Prevalence of Soil Transmitted Helminths in Elementary School Students with Behavioral Risk Factors

The high prevalence of Soil Transmitted Helminths (STH) infection cases is due to several complementary risk factors, including tropical climate factors which provide ideal conditions for the development of worm eggs, unhealthy living behavior factors including defecation habits, eating habits and wearing bedding. feet, not washing hands, not cutting nails regularly. The purpose of this study was to determine the correlation between the prevalence of Soil Transmitted Helminths (STH) infection with behavioral risk factors in school children. This type of research is an analytical epidemiological study in two different areas. The research design used was a cross sectional study. This research was conducted in Bukit Village and Srikembang Village, Betung District, Banyuasin Regency, South Sumatra for 30 days. The research sample was 252 children. Data analysis showed that the type of STH with the highest prevalence in SDN 1 Bukit was A. lumbricoides, while at SDN 1 Sri Kembang was T. trichiura. It can be concluded that the supporting factors for transmission in the two research locations were the habit of washing hands before eating, the habit of children playing in the garden / field, the habit of cutting nails, the habit of defecating, the habit of wearing footwear while playing / working. It is suggested to do further research with environmental risk factor variables. This open access article is under the CC–BY-SA license.


Prevalence of Soil Transmitted Helminths in Elementary School with Behavioral Risk Factors
Wita Asmalinda 2*) Palembang Health Polytechnic of the Ministry of Health, Palembang

A B S T R A C T
The high prevalence of Soil Transmitted Helminths (STH) infection cases is due to several complementary risk factors, including tropical climate factors which provide ideal conditions for the development of worm eggs, unhealthy living behavior factors including defecation habits, eating habits and wearing bedding. feet, not washing hands, not cutting nails regularly. The purpose of this study was to determine the correlation between the prevalence of Soil Transmitted Helminths (STH) infection with behavioral risk factors in school children. This type of research is an analytical epidemiological study in two different areas. The research design used was a cross sectional study. This research was conducted in Bukit Village and Srikembang Village, Betung District, Banyuasin Regency, South Sumatra for 30 days. The research sample was 252 children. Data analysis showed that the type of STH with the highest prevalence in SDN 1 Bukit was A. lumbricoides, while at SDN 1 Sri Kembang was T. trichiura. It can be concluded that the supporting factors for transmission in the two research locations were the habit of washing hands before eating, the habit of children playing in the garden / field, the habit of cutting nails, the habit of defecating, the habit of wearing footwear while playing / working. It is suggested to do further research with environmental risk factor variables.
This open access article is under the CC-BY-SA license.
This open access article is under the CC-BY-SA license.

Prevalence of Soil Transmitted Helminths in Elementary School
Helminths (STH) infection cases is due to several complementary risk factors, including tropical climate factors which provide ideal conditions for the development of worm eggs, unhealthy living behavior factors including defecation habits, eating habits nd wearing bedding. feet, not washing hands, not cutting nails regularly. The purpose of this study was to determine the correlation between the prevalence of Soil Transmitted Helminths (STH) infection with behavioral type of research is an analytical epidemiological study in two different areas. The research design used was a cross sectional study. This research was conducted in Bukit Village and Srikembang Village, Betung District, Banyuasin Regency, South Sumatra for 30 days. The research sample was 252 children. Data analysis showed that the type of STH with the highest prevalence in SDN 1 Bukit was A. lumbricoides, while at SDN 1 Sri Kembang was T. trichiura. It can be mission in the two research locations were the habit of washing hands before eating, the habit of children playing in the garden / field, the habit of cutting nails, the habit of defecating, the habit of wearing footwear while playing / working. It is ested to do further research with environmental risk factor variables. license.
