TMIH434

Tropical Medicine and International Health

volume 4 no 7 pp 522524 july 1999

Viewpoint: The neglect of stool microscopy for intestinal

parasites and possible solutions
S. C. Parija and H. Srinivasa
Department of Microbiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Keywords stool microscopy, protozoa, helminths, diagnostic parasitology

correspondence Professor Dr. S.C. Parija, Department of Microbiology, Jawaharlal Institute of
Postgraduate Medical Education and Research, Pondicherry 605006, India. Email: parijasc@md3.vsnl.net.in

Introduction
It is estimated that nearly one quarter of the worlds population, most of them living in developing countries, harbour
one or more intestinal worms (Bundy et al. 1992). Definitive
diagnosis of most intestinal parasitic infections depends on
the demonstration of cysts and trophozoites, or ova, larvae
and, rarely, adult worms in the stool in cases of protozoal and
helminthic infections, respectively. This is traditionally done
by examination of stool with the help of a light microscope.
The procedure involves examination of wet mounts of
stool specimens either directly or after concentration and
examination of permanently stained faecal smears. Commonly, two types of wet mounts are done: one unstained,
using physiological saline, and another temporarily stained
preparation using either Lugols or DAntonis iodine stain or
lacto-phenol cotton blue (LPCB) stain (Parija & Prabhakar
1995; Parija 1996). When it is not possible to immediately
examine wet mounts, a smear of faeces on a glass microscope
slide can be stained with Trichrome or another permanent
stain. However, permanent staining of faecal smears is
usually restricted to the large central laboratories, as this
technique requires considerable technical expertise.
Why is stool microscopy neglected?
Stool microscopy offers many advantages over other methods
used in parasitology, such as immunodiagnostics. First,
demonstration of parasites in the stool confirms the diagnosis
and is the gold standard. It is a sensitive procedure for most
parasitic infections provided that specimens are collected
properly and that an adequate number are examined.
Secondly, it is a simple procedure that can be done in any laboratory equipped with a light microscope and inexpensive
reagents. Thirdly, stool microscopy is extremely economical.
However, in spite of its advantages, we feel that in recent
years it has been neglected.
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We attempted to analyse the causes of neglect of stool

microscopy by using Cause-and-Effect diagrams (Leehov &
Ersoz 1991), which are commonly used tools in personnel
management in industry and hospitals. The usefulness of
these charts lies in identifying and illustrating the relationship
between an effect, an outcome or a problem and the possible
factors that contribute to it. The diagrams are also called
Ishikawa diagram (for their inventor, Karora Ishikawa et al.
1950), fish bone diagrams (because of their shape) or
fishykawa diagrams (a combination of both). An Ishikawa
diagram analysis of the cause of neglect of stool microscopy
is presented in Figure 1.
Lack of motivation among technicians in performing stool
microscopy is the most important feature. Non-recognition
of their work by peers, either in terms of financial benefit or
career development, inadequate skills due to lack of formal
training and their attitude to handling and examining stool
specimens are some possible factors responsible for this state
of affairs. The problem is compounded further by the attitude of senior laboratory experts towards stool microscopy.
Many of these specialists are either clinical pathologists or
bacteriologists and may not possess the requisite skills. They
therefore feel neither competent nor confident enough to
supervise and guide technicians.
Indifference of clinicians to the results of stool microscopy
is another key factor. There is often a discrepancy between
their clinical impression and the laboratory results, so they
may prefer to treat suspected cases of intestinal parasitic
infections with broad-spectrum anthelminthic agents rather
than awaiting the results of stool microscopy. Lacking awareness of the importance of proper collection and transport of
specimens, and the need to examine adequate numbers, are
other detrimental factors.
Substantial progress has been made in recent years in the
development of a variety of nonmicroscopic methods for the
diagnosis of intestinal parasitic infections such as amoebiasis,
giardiasis, cryptosporidiosis and microsporidiosis. These
1999 Blackwell Science Ltd

