Serological Evidence of Strongyloidiasis in COVID-19 Hospitalized Patients in Northern Iran during the Pandemic: Prevalence and Risk Factors

Serological Evidence of Strongyloidiasis in COVID-19 Hospitalized Patients in Northern Iran during the Pandemic: Prevalence and Risk Factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Serological Evidence of Strongyloidiasis in COVID-19 Hospitalized Patients in Northern Iran during the Pandemic: Prevalence and Risk Factors Sara Nemati, Sara Talezari, Keyhan Ashrafi, Tofigh Yaghubi Kalurazi, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8184413/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Strongyloidiasis, a parasitic infection caused by the intestinal nematode Strongyloides stercoralis , remains a significant public health concern in tropical and subtropical regions. This helminthic infection poses particular risks for immunocompromised individuals, potentially progressing to life-threatening hyperinfection syndrome and disseminated disease. In Iran, endemic foci of S. stercoralis have been well-documented in both northern and southern coastal provinces. The current COVID-19 pandemic has introduced new clinical challenges, as immunosuppressive therapies commonly employed in COVID-19 management may predispose patients to severe parasitic complications. This descriptive cross-sectional study aimed to determine both the seroprevalence of S. stercoralis infection and associated risk factors among COVID-19 patients of Guilan province in northern Iran during 2022. A total of 208 serum samples were collected from patients with COVID-19 referred to Razi Hospital in Rasht City, Guilan province. Demographic data, such as sex, age, job, residential area, and educational level, were recorded through interviews. The presence of the anti- S. stercoralis IgG antibody was detected by S. stercoralis IgG ELISA kit. The seropositive rate of strongyloidiasis was 19.7% of all the studied subjects. The seropositivity rate for strongyloidiasis was 19.7% among the studied subjects. A significant difference ( P = 0.039) was observed between genders, with 25.2% of males and 13.9% of females testing seropositive. The prevalence was significantly higher ( P = 0.014) among farmers and workers compared to other occupational groups. Additionally, illiterate individuals had a significantly higher infection rate ( P = 0.007) than those with formal education. This study highlights a high prevalence of strongyloidiasis among COVID-19 patients in northern Iran. Therefore, screening for Strongyloides infection using serologic methods, particularly in endemic regions should be considered before initiating immunosuppressive therapy in COVID-19 patients. Future epidemiological research should systematically evaluate individual risk factors to facilitate targeted intervention strategies. Strongyloides stercoralis COVID-19 Guilan Serology Introduction Strongyloidiasis is a parasitic infection caused by the nematode Strongyloides stercoralis . While it predominantly affects individuals in tropical and subtropical regions, it can also occur in immunocompromised populations in developed areas (Marcos et al. 2008 ). S. stercoralis causing a wide range of clinical manifestations, from asymptomatic forms to fatal disseminated forms. Clinical syndromes associated with S. stercoralis infection include several different forms such as; asymptomatic intestinal infection, acute infection with skin and pulmonary complications, chronic intestinal disease associated with eosinophilia, malabsorption syndrome, chronic diarrhea, hyperinfection syndrome, and disseminated syndrome (Marcos et al. 2008 , Feely et al. 2010 , Corti et al. 2011 ). In recent years, the prevalence of S. stercoralis has been on the rise in many developing countries due to increased immigration, international travel, immunodeficiency, and individuals receiving immunosuppressive drugs (Buonfrate et al. 2020 , Yang et al. 2025 ). Globally, around 600 million individuals suffer from this parasitic infection, especially in places with inadequate sanitation (Czeresnia and Weiss 2022 ). This infection is endemic in Southeast Asia, sub-Saharan Africa, South America, and Eastern Europe (Genta 1989 , Kridaningsih et al. 2020 ). In Iran, infection with this parasite is endemic in the northern regions (Guilan and Mazandaran provinces) and in the southern regions (Khuzestan and Hormozgan provinces), where the temperature and humidity are sufficient for the parasite survival. The prevalence of S. stercoralis infection in Iran varies from 0.3% to 17.3% (Shokri et al. 2012 , Sharifdini et al. 2014 , Taherkhani et al. 2019 ). Research suggests that the use of corticosteroids, a major risk factor for immunosuppression, may and accelerate the transformation of rhabditiform larvae into invasive filariform (Wang et al. 2013 ). This condition can lead to serious complications such as strongyloidiasis and hyperinfection syndrome/disseminated syndrome (HS/DS), which carries a mortality rate that can reach as high as 100% (Feely et al. 2010 ). Since disseminated strongyloidiasis is fatal in 80% of cases, asymptomatic and chronic infections should be diagnosed and treated before initiating long-term corticosteroid therapy (Al Maslamani. 2009, Khadka et al. 2018 ). The global COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has exposed vulnerabilities in various patient populations, particularly those with pre-existing conditions or weakened immune systems (Corse et al. 2020 ). These findings also highlight concerns regarding the potential consequences for immunocompromised individuals if they contract SARS-CoV-2. After about 2 years of the start of the coronavirus disease 2019 (COVID-19) pandemic, the virus continues to pose a major global health challenge through new mutations. Severe acute respiratory syndrome (SARS) falls under the most fatal complications of this disease. According to the findings, between January 1, 2020, and December 31, 2021, reported COVID-19 deaths worldwide totaled 5.94 million. The drugs dexamethasone, prednisolone, and tocilizumab have anti-inflammatory and immunosuppressive effects and are recommended for the treatment of COVID-19 patients (De Wilton et al. 2021 ). However, COVID-19 patients receiving immunomodulatory therapies may be at risk for hyperinfection and disseminated infections of strongyloidiasis syndromes, which can be severe and even fatal (Al Maslamani et al. 2009 , Marchese et al. 2021 , Jenks et al. 2022 , Norman et al. 2022 ). Research indicates that individuals with strongyloidiasis may be at increased risk for severe COVID-19 outcomes due to the immunosuppressive effects of the infection. Numerous cases of severe strongyloidiasis were reported during the COVID-19 pandemic (De Wilton et al. 2021 , Pereira et al. 2021 , Stylemans et al. 2021 , Ashiri et al. 2023 , Soleymani et al. 2023 ). The interaction between these two infections can complicate diagnosis, treatment, and overall management of affected patients. Understanding the epidemiology, clinical implications, and potential mechanisms of adverse outcomes related to this co-infection is crucial for improving patient care and public health responses (Núñez-Gómez et al. 2021 ). Stool examinations, culturing and searching for specific antibodies in the serum using the enzyme-linked immunosorbent assay (ELISA) technique can increase the likelihood of detecting in immunosuppress individuals. The ELISA technique is currently a commonly employed method for diagnosing strongyloidiasis, known for its excellent sensitivity in identifying this infection, making it suitable for epidemiological research across various populations (Pereira et al. 2021 ). It should be noted that the most reported cases of strongyloidiasis are related to the northern regions of Iran. Also, recent studies have been several cases of hyper-infection and disseminated strongyloidiasis in COVID-19 patients who were treated with immunosuppressive drugs have been reported in the world. It seems necessary to determine the co-infection of S. stercoralis infection in COVID-19 patients who are mainly receiving immunosuppressive drugs. So, this study was conducted to estimate the frequency of S. stercoralis infection in patients with COVID-19 of Guilan province in northern Iran during 2022. Materials and Methods Study location This cross-sectional-descriptive study was conducted among COVID-19 patients of Guilan province in northern Iran during 2022. The study population included COVID-19 patients hospitalized in Razi Hospital, an educational and therapeutic center. Rasht City located in Guilan province. The province (36°34'-38°27'N, 48°53'-50°34'E) comprises Iran's primary Caspian Sea coastal territory in the country's north. The region's subtropical climate is marked by high humidity (annual mean: 80%), abundant precipitation (1,506 mm/year), and moderate thermal regimes (mean annual temperature: 15.8°C). Two predominant physiographic units characterize the province: (1) Caspian coastal plains and (2) Alborz Mountain Forest ecosystems (Mirzaei et al. 2021 ). Study design and sampling The inclusion criteria required: (1) confirmed acute COVID-19 infection, (2) hospitalization status, and (3) availability of clinical and demographic records. The exclusion criteria eliminated: (1) outpatients, (2) mild COVID-19 cases, and (3) individuals who had taken antiparasitic medications within the preceding three months. In this study, a total of 208 individuals were assessed using a sequential sampling method. Informed consent was obtained from all participants. The data collection tool was a researcher-designed checklist that recorded the patients’ demographic information, including age, gender, place of residence (city or village), and the type and dosage of immunosuppressive medication. About 4 mL of blood was drawn from each patient, and the serum was separated and stored at − 20°C until testing. The collected serum samples were then examined using the ELISA method with a NovaTec kit ( S. stercoralis -IgG ELISA, NovaTec Company, Germany). to test for the IgG antibody against S. stercoralis . The optical density (OD) of the samples was read at wavelengths of 450/620 nm with an ELISA Plate Reader. In this study, the qualitative measurement of the antibody against S. stercoralis was conducted using a commercial qualitative ELISA kit (Pereira Vieira Barreto et al. 2022) Data Collection A questionnaire was used to collect demographic data such as age, sex, and place of residence, while clinical and laboratory findings, as well as information about medications used, were obtained from the hospital’s electronic database. Enzyme-Linked Immunosorbent Assay (ELISA) To evaluate the frequency of S. stercoralis and SARS-CoV-2 co-infection, we conducted systematic screening for strongyloidiasis in all COVID-19 patients using serological testing. From each participant, 2 mL of venous blood was drawn and centrifuged at 2000×g for 5 minutes to separate serum. The collected sera were preserved at -20°C prior to analysis by enzyme-linked immunosorbent assay (ELISA). The ELISA test utilized an IgG/IgM kit, following the manufacturer's instructions. The assay was performed using a commercial ELISA plate according to the manufacturer's protocol with minor modifications. Briefly, serum samples were diluted 1:101 in diluent solution (10 µL serum + 1000 µL diluent). Then, 100 µL aliquots of each diluted sample, along with positive