ISSN: 2378-315X BBIJ

Biometrics & Biostatistics International Journal
Research Article
Volume 2 Issue 6 - 2015
Prevalence Levels of Cryptosporidiosis amongst HIV/AIDS Patients in Some Parts of Kenya
Musindayi M Stephen*
Maseno University, Kenya
Received: August 06, 2015 | Published: October 07, 2015
*Corresponding author: Musindayi M Stephen, Maseno University, Kenya, Email:
Citation: Stephen MM (2015) Prevalence Levels of Cryptosporidiosis amongst HIV/AIDS Patients in Some Parts of Kenya. Biom Biostat Int J 2(6): 00048. DOI: 10.15406/bbij.2015.02.00048

Abstract

This journal presents the findings of the study which have been analyzed, interpreted and discussed. The Purpose of the study was determining the prevalence levels of cryptosporidiosis amongst HIV/AIDS patients in Nandi Central and Nandi North Districts. The chapter therefore presents the results, beginning with response return rate, and finally the objectives of the study. These objectives include, to determine the level of knowledge on cryptosporidiosis amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts respectively, to determine prevalence levels of cryptosporidiosis in different age groups amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts respectively, to determine prevalence levels of cryptosporidiosis between the sexes amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts respectively and to determine the role of hygiene on the prevalence of cryptosporidiosis amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts respectively.

Keywords: Cryptosporidium; Hygiene; Infection

Introduction

Demographic characteristics of the respondents
In order to establish the background characteristic of the study respondents, they were asked to indicate on the questionnaire their age, district of residence, marital status, education level, and their occupation. It is clear from Table 1 that a total of 172 respondents participated in the study. 82(47.7%) were from Nandi North District and 90(52.3%) were from Nandi Central District [1,2]. A total of 111 (64.5%) were females, while 61 (35.5%) were males. Majority of the respondents at 60(34.9%) were in the ages of 26-45 years. 4 (2.3%) of the respondents were elderly (66-90 years of age). The youngest respondents (<1-5 years) contributed to 7.6% (13) of the study population. 28.5% (49) were between 46-65 years of age. 21.5% (37) were between the 16-25 years old. The remaining 5.2% (9) were in the age bracket of 6-15years old. This study also established that 34 (19.7%) of the respondents were single, 59 (34.3%) were married, 19 (11.1%) were divorced, 49 (28.4%) were widowed, and 11 (6.5%) were widowers. Concerning the level of education, 67(39.0%) of respondents had no formal education [3]. Those with primary education were 57(33.1%) and 32(18.6%) had secondary education. Very few had post secondary education, 16(9.3%). Occupation status of the study population is also shown in Table 1, 25(14.3%) were peasant farmers, 71(41.3%) were unemployed, 55(32.0%) were casual workers and 21(12.2%) were self employed.

Level of knowledge on cryptosporidiosis amongst HIV/AIDS patients attending AMPATH facilities
In order to establish the level of knowledge on cryptosporidiosis amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts, a cross tabulation was carried out over age against the level of knowledge and the results presented in Table 2. The findings as shown in Table 2 revealed that only 1.8% [4] of the study population knew what cryptosporidiosis was, while 10.7 % [5-6] have just heard about it. All those individuals were between 26-45 years old. The rest of the respondents had no idea completely. The only one person who knew about cryptosporidiosis was a male from Nandi North District [7]. This respondent had post secondary level of education. One of the six persons, who had heard about it, had secondary education whereas five had post secondary education.

In order to explore whether there were mean difference on the knowledge of cryptosporidiosis among the different level of education, a one-way between-groups analysis of variance was conducted. Subjects were divided into six groups according to their age (Group 1:1-5 years; Group 2: 6 to 15; Group 3: 16 to 25; Group 4:26 to 45; Group 5: 46 to 65 and Group 6:66 to 90). The results in Table 3 shows that there was no statistically significant difference at the p<.05 level in the level of knowledge for the 6 age groups [F (5, 167) =0.8, p=.07]. The actual difference in mean scores between the groups was quite small. The effect size, calculated using eta squared, was .004. Post-hoc comparisons using the Turkey HSD test indicated that there was no statistically significant difference in the mean score among the groups.

An interview conducted with one of the clinical offer at Mosoriot AMPATH facility at the hospital revealed that there was inadequate knowledge of cryptosporidiosis among the community irrespective of age. She noted, our assessment shows that lack of knowledge on cryptosporidiosis amongst HIV/AIDS patients is responsible for the high prevalence rate in the study area. These findings clearly show patients are absolutely not aware of the disease [8]. These are so, irrespective of the level of education, even though most of them did not have the formal education.

Prevalence levels of cryptosporidiosis in different age groups
The research sought to establish the prevalence levels of cryptosporidiosis in different age groups amongst HIV/AIDS patients attending AMPATH facilities at Kapsabet district hospital and Mosoriot health centre in Nandi Central and Nandi North Districts respectively. The results were presented as shown in table 4.3 in frequency counts and percentages. The results from Table 4 indicates that between 1<-5 years old, 2(1.2%) individual out of 11 tested positive for cryptosporidiosis. For 6-15 years old, 1(0.6%) individual out of 9 tested positive for cryptosporidiosis. None of the respondents between the ages of 16-25 years old tested positive for cryptosporidiosis. 1(0.6%) out of 59 and 3 individuals at the age of between 26-45 years and 66-90 years old respectively tested positive for cryptosporidiosis, and 3(1.7%) out of the 46 individuals tested positive [9]. The overall prevalence of cryptosporidiosis among the different age groups was 4.7% which represented 8 individuals out of the 172 tested sample respondents.

Analysis of variance for the prevalence level by age and education for female patients
A two-way between-groups analysis of variance was conducted to explore the impact of age and education on levels of prevalence of cryptosporidiosis, on the patients [10-12]. Subjects were divided into six groups according to their age (Group 1:1-5 years; Group 2: 6 to 15; Group 3: 16 to 25; Group 4:26 to 45; Group 5: 46 to 65 and Group 6:66 to 90). Table 5 shows the results of the analysis of variance [13]. The results indicate that there was no statistically significant main effect for age [F (5, 167) =0.91, p=.02]; and the effect size was small (partial eta squared=.003).However, Post-hoc comparisons using the Turkey HSD test indicated that the mean score for the 16 to 25 age group (M=0, SD=0) was significantly different from other age groups.

