Hepatic Alveolar Echinococcosis in Cynomolgus Monkeys (Macaca fascicularis)

Diagnostic accuracy of swine echinococcosis cytopathological tests and challenges for a differential diagnosis: slaughterhouse data

Echinococcosis disease shows clinical signs similar to many diseases. Hence we report cases that need to be confirmed using appropriate tests. A confirmatory study has been conducted to assess the accuracy of two cytopathological tests, with the histopathology test as the reference standard. The first cytopathological test evaluates the Ziehl Neelsen staining with an epifluorescence microscope (cytopath 1). The second cytopathological test uses the same staining followed by a transmitted light microscope examination (cytopath 2). Of a total of 2524 inspected pigs, 101 suspected cases of echinococcosis were detected, of which 67 were found positive with the two cytopathological tests and the histopathological one. The specificity of cytopath 1 (100 % [95 % CI 100 - 100]) and cytopath 2 (100 % [95 % CI 100;100]) were similar, as well as their respective positive predictive values: 100 % [95 % CI 100 - 100] vs. 100 % [95 % CI 100 - 100]. The sensitivity of cytopath 1 is 79.66 % [95 % CI 69.39 - 89.93], while cytopath 2 equals 66.10 % [95 % CI 54.02 - 78.18]. The difference in sensitivity of both tests was not significant. Negative predictive values found for cytopath 1, and cytopath 2 were 40 [95 % CI 18.53 - 61.47] and 28.57 [95 % CI 11.84 - 45.3], leading to the Generalized Estimating Equations (GEE) Model estimate for an odds ratio of 1.4 [95 % CI 0.41 - 5.2], p = 0.06. Cytopath 1 and cytopath 2 are equivalent in terms of specificity (100 % [95 % CI 100 - 100] vs. 100 % [95 % CI 100;100]) and positive predictive value (100 % [95 % CI 100 - 100]. Cytopath 1 is more sensitive than cytopath 2 but not significant (79.66 % [ 95 % CI 69.39 - 89.93] vs. 66.10 % [95 % CI 54.02 - 78.18]). However, the negative predictive value of cytopath 1 is better than that of cytopath 2: 40 % [95 % CI 18.53 - 61.47] vs. 28.57 % [95 % CI 11.84 - 45.3].

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Non-proliferative and Proliferative Lesions of the Non-human Primate (M. fascicularis)

The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the nonhuman primate used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.

Clinical, pathological and parasitological examinations of a German spaniel with alveolar echinococcosis, Germany, 2018

Alveolar echinococcosis (AE) is a parasitic zoonosis occurring in most European countries and also emerging in parts of Asia and North America. AE is caused by the larval stage of Echinococcus multilocularis in intermediate and also in accidental hosts. The principal definitive host is the red fox, but domestic dogs and cats are also potential definitive hosts. Several species of rodents serve as intermediate hosts of this parasite. However, there are also some species acting as accidental intermediate hosts, among them dogs. Since the late 1980s cases of canine AE have been diagnosed. Here, we present a case of canine AE in a two-year old female intact German spaniel from Thuringia, Central Germany. The dog was used as a hunting dog and presented to a small animal clinic for subacute lethargy and inappetence. Abdominal ultrasound and contrast computed tomography (CT) scan were performed and revealed intrahepatic lesions. Multinodular changes of the liver and the greater omentum were demonstrated by exploratory laparotomy. After euthanasia, a necropsy was performed and histological sections of representative tissue samples were prepared. PCR followed by sequencing was conducted with DNA extracted from tissue samples of the liver, hepatic lymph nodes and greater omentum. The sequence herein obtained showed very high similarity with other partial nad2 sequences of E. multilocularis from the GenBank database by BLASTn analysis and was analysed using the maximum likelihood method. The presented case combines the clinical presentation and pathological, parasitological and phylogenetic analyses.

