dacca report

5
8/19/2019 Dacca Report http://slidepdf.com/reader/full/dacca-report 1/5 INTESTINAL PROTOZOA AND HELMINTHS IN SCHOOL CHILDREN OF DACCA, EAST PAKISTAN (EAST BENGAL)* ROBERT E. KUNTZ Naval Medical Research U nit No. 2, Taipei, Taiwan The subcontinent of India has frequently ex perienced the ravages of communicable a nd o th er diseases on an epidemic scale. In the spring of 1958 the Provincial Government of East Paid stan, as a result of extensive occurrences of cholera and smallpox, made a plea for outside assistance. Medical supplies and technical help were offered by several nations. The Commanding Officer of U. S. Naval M edical Research U nit N o. 2 provided technical assistance by offering the services of a group of investigators and technicians from the Unit at Taipei, T aiw an. T he a uth or , serving in the ca pa city of parasitologist, accom panied this group which was designated as the U. S. Naval Medical Mission to East Paid stan T he present report concerns people in an area where there have been few surveys giving the in cid en ce of parasites a nd o th er intestinal micro fauna. D ata and information were obtained from a study of stool specimens c ollec te d in the vicinity of Dacca, the capital. East Pakistan possesses peoplesithvariedulturesnd backgroundsnd the recent partitioning of India and the Pakistans has resulted in a continual two-way migration of refugees. Dacca, w ith a population of approxi mately one-third million, is located on the Burhi Ganga River in the vast alluvial plain formed by the silt desposits from the Ganges, Brahmaputra and Meghana Rivers. The climate is warm and humid and the average rainfall is reported as 80+ inches per year. MATERIALS AND METHODS Most of the fecal samples were obtained from school children 6 to 18 years of age with the majority in the 10 to 16 years age group. Al though the work of the Naval Mission was con cerned primarily with cholera which was preva lent in Dacca at the tim e, study materials for * The opinions or assertions contained herein are the private ones of the author and are not to be construed as officialor reflecting the views of the Department of the Navi. Mail address: APO 63,San Francisco, California th is re po rt were obtained o nly from individuals apparently in a normal state of health. Stools were taken from three areas representing slightly d if fe re nt s oc io lo gi c a nd e co lo gi c h ab it at s. Mirpur Colony High School, a school with an enrollment of approximately 1100 students lo cated a few miles north of Dacca in an area in which a good part of the population was engaged in farming, marketing and allied occupations. As a result of an influx of numerous refugees from India and other parts of Pakistan, a number of people were unemployed. Mirpur is located near a branch of the Burhi Ganga River and the popu lation makes generous use of its waters. As in most villages in this part of the world, the people were crowded into lim ited living space thus en couraging the spread and propagation of certain diseases. The m ajority of the population w as Muslim, the remainder Hindu. Questioning on the spot and macroscopic examination of stools revealed the local diet to consist mainly of rice and vegetables. Water for the village was avail able from tube wells but it is likely that water was taken from small ponds and rivers for house hold use. Teijgaon Polytechnic High School, a specialized, semi-private institution with approximately 500 students is located in Dacca proper. The student body was primarily Muslim and most of the children came from homes in the urban com m unity. The m ajority of parents were shop keepers, merchants and civil servants. Since attendance at this school required tuition, it is reasonable to assume that the students came from a slightly differenteconomic level than character istic of most people of East Pakistan. This as sumption was further supported by the general conditions and appearance of the school as well as of the students. D em ra Secondary School is a small inadequate school crowded with approximately 300 students. Stools were obtained from some parents and y ou ng er children as well as from the students. S in ce this series included several children a nd 16 8