control, negative control, and cut-off calibrators, were dispensed into separate wells of the microtiter plate, with one well reserved for blank (diluent only). The plate was sealed with adhesive film and incubated at 37°C for 1 hour. Following incubation, plates were washed three times with wash buffer using a standardized washing protocol: alternating wash directions (top-bottom, bottom-top, top-bottom) with a 10 ml syringe, ensuring complete well filling without cross-contamination. After final wash, residual liquid was removed by tapping the inverted plate on absorbent paper. Subsequently, 100 µL of conjugate solution was added to all wells except the blank and incubated at room temperature (20–25°C) for 30 minutes under adhesive cover. After repeating the washing procedure three times, 100 µL of TMB substrate solution was added to each well and plates were incubated in the dark (foil-wrapped) for exactly 15 minutes. The reaction was stopped by adding 100 µL stop solution to each well, and optical density was immediately measured at 450 nm with 620 nm reference wavelength using a microplate reader. All steps were performed under controlled conditions to prevent evaporation and ensure assay reproducibility (Pereira Vieira Barreto et al. 2022). The cut-off parameter was obtained from the well corresponding to the cut-off, and then the absorbance number of each well was included in the following formula to obtain a number with a unit of NTU (NovaTec Units) for each well or, in other words, for each sample: $$\:\frac{Sample\:\left(mean\right)\:absorbance\:value\:\times\:10}{Cut\:off}\:=[NovaTec\:Units=NTU]$$ Positive, negative, and suspicious cases were determined according to Table 1 (available in the kit booklet). Table 1 Positive and negative cases in the kit booklet Cut-off 10 NTU Positive > 11 NTU Equivocal 9–11 NTU Negative < 9 NTU • Cases that were between 9 and 11 (Equivocal) were retested twice with the same sample according to the supervisor's opinion. If the result was in the Equivocal scale anew, the sample was reported as a negative case. Statistical analysis The laboratory results obtained from the ELISA test and the data collected from the checklist were analyzed using SPSS 23 software. The descriptive statistics of the data were described with frequency, frequency percentage, and cumulative percentage indices. Chi-square test indices were used to perform inferential statistics of the data. A significance level of 0.05 was considered in all tests. Results Among the study subjects, 31 individuals (14.9%) were in the age group of 70 years. Among these participants, 107 (51.4%) were male and 101 (48.6%) were female. The cohort included 159 (76.4%) urban residents and 49 (23.6%) rural residents (Table 2 ). Table 2 The frequency distribution of demographic variables, eosinophilia, and serological tests results Variable F % Age group 70 years old 81 38.9 Gender Male 107 51.4 Female 101 48.6 Place of residence City 159 76.4 Village 49 23.6 Occupation Farmer and worker 28 13.5 Self-employed 46 22.1 Employed and retired 34 16.3 Housewife 92 44.2 Other 8 3.8 Education Illiterate 95 45.7 Below high school diploma 66 31.7 High school Diploma and above 47 22.6 Underlying disease No 98 47.1 Yes 110 52.9 Type of underlying disease Autoimmune diseases, Kidney transplant, Asthma 14 6.7 Cancer 24 11.5 Diabetes 61 29.3 Autoimmune diseases, kidney transplant, asthma, and diabetes 4 1.9 Cancer and diabetes 7 3.4 Eosinophilia Normal 200 96.2 Eosinophilia 8 3.8 Serological test results Negative 167 80.3 Positive 41 19.7 * F: Frequency distribution Regarding occupation, participants included farmers and workers (n = 28, 13.5%), self-employed individuals (n = 46, 22.1%), employees and retirees (n = 34, 16.3%), housewives (n = 92, 44.2%), and others (n = 8, 3.8%). In terms of education, 95 (45.7%) were illiterate, 66 (31.7%) had less than a high school diploma, and 47 (22.6%) held a high school diploma or higher. Underlying diseases were recorded in 110 (52.9%) of the subjects. Autoimmune diseases, organ transplantation, and asthma were detected in 14 patients (6.7%); cancer was present in 24 patients (11.5%); and diabetes was identified in 61 patients (29.3%). Diabetes combined with one of the autoimmune diseases was found in four patients (1.9%), and diabetes coexisting with cancer was observed in seven patients (3.4%). Eosinophilia was found in 8 patients (3.8%), while the remainder were in a normal condition. The demographic and clinical characteristics of the participants are summarized in Table 2 . Among the 208 patients, 41 (19.7%) were positive in the serological test (Table 3 ). The prevalence of strongyloidiasis was highest in the age group > 70 years, with 22 cases (27.2%). Among the serologically positive cases, 27 (25.2%) were men and 14 (13.9%) were women. Positive serological results were found in patients living in villages (n = 13, 26.5%), in the farmer and worker group (n = 12, 42.9%), among 25 illiterate individuals (26.3%), and in 21 people (21.4%) who had no underlying diseases. Of the 20 serologically positive patients, 15 had diabetes. Additionally, two patients (25%) from the eosinophilia group were serologically positive. Table 3 The frequency distribution of strongyloidiasis prevalence based on demographic variables Strongyloidiasis prevalence Demographic variables Strongyloides infection p-value Negative Positive F % F % 0.068 Age group 70 years old 59 72.8 22 27.2 Gender Male 80 74.8 27 25.2 0.039* Female 87 86.1 14 13.9 Place of residence City 131 82.4 28 17.6 0.170 Village 36 73.5 13 26.5 Occupation Farmer and worker 16 57.1 12 42.9 0.014* Self-employed 36 78.3 10 21.7 Employed and retired 28 82.4 6 17.6 Housewife 80 87 12 13 Other 7 87.5 1 12.5 Education Illiterate 70 73.7 25 26.3 0.007* Below high school diploma 52 78.8 14 21.2 High school Diploma and above 45 95.7 2 4.3 Underlying disease No 77 78.6 21 21.4 0.557 Yes 90 81.8 20 18.2 Type of underlying disease Autoimmune diseases, Kidney transplant, Asthma 12 85.7 2 14.3 0.360 Cancer 22 91.7 2 8.3 Diabetes 46 75.4 15 24.6 Autoimmune diseases, kidney transplant, asthma, and diabetes 4 100 0 0 Cancer and diabetes 6 85.7 1 14.3 Eosinophilia Normal 161 80.5 39 19.5 0.701 Eosinophilia 6 75 2 25 Chi-square test: *Significance at the 0.05 level The relationship between demographic indicators and the status of S. stercoralis infection was assessed using the chi-square test. The results showed significant associations between gender, occupation, and education with the status of S. stercoralis infection, while no significant relationships were observed in the other cases (Table 3 ). Discussion Co-infection with multiple pathogens poses significant challenges to public health, especially in the context of emerging infectious diseases. One such concern is the co-infection of strongyloidiasis and COVID-19 (Núñez-Gómez et al. 2021 ). The current study included; 208 COVID-19 patients screened for S. stercoralis co-infection. In a recent publication, Stauffer et al. developed a structured protocol for the screening and treatment of strongyloidiasis in patients diagnosed with COVID-19 (Stauffer et al. 2020 ). The patients with COVID-19 who receive immunosuppressive therapy while harboring an undiagnosed Strongyloides infection are susceptible to Strongyloides hyperinfection syndrome (HS) (De Wilton, Nabarro et al. 2021 , Núñez-Gómez et al. 2021 ). Although screening immunocompromised patients for asymptomatic strongyloidiasis is critically important given the potential progression from chronic infection to HS clinical practice often underestimates its significance, even in S. stercoralis endemic regions. In the present serological study, the prevalence of strongyloidiasis in COVID-19 patients was 19.7% (41/208). Several case reports on hyperinfection and disseminated infections of strongyloidiasis in COVID-19 patients treated with immunosuppressive drugs have so far been reported in the world (De Wilton et al. 2021 , Kim and Sivasubramanian 2022 , Seeger et al. 2023 ). In Iran, the serological prevalence of strongyloidiasis in different communities has been examined in few studies. A seroepidemiological study in Khuzestan Province reported strongyloidiasis prevalence rates of 11.5%, 42.3%, and 34.7% in patients with malignancy, uncontrolled diabetes, and those taking steroid drugs, respectively (Ashiri et al. 2021 ). A serological study in Ahvaz city revealed that the prevalence of strongyloidiasis was 14.4% in patients with AIDS, leukemia, and other malignancies (Rafiei et al. 2016 ). S. stercoralis infection has so far been scrutinized in numerous seroepidemiological studies in other parts of the world. A serological study was conducted on 149 Bolivian renal patients undergoing hemodialysis in Cochabamba, indicating a strongyloidiasis prevalence rate of 15.1% in patients (Tebib et al. 2023 ). Talukder et al. designed a study in which 576 people were serologically examined in Central Australia. The results showed that a total of 156 people were positive for strongyloidiasis, with an estimated prevalence rate of 27%. The study also examined the prevalence of strongyloidiasis in individuals infected and uninfected with HTLV-1. The results showed the prevalence rates of 30.4% and 22.4% in uninfected and infected individuals, respectively (Talukder et al. 2022 ). According to the previous study, the highest percent change was among men, aged from 65 to 69 years old (77%), and women, aged from 60 to 64 years old (86.8%). The mortality percent rise in the 10–20 years old age group (14.7%) was higher than the 20–30 years old population (8.4%) (Safavi-Naini et al. 2022 ) In current study, 13.9% and 25.2% were respectively female and male out of 24 individuals infected with S. stercoralis . A statistically significant difference was observed between the prevalence of S. stercoralis and the gender of the study population. Similar to the present study, other research (Sharifdini et al. 2014 ) (Naves and Costa-Cruz 2013 ) provided evidence that the prevalence of Strongyloides in men was higher than in women, likely due to greater exposure to sources of contamination, such as working in fields and contact with soil. Several studies conducted in different geographical regions have consistently demonstrated no statistically significant association between gender and S. stercoralis infection rates (Sultana et al. 2012 , Gétaz, Castro et al. 2019 , Sharifdini et al. 2020 , Mirzaei et al. 2021 ). Regarding the age group in the present study, the highest prevalence of strongyloidiasis (27.2%) belonged to the age group over 70 years, but this relationship was not statistically significant. This might have resulted from the small sample size of the present study. As in the present study, no statistically significant relationship was observed between age groups and infection with strongyloidiasis. However, the highest infection with the parasite S. stercoralis was observed in the age group over 60 years, and a significant difference was observed between the prevalence of S. stercoralis and different age groups in the analyzed studies (Sharifdini, Kia et al. 2014 , Sharifdini, Keyhani et al. 2018 ). In line with our work, previous research has reported that the frequency of infection with S. stercoralis increased significantly with age (Senephansiri et al. 2017 , Pacheco-Tenza et al. 2018 ). These results confirm that the high percentage of strongyloidiasis in the elderly is related to past