Skip to main content

Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping



In marginalized setting, under-nutrition and illnesses due to infectious agents create a vicious circle. In our previous study, we reported that easy-to-do hand hygiene interventions were effective in preventing intestinal parasite infections (IPIs) and reduce the rate of anaemia among school-aged children. The aim of this study was to assess the pattern of associations between IPIs, anaemia and diarrhoea among the school-aged children and to explore if the observed impact of hand-washing and nail clipping interventions in our findings was similar across children with different baseline demographic and disease characteristics. The study was based on the analysis of data that was collected during the randomized controlled trial and hence have used the same study participants and study area.


Children with IPIs had a much higher chance of also being anaemic (AOR 2.09, 95% CI 1.15–3.80), having diarrhoea (AOR 2.83, 95% CI 1.57–5.09), and vice versa. Anaemia and diarrhoea were very strongly related (AOR 9.62, 95% CI 5.18–17.85). Overall, hand-washing with soap at key times and weekly nail clipping were efficacious in preventing intestinal parasite re-infection among children despite the differences in baseline demographic characteristics.

Trial registration: NCT01619254 (June 09/2012)


In resource‐poor settings, under‐nutrition and illnesses due to infectious diseases are highly prevalent and closely interlinked. Nutritional deficiencies predispose people to infection, and infections lead to nutritional deficiencies which further reduce resistance to new infections [1,2,3]. Children are especially susceptible to the deleterious effects of under‐nutrition [4] and infections [5] in developing settings.

In Ethiopia, similar to many developing countries, IPIs [6, 7] and anaemia [6, 8] are common among school‐aged children. This suggests that school‐aged children in Ethiopia may be vulnerable to the cyclical ill‐effects of anaemia and illnesses due to parasitic infections. However, there is insufficient evidence regarding the associations of IPIs, anaemia and diarrhoea among these population groups in the country.

Remarkable heterogeneity is documented in the distribution patterns of IPIs [9]. Several demographic [10], socioeconomic [11], and environmental [12] factors influence the distribution patterns of IPIs within a community. These factors can create different distributions of susceptibility to re‐infection by IPIs among a population, and hence, different groups of children may be at different risks of parasitic re‐infection.

A randomised controlled trial revealed a significant impact of regular hand‐washing with soap on the prevention of parasitic re‐infection and anaemia among children [13]. It is unknown if certain characteristics of the children also determined the effects of hand‐washing. One could imagine, for example, that in areas where parasites are distributed by polluted water, that hand‐washing would not be effective in preventing parasitic infections. We set out to explore if the effect of hand‐washing and nail clipping interventions in our findings [13] was similar across the study population despite their different characteristics.

Main text


Description of the trial

In our previous randomized controlled trial [13], we reported that easy-to-do hand washing interventions were effective in preventing intestinal parasite infections (IPIs) and reduce the rate of anaemia among school-aged children. This study was carried out on the analysis of data collected during the randomized controlled trial with the objective of assessing whether the observed efficacy of the easy-to-do hand washing interventions was universally effective to prevent infection among the same school‐aged children with different socio-demographic baseline characteristics. Moreover, we aimed to explore whether infection and malnutrition were interlinked and hence the infection prevention interventions used in the previous study would break the vicious cycle of infection and malnutrition in such marginalized areas for the long-term health benefits of this population group.

Data collection procedure

Baseline data

briefly, demographics (child age, gender, latrine use, maternal age, family size, family drinking water source, and living house ownership), socio economic (maternal education) and pre‐existing disease characteristics (IPIs, anaemia, and thinness) were included for this analysis from data collected during the previous randomized controlled trial [13].

Parasitological analysis

Following 6 months follow‐up, fresh stool specimens were collected from the study subjects. Stool specimens were analysed using direct saline wet mount, formalin ethyl‐acetate concentration technique [14] and the Kato‐Katz technique [15]. A child was classified as re‐infected if an infection was detected by any methods used. Sub‐samples of stool smears, comprising 10% of the total, were re‐examined for quality control purposes.

