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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA–AFRICA  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1395-1402
Urinary schistosomiasis in Boko Haram-related internally displaced Nigerian children


1 Department of Pediatrics, College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
2 Department of Medicine, College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
3 Department of Microbiology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
4 Ramat Library, University of Maiduguri, Maiduguri, Borno State, Nigeria
5 Pediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria

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Date of Submission07-Jul-2017
Date of Acceptance09-Aug-2017
Date of Web Publication27-Dec-2018
 

   Abstract 

We aimed to determine the prevalence of urinary schistosomiasis among internally displaced children in Maiduguri, Nigeria. Data on the children’s sociodemographic characteristics and risk factors for schistosomiasis were collected, over a period of six months, using an interview-based questionnaire. Ten milliliter of urine sample was collected from each child and investigated for hematuria and ova of Schistosoma haematobium. Two hundred and thirty-eight of 385 children had urinary schistosomiasis (62.0%); of this, 125 (53.0%) were males, with a male:female ratio of 1.1:1. Urinary schistosomiasis was the most common among 5–9 years’ age group, low social class children, and children of farmers, P <0.05. Stunting was significantly associated with urinary schistosomiasis, P <0.05. It is concluded that urinary schistosomiasis in children was more frequently associated with stunting and low social class. It was a very common disease among internally displaced children in Nigeria.

How to cite this article:
Yauba SM, Rabasa AI, Farouk AG, Elechi HA, Ummate I, Ibrahim BA, Ibrahim HA, Baba AS, Boda TA, Olowu WA. Urinary schistosomiasis in Boko Haram-related internally displaced Nigerian children. Saudi J Kidney Dis Transpl 2018;29:1395-402

How to cite this URL:
Yauba SM, Rabasa AI, Farouk AG, Elechi HA, Ummate I, Ibrahim BA, Ibrahim HA, Baba AS, Boda TA, Olowu WA. Urinary schistosomiasis in Boko Haram-related internally displaced Nigerian children. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Jan 18];29:1395-402. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1395/248286

   Introduction Top


Boko Haram, is an Islamic terrorist group based in north eastern Nigeria with treacherous activities in Niger, Chad, and northern Cameroon.[1] The group has its headquarters in Maiduguri, Borno State, Nigeria. The kidnapping of 276 Chibok schoolgirls by the terrorist group in April 2014, attracted international condemnation. The group, ranked the deadliest terrorist organization in the world, in 2015,[2],[3] has killed 20,000 and rendered 2.3 million people homeless and displaced.[4] Many of these people are now refugees in Niger, Chad, and Cameroon.[5] Those that remain in Nigeria are quartered in internally displaced persons’ (IDPs) camps, in other Nigerian cities.

One of the health implications of Boko Haram insurgency and the attendant displacement of people from their homes and communities is that of easy spread of communicable diseases among the IDPs in the IDP camps and people of the host communities. A communicable disease such as schistosomiasis can easily be spread through contamination of streams or rivers in the host communities leading to an epidemic of schistosomiasis.

Urinary schistosomiasis is a disease of significant socioeconomic and public health importance second only to malaria.[6] It affects approximately 249 million people worldwide, ranking second only to malaria as the most common parasitic disease; an estimated 280,000 people die yearly from urinary schistosomiasis in Africa alone.[7] The disease which is caused by Schistosoma haematobium is most prevalent in Africa.[8] Its transmission is through water contacts with specific snail hosts.[9],[10] The parasite resides in the venous plexus draining the urinary bladder where deposited eggs with terminal spines clog the venous plexus thereby obstructing the blood circulation. The terminal hematuria that characterizes this disease is, therefore, the result of the rupture of the obstructed venous plexus. With the vascular rupture, the schistosoma eggs are released into the urinary bladder to be excreted in the urine.[11]

A few of the morbidities associated with the infestation include nutritional deficiencies, growth retardation, cognitive impairment as well as decreasing physical activity, school performance, and work capacity and productivity.[12],[13] Urinary schistosomiasis also causes enlargement of the bladder wall, multiple polyps, vesicle calcification, and cystitis cystica.[14] A very serious immune-complex mediated disorder of the kidney associated with urinary schistosomiasis is schistosomal nephritis.[15] This is a chronic glomerulonephritis that is frequently associated with chronic pyelonephritis with resultant nephrotic syndrome.[15] Some of the patients progress to renal failure death. Obstructive uropathy associated with urinary schistoso-miasis has been found to cause significant kidney damage with focal segmental glomerulo-sclerosis and peritubular fibrosis as the resultant renal histopathologic lesions.[15],[16]

Early diagnosis and treatment of urinary schistosomiasis among children can prevent long-term renal disease. The prevalence and some risk factors for urinary schistosomiasis among children living in IDP camps in Maiduguri, Nigeria were determined.