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Page 1: Dacca Report

8/19/2019 Dacca Report

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INTESTINAL PROTOZOA AND HELMINTHS IN SCHOOL CHILDREN OF DACCA,

EAST PAKISTAN (EAST BENGAL)*

ROB ERT E . KUNTZ

N aval M edical Research U nit No. 2, Taipei, Taiwan

The subcontinent of India has frequently ex

p erie nc ed th e ra va ge s o f c ommun ic ab le a nd o th er

diseases on an epidemic scale. In the spring of

1958 the Provincial G overnm ent of East Paid

stan, as a result of extensive occurrences of

cholera and smallpox, made a plea for outside

assistance. M edical supp lies and tech nical help

wer e o ff er ed b y s ev er al n at io ns . The Commandi ng

Officer of U . S. Naval M edical Research U nit

N o. 2 provided technical assistance by offering

the services of a group of investigators and

technicians from the U nit at T aipei, T aiw an. T he

a uth or , ser vin g in th e ca pa city o f p ara sito lo gist,

accom panied this group which was designated as

the U. S. Naval M edical M ission to East Paid

stan

T he present report concerns people in an area

where there have been few surveys giving the

in cid en ce o f p ara sites a nd o th er in testin al m icr o

fauna. D ata and inform ation w ere obtained from

a stu dy of s to ol sp ec im en s c ollec te d in th e v icin ity

of Dacca, the capital. East Pakistan possesses

peo ple sithvar iedult ure snd bac kgr oun dsnd

the recent partitioning of India and the Pakistans

has resu lted in a co ntin ual tw o-w ay m ig ratio n of

refugees. D acca, w ith a population of approxi

mate ly o ne -th ir d m illio n, is lo ca te d o n th e Bur hi

Ganga River in the vast alluvial plain formed by

the silt desposits from the G anges, B rahm aputra

an d M egh ana R ivers. T he clim ate is w arm and

hum id and the average rainfall is reported as

80+ inches p er year.

M ATERIALS AND M ETHODS

Most of the fecal samples were obtained from

school children 6 to 18 years of age w ith the

majority in the 10 to 16 years age group. Al

th ough the w ork of the N aval M ission w as con

c er ne d p rimar ily w ith c ho le ra whic h w as p re va

lent in Dacca at the tim e, study m aterials for

* The opinions or assertions contained herein

a re th e p riva te o ne s o f th e a uth or a nd a re n ot to

b e c on str ue d a s o ffic ia l o r r efle ctin g th e v iews o f

the D ep artm en t of the N avi.

Ma il a dd re ss : APO 63, S an F ra nc is co , Ca li fo rn ia

th is re po rt w ere o btain ed o nly fro m in div id uals

apparently in a normal state of health. Stools

were taken from three areas representing s li ghtl y

d if fe re nt s oc io lo gi c a nd e co lo gi c h ab it at s.

M irpur C olony H igh School, a school w ith an

enrollm ent of approxim ately 1100 students lo

cated a few miles north of Dacca in an area in

w hich a g ood p art of th e po pu latio n w as en gage d

in f arm ing, marketi ng and a llie d o ccupa ti on s. A s

a result of an influx of numerous refugees from

India and other parts of Pakistan, a num ber of

p eo ple w ere u nemp lo ye d. M irp ur is lo ca te d n ea r a

branch of the Burhi Ganga River and the popu

lation makes generous use of its waters. As in

most villages in this part of the world, the people

were crowded into lim ited living space thus en

co ura ging the spread an d p ro pa gatio n o f c ertain

diseases. The m ajority of the population w as

Muslim , th e rem ain der H in du . Q uestio nin g o n

the spot and m acroscopic examination of stools

rev ea led th e lo ca l d ie t to co nsist m ain ly o f rice

a nd v eg eta ble s. Wa te r fo r th e v illa ge w as a va il

able from tube wells but it is likely that water

was taken from small ponds and rivers for house

hol d u se .

Te ij gaon Poly techn ic H igh Schoo l, a spec ia li zed ,

s em i-priv at e in st it ut ion w ith approxima te ly 500

s tu de nts is lo ca te d in D ac ca p ro pe r. T he s tu de nt

body was primarily Muslim and most of the

children came from homes in the urban com

m unity. The m ajority of parents were shop

keepers, m erch ants an d civil servants. Sin ce

attendance at this school required tuition, it is

r ea sonab le t o a ssume tha t th e s tuden ts c ame f rom

a s li ghtl y d if ferent economic l eve l than charact er

istic of m ost people of East Pakistan. This as

sump tio n w as fu rth er su pp orted b y th e gen era l

co nd itio ns a nd a pp eara nce o f th e sch oo l a s w ell

as of th e students.

D em ra Secondary School is a sm all inadequate

s chool crowded with approx imate ly 300 s tudents .

Stools were obtained from some parents and

y ou ng er ch ild re n a s w ell as from th e stu de nts.

S in ce th is series in clu ded seve ral ch ild ren a nd

16 8

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16 9

NTESTINAL PARASITES IN DACCA CHILDREN

parents, the ages ranged from 2 to 55 years.

