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Malaga JL, Fernandez-Baca MV, Castellanos-Gonzalez A, Tanabe MB, Tift C, Morales ML, Lopez M, Valdivia-Rodriguez A, Mamani-Licona F, Cabada MM. The Recombinase Polymerase Amplification Test for Strongyloides stercoralis Is More Sensitive than Microscopy and Real-Time PCR in High-Risk Communities of Cusco, Peru. Pathogens 2024; 13:869. [PMID: 39452739 PMCID: PMC11510723 DOI: 10.3390/pathogens13100869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 09/26/2024] [Accepted: 09/30/2024] [Indexed: 10/26/2024] Open
Abstract
Strongyloidiasis is a neglected, soil-transmitted helminth infection prevalent worldwide. The true burden of strongyloidiasis is unclear due to the lack of sensitive, field-friendly diagnostic tests. PCR tests to detect Strongyloides DNA in stool are sensitive and specific, but the need for expensive equipment limits their use in endemic regions. Isothermal PCR amplification tests are easier to deploy while maintaining sensitivity and specificity. We developed and evaluated a recombinase polymerase amplification lateral flow assay (RPA-LFA) to detect Strongyloides stercoralis in human stool samples. Three hundred stool samples were collected in three communities in the jungle of Cusco, Peru. Samples were tested for S. stercoralis larvae using microscopy (Baermann's, agar plate culture (APC), and rapid sedimentation), real-time PCR, and RPA-LF for Strongyloides DNA. The RPA-LFA showed an analytical limit of detection of 20 pg/µL. The prevalence of S. stercoralis was 27%, 38%, 46.3%, and 46% using microscopy, PCR, microscopy/PCR, and RPA-LFA, respectively. RPA-LFA had a sensitivity and specificity of 59.3% and 58.9%, 66.2% and 71.4%, and 77.2% and 73.1% when microscopy, microscopy/PCR, and real-time PCR were used as the gold standards, respectively. The Strongyloides RPA-LFA is a novel, fast, highly sensitive, and specific molecular method with the potential for deployment in endemic regions.
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Affiliation(s)
- Jose L. Malaga
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
| | - Martha V. Fernandez-Baca
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
- Universidad Peruana Cayetano Heredia—University of Texas Medical Branch Collaborative Research Center—Cusco, Universidad Peruana Cayetano Heredia, Cusco 08002, Peru
| | - Alejandro Castellanos-Gonzalez
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.C.-G.); (M.B.T.)
| | - Melinda B. Tanabe
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.C.-G.); (M.B.T.)
| | - Clara Tift
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Maria Luisa Morales
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
- Universidad Peruana Cayetano Heredia—University of Texas Medical Branch Collaborative Research Center—Cusco, Universidad Peruana Cayetano Heredia, Cusco 08002, Peru
| | - Martha Lopez
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
- Universidad Peruana Cayetano Heredia—University of Texas Medical Branch Collaborative Research Center—Cusco, Universidad Peruana Cayetano Heredia, Cusco 08002, Peru
| | - Angela Valdivia-Rodriguez
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
| | - Frecia Mamani-Licona
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
| | - Miguel M. Cabada
- Sede Cusco—Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (J.L.M.); (M.V.F.-B.); (M.L.M.); (M.L.); (A.V.-R.); (F.M.-L.)
- Universidad Peruana Cayetano Heredia—University of Texas Medical Branch Collaborative Research Center—Cusco, Universidad Peruana Cayetano Heredia, Cusco 08002, Peru
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (A.C.-G.); (M.B.T.)
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Zainol DA, Anuar NS, Abdul Halim NSS, Kaur M, Noordin R, Rahumatullah A. Systematic Review of Strongyloides stercoralis Infection Diagnosis in Southeast Asia: Insights from Parasitological, Molecular, and Serological Approaches. Am J Trop Med Hyg 2024; 111:724-735. [PMID: 39137756 PMCID: PMC11448514 DOI: 10.4269/ajtmh.23-0599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 05/13/2024] [Indexed: 08/15/2024] Open
Abstract
Accurate diagnosis of strongyloidiasis is crucial for effective treatment and prevention of complications. We reviewed the current landscape of diagnostic assays used in detecting Strongyloides infection in Southeast Asia. A literature search was performed using Scopus, PubMed, and Web of Science databases spanning the last three decades. Based on the exclusion and inclusion criteria, 52 papers were included in this review. We outlined the diagnostic methods used and their advantages and drawbacks. Insensitive parasitological methods were commonly used, thus underscoring the underestimation of Strongyloides infection rates in Southeast Asia. A combination of diagnostic methods (i.e., microscopy, molecular techniques, and serology) is preferred because it leads to more effective detection and higher prevalence rates. New approaches have been developed, including urine ELISAs and rapid lateral flow tests. Improving and standardizing diagnostics and making them more accessible can improve Strongyloides prevalence estimates and facilitate control efforts.