infection, and this parasite can persist in the human body for a long time because of its self-infection ability. According to the results obtained in this study, a significant difference was observed between the prevalence of S. stercoralis and different occupations. The highest prevalence of strongyloidiasis belonged to the occupational group of farmers and workers (42.9%). Farmers, particularly rice farmers, have long-term skin contact with soil and are more probably exposed to the penetration of the filariform larvae of S. stercoralis into the skin. Similar to our study, Mirzaei et al. claimed that the frequency of S. stercoralis in farmers (19.8%) was higher than in other occupations, but this relationship was not statistically significant (Mirzaei et al. 2021 ). In a similar study, a statistically significant relationship was found between infection with this parasite and occupation among residents of villages in Fuman County (Sharifdini et al. 2020 ). The present study revealed a significantly higher prevalence of S. stercoralis infection among animal husbandry workers compared to other occupational groups. Notably, no infections were detected among children under six years of age, students, or unemployed individuals (Sharifdini et al. 2020 ). These findings are consistent with epidemiological studies (Senephansiri et al. 2017 , Tuyizere et al. 2018 ), which similarly reported elevated infection rates in agricultural occupational groups relative to other professions. The observed occupational disparity likely stems from differential exposure to contaminated soil, the primary transmission route for S. stercoralis . As Alcaraz et al. demonstrated, agricultural workers exhibit particularly high infection rates due to their frequent and prolonged contact with soil during farming activities (Senephansiri et al. 2017 ). This exposure risk is further compounded by several factors: (1) common practices such as barefoot fieldwork that facilitate larval penetration, (2) handling of potentially contaminated water or fertilizers, and (3) inadequate sanitation infrastructure in rural agricultural communities that increases the probability of soil contamination with infectious larvae. The convergence of these occupational, behavioral, and environmental factors creates conditions particularly conducive to S. stercoralis transmission among agricultural workers, explaining the consistently higher prevalence observed in this population across multiple epidemiological studies (Schär et al. 2013 , Schär et al. 2016 ). In terms of place of residence, the current study recorded the highest prevalence of strongyloidiasis (26.5%) in patients living in rural areas. However, no significant relationship was observed between place of residence and S. stercoralis infection (Ashiri et al. 2021 ). In contrast to our findings, previous research has shown that 18.9% and 14.4% of patients infected with the parasite S. stercoralis lived in rural areas and urban settings, respectively, but no statistically significant relationship was found between infection with S. stercoralis and place of residence (Mirzaei et al. 2021 ). Whereas, Gétaz et al. reported that strongyloidiasis infection was more prevalent among people who lived in rural areas and walked barefoot (Gétaz et al. 2019 ). In our study, the highest rate of S. stercoralis infection (with a frequency of 26.3%) belonged to illiterate individuals, and the lowest infection rate was observed in individuals with a high school diploma or higher. In this study, a statistically significant relationship was found between education level and S. stercoralis infection (Gétaz et al. 2019 ). Likewise, Munisankar et al. documented lower levels of education in most infected individuals in South India (Gétaz et al. 2019 ). On the other hand, Mirzaei et al. detected no significant relationship between S. stercoralis infection and levels of education (Mirzaei et al. 2021 ). In the present study, 21.4% and 18.2% of people without and with underlying diseases were infected with S. stercoralis respectively, and no statistically significant association was observed between underlying diseases and Strongyloides infection. Regarding the type of underlying disease, strongyloidiasis was most prevalent in the diabetic group (24.6%), and the relationship between the type of underlying disease and S. stercoralis infection was not statistically significant. The study indicated a significant relationship between the type of underlying disease and S. stercoralis infection, with asthma and chronic obstructive pulmonary disease being the most influential underlying diseases observed. Additionally, strongyloidiasis was found to be one of the most prevalent parasitic diseases among patients receiving immunosuppressive drugs in northern Iran. According to the previous studies, strongyloidiasis can have severe consequences in immunocompromised individuals, making timely treatment with ivermectin crucial due to its safety and efficacy. Screening is advised for patients scheduled for immunosuppressive therapies such as transplantation or corticosteroid treatment particularly those with potential exposure to the infection, regardless of how long they have been outside endemic regions. This recommendation gains added importance with the increasing use of dexamethasone in COVID-19 management (Ramanathan and Nutman 2008 , Stauffer et al. 2020 , De Wilton et al. 2021 ). In this study, the eosinophilia group showed the highest prevalence of strongyloidiasis (25%). However, no statistically significant association was observed between eosinophilia and S. stercoralis infection. In contrast to our study, another study showed that eosinophilia was significantly associated with the prevalence of S. stercoralis infection (Ashiri et al. 2021 ). In a study in northern Italy strongyloidiasis was 9 times more common in people with eosinophilia than in those with normal eosinophil counts (Buonfrate et al. 2016 ). Conclusion The current study revealed a high prevalence of S. stercoralis infection (19.7%) in COVID-19 patients. This finding is particularly significant given the widespread use of corticosteroids and tocilizumab in COVID-19 treatment. Importantly, administering immunosuppressive drugs to patients with S. stercoralis infection increases the risk of severe and potentially fatal complications, including hyperinfection syndrome and disseminated strongyloidiasis. Therefore, widespread screening of COVID-19 patients with serological methods seems necessary due to the high sensitivity and high speed of these methods before treatment with immunosuppressive drugs. Future epidemiological investigations should focus on identifying individual risk factors and high-risk communities to facilitate targeted intervention strategies. Declarations Consent to participate Authors declare that they have participated in this work. Consent for publication Authors declare that they know the content of this manuscript and agreed to submit it to ….. Conflict of interest The authors declare no competing interests. Acknowledgments The authors would like to thank all people who have contributed to this research. Ethical considerations The protocol of this study was approved by the Ethics Committee of Guilan University of Medical Sciences, Iran (Ref. No. IR.GUMS.REC.1401.194). References Al Maslamani MA, Al Soub HA, Al Khal AL, Al Bozom IA, Abu Khattab MJ, Chacko KC (2009) Strongyloides stercoralis hyperinfection after corticosteroid therapy: a report of two cases. 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Infection 49(3): 539–542 Marcos LA, Terashima A, Dupont HL, Gotuzzo E (2008) Strongyloides hyperinfection syndrome: an emerging global infectious disease. Trans R Soc Trop Med Hyg 102(4):314–318 Mirzaei L, Ashrafi K, Atrkar Roushan Z, Mahmoudi MR, Shenavar Masooleh I, Rahmati B, Saadat F, Mirjalali H, Sharifdini M (2021) Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran: a closer look at risk factors. Epidemiol Health 43:e2021009 Naves MM, Costa-Cruz JM (2013) High prevalence of Strongyloides stercoralis infection among the elderly in Brazil. Rev Inst Med Trop Sao Paulo 55(5):309–313 Norman FF, Chamorro S, Braojos F, López-Miranda E, Chamorro J, González I, Martín O, Pérez-Molina JA (2022) Strongyloides in bronchoalveolar lavage fluid: practical implications in the COVID-19 era. J Travel Med 29(1) Núñez-Gómez L, Comeche B, Subirats M (2021) Strongyloidiasis: An Important Coinfection in the COVID-19 Era. Am J Trop Med Hyg 105(5):1134–1135 Pacheco-Tenza MI, Ruiz-Maciá JA, Navarro-Cots M, Gregori-Colomé J, Cepeda-Rodrigo JM, Llenas-García J (2018) Strongyloides stercoralis infection in a Spanish regional hospital: Not just an imported disease. Enferm Infecc Microbiol Clin (Engl Ed) 36(1):24–28 Pereira CVM, Mastandrea GRA, Medeiros A, Gryschek RCB, Paula FM, Corral MA (2021) COVID-19 and strongyloidiasis: what to expect from this coinfection? Clin (Sao Paulo) 76:e3528 Pereira Vieira Barreto NM, Brito Farias MM, Oliveira CL, Almeida Costa Araujo W, Rios Grassi MF, de Nascimento J, Soares Jacobina MC Aquino Teixeira, B. Galvão-Castro and N. Matos Soares (2022). Evaluation of Strongyloides stercoralis infection in patients with HTLV-1. Biomedica 42(1): 31–40 Rafiei R, Rafiei A, Rahdar M, Keikhaie B (2016) Seroepidemiology of Strongyloides stercoralis amongst immunocompromised patients in Southwest Iran. Parasite Epidemiol Control 1(3):229–232 Ramanathan R, Nutman T (2008) Strongyloides stercoralis infection in the immunocompromised host. Curr Infect Dis Rep 10(2):105–110 Safavi-Naini SAA, Farsi Y, Alali WQ, Solhpour A, Pourhoseingholi MA (2022) Excess all-cause mortality and COVID-19 reported fatality in Iran (April 2013-September 2021): age and sex disaggregated time series analysis. BMC Res Notes 15(1):130 Schär F, Giardina F, Khieu V, Muth S, Vounatsou P, Marti H, Odermatt P (2016) Occurrence of and risk factors for Strongyloides stercoralis infection in South-East Asia. Acta Trop 159:227–238 Schär F, Trostdorf U, Giardina F, Khieu V, Muth S, Marti H, Vounatsou P, Odermatt P (2013) Strongyloides stercoralis: Global Distribution and Risk Factors. PLoS Negl Trop Dis 7(7):e2288 Seeger D, Cornejo Cisneros E, Lucar J, Denyer R (2023) Strongyloides and COVID-19: Challenges and Opportunities for Future Research. Trop Med Infect Dis 8(2) Senephansiri P, Laummaunwai P, Laymanivong S, Boonmar T (2017) Status and Risk Factors of Strongyloides stercoralis Infection in Rural Communities of Xayaburi Province, Lao PDR. Korean J Parasitol 55(5):569–573 Sharifdini M, Ghanbarzadeh L, Barikani A, Saraei M (2020) Prevalence of Intestinal Parasites among Rural Inhabitants of Fouman, Guilan Province, Northern Iran with Emphasis on Strongyloides stercoralis. Iran J Parasitol 15(1):91–100 Sharifdini M, Keyhani A, Eshraghian MR, Beigom Kia E (2018) Molecular diagnosis of strongyloidiasis in a population of an endemic area through nested-PCR. Gastroenterol Hepatol Bed Bench 11(1):68–74 Sharifdini M, Kia EB, Ashrafi K, Hosseini M, Mirhendi H, Mohebali M, Kamranrashani B (2014) An Analysis of Clinical Characteristics of Strongyloides stercoralis in 70 indigenous patients in Iran. Iran J Parasitol 9(2):155–162 Shokri A, Sarasiabi KS, Teshnizi SH, Mahmoodi H (2012) Prevalence of Strongyloides stercoralis and other intestinal parasitic infections among mentally retarded residents in central institution of southern Iran. Asian Pac J Trop Biomed 2(2):88–91 Soleymani E, Davoodi