H ow ever, the m ajority fell w ithin the 10 to 20

years age group. M ost of the children w ere from

fam ilies in w hich p aren ts an d o ld er c hildren w ere

laborers at the nearby jute m ills. The general

la xnes s in s an it at ion, mode o f liv ing and a pro li fi c

fly p op ula tion in th e v illa ge su gg ested a n id eal

h ab ita t f or e ff ec tiv e p ro pa ga tio n a nd tr an sm i ss io n

of p ara sites. V illa gers h ad d ire ct acc ess to th e

nearby Burhi G anga R iver. A s in other villages

in thisgener alrea tubewe llswerep resen tut

th e n ea rb y r iv er a ppar en tly se rv ed a s a s ou rc e o f

wa te r f or g eneral u se .

Even with the aid of a well-trained and ex

perienced interpreter only a very cursory back

ground history (age, occupation of parents, etc.,)

could be obtained. A s in previous surveys, fecal

sam ples w ere fixed by the “ MIF-vial―method1

which facilitates collection of study materials

und er a dv er se c onditio ns a nd g av e a ssu ra nc e o f

immediate and proper fixation of the included

m icrofauna. The m ajority of specim ens w as re

moved from sputum cups and fixed within 2 to

4 hours after passage.

For coll ec tion in t he fi eld 15-m i c apac ity s cr ew

cap vials w ere em ployed and 9.4 m l of M F (m er

thiolate-form alin) solution w as added prior to

departure from Taipei. Lugol's solution (0.6 in )

w as added to M F a few seconds before addition

of fecal sample to vial. W hen volume of stool

perm itted, three samples totaling about 1 m l

were taken from different areas of the stool.

A fter placing in M W fixative the fecal sam ples

were s tir red v igorou sly w it h t he a id o f an app lic a

t or s tic k. Upon r et urn t o t he laborat or y a t Taipei,

the stools were exam ined as opportunity per

m itted . T wo d irect sm ea r p rep ara tio ns (2 2 x 2 2

mm coverslip) of several drops each were ex

amin ed c are fu lly . T he se samp le s w ere w ith drawn

b y p ip ette from th e u pp erm ost la yer o f p articu

la te sed im en t. A t th e tim e o f seco nd p roc essin g,

on e h alf of the rem ainin g vialed specim en w as

s ub jec te d to M L FC co nce ntration .2

SU RV EY F IN DIN GS

S in ce th e p er io d fo r o bs er va tio n o f th e p eo ple

under study w as lim ited, it is difficult to correlate

th e p resen ce an d in cid en ce o f in testin al fau na

w ith d ue re ga rd to e co lo gic fa cto rs a nd th e g en era l

habits of the population. O n the site, there w as a

very definite im pression that all areas in w hich

studies were made provided ideal conditions for

th e w elfa re o f p ara sites o f m an a nd lower v erte

b rates. T able 1 lists th e sp ecies an d inciden ce fo r

intestinal protozoa and helm intha detected in a

single fecal sam ple obtained from people in the

Dacca area. No attempt has been made to cate

gorize data by precise age groups, by occupation

o f f am ilie s r epre sent ed , e tc ., s in ce th e numbers o f

p erson s fro m each o f three localities is n ot g reat.

M ost o f t he in testin al p ro to zo a com m on to m an

a re re pre se nte d b ut th e in cid en ce fo r s ome s pe cie s

is low er than exp ected for th is area. T he total

ra te s fo r E nIa nZOeb a h ie to ly tic a a re mo de ra te ly

h ig h an d su rp ass th ose fo r E ntamo eb a co li a nd

End olim ax n an a, u su ally th e p re domiw in t s pe cie s

in su rveys of this typ e. Sin ce it is believed that

th e i nc id ence o f pat hogenic E . h ie to ly tic a i s ove r

estim ate d in some stu dies, th e la rg er an d sm all

races of E. histolytica have been recognized as

d is tin ct ent it ie s, and t he re fo re lis te d s epara te ly .

The sm all, supposedly non-pathogenic race of

E. histolytica is much more common than the

large form of E . histolytica and the ratios of the

sm all to th e large race fall in th e sam e range as

recorded in sim ilar surveys in E gypt.3

The to ta l r ate s fo r E niamo eb a h is to ly tic a a nd

the o ther amebae , a lone , i nd ic ate t ha t v er y s at is

f ac to ry cond it ions f or tr an sm is sion o f paras it es

exist in the general population of D acca. D irect

person-to-person transm ission, perhaps as a rsult

of very low household sanitation practices and

grossly contam inated food, is suggested by the

incid encefDienia moeba fragi lishe generalse

o f w ate r fr om h ig hly c on tamin ate d p onds in a nd

around the city may well account for prevalence

of cyst -forming protozoans .