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Affiliation(s)
- Dinie Adila Zainol
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Penang, Malaysia
| | - Nor Suhada Anuar
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Penang, Malaysia
| | - Nur Shuhaidatul Sarmiza Abdul Halim
- Neurorehabilitation Engineering and Assistance Systems Research (NEAR), School of Mechanical Engineering, Engineering Campus, Universiti Sains Malaysia (USM), Penang, Malaysia
| | - Mansheender Kaur
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Penang, Malaysia
| | - Rahmah Noordin
- Department of Parasitology and Medical Entomology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Anizah Rahumatullah
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia (USM), Penang, Malaysia
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Yang R, Xu M, Zhang L, Liao Y, Liu Y, Deng X, Wang L. Human Strongyloides stercoralis infection. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00120-8. [PMID: 39142910 DOI: 10.1016/j.jmii.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 06/14/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024]
Abstract
Strongyloides stercoralis is an important soil-transmitted helminth occurring world-wide and affecting 30-100 million people. Because many cases are asymptomatic and sensitive diagnostic methods are lacking, S. stercoralis infection is frequently underdiagnosed. The increasing incidence of autoimmune and wasting diseases and increased use of immunosuppressive agents, as well as the increased use of immunosuppressants and cytotoxic drugs, have increased S. stercoralis infection and their mortality. This review provides information about S. stercoralis epidemiology, life cycle, aetiology, pathology, comorbidities, immunology, vaccines, diagnosis, treatment, prevention, control and makes some recommendations for future prevention and control of this important parasite.
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Affiliation(s)
- Ruibing Yang
- Guangzhou Kingmed Center for Clinical Laboratory, Guangzhou, Guangdong 510320, China
| | - Meiyining Xu
- Department of Parasitology of Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lichao Zhang
- Guangdong Clinical Laboratory Center Guangdong Provincial People's Hospital, Guangzhou 510080, China
| | - Yao Liao
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, Guangdong 510180, China
| | - Yuheng Liu
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, Guangdong 510180, China
| | - Xiaoyan Deng
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, Guangdong 510180, China.
| | - Lifu Wang
- Guangzhou Key Laboratory for Clinical Rapid Diagnosis and Early Warning of Infectious Diseases, KingMed School of Laboratory Medicine, Guangzhou Medical University, Guangzhou, Guangdong 510180, China.
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Wongphutorn P, Noordin R, Anuar NS, Worasith C, Kopolrat KY, Homwong C, Tippayawat P, Techasen A, Pitaksakurat O, Sithithaworn J, Eamudomkarn C, Sithithaworn P. Examination of Diagnostic Performance of New IgG4 Rapid Test Compared with IgG- and IgG4-ELISAs to Investigate Epidemiology of Strongyloidiasis in Northeast Thailand. Am J Trop Med Hyg 2024; 110:254-262. [PMID: 38190756 PMCID: PMC10859814 DOI: 10.4269/ajtmh.23-0518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/16/2023] [Indexed: 01/10/2024] Open
Abstract
Strongyloidiasis, caused by Strongyloides stercoralis, is a neglected tropical disease with a global distribution. The infection can be fatal in immunocompromised individuals, and accurate diagnosis leading to timely treatment can save lives. Serodiagnosis is a sensitive method for diagnosis and is recommended for screening high-risk individuals. A point-of-care rapid test will facilitate the screening activities, especially in low-resource settings. This study aims to apply a new IgG4 immunochromatographic test using S. stercoralis recombinant antigen (SsRapid® cassette test) and to compare it with in-house IgG and IgG4 enzyme-linked immunosorbent assays (IgG- and IgG4-ELISAs) using native Strongyloides ratti antigen to investigate the epidemiology of strongyloidiasis in northeast Thailand. A total of 300 people participated, with 136 males and 164 females of a similar mean age. The reference tests were fecal examinations using the formalin-ethyl acetate concentration technique and an agar plate culture technique. The prevalence of S. stercoralis determined by SsRapid (81.7%) was significantly higher than that by fecal examinations (43.3%) or by antibody detection by IgG-ELISA (53.0%) or IgG4-ELISA (44.0%). The diagnostic sensitivities of SsRapid, IgG-ELISA, and IgG4-ELISA were found to be 93.9%, 77.7%, and 63.1%, respectively. The rate of positive tests by the SsRapid was significantly correlated to the levels of Strongyloides-specific IgG4 and IgG antibodies. By all diagnostic methods, male participants had a significantly higher prevalence of strongyloidiasis than females. Age was significantly associated with the concentration of specific serum IgG but not with the SsRapid grading score. In conclusion, SsRapid was shown to be a sensitive and valuable diagnostic test for the epidemiology study of strongyloidiasis.
