Memoire Online - Gastrointestinal infections and under nutrition among children between 0 and 5 years old. Case of Mareba sector, Bugesera district, eastern province, Rwanda

I, NSENGIYUMVA Wilson, hereby declare that this research project entitled:» Gastrointestinal infections and under nutrition among children between 0 and 5 years old, Case of MAREBA Sector.» is my own contribution and has not been submitted anywhere else for any award in University or Institute of Higher Learning.

APPROVAL

I, KARINE Bernard, the undersigned certify that this research project has been realized under my supervision and it has been submitted with my approval.

Supervisor signature:.....................................................................

DEDICATION

ACKNOWLEDGEMENTS

I thank the almighty God who have been closed to me and gave me protection in my life until I complete my Bachelor's degree and particularly my memoir.

I am highly thankful to my family especially my parents NAMBAJIMANA Edison and MUKAKABANO Eugénie, my brother NIYIGABA William and my sisters NYIRAMWIZA Phoïbe, TUYISHIMIRE Julienne, NIYONSABA Malliam, USANASE Esther for their love unceasing support and encouragement from my childhood until today.

I express my thanks to the government of Rwanda for having financed my studies, through Kigali Institute of Education and its lecturers for the knowledge and skills acquired.

I gratefully thank my supervisor, Mrs. KARINE BERNARD, for her assistance, tireless guidance, critical comments and his valuable scientific advice on this work.

I recognize gratefully the big help and assistance from Mareba Health Center for his acceptance to my request of taking samples at their health center, with no doubt. I thank the medical laboratory technicians of Mareba Health Center regarding my fieldwork collecting data.

I cannot forget to express my thanks to the family of Esdras NSENGIYUMVA, to the family of Mrs. Marc SENTWARI, to the family of Jonas HABYARIMANA, to the family of Joseph SIBOMANA, to the family of Jeremiah AYABAGABO and to the family of Jean Pierre HAKIZIMANA, for their support, encouragement and advices.

I grateful thank to Dr. Ildephonse HABARUGIRA for accepting to review this work, especially for his helpful comments, assistance, suggestions and advices.

I thank to my colleagues: Justin NSANZABAGANWA, Bernard HABINEZA, for their support, encouragement and advice.

Many thanks to my colleagues and classmates, my lovely friends and all those who contributed to the realization of my dissertation for their moral and emotional help.

ABSTRACT

Gastrointestinal infections and malnutrition affect millions of under five years old children worldwide. The presented study was concerned on gastrointestinal infections and under nutrition among 50 under five years old children who attended Mareba Health Center in Bugesera District. Children stool samples were tested at Mareba Health Center laboratory using the optic microscope and their parents were interviewed using a prepared questionnaire about their children feeding habits. 5 causal agents were identified at different proportions among the 38 infected children detected for a given pathogens.

Bacteria were found at the prevalence of (8%), Entamoeba histolytica (8%), Trichomonas intestinalis (14%), yeasts (30%) and the blood parasite such as Plasmodium malaria (16%). According to age, most infected children were between 13 months and 5 years old (34% each) as the children grow up and begin to take food without their parents while it was less among the 0-12 groups of age.

The study shown that 100% of children from 0 to 6 months do not eat anything, they are breastfeed on their mothers. The consummation of vegetables and beans was high among all age groups, but the percentage of children eating vegetable increased slightly from 7-12 months (62.5%) to 25 months-5 years (75%), while the one of beans increased from 87.5% to 93.8%. The consummation of fruits is quite low among children from 7-12 months (25%), but reach 68.7% for the children over 25 months. The children consuming meats, eggs and milk remains below 20% throughout all age groups and most of children were eating less than 2 times per day then 4% severely wasted. As a result, 8% of the children were wasted and among them 44% were moderately underweighted.

A positive relationship seems to exist between Trichomonas intestinalis and underweight, as 100% of the children infected by Trichomonas intestinalis were moderately underweight. Also, 66.6% of the children with double infections (bacteria and yeasts) were also moderately underweight.

LIST OF SIGNS AND ABREVIATIONS

CSVA&N: Comprehensive Food Security and Vulnerability Assessment & Nutrition Survey

LIST OF TABLES

LIST OF FIGURES

CHAPTER I. GENERAL INTRODUCTION

I. 1.BACKGROUND OF THE STUDY

Intestinal parasites are organisms that live in gastrointestinal tract of animals, including humans. They are among the most common and widely distributed animal parasites of man. Infections with intestinal parasites rank among the most important persistent public health problem across the globe and they are important in African children (Cox, 1982).

The World Health Organization (WHO) estimates that 3.5 billion people worldwide are infected with some type of intestinal parasites and as many as 450 million of them are sick as a result and children are most frequently infected with these parasites (WHO, 1997). Intestinal parasites spread in area with poor sanitation and most common areas are in tropical developing countries on the African, Asian, and South American continents. Housing has been identified as a major factor affecting the health of aboriginal people. Inadequate or poorly maintained housing and the absence of functioning infrastructure can pose serious health risk. Overcrowded dwellings and poor quality housing lead to the spread of infectious diseases (Australian Bureau of Statistics & Australian Institute of Health and Welfare, 2008).

Usually, gastrointestinal infections which affect the organs of digestive system cause abdominal cramping followed by diarrhea, fever, loss of appetite, nausea, vomiting, weight loss, dehydratation, mucus or blood in the stool which cause under nutrition.

Increasing evidence suggests that protein-calorie malnutrition (PCM) is the underlying reason for the increased susceptibility to infections observed in these areas. Moreover, certain infectious diseases also cause malnutrition, which can result in a vicious cycle. Malnutrition and gastrointestinal infections represent a serious public health problem and mechanisms underlying the malnutrition induced by intestinal helminthes have been described (Mofft, 2003). The increased incidence and severity of infections in malnourished children is largely due to deterioration of immune function; limited production and/or diminished functional capacity of all cellular components of the immune system have been reported in malnutrition. There is a cyclical relationship between malnutrition, immune response dysfunction, increased susceptibility to infectious disease and metabolic responses that further alter nutritional status.

The consequences of malnutrition are diverse and included: increased susceptibility to infections, impaired child development, increased mortality rate and individuals who come to function in suboptimal ways (Leonor, 2011).

I.2. STATEMENT OF THE PROBLEM

In individual children, in developed countries, it is possible to follow a sequence of infections of gastrointestinal tract leading to diarrhea which, if long persist, may in turn lead to under nutrition. Gastrointestinal infections continue to cause illness and death and contribute to economic loss in most part of the world including Rwanda and even in high income countries. Recently, a research published in Neglected tropical diseases showed that Rwandan inhabitants from Northern province infected with more than two species of parasitic worms are more likely to be underweight than those with just one or with no infection (Kaberuka et al., 2009).