   Methods Top


This cross-sectional study was conducted in three selected IDP camps in Maiduguri, Nigeria between September 1, 2014, and February 28, 2015, among internally displaced children with either terminal, microscopic, or dipstick hema-turia. The IDP camps were Yerwa, Government College, and Bakasi camps in Maiduguri. Yerwa, Government College and Bakasi IDP camps hosted displaced persons from Bama, Gwoza and Monguno local government areas (LGA), respectively. Using an assumed prevalence rate of 50.0%, a sample size of 385 was determined using the standard formula for sample size determination.[17] Data on the socio-demographic characteristics of the children and relevant risk factors were collected using an interview-based questionnaire.

Socioeconomic status determination

The social class was determined based on the method described by Ogunlesi et al.[18] This was based on the highest educational qualification and current occupation of both parents of each child. A score was awarded for the education and occupation of each parent, and the sum of the four scores was done and the mean determined by dividing by 4. A socioeconomic class I–II, III, and IV–V were classified upper, middle, and lower social class, respectively.

Height measurement and determination of stunting

The height was measured with the child standing barefooted against a flexible height tape measure hanged on the wall by placing a ruler horizontally on the child’s vertex to touch the flexible tape while he looked straight on. The height was measured to the nearest 0.1 cm. Children who were below two years of age had their length determined using the length board as described by the World Health Organization (WHO).[19] The measured height or length was compared with a standard height-for-age nomogram; any child whose height-for-age was less than the 90th percentile was considered stunted.[20]

Urine sample collection and laboratory methods

Two aliquots each of 10 mL of urine sample were collected from each child between 10.00 and 14.00 h. In one of the urine samples, urinalysis by dipstick and microscopy for hematuria was carried out. Dipstick urinalysis was done by dipping the reagent strip (Urine-10 parameters) into the urine for 5 s. The change in the color of the strip was compared with manufacturer’s color chart to estimate the amount of blood in the urine. The second 10 mL urine aliquot was centrifuged at 5000 rpm for 5 min and the supernatant discarded. The sediment was transferred to a clean glass slide. The glass slide was examined under a light microscope at a high-power objective, ×40 for identification of the terminal spine of S. hematobium ova which were counted and recorded as eggs/10 mL of urine. Based on the WHO recommendation, the intensity of infestation was expressed as negative (0 egg/10 mL urine), moderate (<50 eggs/10 mL urine), and heavy (>50 eggs/10 mL urine).[21] Infected children were treated with praziquantel, 40 mg/kg as recommended by WHO.[11] Permission for the study was granted by the authorities incharge of the IDP camps. Informed consent was obtained from parents/guardians of each child. The study conformed to the provisions of the revised Declaration of Helsinki, 2008.


   Statistical Analysis Top


Data were analyzed using the Epi Info version 7.0 (CDC, Atlanta, GA, USA). Differences between proportions were tested by the Chi-squared (χ2) test. Student’s t-test was used for variation in mean values between subgroups. P <0.05 was considered statistically significant.


   Results Top


[Table 1] shows the overall sociodemographic characteristics of the study population as well as factors associated with urinary schistoso-miasis in the children. There was a total of 5000 children, in the three IDP camps, out of which 385 children were studied; these children were distributed among the three selected IDP camps [Figure 1]. Overall, 238 of 385 (62.0%) children were infected with S. hematobium. Their ages ranged between 1.0 and 18.0 years (mean age: 6.3 ± 3.2). Majority of the infected children were in 5–9 years’ age group, P <0.05. There were 205 (53.2%) males and 180 (46.8%) females with no significant gender difference, χ2 = 0.132, P = 0.716. Infestation intensity was negative, moderate and severe in 147 (38.2%), 141 (36.6%), and 97 (25.2%) children, respectively. Severely infected children were significantly less in number compared to moderately infected children, P = <0.05. The overall mean egg intensity was 58.3 ± 9.6 eggs/10 mL of urine. The mean egg intensity in those with moderate and severe infections was 42.7 ± 8.7 and 74.2 ± 10.9 eggs/mL of urine, respectively. Children from Gwoza LG had the highest mean egg intensity (76.8 ± 10.5 eggs/mL of urine) compared to Monguno and Bama children with mean egg intensities of 43.2 ± 6.1 (P = 0.001) and 52.6 ± 8.1 (P = 0.001) eggs/mL of urine, respectively. There was no significant difference in the mean egg intensities between Monguno and Bama LGs, P = 0.210.
Table 1: Sociodemographic characteristics and factors predisposing to urinary schistosomiasis in internally displaced children.

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Figure 1: Number of children studied per local government area per camp.

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Majority of the parents were farmers. Most of the children (68.3%) patronize the streams. The frequency of the presenting clinical features is shown in [Figure 2]. Urinary schistosomiasis prevalence was significantly higher among children from Monguno LGA compared to children from either Gwoza or Bama LGA, χ2 = 9.51, P = 0.01 [Table 1]. The infection rate was similar between Gwoza and Bama LGAs, P = 0.596.
Figure 2: Frequency of clinical features of urinary schistosomiasis in internally displaced children.

