Intestinal Parasites in Some Patients seen at San Lazaro Hospital, Manila, Philippines

John H. Cross,* Grizelda Zaraspe,* Lily Alquiza* and Catherine Ranoa**

(*U.S. Naval Medical Research Unit No. 2, Manila, Philippines; **San Lazaro Hospital, Manila; This study was supported through funds provided by the U.S. Naval Medical Research and Development Command under Work Unit No. 3M162770A.871.AF429 and by the Philippine Ministry of Health. The opinions and assertions contained herein are those of the authors and are not to be construed as official or reflecting the views of the U.S. Navy Department or the Naval Service at large Reprint requests to Publications Office, U.S. Naval Medical Research Unit No. 2, APO San Francisco, California 96528.) No Abstract Available. [Phil J Microbiol Infect Dis 1989; 18(1):25-27] Key Words: parasitic infections, intestinal parasitism

INTRODUCTION Intestinal parasitic infections are not unique to the Philippines and a number of reports are published on prevalence rates dating back to the beginning of the century. Cabrera 1 in 1971 reviewed data from 1908 to 1970 and recently Cross and Basaca-Sevilla (1984) 2 published a report on stool examinations conducted among many of the Philippine Islands. In these surveys of urban and rural populations, over 30,000 single stools were examined and 86% were found to have one or more intestinal parasitic infections. In 1980, the U.S. Naval Medical Research Unit No. 2 (NAMRU-2) initiated a variety of studies in collaboration with the staff at San Lazaro Hospital. Most patients involved in these studies submitted stool specimens that were examined by the NAMRU.2 Parasitology laboratory. This report presents the results of those examinations performed from 1980 until 1984. MATERIALS AND METHODS Stool samples were collected from patients admitted to the hospital for malaria, schistosomiasis, gastroenteritis, amebiasis, hepatitis, diarrhea and a small number of other diseases. However, all patients admitted to the hospital with these conditions were examined. Stool specimens were collected in clean paper cartons and the specimens preserved and examined by a variety of methods, depending on the admission diagnosis. All stools were preserved in 10% formalin; diarrheic and dysenteric stools were preserved in polyvinyl alcohol (PVA). The formalinized stools were examined microscopically by direct smear and after formalin-ether concentration. The PVA specimens were examined after smearing onto slides and staining with trichrome stain. Selected stools were also cultured for hookworm and Strongyloides stercoralis by the Harada-Mori method (1955) 3 and others examined for cryptosporidium by a modified Kinyoun staining procedure (Ma and Soave, 1983).4 In most cases only single stools were examined from each patient but in some cases of suspected schistosomiasis and amebiasis, multiple stools were examined. RESULTS A total of 3,687 stool specimens were examined from 2,321 males and 1,366 females. Ages ranged from infants to 80 year olds. The patients for the most part were from Metro-Manila and surrounding provinces, but some were from northern and southern Luzon, Leyte, Samar, Mindanao and other islands.

Sixty-four percent had one or more intestinal parasites. No parasites were found in the stools of 36%. The most commonly found parasites were the soil-transmitted helminths, Trichuris trichiura (46%), Ascaris lumbricoides (30%) and hookworm (29%). The most common protozoa found were Entamoeba coli (8%), Endolimax nana (4%), cryptosporidium (3%) and Giardia lamblia (2%). E. histolytica was found in less than 2% of the stools and other protozoa at 1% or less (Table 1).
Table 1. Stool specimens from San Lazaro Hospital examined by NAMRU-2, 1980-1984 Total number of stools examined Total male Total female Parasites found Ascaris lumbricoides Trichuris trichiura Hookworm Enterobius vermicularis Schistosoma japonicum Echinostoma sp. Capillaria philippinensis Taenia sp. Entamoeba histolytica Entamoeba coli Endolimax nana Iodamoeba buetschlii Entamoeba hartmanii Chilomastix mesnili Giardia lamblia Blastocystis hominis (3,482 stools) Cryptosporidium sp. (735 stools) Heterophyid Didymozoid No parasites found Total number of Harada-Mori cultures, 1,553 Necator americanus Ancylostoma duodenale Strongyloides stercoralis 3,687 2,321 1,366 Number found 1,109 1,706 1,083 3 58 2 2 2 56 306 151 19 6 8 82 35 19 10 1 1,314 544 523 1 10