Diarrhoea incidence

Data on self‐reported diarrhoeal episodes were collected using a separate questionnaire on a weekly basis during the study period. Diarrhoea was defined as the passage of three or more loose or liquid stools per day [16].


Anthropometric measurements were taken at the start and the end of the follow‐up in duplicate and the average of the two measurements was recorded. Portable weight scales and locally made stadiometers with a sliding headpiece were used to measure weight (to the nearest 0.1 kg) and height (to the nearest 0.1 cm), respectively. Each child was weighed with minimal clothing and barefooted. The weighing scales were calibrated using standard calibration weights of 5 kg iron bars. Height measurements were taken with children faced forwards, barefooted with feet flat and together, and their heels and back against the rod. Anthropometric measurements were converted into BMI‐for‐age Z scores using WHO AnthroPlus software, version 1.0.4 (WHO Anthro 2007, WHO, Geneva, Switzerland). Children below − 2Z scores for BMI‐for‐age were classified as thin.

Statistical analysis

Statistical analysis was computed using SPSS for Windows version 16.0 (Chicago, USA). Associations between post‐intervention IPIs, anaemia, and diarrhoea were analyzed using binary and multivariate logistic regression models by odds ratios (OR) and 95% confidence intervals (CI). The impact of hand‐washing with soap and nail clipping on intestinal parasite re‐infection across children with different demographic and disease characteristics was analysed using logistic regression models. Stratifications included baseline demographics (child age, gender, latrine use, maternal education, maternal age, family size, family drinking water source, and living house ownership) and pre‐existing disease characteristics (IPIs, anaemia, and thinness). Possible moderating effects of each baseline variable on the effect of intervention were identified by adding interaction terms to the regression model [17]. Statistical significance was set at p < 0.05.


Baseline characteristics and the trial profile of the original project have been described previously [13]. Briefly, 365 (99%) children were analysed for six‐month follow‐up. Boys comprised 41% (n = 150) of the study participants and mean age was 10 (SD = 2.6) years. Following 6 months follow‐up, 21% (95% CI 17–25%) of the children were re‐infected with intestinal parasites, 18% (95% CI 14–22%) of the children were anaemic and 17% (95% CI 13–21%) had diarrhoea.

Table 1 describes the multivariate logistic regression analysis results of the associations between intestinal parasitosis, anaemia, and diarrhoea. Effects were adjusted for each intervention. Current intestinal parasitosis, a history of diarrhoea in the previous week, and current anaemia were independently associated. IPIs were significantly associated with anaemia (AOR 2.09, 95% CI 1.15–3.80) and diarrhoea (AOR 2.83, 95% CI 1.57–5.09), and vice versa. Anaemia and diarrhoea were also strongly related (AOR 9.62, 95% CI 5.18–17.85), meaning that children with diarrhoea had a very high chance of also having anaemia, and vice versa.

Table 1 Associations between intestinal parasitic infections, anaemia and diarrhoea among school-aged children, Ethiopia (n = 365)

Both hand‐washing with soap (AOR 0.32, 95% CI 0.20–0.62, p = 0.001) and weekly finger nail clipping (AOR 0.51, 95% CI 0.27–0.95, p = 0.035) interventions were reported to have a significant impact in reducing intestinal parasite re‐infection rates among the study participants [13].

In this study, we explored if these impacts were similar across children with different demographic and disease backgrounds. Overall, interventions seem equally efficacious among children regardless of age, gender, drinking water source, latrine use, mother’s age, mother’s education, family size, house ownership, and history of intestinal parasitosis, anaemia and thinness at baseline (Table 2). The impact of hand‐washing was similar for the whole group and for children who had IPIs at baseline, but the effect significantly increased in children who were parasite‐free at baseline (AOR 0.48 vs. AOR 0.31, p = 0.048). The effects of hand‐washing and nail clipping were higher for children whose drinking water sources were wells and streams compared to those who used pipeline and boreholes, but the effects were not statistically significant (AOR 0.44 vs. AOR 0.08, p = 0.134 and AOR 0.68 vs. AOR 0.09, p = 0.053; respectively).

