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Landless Farmworkers in Sergipe – Brazil: Assessment on S. mansoni in
Epidemiological Queries
Author Information
* Correspondence: MsC Genilde Gomes de Oliveira. Federal University of Sergipe Brazil. Email address [email protected].
Address: Claúdio Batista Street, no number; Sanatório Neighborhood. Aracaju City,
United of Sergipe- Brazil
Drª Angela Maria da Silva. Federal University of Sergipe - Brazil. Email address:
[email protected]
DRª Karina Conceição Gomes Machado de Araujo. Federal University of Sergipe Brazil. Email address: [email protected]
Dr. Roque Pacheco de Almeida. Federal University of Sergipe - Brazil. Email address:
[email protected]
MsC Marcio Bezerra Santos. Federal University of Sergipe - Brazil. Email address:
[email protected]
MsC Luciana Barros de Santana. Federal University of Sergipe - Brazil. Email address:
[email protected]
1Landless
Farmworkers in Sergipe – Brazil: Assessment on S. mansoni in
Epidemiological Queries
Abstract
Background: Schistosomiasis mansoni is a disease caused by the digenetic trematode
Schistosoma mansoni. It is an endemic disease in 78 tropical and subtropical countries.
In Brazil, it affects the States of Alagoas, Pernambuco, Sergipe, Bahia, Paraíba, and
Minas Gerais. The Movimento de Sem Terras [Landless Workers' Movement] – MST is
a Brazilian movement, which has as objective the implementation of the land reform.
Methods: This is a cross-sectional study conducted in 2010 and 2015, when 13
Landless settlements were investigated. These farmworkers are susceptible to the
disease due to migration to areas considered by them as nonproductive areas and they
use the river water for consumption, domestic chores and leisure. In 2010, 601
individuals were enrolled in the research, as they delivered the stool pathophysiology
test in 2015, 1139. In the two queries, TF (Test® Three Fecal Test) was used for stool
analysis and in the second query the positive results were submitted to an abdominal
ultrasound.
Results: In 2010, a 4.3% proportion of positive parasitological tests for S. mansoni was
obtained in the intestinal chronic phase. In 2015, 2.6% were infected, eight of them in
the hepato-intestinal phase. In the second query, a disordered population increase was
observed; the settlements maintained the social-demographic conditions of the first,
such as lack of basic sanitation, sewerage systems, treated water for consumption and
education level. In the two queries, the positive human cases were treated and the most
severe ones were referred to the outpatient department of University Hospital of
Universidade Federal de Sergipe for follow-up. Out of the 13 settlements assessed in
2010, 08 (61.5%) had a positive result for S. mansoni. In 2015, 11 (84.6%) showed a
positive result. In the year of 2010 and 2015, the occurrence of nine species of
helminths and four species of protozoa was shown.
Conclusion: The second query shows a worrying scenario, there was an increase in the
number of settlements with focus of the disease and there was a worsening in the
clinical setting, considering that in 2010 the intestinal chronic setting was evidenced,
and in the second query the hepatic impairment was observed. The pressing need for
intervention by the government regarding disease prevention and control is notorious.
Key-words: Schistosomiasis, epidemiology, parasitoses.
1
The manuscript does not have trial registration number for the case of two independent
cross-sectional studies. The second survey is an extension of the first authorized by the
Research Ethics Committee of the Universidade Federal de Sergipe -UFS, CAAE –
0081.0.107.000-08.
BACKGROUND
Schistosomiasis mansoni is a disease caused by the digenetic trematode
(Schistosoma mansoni), the important manifestation of which is related to liver fibrosis
caused by the parasite1. It is characterized as asymptomatic in the beginning, and it can
evolve to extremely severe forms and lead to the patient's death2.
Its distribution is associated with several factors, including complex social and
cultural processes related to human behavior and disordered occupation of urban areas3.
It is endemic in 78 countries, tropical and subtropical, 42 of them located in Africa4.
According to the World Health Organization – WHO (2012), approximately 240 million
people are infected with this disease, specially in Africa, Asia and the Americas5, of
those, 120 million experience symptoms and 20 million experience severe diseases all
over the world4.