The importance of being parasiticidal… an update on drug development for the treatment of alveolar echinococcosis

The lethal disease alveolar echinococcosis (AE) is caused by the metacestode stage of the fox tapeworm Echinococcus multilocularis. Current chemotherapeutical treatment of AE relies on albendazole and mebendazole, with the caveat that these compounds are not parasiticidal. Drugs have to be taken for a prolonged period of time, often life-long, which can cause adverse effects and reduces the patients' quality of life. In some individuals, benzimidazoles are inactive or cause toxicity, leading to treatment discontinuation. Alternatives to benzimidazoles are urgently needed. Over the recent years, in vivo and in vitro models for low-to-medium throughput drug discovery against AE have been set in place. In vitro drug tests include the phosphoglucose-isomerase (PGI) assay to measure physical damage induced to metacestodes, and viability assays to assess parasiticidal activity against metacestodes and stem cells. In vitro models are also employed for studies on mechanisms of action. In vivo models are thus far based on rodents, mainly mice, and benefits could be gained in future by comparative approaches in naturally infected dogs or captive monkeys.

For the identification of novel drugs against AE, a rare disease with a low expected market return, drug-repurposing is the most promising strategy. A variety of chemically synthesized compounds as well as natural products have been analyzed with respect to in vitro and/or in vivo activities against AE. We here review and discuss the most active of these compounds including anti-infective compounds (benzimidazoles, nitazoxanide, amphotericin B, itraconazole, clarithromycin, DB1127, and buparvaquone), the anti-infective anti-malarials (artemisinin, ozonids, mefloquine, and MMV665807) and anti-cancer drugs (isoflavones, 2-methoxyestradiol, methotrexate, navelbine, vincristine, kinase inhibitors, metallo-organic ruthenium complexes, bortezomib, and taxanes). Taking into account the efficacy as well as the potential availability for patients, the most promising candidates are new formulations of benzimidazoles and mefloquine. Future drug-repurposing approaches should also target the energy metabolism of E. multilocularis, in particular the understudied malate dismutation pathway, as this offers an essential target in the parasite, which is not present in mammals.

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Benzimidazoles are used to treat AE, but new drugs are needed.

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New drugs against AE can be identified by drug repurposing.

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Drugs against other infectious diseases and cancer can be repurposed against AE.

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Most promising are new formulations of benzimidazoles and mefloquine.

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Future approaches should include targeting the energy metabolism of the parasite.

Laboratory Diagnosis of Echinococcus spp. in Human Patients and Infected Animals

Among the species composing the genus Echinococcus, four species are of human clinical interest. The most prevalent species are Echinococcus granulosus and Echinococcus multilocularis, followed by Echinococcus vogeli and Echinococcus oligarthrus. The first two species cause cystic echinococcosis (CE) and alveolar echinococcosis (AE) respectively. Both diseases have a complex clinical management, in which laboratory diagnosis could be an adjunctive to the imaging techniques. To date, several approaches have been described for the laboratory diagnosis and followup of CE and AE, including antibody, antigen and cytokine detection. All of these approaches are far from being optimal as adjunctive diagnosis particularly for CE, since they do not reach enough sensitivity and/or specificity. A combination of several methods (e.g., antibody and antigen detection) or of several (recombinant) antigens could improve the performance of the adjunctive laboratory methods, although the complexity of echinococcosis and heterogeneity of clinical cases make necessary a deep understanding of the host-parasite relationships and the parasite phenotype at different developmental stages to reach the best diagnostic tool and to make it accepted in clinical practice. Standardization approaches and a deep understanding of the performance of each of the available antigens in the diagnosis of echinococcosis for the different clinical pictures are also needed. The detection of the parasite in definitive hosts is also reviewed in this chapter. Finally, the different methods for the detection of parasite DNA in different analytes and matrices are also reviewed.

