Cercarial dermatitis in central India: an emerging health problem among tribal communities

Zoonotic Threats: The (Re)emergence of Cercarial Dermatitis, Its Dynamics, and Impact in Europe

Cercarial dermatitis (CD), or "Swimmer's itch" as it is also known, is a waterborne illness caused by a blood fluke from the family Schistosomatidae. It occurs when cercariae of trematode species that do not have humans as their definitive host accidentally penetrate human skin (in an aquatic environment) and trigger allergic symptoms at the site of contact. It is an emerging zoonosis that occurs through water and is often overlooked during differential diagnosis. Some of the factors contributing to the emergence of diseases like CD are related to global warming, which brings about climate change, water eutrophication, the colonization of ponds by snails susceptible to the parasite, and sunlight exposure in the summer, associated with migratory bird routes. Therefore, with the increase in tourism, especially at fluvial beaches, it is relevant to analyze the current epidemiological scenario of CD in European countries and the potential regions at risk.

Scratching the Itch: Updated Perspectives on the Schistosomes Responsible for Swimmer's Itch around the World

Although most studies of digenetic trematodes of the family Schistosomatidae dwell on representatives causing human schistosomiasis, the majority of the 130 identified species of schistosomes infect birds or non-human mammals. The cercariae of many of these species can cause swimmer's itch when they penetrate human skin. Recent years have witnessed a dramatic increase in our understanding of schistosome diversity, now encompassing 17 genera with eight more lineages awaiting description. Collectively, schistosomes exploit 16 families of caenogastropod or heterobranch gastropod intermediate hosts. Basal lineages today are found in marine gastropods and birds, but subsequent diversification has largely taken place in freshwater, with some reversions to marine habitats. It seems increasingly likely that schistosomes have on two separate occasions colonized mammals. Swimmer's itch is a complex zoonotic disease manifested through several different routes of transmission involving a diversity of different host species. Swimmer's itch also exemplifies the value of adopting the One Health perspective in understanding disease transmission and abundance because the schistosomes involved have complex life cycles that interface with numerous species and abiotic components of their aquatic environments. Given the progress made in revealing their diversity and biology, and the wealth of questions posed by itch-causing schistosomes, they provide excellent models for implementation of long-term interdisciplinary studies focused on issues pertinent to disease ecology, the One Health paradigm, and the impacts of climate change, biological invasions and other environmental perturbations.

The Clean India Mission: Public and animal health benefits

The Clean India Mission is a national campaign that aims for complete elimination of open defecation from the country. In India, 564 million people do not have access to toilets and defecate in the open environment. The 'Millennium development goals' have given increased weightage to elimination of open defecation for improving health, nutrition and productivity of developing country populations. The Indian economy bears an estimated annual total loss (in terms of health, education, access time and tourism) of US$ 54 billion due to lack of toilets, poor hygiene and over US$ 38.5 billion in treatment costs for diseases occurring due to poor hygiene. Out of 1415 human pathogens, at least more than 10% of pathogens are transmitted through the faecal-oral route. The practice of open defecation helps pathogens persist in the environment and cause diseases. This review focuses on the current status and harms of open defecation, as well as the public and animal health benefits of implementing 'The Clean India Mission' in India.

Agents of swimmer's itch-dangerous minority in the Digenea invasion of Lymnaeidae in water bodies and the first report of Trichobilharzia regenti in Poland

Trichobilharzia spp. have been identified as a causative agent of swimmers’ itch, a skin disease provoked by contact with these digenean trematodes in water. These parasites have developed a number of strategies to invade vertebrates. Since we have little understanding of the behavior of these parasites inside the human body, the monitoring of their invasion in snail host populations is highly recommended. In our research, lymnaeid snails were collected from several Polish lakes for two vegetation seasons. The prevalence of bird schistosomes in snail host populations was significantly lower than that of other digenean species. We were the first to detect the presence of the snails emitted Trichobilharzia regenti (potentially the most dangerous nasal schistosome) in Poland. In addition, by sequencing partial rDNA genes, we confirmed the presence of the snails positive with Trichobilharzia szidati in Polish water bodies, showing that swimmer’s itch is more frequent during summer months and that large snails are more often infected with bird schistosomes than small ones.