The high prevalence of STH infection cases is caused by several complementary risk factors, including tropical climate factors which provide ideal conditions for the development of worm eggs (Supriastuti, 2006;Shang Y., 2010), unhealthy life behavior factors include, habits. defecation, how to eat and use footwear (Simarmata, N., 2015;Ahdal, MT, 2014), not washing hands, not cutting nails regularly (Rahmayanti, 2014), defecating (BAB) carelessly (Wahyuni, D. 2016) ). T. trichiura and A. lumbricoides infections typically affect children 5-10 years of age. As you get older, the cases of infection will decrease. A different profile occurs in hookworm infections whose maximum intensity is at the age of 20-25 years. School-age children have the highest risk for clinical manifestations of this infection, transmission can occur due to hand contact with children whose nails are contaminated with worms (Suriptiastuti, 2006;Rahmayanti, 2014;Depkes RI, 2016).
According to research by Alamsyah (2017), the habit of not using footwear while working, and rarely washing hands, is a supporting factor for finding worm eggs in fecal samples. Samples that do not use hand protection are a good intermediate medium for the development of worm larvae that infect humans through hands and nails (Elfred, 2016). According to Umamah's research (2019), hookworm infections found in the feces of adults who are looking for farmers are due to low personal hygiene, such as rarely wearing gloves and footwear while working, rarely washing hands before and after working and eating. Worm eggs or larvae that stick to the hands will enter the body when the person feeds his food.
According to Wahyuni's research (2016), the prevalence of STH is still high, allegedly due to poor sanitation of the living environment, moist soil conditions and protected by close proximity to houses due to the density of the population, flood-prone areas, the habits of children playing on the ground and low personal hygiene. The purpose of this study was to determine the correlation between the prevalence of STH infection and behavioral risk factors in school children.
This study is different from other similar studies, in this study using behavioral variables that support each other as many as 10 variables. In this study also showed the types of STH infection single, double 2 and double 3, which had not existed in previous studies.

Method
This type of research is an analytical epidemiological study in two different areas. The research design used was a cross sectional study. This research was conducted on elementary school students in Bukit Village and Srikembang Village, Betung District, Banyuasin Regency, South Sumatra for 30 days. This location is located approximately 65 km north of Palembang city. The samples of this research were students of SDN 1 Bukit and students of SDN 1 Srikembang. The number of samples was 252 people. Stool samples were taken from SDN 1 Bukit and SDN 1 Srikembang students using the simple random sampling method. All students at SDN 1 Bukit were taken as samples regardless of age and gender. All samples were given an explanation of the objectives, procedures for examining the benefits and risks of being sampled in this study. After obtaining the consent of the sample (represented by the parents), he signed the concent informed. The variables in this study were the dependent variable (dependent) the prevalence of STH infection and the independent variable (independent) behavioral effects.
The collection and examination of feces is carried out by officers from the parasitology laboratory, Faculty of Medicine, Sriwijaya University. Examination of eggs in feces using the Kato Katz method. Equipment and materials used, among others; cellophane measuring 2.5x3cm, malachite green glycerin solution (100 ml glycerin, 100 ml distilled water and 1 ml malachite green 3% in distilled water), cellophane soaked in solution for 18-24 hours before use, 3x4 cm gauze for filtering feces, 3x4 cm thick cardboard with a hole in the center with a diameter of 6 mm, glass objects, rubber bottle caps, filter paper measuring 10x10 cm, oil paper 10x10 cm, stick, microscope, stool. The procedure for examining the stool is that the stool is taken from the stool bottle as much as possible with a stick, then placed on oil paper, then the gauze is placed over the stool. On a glass object, vinyl is placed with a hole in the middle of the glass, the gauze placed on top of the stool is pressed with a stick. Then, with the stool that comes out on the gauze, it is inserted into the vinyl hole using a stick. After the vinyl hole is full, the vinyl is removed, and the stool that is located on the glass is covered with cellophane which has been soaked in malachite green glycerin solution. Cellophane is pressed with another glass object or rubber bottle cap to flatten the stool under the cellophane. The excess of malachite green glycerin is drained by placing the stool preparation upside down on filter paper for 20-30 minutes. The dried stool is examined under a microscope, the eggs found are counted, then the number of eggs obtained is multiplied by 26 to determine the number of eggs in 1 gram of feces.