Table 2 Impact of hand-washing on parasite re-infection rates across children with different base-line demographic and disease characteristics (n = 365)


Findings of the present study demonstrate a clear relationship between IPIs, anaemia and diarrhoea among children. Children with IPIs had a much higher chance of also being anaemic and having diarrhoea. Anaemia and diarrhoea were also very strongly related, as children with diarrhoea had a very high chance of also having anaemia, and vice versa. Hand-washing with soap and nail clipping prevents the children from intestinal parasite infections regardless their demographic differences and hence breaks the vicious cycle of IPIs, anemia and diarrhoea among the children.

Associations observed between anaemia and IPIs in our data concord with other studies that showed IPIs to be substantially linked with anaemia in children [18,19,20,21]. IPIs can decrease food and nutrient intake, cause intestinal blood losses, induce red blood cell destruction by the spleen, and induce autoimmune reactions leading to chronic inflammation [20, 21]. These effects may have accounted for the considerable proportion of anaemia observed among the children infected with intestinal parasites.

Although in most instances IPIs are asymptomatic, they may also cause diarrhea [22]. IPIs can induce diarrhoea by increasing small intestine motility while reducing its digestive and absorptive capacities [23]. Our finding that diarrhoea may contribute substantially to anaemia among children was also consistent with other reports from developing settings [24]. Diarrhoeal diseases are reported to be associated with an increased production of cytokines, interleukin 6 and tumour necrosis factor alpha [25]. These cytokines are indicated to play a significant role in causing anaemia [24]. Repeated episodes of diarrhoea in children are also reported to lead to decreased nutrient absorption, due to injury of the small intestine mucosa [26]. In our data, anaemia was also an independent risk factor for both IPIs and diarrhoea. In agreement with our findings, Levy et al. [27] have reported that anaemia increases rates of infection in children. Furthermore, reports from several studies have indicated that anaemia can predispose people to infections by lowering host immunity [28, 29]. In general, our findings strengthen the well‐established notion that infection and malnutrition are intricately linked [1, 30, 31].

The observed significant preventive impact of hand‐washing and nail clipping on intestinal parasite re‐infection rates made us curious to explore whether the intervention effect noted in the whole cohort was homogenous across children with different backgrounds. Hand‐washing with soap and nail clipping interventions consistently favoured reduction of intestinal parasite re‐infection rates across each sub‐group analysed. A significant difference in the effect of hand‐washing was observed only for baseline parasitic infection status. Based on our data, it is possible to suggest that benefit from the interventions is likely to be more universal among the study groups. The observed increased benefit of hand‐washing among children who were parasite‐free at baseline should be interpreted with caution, although analyses were based on formal tests of interaction. Children were made parasite‐free at recruitment and this might have affected our analysis at follow‐up. The difference in effect for hand‐washing and nail clipping between children who use pipeline and borehole water sources and those using wells and streams is quite large, but not significant because of the small number of children who use wells and streams.

In conclusion, our findings emphasise that intestinal parasitosis, anaemia and diarrhoea were independently associated. Furthermore, hand‐washing with soap and nail clipping were efficacious in preventing intestinal parasite re‐infection despite baseline differences and hence can be universally used as infection prevention interventions among school‐aged children to break the vicious cycle of infection and malnutrition for the long‐term health benefits of this population.


The following limitation should be considered when interpreting the results of the present study: the study was powered to determine the overall effect of the interventions in the original randomized controlled trial. Our subgroup analyses might hence be underpowered to detect subgroup effects, unless the differences in treatment effects between subgroups would have been very large.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.



adjusted odds ratio




confidence interval


intestinal parasitic infections


odds ratio


standard deviation


World Health Organization


  1. Muller O, Krawinkel M. Malnutrition and health in developing countries. CMAJ. 2005;173:279–86.

    Article  Google Scholar 

  2. Schaible UE, Kaufmann SHE. Malnutrition and infection: complex mechanisms and global impacts. PLoS Med. 2007;4:e115.

    Article  Google Scholar 

  3. Brown KH. Diarrhea and malnutrition. J Nutr. 2003;133:328S–32S.

    Article  Google Scholar 

  4. de Benoist B, McLean E, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993–2005. World Health Organization Global Database on Anemia. Geneva: WHO; 2008.