Immunization of rhesus macaques with Echinococcus multilocularis recombinant 14-3-3 antigen leads to specific antibody response

E. multilocularis (Em) is the etiologic agent of alveolar echinococcosis (AE), a severe and potentially fatal disease, primarily affecting the liver of and occurring in aberrant intermediate hosts, e.g., humans and non-human primates. Due to increasing numbers of spontaneous cases of AE in the Old World monkey colonies of the German Primate Center, the question arose as to whether vaccination of non-human primates may represent a useful prophylactic approach. In this pilot study, the recombinant antigen Em14-3-3, which has provided a 97 % protection against E. multilocularis challenge infection in rodent models, was used for the first time to immunize rhesus macaques. In order to increase immunogenicity, the antigen was formulated with different adjuvants including Quil A®, aluminum hydroxide (alum), and muramyl dipeptide (MDP). Also, different vaccination regimens were tested. All vaccinated animals developed antigen-specific antibodies. While Quil A® induced a local adverse reaction, alum proved to be the most potent adjuvant in terms of induced antibody levels, longevity as well as tolerability. In conclusion, our pilot study demonstrated that recombinant Em14-3-3 is safe and immunogenic in rhesus monkeys. As a next step, efficacy of the vaccination remains to be explored.

Detection of Echinococcus Multilocularis Infection in a Colony of Cynomolgus Monkeys (Macaca Fascicularis) using Serology and Ultrasonography

Five animals in a colony of cynomolgus monkeys ( Macaca fascicularis) died or were euthanatized because of alveolar echinococcosis, during a period of 5 years. The remainder of the colony was screened for possible infection with Echinococcus multilocularis, using serology and ultrasonography. A total of 46 animals out of a group of 55 were examined. The presence of anti-Em2 antibodies analyzed with enzyme-linked immunosorbent assay was demonstrated in 3 monkeys. In 2 of these 3 monkeys, multilocular structures compatible with metacestodal cysts in the liver were identified, using ultrasonography. The presence of alveolar echinococcosis was subsequently confirmed at postmortem examination in 1 animal. The other animals are still alive. Two other monkeys were negative in the serological examination but had cystic structures in the liver, which were identified as bile duct cysts at postmortem examination in 1 animal. The other monkey is still alive. These findings suggest that serology for antibodies against the Em2 antigen may represent a useful method in identifying animals that might be infected with E. multilocularis and are therefore at risk of developing fatal alveolar echinococcosis.

Spontaneous and Drug-Induced Hepatic Pathology of the Laboratory Beagle Dog, the Cynomolgus Macaque and the Marmoset

This review focuses on the background hepatic pathology present in three of the most commonly used species in the safety assessment of drugs, namely the beagle dog, the marmoset and the cynomolgus macaque. Both the nonneoplastic and neoplastic pathology are reviewed with a discussion on the potential impact that significant background pathology might have on the interpretation of any drug-induced pathology during subsequent testing. Although specific instances, such as parasitological infection in wild-caught primates can pose problems of interpretation, in general the background pathology in both the dog and the nonhuman primates, is not significantly different from that seen in the liver of laboratory rodents and with experience should not pose significant problems for the experienced pathologist. The relative merits of the primate versus the dog as a choice of second species are also considered in some detail. Although there is an inbuilt prejudice that the primate will more closely mimic subsequent effects that might occur in man in the clinic, insofar as the liver is concerned, there are many instances where the dog has been more representative of human exposure and metabolism and there is little evidence to show that the nonhuman primate is consistently better than dog in predicting human liver toxicity. As with most areas of science, comparative toxicology would dictate that the more information gained, from as wide a range of species as is practical, will give the best assessment for any subsequent problems in the clinic. This pragmatic approach should prove to be more successful than one based entirely upon an assumption, and in many cases the assumption is incorrect, that the primate always predicts human toxicity better than the nonprimate, including the dog.

Amyloidosis enhancing activity of bovine amyloid A fibrils in C3H/HeN mice and cynomolgus monkeys (Macaca fascicularis)

BACKGROUND

In experimentally induced cases of AA amyloidosis, the development of disease is enhanced by the administration of homogenous or heterogeneous amyloid fibrils. In recent years, cross-species transmission of animal amyloidosis into human has become of particular concern.

METHODS

Cynomolgus monkeys (Macaca fascicularis) and C3H/HeN mice were inoculated with bovine amyloid fibrils under acute inflammation.

RESULTS

Amyloid A deposits were not detected in any of the monkeys, but mild-to-severe AA deposits were found in all mice.