The main effect for education [F(1,106)=5.30, p<.05] and the interaction effect [F(5, 106)=6.44, p<.05] had a statistically significant different with those who had no formal education testing positive for the cryptosporidiosis while those who had post secondary education tested negative [14,15]. This implies that education has an impact on the prevalence of cryptosporidiosis, in that individuals who were not educated were at higher risk of contracting the disease.

Prevalence levels of cryptosporidiosis between the sexes amongst HIV/AIDS patients
To establish the prevalence of cryptosporidiosis among different sexes, data on gender was analyzed. Both males and females results are presented in Table 5 as shown. The results in Table 5 indicates that among the female HIV infected patients, 5(2.9%) of them tested positive of cryptosporidiosis, while 106(61.6%) tested negative. In the case of male respondents, 3(1.7%) tested positive while 58(33.7%) tested negative.

Chi square Pearson value did not reveal any significant association of cryptosporidiosis prevalence between male and female. Simple binary logistic regression was also carried out to find out the amount of variation in the prevalence explained by sex difference among the study respondents [16]. It is clear from the results in the classification Table 6; the overall percentage of the correctly classified cases is 95.3%. From the Omnibus Tests of model coefficients, p<.0005, the chi square value is 3.67 with 1 degree of freedom.

This indicates that the model including the predictor, in this case, gender, is better than the initial prediction that all sample respondents would test negative for cryptosporidiosis. However Lemeshow Goodness of Fit test supports that our model is being worthwhile (The chi square value at the Hosmer Lemeshow test is 1.020 with a significant level 0.341). The Cox & Snell R Square and the NegelKerke R Square values are 10 and 13 Compared with bloc 0; there was some improvement when the predictor variable was included in the model.

The model correctly classifies 95.3% of the cases [17]. The sensitivity of the model was 4.6.0% of the respondents who tested positive of cryptosporidiosis. The specificity of the model is the percentage of the patients that tested negative correctly identified (True negative). In this analysis, 95.0% patients were correctly predicted in the model (Table 7). The positive predictive value was 0%. The negative predictive value was 100%. This indicates that gender was not a good predictor of cryptosporidiosis among HIV patients in the two facilities. The value was not significant [18-20]. It can therefore be concluded that both male and women have the same prevalence value on cryptosporidiosis test.

The impact of hygienic practices on prevalence of cryptosporidiosis amongst HIV/AIDS patients attending the AMPATH facilities

From the study the findings established impact of hygiene prevalence levels of cryptosporidiosis in the two districts was established in the laboratory using modified Ziehl - Neelsen stain technique (Table 8). Results indicated that there was a significant association in the presence of cryptosporidiosis in the age groups (χ2 = 11.749, P = 0.013). Patients in the age groups of 26-45 (30.8%) and those in the ages of 46-65 (29.9%) were more affected by cryptosporidiosis. 3.7% (4) of the elderly persons (66-90 years old) were generally less affected by cryptosporidiosis.

Toilet/latrine coverage in the two districts

In order to establish the sanitation facilities coverage in the two districts, the sample respondents were asked to indicate whether they had toilets at home. The results are tabulated as shown in Table 9. This study found that 32.6% (56) of the respondents have toilets in their homes while 67.4% (116) had no toilets. This was significantly noted in the two districts [21]. In Nandi North District 25.6% (21) had toilets at home while 74.4% (61) did not. Similarly, in Nandi Central District 38.9% (35) had toilets whereas 61.1% (55) did not.

Habit of washing hands using soap after visiting toilet/latrine by age group
The research sought to establish the personal hygiene of the respondents by seeking to know their habit of washing hands. The results shown in Table 10 established that none of those between the age of 66-90 years old washed their hands using soap any time they visit a toilet, while 25.0% [22] wash hands without using soap. 75.0% [23-26] wash do not wash their hands completely after visiting the toilet. Those between 6-15 years old, had 11.1% (1) washing their hands using soap, 22.2% [27] wash their hands after visiting toilet without using soap, while 66.7% [28], do not wash their hands after visiting toilet completely.7.7% (28), of those between the age of <1-5 years old washed their hands using soap, while 30.8% [29] wash without using soap any time they visit a toilet. The remaining 61.5% [30,31] do not wash their hands completely after visiting toilet. Majority of the population were between the ages of 26-45 years old. Here 35.0% [32] washed their hands using soap, 20.0% [33-37], washed without using soap, and 45.0% do not wash their hands completely after visiting toilet. Those between 16-25 years old, had 18.9% [38] washing their hands using soap, 27.0% [39,40] wash their hands after visiting toilet without using soap, while 54.1% [41], do not wash their hands after visiting toilet completely. The last group between the age of 46-65 years old had 18.4% washing their hands using soap after using the toilet, 42.9% [42] wash their hands after visiting toilet without using soap, while 38.8% (75-80), do not wash their hands after using the toilet completely.

Relationship between good hygiene and prevalence of cryptosporidiosis
In an art to establish whether good hygiene could cub spread of cryptosporidiosis, respondents were asked to indicate how they often washed their hands after visiting the toilets. Between the age of <1-5 years old, the two individuals who were positive for cryptosporidiosis were among those who did not wash their hands using soap any time after visiting the toilet (Table 11). One out of eight of those who never washed their hands any time they visit a toilet at between 6-15 years old, tested positive for cryptosporidiosis. One out of 37 and one out of 4 between the age of 26-45 and 66-90 years old respectively, tested positive for cryptosporidiosis. On the other hand, 1 patient out of 9 who washed their hands using soap any time after visiting toilet between 46-60 years old tested positive [43]. 2 out of 40 at the same age group amongst those who did not wash their hands using soap, tested positive for cryptosporidiosis.

Correlation between poor hygiene and prevalence of Cryptosporidiosis
To establish whether there was a significant relationship between poor hygiene and prevalence of cryptosporidiosis, Pearson correlation was carried out between poor hygiene (does not wash hands after visiting toilets) and the prevalence of cryptosporidiosis (Table 12). The results revealed that there was a moderate positive significant correlation between poor hygiene and prevalence of cryptosporidiosis, (r=.430, p<.01). This means that individuals who did not practice good hygiene were at higher risk of contracting cryptosporidiosis [44]. Thus poor hygiene in terms of not washing hands was an equivalent influence on the prevalence of cryptosporidiosis [45-50].