In Pak is ta n, a s in o th er c ountr ie s o f th e A sia n

In dian area, it is difficult to estim ate th e tru e

s ig ni fi ca nc e o f ameb ia sis s in ce t he re is a t en de nc y

in statistica l re po rts to in dica te m orb id ity a nd

m ortality due to all types of dysentery and diar

rheas in a single category. A visit to several

hospitals and health institutions in the D acca

area revealed that inform ation on am ebiasis was

essentially lacking and frequently no attem pt

w as m ad e to d ifferen tiate th is d ise ase from o th er

sim ilar co nd itio ns. W he n d ifferen tiatio n is co n

s id er ed , d et ermi na tio ns a re b as ed a lmo st e nt ir ely

on c lini ca l evidence .

Giardia lamblia is well represented but no

higher than expected in a population sample con

sistin g p rim arily of scho ol age child ren . T here is

no ade quate e xp la na tio n fe r th e low in cid en ce o r

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MirpurTeijgaonDemraDirect

@Direc t

smear M IFCDirect smearIFCProtozoaEntamoeba

h is to ly tic a ( LR onl y)@...

E ntamo eb a h is to lytic a (S R o nly )

Ent amo eb a h is to ly tic a ( LR and SR) ...

To ta l E . h is to ly tic a

Ent amoe ba c oli

E ndolim ax nana

lodamoeba bü ts ch li i

Dien tamoeba frag il is

Giardia l amb li a

Ch il oma st ix me sn il i

T ri ch omon as h om in is

En te romonas homini s

B alan tidium c oli

Isospora

6

24

7

37

37

23

18

9

16

—

1

—

1

15

19

4

25

34

14

17

3

8

—

—

—

—

—11

20

4

35

16

25

13

10

21

—

—

â

—

—6

20

5

31

20

20

6

15

20

—

1

â

—

11 0

25

4

39

20

10

19

4

14

2

3

2

—

—9

25

4

38

23

9

17

4

17

2

1

—

—HelminthsHookworm

Asca ri s lumb ri co id es

Enterob ius vermicularis

Heterodera

T ri chur is t ri ch iu ra

Acanthocephalan

Diphyflobothrium

Hym eno lep is n an a

Taenia

Fasc io lops is bus ki

Haplor ch is t ai chui

T yr og ly ph oid m ite

44

62

3

—

55

—

1

—

1

—

—

52 9

75

1

—

84

2

—

—

1

—

1

—52

36

6

1

39

—

—

—

—

—

1

124

40

3

1

56

—

—

—

—

—

1

—47

82

1

1

67

—

—

1

—

1

1

—13

83

1

1

87

—

—

1

—

1

—

2Negative

for protozoa

N eg ativ e fo r h elm in th s

N egative for both

19

7

02 2

3

034

26

03 9

19

03 5

6

03 6

6

0No.

of s tools exam ined 11711780809898

17 0

ROBER T E . K UN TZ

TABLE I

Incidence per cent)* of intestinal protozoa and helm inths in school children in the vicinity of D acca, East

Pakistan

* Given as nearest whole number.

t M IF C (m erthio la te -io dine -form alin co nc en tra tio n).

@ LR = large race E. histolytica with cysts measuring more than lOp; SR small race with cysts less

th an lOp .

absence o f o ther f lagel la te s. Chil omas ti x, a cosmo

po litan pro to zo an rep orted in m ost su rve ys, w as

d etected in o nly tw o p erso ns; b oth w ere m em bers

of the sam e fam ily. A sin gle stool contained cysts

o f Ba lant id ium coli wh ich is v er y preva lent in the

pigs of East Pakistan, and Isospora w as recog

n iz ed in a no th er sample .

Surveys for intestinal fauna of man in East

P ak istan are few o r lack in g. T herefo re, th ere a re

no fig ur es fo r c ompar iso n o f fin din gs fo r p eo ple

in th e D acca a rea w ith th ose in o th er p arts o f th e

country. Recently Dutt and Ghosh4 reported an

incidence of 11.3 and 7.5 r espectively for

E . h istolytica a nd G . lamb lia in a su rvey in W est

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17 1

NTESTINAL PARASITES IN DACCA CHILDREN

Bengal. They also stated that G upta, vi aL., in

1 95 4, h ad re po rte d a n in cid en ce o f 1 1.1 a nd 1 4.7

o f B . histo ly tic a and G . la mblia resp ective ly in a

study of hospital patients at C alcutta w hich lies

150 m iles southw est of D acca.