Young children between 0 and 5 years old are very vulnerable, their parents needs relevant knowledge of hygiene and nutrition to protect their children as well as providing to their children food in adequate quantity and quality so, most of gastrointestinal infections can be avoided.

It is in this context that this research aims is to have a better understanding in the relationship which may exist between gastrointestinal infections and malnutrition among children between 0 and 5 years old in Mareba Sector.

I.3. RESEARCH OBJECTIVES

The general objective of this study is to find out the risk factors associated with gastrointestinal infections and under nutrition among children between 0 and 5 years old and to find out if the mentioned are intrinsically linked.

-To find out which gastrointestinal infections agents affect children between 0 and 5 years.

-To find out how gastrointestinal infections affect children between 0 and 5 years.

-To identify which gastrointestinal infections are more prevalent among malnourished children.

-To find out what are the nutritional and hygiene habits among children between 0 and 5 years old.

I.4. HYPOTHESIS

-Gastrointestinal infections in Eastern provinces are linked with under nutrition in children between 0 and 5 years old.

-Lack of hygiene is present among children who suffer of gastrointestinal infections and under nutrition.

-Lack of fruits, vegetables, meats and eggs is present among the children with under nutrition and gastrointestinal infections.

I.5. RESEARCH QUESTIONS

-Are there some children between 0 and 5 years who have under nutrition in MAREBA Sector?

-What are the factors that contribute to gastrointestinal infections and under nutrition?

I.6. SIGNIFICANCE OF THE STUDY

This study will be significant to the parents of children in MAREBA Sector/BUGESERA District. It will show them which of their habits are risk factors of gastrointestinal infections and under nutrition for their children and how to prevent gastrointestinal infections transmission and under nutrition in children. The health administrators, the Ministry of Health, the Governments and other researchers will be aware of the main causes and factors associated with gastrointestinal infections and under nutrition.

I.7. LIMITATION AND DELIMITATION

It will not be easy or possible to cover all MAREBA Sector, so to overcome this problem and hope to finish this study on time, only some children who came to MAREBA Health Center have been selected as sample and data collected will be analyzed. The results found will be generalized to MAREBA Sector.

CHAP II. LITERATURE REVIEW

II.1. DEFINITION OF GASTROINTESTINAL INFECTIONS

Infection is the invasion of a host by an organism with subsequent establishment and multiplication of the agent. A gastrointestinal infection is any infection of the digestive tract; gastrointestinal meaning having to do with the organs of digestive system, the system that process food. It includes the month, esophagus, stomach, intestine, colon and rectum and other organs involved in digestion, including the liver and pancreas (Prescott et al., 2005).

II.2.PREVALENCE OF GASTROINTESTINAL INFECTIONS

II.2.1. Prevalence of gastrointestinal infections worldwide

The prevalence of gastrointestinal infections is high, mostly in developing countries children. In 1998, 2.2 million people die because of diarrheal diseases and the majorities were children. The World Health Organization (WHO) in 2007 estimated that, the 53% of school-aged children in developing countries were infected by gastrointestinal infections.

A research done on children of various nationalities from India subcontinent, Middle- East, South- East Asia shown that among infected children, the protozoan infections (92.2%) were higher than the helminthes infections (7.8%). Entamoeba histolytica (71.8%) and Giardia lambia (17.5%) were the commonest intestinal protozoa parasites identified.

About 400 million school age children are infected by round worm, whip worm, hook worm, Schistosomiasis and flukes. These helminthes infections especially hook worm infections cause iron deficiency anemia and reduce growth and may negatively affect cognition (Rwanda Demographic and Health Survey, 2005).

ll.2.2. Prevalence of gastrointestinal infection in different African countries

In Africa, more than 2.3 billions of people still live without access to sanitation facilities and are enable to have basic hygiene such as washing their hands with soap and water. Diseases related to poor sanitation and water availability may cause many people to fall ill or even die; children are more vulnerable to those related infections and consequently the most affected.

In 1996-1997; the prevalence of diarrhea, the most outcome of gastrointestinal infections have increased from 18% to 60% in Kenya and from 16% to 21% in Uganda due to the lack of safe disposal of feces and waste water. In Bruea (Cameron) due to the lack adequate sanitation (safe disposal of feces, cleaned water supplies, waste water disposal) intestinal protozoa infections raised and Entamoeba histolytica was seen to be the most prevalence (24%) followed by Trichomonas intestinalis with 11.2% and the lowest was Giardia with 0.6%. The most prevalent morbidity effects were abdominal pain, dysentery and body weakness (Stoltzfus et al., 1997).

II.2.3. Prevalence of gastrointestinal infections in Rwanda

A Survey done in 2008 on 8313 children from 30 districts by TRAC PLUS on helminthes infections have identified six species of intestinal helminthes with an overall prevalence of 65.8% for soil-transmitted helminthes (STH) infections. The predominant parasite was Ascaris lumblicoides which was observed in 38.6% of the children, followed by hookworms in 31.6%, Trichuris trichiura in 27.0%, and Schistosoma mansoni in 2.7% of the children. Overall, the prevalence per district varied from 0% to 69.5% (TRAC PLUS, 2008). Others researches conducted by KIE students in Rwanda shown that protozoa affecting children were Entamoeba histolytica, G. lamblia, and T. intestinalis. The highest rate was among the 4-5 years old and the rate of infection found to be associated to quality of food, water taken and where they were living (Umutoni, 2010; Mukagihana, 2011; Mugaju, 2011).

II.3. INFECTIOUS AGENTS OF GASTROINTESTINAL INFECTIONS

There are many infectious agents causing gastrointestinal infections. But they are mainly bacteria, viruses and parasites. All may have common clinical features of nausea, vomiting, diarrhea and anorexia (Prescott et al., 2005).

II.3.1. Protozoa

Human intestinal protozoa infections are found worldwide, in both developing and industrialized countries. Protozoa produce diarrhoeal diseases by infecting the small or large intestine, or both. For example, Entamoeba histolytica can become a highly virulent and invasive organism that causes a potentially lethal systemic disease (Ali et al., 2008).

Giardiasis and Cryptosporidiosis are important causes of diarrhea in children; the latest is particularly associated with growth failure and malnutrition. They also cause water -borne and food-borne outbreaks (Ali et al., 2008).

II.3.1.1. Amoebiasis (Amebiasis)

Amoebiasis refers to infection of human intestinal tract caused by protozoan parasite Entamoeba histolytica (Cedric, 2004). Amoebiasis is a major cause of parasitic death worldwide. About 500 million people are infected and many as 100.000 die of Amebiasis each year (Prescott, 2005). It is estimated that 40-50 millions cases of amoebic colitis and liver abscess occur annually with 40 000 to 110 000 deaths (WHO/PAHO/UNESCO report, 1997).