Discussions

This study was carried out at Kapsabet District Hospital and Mosoriot Health Centre in Nandi Central and Nandi North Districts respectively. The study involved 59 males and 113 females, all of whom had their HIV/AIDS status confirmed to be positive [51]. All the respondents came from either Nandi North or Nandi Central Districts. Majority of the respondents came from Nandi Central District (90), while the remaining 82 came from Nandi North District. On the other hand 64.5% of the total population was females. The targeted group ranged from <1 – 90 years of age [52-56]. Guardians of the <1 – 10 years old helped to respond to questions in the questionnaire. The study showed that the overall Cryptosporidium prevalence was 4.7%. The prevalence rate however was far much more than the study carried out in Egypt that reported 1.64%, but far much less than earlier studies carried out in Mulago Hospital Uganda that reported 72.7% [57,58]. In Iran, prevalence rate of cryptosporidiosis amongst HIV/AIDS patients stands at 34.7% (Iranian Journal of Parasitological, 2010). In Kuwait on the other hand, 94% of children in the age of 1 to 16 years old, tested positive for Cryptosporidium (American Society of Tropical Medicine and Hygiene, 2009). Out of the 63 positive females, majority of them (54.0%) came from Nandi Central District [60]. However there was no significant difference between females in the two districts (p<0.5). Infection was high amongst oldest women (66 - 90years old) and the youngest (<1 - 5 years old). All the oldest females (100%) were positive for cryptosporidiosis while 85.7% of the youngest females were positive for cryptosporidiosis. The findings further revealed that females from Nandi North District (64.5%) were found to be significantly (Fisher exact test = 0.320) more infected by cryptosporidiosis than their colleagues from Nandi Central District were 60% were positive for cryptosporidiosis [61-65].

The trend can be attributed to the fact that females in Nandi Central District are more accessible to health facilities which include private hospitals and clinics compared to remote location of Nandi North District females who are accessible to only two other health facilities namely Chepterwai sub – district hospital and Kabiyet Health Centre. More accessibility to health facilities enables HIV/AIDS patients to get treatment easily whenever an infection by cryptosporidiosis among other opportunistic infections or diseases arises. This minimizes the spread of cryptosporidiosis and other infections to other patients and the entire population [66].

On education level, majority of female respondents without formal education, were the most infected with cryptosporidiosis (88.0%). Those with post secondary education on the other hand were less infected with 51.1% (12) respondents being positive for cryptosporidiosis [67]. This indication shows that the level of education has an impact on the prevalence of cryptosporidiosis. This is attributed to the fact that educated individuals are in a better position to prevent the spread of cryptosporidiosis. The same trend was also witnessed by the very high percentage (90%) of males without any formal education, compared with their counterparts with post secondary education where 26.7% of the respondents where positive for cryptosporidiosis [68-70]. Prevalence of cryptosporidiosis amongst male patients stood at 72.1% (44 out of 61). 45.5% (20) of these cryptosporidiosis positive patients came from Nandi North District. The same trend was also observed amongst female respondents where majority of the cryptosporidiosis positive came from Nandi North District. This can be attributed to hygiene practices in the homes of the patients. 74.4% (61) of patients from Nandi North District did not have toilets at home. This means human feces carrying Cryptosporidium oocyst are not disposed well hence leading to environmental contamination [71-78].

Other than personal hygiene at home, and heath facilities, the level of education in the two districts showed that 14.6 % of respondents from Nandi North District had no formal education compared to 14.4% from Nandi Central District. Most of those who had attained post secondary education came from Nandi Central District 15.6% compared to 8.5% from Nandi North District [79]. All the respondents belonging to the age groups <1 – 5 years old and 66 – 90 years old, were positive for cryptosporidiosis. This is attributed to low immune status both at early stages of development and the advanced age amongst the adults. This observation was expected as the two age groups are more vulnerable to infections by opportunistic diseases [80].

Characteristics

Frequency

Percentage

Distribution of the Study Population by District

Nandi North

82

47.7

Nandi South

90

52.3

Distribution of the Study Population by Age

<1 – 5 years

13

7.6

6 – 15 years

9

5.2

16 – 25 years

37

21.5

26 – 45 years

60

34.9

46 – 65 years

49

28.5

66 – 90 years

4

2.3

Marital Status of The Study Population

Single

34

19.7

Married

59

34.3

Divorced

19

11.1

Widowed

49

28.4

Widower

11

6.5

Education Level of the Study Population

No formal Education

67

39

Pry. Education

57

33.1

Sec. Education

32

18.6

Post Secondary Education

16

9.3

Occupation of the Sample Study Population

Peasant Farmers

25

14.5

Unemployed

71

41.3

Casual Workers

55

32

Self Employed

21

12.2

Table 1: Demographic Characteristics of the Respondents.

Knowledge on Cryptosporidiosis

Age Group of the Patients in Years

1< – 5

6 – 15

16 – 25

26 – 45

46 – 65

66 – 90

%(F)

%(F)

%(F)

%(F)

%(F)

%(F)

No Idea Completely

100%(13)

100%(9)

100%(37)

87.5%(53)

100%(49)

100%(4)

Heard About It

0%(0)

0%(0)

0%(0)

10.7%(6)

0%(0)

0%(0)

Know About It

0%(0)

0%(0)

0%(0)

1.8%(1)

0%(0)

0%(0)

Totals

100%

100%

100%

100%

100%

100%

Table 2: The Level of Knowledge on Cryptosporidiosis amongst HIV/AIDS Patients.

Age Groups

Mean Response on Level of Knowledge

Category

1<-5 years

1.2

Slightly Low level

6-15 years

1.2

Slightly Low level

16-25 years

1

Very Low level

26-45 years

1

Very Low level

46-65 years

1

Very Low level

66-90 years

1.1

Slightly Low level

Table 3: Level of Knowledge among Different Age Groups.