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Affiliation(s)
| | - Rahmah Noordin
- Department of Parasitology and Medical Entomology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Institute for Research in Molecular Medicine, Universiti Sains Malaysia, Penang, Malaysia
| | - Nor Suhada Anuar
- Institute for Research in Molecular Medicine, Universiti Sains Malaysia, Penang, Malaysia
| | - Chanika Worasith
- Department of Adult Nursing, Faculty of Nursing, Khon Kaen University, Khon Kaen, Thailand
| | - Kulthida Y. Kopolrat
- Faculty of Public Health, Kasetsart University Chalermphrakiat Sakon Nakhon Province Campus, Sakon Nakhon, Thailand
| | - Chutima Homwong
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand
| | | | - Anchalee Techasen
- Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Opal Pitaksakurat
- Department of Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Chatanun Eamudomkarn
- Department of Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Paiboon Sithithaworn
- Cholangiocarcinoma Research Institute, Khon Kaen University, Khon Kaen, Thailand
- Department of Parasitology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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García-Aguilar JA, Alger J. Frequency of strongyloidiasis and associated factors: Analysis of 13 years of laboratory results in a tertiary referral hospital in Honduras, 2010-2022. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:492-505. [PMID: 38109136 PMCID: PMC10776084 DOI: 10.7705/biomedica.7086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION The frequency of detected strongyloidiasis is affected by the selected laboratory method in the studied population. Considering that Honduras has few community-based studies, the analysis of the laboratory record data can provide information helping to understand this parasitosis. OBJECTIVE To estimate the frequency and to identify the factors associated with strongyloidiasis, analyzing the laboratory records of the Servicio de Parasitología at Hospital Escuela in Tegucigalpa (Honduras) between 2010 and 2022. MATERIALS AND METHODS We carried out a descriptive, cross-sectional, analytical study. The laboratory diagnosis consisted of stool samples' examination by direct smear and modified Baermann technique. We estimated frequencies and percentages. The statistical association was calculated with prevalence ratios and a 95% confidence interval. Software R, version 4.2.0, and epiR package, version 2.0.46, were used to perform the analysis. RESULTS The frequency of strongyloidiasis was 0.29% (112/38,085). It was higher with the modified Baermann technique (0.87%; 40/4,575) among male patients (0.44%; 70/15,758). Regarding the age, strongyloidiasis was higher in the 20-40 years old group (0.41%; 28/6,886) with direct smear and 41-61 years old (1.14%; 14/1,232) group with the modified Baermann technique. Among the factors associated with strongyloidiasis were age between 20 and 61 years old (PR=2.26, CI 95%=1.53-3.31), male patients (PR=2.34, CI 95%=1.60‑3.44), mucus (PR=1.86, CI 95%=1.22-2.83) and Charcot-Leyden crystals in stool (PR=8.47, CI 95%=5.14-13.96); watery stool (PR=2.39, CI 95%=1.55-3.68), and other helminthiases (PR=6.73, CI 95%=3.98-11.38). Associated factors to cases detected with the modified Baermann technique were outpatient consultation (PR=4.21, CI 95%=1.91-9.28) and formed stools (PR=3.99, CI 95%=1.94-8.19). CONCLUSIONS The modified Baermann technique increased the detection of strongyloidiasis almost four times. Most cases were distributed among male adults. The cases diagnosed exclusively with the modified Baermann technique have differences from those with observed larvae in the direct smear. It is necessary to develop community-based population studies.
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Affiliation(s)
- Jorge Alberto García-Aguilar
- Servicio de Parasitología, Departamento de Laboratorio Clínico, Hospital Escuela, Tegucigalpa, Honduras; Instituto de Enfermedades Infecciosas y Parasitología Antonio Vidal, Tegucigalpa, Honduras; Asociación Hondureña de Parasitología, Tegucigalpa, Honduras.
| | - Jackeline Alger
- Servicio de Parasitología, Departamento de Laboratorio Clínico, Hospital Escuela, Tegucigalpa, Honduras; Instituto de Enfermedades Infecciosas y Parasitología Antonio Vidal, Tegucigalpa, Honduras; Asociación Hondureña de Parasitología, Tegucigalpa, Honduras.
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Seeger D, Cornejo Cisneros E, Lucar J, Denyer R. Strongyloides and COVID-19: Challenges and Opportunities for Future Research. Trop Med Infect Dis 2023; 8:127. [PMID: 36828543 PMCID: PMC9967524 DOI: 10.3390/tropicalmed8020127] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Strongyloides stercoralis is a soil transmitted helminth endemic to tropical and subtropical areas that can persist for decades in immunocompetent human hosts as a chronic asymptomatic infection. The use of corticosteroids, a mainstay of treatment for patients hospitalized with severe coronavirus disease (COVID-19), can trigger a life-threatening Strongyloides hyperinfection syndrome and disseminated disease. We identified 22 previously published cases of strongyloidiasis occurring in individuals with COVID-19, with one death reported among the seven patients who had Strongyloides hyperinfection syndrome. A total of seventeen patients had previously received corticosteroids, and of the five with no prior corticosteroid use, one presented with hyperinfection syndrome. We identify the key challenges in the diagnosis and treatment of Strongyloides within the context of COVID-19, including our imprecise knowledge of the global distribution of Strongyloides, the overlapping symptoms and signs of COVID-19 and Strongyloides hyperinfection syndrome, the limited utility of eosinophilia as a clinical marker for strongyloidiasis in this setting, the lack of validated algorithms to screen for Strongyloides prior to corticosteroid use, and the paucity of treatment options for critically ill patients with COVID-19 who cannot take oral ivermectin. Future research should focus on improved diagnostic methods and population prevalence estimates, optimizing the approaches for Strongyloides screening in persons with COVID-19 (including clinical trial participants and strategies for resource-limited settings) and better defining the role of pre-emptive treatment.