In Brazil, it is endemic in the littoral zone, however, its higher prevalence is
observed in the States of Alagoas, Pernambuco, Sergipe, Bahia, Paraíba, and Minas
Gerais6. The State of Sergipe has one of the highest prevalences in the country,
according to the data from the Ministry of Health, the mean prevalence of
schistosomiasis in Sergipe during the period of 1980 through 1989 was 17.3%, the
second highest in Brazil, only lower than the one of the State of Alagoas. Considering
the period between 1990 and 2002, the State mean was 17.7%, way above the national
mean of 9.2%7.
The precarious socioeconomic conditions, the difficulties of having access to
health services, the migratory movements and the bad conditions of water treatment and
sewer constitute the main factors for transmission of Schistosomiasis in endemic areas8.
The Movimento de Sem Terra [Landless Workers' Movement] - MST is a
Brazilian social movement initiated in the '80s, the main objective of which was to
implement the land reform9. This population becomes susceptible to Schistosomiasis
due to migration to lands considered by them as nonproductive areas, and they settle in
farms under poor hygiene conditions, with no proper place for human waste and with
no drinkable water, and they use the river water for consumption, domestic chores and
leisure, favoring cycle of the disease progression10.
Settlement is a set of independent farming units, settled by INCRA (Instituto
Nacional de Colonização e Reforma Agrária [National Institute for Colonization and
Agrarian Reform] where originally, there was a land real estate owned by a single
owner. Each of these units is given by INCRA to a family with no economic
conditions to purchase and maintain a land real estate by any other means. The land
workers receiving the lot undertake to live in the parcel and to explore it for their own
support, operated exclusively by the family11.
In light of the severity and the harmful effects caused by the intestinal
parasitoses and the scarce study on the current situation of enteroparasitoses in the State
of Sergipe, this study assessed the occurrence of intestinal parasites based on the
Schistosomiasis mansoni population living in Landless settlements in the South of the
State of Sergipe and its clinical correlation.
METHODOLOGY
These are two cross-sectional studies conducted in 2010 and 2015. Thirteen
Landless settlements were investigated, located in cities in the South region of the State
of Sergipe, as shown in the map below (figure 1).
It was attempted to maintain the same population from the first query, that is,
from 2010, thus, the settlements investigated in the second query were the same as those
in the first query. In 2010, 822 residents of settlements were interviewed, out of those,
601 were enrolled in the research, as they delivered the stool pathophysiology test. In
2015, 1772 were interviewed and 1139 delivered the stools for the analysis, being
enrolled in the research.
The test was conducted in the first stool bulk, in three samples, collected every
other day. The stool was collected in an individual collector from the Kit TF Test®
(Three Fecal Test). Based on the study conducted by Carvalho et al, in 2012, the TF
Test® provides a reliable estimate of the infection prevalence by the protozoa in
endemic areas. The socioeconomic and practical aspects showed that the TF-Test®
technique is appropriate for individual diagnosis, population queries, as well as for the
evaluation of chemotherapy administered in programs of intestinal parasitoses control12.
The stool samples were submitted to the clinical analysis laboratory of the and
analyzed by a single previously trained professional.
The entire studied population signed an informed consent form (ICF), consenting
to participate in the research. At the end of the study, treatment for all the individuals
infected with S. mansoni was conducted, and the most severe cases were referred to
the outpatient department of HU/UFS.
Statistical Analysis
The epidemiological data were described by simple and percent frequencies. The
prevalence ratios and its respective confidence intervals were calculated to identify the
potential factors associated with the year of assessment and the prevalence of
Schistosoma mansoni. The analysis of categorical data was conducted along with the
qui-square test and Fisher's exact test for small samplings.
Then, the prevalence ratio measure of association was calculated with the
respective 95% confidence intervals. The prevalence ratio was estimated through the
prevalence calculation of the number of people with positive tests for Schistosoma
mansoni compared with those with negative test.
Ethical Considerations
This Research Project was approved by the Research Ethics Committee of the
Universidade Federal de Sergipe -UFS, CAAE – 0081.0.107.000-08.
RESULTS
Figure 2 shows the result of the stool pathophysiology test - EPF in 2010 and
2015.
In table 1 the characterization of prevalence by gender and risk behavior of the
Landless from the two queries can be observed.
In table 2, the main clinical manifestations of the Landless with positive results for S.
mansoni are presented.