L, Shayesteh Azar S, Mirbadiei SR, Parandin F, Azimi A, Mizani A, Khorshidvand Z, Fakhar M (2023) Fatal Disseminated Strongyloidiasis in an Immunosuppressed Patient During COVID-19 Pandemic. Acta Parasitol 68(3):711–717 Stauffer WM, Alpern JD, Walker PF (2020) COVID-19 and Dexamethasone: A Potential Strategy to Avoid Steroid-Related Strongyloides. Hyperinfection Jama 324(7):623–624 Stylemans D, Van Cauwelaert S, D'Haenens A, Slabbynck H (2021) COVID-19-Associated Eosinopenia in a Patient With Chronic Eosinophilia Due to Chronic Strongyloidiasis. Infect Dis Clin Pract (Baltim Md) 29(5):e305–e306 Sultana Y, Gilbert GL, Ahmed BN, Lee R (2012) Seroepidemiology of Strongyloides stercoralis in Dhaka. Bangladesh Parasitol 139(11):1513–1520 Taherkhani K, Barikani A, Shahnazi M, Saraei M (2019) Prevalence of Intestinal Parasites among Rural Residents of Takestan in North-West of Iran. Iran J Parasitol 14(4):657–663 Talukder MR, Pham H, Woodman R, Wilson K, Taylor K, Kaldor J, Einsiedel L (2022) The Association between Diabetes and Human T-Cell Leukaemia Virus Type-1 (HTLV-1) with Strongyloides stercoralis: Results of a Community-Based, Cross-Sectional Survey in Central Australia. Int J Environ Res Public Health 19(4) Tebib N, Tebib N, Paredes M, Castro R, Baggio S, Torrico MV, Leon AAF, Zamorano MH, Chappuis F, Getaz L (2023) Prevalence and risk factors of Strongyloides stercoralis in haemodialysis in Cochabamba, Bolivia: a cross-sectional study. BMC Nephrol 24(1):27 Tuyizere A, Ndayambaje A, Walker TD, Bayingana C, Ntirenganya C, Dusabejambo V, Hale DC (2018) Prevalence of Strongyloides stercoralis infection and other soil-transmitted helminths by cross-sectional survey in a rural community in Gisagara District, Southern Province. Rwanda Trans Royal Soc Trop Med Hygiene 112(3):97–102 Wang C, Xu J, Zhou X, Li J, Yan G, James AA, Chen X (2013) Strongyloidiasis: an emerging infectious disease in China. Am J Trop Med Hyg 88(3):420 Yang R, Xu M, zhang L, Liao Y, Liu Y, Deng X, Wang L (2025) Human Strongyloides stercoralis infection. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8184413","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589366538,"identity":"6938ecbe-33ee-4d99-bf7b-675d9d913301","order_by":0,"name":"Sara Nemati","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYHADxsYHEhUMDAbE62BjbDawOEOaFgY2gco2IrTIt599+IFxh000//zmNoab8w7Lm7M3H2D4UbENpxaDM+nGEoxn0nJnHGNsezhz22HDnT3HEhh7ztzGrYUhjUGCse1wbsMxxnZjyW2HGTfcyDFgZmzDrUW+/xnzD8a2/7nzgbZI/51z2J6gFoYbaWxAWw7kbgBqkZBsOJxIUIvBjWdsFoltybkbjyU2G0gcS0/ecOZYwkF8fpHvT2O+8bHNLnfe4eMPH0jUWNtuON588MGPCjwOA4EEBLMZTB7Arx4V1JGieBSMglEwCkYIAABLJl3wzgSpYwAAAABJRU5ErkJggg==","orcid":"","institution":"Shahid Beheshti University of Medical Sciences Research Institute for Gastroenterology and Liver Diseases","correspondingAuthor":true,"prefix":"","firstName":"Sara","middleName":"","lastName":"Nemati","suffix":""},{"id":589366539,"identity":"6a87684a-9faf-45eb-a0cc-cef4a5af7132","order_by":1,"name":"Sara Talezari","email":"","orcid":"","institution":"Guilan University of Medical Sciences Shahid Beheshti Nursing and Midwifery School of Rasht","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Talezari","suffix":""},{"id":589366540,"identity":"bd0946ad-37c5-4a7d-9f4d-eaf185e91d16","order_by":2,"name":"Keyhan Ashrafi","email":"","orcid":"","institution":"Guilan University of Medical Sciences Shahid Beheshti Nursing and Midwifery School of Rasht","correspondingAuthor":false,"prefix":"","firstName":"Keyhan","middleName":"","lastName":"Ashrafi","suffix":""},{"id":589366541,"identity":"6ead41a1-c16a-4be7-a0cb-552f4bef824c","order_by":3,"name":"Tofigh Yaghubi Kalurazi","email":"","orcid":"","institution":"Guilan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tofigh","middleName":"Yaghubi","lastName":"Kalurazi","suffix":""},{"id":589366542,"identity":"20040105-10ec-4216-83fe-3460e18d7cf5","order_by":4,"name":"Eshrat Beigom Kia","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Eshrat","middleName":"Beigom","lastName":"Kia","suffix":""},{"id":589366543,"identity":"9e45903e-79c9-4c59-86db-969d150f2a70","order_by":5,"name":"Zohreh Fakhrieh-Kashan","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zohreh","middleName":"","lastName":"Fakhrieh-Kashan","suffix":""},{"id":589366544,"identity":"f121d7b2-b924-423f-83d6-5875ae942c16","order_by":6,"name":"Zahra Atrkar Roushan","email":"","orcid":"","institution":"Guilan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"Atrkar","lastName":"Roushan","suffix":""},{"id":589366545,"identity":"3320db44-ea52-4246-a8b2-350511aee2a6","order_by":7,"name":"Mohammad Haghighi","email":"","orcid":"","institution":"Guilan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Haghighi","suffix":""},{"id":589366546,"identity":"9e1577c2-7fee-44cb-a3c1-4a58427b4fee","order_by":8,"name":"Arash Pourgholaminejad","email":"","orcid":"","institution":"Guilan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Arash","middleName":"","lastName":"Pourgholaminejad","suffix":""},{"id":589366547,"identity":"507086fe-7c00-4e1f-96cd-bfdb1d6f819a","order_by":9,"name":"Meysam Sharifdini","email":"","orcid":"","institution":"Guilan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Meysam","middleName":"","lastName":"Sharifdini","suffix":""}],"badges":[],"createdAt":"2025-11-23 09:04:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8184413/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8184413/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103049288,"identity":"46fe44ac-b4f7-40d0-9c18-255ae1351827","added_by":"auto","created_at":"2026-02-20 07:39:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":820374,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8184413/v1/4c27e0a2-5be9-4465-a718-04e94d0c9ae5.pdf"}],"financialInterests":"","formattedTitle":"Serological Evidence of Strongyloidiasis in COVID-19 Hospitalized Patients in Northern Iran during the Pandemic: Prevalence and Risk Factors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStrongyloidiasis is a parasitic infection caused by the nematode \u003cem\u003eStrongyloides stercoralis\u003c/em\u003e. While it predominantly affects individuals in tropical and subtropical regions, it can also occur in immunocompromised populations in developed areas (Marcos et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). \u003cem\u003eS. stercoralis\u003c/em\u003e causing a wide range of clinical manifestations, from asymptomatic forms to fatal disseminated forms. Clinical syndromes associated with \u003cem\u003eS. stercoralis\u003c/em\u003e infection include several different forms such as; asymptomatic intestinal infection, acute infection with skin and pulmonary complications, chronic intestinal disease associated with eosinophilia, malabsorption syndrome, chronic diarrhea, hyperinfection syndrome, and disseminated syndrome (Marcos et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2008\u003c/span\u003e, Feely et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e, Corti et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recent years, the prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e has been on the rise in many developing countries due to increased immigration, international travel, immunodeficiency, and individuals receiving immunosuppressive drugs (Buonfrate et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Yang et al. \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Globally, around 600\u0026nbsp;million individuals suffer from this parasitic infection, especially in places with inadequate sanitation (Czeresnia and Weiss \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This infection is endemic in Southeast Asia, sub-Saharan Africa, South America, and Eastern Europe (Genta \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1989\u003c/span\u003e, Kridaningsih et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Iran, infection with this parasite is endemic in the northern regions (Guilan and Mazandaran provinces) and in the southern regions (Khuzestan and Hormozgan provinces), where the temperature and humidity are sufficient for the parasite survival. The prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e infection in Iran varies from 0.3% to 17.3% (Shokri et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, Sharifdini et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, Taherkhani et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch suggests that the use of corticosteroids, a major risk factor for immunosuppression, may and accelerate the transformation of rhabditiform larvae into invasive filariform (Wang et al. \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This condition can lead to serious complications such as strongyloidiasis and hyperinfection syndrome/disseminated syndrome (HS/DS), which carries a mortality rate that can reach as high as 100% (Feely et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Since disseminated strongyloidiasis is fatal in 80% of cases, asymptomatic and chronic infections should be diagnosed and treated before initiating long-term corticosteroid therapy (Al Maslamani. 2009, Khadka et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe global COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, has exposed vulnerabilities in various patient populations, particularly those with pre-existing conditions or weakened immune systems (Corse et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These findings also highlight concerns regarding the potential consequences for immunocompromised individuals if they contract SARS-CoV-2. After about 2 years of the start of the coronavirus disease 2019 (COVID-19) pandemic, the virus continues to pose a major global health challenge through new mutations. Severe acute respiratory syndrome (SARS) falls under the most fatal complications of this disease. According to the findings, between January 1, 2020, and December 31, 2021, reported COVID-19 deaths worldwide totaled 5.94\u0026nbsp;million. The drugs dexamethasone, prednisolone, and tocilizumab have anti-inflammatory and immunosuppressive effects and are recommended for the treatment of COVID-19 patients (De Wilton et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, COVID-19 patients receiving immunomodulatory therapies may be at risk for hyperinfection and disseminated infections of strongyloidiasis syndromes, which can be severe and even fatal (Al Maslamani et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2009\u003c/span\u003e, Marchese et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Jenks et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, Norman et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch indicates that individuals with strongyloidiasis may be at increased risk for severe COVID-19 outcomes due to the immunosuppressive effects of the infection. Numerous cases of severe strongyloidiasis were reported during the COVID-19 pandemic (De Wilton et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Pereira et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Stylemans et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Ashiri et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e, Soleymani et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The interaction between these two infections can complicate diagnosis, treatment, and overall management of affected patients. Understanding the epidemiology, clinical implications, and potential mechanisms of adverse outcomes related to this co-infection is crucial for improving patient care and public health responses (N\u0026uacute;\u0026ntilde;ez-G\u0026oacute;mez et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStool examinations, culturing and searching for specific antibodies in the serum using the enzyme-linked immunosorbent assay (ELISA) technique can increase the likelihood of detecting in immunosuppress individuals. The ELISA technique is currently a commonly employed method for diagnosing strongyloidiasis, known for its excellent sensitivity in identifying this infection, making it suitable for epidemiological research across various populations (Pereira et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt should be noted that the most reported cases of strongyloidiasis are related to the northern regions of Iran. Also, recent studies have been several cases of hyper-infection and disseminated strongyloidiasis in COVID-19 patients who were treated with immunosuppressive drugs have been reported in the world. It seems necessary to determine the co-infection of \u003cem\u003eS. stercoralis\u003c/em\u003e infection in COVID-19 patients who are mainly receiving immunosuppressive drugs. So, this study was conducted to estimate the frequency of \u003cem\u003eS. stercoralis\u003c/em\u003e infection in patients with COVID-19 of Guilan province in northern Iran during 2022.