Entamoeba histolytica has a worldwide distribution and the infection occurs all over in Africa. It is mostly found in subtropical and tropical countries where the prevalence may exceed 50% (Cedric, 2004).

II.3.1.2. Gardiasis

Giardia, the causal agent of gardiasis was discovered by Van Leeuwenhoek in 1861 when he examined his own stool. Giardia is worldwide distributed and an estimate of 200 million people is infected each year. Giardiasis is endemic in children day care centers in the United States with estimate of 15% to 50% of diapered children being infected. It was found in 10% of children rising in Cairo and the highest prevalence rate have been recorded in the studies from Guatemala in which in one cohort had infection by 3 years of age, or from the Gambia where the prevalence was 45% in children with diarrhea (Prescott et al., 2005).

II.3.2. Bacteria

African children bellow 3 years experience 3-10 episodes of diarrhea caused by bacteria each year and spend 10-15% of their days with diarrhea. About 1.5 million children below age 3 years die each year from diarrhea.

Infectious diarrhea is a leading cause of morbidity and mortality worldwide. In the United States, 100 million people are affected by acute diarrhea every year. Most diarrheas are viral in origin, but bacteria remain an important cause.

Common bacterial pathogens that cause diarrhea include Bacillus cereus, Campylobacter species, Salmonella, Shigella, and Escherichia coli (Marignani et al., 2004).

Tick-borne relapsing fever, called borreliosis, caused by Borrelia crocidurae, is another bacterial pathogen rising in West Africa, according to Raoult and his collaborators. In 27 of 206 samples from people living in rural Senegal, 12% were positively identified.

Another bacterial agent emerging in Africa, Tropheryma whipplei, causes Whipple disease, a rare infection that appears to be passed via human- to-human contact and typically causes gastrointestinal distress by interfering with digestion. However, if left untreated, it can affect other organs and may be fatal (John, 2009).

II.3.3. Virus

Acute viral gastroenteritis (inflammation of the stomach or intestine) is caused by four major categories of viruses: rotraviruses, Norwalk-like viruses, norovirus, adenovirus, other caliciviruses and astroviruses (Prescott et al., 2005). Viruses do not respond to antibiotics and infected children usually make a full recovery after a few days (Haffejee, 1991).

Infection is seen in all part of the world especially in infants less than 2 years of age and is frequent in cooler months of the year. It impact is seen in part of Africa and Latin America where more than three million infants die from viral infection each year and children may have a total of 60 days of diarrhea in each year (Cedric, 2004).

Viral gastroenteris attacks the upper intestinal epithelial cells of the villi, causing mal absorption, impairment of sodium transport and diarrhea. The symptoms include nausea, vomiting, excessive sweating, fever, muscle pain and weight loss, develop fever, headaches, runny nose, cough and fatigue (Prescott et al., 2005).

II.3.4. Helminthes

Derived from the Greek word «helminthes» meaning «worm,» is a broad categorical term referring to various types of parasitic worms that reside in the body.

One of the major health problems faced by hundreds of millions of children is infection by helminthes. Children are often the group that has the highest infection rate as well as the highest worm burden, which contributes greatly to the contamination of the environment.

Helminthes produce a wide range of symptoms including intestinal manifestations (diarrhea and abdominal pain), general malaise and weakness that may affect working and learning capacities and impair physical growth. Hookworms cause chronic intestinal blood loss that result in anemia. Intestinal helminthes is one of the major health problems like impairment of physical and mental development (WHO, 1995). In Uganda, a retrospective study have shown that helminthes infections of children consist of 82.1% Ancylostoma duodenale and Necator americanus, 18.9% Ascaris lumbricoides, 7.0% Trichuris trichiura, 1.0% Enterobius vermicularis, and 0.5% with Hymenolepis nana (Ministry of Health, Uganda, 1997).

II.4. RISK FACTORS OF GASTROINTESTINAL INFECTIONS AMONG CHILDREN

II.4.1. Poor hygiene

The spread of an intestinal infection is ensured if public health and hygiene are poor and if the parasites appear in high number. It is estimated that worldwide, 2.6 billion lack adequate sanitation and in Rwanda, 62% of the population lack adequate sanitation (John, 2008).

II.4.2. Contact with animals

Human can live in daily contact directly or indirectly with a wide variety of animals. Contact with animals including their wastes can be a source of intestinal parasites. Animals can also be a reservoir for the parasites, such as reptiles, fishes, dogs, cats, pigs and rodents which can infect human who handle them. Dog, cats, and pigs are the commonest domesticated animals and all are reservoir of infections. For example, dog can transmit 65 different parasites and cat about 40 (Lippnicott, 2006).

II.4.3. Contaminated water

Water bodies are still the main cause of intestinal parasites due to poor sanitation and unboiled water that many people take up and cause long suffer from diarrhea and related diseases. According to national library of medicine, swimming a creek, river or lake may cause infection with intestinal parasite such as Giardia, Schistosoma and working through mud or puddle without proper food can allow worms to enter the body through the skin which then infect intestine. In Rwanda, 31% of the rural population is lacking access to safe water and expose themselves to gastrointestinal infections (John, 2008).

II.4.4. Contaminated soil

Soil that is fertilized with human or animal wastes may contain parasites, such as hook worms which can enter the skin and affect the intestine. Walking with bare foot can result in small cut or abrasion that can allow parasites' egg or cyst to enter the body and intestinal infections (TRAC PLUS, 2008).

II.4.5. Malnutrition

Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess (too high an intake), or in the wrong proportions. A number of different nutritional disorders may arise, depending on which nutrients are under or overabundant in the diet. Lack of major dietary items, essential amino acids, essential fatty acids, vitamins or minerals leads to a group of diseases collectively known as malnutrition.

ll.5.1. Different types of malnutrition

Two major kinds of protein-energy malnutrition (PEM) are classified as marasmus and kwashiorkor, or a combination of both. Marasmus condition is characterized by extreme wasting of the muscles and a daunt expression due to complete absence of food; whereas kwashiorkor is identified as swelling of the extremities and belly, which is deceiving to their actual nutritional status. Those child don't eat enough protein source and given instead an almost pure carbohydrate energy source such as sweet potatoes and cassava (WHO, 2005).

ll.5.2. How malnutrition is calculated

Weight loss is often the first clue to an underlying cause of malnutrition. The loss of more than 10% of the patient's usual weight necessitates a thorough nutritional assessment. Recent unintentional loss of 10% to 20% of the patient's usual weight indicates moderate PEM, and loss of more than 20% indicates severe PEM.