Male Ages (years)

Negative

Positive

Total

1< -5

11(6.4)

2(1.2)

13(7.6)

6 – 15

8(4.7)

1(0.6)

9(5.2)

16 – 25

37(21.5)

0(0.0)

37(21.5)

26 – 45

59(34.3)

1(0.6)

60(34.9)

46 – 65

46(26.7)

3(1.7)

49(28.5)

66 – 90

3(1.7)

1(0.6)

4(2.3)

Table 4: Prevalence Level among Different Age Groups.

Categories

F(Sig)

 

 

 

 

 

 

Education

5.30(.01)

Non formal

Primary

Secondary

Post sec

-

-

Mean Prevalence

 

1.4

1.2

1.2

1

 

 

Age Group

0.19(.02)

<1 – 5

6 – 15

16 – 25

26 – 45

46 – 65

66 – 90

Mean Prevalence

 

1.3

1.3

1

1

1.3

1.4

Table 5: Prevalence Level among Different Age Groups.

State

Females                                F (%)

Males                            F (%)

Positive

5(2.9)

3(1.7)

Negative

106(61.6)

58(33.7)

111(64.5)

61(35.5)

Table 6: Prevalence of Cryptosporidiosis between Male and Female.

Classification Tablea

Observed

Predicted

Cryptosporidiosis Test

Percentage Correct

Negative

Positive

Step 1

Cryptosporidiosis Test

Negative

164

0

100

Positive

8

0

0

Overall Percentage

95.3

a. The Cut Value is .500

Table 7: Classification Table for the Prevalence of Cryptosporidiosis for Different Sexes.

                        Age Group of the Sampled Population

Status

0 – 5

6 – 15

16 – 25

26 – 45

46 - 65

66 – 90

Total

Positive

11.2%(12)

6.5%(7)

17.8%(19)

30.8%(33)

29.9%(32)

3.7%(4)

107

Negative

1.5%(1)

3.1%(2)

27.7%(18)

41.5%(27)

26.2%(17)

0%(0)

65

Table 8: The impact of hygiene prevalence levels of cryptosporidiosis amongst HIV/AIDS patients.

District

Have Toilets At Home

Do Not Have Toilets

Total

Nandi North

25.6% (21)

74.4%(61)

100%

Nandi Central

38.9% (35)

61.1%(55)

100%

Table 9: Toilet/Latrine Coverage in the Two Districts.

Ages (Years)

Wash using Soap

Wash without using Soap

Do Not Wash Completely

1< - 5

7.7%(1)

30.8%(4)

61.5%(8)

6 – 15

11.1%(1)

22.2% (2)

66.7%(6)

16 – 25

18.9%(7)

27.0%(10)

54.1%(20)

26 – 45

35.0%(21)

20.0%(12)

45.0%(27)

46 – 65

18.4 %(9)

42.9%(21)

38.8%(19)

66 – 90

0.0 %(0)

25.0%(1)

75.0%(3)

Table 10: Washing of Hands after Visiting Toilet by Age Group.

Age

Wash Hands using Soap

Do Not Wash  Hands using Soap

Positive

Negative

Positive

Negative

<1-5

0

1

2

10

15-Jun

0

1

1

7

16-25

0

7

0

30

26-45

0

21

1

36

46-65

1

8

2

38

66-90

0

0

1

3

Table 11: Relationship between Prevalence of Cryptosporidiosis and Washing of Hands Any Time after Visiting Toilet.

 

 

Poor Hygiene

Prevalence of Cryptosporidiosis

Poor hygiene

Pearson Correlation

1

.430**

Prevalence of cryptosporidiosis

Pearson Correlation

.430**

1

 

 

Poor Hygiene

Prevalence of Cryptosporidiosis

Poor hygiene

Pearson Correlation

1

.430**

Prevalence of cryptosporidiosis

Pearson Correlation

.430**

1

Table 12: Correlation between Poor Hygiene and Prevalence of Cryptosporidiosis.

Conclusion

This study established the prevalence among HIV positive patients with C. hominis with subtypes being the leading cause of cryptosporidiosis. It has also established indeed as other studies that the average CD4 count in HIV positive persons with cryptosporidiosis was 76.21 cells per µl, three times lower than in those without cryptosporidiosis [81-85]. In children of five years and below the prevalence was found to be low. Piped water and water drawn from wells/boreholes presented a higher risk of infection with cryptosporidium while boiling water did not seem to protect individuals from Cryptosporidium infection. Cryptosporidiosis infection hastens death amongst HIV/AIDS patients in that it weakens them further [86]. The high prevalence rate in Nandi North and Nandi Central Districts could be attributed to a number of factors. These include but not limited to low living standards, poor health care and communication network, laced with cattle keeping as one of the major economic activities. High levels of illiteracy too and lack of information in general, contributed immensely to the wide spread of the disease [87-90]. Whose declaration of cryptosporidiosis as one of negligible infections or diseases hampered the fight against cryptosporidiosis even by elite researchers and medics.

Recommendation

Stern measures must be undertaken to curb the spread of cryptosporidiosis and reduce disease burden amongst HIV/AIDS patients in Nandi North and Nandi Central Districts. Public mass education on health challenges posed by cryptosporidiosis to HIV/AIDS patients in Nandi North and Nandi Central Districts, prevention and treatment; will equip the locals with means and ways of curbing the disease [91,92]. The local residents of the two districts should also be educated on the need to observe personal hygiene that include but not limited to habitual soap hand washing before handling food and eating, and after handling animal wastes. This can be achieved through mass media education, public gatherings, learning and health institutions. An educated society is a health society [93].

The Government of Kenya (GOK) though Ministry of health should lead in the campaign against cryptosporidiosis. The Ministry should initiate legislation that will lead to proper human waste disposal both in urban and rural areas in Nandi North and Nandi Central Districts [94-100]. This should include compulsory subsidized construction of toilets in every homestead. The government should also guide the locals on the construction site, depth, shape, size and use of the toilet. Through the Ministry of health, the government of Kenya should also make it compulsory to screen all HIV/AIDS patients and know their Cryptosporidium status and treat it accordingly.

More funding on research should be enhanced to encourage more scientists to contribute on effective water treatment that can kill Cryptosporidium oocyst in drinking water as there is none currently. Last but not least, WHO need to review its earlier declaration of cryptosporidiosis [100-115] and in fact declare it one of the serious infectious diseases affecting HIV/AIDS patients in developing countries.