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy location\u003c/h2\u003e \u003cp\u003eThis cross-sectional-descriptive study was conducted among COVID-19 patients of Guilan province in northern Iran during 2022. The study population included COVID-19 patients hospitalized in Razi Hospital, an educational and therapeutic center. Rasht City located\u003c/p\u003e \u003cp\u003ein Guilan province. The province (36\u0026deg;34'-38\u0026deg;27'N, 48\u0026deg;53'-50\u0026deg;34'E) comprises Iran's primary Caspian Sea coastal territory in the country's north. The region's subtropical climate is marked by high humidity (annual mean: 80%), abundant precipitation (1,506 mm/year), and moderate thermal regimes (mean annual temperature: 15.8\u0026deg;C). Two predominant physiographic units characterize the province: (1) Caspian coastal plains and (2) Alborz Mountain Forest ecosystems (Mirzaei et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and sampling\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria required: (1) confirmed acute COVID-19 infection, (2) hospitalization status, and (3) availability of clinical and demographic records. The exclusion criteria eliminated: (1) outpatients, (2) mild COVID-19 cases, and (3) individuals who had taken antiparasitic medications within the preceding three months.\u003c/p\u003e \u003cp\u003eIn this study, a total of 208 individuals were assessed using a sequential sampling method. Informed consent was obtained from all participants. The data collection tool was a researcher-designed checklist that recorded the patients\u0026rsquo; demographic information, including age, gender, place of residence (city or village), and the type and dosage of immunosuppressive medication. About 4 mL of blood was drawn from each patient, and the serum was separated and stored at \u0026minus;\u0026thinsp;20\u0026deg;C until testing. The collected serum samples were then examined using the ELISA method with a NovaTec kit (\u003cem\u003eS. stercoralis\u003c/em\u003e-IgG ELISA, NovaTec Company, Germany). to test for the IgG antibody against \u003cem\u003eS. stercoralis\u003c/em\u003e. The optical density (OD) of the samples was read at wavelengths of 450/620 nm with an ELISA Plate Reader. In this study, the qualitative measurement of the antibody against \u003cem\u003eS. stercoralis\u003c/em\u003e was conducted using a commercial qualitative ELISA kit (Pereira Vieira Barreto et al. 2022)\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA questionnaire was used to collect demographic data such as age, sex, and place of residence, while clinical and laboratory findings, as well as information about medications used, were obtained from the hospital\u0026rsquo;s electronic database.\u003c/p\u003e\n\u003ch3\u003eEnzyme-Linked Immunosorbent Assay (ELISA)\u003c/h3\u003e\n\u003cp\u003eTo evaluate the frequency of \u003cem\u003eS. stercoralis\u003c/em\u003e and SARS-CoV-2 co-infection, we conducted systematic screening for strongyloidiasis in all COVID-19 patients using serological testing. From each participant, 2 mL of venous blood was drawn and centrifuged at 2000\u0026times;g for 5 minutes to separate serum. The collected sera were preserved at -20\u0026deg;C prior to analysis by enzyme-linked immunosorbent assay (ELISA). The ELISA test utilized an IgG/IgM kit, following the manufacturer's instructions. The assay was performed using a commercial ELISA plate according to the manufacturer's protocol with minor modifications. Briefly, serum samples were diluted 1:101 in diluent solution (10 \u0026micro;L serum\u0026thinsp;+\u0026thinsp;1000 \u0026micro;L diluent). Then, 100 \u0026micro;L aliquots of each diluted sample, along with positive control, negative control, and cut-off calibrators, were dispensed into separate wells of the microtiter plate, with one well reserved for blank (diluent only). The plate was sealed with adhesive film and incubated at 37\u0026deg;C for 1 hour. Following incubation, plates were washed three times with wash buffer using a standardized washing protocol: alternating wash directions (top-bottom, bottom-top, top-bottom) with a 10 ml syringe, ensuring complete well filling without cross-contamination. After final wash, residual liquid was removed by tapping the inverted plate on absorbent paper. Subsequently, 100 \u0026micro;L of conjugate solution was added to all wells except the blank and incubated at room temperature (20\u0026ndash;25\u0026deg;C) for 30 minutes under adhesive cover. After repeating the washing procedure three times, 100 \u0026micro;L of TMB substrate solution was added to each well and plates were incubated in the dark (foil-wrapped) for exactly 15 minutes. The reaction was stopped by adding 100 \u0026micro;L stop solution to each well, and optical density was immediately measured at 450 nm with 620 nm reference wavelength using a microplate reader. All steps were performed under controlled conditions to prevent evaporation and ensure assay reproducibility (Pereira Vieira Barreto et al. 2022).\u003c/p\u003e \u003cp\u003eThe cut-off parameter was obtained from the well corresponding to the cut-off, and then the absorbance number of each well was included in the following formula to obtain a number with a unit of NTU (NovaTec Units) for each well or, in other words, for each sample:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\frac{Sample\\:\\left(mean\\right)\\:absorbance\\:value\\:\\times\\:10}{Cut\\:off}\\:=[NovaTec\\:Units=NTU]$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePositive, negative, and suspicious cases were determined according to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (available in the kit booklet).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePositive and negative cases in the kit booklet\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCut-off\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 NTU\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;11 NTU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEquivocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u0026ndash;11 NTU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;9 NTU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u0026bull; Cases that were between 9 and 11 (Equivocal) were retested twice with the same sample according to the supervisor's opinion. If the result was in the Equivocal scale anew, the sample was reported as a negative case.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe laboratory results obtained from the ELISA test and the data collected from the checklist were analyzed using SPSS 23 software. The descriptive statistics of the data were described with frequency, frequency percentage, and cumulative percentage indices. Chi-square test indices were used to perform inferential statistics of the data. A significance level of 0.05 was considered in all tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the study subjects, 31 individuals (14.9%) were in the age group of \u0026lt;\u0026thinsp;40 years, 96 (45.2%) were aged 40\u0026ndash;70 years, and 81 (38.9%) were \u0026gt;\u0026thinsp;70 years. Among these participants, 107 (51.4%) were male and 101 (48.6%) were female. The cohort included 159 (76.4%) urban residents and 49 (23.6%) rural residents (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency distribution of demographic variables, eosinophilia, and serological tests results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;70 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer and worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed and retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow high school diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school Diploma and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eUnderlying disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eType of underlying disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune diseases, Kidney transplant, Asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune diseases, kidney transplant, asthma, and diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer and diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEosinophilia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEosinophilia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSerological test results\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* F: Frequency distribution\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding occupation, participants included farmers and workers (n\u0026thinsp;=\u0026thinsp;28, 13.5%), self-employed individuals (n\u0026thinsp;=\u0026thinsp;46, 22.1%), employees and retirees (n\u0026thinsp;=\u0026thinsp;34, 16.3%), housewives (n\u0026thinsp;=\u0026thinsp;92, 44.2%), and others (n\u0026thinsp;=\u0026thinsp;8, 3.8%).\u003c/p\u003e \u003cp\u003eIn terms of education, 95 (45.7%) were illiterate, 66 (31.7%) had less than a high school diploma, and 47 (22.6%) held a high school diploma or higher. Underlying diseases were recorded in 110 (52.9%) of the subjects. Autoimmune diseases, organ transplantation, and asthma were detected in 14 patients (6.7%); cancer was present in 24 patients (11.5%); and diabetes was identified in 61 patients (29.3%). Diabetes combined with one of the autoimmune diseases was found in four patients (1.9%), and diabetes coexisting with cancer was observed in seven patients (3.4%). Eosinophilia was found in 8 patients (3.8%), while the remainder were in a normal condition. The demographic and clinical characteristics of the participants are summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAmong the 208 patients, 41 (19.7%) were positive in the serological test (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The prevalence of strongyloidiasis was highest in the age group\u0026thinsp;\u0026gt;\u0026thinsp;70 years, with 22 cases (27.2%). Among the serologically positive cases, 27 (25.2%) were men and 14 (13.9%) were women. Positive serological results were found in patients living in villages (n\u0026thinsp;=\u0026thinsp;13, 26.5%), in the farmer and worker group (n\u0026thinsp;=\u0026thinsp;12, 42.9%), among 25 illiterate individuals (26.3%), and in 21 people (21.4%) who had no underlying diseases. Of the 20 serologically positive patients, 15 had diabetes. Additionally, two patients (25%) from the eosinophilia group were serologically positive.