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Affiliation(s)
- Daniel Seeger
- Infectious Diseases Section, DC Veterans Affairs Medical Center, Washington, DC 20422, USA
- Division of Infectious Diseases, School of Medicine and Health Sciences, George Washington University, Washington, DC 20052, USA
| | - Enrique Cornejo Cisneros
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, 15102, Peru
| | - Jose Lucar
- Division of Infectious Diseases, School of Medicine and Health Sciences, George Washington University, Washington, DC 20052, USA
| | - Rachel Denyer
- Infectious Diseases Section, DC Veterans Affairs Medical Center, Washington, DC 20422, USA
- Division of Infectious Diseases, School of Medicine and Health Sciences, George Washington University, Washington, DC 20052, USA
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Camacho-Alvarez I, Chavez-Mamani EM, Philippe G, Luizaga-López JM, Torrico MC, Gétaz L, Jacobs F. A simple parasitological technique to increase detection of Strongyloides stercoralis in Bolivian primary health care system. BMC PRIMARY CARE 2022; 23:284. [PMID: 36396996 PMCID: PMC9673357 DOI: 10.1186/s12875-022-01888-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Strongyloides stercoralis is widespread; however, there is limited information on its prevalence owing to laboratory underestimation and low clinical manifestations. The Baermann method and agar culture stand out among the parasitological techniques. Strongyloides stercoralis is present in Bolivia, but its prevalence in children remains unknown. The objective of this study was to estimate the applicability of simple parasitological techniques to increase the detection of this parasite in children living in the tropics. METHODS This cross-sectional study was conducted in a tropical village in Cochabamba, Bolivia. Participants were 304 children aged 5 - 12 years who provided stool samples for different parasitological analyses (direct examination, Ritchie, Baermann, and Dancescu techniques), and their parents provided informed consent. RESULTS Up to 64.8% of pathogenic parasites were detected using the modified Ritchie method. The Baermann technique identified 17.8% of Strongyloides stercoralis cases, and a high sensitivity with respect to the Baermann technique was only for the Dancescu technique (75.9%) that is also specific for Strongyloides stercoralis, followed by 66.7% for the modified Ritchie technique, which is used in second-line care. DISCUSSION The Baermann technique is the best parasitological option for improving Strongyloides stercoralis diagnosis in the first-line care of the Primary Health Care System. A particular cycle of reinfection, combined with the environment and some other risk factors are related with persistence. Control is difficult without a proper diagnosis, and the Baermann technique is an approach to the solution. We conclude that with a high suspicion of the presence of Strongyloides stercoralis, the use of the Baermann technique is strongly recommended as support for direct examination in primary health care systems especially in tropical areas.
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Affiliation(s)
- Ivana Camacho-Alvarez
- Medical Sciences Université Libre de Bruxelles (Belgium); Public Health and Epidemiology, University of San Simón (Bolivia), Cochabamba, Bolivia.
| | - Elia M Chavez-Mamani
- Biomedical and Social Research Institute, Medicine Faculty, University of San Simón, Cochabamba, Bolivia
| | - Goyens Philippe
- Nutrition and Metabolism Unit, Department of Pediatrics, Hôpital Universitaire des Enfants Reine Fabiola HUDERF, Brussels, Belgium
| | - Jenny M Luizaga-López
- Biomedical and Social Research Institute, University of San Simón, Cochabamba, Bolivia
| | - Mary Cruz Torrico
- Medical Research Laboratory, Parasitology, Medicine Faculty, University of San Simón, Cochabamba, Bolivia
| | - Laurent Gétaz
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Frédérique Jacobs
- Infectious Diseases Department at Université Libre de Bruxelles, CUB-Erasme, Brussels, Belgium
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Gandasegui J, Onwuchekwa C, Krolewiecki AJ, Doyle SR, Pullan RL, Enbiale W, Kepha S, Hatherell HA, van Lieshout L, Cambra-Pellejà M, Escola V, Muñoz J. Ivermectin and albendazole coadministration: opportunities for strongyloidiasis control. THE LANCET. INFECTIOUS DISEASES 2022; 22:e341-e347. [PMID: 35850127 DOI: 10.1016/s1473-3099(22)00369-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 06/15/2023]
Abstract
In 2020, WHO recognised the importance of strongyloidiasis alongside soil-transmitted helminths (STH) in their 2021-30 roadmap, which aspires to target Strongyloides stercoralis with preventive chemotherapy by use of ivermectin. Combination treatment with both albendazole, the primary drug used to treat STH, and ivermectin, would improve the efficiency of mass drug administration targeting both STH and S stercoralis. In this Personal View, we discuss the challenges and opportunities towards the development of an efficient control programme for strongyloidiasis, particularly if it is to run concurrently with STH control. We argue the need to define the prevalence threshold to implement preventive chemotherapy for S stercoralis, the target populations and optimal dosing schedules, and discuss the added benefits of a fixed-dose coformulation of ivermectin and albendazole. Implementation of an efficient control programme will require improvements to current diagnostics, and validation of new diagnostics, to target and monitor S stercoralis infections, and consideration of the challenges of multispecies diagnostics for S stercoralis and STH control. Finally, the evolution of ivermectin resistance represents a credible risk to control S stercoralis; we argue that genome-wide approaches, together with improved genome resources, are needed to characterise and prevent the emergence of resistance. Overcoming these challenges will help to reduce strongyloidiasis burden and enhance the feasibility of controlling it worldwide.