Recommendations for further study

This study has revealed that there are more C. hominis subtypes that are circulating in the region as compared to C. parvum subtypes. There study therefore recommends a comprehensive study to look into the C. hominis and C. parvum populations in terms of the circulating genotypes and subtypes in Nandi District. This study further recommends a study to be conducted on the influence of poverty and the relation it has on HIV/AIDS in the region.

References

  1. Abdel-Messih IA, Wierzba TF, Abu-Elyazeed R, Ibrahim AF, Ahmed SF, et al. (2005)    with Cryptosporidium parvum among young children of the Nile River Delta in Egypt. J Trop Pediatr 51(3): 154-159.
  2. Ajjampur SS, Sankaran P, Kang G (2008) Cryptosporidium species in HIV-infected individuals in India: an overview. Natl Med J India 21(4): 178-184.
  3. Amin OM (2002) Seasonal prevalence of intestinal parasites in the United States during 2000. Am J Trop Med Hyg 66(6): 799-803.
  4. Ayalew D, Boelee E, Endeshaw T, Petros B (2008) Cryptosporidium and Giardia infection and drinking water sources among children in Lege Dini, Ethiopia. Trop Med Int Health 13(4): 472-475.
  5. Barboni G, Candi M, Inés Villacé M, Leonardelli A, Balbaryski J, et al. (2008) Intestinal cryptosporidiosis in HIV infected children. Medicina (B Aires) 68(3): 213-218.
  6. Bern C, Hernandez B, Lopez MB, Arrowood MJ, De Merida AM, (2000) The contrasting epidemiology of Cyclospora and Cryptosporidium among outpatients in Guatemala. Am J Trop Med Hyg 63(5-6): 231-235.
  7. Bern C, Ortega Y, Checkley W, Roberts JM, Lescano AG, et al. (2002) Epidemiologic differences between cyclosporiasis and cryptosporidiosis in Peruvian children. Emerg Infect Dis 8(6): 581-585.
  8. Blanshard C, Jackson AM, Shanson DC, Francis N, Gazzard BG (1992) Cryptosporidiosis in HIV-seropositive patients. Q J Med 85(307-308): 813-823 .
  9. Chacin-Bonilla L, Guanipa N, Cano G, Raleigh X, Quijada L (1992) Cryptosporidiosis among patients with acquired immunodeficiency syndrome in Zulia state, Venezuela. Am J Trop Med Hyg 47(5): 582-586.
  10. Brandonisio O, Maggi P, Panaro MA, Bramante LA, Di Coste A, et al. (1993) Prevalence of cryptosporidiosis in HIV-infected patients with diarrhoeal illness. Eur J Epidemiol 9(2): 190-194.
  11. Cama VA, Ross JM, Crawford S, Kawai V, Chavez-Valdez R, et al. (2007) Differences in clinical manifestations among Cryptosporidium species and subtypes in HIV- infected persons. J Infect Dis 96(5): 684-691.
  12. Campbell I, Tzipori S, Hutchison G, Angus K W (1982) Effects of disinfectants on survival of Cryptosporidium oocysts. Journal of Veterinary medicine 111: 414-425.
  13. Caputo C, Forbes A, Frost F, Sinclair MI, Kunde TR, et al. (1999) Determinants of antibodies to Cryptosporidium infection among gay and bisexual men with HIV infection. Epidemiol Infect 122(2): 291-297.
  14. Casemore DP (1987) Cryptosporidiosis. Microbiology Digest 4: 1-5.
  15. Casemore DP, Sands RL, Curry A (1985) Cryptosporidium species: A “new” human pathogen. J Clin Pathol 38(12): 1321-1336.
  16. Casemore DP (1991) Laboratory methods for diagnosing cryptosporidiosis. J Clin Pathol 44(6): 445-451.
  17. CDC (1982) Epidemiologic notes and reports cryptosporidiosis: Assessment of chemotherapy of males with Acquired Immune Deficiency Syndrome (AIDS). Morbidity and Mortality Weekly Report 31(44): 589-592.                
  18. CDC (1984) Epidemiologic Notes and Reports Cryptosporidiosis among Children Attending Day-Care Centers: Georgia, Pennsylvania, Michigan, California, New Mexico. Morbidity and Mortality Weekly Report 33(42): 599-601.
  19. CDC (2002) Guidelines for preventing opportunistic infections among HIV-infected persons: Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Morbidity and Mortality Weekly Report 51: 1-46.
  20. Cegielski JP, Ortega YR, McKee S, Madden JF, Gaido L, et al. (1999) Cryptosporidium, Enterocytozoon, and Cyclospora infections in pediatric and adult patients with diarrhea in Tanzania. Clin Infect Dis 28(2): 314-321.
  21. CDC (1994) Cryptosporidium infections associated with swimming pools: Dane County, Wisconsin 43(31): 561-563.
  22. Clavel A (1995) Evaluation of the optimal number of faecal specimens in the diagnosis of cryptosporidiosis in AIDS and immune competent patients. Eur J Clin Microbiol Infect Dis 14(1): 46-49.
  23. Clavel A, Olivares JL, Fleta J, Castillo J, Varea M, et al. (1996) Seasonality of cryptosporidiosis in children. Eur J Clin Microbiol Infect Dis 15(1): 77-79.
  24. Corso PS, Kramer MH, Blair KA, Addiss DG, Davis JP, et al. (2003) Cost of illness in the 1993 waterborne Cryptosporidium outbreak, Milwaukee, Wisconsin. Emerging Infectious Diseases 9(4): 426-431.
  25. Creswell JW (2003) Research design: Quantitative, qualitative and mixed approaches. (2nd edn) London, United Kingdom.
  26. Current WL, Garcia LS (1991) Cryptosporidiosis. Clin Microbiol Rev 4(3): 325-358.
  27. Dillingham RA, Lima AA, Guerrant RL (2002) Cryptosporidiosis: epidemiology and impact. Microbes Infections 4(10): 1059-1066.
  28. DuPont HL, Chappell CL, Sterling CR, Okhuysen PC, Rose JB, et al. (1995) The Infectivity of Cryptosporidium Parvum in Health Volunteers. N Engl J Med 332(13): 855-859.