A ltho ug h g ov ern men t h ealth reco rd s p resen t

in s ome deta il t he s ta tis tic s r el at ing t o morb id it y

and m ortality due to snake bites, attacks by w ild

anim als and the m ore im portant com municable

diseases, no m ention is m ade of helm inth para

sites. T his, probably, is to be expected in a land

w here the significance of the latter is overshad

ow ed by the m ore devastating diseases su ch as

m alaria, c ho lera, an d sm allp ox. U po n qu estio n

ing officials and technicians at hospitals and

schools it w as learned that helm inth infections

are co nsidered as †œaart o f da ily liv in g―an d

that “everybodyhas worms― .Figures presented

in Table 1 tend to support this thesis.

It is d ou btfu l th at th ere h ave b een a ny ex ten

s iv e improvemen ts f or t he c on tr ol o r r educ ti on o f

helm inth diseases since Chandler's work in this

area 30 years ago. Ascaris and Trichuris are

found in the m ajority of persons exam ined and

hookworm is also com mon. It is assum ed that

Necat or amer ic anus is th e p re va ilin g s pe cie s in th e

D acca re gion b ut ex ten siv e m ig ratio ns of p eop le

i n recent years have probably int roduced Ancylos

toma duodenale. It is likely that multiple stool

sp ec im e ns wou ld h av e d emo nstra te d e ve n g re ate r

num bers of infections by worm s. As with certain

o f th e p ro toz oa , th e rates for in cid en ce of h oo k

w orm , A scaris, and w hipw orm corroborate obser

v atio ns r ev ea lin g a v er y low s ta nd ar d o f sa nita

tion in the majority of homes. In view of the

latter, the very low incidence (1 person) for H y

men ole pis n an a is pu zzlin g. H ow ev er, C ha nd le r s5

survey of India showed H. nana to be erratic in

o cc ur re nc e a nd p ra ctic all y a bs en t in s ome r eg io ns .

Although it may be argued that the nem atodes

h av e mu ch mo re re sista nt e gg s th an Hymen ole pis,

it is not believed that this is the lim iting factor

for infection by this parasite in Dacca where

most environments appear to be optimal for

p ro pa ga ti on a nd t ra nsm is sio n.

B oth Stronqyloides stercoralis and Tricho

stro nq ylu s w ere a bsen t altho ug h the ha bits of th e

people along w ith their close association with

c erta in a nim ldR wo uld s eem to a llow in fe ctio n b y

these worms. Dutt and Ghosh4 reported a low

rate of infection for Stronqyloides in W est B engal,

i.e., 0.4 , and did not list Trichostrongylus.

Earlier, Chandler found Trichostrongylus to be

rare in the area now know n as E ast P akistan, and

S tron gylo id es to b e very erra tic in d istribu tion

w ith a v ery low in cid en ce in some p la ces.

S in ce t he se s tud ie s we re bas ed ent ir el y upon an

e xamin ati on o f f ec al s amp le s th e r at es o f in fe ctio n

f or Enterob iusprobably are much lower than they

would have been had the scotch tape method

been em ployed. In view of the closeness of the

p eop le to th e so il an d th e fac t th at th ey ea t m an y

f re sh veg et ab le s, th e pauci ty o f He te rode ra is no t

re ad ily u nd ers to od . Howev er, C ha nd le r lik ew is e

reco rd ed lo w ra tes fo r th is h elm in th in certa in

lo ca litie s. E gg s o f a n a ca nth oc ep ha la n were fo un d

in 2 fecal sam ples. T hese possessed the general

char ac te ri st ic s o f Mac racan tho rhynchus h ir ud ina

ceus but have not been listed as such since the

mea su reme nts w ere c on sid era bly le ss th an g iv en

for this parasite. The specific identity of the

D iphyliobothrium is also questionable since m eas

urements do not agree w ith those given for

diphyllobothriids reported for man. Possibly

th ese represent instances in w hich th e eggs of

animal parasites have been consumed with con

tam in ated fo od s in an en virom en t w here rats an d

dom estic animals have access to food intended

for h um an use.

