parasitic infections among non-Saudi workers in the present study was 22.3%, and the prevalence of protozoan infection was higher than helminth infection. Most of the workers were from Asian countries and were prevalent with Trichuris trichiura, Blastocystis hominis, Endolimax nana and Ascaris lumbricoides. Single intestinal infections were among 86% of the infected cases. The main significant factors associated with intestinal parasitic infections were personal hygiene practices (such as proper handwashing before meals and after using the toilet), source of drinking water and type of living accommodation. Conclusion Intestinal parasites were slightly more prevalent among non-Saudi workers in Bahrah. There is a need for public health awareness programs to prevent spreading of the infections.


Introduction
Infections with intestinal parasites are among the common neglected diseases in many tropical and 1, 2 subtropical regions of the world [1]. These organisms can live, replicate or cause clinical manifestations in the human gastrointestinal system. Globally, the World Health Organization estimated that 24% of the world's population is infected with soil-transmitted helminth, while more than three billion have no symptoms and over 800 million children are at risk of infection. The intestinal parasitic infection can lead to many severe complications such as malnutrition, growth retardation, several types of anemia, cancer, poor school performance and other problems [2,3]. Most of the intestinal parasites are transmitted mainly among communities with low socioeconomic condition due to poor sanitation and hygiene practices, contaminated food, water and soil. Saudi Arabia's climate is hot most of the year. In addition, many workers in Bahrah are non-Saudis from Asian and African countries, where tropical diseases including enteroparasitic infections are prevalent.
Bahrah is a town in Makkah Province, in the western region of Saudi Arabia, and is located between Makkah and Jeddah. Its population in 2017 according to the General Authority for Statistics was 96,646, of which 71% were Saudis and 29% were non-Saudis (25% males and 4% females) [4].
The present study was conducted to determine for the first time the prevalence and risk factors of intestinal parasites among non-Saudi people living in Bahrah, Saudi Arabia.

Study design and sample collection
This cross-sectional study was conducted for a six-month period (March to August 2019) in Bahrah town of the western region of Saudi Arabia. A total of 500 participants were provided with a labeled, clean plastic stool sample collector and instructions for collection. Each one was provided with a consent form and a questionnaire related to personal data, sociodemographic data, health and awareness about intestinal parasites. All samples related to incomplete forms or with insufficient quantity were excluded.

Parasitological analysis of the samples
Sample analysis included gross examination to check for color, consistency, presence of macroscopic blood, mucous, adult worms (of Ascaris lumbricoides and Enterobius vermicularis) or gravid segments of Taenia species.
In addition, stool samples were prepared and examined by different techniques including the direct smears, sedimentation method, trichrome staining and modified Kinyoun's staining. All wet smears were examined using 10x and 40x objective lenses, while permanently stained smears were examined using the oil immersion objective lens. Direct smears were prepared by emulsifying 2 mg of stool with saline and iodine on a glass microscope slide [5,6]. Sedimentation technique was performed as described in previous studies with slight modification: 2-3 g of stool sample was emulsified in 10 ml of 10% formal-saline and left for 30 minutes [5,7]. Preserved stool was then passed through two layers of gauze, centrifuged at 2000 rpm for 10 minutes and the supernatant was disposed of. In case of unclear supernatant, the washing step was repeated. The sediment was resuspended in 10 ml formal saline (10% v/v), 3 ml of diethyl ether was dispensed and shaken vigorously for 20 seconds and then centrifuged at 2000 rpm for 10 minutes. The sediment was mixed with two drops of iodine and then examined under a light microscope. Para-Pak® (Meridian Bioscience, Germany) trichrome stain was used and performed based on the manufacturer's procedure [8]. For microscopic detection of Cryptosporidium, 5 mg of smeared stool was left to air dry, fixed in alcohol and then stained with carbol fuchsin for 10 minutes. After that, smears were rinsed with tap water, decolorized in 1% sulfuric acid for 1 minute, washed with tap water and counter-stained with methylene blue for 5 minutes. Finally, stained smears were rinsed with tap water, air dried and then examined [6].

Rapid test for Cryptosporidium and Giardia
Rapid chromatographic immunological detection of Cryptosporidium and Giardia using the CerTest Biotec (Zaragoza, Spain) rapid card was carried out using stool samples according to the manufacturer's instructions [9].

Statistical analysis
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY). Demographic data and categorical variables were analysed by descriptive analysis. The chi-square (χ 2 ) test was used to analyse the level of significant association between sociodemographic variables and intestinal parasitic infection. A P value < .05 was considered statistically significant.