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   Discussion Top


Urinary schistosomiasis is a notable acquired urinary tract disorder that has been associated with chronic kidney disease in untreated children.[15] Severe urinary schistosomiasis may be complicated by chronic pyelonephritis leading to hypertension or chronic kidney failure in people living in schistosomiasis endemic communities.[2],[23] Renal histopathologic studies on urinary schistosomiasis with pyelonephritic complication revealed tubulointerstitial changes such as patchy areas of tubular atrophy, thyroidlike areas, interstitial cellular infiltration, and interstitial fibrosis. Associated glomerular abnormalities were periglomerular fibrosis, intra-capsular hyalinizing fibrosis, and/or invasion by interstitial inflammatory cells.[15] These serious structural kidney defects should, therefore, be an important indication for institution of preventive measures and routine screening of susceptible communities for evidence of urinary schistosomiasis with the intention to treat identified cases promptly. A strong effort made to prevent schistosomiasis in some Chinese villages through annual treatment of farmers and cattle, optimization of animal grazing sites, sewage management, drinking water supplies, and health education had resulted in significant reductions in human, snail, and wild mouse schistosomiasis infection rates.[24],[25]

A strong point of this study is that it has brought to focus the burden of a disease in some neglected Nigerian communities and the need for community pediatricians and physicians to engineer the governments to support a well-coordinated therapeutic and interventional schistosomiasis programs in these and other susceptible communities in Nigeria. The displacement caused by Boko Haram, seemed to affect people from Gwoza and Bama LGAs more than Monguno LGA; however, the prevalence of urinary schistosomiasis was significantly higher in Monguno (49.0%) LGA compared to either Gwoza (30.0%) or Bama (21.0%) LGA. This may be because the former is predominantly a riverine area with higher frequency of exposure to infected water. The high overall prevalence (62.0%) observed in this study was like that reported by Ekpo (58.1%) et al[26] and Mafiana et al (71.8%).[27] This may be because many of the parents of these children were farmers and fishermen by occupation. The children, probably, acquired the infection crossing or swimming in rivers or engaged in freshwater irrigation farming when they accompany their parents to the farm or rivers to fish. This study revealed that rivers and water reservoirs in the LGAs were frequently visited by the children. The prevalence of the disease is relatively lower in pre-school age compared to school age children. The 35.9% and 13.0% prevalence rate found by Geleta et al[28] in Ethiopia and Moyo et al[29] in Malawi, respectively, were like the 22.7% found among pre-school age children in this study. However, the high prevalence of 58.1% observed by Ekpo et al[26] among preschool children demonstrated their undue exposure to infested freshwater in that community. Children older than five years of age were found to be significantly more prone to urinary schistosomiasis (77.3%) than those who were younger (22.7%) in this study. This may be due to the ease with which the former engages in activities that bring them in contact with infected sources of water unlike younger children who are still under the care and protection of their mothers. A further comparison among older age groups revealed no significant difference in the infection rate. The fact that the infection rate was highest in the 5–9 years compared to 10–14 and 15–18 years’ age groups could mean higher level of immunity in the older age groups against the disease. Similarly, Geleta et al[28] in Ethiopia found the infection to be more common in older children, especially, among those who were aged 13–14 years.

Higher prevalence was not associated with a corresponding increase in the egg intensity as Gwoza and Bama LGs with lower prevalence compared with Monguno had severer egg intensities. The difference in the severity of egg intensity could be due to variations in immunity status of the children and frequency of exposure to infested water sources.

While Geleta et al[28] reported male predominance, this study like that by Mafiana et al,[27] revealed that both genders were similarly infected indicating that both were similarly engaged in occupational or domestic activities that brought them in contact with infested water as more children who were exposed to streams were significantly infected with S. hematobium.

This study showed that urinary schistosomiasis is a disease of children from low social class as more children from the former were significantly infected compared to children from either middle or upper social class. The pattern of occupation of the parents of the infected children reflects this better as more children whose parents were farmers were significantly more infected compared to children whose parents were not.

Like the study by Mafiana et al,[27] majority of the infected children were significantly stunted. This may be due to anemia brought about by recurrent or chronic hematuria that was a major presenting feature in this study. Abdominal pains, dysuria, and body weakness were less frequent features.


   Conclusions Top


It is concluded that urinary schistosomiasis in children was more frequently associated with stunting and low social class. It is a very common disease among internally displaced children in Nigeria.

It is recommended that LGAs with high prevalence of urinary schistosomiasis be visited by pediatricians and community physicians after the return of the IDPs for community screening because considerable number of children from the affected areas reside in other IDP camps located outside Borno state and Nigeria. As a preventive measure, all children and adults in these and other communities who depend on streams and rivers as sources of water should routinely receive oral praziquantel to reduce the burden of urinary schistosomiasis and associated complications.

Conflict of interest: none declared.

 
   References Top

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26.
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27.
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Moyo VB, Changadeya W, Chiotha S, Sikawa D. Urinary schistosomiasis among Preschool children in Malengachanzi, Nkhotakota district, Malawi: Prevalence and risk factors. Malawi Med J 2016;28:10-4.  Back to cited text no. 29
    

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Correspondence Address:
Dr. Saad Mohammed Yauba
Paediatric Nephrology and Endocrinology Unit, University of Maiduguri Teaching Hospital, Maiduguri
Nigeria
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DOI: 10.4103/1319-2442.248286

PMID: 30588972

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