Tools and materials for fecal examination using the Harada-Mori modified method are that the bottom part of the plastic ice bag is partially folded inward so that the bottom will be in the shape of a point, distilled water, filter paper measuring 4x8 cm, stick, microscope, binocular microscope, scissors, spirit lamp, solution lugol, matches, stool. How the Harada-Mori modification method works, among others: feces are taken with a stick, then rubbed lengthwise on filter paper, then filter paper that has been given feces is put into a plastic bag. then the bag is filled with enough distilled water to touch the bottom of the filter paper. The top of the plastic bag is closed tightly by burning then the plastic bag is hung on the rope for 5-7 days. After that, the preparation is viewed under a binocular microscope to confirm the presence or absence of larvae. If the larvae are present, the lower end of the plastic bag is cut off and the contents are placed in a petri dish. The larvae are killed by heating them on a spirit lamp or by giving them a few drops of lugol solution, then the larvae are identified as one. The measuring instrument uses a behavior questionnaire that has been used previously by other researchers (Nuryanti, NM., 2018;Anwar, C., 1997) and has been modified is distributed to each student to ask the parents/ guardians' willingness to be filled in.

Results and Discussion
An analytical epidemiological study has been conducted in two different areas using a cross sectional design. The research data were collected in a research formula that had been prepared, then statistical analysis was carried out including descriptive analysis to determine the frequency distribution of each variable, Fischer's exact test for categorical data, regression test was used to see the effect of behavioral aspects on the prevalence of STH.
The Table 1. it is found that most of the respondents parents education has graduated from elementary school. Meanwhile, most of the respondents parents work as farmer. The Table 2 shows that SDN 1 Bukit A. lumbricoides is the type of STH with the highest prevalence, while SDN 1 Sri Kembang T. trichiura is the type of STH with the highest prevalence. A total of 45 samples of SDN 1 Bukit and 77 samples of SDN 1 Sri kembang were not found type of infection is the number of worms present in one individual, which are further classified into single infection, double infection 2 and multiple infection 3. Types of infection STH for SDN 1 Bukit students and SDN 1 Sri Kembang students are shown in Table 3.   Table 3, it can be seen that the percentage of single infections is almost the same among primary school students in the two villages. For SDN 1 Bukit the percentage of single infections was 14%, while SDN 1 Sri Kembang was 15.8%. For double infection the percentage is larger at SDN 1 Bukit than at SDN 1 Sri Kembang. Table 3 shows the percentage of multiple infections for SDN 1 Bukit as much as 9%, while SDN 1 Sri Kembang is 5.9%.   From Table 4, it can be seen that the intensity of A. lumbricoides infection in SDN 1 Bukit students was higher than SDN 1 Sri Kembang students, while the intensity of T. trichiura infection in SDN 1 Sri Kembang students was higher than SDN 1 Bukit students. No hookworm infection was found in the sample because these worms are more likely to infect productive age who work in mining or plantation areas (Wahyuni, 2016).
Using the classification from Kobayashi (1980) in the APCO Research Group, the intensity of infection was classified into four categories based on the number of eggs found, namely light, moderate, severe and very heavy. The proportions of each intensity category are shown in Table 5.
From Table 6, it can be seen that the behavioral aspects of the STH prevalence in SDN 1 Bukit generally do not have a significant effect, except for the behavioral aspect of accumulating feces after defecating in the yard / garden. Although the habit of washing hands without soap before eating did not affect the prevalence of A. lumbricoides, the number infected with A. lumbricoides was smaller than those who were not infected. The habit of cutting nails in one week is generally only once. The habit of wearing footwear when working in the fields, playing around the house, at school and playing in the garden generally uses footwear. The habit of burying feces with soil after defecation has mostly been carried out, and many still sometimes like to play in the garden or field. The results of this study are not in line with Nuryanti's (2018) study, which states that the habit of washing hands using soap has a significant relationship with the prevalence of A. lumbricoides infection.
Humans are the only definitive host for A. lumbricoides. Adult worms usually live in the intestinal cavity. These worms receive food from the host food that is being digested. Male or female worms can be found in people even if they have a mild infection. A female worm has the ability to produce 26 million eggs, and an average of 200,000 eggs a day. The eggs do not divide when removed by the host with feces. If the environmental conditions in the soil are favorable, within 3 weeks the eggs will form an infective second stage larvae. The optimum temperature for egg growth is approximately 25 ° C with a range between 21 ° and 30 ° C. Lower temperatures inhibit growth but benefit the length of life. At 37 ° C the eggs only grow to the eightcell stage. Because eggs require charcoal, their growth is stunted when they are present in a rotting environment.