    Google Scholar 

  5. Gilgen DD, Mascie-Taylor CG, Rosetta LL. Intestinal helminth infections, anemia and labor productivity of female tea puckers in Bangladesh. Trop Med Int Health. 2001;6:449–57.

    Article  CAS  Google Scholar 

  6. Mahmud MA, Spigt M, Mulugeta Bezabih A, Lopez Pavon I, Dinant GJ, Blanco Velasco R. Risk factors for intestinal parasitosis, anemia, and malnutrition among school children in Ethiopia. Pathog Glob Health. 2013;107:58–65.

    Article  Google Scholar 

  7. Mathewos B, Alemu A, Woldeyohannes D, Alemu A, Addis Z, Tiruneh M, et al. Current status of soil transmitted helminths and Schistosoma mansoni infection among children in two primary schools in North Gondar, Northwest Ethiopia: a cross sectional study. BMC Res Notes. 2014;7:88.

    Article  Google Scholar 

  8. Assefa S, Mossie A, Hamza L. Prevalence and severity of anemia among school children in Jimma Town, Southwest Ethiopia. BMC Hematol. 2014;14:3.

    Article  Google Scholar 

  9. Brooker S, Alexander N, Geiger S, Moyeed RA, Stander J, Fleming F, et al. Contrasting patterns in the small-scale heterogeneity of human helminth infections in urban and rural environments in Brazil. Int J Parasitol. 2006;36:1143–51.

    Article  Google Scholar 

  10. Schmidlin T, Hurlimann E, Silue KD, Yapi RB, Houngbedji C, Kouadio BA, et al. Effects of hygiene and defecation behavior on helminths and intestinal protozoa infections in Taabo, Cote d’Ivoire. PLoS ONE. 2013;8(6):e65722.

    Article  CAS  Google Scholar 

  11. Alum A, Rubino JR, Ijaz MK. The global war against intestinal parasites—should we use a holistic approach? Int J Infect Dis. 2010;14:e732–8.

    Article  Google Scholar 

  12. Garbossa G, Pia Buyayisqui M, Geffner L, Lopez Arias L, de la Fourniere S, Haedo AS, et al. Social and environmental health determinants and their relationship with parasitic diseases in asymptomatic children from a shantytown in Buenos Aires, Argentina. Pathog Glob Health. 2013;107:141–52.

    Article  Google Scholar 

  13. Mahmud MA, Spigt M, Bezabih AM, Pavon IL, Dinant G-J, Velasco RB. Efficacy of handwashing with soap and nail clipping on intestinal parasitic infections in school-aged children: a factorial cluster randomized controlled trial. PLoS Med. 2015;12(6):e1001837.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zeibig EA. Clinical parasitology. A principal approach. The curtis center. Independence Square west Philadelphia: Saunders; 1997.

    Google Scholar 

  15. World Health Organization. Cellophane faecal thick smear examination technique (Kato) for diagnosis of intestinal schistosomiasis and gastrointestinal helminth infections. PDP 83:3. 1993. Accessed 07 Dec 2019.

  16. World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. WHO/FCH/CAH/05.1. Geneva: World Health Organization; 2005.

    Google Scholar 

  17. Assmann SF, Pocock SJ, Enos LE, Kasten Linda E. Subgroup analysis and other (mis)uses of baseline data in clinical trials. Lancet. 2000;355:1064–9.

    Article  CAS  Google Scholar 

  18. Stephenson LS, Holland CV, Cooper ES. The public health significance of Trichuris trichiura. Parasitology. 2000;121:S73–95.

    Article  Google Scholar 

  19. Gulani A, Nagpal J, Osmond C, Sachdev HPS. Effect of administration of intestinal anthelmintic drugs on haemoglobin: systematic review of randomised controlled trials. BMJ. 2007;334:1095.