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe frequency distribution of strongyloidiasis prevalence based on demographic variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c2\" namest=\"c1\" rowspan=\"3\"\u003e \u003cp\u003eStrongyloidiasis prevalence\u003c/p\u003e \u003cp\u003eDemographic variables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003eStrongyloides\u003c/em\u003e infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e90.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;70 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e72.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e74.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.039*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e86.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e73.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer and worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0.014*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e78.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed and retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow high school diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e78.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school Diploma and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUnderlying disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eType of underlying disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune diseases, Kidney transplant, Asthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e75.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune diseases, kidney transplant, asthma, and diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer and diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEosinophilia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e80.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEosinophilia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cb\u003eChi-square test: *Significance at the 0.05 level\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe relationship between demographic indicators and the status of \u003cem\u003eS. stercoralis\u003c/em\u003e infection was assessed using the chi-square test. The results showed significant associations between gender, occupation, and education with the status of \u003cem\u003eS. stercoralis\u003c/em\u003e infection, while no significant relationships were observed in the other cases (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCo-infection with multiple pathogens poses significant challenges to public health, especially in the context of emerging infectious diseases. One such concern is the co-infection of strongyloidiasis and COVID-19 (N\u0026uacute;\u0026ntilde;ez-G\u0026oacute;mez et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The current study included; 208 COVID-19 patients screened for \u003cem\u003eS. stercoralis\u003c/em\u003e co-infection. In a recent publication, Stauffer et al. developed a structured protocol for the screening and treatment of strongyloidiasis in patients diagnosed with COVID-19 (Stauffer et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The patients with COVID-19 who receive immunosuppressive therapy while harboring an undiagnosed Strongyloides infection are susceptible to Strongyloides hyperinfection syndrome (HS) (De Wilton, Nabarro et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, N\u0026uacute;\u0026ntilde;ez-G\u0026oacute;mez et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although screening immunocompromised patients for asymptomatic strongyloidiasis is critically important given the potential progression from chronic infection to HS clinical practice often underestimates its significance, even in \u003cem\u003eS. stercoralis\u003c/em\u003e endemic regions.\u003c/p\u003e \u003cp\u003eIn the present serological study, the prevalence of strongyloidiasis in COVID-19 patients was 19.7% (41/208). Several case reports on hyperinfection and disseminated infections of strongyloidiasis in COVID-19 patients treated with immunosuppressive drugs have so far been reported in the world (De Wilton et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e, Kim and Sivasubramanian \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, Seeger et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Iran, the serological prevalence of strongyloidiasis in different communities has been examined in few studies. A seroepidemiological study in Khuzestan Province reported strongyloidiasis prevalence rates of 11.5%, 42.3%, and 34.7% in patients with malignancy, uncontrolled diabetes, and those taking steroid drugs, respectively (Ashiri et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A serological study in Ahvaz city revealed that the prevalence of strongyloidiasis was 14.4% in patients with AIDS, leukemia, and other malignancies (Rafiei et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eS. stercoralis\u003c/em\u003e infection has so far been scrutinized in numerous seroepidemiological studies in other parts of the world. A serological study was conducted on 149 Bolivian renal patients undergoing hemodialysis in Cochabamba, indicating a strongyloidiasis prevalence rate of 15.1% in patients (Tebib et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Talukder et al. designed a study in which 576 people were serologically examined in Central Australia. The results showed that a total of 156 people were positive for strongyloidiasis, with an estimated prevalence rate of 27%. The study also examined the prevalence of strongyloidiasis in individuals infected and uninfected with HTLV-1. The results showed the prevalence rates of 30.4% and 22.4% in uninfected and infected individuals, respectively (Talukder et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the previous study, the highest percent change was among men, aged from 65 to 69 years old (77%), and women, aged from 60 to 64 years old (86.8%). The mortality percent rise in the 10\u0026ndash;20 years old age group (14.7%) was higher than the 20\u0026ndash;30 years old population (8.4%)\u003c/p\u003e \u003cp\u003e(Safavi-Naini et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn current study, 13.9% and 25.2% were respectively female and male out of 24 individuals infected with \u003cem\u003eS. stercoralis\u003c/em\u003e. A statistically significant difference was observed between the prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e and the gender of the study population. Similar to the present study, other research (Sharifdini et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) (Naves and Costa-Cruz \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) provided evidence that the prevalence of \u003cem\u003eStrongyloides\u003c/em\u003e in men was higher than in women, likely due to greater exposure to sources of contamination, such as working in fields and contact with soil. Several studies conducted in different geographical regions have consistently demonstrated no statistically significant association between gender and \u003cem\u003eS. stercoralis\u003c/em\u003e infection rates (Sultana et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, G\u0026eacute;taz, Castro et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Sharifdini et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Mirzaei et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding the age group in the present study, the highest prevalence of strongyloidiasis (27.2%) belonged to the age group over 70 years, but this relationship was not statistically significant. This might have resulted from the small sample size of the present study. As in the present study, no statistically significant relationship was observed between age groups and infection with strongyloidiasis. However, the highest infection with the parasite \u003cem\u003eS. stercoralis\u003c/em\u003e was observed in the age group over 60 years, and a significant difference was observed between the prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e and different age groups in the analyzed studies (Sharifdini, Kia et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, Sharifdini, Keyhani et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In line with our work, previous research has reported that the frequency of infection with \u003cem\u003eS. stercoralis\u003c/em\u003e increased significantly with age (Senephansiri et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, Pacheco-Tenza et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These results confirm that the high percentage of strongyloidiasis in the elderly is related to past infection, and this parasite can persist in the human body for a long time because of its self-infection ability.\u003c/p\u003e \u003cp\u003eAccording to the results obtained in this study, a significant difference was observed between the prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e and different occupations. The highest prevalence of strongyloidiasis belonged to the occupational group of farmers and workers (42.9%). Farmers, particularly rice farmers, have long-term skin contact with soil and are more probably exposed to the penetration of the filariform larvae of \u003cem\u003eS. stercoralis\u003c/em\u003e into the skin. Similar to our study, Mirzaei et al. claimed that the frequency of \u003cem\u003eS. stercoralis\u003c/em\u003e in farmers (19.8%) was higher than in other occupations, but this relationship was not statistically significant (Mirzaei et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In a similar study, a statistically significant relationship was found between infection with this parasite and occupation among residents of villages in Fuman County (Sharifdini et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The present study revealed a significantly higher prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e infection among animal husbandry workers compared to other occupational groups. Notably, no infections were detected among children under six years of age, students, or unemployed individuals (Sharifdini et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These findings are consistent with epidemiological studies (Senephansiri et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, Tuyizere et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), which similarly reported elevated infection rates in agricultural occupational groups relative to other professions.