In the years 2010 and 2015, the occurrence of nine species of helminths (Ascaris
lumbricoides, Enterobius vermicularis, Taenia solium, Taenia saginata, Trichuris
trichiura, Ancylostoma duodenale, Hymenolepis nana, Strongyloides stercoralis, and
Schistosoma mansoni) and four species of protozoa (Entamoeba sp., Endolimax nana,
Giardia lamblia and Iodamoeba bütschlii.) were observed. The highest prevalence in
the two periods studied was of the protozoa E. nana, 327 (55%) in 2010 and 523 (32%)
in 2015. As shown in table 3.
DISCUSSION
The studied population increased since the last epidemiological query. In 2015,
the double of parasitological tests was assessed and it was observed that the increase
occurred in a disordered manner, with houses being built in the backyards, aggregating
relatives; this disordered increase makes the population more vulnerable to the
infection. Dabo et al, 2015 emphasizes that due to the migration and rapid and
disordered urbanization, urban areas in Africa and South America are now the focus of
transmission13.
The field study conducted with the same population in 2010 and 2015 showed
some important particularities for the epidemiological query. In 2010 the entire
population diagnosed with S. mansoni was treated with praziquantel; nevertheless, in
the new query it was observed the presence of helminthiasis in the population, also, one
of the families that had been treated in the first query experienced the infection again in
the second query, possibly as a consequence of reinfection. These data show the need
for continuous control in risk populations and indicates the need to associate it with
chemotherapy, control of molluscs in the water, supply of treated water, sanitation
facilities and health education14.
Among the patients with positive results in 2015, 29 (2.6%) were positive for
Schistosomiasis, out of those, 23 (79.3%) made use of the rivers nearby the settlement
to bathe, none of them had access to basic sanitation and treated water, so they used the
water from the river or artesian wells. An identical scenario to that seen in 2010, with a
prevalence of 26 (4.3%) and a usage frequency of the river of 61.5% was observed.
Regarding the transmission conditions, Schistosomiasis is classically described as a land
disease, which occurs in areas with no drinkable water and proper sanitation13.
For some Landless, the contact with the river may be pointed out as accidental,
involuntary and inevitable, considering that they need to cross it on a daily basis in
order to conduct their social and labor activities, the study shows recreation by the river
with a statistical significance of p 0.025. The study by Abou-Zeid et al, 2013, showed
the higher risk for infection with Schistosomiasis in the rural area, with a five-fold
increase compared with the urban area. Other factors identified were the risk associated
with swimming and bathing in rivers and contact with rivers more frequently than once
a week15.
Despite the reduction in the prevalence, the situation of the Landless is still
worrying in the South region of Sergipe. In 2010, 08 settlements had positive cases, in
the new query, another three settlements were infected, that is, 11 showed positivity. In
the study by Oliveira et al, 2013, it can be noticed that the Schistosomiasis control has
been challenging for the public health services, because the importance of the disease is
not restricted to its prevalence and geographical distribution, but it also incorporates
issues as molluscicide-resistant molluscs, poor housing conditions and basic sanitation
and economical activities related to the use of water. The presence of infection with
S. mansoni in the settlements is worrying, because these migratory populations can
transmit the disease to other regions, so development of public policies towards the
disease control by the managers is required16.
Symptoms such as headache and abdominal pain were the most prevalent in
patients infected with S.mansoni, both in 2010 and 2015, showing an elevated rate of
occurrences of symptoms, a setting similar to the one described in the literature on
clinical manifestations in individuals with the parasite, in addition to these symptoms,
cercarial dermatitis and Katayama fever may manifest in the acute phase of the
disease17. In 2010, the intestinal clinical form was observed in all settlements; however,
in 2015 the hepato-intestinal clinical form was observed in 08 out of 29 positive human
cases. The intestinal form of Schistosomiasis mansoni is characterized by abdominal
pain, diarrhea, bloody stools, nausea, fatigue, and somnolence18. The hepato-intestinal
phase is characterized by the presence of diarrhea and epigastralgia. During physical
examination, the patient experiences palpable liver, with nodules which in the most
advanced phases correspond to areas with fibrosis due to periportal granulomatosis of
Symmers' Fibrosis10.