Results
Of the 500 participants, the number of overall samples that fulfilled the requirements was 355, while the total number of infected cases with intestinal parasites was 22.3% (79/355) from 10 nationalities with no significant difference (P > .05), as shown in Table 1.

Gender
The results revealed that the majority (67.1%) were aged 20-39 years, representing about 80% of the infected cases with a significance difference (P < .05) as shown in Table 3.    Tables 1, 4 illustrate that the most frequent intestinal parasitic infections were reported in Bangladeshis (26.6%) and Indians (22.8%), while the least were among the Nepalis (2.5%). There was no significant difference in relation to nationality and overall infection among workers (P > .05).

Occupation
In the present study, it was found that the source of drinking water and eating at home were statistically significant factors in intestinal parasitic infections (P < .05), as shown in Table 7.     Out of the 79 positive cases, 45 were positive for FOB, but without significant association (P > .05), as illustrated in Table 11.

Discussion
This is the first study regarding the prevalence of intestinal parasitic infections among non-Saudi workers in Bahrah, Saudi Arabia. The World Health Organization attributed the spreading of intestinal parasites to several factors such as the status of personal hygiene, level of environmental sanitation, drinking water sources, health education practices and control programs [11].  [12][13][14][15][16]. Like our findings, all these previous studies found that the majority of workers were from Asian countries, within the age range of 20-40 years.
In this study, among the 14 detected parasites, seven were protozoa and seven were helminths, of which, five were nematodes, one cestoda and one trematoda. A total of 68 participants were positive with one intestinal parasite, while 11 were positive for two parasites. This is in agreement with previous studies in Saudi Arabia, where the single infection rate is higher than the mixed infection rate [12][13][14][15][16]. In the present study, none of the cases revealed Cryptosporidium parasites. This opportunistic coccidian parasite is common among immunocompetent and immunocompromised individuals and transmission occurs mainly by contaminated drinking water or swimming pools [17,18].
In the present study, at least one participant from each nationality (except Sudanese), was infected with B. hominis. Although this parasite is common worldwide, its pathogenicity is still uncertain with great controversy [19][20][21][22][23].
The detected pathogenic protozoa parasites (E. histolytica and G. lamblia) were detected in 11.4% of the infected cases, while nonpathogenic organisms (E. nana, E. coli, C. mesnili and I. bütschlii) were detected in more cases (29.1%). Nonpathogenic intestinal protozoa should not be neglected and should considered as a health concern for the infected person, as their oral-fecal route of transmission is similar to the pathogenic organisms. This explains the detection of many mixed infections between pathogenic and nonpathogenic organisms leading to abdominal symptoms [24,25].
This study, consistent with previous studies in Saudi Arabia, revealed that the common detected parasites were protozoa and nematodes. The obvious explanation is the simple and direct mode of infection with these parasites. On the other hand, S. mansoni infection in two participants from Africa (Egypt and Sudan) was mainly contracted from their hometowns, as this fluke requires snail intermediate hosts, which are not found in Bahrah, to form the infective cercariae [26,27]. A similar observation was reported in previous studies in Jeddah and Al-Madina [14,15].
Although in this study the majority of workers were from Asian regions, there was not any statistically significant difference between nationality and the intestinal parasitic infection. That was not in agreement with previous studies [15]. A similar finding was observed regarding gender, age and occupation.
Findings from this study revealed that all investigated personal hygiene practices, source of drinking water/meals and type of accommodation showed significant association with intestinal parasitic infection. None of the previous studies on non-Saudi workers investigated these factors.
Results of this study indicated similar previous observations that there was no significant association between intestinal parasitic infection and positive FOB, but were inconsistent with another investigation [28][29][30].

Conclusions
This study provides insights about the prevalence of intestinal parasites and clarifies related factors among non-Saudi workers in Bahrah. The prevalence was slightly high (22.3%) and was associated mainly with hygiene practices, individual habits and awareness. Among the positive cases, almost 86% were single infections and 14% mixed infections. Intestinal protozoa and nematodes were the most predominant parasites, followed by cestodes and trematodes.
These findings draw attention for the need of more awareness about diagnosis protocols, control of intestinal parasitic infection, in addition to personal hygiene, eating habits and lifestyle.

Additional Information Disclosures
Human subjects: Consent was obtained by all participants in this study. Ethics and Research Committee of Faculty of Applied Medical Sciences, King Abdulaziz University issued approval 019-22. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.