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Affiliation(s)
- Javier Gandasegui
- Barcelona Institute for Global Health, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
| | - Chukwuemeka Onwuchekwa
- Barcelona Institute for Global Health, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
| | - Alejandro J Krolewiecki
- Barcelona Institute for Global Health, Hospital Clínic Universitat de Barcelona, Barcelona, Spain; Instituto de Investigaciones de Enfermedades Tropicales, Universidad Nacional de Salta, Orán, Argentina
| | | | - Rachel L Pullan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Wendemagegn Enbiale
- Bahir Dar University, College of Medicine and Health Science, Bahir Dar, Ethiopia; Amsterdam UMC, University of Amsterdam, Department of Dermatology, Amsterdam Institute for Infection and Immunity, Academic Medical Centre, Amsterdam, Netherlands
| | - Stella Kepha
- Eastern and Southern Africa Centre of International Parasite Control, Nairobi, Kenya; Medical Research Institute, Nairobi, Kenya
| | - Hollie Ann Hatherell
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Lisette van Lieshout
- Department of Parasitology, Leiden University Medical Centre, Leiden, Netherlands
| | - María Cambra-Pellejà
- Instituto de Ganadería de Montaña, Consejo Superior de Investigaciones Científicas Universidad de León, Grulleros, Spain; Departamento de Sanidad Animal, Facultad de Veterinaria, Universidad de León, Campus de Vegazana, León, Spain
| | | | - José Muñoz
- Barcelona Institute for Global Health, Hospital Clínic Universitat de Barcelona, Barcelona, Spain.
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Buonfrate D, Tamarozzi F, Paradies P, Watts MR, Bradbury RS, Bisoffi Z. The diagnosis of human and companion animal Strongyloides stercoralis infection: Challenges and solutions. A scoping review. ADVANCES IN PARASITOLOGY 2022; 118:1-84. [PMID: 36088083 DOI: 10.1016/bs.apar.2022.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Strongyloidiasis is the infection caused by soil-transmitted nematodes of Strongyloides species, infecting humans and some animals. Strongyloides stercoralis is the species with most clinical and epidemiological relevance in humans and dogs, due to its high prevalence and its capacity of inducing a life-threatening hyperinfection. Diagnosis of strongyloidiasis is challenging, due to the absence of a single reference standard test with high sensitivity and specificity, which also hampers the estimation of the accuracy of other diagnostic tests. In this chapter, we review the deployment and performance of the parasitological, immunological, molecular tests for the diagnosis of strongyloidiasis in humans and in dogs. Further, we comment the available evidence from genotyping studies that have addressed the zoonotic potential of S. stercoralis. Finally, we discuss the use of different diagnostic methods in relation to the purpose (i.e., screening, individual diagnosis, inclusion in a clinical trial) and the setting (endemic/non-endemic areas) and report the accuracy figures reported by systematic reviews on either parasitological, serological or molecular techniques published in literature.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy.
| | - Francesca Tamarozzi
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy
| | - Paola Paradies
- Department of Emergency and Organs Transplantation, Veterinary Section, Campus of Veterinary Medicine, University of Bari, Bari, Italy
| | - Matthew R Watts
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research - New South Wales Health Pathology and Sydney Institute for Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Richard S Bradbury
- School of Health and Life Sciences, Federation University Australia, Berwick, VC, Australia
| | - Zeno Bisoffi
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy; Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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10
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Unterköfler MS, Eipeldauer I, Merz S, Pantchev N, Hermann J, Brunthaler R, Basso W, Hinney B. Strongyloides stercoralis infection in dogs in Austria: two case reports. Parasit Vectors 2022; 15:168. [PMID: 35570317 PMCID: PMC9107779 DOI: 10.1186/s13071-022-05270-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Background Strongyloides stercoralis is endemic in tropical and subtropical regions, but reports of infections in central and northern Europe have been recently increasing. Infections occur mainly in humans and dogs. In dogs, both dog-adapted and zoonotic S. stercoralis genotypes seem to occur. Clinical manifestations mainly include gastrointestinal and respiratory signs. The severity of the disease can vary greatly and depends on the immune status of the host. The infection is potentially fatal in immunosuppressed individuals, either medically induced or due to an underlying disease, in which hyperinfections and disseminated infections with extraintestinal parasite dissemination may occur. Methods Diagnosis was based on coproscopy, including flotation and the Baermann funnel technique, histology of small intestinal biopsies and molecular analysis of mitochondrial cytochrome oxidase subunit I (COI) and hypervariable regions I and IV (HVR I and HVR IV) of the nuclear 18S rDNA loci. Results Two independent cases of severe canine S.stercoralis infection in Austria are presented. In both cases, S. stercoralis was detected in histological sections of the small intestine and with the Baermann funnel technique. Molecular analysis revealed strains with zoonotic potential. Case 1 was a 1-year-old female French bulldog with a long history of respiratory and gastrointestinal signs, severe emaciation and apathy before S.stercoralis infection was diagnosed. Treatment with moxidectin (2.5 mg/kg body weight [BW], oral route) did not eliminate the infection, but treatment with ivermectin (0.2 mg/kg BW, subcutaneously) was successful. Case 2 consisted of two 2-month-old Pomeranian puppies, one female and one male, from a litter of four, which died soon after presenting dyspnoea and haemorrhagic diarrhoea (female) or torticollis (male); S.stercoralis infection was first diagnosed post-mortem. Conclusion More attention should be paid to this nematode because although it appears to be rare in Austria, it is easily overlooked on standard coproscopy unless a Baermann funnel technique is used, and even then, it can be missed. Moxidectin is not always successful in eliminating the infection, and treatment with ivermectin should be considered in cases of infection. Graphical Abstract ![]()
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Affiliation(s)
| | - Iris Eipeldauer
- Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
| | | | | | - Josef Hermann
- Veterinary Practice Dipl.Tzt. Josef Hermann, Trautmannsdorf, Austria
| | - René Brunthaler
- Institute of Pathology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Walter Basso
- Institute of Parasitology, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Barbara Hinney
- Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
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11
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Jember TH, Amor A, Nibret E, Munshea A, Flores-Chavez M, Ta-Tang TH, Saugar JM, Benito A, Anegagrie M. Prevalence of Strongyloides stercoralis infection and associated clinical symptoms among schoolchildren living in different altitudes of Amhara National Regional State, northwest Ethiopia. PLoS Negl Trop Dis 2022; 16:e0010299. [PMID: 35482629 PMCID: PMC9049318 DOI: 10.1371/journal.pntd.0010299] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Background Strongyloides stercoralis is a parasite that causes strongyloidiasis in humans. It is prevalent in the tropics and sub-tropics where poor sanitation is a common problem. The true prevalence of S. stercoralis in Ethiopia is underestimated due to the lack of a “Gold” standard diagnostic method. Moreover, its prevalence across altitudinal gradient in Amhara Region has not been studied. Methods A cross-sectional study was conducted among 844 schoolchildren in Amhara Region from April to December 2019. A stool sample was collected from each study participant and processed using formol ether concentration technique (FECT), spontaneous tube sedimentation technique (STST), Baermann concentration technique (BCT), agar plate culture (APC) and real-time polymerase chain reaction (RT-PCR). Data were entered using EpiData and analyzed by SPSS version 23 statistical software. Prevalence of S. stercoralis infection was determined using a single diagnostic technique and combination of techniques. Association of clinical variables with S. stercoralis infection was assessed by logistic regression and independent variables with p<0.05 were considered statistically significant. Results Prevalence of soil-transmitted helminths (STHs) and S. mansoni infections was 38.0% and 20.4%, respectively. Among STHs, the prevalence of hookworm infection was 32.8%. Prevalence of S. stercoralis infection was 39.0%, 28.8%, 10.9%, 10.3%, 4.0% and 2.0% by the respective, combinations of the five methods, RT-PCR, APC, BCT, STST and FECT. The highest prevalence rates, 48.2%, 45.0% and 41.1% of S. stercoralis were recorded in the age group of 12–14 years, males and rural dwellers, respectively. Prevalence rates of S. stercoralis infection in highland, semi-highland and lowland areas were 40.4%, 41.8% and 25.9%, respectively. Having abdominal pain (AOR = 2.48; 95% CI:1.65–3.72), cough (AOR = 1.63;95%CI:1.09–2.42), urticaria (AOR = 2.49;95%CI:1.50–4.01) and being malnourished (AOR = 1.44;95%:1.10–2.01) were significantly associated with strongyloidiasis. Conclusion Prevalence of S. stercoralis infection was high and varied across different altitudes in Amhara Region. Some clinical syndromes were found to be significantly associated with S. stercoralis infection. Therefore, proper diagnosis and preventive strategies against S. stercoralis infection are highly recommended to be devised and implemented in Amhara Region. Prevalence of S. stercoralis is under-reported in many resource-poor countries including Ethiopia. We carried out a school-based cross-sectional study among 844 schoolchildren across highlands, semi-highlands and lowland areas of Amhara Region. We used an approach made of five diagnostic methods, namely, FECT, STST, BCT, APC, and RT-PCR. The total prevalence of S. stercoralis was 39.0%. The highest S. stercoralis prevalence (41.8%) was observed in the semi-highland areas of the region. Strongyloidiasis was significantly higher among 12–14 years age groups, males, and rural dweller children. Clinical symptoms such as presence of abdominal pain, cough, skin rash and malnourishment were significantly associated with strongyloidiasis. We recommend that preventive strategies against strongyloidiasis in Amhara Region should be implemented.