Malnutrition is diagnosed by anthropometric measurements and physical examination. Correlation of malnutrition and growth retardation allows assessment of the individual nutritional state.

II.5.2.1. Z-score method and malnutrition characterization

The Z-score is used to describe how far a measurement is from the median, or average. For instance, a weight for height (W/H) Z-score calculated for an individual tells us how an individual's weight compares to the average weight of an individual of the same height in the WHO Growth Standard (GS).

For example, a positive W/H Z-score means that the individual's measurement is higher than the median weight value of an individual of the same height in the WHO GS, while a negative W/H-Z score means that the individual's weight is lower than the average weight of an individual of the same height in the WHO GS (WHO, 2005).

Method of percentage in calculation of malnutrition is done by the percent of median. This is merely the weight, height, age of child relative to the average weight of the comparable children in the reference population, expressed as a percentage. This can be calculated from a table giving information about the reference population.

For instance, the percentage of reference W/H is the children weight for a given height over reference W/H (Table A5.4) X100. The percentage of reference height (length for children above 24 months) for age (H/A) is the height (length) of a child over reference height (length) for age (Table A5.2) X100. The percentage of reference weight for age (W/A) is the weight over reference W/A (Table A5.1) X100 (Table A1,2.5 in annexes 2). As shown in table 11, the severity of malnutrition depends on the percentage obtained.

II.5.2.2. Weight for height method

W/H is a nutrition index which is a calculation of two measures-weight and height into a single value so that children of different ages can be compared. There are several nutrition indices, W/H specifically assesses wasting, a condition that reflects a deficit in weight relative to height due to a loss of both tissue and fat mass, one form of acute malnutrition (WHO, 2005). W/H is an indicator of acute malnutrition that tells us if a child is too thin for a given height (wasting).

II.5.2.3 Height for age method

Prevalence of child malnutrition H/A is the percentage of a children whose height for age is more than two standard deviations below the median for the international reference population ages 0 to 59 months. For children up to two years of age, height is measured by recumbent length. For older children, height is measured by stature while standing (WHO, 1995). H/A is an indicator of chronic malnutrition. A child exposed to inadequate nutrition for a long period of time will have a reduced growth and therefore a lower height compared to other children of the same age (stunting) (Refer Table 11).

II.5.2.4 Weight for age method

The W/A provides children's weight percentile based on age. Underweight, or low W/A, is commonly used in growth monitoring program for children. W/A is often used to tell if a child is normal, overweight or underweight. When a child weighs less than expected for their age, they are underweight, and when they weigh more than they should for their age, they are overweight. Children who are taller would be expected to weigh more than other children, just as children who are shorter would be expected to weigh a little less and still be healthy (WHO, 1995). W/A is a composite indicator of both long-term malnutrition (deficit in height/"stunting") and current malnutrition (deficit in weight/ "wasting") (Refer Table 11).

ll.5.4. Prevalence of malnutrition

Malnutrition and gastrointestinal infections are amongst the most prevalent chronic conditions affecting human health globally. More than 70% of children with PEM live in Asia, 26% live in Africa, and 4% in Latin America and the Caribbean (WHO, 1995).

In 2009, the WHO estimated that 27% of children in developing countries under the age of 5 years were malnourished. Approximately 178 million children (32% of children in the developing world) suffer from chronic malnutrition. Although the prevalence of childhood malnutrition is decreasing in Asia, countries in South Asia still have both the highest rates of malnutrition and the largest numbers of malnourished children. Indeed, the prevalence of malnutrition in India, Bangladesh, Afghanistan, and Pakistan (38-51%) is much higher than in sub-Saharan Africa (26%). In Mexico, the most recent national nutrition survey estimated that 1.8 million children under 5 years of age are malnourished (El. Ref.2).

The World Bank estimates that India is ranked 2^nd in the world of the number of children suffering from malnutrition, after Bangladesh (in 1998), where 47% of the children exhibit a degree of malnutrition. The prevalence of underweight children in India is among the highest in the world, and is nearly double that of Sub-Saharan Africa with direct consequences on morbidity, mortality, productivity and economic growth. Every day, 1,000 Indian children die because of malnutrition alone.

Poor nutrition remains a global epidemic contributing to more than half of all child deaths, about 5.6 million per year. Estimate of incidence of clinical malnutrition suggests that between 5 and 8 million cases occur annually. As an example, more than half (57%) of children in Burundi have stunted growth as a result of poor diet and the proportion of underweight children in South Africa has been increasing by 5 per cent a year (WHO, 1995).

ll.5.6. Causes of malnutrition

According to the United Nations Children's Fund (UNICEF), framework of causes of malnutrition, it is recognized that there are two immediate causes of malnutrition, which are inadequate dietary intake and infections (Pelletier et al., 1995). The cause of individual nutritional status depends on the interaction between food that is eaten, the overall state of health but also the physical environment. Malnutrition is both a medical and a social disorder, often rooted in poverty. Combined with poverty, malnutrition contributes to a downward spiral that is fuelled by an increased burden of disease, stunted development and reduced ability to work (Pelletier et al., 1995).

The poverty lead to many factors such as unhealthy environment, insufficient household food security, insufficient supply of protein, insufficient child maternal care, little education of women and malfunctioning of society such as war and natural disaster. All of these factors are direct or indirect causes of malnutrition (middle, moderate, severe: Marasmus-Kwashiorkor, micronutrients deficiencies) as shown in figure 1.

Poverty is the main underlying cause of malnutrition and its determinants. Adapted from (Müller and Krawinkel, 2005).

ll.5.7. Malnutrition in Rwanda

The nutritional situation in Rwanda remains persistently poor. For the last two decades, under nutrition remained a significant public health problem contributing to the high infant, child and maternal mortality.

In Rwanda a combination of poor knowledge on appropriate feeding, poverty and the traditional monotonous food consumption practices based mainly on traditional grains, roots and tubers led to a persistent problem of malnutrition among the most vulnerable populations.

In addition, a child mortality rate higher than 70 per 1000 is considered an indicator of Vitamin A deficiency, and in Rwanda this rate is 103 per 1000 (RIDHS, 2007/2008). The 1996 National Nutrition Survey reported prevalence rates of 25% and 21% for sub-clinical Vitamin A deficiency (serum retinol < 20 ìg/dl) for infants under 6 months of age and between 6 and 12 months of age, respectively. This may be an indication of inappropriate feeding practices in early childhood (Government of Rwanda, 2009).