The real threat of swimmers' itch in anthropogenic recreational water body of the Polish Lowland

After numerous reports the local press about the “stinging water” in created on the Dzierżęcinka River—Water Valley reservoir and recognizing in bathers the symptoms of swimmers’ itch, environmental study on the presence of bird schistosome larvae in snail hosts was conducted. Snails belonging to Lymnaeidae and Planorbidae were collected at two sites: (i) part of anthropogenic reservoir (192 individuals) and (ii) the river part (37 individuals). Higher prevalence of Digenea was observed in snail populations living in Water Valley (29.8 %) compared to Dzierżęcinka River (21.3 %). The larvae of bird schistosomes were recorded in both localities in 1.8 % of collected snails. The prevalence of bird schistosomes reached 2.9 % in Planorbarius corneus, 2.8 % in Radix auricularia, and 5.9 % in Radix balthica/labiata. Laboratory tests have shown that at 19 °C the number of bird schistosome cercariae released from snail hosts significantly exceeded the number of cercariae of other identified Digenea species. It is worth underlining that despite the low prevalence of bird schistosomes, the high number of released cercariae was sufficient to create a real threat of swimmers’ itch in bathers. As indicated by the example presented, anthropogenic reservoirs create excellent conditions for Digenea species including bird schistosomes. In view of the real risk of people using the waters, tests on presence of the parasites in snail hosts should be included to the standard procedure of security control in bathing places.

Schistosome infections: an Indian perspective

Schistosomiasis is an endemic helminthic disease of human. Schistosomes display considerable biodiversity in habitat, host range, and epidemiology globally. In spite of the noticeable presence of sero-positivity for schistosomal antibody and passage of schistosome eggs in human faeces, Indian subcontinent has always been considered as a low risk region for human schistosomiasis. Several species has been described in India which may have association with human infection and cercarial rash. Although sporadic cases are not uncommon, the status of human schistosomiasis in India is not well investigated. In this review different aspect of schistosomal infection in human in India has been described briefly.

Real-time PCR and sequencing assays for rapid detection and identification of avian schistosomes in environmental samples

Cercarial dermatitis, also known as swimmer's itch, is an allergenic skin reaction followed by intense itching caused by schistosome cercariae penetrating human skin. Cercarial dermatitis outbreaks occur globally and are frequently associated with freshwater lakes and are occasionally associated with marine or estuarine waters where birds reside year-round or where migratory birds reside. In this study, a broadly reactive TaqMan assay targeting 18S rRNA gene (ribosomal DNA [rDNA]) sequences that was based on a genetically diverse panel of schistosome isolates representing 13 genera and 20 species (the 18S rDNA TaqMan assay) was developed. A PCR assay was also developed to amplify a 28S rDNA region for subsequent sequencing to identify schistosomes. When applied to surface water samples seeded with Schistosoma mansoni cercariae, the 18S rDNA TaqMan assay enabled detection at a level of 5 S. mansoni cercariae in 100 liters of lake water. The 18S rDNA TaqMan and 28S rDNA PCR sequencing assays were also applied to 100-liter water samples collected from lakes in Nebraska and Wisconsin where there were reported dermatitis outbreaks. Avian schistosome DNA was detected in 11 of 34 lake water samples using the TaqMan assay. Further 28S rDNA sequence analysis of positive samples confirmed the presence of avian schistosome DNA and provided a preliminary identification of the avian schistosomes in 10 of the 11 samples. These data indicate that the broadly schistosome-reactive TaqMan assay can be effective for rapid screening of large-volume water samples for detection of avian schistosomes, thereby facilitating timely response actions to mitigate or prevent dermatitis outbreaks. Additionally, samples positive by the 18S rDNA TaqMan assay can be further assayed using the 28S rDNA sequencing assay to both confirm the presence of schistosomes and contribute to their identification.

Avian schistosomes and outbreaks of cercarial dermatitis

Cercarial dermatitis (swimmer's itch) is a condition caused by infective larvae (cercariae) of a species-rich group of mammalian and avian schistosomes. Over the last decade, it has been reported in areas that previously had few or no cases of dermatitis and is thus considered an emerging disease. It is obvious that avian schistosomes are responsible for the majority of reported dermatitis outbreaks around the world, and thus they are the primary focus of this review. Although they infect humans, they do not mature and usually die in the skin. Experimental infections of avian schistosomes in mice show that in previously exposed hosts, there is a strong skin immune reaction that kills the schistosome. However, penetration of larvae into naive mice can result in temporary migration from the skin. This is of particular interest because the worms are able to migrate to different organs, for example, the lungs in the case of visceral schistosomes and the central nervous system in the case of nasal schistosomes. The risk of such migration and accompanying disorders needs to be clarified for humans and animals of interest (e.g., dogs). Herein we compiled the most comprehensive review of the diversity, immunology, and epidemiology of avian schistosomes causing cercarial dermatitis.

Indian schistosomes: a need for further investigations

India is uniquely positioned with regard to schistosomes and schistosomiasis—discovering seven new mammalian species with the existence of three more schistosome species: Orientobilharzia turkestanicum, O. harinasutai, and Schistosoma haematobium(?). An endemic focus of urinary schistosomiasis was reported from Gimvi village of Ratnagiri, Maharashtra with infrequent occurrence of schistosome eggs in human stools. Cercarial dermatitis has been reported to be more abundant in rural population using ponds, tanks, and so forth, for their domestic purposes. Few dermatitis cases were tested positive by CHR. Schistosome antigen was also detected in urine of five cases suggesting existence of active schistosomiasis in India. Nevertheless, human kind does not appear to be the usual host for Indian schistosomes in contrast to S. haematobium, S. mansoni, or S. japonicum. Various reasons for this phenomenon are discussed including evolution of Indian schistosomes, immune mechanisms, and environmental conditions. These and other aspects such as seasonal effect on the prevalence, snail infectivity, heterologous mating, existence of hybrids, and number of schistosomes in heterologous infections need further investigations with application of molecular techniques. Joint efforts by the national as well as international scientific community would be much more rewarding for better understanding of the parasite and the infection.