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Affiliation(s)
- Tadesse Hailu Jember
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- * E-mail:
| | - Arancha Amor
- Mundo Sano Foundation and Institute of Health Carlos III, Madrid, Spain
| | - Endalkachew Nibret
- Biology Department, Science College, Bahir Dar University, Bahir Dar, Ethiopia
| | - Abaineh Munshea
- Biology Department, Science College, Bahir Dar University, Bahir Dar, Ethiopia
| | - Maria Flores-Chavez
- Mundo Sano Foundation and National Centre for Microbiology Institute of Health Carlos III, Madrid, Spain
| | - Thuy-Huong Ta-Tang
- National Center of Tropical Medicine, Institute of Health Carlos III, Biomedical Research Networking Center of Infectious Diseases (CIBERINFEC), Madrid, Spain
| | - Jose M Saugar
- National Centre of Microbiology, Institute of Health Carlos III, (CIBERINFEC), Madrid, Spain
| | - Agustín Benito
- National Centre of Tropical Medicine, Institute of Health Carlos III, (CIBERINFEC), Madrid, Spain
| | - Melaku Anegagrie
- Mundo Sano Foundation and Institute of Health Carlos III, Madrid, Spain
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12
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Hailu T, Amor A, Nibret E, Munshea A, Anegagrie M, Flores-Chavez MD, Tang THT, Saugar JM, Benito A. Evaluation of five diagnostic methods for Strongyloides stercoralis infection in Amhara National Regional State, northwest Ethiopia. BMC Infect Dis 2022; 22:297. [PMID: 35346087 PMCID: PMC8962492 DOI: 10.1186/s12879-022-07299-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Strongyloides stercoralis is an intestinal parasite that can cause chronic infection, hyperinfection and/or a dissemination syndrome in humans. The use of techniques targeting ova fails to detect S. stercoralis, as only larvae of the parasite are excreted in faeces. Due to the absence of “Gold” standard diagnostic method for S. stercoralis, there is a paucity of reported data worldwide.
Objective
This study aimed to evaluate the performance of diagnostic methods of S. stercoralis infection by taking the composite reference as a “Gold” standard.
Methods
A cross-sectional study was conducted among 844 schoolchildren in Amhara Region, Ethiopia, from April to December 2019. Stool samples were collected and processed with formol-ether concentration technique (FECT), spontaneous tube sedimentation technique (STST), Baermann concentration technique (BCT), agar plate culture (APC) and real-time polymerase chain reaction (RT-PCR). Sensitivity, specificity, positive predictive value, and negative predictive value of each diagnostic method were computed against the composite reference. The agreements of diagnostic methods were evaluated by Kappa value at 95% CI.
Results
The composite detection rate of S. stercoralis by the five diagnostic methods was 39.0% (329/844). The detection rate of the parasite from stool samples by FECT, STST, BCT, APC and RT-PCR was 2.0% (17/844), 4.0% (34/844), 10.2% (86/844), 10.9% (92/844) and 28.8% (243/844), respectively. The highest detection rate (37.8%; 319/844) of S. stercoralis was recorded by a combination of BCT, APC, and RT-PCR followed by a combination of STST, BCT, APC and RT-PCR (37.3%; 315/844). The sensitivity of FECT, STST, BCT, APC and RT-PCR against the composite reference was 5.2%, 10.3%, 26.4%, 28.0% and 73.9%, respectively. The diagnostic agreements of RT-PCR, APC, BCT, STST and FECT with the composite reference in detection of S. stercoralis were substantial (0.775), fair (0.321), fair (0.305), slight (0.123), and slight (0.062), respectively.
Conclusion
RT-PCR detected the highest number of S. stercoralis infections. A combination of RT-PCR with APC and/or BCT better detected S. stercoralis from stool samples compared to other combinations or single diagnostic methods. Therefore, RT-PCR and combination of RT-PCR with APC and/or BCT diagnostic methods should be advocated for detection of S. stercoralis infection.
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Modified Nonnutrient Agar Plate Culture for the Diagnosis of Strongyloides stercoralis and Hookworm Infections in La-Ngu District, Satun Province, Southern Thailand. J Parasitol Res 2022; 2022:1117400. [PMID: 35371565 PMCID: PMC8975711 DOI: 10.1155/2022/1117400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
Due to the low prevalence and light intensity of Strongyloides stercoralis (S. stercoralis, Ss) and hookworm (HW) in Thailand, an increase in the efficacy of detection with the appropriate diagnosis is needed. This cross-sectional survey is aimed at using modified nonnutrient agar plate culture (mNNAPC) to assess the prevalence of S. stercoralis and hookworm infections and to report intestinal parasitic infections in La-Ngu villagers, Satun Province in Southern Thailand. We used wet smear, modified Harada-Mori filter paper culture (mHMFPC), and mNNAPC to investigate 204 villagers (4 villages) between August 2016 and January 2017. The combination of mHMFPC and mNNAPC raised the prevalence of S. stercoralis and hookworm infections among the study population from 3.4% and 1.0% to 6.9% and 2.5%, respectively. There were no significant differences between demographic characteristics and these infections (p < 0.05). Three types of protozoal infections, Blastocystis spp. (2.9%), Entamoeba histolytica-like (0.5%), and Giardia duodenalis (0.5%), and 3 species of helminthic infections, S. stercoralis (6.9%) (14 cases), hookworm 2.5%, and Enterobius vermicularis 0.5%, were demonstrated in this area. The mNNAPC showed the highest efficacy in detecting both parasites (Ss 92.9% and HW 80%), whereas the wet smear detected none.
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Hailu T, Nibret E, Amor A, Munshea A, Anegagrie M. Determinant factors of chronic Strongyloides stercoralis infection among schoolchildren in Amhara National Regional State, northwest Ethiopia. Acta Trop 2022; 226:106280. [PMID: 34919948 DOI: 10.1016/j.actatropica.2021.106280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/11/2021] [Accepted: 12/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Strongyloides stercoralis is one of the most neglected parasites that is commonly found in tropical and sub-tropical countries. The majority of chronic S. stercoralis infections are characterized by minor clinical signs and symptoms. The extent to which socio-demographic, personal and environmental risk factors associated with S. stercoralis infection is not well known in Amhara Regional, Ethiopia. OBJECTIVE This study aimed to assess socio-demographic, personal and environmental risk factors associated with S. stercoralis infection among schoolchildren in Amhara Region. METHODS A total of 844 schoolchildren were randomly selected and participated in the study. Stool samples were collected and checked for S. stercoralis infection using five diagnostic methods. A structured questionnaire was also used to obtain socio-demographic, personal and environmental data from parents of the children. The degree of association between socio-demographic, personal and environmental factors with S. stercoralis infection was first assessed by univariate logistic regression and then analyzed by multivariate logistic regression. Variables with p<0.05 were considered as statistically significant. RESULTS Among 844 participants, 329 (39.0%) were infected with S. stercoralis. Prevalences of S. stercoralis among 12-14 years old, males, and rural dwellers were 48.2% (109/226), 45.0% (196/436) and 41.1% (306/745), respectively. Being in the age group of 10-11years (AOR=1.56;95%CI:1.10-2.24), and 12-14 years (AOR=1.96;95%CI:1.32-2.90), male (AOR=1.55;95%CI:1.16-2.06), and rural dweller (AOR=1.86;95%CI:1.12-3.10); having family income of < 1000 Birr per month (AOR=2.03;95%CI:1.48-2.77), and family size of 5-9 members (AOR=2.36; 95%CI:1.57-3.54) were significantly associated with S. stercoralis infection. The habit of not wearing shoes (AOR=1.41; 95%CI:1.05-1.90), close contacting with pets (AOR=1.49;95%:1.09-2.04), participating in irrigation (AOR=1.49; 95%CI:1.10-2.00) and playing with soil (AOR=1.62;95%CI:1.20-2.18) were risk factors of S. stercoralis infection. Besides, presence of wet environment (AOR=1.62;95%CI:1.19-2.22), living around sandy soil (AOR=2.75; 95%CI: 1.81-4.19) and red clay soil (AOR=2.24;95%CI:1.58-3.17), living in semi-highland folds (AOR=2.47;95%CI:1.48-4.14) and highland areas (AOR=1.65;95%CI:1.06-2.57) were determinant factors for S. stercoralis. CONCLUSION S. stercoralis infection among schoolchildren was highly prevalent in Amhara Region. Several determinant factors were also identified. Therefore, proper implementation of sanitation and hygiene programs and health care of pets should be advocated to break the transmission cycle of S. stercoralis.
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Affiliation(s)
- Tadesse Hailu
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Bahir Dar University, Ethiopia, P. O. Box: 79.
| | - Endalkachew Nibret
- Biology Department, Science College, Bahir Dar University, Ethiopia, P. O. Box: 79
| | - Arancha Amor
- Mundo Sano Foundations, Institute of Health Carlos III, Spain
| | - Abaineh Munshea
- Biology Department, Science College, Bahir Dar University, Ethiopia, P. O. Box: 79
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A Practical Approach to Screening for Strongyloides stercoralis. Trop Med Infect Dis 2021; 6:tropicalmed6040203. [PMID: 34941659 PMCID: PMC8704417 DOI: 10.3390/tropicalmed6040203] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/17/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Strongyloides stercoralis, causative agent of a neglected tropical disease, is a soil-transmitted helminth which may cause lifelong persisting infection due to continuous autoinfection. In the case of immunosuppression, life-threatening hyperinfection and disseminated strongyloidiasis can develop. We propose a pragmatic screening algorithm for latent strongyloidiasis based on epidemiologic exposure and immunosuppression status that can be applied for any kind of immunosuppressive therapy. The algorithm allows the diagnosis of latent strongyloidiasis with optimal accuracy in a well-equipped setting, while for endemic settings where the complete testing array is unavailable, an empiric treatment is generally recommended. Accurate diagnosis and extensive empiric treatment will both contribute to decreasing the current neglect of strongyloidiasis.
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