According to the Rwanda Demographic and Health Survey (RDHS, 2005) and the 2009 Rwanda Comprehensive Food Security and Vulnerability Assessment & Nutrition Survey (CSVA&N), rates of malnutrition remain consistently high in Rwanda. For example, between the two surveys there were no significant changes in stunting (51% to 52%), underweight (19.8% to 15.8%) and wasting (5% to 4.6%). Furthermore, in May 2009, a nationwide screening using Mid-Upper Circumference (MUAC) found 8.7% of all children under five years of age to be suffering from wasting or acute malnutrition, (MUAC<12.5 cm). Although MUAC and W/H always give different figures of prevalence for wasting, the recent screening (2009) confirms a persistence of acute malnutrition in the country. There was also no significant improvement in malnutrition among women of reproductive age between the 2005 RDHS and the 2009 CSVA&N (9.9% to 7%) (Government of Rwanda, 2009).

The 2005 RHDS founds that the problem of malnutrition was more pronounced in rural than urban areas. This generally alarming situation is partly due to recurring food crises and chronic food deficits at the household level. The situation requires an effective and immediate response system concomitant with concerted long-term actions to improve nutrition and food security. The 2003 Annual Report of the Ministry of Health ranked severe protein-energy malnutrition amongst the ten leading causes of morbidity in health centers for children less than 59 months of age, and in hospitals, it was ranked the fourth leading cause of mortality for children less than 5 to 12 months of age and second leading cause of mortality for children between one and 14 years of age (Government of Rwanda, 2009).

ll.5.7.1.1 Lack of energy, proteins, vitamins, and minerals in Rwandese children diet

According to the Rwanda Interim Demographic and Health Survey (RIDHS) of 2007-2008, anaemia, which is a common manifestation of iron deficiency, affects 47.5% in children under five years in Rwanda and is most pronounced (65.5%) in children from six to 23 months of age. Children, particularly infants and those under five years of age are also at an increased risk for malnutrition due to a greater need for energy and nutrients during periods of rapid growth and development.

II.6. MEASURES TO PREVENT MALNUTRITION

ll.6.1. What should be eaten to prevent malnutrition

According to Food and Agriculture Organization (FAO), eating well is vital for a healthy and active life, but many people in virtually all countries do not eat well because of poverty and a lack of nutrition education. Foods such as meat, fish, and poultry contain all of the essential dietary amino acids. Foods such as fruits, vegetables, grains, and beans contain a variety of vitamins, grains and beans having also proteins.

II.6.1.1. Balanced diet for children

To avoid malnutrition, a balanced diet is one that has adequate daily servings from each of the food groups (energy giving food, protein giving food, vitamin and mineral giving food) and provides adequate nutrition for growth, and good health, both physical and mental. The source of energy includes mainly rice, wheat, cassava, bananas, sweet potatoes, bread to supply metabolic demands. The source of proteins include beans, cassava leaves, meat, fish and eggs and contain all essential amino acids to build organism such as in muscles. The source of essential fatty acids include the vegetable seed oils to protect organism against diseases. The source of micronutrients (vitamins and mineral elements) includes the dark green leaves, red and white meats for many biochemical reactions in the body. These groups of food must be found in the daily diet of children. The age of child is the determining factor in portion sizes and amount of each food group recommended (RIDHS, 2005). Breastfeeding a baby for at least six months is considered the best way to prevent early-childhood malnutrition.

Talking to a doctor before putting a child on any kind of diet, such as vegan, vegetarian, or low-carbohydrate, can help assure that the child gets the full supply of nutrients that he or she needs (Brookes, 1999). In society where the prevalence of malnutrition is high, sugar, cooking oil, maize flour and wheat flour could be potential vehicles for delivering vitamins and minerals.

ll.6.2. How malnutrition decrease immune system and lead to gastrointestinal infections?

The first line of defense against these types of infection is the innate (non specific) immune response, particularly epithelial barriers and the mucosal immune response. Protein Malnutrition (PM) significantly compromises mucosal epithelial barriers in the gastrointestinal, respiratory and urogenital tracts. For example, vitamin A, protein, micronutrients deficiencies induce the loss of mucus-producing cells. This loss of the protective mucus blanket increases susceptibility to infection by pathogens that would ordinarily be trapped in the mucus and swept away by the cleansing flow of mucus out of the body. Malnourished children suffer in greater proportion from bacterial gastrointestinal and respiratory infections (Chandra, 1999).

The human body requires a balanced diet that provides nutrients, minerals, and vitamins for a functional and effective immune response. Immune function is impacted by factors including hormonal status, age, and nutritional status. Malnutrition results in a depressed immune system that raises the risk of infections (Hedlund, 1995).

Severe PM in newborns and small children has been shown to cause atrophy of the thymus with reduced cell numbers and subsequently ill-developed peripheral lymphoid organs, i.e., lymph nodes and spleen. Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity (Savino, 2002).

Several studies on the effects of malnutrition at the immunological level have been conducted in humans and in experimental animal models. Multiple immune system abnormalities, including lymphoid organ atrophy, profound T-cell deficiency, altered ratios of T-cell subsets, and decreased natural killer (NK) cell activity and cytokine production have been described in individuals. In addition, these studies indicate that malnutrition decreases T-cell function, cytokine production and the ability of lymphocytes to respond appropriately to cytokines (Bhaskaram, 1992).

As shown in figure 2, nutritional deficiencies can affect immune response and increase susceptibility to infections. In turn, infection further aggravates nutritional deficiencies by increasing metabolic demands, decreasing nutrient intake, or blocking absorption from the gut (Calder et al., 2002). Nutritional and dietary supplements stimulate immune response and may result in fewer infections, particularly in the elderly and in malnourished, critically ill individuals (Chandra, 1999).

Figure 2: Relationship between nutrition and infection. Adapted from (Brown, 2003).

ll.6.3. How infections could be avoided by well nutrition

The human body requires a balanced diet that provides nutrients, minerals, and vitamins for a functional and effective immune response (Chandra,1999).

Recently, convincing evidence has been gathered to show that a set of proven and available interventions can solve these nutrition problems. Several of these direct and indirect nutrition interventions focus on the period from minus -9 to 24 months (i.e., from pregnancy to two years old) because during this «window of opportunity,» effective nutrition interventions have a high impact in reducing death and disease and avoiding irreversible harm to health and cognitive development due to under nutrition. Recent economic studies found that such interventions are highly cost-effective, with major returns to individual intellectual development, and earnings and national economic growth (Government of Rwanda, 2009). Relapse is reduced by training parents how to feed their child frequently with energy and nutrient dense foods. The regimen was tested in a South African project and found to reduce mortality from 30% to 20% (Schofield and Ashworth, 1997).

CHAPTER III. METHODOLOGY DESCRIPTION

III.1.STUDY SITE AND STUDIED POPULATION

The study was carried out in BUGESERA District case study of MAREBA Sector and Mareba Health Center. This center was selected as the area of the study because it is the one that has the highest number of patients from various areas in Mareba Sector. The studied population was 50 under five years old children brought by their parents for gastrointestinal infections test and malnutrition at Mareba Health Center.

III.2. SAMPLE STOOLS COLLECTION

The fresh stools were collected in a well disinfected solid bottle offered by laboratory itself to the parents who brought them in the laboratory of the microbiological investigation.

III.3. STOOLS SMEAR PREPARATION

On a microscopic slid, a drop of saline solution 1% was putted, then a small amount of stools was mixed slowly till the mixture change the color and a cover slip was placed over the drop.

III.3.1. MICROSCOPIC EXAMINATION

The prepared fecal solution was directly examined using the optic microscope at a magnification of 100X (10X objective). For clear identification of different forms of parasites, the prepared stool slide was objected at magnification of 400X (40X objective).

III.5. RISK FACTORS INVESTIGATION

By personal interview using fill-in method; a prepared questionnaire was used for interviewing each parent of the 50 children. By questionnaires, information were obtained about their knowledge on avoidance of gastrointestinal infections and malnutrition, about sanitary habits of the children; kind of water and other drinks (milk, porridge) they consume at home, sanitation before breast feeding and food feeding children and about their nutritional habits; if children eat fruits, vegetables, eggs, meats, beans and breastfeed milk.

III.6. IDENTIFICATION OF MALARIA

During this study, some children have also been tested for malaria and data have been added to the present work. The finger of every child was cleaned by alcohol before taking blood in order to avoid contamination of microbes. On microscopic slide, the blood was mixed with a drop of methylen blue and after drying methylen blue was removed by water. The prepared blood solution was directly examined using the optic microscope at a magnification of 100X (10X objective).

III.7. IDENTIFICATION OF MALNUTRITION AMONG CHILDREN

-Weight where Salter scale was used and the child was placed in the weighing pants/hammock, without touching anything;

-Height where the child was placed on the height board, standing upright in the middle of the board with arms at his/her sides. The child's ankles and knees were firmly pressed against the board the child's head straight;

-The percentage of reference weight for height was obtained by dividing the children weight by reference W/H (Table A5.4) X100. The percentage of reference H/A was calculated by dividing the height (length) by reference height (length) for age (Table A5.2) X100. The percentage of reference W/A was calculated by dividing the weight by reference W/A (Table A5.1) X100 (Tables A5.1, A5.2, A5.4 are found in Annexe2). By these percentages the types of malnutrition were classified as follow: W/H (<70% to <80% Moderate malnutrition; <70% Severe malnutrition), H/A (>85% to <90% Moderate stunted; <85% Severe stunted), W/A (>60% to <80% Moderate underweight; <60% Severe underweight) (El. Ref.1).

CHAPTER IV. RESULTS INTERPRETATION

Figure 3: The prevalence of gastrointestinal infection according to identified parasites in 50 infected children.

This figure above shows that the main causal agent of gastrointestinal infections identified among the stool sample was the yeasts with 30%, followed by Trichomonas intestinalis (14%), Entamoeba histolytica (8%), bacterial agents (8%) and 6% of the sample with White Blood Cells were found. Among the children tested for malaria, 16% were found to be infected by Plasmodium malaria at trophozoites stage.

This figure shows that the highest prevalence of infections was found in children from 25 months to 5years (34%), followed by children from 13 to 24 months (32%), from 0 to 6 months (18%) and children from 7 to 12 months (16%).

Figure 5: Gender presentation of children infected by gastrointestinal parasite.

The above figure shows that among the 50 children tested, 19 were girls with percentage of 73.60% positive and 26% unidentified infections, 31 were boys with a percentage of 77.4% positive and 22.5% with unidentified infections.

This figure shows that considering Weight for age method 4% present moderate and 4% severe underweight. By Length for age method no underweight observed and by Weight for height method 44% children present underweight.

Figure 7: Prevalence of malnutrition among children according to the infectious agents

According to the figure above, the majority of the infected children were moderately underweight. A positive relationship seems to exist between Trichomonas intestinalis and underweight, as 100% of the children infected by Trichomonas intestinalis were moderately underweight. Also, 66.6% of the children with double infections (bacteria and yeasts) were also moderately underweight.

Figure 8: Percentage of parents who agree that their children have sufficient nutrition and sufficient weight

Interviewed parents responded that the nutrition and the weight of most of children below 6 months are sufficient (88.9%) because they are breasted by their mothers. But for children from7 to 12 months, the percentage of responders who answered that the nutrition and weight are sufficient is low (12.5%) and (37.5%). And the level of satisfaction was even lower for older children as only 5.9% and 6.3% of parents agreed that the nutrition and the weight of their children between 13 months and 5 years old were sufficient. They said that children above 6 months lack a balanced diet due to economic reason.

According to interviewed parents, none of the children from 0 to 6 months eat and drink porridge, (88.9%) are breasted by their mothers. The times of breastfeeding decrease when age increase from 88.9% to 18.8%. Unless children from 0 to 6 months who did not drink porridge, more than 80% of children from7 months to 5 years drink porridge. The times of eating increase with age of children as they become mature. But the percentage of children eating more than 2 times per day remains low, with not more than 43.8% among the 25 months to 5 years.

Figure 10: Classification of children ages and percentage of children taking food.

This figure shows the all children from 0 to 6 months eat any meal; they feed on the milk of their mothers. The consummation of vegetables and beans was high among all age groups, but the percentage of children eating vegetable increased slightly from 7-12 months (62.5%) to 25 months-5years (75%), while the one of beans increased from 87.5% to 93.8%. The consummation of fruits is quite low among the 7-12 months (25%), but increased between 13-24 months to 52.9% to reach 68.7% for the children over 25 months. The children consuming meats, eggs and milk remains below 20% throughout all ages groups. The consummation of meat and eggs even decreased from 12.5% among the 7-12 months to 6.2% among the 25 months- 5 years. The consummation of milk only increased slightly from 12.5% among the 7-12 months to 18.7% among the 25 months- 5 years.

This figure shows that 0% of 0 to 6 months children drink water and 88.9% feed (breast) on their parents. A high percentage of children from 7 months to 5 years take food without their parents and drink unboiled water. The percentage of children taking food with their parents and drink boiled water decrease according to the increasing of age (12.5% to 6.2%). It is constant to children from 7 to 12 months (12.5%).

Children sickness times increase with age (11.1 to 62.5%). The highest prevalence of symptoms is found in children under 6 months (88.9%) and decrease with increasing of age, unless 25 months to 5 years the percentage is less increased. The percentages of children manifesting symptoms more than one day per week at all age were low.

CHAPTER V. DISCUSSION

Data collected from Mareba Health Center shows that among the children who attend a consultation, most were tested positive, having gastrointestinal or malaria infection with a prevalent rate of 76%.