    Article  CAS  Google Scholar 

  20. Tolentino K, Friedman JF. An update of anemia in less developed countries. Am J Trop Med Hyg. 2007;77:44–51.

    Article  Google Scholar 

  21. Friedman JF, Kanzaria HK, McGarvey ST. Human schistosomiasis and anaemia: the relationship and potential mechanisms. Trends Parasitol. 2005;21:386–92.

    Article  Google Scholar 

  22. Kaiser L, Surawicz CM. Infectious causes of chronic diarrhoea. Best Pract Res Clin Gastroenterol. 2012;26:563–71.

    Article  Google Scholar 

  23. Cotton JA, Beatty JK, Buret AG. Host parasite interactions and pathophysiology in Giardia infection. Int J Parasitol. 2011;41:925–33.

    Article  CAS  Google Scholar 

  24. Semba RD, de Pee S, Ricks MO, Sari M, Bloem MW. Diarrhoea and fever as risk factors for anemia among children under age five living in urban slum areas of Indonesia. Int J Infect Dis. 2008;12:62–70.

    Article  Google Scholar 

  25. Jiang B, Snipes-Magaldi L, Dennehy P, Keyserling H, Holman RC, Bresee J, et al. Cytokines as mediators for or effectors against rotavirus disease in children. Clin Diagn Lab Immunol. 2003;10:995–1001.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Fagundes-Neto U. Persistent diarrhoea: still a serious public health problem in developing countries. Curr Gastroenterol Rep. 2013;15:345.

    Article  Google Scholar 

  27. Levy A, Fraser D, Rosen SD, Daqan R, Deckelbaum RJ, Coles C, et al. Anemia as a risk factor for infectious diseases in infants and toddlers: results from a prospective study. Eur J Epidemiol. 2005;20:277–84.

    Article  Google Scholar 

  28. Ekiz C, Aqaoqlu L, Karakas Z, Gurel N, Yalcin I. The effect of iron deficiency anemia on the function of the immune system. Hematol J. 2005;5:579–83.

    Article  CAS  Google Scholar 

  29. Beard JL. Iron biology of immune function, muscle metabolism and neuronal functioning. J Nutr. 2001;131:568S–80S.

    Article  CAS  Google Scholar 

  30. Katona P, Katona-Apte J. The interaction between nutrition and infection. Clin Infect Dis. 2008;46:1582–8.

    Article  Google Scholar 

  31. Schaible UE, Kaufmann SHE. Malnutrition and infection: complex mechanisms and global impacts. PLoS Med. 2007;4:e115.ican.

    Article  Google Scholar 

Download references


The authors are grateful for all the children and their parents and/or guardians for the participation. We thank the fieldworkers who implemented the interventions and carried out the follow-up. We express our sincere gratitude to the laboratory personnel involved in the field work. Our sincere acknowledgement also goes to the Tigray Regional Health Bureau, Mekelle University, Ethiopia and Alcala University, Spain for their support and cooperation.



Author information

Authors and Affiliations



MAM participated in all phases of the study including writing the proposal, data collection and writing the manuscript. MAM, MS, AMB, G-JD, RBV conceived and designed the experiments. MAM, MS, and G-JD analysed the data. MAM and MS wrote the first manuscript. MAM, MS, AMB, G-JD and RBV contributed to the writing of the manuscript. MS and G-JD revised and approved the manuscript. All authors have read, and confirm that they meet, ICMJE criteria of authorship. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mahmud Abdulkader Mahmud.

Ethics declarations

Ethics approval and consent to participate

The study protocol and informed consent procedure for the initial randomized controlled trial was approved by the Institutional Review Board of the College of Health Sciences, Mekelle University, Ethiopia. Written informed consent was obtained from each child’s parents and/or guardians. Children diagnosed positive for IPIs at follow‐up were treated with standard medication [16], and children with anaemia and/or diarrhoea were sent to the health facilities for further medical attention.

Consent for publications

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mahmud, M.A., Spigt, M., Bezabih, A.M. et al. Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping. BMC Res Notes 13, 1 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: