Introduction

Enterobiasis, commonly known as pinworm infection, is one of the most common helminth infections in the world.  It is caused by small, white, thread-like parasitic roundworms called Enterobius vermicularis.¹ Enterobiasis is highly contagious and can affect individuals of all ages; however, its prevalence is highest among preschool and school-aged children. It affects approximately 20% of preschool and primary school children worldwide and can also spread among family members of infected children easily. This high prevalence is associated with poor hygiene habits common among the highest-risk age group, 4-11 years, such as uncontrolled anus-finger-mouth contact, biting nails, and not washing hands properly. Regular exposure to crowded educational settings and a lack of hygiene practices at schools also contributes to widespread transmission of enterobiasis among young children. Given these high rates, enterobiasis in preschool and school-age children continues to be a significant concern for both health care providers and educators.^1,2

Transmission and Symptoms

Enterobiasis can be transmitted directly from an infected individual to others or indirectly through contact with contaminated items. Transmission occurs among humans through the faecal-oral route when individuals ingest the eggs of the pinworms after contact with a contaminated person or surface. These pinworms live in the intestines of the infected individuals, and at night, adult female worms migrate from the small intestine to the anal area to lay their eggs as a sticky substance, which then spreads to clothing, bedding and other objects.¹ Direct contact with the infected individual or with contaminated items expose the uninfected individual to the eggs, and once the eggs are ingested, either by swallowing or inhaling, the infection can spread. After the ingestion of the eggs, they develop into adult worms in the small intestine, starting the cycle of transmission once again. Spread in schools occurs when an infected child scratches their anal area, resulting in contamination of their fingers, and then touches surfaces and objects with their unwashed hands. When other children handle these contaminated objects or surfaces and then touch their mouths without washing their hands, they ingest the eggs, leading to transmission and infection. Self-infection is also very common among young children. Children are not the only ones who are at high risk of pinworm infection in school settings; adults may also become infected through direct contact with the anal area of the infected child during cleaning, especially if they fail to wash their hands or disinfect the surface effectively after a diaper change. Objects and surfaces in school settings are at high risk of contamination, and the risk increases with inadequate hygiene. Therefore, good hygiene practices, especially in these settings, play a significant role in transmission and prevention.^1,3,4

Common symptoms of enterobiasis include itching around the anal area, predominantly during nighttime, leading to difficulty in sleeping, irritability and restlessness; however, in some cases it can also be asymptomatic. Other symptoms may include abdominal pain and upset stomach. Repeated itching can further cause skin irritation and increase the risk of bacterial infections.⁵ Diagnosis is usually based on clinical suspicions from the presence of symptoms or direct observation of the worms around the anal area. Further confirmation is done by microscopic diagnosis of the swab obtained through the adhesive tape test, performed immediately after waking up.^3,6

Prevention Strategies

Personal hygiene

Regular and proper handwashing with soap and warm water, especially after using the toilet, and changing diapers, and before meals is the most important and effective way of preventing transmission. Prevention strategies and education should focus on children, as they are the highest risk group for pinworm infection. Children, staff members of schools, carers and parents should be educated about the importance of effective monitoring and regular, thorough hand washing. In addition, children should be discouraged from biting their nails or sucking their thumbs to reduce the risk of transmission through ingestion. The nails should be kept short to prevent accumulation of dirt and transmission of eggs. Morning showers can be recommended for infected children, to remove possible accumulated pinworm eggs from the anal area. If morning showers are not possible, night clothes, especially underwear, should be changed and handled carefully. Contaminated items such as bedding and clothes should be washed in high temperatures. Ironing the clothes and bedding can be helpful since heat kills pinworm eggs.⁵

Environmental measures

Frequent changing of underwear and nightclothes reduces the risk of transmission. After diagnosis, clothes and bed linen should be washed and dried at high temperatures to kill pinworm eggs, preventing reinfection. In high risk settings such as schools, surfaces and objects should be disinfected effectively and frequently.^5,6,7 Sharing sleeping spaces and co-bathing with infected children should be avoided by parents to prevent spreading.⁷

School and daycare education

Hygiene should be promoted in schools through activities and routines. Children should be encouraged to wash their hands before every meal and after using the toilet.³ Hygiene routines can be introduced for children to develop the habit of washing hands regularly, and teachers should monitor children to ensure thorough handwashing. If required, child friendly educational materials such as explanatory videos can be used to teach children how to properly wash their hands using soap, providing clear instructions and entertaining visuals for children while educating them about the importance of hand washing. Teachers should collaborate with parents to reinforce preventive routines and encourage parents to report if their child is infected, as early intervention is important to prevent further transmission.

Control Through Treatment

Early diagnosis through frequent children monitoring by parents and teachers plays a significant role in prevention and control. Anthelmintic medications such as mebendazole, pyrantel pamoate and albendazole are prescribed for the treatment of enterobiasis. Treatment requires administration of two doses of medication; the first dose is given at the time of diagnosis, and the second is given two weeks later. Albendazole is recommended to be taken on an empty stomach. The entire household and people who had close contact with the infected individual should be treated at the same time to prevent recurrence.^1,3 The medication only kills the worms, not the eggs. Therefore, the second dose of the medication plays an important role in the treatment and should not be skipped. Adherence to both doses is essential in preventing reinfection and complete eradication of the parasites.⁵

Role of Parents, Teachers, and Healthcare Providers

A parent's role is important in the prevention and control of enterobiasis by educating their children about hygiene, practising good hygiene at home, monitoring symptoms and ensuring full adherence to the treatment. Parents are the most important contributors in early diagnosis, as they are the ones who are able to monitor the symptoms at night. Early diagnosis and effective treatment reduce the prevalence of pinworm infections. Teachers support the development of good hygiene habits, watch for the signs of infection in children and ensure that the environment is cleaned properly for children. Healthcare providers play a significant role in educating and raising awareness about pinworms, providing reliable information about the symptoms, and clear instruction emphasising the importance of prevention alongside the treatment.⁷

Challenges in Prevention and Control

High rates of pinworm infection in children remains a challenge due to behavioural habits, requiring further health education and strict hygiene standards in schools and daycare centers with regular monitoring. Limited hygiene awareness of the young children, crowded families and school settings increase the risk of both transmission and infection. Reinfection is also a significant concern, as the eggs can survive up to 3 weeks on surfaces and some families do not adhere to the treatment regimen.⁷ Parental awareness of the importance of reporting the infections should be increased to support prevention efforts. Failure to inform the school and daycare centres due to stigma-related concerns contributes to widespread infection in these settings.

Summary

Enterobiasis is common in young children. It poses a significant concern for children in school and daycare settings. High prevalence of the infection is significantly associated with the age of children, poor hygiene habits of young children, and ineffective environmental hygiene control.⁴ Effective control and prevention of enterobiasis requires the combination of early anthelminthic treatment, good hygiene practices and other preventive strategies such as educating children about health and promoting personal hygiene. The impact of health education among school-age children has proven to be significant in reducing the prevalence of infection. These preventive strategies reduce the risk of infection transmission and recurrence. Regular deworming programmes and periodic screenings can be promoted in high-risk areas to reduce infection prevalence.⁷ By increasing awareness of the importance of personal and environmental hygiene, as well as ensuring the cooperation of parents, educators and healthcare providers, reinfection can be minimised and transmission rates can be reduced, improving overall health in the community.