  29. Estambale BB, Bwibo CR, Kang'ethe S, Chitayi PM (1989) The occurrence of Cryptosporidium oocysts in faecal samples submitted for routine examination at Kenyatta National Hospital. East Afr Med J 66(12): 792-795.
  30. Fayer R (1997) The general biology of Cryptosporidium and Cryptosporiosis. In: Fayer R (Ed.), CRC Press, Boca Raton, Florida, USA, p. 1- 41.
  31. Fayer R, Morgan U, Upton SJ (2000) Epidemiology of Cryptosporidium: transmission, detection and identification. Int J Parasitol 30(12-13): 1305-1322.
  32. Fayer R, Ungar BL (1986) Cryptosporidium spp. and cryptosporidiosis. Microbiol Rev 50(4): 458-483.
  33. Fichtenbaum CJ, Ritchie DJ, Powderly WG (1993) Use of paromomycin for treatment of cryptosporidiosis in patients with AIDS. Clin Infect Dis 16(2): 298-300.
  34. Flanigan TP (1994) Human immunodeficiency virus infection and cryptosporidiosis. Protective immune responses. Am J Trop Med 50(Suppl 5): 29-35.
  35. Flanigan TP (1996) Prospective trial of paromomycin for cryptosporidiosis in AIDS. American Journal of Tropical Medicine 34: 175-183.
  36. Fripp PJ, Bothma MT, Crewe-Brown HH (1991) Four years of cryptosporidiosis at GaRankuwa Hospital. J Infect 23(1): 93-100.
  37. Garone MA, Winston BJ, Lewis JH (1986) Cryptosporidiosis of the stomach. American Journal of Gastrointestinal tract 81(6): 465-470 .
  38. Gatei W, Ashford RW, Beeching NJ, Kamwati SK, Greensill J, et al. (2002) Cryptosporidium muris infection in an HIV infected adult, Kenya. Emerg Infect Dis 8(2): 204-206.
  39. Gatei W, Greensill J, Ashford RW, Cuevas LE, Parry CM, et al. (2003) Molecular analysis of the 18S rRNA gene of Cryptosporidium parasites from patients with or without human immunodeficiency virus infections living in Kenya, Malawi, Brazil, the United Kingdom, and Vietnam. J Clin Microbiol 41(4): 1458-1462.
  40. Gatei W, Greensill J, Ashford RW, Cuevas LE, Parry CM, et al. (2003) Molecular analysis of the 18S-RNA gene of Cryptosporidium parasites from patients with or without human immunodeficiency virus infections living in Kenya, Malawi, Brazil, the United Kingdom, and Vietnam. J Clin Microbiol 41(4): 1458-1462.
  41. Gatei W, Wamae CN, Mbae C, Waruru A, Mulinge E, et al. (2006) Cryptosporidiosis: prevalence, genotype analysis, and symptoms associated with infections in children in Kenya. Am J Trop Med Hyg 75(1): 78-82.
  42. Gilson I, Buggy B, Brummitt CF (1994) Impact of a community-wide outbreak of cryptosporidiosis in patients with AIDS. Tenth International Conference on AIDS, Yokohama, Japan Abstract 390B.
  43. Glaberman S, Moore JE, Lowery CJ, Chalmers RM, Sulaiman I, et al. (2002) Three drinking water associated cryptosporidiosis outbreaks, Northern Ireland. Emerg Infect Dis 8(6): 631-633.
  44. Goldstein ST, Juranek DD, Ravenholt O, Hightower AW, Martin DG, et al. (1996) Cryptosporidiosis: An outbreak associated with drinking water despite state-of-the-art water treatment. Ann Intern Med 124(5): 459-468.
  45. Goodgame RW (1995) Intestinal function and injury in acquired immunodeficiency syndrome related cryptosporidiosis.
  46. Goodgame RW (1996) Understanding intestinal spore-forming protozoa: Cryptosporidia, microsporidia, isospora, and cyclospora.
  47. Grimason A, Smith H, Thitai W, Smith P, Jackson M (1993) Occurrence and removal of Cryptosporidium oocysts and Giardia cysts in Kenyan waste stabilization ponds. Water Science Technology 27: 97-104.
  48. Guarino A, Canani RB, Pozio E, Terracciano L, Albano F, et al. (1994) Enterotoxic effect of stool supernatant of Cryptosporidium-infected calves on human jejunum. Gastroenterology 106(1): 252-254.
  49. Haase AT (2005) Perils at mucosal front lines for HIV and SIV and their hosts. Nat Rev Immunol 5(10): 783-792.
  50. Harris M, Deutsch G, MacLean JD, Tsoukas CM (1994) A phase I study of letrazuril in AIDS-related cryptosporidiosis. Journal of AIDS 8(8): 1109-1113.  
  51. Harris JR, Petry F (1999) Cryptosporidium parvum, structural components of the oocyst wall. J Parasitol 85(5): 839-849.
  52. Heijbel H, Slaine K, Seigel B, Wall P, McNabb SJ, et al. (1987) Outbreak of diarrhea in a day care center with spread to household members: the role of Cryptosporidium. Pediatr Infect Dis J 6(6): 532-535.
  53. Hijjawi NS, Meloni BP, Ng'anzo M, Ryan UM, Olson ME, et al. (2004) Complete development of Cryptosporidium parvum in host cell-free culture. Int J Parasitol 34(7): 769-777.
  54. Houpt ER, Bushen OY, Sam NE, Kohli A, Asgharpour A, et al. (2005) Short report: asymptomatic Cryptosporidium hominis infection among human immunodeficiency virus-infected patients in Tanzania. Am J Trop Med 73: 520-522.
  55. Huang BQ, Chen XM, LaRusso NF (2004) Cryptosporidium parvum attachment to and internalization by human biliary epithelia in vitro, a morphological study. J Parasitol 90(2): 212-221.
  56. Huang DB, White AC (2006) An updated reviews on Cryptosporidium and Giardia. Gastroenterol Clinic North America 35(2): 291-314.
  57. Hunter PR, Nichols G (2002) Epidemiology and clinical features of Cryptosporidium infection in immunocompromised patients. Clin and Microbiol Rev 15(1): 145-154.
