Spatial Analysis of Blastocystosis Patients in Lampung Province:

Study on Malignancy Patients who Received Chemotherapy at

RSUDAM Lampung Province in 2022

Jhons Fatriyadi Suwandi

1,* a

, Noviany

, Juspeni Kartika

and Agnes Kurniawan

Department of Microbiology and Parasitologi, Faculty of Medicine, University of Lampung, Bandar Lampung, Indonesia

Department of Chemistry, Faculty of Mathematics and Natural Sciences, University of Lampung,

Bandar Lampung, Indonesia

Department of Internal Medicine, Faculty of Medicine, University of Lampung / Dr. H Abdul Moeloek General Hospital of

Lampung Province, Bandar Lampung, Indonesia

Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Keywords: Blastocystis sp, Immunosuppressive, Spatial Analysis, Malignancy.

Abstract: Blastocystosis is an intestinal protozoan infection that can cause diarrhea. In the immunocompetent group, it

can be asymptomatic. However, in immunosuppressed patients, it can be severe. The disease is transmitted

by the oro-faecal route through food that has been contaminated with the faeces of patients. Spatial analysis

can be used to map people to determine the risk of the parasite spreading. The aim of this study was to

investigate the mapping of blastocystosis patients, studies in patients with malignancies at Lampung

Provincial Hospital. We diagnosed Blastocystis infection in 62 fecal samples from study subjects through

fecal microscopic examination. To determine the location of the patients' residences, we used Google Maps

and Google Art applications based on the addresses listed on the questionnaire. The coordinate data were

analyzed, and mapped using the ArcGIS 10.8.2. The results of the microscopic examination showed that

32.26% of the samples were positive for Blastocystis infection. Patients are distributed within the coordinates

of 104.6380950 to 109.1035280 East and 3.9533070 to 7.0776440 South. The majority of patients are located

in Bandar Lampung City, with the farthest origin of residence being Purbalingga Regency in Central Java

Province. The buffering pattern was obtained using a radius of 10 kilometers.

INTRODUCTION

Several species of intestinal protozoa have been

reported to be one of the causes of intestinal disorders

such as diarrhea, which can be persistent and chronic

diarrhea or acute diarrhea. Intestinal protozoal

infections in immunocompetent groups are usually

asymptomatic or mildly symptomatic.

In immunosuppressive groups such as patients

with HIV/AIDS, malignancies, patients on

immunosuppressive therapy and several other

conditions of impaired immunity can be severe and

can cause death (Esteghamati et al., 2019; Fletcher et

https://orcid.org/0000-0002-6938-1628

https://orcid.org/0000-0002-4046-6134

https://orcid.org/0000-0003-1969-5503

al., 2014). Intestinal protozoa that have been reported

as causes of infection are Giardia lamblia,

Cryptosporidium sp, Amoeba, Isospora sp,

Cyclospora sp and Blastocystis sp (Boughattas et al.,

2017; Esteghamati et al., 2019; Giannakopoulos et al.,

2019; Laksemi et al., 2020).

Intestinal protozoal infections are often overlooked

and underdiagnosed. This is because the symptoms are

mild and even asymptomatic, especially in

immunocompetent groups. However, intestinal

protozoal infection is one of the infections that can

cause increased morbidity and mortality in the

community. Impaired nutrient absorption, resulting in

impaired growth and development, especially in

Suwandi, J. F., Noviany, , Kartika, J. and Kurniawan, A.

Spatial Analysis of Blastocystosis Patients in Lampung Province: Study on Malignancy Patients who Received Chemotherapy at RSUDAM Lampung Province in 2022.

DOI: 10.5220/0013672300003873

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 353-358

ISBN: 978-989-758-740-5

353

children under five years of age, may lead to cognitive

impairment in the future. It is therefore important to

overcome this infection (Faria et al., 2017).