\u003c/p\u003e \u003cp\u003eThe observed occupational disparity likely stems from differential exposure to contaminated soil, the primary transmission route for \u003cem\u003eS. stercoralis\u003c/em\u003e. As Alcaraz et al. demonstrated, agricultural workers exhibit particularly high infection rates due to their frequent and prolonged contact with soil during farming activities (Senephansiri et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This exposure risk is further compounded by several factors: (1) common practices such as barefoot fieldwork that facilitate larval penetration, (2) handling of potentially contaminated water or fertilizers, and (3) inadequate sanitation infrastructure in rural agricultural communities that increases the probability of soil contamination with infectious larvae. The convergence of these occupational, behavioral, and environmental factors creates conditions particularly conducive to \u003cem\u003eS. stercoralis\u003c/em\u003e transmission among agricultural workers, explaining the consistently higher prevalence observed in this population across multiple epidemiological studies (Sch\u0026auml;r et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Sch\u0026auml;r et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn terms of place of residence, the current study recorded the highest prevalence of strongyloidiasis (26.5%) in patients living in rural areas. However, no significant relationship was observed between place of residence and \u003cem\u003eS. stercoralis\u003c/em\u003e infection (Ashiri et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In contrast to our findings, previous research has shown that 18.9% and 14.4% of patients infected with the parasite \u003cem\u003eS. stercoralis\u003c/em\u003e lived in rural areas and urban settings, respectively, but no statistically significant relationship was found between infection with \u003cem\u003eS. stercoralis\u003c/em\u003e and place of residence (Mirzaei et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Whereas, G\u0026eacute;taz et al. reported that strongyloidiasis infection was more prevalent among people who lived in rural areas and walked barefoot (G\u0026eacute;taz et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, the highest rate of \u003cem\u003eS. stercoralis\u003c/em\u003e infection (with a frequency of 26.3%) belonged to illiterate individuals, and the lowest infection rate was observed in individuals with a high school diploma or higher. In this study, a statistically significant relationship was found between education level and \u003cem\u003eS. stercoralis\u003c/em\u003e infection (G\u0026eacute;taz et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Likewise, Munisankar et al. documented lower levels of education in most infected individuals in South India (G\u0026eacute;taz et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). On the other hand, Mirzaei et al. detected no significant relationship between \u003cem\u003eS. stercoralis\u003c/em\u003e infection and levels of education (Mirzaei et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present study, 21.4% and 18.2% of people without and with underlying diseases were infected with \u003cem\u003eS. stercoralis\u003c/em\u003e respectively, and no statistically significant association was observed between underlying diseases and \u003cem\u003eStrongyloides\u003c/em\u003e infection. Regarding the type of underlying disease, strongyloidiasis was most prevalent in the diabetic group (24.6%), and the relationship between the type of underlying disease and \u003cem\u003eS. stercoralis\u003c/em\u003e infection was not statistically significant. The study indicated a significant relationship between the type of underlying disease and \u003cem\u003eS. stercoralis\u003c/em\u003e infection, with asthma and chronic obstructive pulmonary disease being the most influential underlying diseases observed. Additionally, strongyloidiasis was found to be one of the most prevalent parasitic diseases among patients receiving immunosuppressive drugs in northern Iran. According to the previous studies, strongyloidiasis can have severe consequences in immunocompromised individuals, making timely treatment with ivermectin crucial due to its safety and efficacy. Screening is advised for patients scheduled for immunosuppressive therapies such as transplantation or corticosteroid treatment particularly those with potential exposure to the infection, regardless of how long they have been outside endemic regions. This recommendation gains added importance with the increasing use of dexamethasone in COVID-19 management (Ramanathan and Nutman \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2008\u003c/span\u003e, Stauffer et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, De Wilton et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the eosinophilia group showed the highest prevalence of strongyloidiasis (25%). However, no statistically significant association was observed between eosinophilia and \u003cem\u003eS. stercoralis\u003c/em\u003e infection. In contrast to our study, another study showed that eosinophilia was significantly associated with the prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e infection (Ashiri et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In a study in northern Italy strongyloidiasis was 9 times more common in people with eosinophilia than in those with normal eosinophil counts (Buonfrate et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study revealed a high prevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e infection (19.7%) in COVID-19 patients. This finding is particularly significant given the widespread use of corticosteroids and tocilizumab in COVID-19 treatment. Importantly, administering immunosuppressive drugs to patients with \u003cem\u003eS. stercoralis\u003c/em\u003e infection increases the risk of severe and potentially fatal complications, including hyperinfection syndrome and disseminated strongyloidiasis. Therefore, widespread screening of COVID-19 patients with serological methods seems necessary due to the high sensitivity and high speed of these methods before treatment with immunosuppressive drugs. Future epidemiological investigations should focus on identifying individual risk factors and high-risk communities to facilitate targeted intervention strategies.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConsent to participate\u003c/h2\u003e \u003cp\u003eAuthors declare that they have participated in this work.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Authors declare that they know the content of this manuscript and agreed to submit it to \u0026hellip;..\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors would like to thank all people who have contributed to this research.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The protocol of this study was approved by the Ethics Committee of Guilan University of Medical Sciences, Iran (Ref. No. IR.GUMS.REC.1401.194).\u003c/p\u003e \u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl Maslamani MA, Al Soub HA, Al Khal AL, Al Bozom IA, Abu Khattab MJ, Chacko KC (2009) Strongyloides stercoralis hyperinfection after corticosteroid therapy: a report of two cases. Ann Saudi Med 29(5):397\u0026ndash;401\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshiri A, Beiromvand M, Rafiei A, Heidari R, Takesh A (2023) Prevalence of asymptomatic strongyloidiasis co-infection in COVID-19 patients residing in endemic areas. Eur J Med Res 28(1):281\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshiri A, Rafiei A, Beiromvand M, Khanzadeh A, Alghasi A (2021) Screening of Strongyloides stercoralis infection in high-risk patients in Khuzestan Province, vol 14. Southwestern Iran. Parasites \u0026amp; Vectors\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuonfrate D, Baldissera M, Abrescia F, Bassetti M, Caramaschi G, Giobbia M, Mascarello M, Rodari P, Scattolo N, Napoletano G, Bisoffi Z (2016) Epidemiology of Strongyloides stercoralis in northern Italy: results of a multicentre case-control study, February 2013 to July 2014. Euro Surveill 21(31).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuonfrate D, Bisanzio D, Giorli G, Odermatt P, F\u0026uuml;rst T, Greenaway C, French M, Reithinger R, Gobbi F, Montresor A, Bisoffi Z (2020) Global Preval Strongyloides stercoralis Infect Pathogens 9(6)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorse T, Dayan L, Kersten S, Battaglia F, Terlecky SR, Han Z (2020) Clinical Outcomes of COVID-19 Patients with Pre-existing, Compromised Immune Systems: A Review of Case Reports. Int J Med Sci 17(18):2974\u0026ndash;2986\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorti M, Villafa\u0026ntilde;e MF, Trione N, Risso D, Abu\u0026iacute;n JC, Palmieri O (2011) [Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients]. Rev Chil Infectol 28(3):217\u0026ndash;222\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCzeresnia JM, Weiss LM (2022) Strongyloides stercoralis Lung 200(2):141\u0026ndash;148\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Wilton A, Nabarro LE, Godbole GS, Chiodini PL, Boyd A, Woods K (2021) Risk of Strongyloides Hyperinfection Syndrome when prescribing dexamethasone in severe COVID-19. Travel Med Infect Dis 40:101981\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeely NM, Waghorn DJ, Dexter T, Gallen I, Chiodini P (2010) Strongyloides stercoralis hyperinfection: difficulties in diagnosis and treatment. Anaesthesia 65(3):298\u0026ndash;301\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGenta RM (1989) Global prevalence of strongyloidiasis: critical review with epidemiologic insights into the prevention of disseminated disease. Rev Infect Dis 11(5):755\u0026ndash;767\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026eacute;taz L, Castro R, Zamora P, Kramer M, Gareca N, Torrico-Espinoza MDC, Macias J, Lisarazu-Vel\u0026aacute;squez S, Rodriguez G, Valencia-Rivero C, Perneger T, Chappuis F (2019) Epidemiology of Strongyloides stercoralis infection in Bolivian patients at high risk of complications. PLoS Negl Trop Dis 13(1):e0007028\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenks NP, Driscoll B, Locke T (2022) Strongyloidiasis Hyperinfection Syndrome in COVID-19 Positive Migrants Treated with Corticosteroids. J Immigr Minor Health 24(6):1431\u0026ndash;1434\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhadka P, Khadka P, Thapaliya J, Karkee DB (2018) Fatal strongyloidiasis after corticosteroid therapy for presumed chronic obstructive pulmonary disease. JMM Case Rep 5(9):e005165\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JM, Sivasubramanian G (2022) Strongyloides Hyperinfection Syndrome among COVID-19 Patients Treated with Corticosteroids. Emerg Infect Dis 28(7):1531\u0026ndash;1533\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKridaningsih TN, Sukmana DJ, Mufidah H, Diptyanusa A, Kusumasari RA, Burdam FH, Kenangalem E, Poespoprodjo JR, Fuad A, Mahendradhata Y, Supargiyono S, Utzinger J, Becker SL, Murhandarwati EEH (2020) Epidemiology and risk factors of Strongyloides stercoralis infection in Papua, Indonesia: a molecular diagnostic study. Acta Trop 209:105575\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarchese V, Crosato V, Gulletta M, Castelnuovo F, Cristini G, Matteelli A, Castelli F (2021) Strongyloides infection manifested during immunosuppressive therapy for SARS-CoV-2 pneumonia. Infection 49(3): 539\u0026ndash;542\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcos LA, Terashima A, Dupont HL, Gotuzzo E (2008) Strongyloides hyperinfection syndrome: an emerging global infectious disease. Trans R Soc Trop Med Hyg 102(4):314\u0026ndash;318\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirzaei L, Ashrafi K, Atrkar Roushan Z, Mahmoudi MR, Shenavar Masooleh I, Rahmati B, Saadat F, Mirjalali H, Sharifdini M (2021) Strongyloides stercoralis and other intestinal parasites in patients receiving immunosuppressive drugs in northern Iran: a closer look at risk factors. Epidemiol Health 43:e2021009\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaves MM, Costa-Cruz JM (2013) High