Infective eggs, when ingested by humans, will hatch in the upper part of the small intestine and release rabditiform larvae (200-300x14μ in size), which penetrate the intestinal wall and enter the small veins or lymph vessels. Through the portal circulation, these larvae enter the liver, then the heart and the lungs. The larvae may reach the lungs 1 to 7 days after infection. Because these larvae have a diameter of 0.02 mm, and the diameter of the pulmonary capillaries is only 0.01 mm, they burst and the larvae exit into the alveoli. Occasionally several larvae can enter the left heart through the pulmonary veins and be spread as embolism to various organs in the body. In the lungs of these larvae undergo second and third changes. The larvae migrate or are carried by the bronchioles to the bronchi, up the trachea to the epiglottis, and down the esophagus and into the small intestine. In the small intestine, the larvae grow into adult worms (Gandahusada, 2010;Depkes RI, 2016). For egg development A. lumbricoides and T. trichiura require clay soil, moist and protected from sunlight. This is different from hookworms because these worm larvae need oxygen for their growth, so the most suitable and profitable soil type is sandy, loose, humid soil and protected from direct sunligh. From the logistic regression results in Table 7. that the risk factors for washing hands before eating show a significant correlation with value (p = 0.021). The unadjusted odd ratio value of 1,658 after adjustments obtained an adjusted odd ratio value of 49,167, meaning that washing hands before eating without soap has a risk factor for infection with A. Lumbricoides at SDN 1 Bukit 49,167 times greater than washing hands with soap. A large number of adult A. lumbricoides worms, especially in children, can cause malnutrition. In addition, worm body fluids can cause toxic reactions resulting in symptoms similar to typhoid fever accompanied by signs of allergies such as urticaria, facial edema, conjunctivitis and upper respiratory irritation. Adult worms can also have various mechanical consequences, such as intestinal obstruction, intussusception or perforation of the ulcer in the intestine. Migration of worms to organs such as the stomach, esophagus, mouth, nose, rhyme glottis or bronchi can obstruct the patient's breathing. Appendicitis, liver abscess, bile duct obstruction and acute pancreatitis may also occur. Table 8 shows the results of the analysis of the p value of the ten variables (p> 0.05), Ho failed to be rejected, which means that there is no correlation of risk factors for behavior with the prevalence of T. Trichiura. The absence of a correlation in this study is presumed because the number of respondents who had a positive T. trichiura prevalence was less than the negative result. Even so, the risk factors for this behavior should still be a concern by improving individual hygiene. The results of this study are different from Wahyuni's (2016) research, which states that there is a significant relationship between behavioral factors and the incidence of T. Trichiura infection. From the logistic regression results in Table 9. that the risk factors for children like to play in the garden / fields show a significant correlation with value (p = 0.016). The unadjusted odds ratio value of 2,250 after adjustment, the adjusted odd ratio value was 53,039, meaning that children who never/ sometimes play in the garden / field have a 53,039 times greater risk factor for T. trichiura infection compared to children always playing. in gardens / fields that are directly related to the land. Eggs containing embryos when swallowed by humans, the larvae that become active exit through the egg wall that is no longer strong, enter the proximal small intestine and penetrate the intestinal villus, staying there for 3 to 10 days near Lieberkuhn's kripti. After becoming an adult the worms descend further down into the cecum area. A spear-like structure on the part helps the worm penetrate and then place its whip-like anterior portion into the intestinal mucosa of its host, where it takes its food. Its secretion may liquefy adjacent mucosal cells. The growth period, from swallowing eggs to adult worms laying eggs, is approximately 30 to 90 days. His life may be for several years. In severe infections, especially in children, these worms are spread throughout the colon and rectum. Sometimes seen in the rectal mucosa that has prolapsed as a result of pushing the patient during defecation. This worm inserts its head into the intestinal mucosa, causing trauma that causes irritation and inflammation of the intestinal mucosa. Bleeding may occur at the site of attachment. In addition, it seems that these worms suck the blood of the host, so they can cause anemia (Depkes, 2016). From Table 10, it can be seen that the behavioral aspects associated with the prevalence of STH in SDN 1 Sri Kembang did not have a significant effect on the prevalence of A. lumbricoides, except for the behavior of defecating in the yard / garden heaped up and wearing footwear when playing around the house. There was a significant correlation on the behavior of washing hands before eating (p = 0.025), defecating in the yard / garden heaped up (p = 0.020) and defecating around the house (p = 0.019).