Blastocystis sp is a cosmopolitan protozoan

parasite. Symptoms are generally atypical and include

abdominal pain, constipation, diarrhea, flatulence, and

irritable bowel syndrome (IBS). Several species of this

parasite are found in the gastrointestinal tract of

animals and humans. Several subtypes have also been

identified. Not all subtypes infect humans, with only 9

of the 17 reported subtypes found in humans (Asfaram

et al., 2019; Dacal et al., 2018; Ramírez et al., 2016;

Villamizar et al., 2019; Wawrzyniak et al., 2013) This

protozoan is thought to be transmitted by the fecal-oral

route. Transmission can occur from person to person,

but the possibility of transmission from person to

animal and vice versa is unclear (Ramírez et al., 2016).

Geographic Information Systems (GIS) are an

important tool for studying the distribution of disease

within a location or region. Disease mapping is useful

for understanding the distribution of disease incidence

and identifying underlying geographic risk factors. In

addition, disease mapping facilitates decision making

and rapid response for disease management. There are

not many studies that discuss the spatial analysis of

intestinal protozoan infections, especially

blastocystosis in Indonesia. In fact, one of the factors

in the spread of diseases, especially orofaecally

transmitted diseases, is closely related to

geographical, environmental and socio-cultural

conditions (Fletcher et al., 2014). The use of spatial

analysis on the spread of parasitic diseases has been

done in Lampung Province (Dharmamedula et al.,

2017; Suwandi et al., 2014; Wardani et al., 2018), but

blastocystosis infection has never been done. This

paper discusses the spatial analysis of blastocystosis

patients in the group of malignancy patients who

received chemotherapy in Lampung Province.

MATERIALS AND METHODS

The design of this study was cross-sectional

analytical observational conducted at RSUDAM

Lampung Province. The population of this study were

patients with malignancies who received

chemotherapy with or without symptoms of diarrhea

at RSUDAM Lampung Province in the period

October to November 2022. The sample of this study

is part of the population determined based on

inclusion and exclusion criteria. Inclusion criteria for

determining research subjects, namely patients with

malignancies who receive chemotherapy with or

without diarrhea symptoms; age> 1 year; have

received at least 1 chemotherapy with a minimum

rarity of at least 1 week since the first chemotherapy;

willing to participate in the study by signing an

informed consent. Exclusion criteria are suffering

from severe complications, not willing to provide

feces.

To determine blastocystosis infection, fecal

parasitologic examination was performed on all fecal

samples of the study subjects. Fecal examination was

performed using the formalin ether concentration

technique. This technique is used to increase the

sensitivity, especially when the number of parasites is

low. Approximately 1 ml of fecal suspension in 5%

formalin was added to 5 ml of 10% formalin and

stirred until homogeneous. After filtering the feces to

separate the fiber, 2 ml of diethyl ether was added.

The solution was shaken vigorously and centrifuged

at 2500 rpm for 2 minutes. The precipitate was

removed and the supernatant was collected. The

sediment from this concentration test is used for

direct testing with 1% Lugol's solvent, which is then

read under a microscope at 400X magnification. The

result of the test is positive if Blastocystis sp is found

or negative if not found.

In order to determine the coordinates of the

location of the research subject's residence, it was

carried out with the help of google map and google

earth devices. The home address contained in the

questionnaire was entered into google map or google

earth to find the location of the research subject's

home. The coordinate points that were successfully

found were then analyzed to see the mapping of

patients and the buffering pattern formed using

ArcGIS 10.8.2 software. The patients were mapped

based on the results of the microscopic examination.

The buffering pattern refers to the gate distance of

houseflies as one of the mechanical vectors for the

spread of intestinal protozoa. This research has

received ethical approval from the Health Ethics

Committee of the Faculty of Medicine, University of

Lampung No. 2059/UN26.18/PP/05.02.00/2022.

RESULTS AND DISCUSSION

Geographically, the residence of the research

subjects is located at the coordinates 104.6380950

east longitude - 109.1035280 east longitude and

3.9533070 south latitude - 7.0776440 south latitude.

Administratively, Bandar Lampung City is the place

where most of the research subjects live.

Thesesubjects generally live in densely populated

neighborhoods. Figure 1 shows the distribution of

research subjects.

ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH

354

Figure 1: Distribution of All Research Subjects

Based on the results of microscopic examination

of fecal parasitology, 20 subjects (32.26%) were

positive for Blastocystis sp, 1 subject (1.61%) was

positive for Entamoeba histolytica, and 1 subject

(1.62%) was positive for hookworm. Almost all

subjects found to have parasites resided in Lampung

province, only 1 person came from Purbalingga,

Central Java. The distribution of patients found

positive for parasites by microscopic examination is

shown in Figure 2. Administratively, the location of

the most positive patients was found in Bandar

Lampung City.

Based on satellite imagery, it appears that the

research subjects who were positive for

blastocystosis in Bandar Lampung were located in

densely populated areas. This will certainly have an

impact on the risk area for the spread of this infection.

The satellite image is shown in Figure 3.

can result in the parasite entering the human body

(CDC, 2019). The presence of mechanical vectors

also increases the transmission process by these

vectors. Houseflies (Musca domestica) are one of the

mechanical vectors that are suspected to be one of the

factors that facilitate the spread of this parasite. The

ability to fly and move far from the housefly, as well

as the resistance of the parasite attached to the fly's

body, are important in the transmission process of

this parasite (Hastutiek & Fitri, 2013; Szostakowska

Figure 2: Distribution of Research Subjects Positive for

Blastocystis sp and Other Intestinal Parasitic Infections

Figure 3: Satellite images of blastocystosis in Bandar

Lampung

et al., 2004). In addition to houseflies as potential

mechanical vectors, cockroaches have been reported

as potential mechanical vectors in the transmission of

Blastocystis sp (Dokmaikaw & Suntaravitun, 2019;

Ma et al., 2020).

Spatial Analysis of Blastocystosis Patients in Lampung Province: Study on Malignancy Patients who Received Chemotherapy at RSUDAM

Lampung Province in 2022

355

The mechanism of transmission of Blastocystis sp

remains unclear. The infective stage that can be

transmitted to humans has not been identified. In

general, this transmission is fecal-oral. Parasite

contamination from feces on food or eating utensils

Buffer zones are areas of potential or risk for

transmission. The radius of this buffer area refers to

the area of contact and transmission of parasites by

mechanical vectors of houseflies, which are abundant

in the environment. The flight distance of houseflies

can reach 32 km (20 miles) (Hastutiek & Fitri, 2013;

Puspitarani et al., 2017; Szostakowska et al., 2004;

Zurek et al., 2001). In this study, the radius of the

buffer area is up to 10 km, and an overview of the

buffer area is shown in Figure 4.

Figure 4: Buffering patterns in patients with blastocystosis

Based on the prevalence obtained, this study has

a higher prevalence (32.26%) compared to research

in Sydney (5%) (Fletcher et al., 2014); in Rio de

Janeiro (12.7%) (Faria et al., 2017); in Iran (5.2%)

(Asfaram et al., 2019) and in Padang by 21.3%

(Nofita et al., 2015). Other studies in Brazil showed

a similar prevalence (31%) (Bertozzo et al., 2022)

and in Manado (36,4%) (Muflihatun et al., 2015).

This could be due to the different study populations.

In this study, the population was a high-risk group,

namely patients suspected of having a compromised

immune system. In the immunocompromised

population, the incidence of protozoal infections

tends to be high and can cause opportunistic

infections, including Blatocystosis (Laksemi et al.,

2020; Xu et al., 2021).

The incidence of intestinal protozoan infections

such as Blastocystis sp is inextricably linked to

favorable environmental conditions such as poor

sanitation, population density, availability of

mechanical vectors, and community behavior. Open

defecation practices may result in environmental

contamination by human feces containing protozoa.

This is consistent with the results of other spatial

analysis studies, such as those in Rio de Janeiro

(Faria et al., 2017) and Iran (Asfaram et al., 2019).

CONCLUSIONS

The prevalence of blastocystosis in risk groups such

as patients with malignancies was 32.26%. The

buffering pattern formed is quite extensive, especially

in Bandar Lampung City, although in general the

subtype of this parasite is not yet known.

ACKNOWLEDGEMENTS

We would like to thank all those who helped this

study, especially the patients (volunteers) who were

willing to be the subject of this study. As well as to

the University of Lampung HETI Project which has

funded this research.

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