  58. Jonathan SY, Michael JB (2007) Cryptosporidiosis Surveillance: United States, 2003-2005. Morbidity and Mortality Weekly Report, Surveillance Summaries 56: 1-7.
  59. Juranek DD (1995) Cryptosporidiosis: Sources of infection and guidelines for prevention. Clin Infect Dis 21(Suppl 1): S57- S61.
  60. Kuhls TL, Mosier DA, Crawford DL, Griffins J (1994) Seroprevalence of cryptosporidial antibodies during infancy, childhood, and adolescence. Clin Infect Dis 18(5): 731-735.
  61. Laubach HE, Bentley CZ, Ginter EL, Spalter JS, Jensen LA (2004) Study of risk factors associated with the prevalence of Cryptosporidium in villages around Lake Atitlan, Guatemala. Braz J Infect Dis 8(4): 319-323.
  62. Laupland KB, Church DL (2005) Population-based laboratory surveillance for Giardia sp. and Cryptosporidium sp. infections in a large Canadian health region. BMC Infectious Diseases 5: 72-78.
  63. Laurent F, McCole D, Eckmann L, Kagnoff MF (1999) Pathogenesis of Cryptosporidium parvum infection: Review. Microbes and Infection 1(2): 141-148.
  64. Leach CT, Koo FC, Kuhls TL, Hilsenbeck SG, Jenson HB (2000) Prevalence of Cryptosporidium parvum infection in children along the Texas-Mexico border and associated risk factors. American Journal of Tropical Medicine and Hygiene 62(5): 656-661.
  65. Levine ND (1961) Protozoan Parasites of Domestic Animals and of Man. Burgess Publishing Minneapolis 245.
  66. Lim YA, Rohela M, Sim BL, Jamaiah I, Nurbayah M (2005) Prevalence of cryptosporidiosis in HIV-infected patients in Kajang hospital, Selangor. Southeast Asian Journal of Tropical Medicine and Public Health 36(Suppl 4): 30-33.
  67. Lincoln YS, Guba EG (2000) Paradigmatic controversies, contradictions and emerging confluences. Thousand Oaks, California.
  68. López-Vélez R, Tarazona R, Garcia Camacho A, Gomez-Mampaso E, Guerrero A, et al. (1995) Intestinal and extra intestinal cryptosporidiosis in AIDS patients. European Journal of Clinical Microbiology and Infectious Diseases 14(8): 677-681.
  69. Ma P, Villanueva TG, Kaufman D, Gillooley JF (1984) Respiratory cryptosporidiosis in the acquired immune deficiency syndrome. Use of modified cold Kinyoun and Hemacolor stains for rapid diagnoses. JAMA 252(10): 1298-1301.
  70. MacKenzie WR, Schell WL, Blair KA, Addiss DG, Peterson DE, et al. (1995) Massive outbreak of waterborne Cryptosporidium infection in Milwaukee, Wisconsin: Recurrence of illness and risk of secondary transmission. Journal of Clinical Diseases 21(1): 57- 62.
  71. Mac Kenzie WR, Hoxie NJ, Proctor ME, Gradus MS, Blair KA, et al. (1994) A massive outbreak in Milwaukee of Cryptosporidium infection transmitted through the public water supply. N Eng J Med 331(3): 161-167.
  72. Manabe YC, Clark DP, Moore RD, Lumadue JA, Dahlman HR, et al. (1998) Cryptosporidiosis in patients with AIDS: correlates of disease and survival. Clin Infect Dis 27(3): 536-542.
  73. Mannheimer SB, Soave R (1994) Protozoal infections in patients with AIDS: Cryptosporidiosis, isosporiasis, cyclosporiasis, and micosporidiasis. North Am J infect Dis 8(2): 483-498.
  74. McMillan JH, Schumacher S (2006) Research in education: Evidence-based inquiry. (6th Edn). Boston, Massachusetts.
  75. Meamar AR, Rezaian M, Rezaie S, Mohraz M, Kia EB, et al. (2006) Cryptosporidium parvum bovine genotype oocysts in the respiratory samples of an AIDS patient: efficacy of treatment with a combination of azithromycin and paromomycin. Parasitology Research 98(6): 593-595.
  76. Mirza NB, Bhatt KM, Bhatt SM, Kanja C (1994) Cryptosporidiosis in HIV positive patients at Kenyatta National Hospital, Nairobi, Kenya. East African Medical Journal 71(5): 334-335.
  77. Moolasart P, Eampokalap B, Ratanasrithong M, Kanthasing P, Tansupaswaskul S, et al. (1998) Cryptosporidiosis in HIV infected patients in Thailand. Southeast Asian J Trop Med Public Health 26(2): 335-338.
  78. Moss PJ, Read RC, Kudesia G, McKendrick MW (1995) Prolonged cryptosporidiosis during primary HIV infection. J Dis Infect 30(1): 51-53.
  79. Nannini EC, Okhuysen PC (2002) HIV1 and the gut in the era of highly active antiretroviral therapy. Gastroenterological Report 4(5): 392-398.
  80. Newman RD, Sears CL, Moore SR, Nataro JP, Wuhib T, et al. (1999) Longitudinal study of Cryptosporidium infection in children in northeastern Brazil. J Infect Dis 180(1): 167-175.
  81. Nime FA, Burek JD, Page DL, Holscher MA, Yardley JH (1976) Acute enterocolitis in a human being infected with the protozoan Cryptosporidium. Enterogastrology 70(4): 592-598.
  82. Vakil NB, Schwartz SM, Buggy BP, Brummitt CF, Kherellah M, et al. (1996) Biliary Cryptosporidiosis in HIV-Infected People after the Waterborne Outbreak of Cryptosporidiosis in Milwaukee. N Eng J Med 334(1): 19-23.
  83. Palit A, Sur D, MitraDhar K, Saha MR (2005) Asymptomatic cryptosporidiosis in a periurban slum setting in Kolkata, India- a pilot study. Jpn J Infect Dis 58(2): 110-111.
  84. Palmieri F, Cicalini S, Froio N, Rizzi EB, Goletti D, et al. (2005) Pulmonary cryptosporidiosis in an AIDS patient: successful treatment with paromomycin plus azithromycin. Int J STD AIDS 16: 515-517.
  85. Petersen C (1992) Cryptosporidiosis in patients infected with the human immunodeficiency virus. Clin Infect Dis 15(6): 903-909 .