Tabel 7. Regression Results of Behavior Risk Factors with the Prevalence of A. lumbricoides in SDN 1 Bukit Risk Factors
According to Wahyuni (2016), A. Lumbricoides is a type of nematode that produces the most eggs and these worm eggs are able to survive in the outside environment compared to other intestinal nematode eggs. From Table 10, it can be seen that the behavioral aspects associated with the prevalence of STH in SDN 1 Sri Kembang did not have a significant effect on the prevalence of A. lumbricoides, except for the behavior of defecating in the yard / garden heaped up and wearing footwear when playing around the house. There was a significant correlation on the behavior of washing hands before eating (p = 0.025), defecating in the yard / garden heaped up (p = 0.020) and defecating around the house (p = 0.019).
According to Wahyuni (2016), A. Lumbricoides is a type of nematode that produces the most eggs and these worm eggs are able to survive in the outside environment compared to other intestinal nematode eggs.  Table 12, it appears that the behavioral factors that have a significant correlation with the prevalence of T. trichiura in SDN 1 Sri Kembang are the habit of washing hands before eating (p = 0.025), the habit of defecating in the garden / yard heaped up (p = 0.020), the habit of throwing away large water around the house (p = 0.019). From the logistic regression results in Table 13. that the behavioral factors with the prevalence of T. trichiura in SDN 1 Sri Kembang showed that there was no significant correlation seen from the p value, unadjusted odd ratio and adjusted odd ratio. The habit of cutting nails is generally done only once a week, so this habit has no effect on STH infection. The results of this study are not in line with Wahyuni's (2016) research, which states that there is a relationship between routine nail cutting and the prevalence of T. Trichiura infection. Elementary school students have already worn footwear when working in the fields and at school, so it does not affect STH infection. In contrast to the results of Wahyuni's (2016) study, there was a significant relationship between the habit of using footwear and the prevalence of STH. The habit of defecating in the yard is generally no longer practiced. However, elementary school students who defecate in the yard or garden do not accumulate their feces, even though they sometimes still play in the garden or fields, so there are still cases of worm infection with A. lumbricoides and T. trichiura. According to Primadana (2019) and Riswanda (2016) clinical symptoms due to STH infestation in the gastrointestinal tract generally only appear when the intensity of the infestation is in the moderate and severe categories. The morbidity of the prevalence of worms is directly related to the prevalence of worms in the human body. The number of worm eggs can be an illustration of the severity of STH infestation (WHO, 2015: Primadana;2019). The spread of A. lumricoides infection has the same pattern as T.trichuris. The spread of T.trichuris is cosmopolitan in nature, especially in hot and humid areas (Hairani, B, 2014). The way to break the chain of STH infection transmission is by improving health behavior, improving sanitation, increasing knowledge and taking antimintic drugs (Noviastuti, 2015).

Risk Factors
Based on the results of the discussion analysis, it can be concluded that the worms found at the study site were A. lumbricoides and T. trichiura, while the hookworms were not found. The type of STH with the highest prevalence in SDN 1 Bukit was A. lumbricoides, while at SDN 1 Sri Kembang was T. trichiura. The infection intensity of A. lumbricoides in SDN 1 Bukit was higher than SDN 1 Sri Kembang, while for T. trichiura it was higher in SDN 1 Sri Kembang with mild to very severe infection degrees. The supporting factors for transmission in the two research locations were the habit of washing hands before eating, the habit of children playing in the garden / field, the habit of cutting nails, the habit of defecating, the habit of wearing footwear while playing / working. It is suggested to do