Percentage 30 46 29 1 1 1 1 1 1.5 8 4 1 1 1 2 1 3 1 1 36 35 34 1 1

It has only been in recent years that Blastocystis hominis has been considered as a potential pathogenic protozoon. At one time, it was considered a non-pathogenic fungus and an artifact in feces. It has now been recognized as a cause of gastroenteritis. Cryptosporidium sp., on the other hand, known to be a cause of diarrhea in animals, especially calves, is now considered a human pathogen and a cause of diarrhea. The parasite has been found in the feces of most of the patients with acquired immunodeficiency syndrome (AIDS) as well as in some immunocompetent persons. Previously, this organism would have been an unidentified cause of diarrhea unless the feces were examined for the parasite by acid-fast staining or another method used to detect the parasite. Direct examination of t e feces for hookworm and Harada-Mori h cultures had similar results. However, the latter method enabled species identification that was not possible with the former method of examination. Necator americanus was more commonly found. The 10 cases of strongylo idiasis were all detected by culture. DISCUSSION Although the overall prevalence rate of intestinal parasites was low (64%) compared to other reports, the results of this study were not too different from data obtained from other urban areas. For example in a survey reported by Cross and Basaca-Sevilla in 1985 on Dumaguete City,

the overall number of people infected was 63%. As in other surveys, the soil-transmitted helminths were the most common followed by protozoa. For E. histolytica we used formalin-ether concentration and PVA trichrome staining, but only found cysts and trophozoites of the parasite in less than 2% of those examined. At the time of the study, we were able to detect significant antibody levels to E. histolytica in the sera of a number of patients but we were not able to find the parasite. In our opinion, serologic evidence of the disease is an important adjunct for the diagnosis of amebiasis. Significant antibody levels by IHA (indirect hemagglutination > 1:128) or positive reactions by gel diffusion or latex agglutination should be considered in the diagnosis of the disease. The prevalence for G. lamblia (2%) was low compared to the survey showing 6% by Cross and Basaca-Sevilla in 1984 as were the prevalences for E. nana (4% vs %9) and E. coli (8% vs 21%). The only explanation is that these parasitosis occur less frequently among urban populations. It is recommended that in the future, laboratory technicians and physicians should search for the presence of B. hominis and cryptosporidium i the stools. Both cause diarrhea and at n times, epidemics have been reported, especially with cryptosporidium. These parasitic infections continue to persist in the Philippines. This is unfortunate since all of them are treatable and could essentially be e radicated with improvement in sanitation, health education and with the use of anti-parasitic drugs. SUMMARY A total of 3,687 stool specimens from patients seen at San Lazaro Hospital in Manila were examined for intestinal parasites by various methods: direct, formalin-ether concentration, polyvinyl-alcohol-trichrome staining, Harada-Mori culture and acid fast staining. The following parasites were found: Trichuris trichiura 46%, Ascaris lumbricoides 30%, hookworm eggs 29%, Entamoeba coli 8%, Blastocystis hominis 1%, Endolimax nana 4%, Cryptosporidium sp. 753 stools 3%. Giardia lamblia 2%, Entamoeba histolytica 1.5%, lodamoeba buetschlii 1%, Schistosoma japonicum 1%, and Enterobius vermicularis, Echinostoma sp., Heterophyid, Didymozoid, Capillaria philippinensis, Taenia sp., Entamoeba hartmarmi and Chilomastix mesnili < 1%. Thirty-five percent of the Harada-Mori cultures yielded larvae: Necator americanus 34%, Ancylostoma duodenale < 1% and Strongyloides stercoralis < 1%. It is recommended that stool specimens be more closely examined for Blastocystis hominis and Cryptosporidium sp. in cases of diarrhea. REFERENCES
1. 2. 3. 4. Cabrera BD 1970. A review of the parasitic disease of the gastro-intestinal system in the Philippines. In Proc. 7th Seameo Tropmed Sem. "'Infectious Diseases of the Gastrointestinal System in Southeast Asia and the Far East," (ed. JH Cross), 28 Sept Oct. 1970, Taipei, Taiwan, R.O.C. Cross JH and Basaca-Sevilla V 1984. Biomedical Survey in the Philippines. NAMRU-2 SP-47, 119 pp. Harada Y, Mori O. A new method for culturing hookworm. Yanago Acta Med 1955; 1:177-179. Ma P, Soave R 1983. Three-step examination for cryptosporidiosis in 10 homosexual men with protracted watery diarrhea. J Infect Dis1947:824-828.