prevalence of Strongyloides stercoralis infection among the elderly in Brazil. Rev Inst Med Trop Sao Paulo 55(5):309\u0026ndash;313\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman FF, Chamorro S, Braojos F, L\u0026oacute;pez-Miranda E, Chamorro J, Gonz\u0026aacute;lez I, Mart\u0026iacute;n O, P\u0026eacute;rez-Molina JA (2022) Strongyloides in bronchoalveolar lavage fluid: practical implications in the COVID-19 era. J Travel Med 29(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eN\u0026uacute;\u0026ntilde;ez-G\u0026oacute;mez L, Comeche B, Subirats M (2021) Strongyloidiasis: An Important Coinfection in the COVID-19 Era. Am J Trop Med Hyg 105(5):1134\u0026ndash;1135\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacheco-Tenza MI, Ruiz-Maci\u0026aacute; JA, Navarro-Cots M, Gregori-Colom\u0026eacute; J, Cepeda-Rodrigo JM, Llenas-Garc\u0026iacute;a J (2018) Strongyloides stercoralis infection in a Spanish regional hospital: Not just an imported disease. Enferm Infecc Microbiol Clin (Engl Ed) 36(1):24\u0026ndash;28\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira CVM, Mastandrea GRA, Medeiros A, Gryschek RCB, Paula FM, Corral MA (2021) COVID-19 and strongyloidiasis: what to expect from this coinfection? Clin (Sao Paulo) 76:e3528\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira Vieira Barreto NM, Brito Farias MM, Oliveira CL, Almeida Costa Araujo W, Rios Grassi MF, de Nascimento J, Soares Jacobina MC Aquino Teixeira, B. Galv\u0026atilde;o-Castro and N. Matos Soares (2022). Evaluation of Strongyloides stercoralis infection in patients with HTLV-1. Biomedica 42(1): 31\u0026ndash;40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRafiei R, Rafiei A, Rahdar M, Keikhaie B (2016) Seroepidemiology of Strongyloides stercoralis amongst immunocompromised patients in Southwest Iran. Parasite Epidemiol Control 1(3):229\u0026ndash;232\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamanathan R, Nutman T (2008) Strongyloides stercoralis infection in the immunocompromised host. Curr Infect Dis Rep 10(2):105\u0026ndash;110\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSafavi-Naini SAA, Farsi Y, Alali WQ, Solhpour A, Pourhoseingholi MA (2022) Excess all-cause mortality and COVID-19 reported fatality in Iran (April 2013-September 2021): age and sex disaggregated time series analysis. BMC Res Notes 15(1):130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026auml;r F, Giardina F, Khieu V, Muth S, Vounatsou P, Marti H, Odermatt P (2016) Occurrence of and risk factors for Strongyloides stercoralis infection in South-East Asia. Acta Trop 159:227\u0026ndash;238\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSch\u0026auml;r F, Trostdorf U, Giardina F, Khieu V, Muth S, Marti H, Vounatsou P, Odermatt P (2013) Strongyloides stercoralis: Global Distribution and Risk Factors. PLoS Negl Trop Dis 7(7):e2288\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeeger D, Cornejo Cisneros E, Lucar J, Denyer R (2023) Strongyloides and COVID-19: Challenges and Opportunities for Future Research. Trop Med Infect Dis 8(2)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenephansiri P, Laummaunwai P, Laymanivong S, Boonmar T (2017) Status and Risk Factors of Strongyloides stercoralis Infection in Rural Communities of Xayaburi Province, Lao PDR. Korean J Parasitol 55(5):569\u0026ndash;573\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharifdini M, Ghanbarzadeh L, Barikani A, Saraei M (2020) Prevalence of Intestinal Parasites among Rural Inhabitants of Fouman, Guilan Province, Northern Iran with Emphasis on Strongyloides stercoralis. Iran J Parasitol 15(1):91\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharifdini M, Keyhani A, Eshraghian MR, Beigom Kia E (2018) Molecular diagnosis of strongyloidiasis in a population of an endemic area through nested-PCR. Gastroenterol Hepatol Bed Bench 11(1):68\u0026ndash;74\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharifdini M, Kia EB, Ashrafi K, Hosseini M, Mirhendi H, Mohebali M, Kamranrashani B (2014) An Analysis of Clinical Characteristics of Strongyloides stercoralis in 70 indigenous patients in Iran. Iran J Parasitol 9(2):155\u0026ndash;162\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShokri A, Sarasiabi KS, Teshnizi SH, Mahmoodi H (2012) Prevalence of Strongyloides stercoralis and other intestinal parasitic infections among mentally retarded residents in central institution of southern Iran. Asian Pac J Trop Biomed 2(2):88\u0026ndash;91\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoleymani E, Davoodi L, Shayesteh Azar S, Mirbadiei SR, Parandin F, Azimi A, Mizani A, Khorshidvand Z, Fakhar M (2023) Fatal Disseminated Strongyloidiasis in an Immunosuppressed Patient During COVID-19 Pandemic. Acta Parasitol 68(3):711\u0026ndash;717\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStauffer WM, Alpern JD, Walker PF (2020) COVID-19 and Dexamethasone: A Potential Strategy to Avoid Steroid-Related Strongyloides. Hyperinfection Jama 324(7):623\u0026ndash;624\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStylemans D, Van Cauwelaert S, D'Haenens A, Slabbynck H (2021) COVID-19-Associated Eosinopenia in a Patient With Chronic Eosinophilia Due to Chronic Strongyloidiasis. Infect Dis Clin Pract (Baltim Md) 29(5):e305\u0026ndash;e306\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSultana Y, Gilbert GL, Ahmed BN, Lee R (2012) Seroepidemiology of Strongyloides stercoralis in Dhaka. Bangladesh Parasitol 139(11):1513\u0026ndash;1520\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaherkhani K, Barikani A, Shahnazi M, Saraei M (2019) Prevalence of Intestinal Parasites among Rural Residents of Takestan in North-West of Iran. Iran J Parasitol 14(4):657\u0026ndash;663\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTalukder MR, Pham H, Woodman R, Wilson K, Taylor K, Kaldor J, Einsiedel L (2022) The Association between Diabetes and Human T-Cell Leukaemia Virus Type-1 (HTLV-1) with Strongyloides stercoralis: Results of a Community-Based, Cross-Sectional Survey in Central Australia. Int J Environ Res Public Health 19(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTebib N, Tebib N, Paredes M, Castro R, Baggio S, Torrico MV, Leon AAF, Zamorano MH, Chappuis F, Getaz L (2023) Prevalence and risk factors of Strongyloides stercoralis in haemodialysis in Cochabamba, Bolivia: a cross-sectional study. BMC Nephrol 24(1):27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuyizere A, Ndayambaje A, Walker TD, Bayingana C, Ntirenganya C, Dusabejambo V, Hale DC (2018) Prevalence of Strongyloides stercoralis infection and other soil-transmitted helminths by cross-sectional survey in a rural community in Gisagara District, Southern Province. Rwanda Trans Royal Soc Trop Med Hygiene 112(3):97\u0026ndash;102\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang C, Xu J, Zhou X, Li J, Yan G, James AA, Chen X (2013) Strongyloidiasis: an emerging infectious disease in China. Am J Trop Med Hyg 88(3):420\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang R, Xu M, zhang L, Liao Y, Liu Y, Deng X, Wang L (2025) Human Strongyloides stercoralis infection. J Microbiol Immunol Infect 58(2):164\u0026ndash;179\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-parasitic-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jopd","sideBox":"Learn more about [Journal of Parasitic Diseases](https://www.springer.com/journal/12639)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jopd/default.aspx","title":"Journal of Parasitic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Strongyloides stercoralis, COVID-19, Guilan, Serology","lastPublishedDoi":"10.21203/rs.3.rs-8184413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8184413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eStrongyloidiasis, a parasitic infection caused by the intestinal nematode \u003cem\u003eStrongyloides stercoralis\u003c/em\u003e, remains a significant public health concern in tropical and subtropical regions. This helminthic infection poses particular risks for immunocompromised individuals, potentially progressing to life-threatening hyperinfection syndrome and disseminated disease. In Iran, endemic foci of \u003cem\u003eS. stercoralis\u003c/em\u003e have been well-documented in both northern and southern coastal provinces. The current COVID-19 pandemic has introduced new clinical challenges, as immunosuppressive therapies commonly employed in COVID-19 management may predispose patients to severe parasitic complications. This descriptive cross-sectional study aimed to determine both the seroprevalence of \u003cem\u003eS. stercoralis\u003c/em\u003e infection and associated risk factors among COVID-19 patients of Guilan province in northern Iran during 2022. A total of 208 serum samples were collected from patients with COVID-19 referred to Razi Hospital in Rasht City, Guilan province. Demographic data, such as sex, age, job, residential area, and educational level, were recorded through interviews. The presence of the anti- \u003cem\u003eS. stercoralis\u003c/em\u003e IgG antibody was detected by \u003cem\u003eS. stercoralis\u003c/em\u003e IgG ELISA kit. The seropositive rate of strongyloidiasis was 19.7% of all the studied subjects. The seropositivity rate for strongyloidiasis was 19.7% among the studied subjects. A significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039) was observed between genders, with 25.2% of males and 13.9% of females testing seropositive. The prevalence was significantly higher (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014) among farmers and workers compared to other occupational groups. Additionally, illiterate individuals had a significantly higher infection rate (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007) than those with formal education. This study highlights a high prevalence of strongyloidiasis among COVID-19 patients in northern Iran. Therefore, screening for \u003cem\u003eStrongyloides\u003c/em\u003e infection using serologic methods, particularly in endemic regions should be considered before initiating immunosuppressive therapy in COVID-19 patients. Future epidemiological research should systematically evaluate individual risk factors to facilitate targeted intervention strategies.\u003c/p\u003e","manuscriptTitle":"Serological Evidence of Strongyloidiasis in COVID-19 Hospitalized Patients in Northern Iran during the Pandemic: Prevalence and Risk Factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 09:22:14","doi":"10.21203/rs.3.rs-8184413/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-11T05:37:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T11:23:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Parasitic Diseases","date":"2025-11-23T04:04:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-parasitic-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jopd","sideBox":"Learn more about [Journal of Parasitic Diseases](https://www.springer.com/journal/12639)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jopd/default.aspx","title":"Journal of Parasitic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"55711bba-8eb3-445f-a6c4-1f63d67911b1","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T09:22:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 09:22:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8184413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8184413","identity":"rs-8184413","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}