Tropical Medicine and International Health

S. C. Parija and H. Srinivasa

volume 4 no 7 pp 522524 july 1999

Viewpoint: stool microscopy and intestinal parasites

Work
force

Method

Lack of motivation among stool

microscopists
Lack of formal training in
stool microscopy

Improper collection of
specimens

Non-recognition of work of stool

microscopists by their peers

Delay in transport of specimens

Poor quality control

Examination of inadequate
number of specimens
No CME programme on stool microscopy
Stool concentration
not done routinely

Reluctance to handle stool

specimens

Increasing availabilities of
non-microscopic methods

Empirical treatment by doctors

Apathy of clinicians to stool
microscopy reports
Neglect of
stool
microscopy
Lack of reagents and chemicals

Sophisticated, high-tech and highly

appealing non-microscopic methods
No specific budgetary
support for stool
microscopy

Ineffective supervision by
laboratory consultants

Non-availability of a lab manual

on stool microscopy
No charts and other education
materials on stool microscopy

Eye strain on examination of a

large number of specimens

No standard sets of slides of intestinal

parasites for reference
Miscellaneous

Materials

Figure 1 Cause and effect diagram on neglect of stool microscopy.

include antigen detection in faeces, direct fluorescent antibody methods, and molecular biological techniques such as
DNA probes and polymerase chain reaction (PCR). Many of
these tests, unlike stool microscopy, are hi-tech and appeal to
laboratory workers. They have the advantage of being highly
sensitive and specific without the need for the skill of technicians for morphological detection and identification of
parasites. However, the vast majority of these methods are
not suitable for use in laboratories in resource-poor countries.
Increasing the use and reliability of stool microscopy
In these changing circumstances, there is an urgent need to
strengthen stool microscopy in diagnostic microbiology
laboratories. This can be achieved primarily by motivation of
senior laboratory experts to make stool microscopy reliable.
A change of attitude to stool microscopy and effective supervision will instill a sense of confidence and importance
among laboratory personnel carrying out the tests, which in
turn will increase the reliability of results and change the attitude of clinicians.

1999 Blackwell Science Ltd

Developing the skills of the stool microscopist is therefore

of primary importance. Regular training including both
internal and external quality control should form an integral
part of stool microscopy. Internal quality control should be
routine practice and encompass all steps of routine microscopy, i.e. collection and processing of specimens, recording
and reporting of results and quality control of reagents.
Availability of preserved samples of stool for protozoal cysts
and helminthic eggs and larvae and permanent stained faecal
smears for these parasites would be helpful. External quality
control by a regional or national laboratory would help
remove the bias associated with internal quality control. The
referral laboratory could send coded faecal samples to the
participating laboratory for examination as for routine
samples, compare results and report with feedback within a
specified period.
Concentration of stool for intestinal helminthic ova and
protozoal cysts is a useful procedure to increase sensitivity of
stool microscopy. At least one method, such as formalin-ether
concentration, should be routine procedure in stool
microscopy. Saturated salt floatation is another simple
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Tropical Medicine and International Health

S. C. Parija and H. Srinivasa

Viewpoint: stool microscopy and intestinal parasites

method which could be easily adapted in a rural health centre

laboratory.
Continuing medical education is important to maintain
these skills. Special emphasis needs to be given to training of
laboratory technicians working in peripheral or rural health
facilities. This includes provision of relevant literature, stool
microscopy manuals and WHO charts. Training needs to be
followed-up with regular performance appraisals. In order to
be successful, training programmes should be repetitive and
self-sustained.
We are confident that these approaches would result in
motivated, competent laboratory personnel at the primary
health care level. We believe that stool microscopy will continue as the most important diagnostic method. The procedure cannot be replaced by developments in diagnostic

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parasitology in the near future, especially in resource-poor

countries.

References
Bundy DAP et al. (1992) Evaluating measures to control intestinal
parasitic infections. World Health Statistics Quarterly 45,
168179.
Leehov W & Ersoz CJ (1991) The health care managers guide to
continuous quality improvement cause-and-effect diagrams. Pp.
160165.
Parija SC (1996) Text Book of Medical Parasitology, Protozoology
and Helminthology. Text and Color Atlas. AIPD.
Parija SC & Prabhakar PK (1995) Evaluation of lacto-phenol cotton
blue for the microscopic preparation of faeces. Journal of Clinical
Microbiology 33, 10191021.

1999 Blackwell Science Ltd