This research showed that the most prevalent infectious agent found were yeasts (30%), followed by malaria at trophozoites stage (16%) and Trichomonas intestinalis (14%). Bacteria and Entamoeba histolytica were equally found among 8% of the children and white blood cells among 6%. The presence of white blood cells in the stool explains the fact that there are unidentified infectious agents which can cause these cells to come out in the stools. According to Samie et al., (2006), in invasive amoebiasis, white blood cells can be present in the stool, and in severe cases, pus can be visible.

The number of children infected with amoeba was lower than what found in subtropical and tropical countries where the prevalence may exceed 50%. In my study the percentage of children positively identified was higher than what found in rural of Senegal. A study done in Nyamata in 2010 and Cameroun in 2007 have shown the similar percentage of children infected by Trichomonas intestinalis but for Entamoeba histolytica the percentage was less in our study.

In our study, there were no intestinal helminthes. This is different to a survey done in 2008 on 8313 children from 30 districts by TRAC PLUS on helminthes infections where six species of intestinal helminthes were identified and lead to malnutrition.

The high prevalence of gastrointestinal infections may be due to the fact that the large number of interviewed parents (>90%) in the area of the study don't boil water taken by their children due to the local activities which do not allow them the time and accessibility to find firewood every time they need to prepare water to their children. Also, infective stages of bacteria resist to chlorination and require the proper refrigeration or adequate cooking (Prescott et al., 2005) which are not easy to apply due to economic reason.

Our research have shown that the highest infection rate was found in children from 13 months to 5 years (34%) and increase with age (16-34%) because children become able to go without their parents in surrounding area where they become exposed to different infectious agents.

This is similar to the research done by Umutoni, 2010 where the highest rate was found among children between 4-5 years old.

Our results have shown that the majority of the infected children were moderately underweight. A positive relationship seems to exist between Trichomonas intestinalis and underweight, as 100% of the children infected by Trichomonas intestinalis were moderately underweight. Also, 66.6% of the children with a double infections (bacteria and yeasts) were also moderately underweight. This is different from the results found in Northern Rwanda in 2009, where a relationship was only established with the double worms' infections ( Kaberuka et al.,2009).

As explained by Ali et al., 2008 protozoa and bacteria produce diarrhoeal diseases by infecting the small or large intestine, or both and leading to growth failure and malnutrition which in turn would weaken the immune system, increasing the risk of infections.

Our study shown that the number of young children eat fruits is very low, and most do not eat vegetables which are the main source of Vitamin A. In addition to its role in the prevention and treatment of night blindness, Vitamin A reduces susceptibility and the severity of infectious diseases. Consequently, Vitamin A improves child survival. The children who are under this research might be deficient in Vitamin A and are at risk to these diseases. This is similar to the study done by RIDHS in 2007/2008 which showed that Rwandese children would suffer from Vitamin A deficiency (RIDHS, 2007/2008).

Consequently children are exposed to many infections due to the lack of high amount of vitamins found in fruits and might have been exposed to vitamin A carency. The very low consummation of meat leads to presume that a high percentage of these children might be anemic, by lack of iron. The results would then be similar to the results of the study done by Rwanda Interim Demographic and Health Survey (RIDHS) of 2007/2008 showing that anaemia is a common manifestation of iron deficiency, which affects 47.5% in children under five years in Rwanda and is most pronounced (65.5%) in children from six to 23 months of age. This situation can partly be explained by the consumption of a diet based mainly on cereals and tubers that is a poor source of iron or only includes iron with low bioavailability.

Also the number of children taking milk and eggs are low which is in agreement with the finding with the high degree of malnutrition found in these results and the Rwandese survey. Also, the majority was eating less than 2 times a day.

These lead to the loss of weight, decreasing of immune system, gastrointestinal infections and malnutrition. Indeed, 8% were wasted and 44% were underweight. These results show higher percentage of malnutrition among the children under study higher than the results from RDHS (2005). This constatation even reinforce the idea that there is a relationship between malnutrition and gastrointestinal infections.

According to interviewed parents, the nutrition of their children is not sufficient so they cannot get a balanced diet to their children for economic reason.

The high prevalence of children with yeast is more than expected and might be Human Imuno-deficiency Virus positive (HIV+) due to the loss of body capacity to fight against diseases.

During this research, it has been shown that there are children suffer from malaria (16%), and the cause is that children are bitten by mosquito because they do not sleep under mosquito net.

It has been shown that prevalence of malaria infections was high (16%) because children do not sleep under mosquito net and environment they live is favorable for Plasmodium malaria reproduction.

Fortunately, most of parents breast their children without giving anything until 6 months. They breast their children more than five times per day but the times of breastfeeding decrease when children grow up while the WHO recommend breastfeeding up to two years.

CHAP VI. CONCLUSION AND RECOMANDATION

VI.1.CONCLUSION

Gastrointestinal parasites are highly prevalent in this research and poverty was implicated as an important risk factor for infections. Malnutrition is considered the most common cause of immunodeficiency throughout the world. In this research, malnutrition contributes to 52% of all children. The causes of malnutrition are multiple and complex and infections are a common precipitating factor.

An acute gastrointestinal infection is the most important cause of high morbidity and mortality among malnourished children and malnutrition is an important associated factor in these deaths.

Particularly, defects in the innate immune response resulting from protein calorie malnutrition may contribute to the susceptibility of malnourished children to infection.

Children studied present gastrointestinal infections and malnutrition. A positive relationship might have been observed between Trichomonas intestinalis and double infections with moderate children underweight. Among the risk factors there are nutrition factors: low consummation of fruits, vegetable and meat proteins. And hygienic factors; unboiled water and children taking food without their parents. The sensible control measures have to be planed for sustainable well being of children.

VI.2.RECOMANDATION

Adequate sanitation contributes strongly to the gastrointestinal infections reduction among children. The different control measures of gastrointestinal infections and reduction of death of children due to gastrointestinal infections and malnutrition involves different partners:

· Specific information for parents especially uneducated ones, should be planed for explaining them the means of gastrointestinal intestinal infections, the means of preventions and their relationship with malnutrition. It is also of interested to educate parents how they can prepare a balanced diet for their children by using the food eaten at home to avoid malnutrition.

· Laboratory should be well equipped with all required materials so it can be able to detect all possible pathogens such as viruses and identify the genus of bacteria.

· Parents especially women and caretakers are most to be with children for long time, they have to always wash their hand with soap and water thoroughly after using bathroom and before eating, clean breast and nipple before breast feeding children, keep all materials of children cleaned and wash fruits and vegetables to be given to the children.

ü Provide nutritionally adequate meals to all children especially under 5 years old.

ü Establish home gardens (Akarima k'igikoni) and promote the consumption of fruits and vegetables.