F asC iO lO pa is a nd H ap lo rc his ta ich ui a re th e o nly

representatives of the trem atoda, although the

domestic animals of East Pakistan are heavily

infected w ith F asciola an d o th er h elm in th s. C er

tainly, the consum ption of num erous brackish

an d fresh water fishes in the D acca area offers

oppor tun ity for grea ter inf ec ti on wi th t rematodes

than indicated in the present survey.

C oncen tration of p arasites b y th e use of th e

M IFC m eth od d id n ot g rea tly alter th e fin din gs

for m ost sp ecies. A s a m atter o f fa ct th e ra tes for

a number o f p ro to zo a a nd h elm in th s w er e h ig he r

b y th e d ir ec t sme ar e xamin atio n. T his is a n in di

ca tion of th e effica cy o f th e M IF v ia l a nd d irect

sm ear tech nic by w hich gradual sedim entation is

re sp on sib le fo r c on sid era ble c on ce ntra tio n o f th e

in clu ded o rg an ism s an d eg gs. T here a re ex cep

tio ns . In s amp le s fr om a ll th re e s ch oo ls th e r ate s

fo r A sc ar is a nd T ric hu ris w er e e le va te d a nd th e

eggs of an unidentified acanthocephalan w ere

found as a result of em ploym ent of the M IFC

technic.

T he in cid en ce o f in testin al fa un a is g iv en fo r

each of three schools from w hich stool sam ples

wer e o bta in ed . H ow ev er , s in ce th e liv in g c ondi

tio ns in th e differen t areas w ere c om parab le an d

the overall pictu re of parasitism sim ilar, it is

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172

ROBERT E. KUNTZ

u nn ec es sa ry fo r a dd itio na l d isc us sio n re ga rd in g

th e fin din gs fo r ea ch sch ool. It is q uite o bv io us

th at p ar as ite s a nd r ela te d i nt es ti na l f au na f lo uri sh

in th e pop ulations stu died and their presen ce

reflects the low sanitary standards of people

living in an environment where transm ission for

c erta in p ara site s is o ptim al. A ll s to ols c on ta in ed

a t le ast o ne sp ec ie s o f in te stin al fa un a and only a

few escaped infection by helminths. Although

h elm in th d ise ase s e lic it little a tte ntio n, it sh ou ld

be noted that in a cholera ward visited by the

a uth or, tw o ch ild ren su ffered n oticea bly w ith

in te stin al o cc lu sio n by As ca ris a nd o th er p atie nts

were anem ic as a result of heavy hookworm

infection.

SUMMARY

A survey based upon a study of single stool

specim en s from 300 stu den ts in th e vicin ity of

Dacca, East Pakistan, indicates the occurrence

of parasites and intestinal fauna in this general

a re a. En t amoeb a h is to ly tic a, B . c oli a nd Endo limax

n an a w ere p re va le nt, s up po rtin g o bse rv atio ns in

dicating that the people, in general, live in an

envi ronmen t wh ich pe rmi ts e ff ec ti ve t ran smi ss ion

o f c er ta in p ar as ite s. T he sma ll, n on -p ath og en ic

race of E. histolytica was m uch m ore com mon

than the larger race. B alantidium coii and Iso

spora were uncom mon with a single infection

d ete cte d fo r e ac h. Hoo kworm , A sc aris a nd T ric hu

ne occurred in a high percentage of the popula

tio n a nd eg gs of H ym en ok pis n an a w ere fo un d in

a s in gle sto ol. A n u nid en tifie d a ca nth oc ep ha la n

w s re orded s well s singleinfe tionith

Fasc io lopsi s and Diphyl lobothn ium , and three w it h

H apiorchis taichui. All persons studied possessed

a t le as t one spe cie s o f paras ite .

ACKNOWLEDGEMENTS

The author is indebted to Dr. Thomas A .

Cockburn, ICA, Dacca and to the M inistry of

Health of East Pakistan for the use of laboratory

and o ther f ac ilit ie s during the fi eld phas es o f t his

study. D r. Raymond H. Watten, LCDR, MC,

USN, Charles Knight, HM C, USN and James

E . R eese Jr., HM1, U SN , assisted in ob tain in g

inform ation and specim ens. G . M . M alakatis,

H M1, U SN and Jam es E. R eese, Jr., H M1, U SN ,

p ro cessed the fecal sp ecim en s. M r. Jalal-U dd in

A hm ed, D epartm ent of H ealth served in the ca

pacity of interpreter and as liaison officer for

th e M is sio n.

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