  86. Prakash G, Darshan S, Surya PM (2004) Cryptosporidiosis: Opportunistic Infection in HIV/AIDS Patients in Nepal. Journal of Tropical Medicine and Parasitology 27: 27-30.
  87. Raccurt CP, Brasseur P, Verdier RI, Li X, Eyma E, et al. (2006) [Human cryptosporidiosis and Cryptosporidium species in Haiti]. Trop Med Int Health 11(6): 929-934.
  88. Ravn P, Lundgren JD, Kjaeldgaard P, Holten-Anderson W, Højlyng N, et al. (1991) Nosocomial outbreak of cryptosporidiosis in AIDS patients. BMJ 302(6771): 277-280.
  89. Ribeiro PC, Pile E, Queiroz MM, Norberg A N, Tenório JR (2004) Cryptosporidiosis occurrence in HIV+ patients attended in a hospital, Brazil. Rev Saude Publica 38(3): 469-470.
  90. Robinson P, Okhuysen PC, Chappell CL, Lewis DE, Shahab I, et al. (2001) Expression of IL-15 and IL-4 in IFN-gamma-independent control of experimental human Cryptosporidium parvum infection. Cytokine 15(1): 39-46.
  91. Rose JB, Huffman DE, Gennaccaro A (2002) Risk and control of waterborne cryptosporidiosis. FEMS Microbiology Review 26(2): 113-123.
  92. Rossignol JF (2010) Cryptosporidium and Giardia: treatment options and prospects for new drug. Experimental Parasitology 124(1): 45-53.
  93. Rotz LD, Khan AS, Lillibridge SR, Ostroff SM, Hughes JM (2002) Public health assessment of potential biological terrorism agents. Emerg Infect Dis 8(2): 225-230.
  94. Savioli L, Smith H, Thompson A (2006) Guardia and Cryptosporidium join the 'Neglected Diseases Initiative'. Trends of Parasitology 22(5): 203-208.  
  95. Sherwood D, Angus KW, Snodgrass DR, Tzipori S (1982) Experimental cryptosporidiosis in laboratory mice. Infect Immun 38(2): 471-475.
  96. Shojaei S (1991) Study on the cryptosporidiosis in children infected with diarrhea and Acquired Immune-Deficiency in Patientin Takhti and Imam Khomeini hosptals in Tehran. (MS Thesis). School of public Health, Tehran University of Medical Sciences.
  97. Simango C, Mutikani S (2004) Cryptosporidiosis in Harare, Zimbabwe. Cent Afr J Med 50(5-6): 52-54.
  98. Simwa JM, Chunge RN, Kinoti SN, Karumba PN, Wamola I, et al. (1989) Cryptosporidiosis and childhood diarrhea in a rural community in Kenya. East Afr Med J 66(8): 520-525.
  99. Soave R (1995) Waterborne cryptosporidiosis - setting the stage for control of an emerging pathogen. Clin Infect Dis 21(1): 63-64.
  100. Sorvillo FJ, Lieb LE, Kerndt PR, Ash LR (1994) Epidemiology of cryptosporidiosis among persons with acquired immunodeficiency syndrome in Los Angeles Country. Am J Trop Med Hyg 51(3): 326-331.
  101. Sun T, Teichberg S (1998) Protozoal infections in the acquired immunodeficiency syndrome. J Electron Microsc Tech 8(1): 79-103.
  102. Taherkhani H, Fallah M, Jadidian K, Vaziri S (2007) A Study on the Prevalence of Cryptosporidium in HIV Positive Patients. J Res Health Sci 7(2): 20-24.
  103. Tumwine JK, Kekitiinwa A, Bakeera-Kitaka S, Ndeezi G, Downing R, et al. (2005) Cryptosporidiosis and microsporidiosis in Ugandan children with persistent diarrhea with and without concurrent infection with the human immunodeficiency virus. Am J Trop Med Hyg 73(5): 921-925.
  104. Tumwine JK, Kekitiinwa A, Nabukeera N, Akiyoshi DE, Rich SM, et al. (2003) Cryptosporidium parvum in children with diarrhea in Mulago Hospital, Kampala, Uganda. Am J Trop Med Hyg 68(6): 710-715.
  105. Tyzzer EE (1907) A protozoan found in the peptic glands of the common mouse. Proceedings of the Society of Experimental Biology and Medicine 5: 12-13.
  106. Ungar BL P, Dubey JP, Speer CA, Fayer R (1990) Cryptosporidiosis of man and animals. Boca Raton, CRC Press, p. 59-82.
  107. Upton SJ (2000) Suborder Eimeriorina. In: LeeJJ & Leedale GF et al. (Eds.), An Illustrated Guide to the Protozoa, (2nd edn), Society of Protozoologists 1: 318-324.
  108. Upton SJ, Current WL (1985) The species of Cryptosporidium (Apicomplexa, Cryptosporidiidae) infecting mammals. Journal of Parasitology 71(5): 625-629.
  109. Vakil NB (1996) Biliary cryptosporidiosis in HIV-infected people after the waterborne outbreak of cryptosporidiosis in Milwaukee. New England Journal of Medicine 334(1): 19-23 .
  110. Wang HC, Dann SM, Okhuysen PC, Lewis DE, Chappell CL, et al. (2007) High levels of CXCL10 are produced by intestinal epithelial cells in AIDS patients with active cryptosporidiosis but not after reconstitution of immunity. Infect Immunol 75(1): 481-487.
  111. Werneck-Silva AL, Prado IB (2009) Gastro duodenal opportunistic infections and dyspepsia in HIV-infected patients in the era of highly active antiretroviral therapy. J Gastroenterol Hepatol 24(1): 135-139.
  112. Xiao L (2010) Molecular epidemiology of cryptosporidiosis: an update. Exp Parasitol 124(1): 80-89.
  113. Xiao L, Fayer I, Ryan U, Upton SJ (2004) Cryptosporidium taxonomy: Recent advances and implications for public health. Clinical Microbiology Reviews 17: 72-97.
  114. Xiao L, Sulaiman I, Fayer R, Lal AA (1998) Species and strain-specific typing of Cryptosporidium parasites in clinical and environmental samples. Memorias do Instituto Oswaldo Cruz 93: 687-692.
  115. Jonathan SY, Ryan MW, Sarah AC, Michael JB, M CH (2010) Cryptosporidiosis surveillance: United States, 2009-2010. MMWR Surveillance Summary 61(SS05): 1-12.
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