The occurrence of helminths and protozoa evidenced in 2010 was repeated in
2015, according to table 3. Oliveira et al 2012 conducted a study in land settlements in
Sergipe, identifying high rates of parasite infections, predominantly with Endolimax
nana,
Entamoeba
histolytica,
Giardia
lamblia,
Ascaris
lumbricoides,
and
Ancilostomideos. It was observed that the land settlements counted with minimal
sanitation conditions and practices of personal and domestic hygiene, thus promoting
conditions for the dissemination of parasite infections19. Infections with helminths are a
noticeable subgroup among other neglected tropical diseases (NTD), propagated mainly
due to lack of access to drinkable water and sanitation.
CONCLUSION
The second query shows a worrying scenario, the number of settlements with
focus of the disease has increased, and there was worsening in the clinical setting,
considering that in 2010 the intestinal chronic setting was observed and in the second
query, liver impairment was observed. Also, the presence of nine species of
helminthiases was observed in the two periods, supporting the evidence that
governmental interventions are required regarding population education, basic
sanitation and water treatment for consumption, seeking prevention and control of the
disease.
DECLARATIONS
Presentation Letter
We declare for the intent of publication that the entitled paper: Landless Farmworkers
in Sergipe – Brazil: Assessment on S. mansoni in Epidemiological Queries, it’s
being submitted for exclusivity publication at Infectious Diseases of Poverty. We also
emphasize that the paper is extremely relevant since it’s related to a neglected disease,
considered a big public health issue.
All the related authors approve the paper for publication.
Authors’ Contributions
GGO – Been involved in drafting the manuscript and acquisition of data; AMS – Been
involved in drafting the manuscript and revising critically for important intellectual
content; KCA – Analysis and interpretation of data; RPA – Analysis and interpretation
of data; MBS – Acquisition of data and LBS – Acquisition of data.
All the authors read and approved the final manuscript.
Availability of Data and Materials
The Manuscript’s data were not shared because it is a research with possibilities new
developments. The data will be available after the effective research’s conclusion.
Competing Interest
The authors declare that there have no competing interest.
Approval of the Ethics Committee
This research project was approved by the Research Ethics Committee of the
Universidade Federal de Sergipe -UFS, CAAE – 0081.0.107.000-08.
Consent to Publish
I, _____________________________________________________________,
undersigned, allow the researcher: Genilde Gomes de Oliveira , under the
guidance of the Dr. Ângela Maria da Silva, to develop the research described below:
Landless Farmworkers in Sergipe – Brazil: Assessment on S. mansoni in
Epidemiological Queries. The study will be made in the settlements of the landless
rural workers, located in the southern region of the State of Sergipe
Expected benefits: Contribute with the upkeep of Community Health.
Informations: The participants are guaranteed will be answered about any
question and will be clarified about any doubt associated to the research subjects. And
the aforementioned researcher is committed to provide updated informations got during
the study.
Withdrawal of Consent: The voluntary is free to withdraw you consent of any
moment and leave the study, without harm to voluntary.
Legal Aspect: Prepared in accordance with the guidelines and standards of
research involving humans comply with Resolution nº. 466/2012.
Reliability: The voluntarys will have the right to privacy. The identity (full
names) of the participant will not be released. Yet the voluntarys signed the term of
consent to the results can presented at conferences and publications.
About the indemnity: Don’t have predictables harms in the research results,
nevertheless will have indemnity if necessary.
Aracaju, _____de _____de 200____
_____________________________________
Signature of Research/ Legal Representative.
________________________________________
Signature of Witness
_________________________________________
Signature of Representative about the Study.
Acknowledgements
None
Funding
Financed by authors
List of abbreviations
MST – Movimento de Sem Terras [Landless Workers' Movement]
TF TEST - Three Fecal Test
WHO- World Health Organization
INCRA (Instituto Nacional de Colonização e Reforma Agrária [National Institute for
Colonization and Agrarian Reform]
HU - University Hospital
UFS- Universidade Federal de Sergipe
EPF – Exame Parasitológico de Fezes [Stool pathophysiology test]
S. mansoni - Schistosoma mansoni
ICF - Informed Consent Form
NTD - Neglected Tropical Diseases
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Figure legends
Figure 01: Space Distribution of the MST Settlements by City
LEGEND
Brazil
Sergipe
Southern Region of Sergipe
Settlements