· Most of parents breast their children and they should breast them until 6 months without giving any other food, and also continue to breast them until 2 years old. They have to take a balanced diet in order to breast their children sufficiently.

· It has been found that, in our study many children do not eat meats because of high cost; the parents should grow the house eatable mice and doves in order to provide animal proteins and iron to their children at low cost.

· In village, the parents should associate and collect together the food for their children so one of them will be able to feed all children frequently.

The control measures of gastrointestinal infections, education of people to prepare a balanced diet and control measures of how they prepare the food must be taken in consideration at the level of sector.

GROSSARY

CD4+Tcells: they are the T. lymphocytes that use CD4 co-receptors to bind onto other cells.

Gastrointestinal infection: are infections of digestive tract affecting human

Infection: the process of entry of a parasite into a host and its subsequent establishments multiplication within the host's body.

Malnutrition: Any disorder or condition resulting from excess or deficient nutrient intake. Malnutrition takes both forms: under nutrition (wasting, underweight, stunting or micronutrient deficiencies) and over-nutrition (overweight and obesity).

Protein-Energy Malnutrition (PEM): a form of under-nutrition that results from inadequate protein or calorie intake to meet an individual's needs for normal growth, body maintenance, and the energy necessary for ordinary human activities.

Stunting: A slowing of skeletal (linear) growth that results in reduced stature or length relative to age, a condition that usually results from extended periods of inadequate food intake and/or frequent infection, especially during the years of fastest growth for children.

TRAC PLUS: Treatment and Research AIDS Centre and includes (Plus) the National Malaria Control Program (PNILP) and the National Tuberculosis and Leprosy Control Program (PNILT).

Underweight: A condition that reflects a deficit in weight for age or low weight-for-height; a composite measure of stunting and wasting.

Wasting: A condition that reflects a deficit in weight relative to height due to a loss of both tissue and fat mass, usually resulting from recent severe inadequate nutritional intake and/or episode of illness.

REFERENCES

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APENDICES

Table 2: THE PREVALENCE OF GASTROINTESTINAL INFECTION ACCORDING TO IDENTIFIED PARASITES IN 50 INFECTED CHILDREN.

Table 4: GENDER PRESENTATION OF CHILDREN INFECTED BY GASTROINTESTINAL PARASITE

N^o of child	Weight (Kg)	Height (Cm)	Age (Months)	Sex (F/M)	Weight/Height in %	Length/Age in %	Weight/Age in %	Infection
1.	7	72	13M	F	77.7(M)	94.2	69.3(M)	Bacteria and Yeast
2.	7	68	9M	F	88.6	95.2	78.6(M)	Bacteria and Yeast
3.	9.2	78	19M	F	88.4	94.4	80.7	Bacteria and Yeast
4.	11	91	36M	F	84.6	96.2	76.3(M)	Trichomonas intestinalis
5.	13	80	24M	M	120.3	94	106.5	WBCs
6.	10	82	24M	M	89.2	96.3	81.6	-
7.	15	89	36M	M	119.04	94.1	104.1	Yeast
8.	10	81	24M	M	90.9	95.1	81.9	-
9.	8	64	6M	M	117.6	95.6	106.6	Yeast
10.	12	88	36M	F	96.77	93.1	83.3	Yeast
11.	14	86	36M	F	116.6	91	97.2	WBCs
12.	10	79	24M	M	94.3	92.8	81.9	P.troph
13.	7	64	8M	F	102.9	91.2	82.3	-
14.	5	57	4M	M	104.1	90.6	78.1(M)	Yeast
15.	3.7	51	2M	M	105.7	88.5	74(M)	Bacteria
16.	5.2	60	5M	M	92.8	92.3	74.2(M)	Yeast
17.	4.8	58	4M	M	94.1	92.2	75(M)	Trichomonas intestinalis
18.	8	70	10M	M	94.1	96.2	86.9	-
19.	15	113	5Y	M	64.9(S)	103.4	82.4	P.troph
20.	7.9	75	11M	M	81.4	101.3	82.2	E.histolytica
21.	3.7	51	2M	F	105.7	59.9	74(M)	-
22.	7	70	12M	M	82.3	93	70.7(M)	Yeast
23.	8.1	72	14M	M	101.1	92.9	77.8(M)	Trichomonas intestinalis
24.	10.3	80	27M	F	95.3	91.3	81.1	E.histolytica
25.	4.3	54	3M	M	104.8	89.5	74.1(M)	-
26.	9	80	24M	M	83.3	94	73.7(M)	Trichomonas intestinalis
27.	8	79	24M	F	75.4(M)	92.8	65.5(M)	Yeast
28.	14	110	5Y	F	101.8	100.7	79.9(M)	Yeast
29.	13	93	4Y	M	96.2	90.9	79.2(M)	Trichomonas intestinalis
30.	13.1	92	4Y	M	99.2	89.9	79.8	-
31.	8	70	12M	M	94.1	93	80.8	P.troph
32.	10	81	24M	M	90.9	95.1	81.9	P.troph
33.	13.7	94	4Y	M	100	91.8	83.5	E.histolytica
34.	10.3	80	26M	F	95.3	92.2	82.4	-
35.	8	70	13M	F	94.1	91.6	79.2(M)	-
36.	10.5	87	36M	M	86	92.06	79.9(M)	Trichomonas intestinalis
37.	8	70	12M	M	94.1	93	80.8	WBCs
38.	7	81	13M	M	63.6(S)	106	69.3(M)	Yeast
39.	11.5	87	3.4M	M	94.2	89.5	76.1(M)	Yeast
40.	13	92	4Y	F	98.4	89.9	79.2(M)	P.troph
41.	15	96	4Y	M	105.6	93.8	91.4	P.troph
42.	9.1	76	17M	M	91.9	97.5	82.2	-
43.	10	83	24M	F	87.7	97.5	81.9	Yeast
44.	9.3	77	17M	F	89.4	95.4	84.5	E.histolytica
45.	12	93	4Y	M	88.8	90.9	73.1(M)	Trichomonas intestinalis
46.	10	82	18M	M	89.2	100.3	89.2	-
47.	8	70	12M	M	94.1	93	80.8	P.troph
48.	5	58	4M	F	98	92.2	78.1(M)	P.troph
49.	13.2	93	4Y	F	97.7	90.9	80.4	-
50.	10	85	24M	F	84.7	99.8	81.9	Yeast

Table 7: PREVALENCE OF MALNUTRITION AMONG CHILDREN ACCORDING TO THE INFECTIOUS AGENTS

Gastrointestinal infections and under nutrition among children between 0 and 5 years old. Case of Mareba sector, Bugesera district, eastern province, Rwanda

DECLARATION