Parasitological and molecular study of the furcocercariae from Melanoides tuberculata as a probable agent of cercarial dermatitis

Cercarial dermatitis is caused by animal schistosomes in many parts of the world including Iran. Various stages of the parasites have been studied in intermediate and definitive hosts in northern and southwestern Iran; however, no molecular investigation for species identification and classification of these agents has been carried out, so far. In the present study, more than 3,800 aquatic snails were collected from water sources of Khuzestan, southwest Iran. The snails were identified as Lymnaea gedrosiana, Radix auricularia, Melanoides tuberculata, Melanopsis sp. and Physa acuta. They were examined for schistosome cercariae. Two specimens of M. tuberculata were infected with ocellate furcocercariae belonging to the family Schistosomatidae. Molecular studies were carried on these schistosomatid samples. Both samples belong to an unknown schistosome species and genus in sister position to Gigantobilharzia-Dendritobilharzia clade. They differ from other species in their ITS sequence region as well as in their intermediate host specificity--This is one of the first reports on schistosome cercariae from M. tuberculata and the first including molecular data. Due to adaptability and invasiveness of this snail species, this new schistosome species, as a potential causative agent of cercarial dermatitis in humans, needs to be studied further.

Confirmation of the presence of Trichobilharzia by examination of water samples and snails following reports of cases of cercarial dermatitis

In case of cercarial dermatitis after exposure to fresh water lakes, managers responsible for bathing water quality wish to confirm the presence of Trichobilharzia, which substantiates taking measures to protect bathers from further exposure. A novel approach, including concentration of suspected water samples by filtration and PCR detection of the parasite, is proposed. This approach has been applied to bathing sites with a history of cercarial dermatitis, sampled from 2005 to 2008. Examination of snails, the standard procedure for confirmation of the parasite's presence, and analysis of water samples, appear to be complementary procedures that enhance the chance of parasite detection in implicated bathing water. Water analysis is particularly valuable when snails cannot be found; it confirmed the presence of Trichobilharzia on 25% of sampling days with reported skin conditions and no snails found. PCR of the ToSau3A repeat directly confirmed the parasite in the water. The application of the combination of analysis of water samples and examination of snails is suggested when cases of (presumptive) cercarial dermatitis are reported or when lakes with a history of cercarial dermatitis are inspected prior to the bathing season, in order to guide interventions to prevent (further) cases of swimmers' itch.

Orientobilharzia species: neglected parasitic zoonotic agents

Parasites of the genus Orientobilharzia belong to Platyhelminthes, Trematoda, Digenea, Schistosomatidae, and the type species is Orientobilharzia turkestanicum. O. turkestanicum was first described by Skrjabin from cattle in Russian Turkestan in 1913. Adult worms of Orientobilharzia species live in the portal veins or intestinal veins of cattle, sheep and other mammals, and often cause orientobilharziasis in China, India, Mongolia, Pakistan, Iraq, Iran in Asia, and Russia and Turkey in Europe. More importantly, the cercariae of Orientobilharzia species can infect humans and often cause cercarial dermatitis. Though Orientobilharzia species have been confirmed as zoonotic agents, they have been largely neglected, compared with other pathogens causing cercarial dermatitis, such as Trichobilharzia spp., Schistosoma spindale and Bilharziella sp., which have attracted considerable attention. Here we review the current status of knowledge on the taxonomy of Orientobilharzia spp., human and animal infections with Orientobilharzia spp., and address some considerations for further work on the systematics and pathogenesis of these organisms.

In vitro cultivation of early schistosomula of nasal and visceral bird schistosomes (Trichobilharzia spp., Schistosomatidae)

Cercariae of bird schistosomes (Trichobilharzia szidati and Trichobilharzia regenti) were mechanically stimulated to transform to schistosomula and kept in different cultivation media supplemented with duck red blood cells and/or homogenized nervous tissue. The development under in vitro conditions was compared with that in vivo, using the following characters: emptying of penetration glands, surface changes, food uptake, and growth of early schistosomula. The results show that the cultivation medium routinely used for human schistosomes is also suitable for mass production of early schistosomula of bird schistosomes, including the unique nasal species-T. regenti. The changes observed resemble those present in worms developing in vivo; therefore, the in vitro produced early schistosomula might be used for further studies of host-parasite interactions.