CONCLUSIONS

These results suggest that unlike in rodents, cross-species transmission of AA amyloidosis is less likely to develop, at least during acute inflammation, in primates.

Acute-phase responses in cattle infected with hydatid cysts and microbial agents

The aim of this study was to investigate the effect of hydatid cysts and microbial agents on the acute-phase response in cattle. Twenty-seven cattle with hydatid cysts and eight apparently healthy cattle comprised the study and control groups, respectively. Parasitological, microbiological, histopathological and immunohistochemical examinations of the liver and lungs were undertaken, and 49 of these organs were infected with cysts. In 14 of 31 (45.1%) livers and 10 of 18 (55.5%) lungs microbial growth was observed. The most frequent species occurring in the liver were Staphylococcus aureus, Escherichia coli, Corynebacterium spp. and Campylobacter spp., whereas in the lungs the most common species was Candida spp., followed by Streptococcus spp., Mannheimia haemolytica, Corynebacterium spp., Micrococcus spp. and S. aureus. The concentration of serum interleukin (IL-6) in infected cattle, 455.35 ± 39.68 pg/ml, was significantly higher than that of 83.02 ± 17.87 pg/ml in the control group (P0.05). The highest concentrations of IL-6 were detected in serum of the cattle where microbial growth had been detected, followed by cattle infected with bacteria + Trichostrongylus sp. (P< 0.001). Consequently, SAA showed an important increase in the group infected with hydatid cysts, whereas haptoglobin level decreased. It was noticed that IL-6, like SAA, had a significant role in hydatid cyst infection. Therefore IL-6 and SAA appear to be major markers in the detection of infection of cattle with hydatid cysts.

Fatal echinococcosis in three lemurs in the United Kingdom--A case series

Tapeworms of the genus Echinococcus reside in the small intestine of a number of carnivorous species, predominantly canids. In enzootic areas, hydatidosis caused by taeniid metacestodes can present a significant problem in accidental intermediate hosts, including humans. Whereas the United Kingdom is currently considered free of Echinococcus multilocularis, Echinococcus granulosus sensu stricto (s.s.) and Echinococcus equinus are endemic in the UK and have been reported in a variety of captive mammals. The presentation of echinoccocosis in non-human primates widely parallels disease in humans, and public health concerns are related to the four genera, E. granulosus, E. multilocularis, Echinococcus vogeli and Echinococcus oligarthrus. In contrast, sporadic outbreaks and individual hydatid disease cases in non-human primates have been associated with several Echinococcus and Taenia species. Here we describe three fatal cases of cystic echinococcosis in two captive ring-tailed lemurs (Lemur catta) and one captive red-ruffed lemur (Varecia variegata rubra) and provide molecular tapeworm characterisation. To the best of the authors' knowledge, this includes the first report of Echinococcus ortleppi in a UK born ring-tailed lemur and provides the first in depth case reports of echinococcosis due to E. equinus in UK born ring-tailed and red ruffed lemurs with detailed clinical and pathological findings. The cestode life cycle and implications for zoo collections are discussed.

Description of vertebral and liver alveolar echinococcosis cases in Cynomolgus monkeys (Macaca fascicularis)

Background

Echinococcus multilocularis, the causative agent of alveolar echinococcosis, is a fox tapeworm widely distributed in Europe with an increase of endemic area in recent years. Many mammal species including humans and non-human primates can be infected by accidental ingestion of eggs.

Case presentation

In March 2011, a 5-year-old zoo-raised male cynomolgus macaque (Macaca fascicularis) presented a paresis of the lower limbs which evolved into paralysis. Lesions in liver and vertebra were observed on tomography scan. E. multilocularis infection was diagnosed post-mortem by morphological and histological examination and detection of Em DNA by polymerase chain reaction. Serodiagnosis of other primates of the colony using enzyme-linked immunosorbent assay (ELISA) was negative. In June 2013, at necroscopy, a hepatic and a paravertebral masses were detected in a second cynomolgus macaque of the same colony. Serology and DNA isolated from hepatic and abdominal cysts confirmed E. multilocularis infection.

Conclusions

We described hear vertebral and liver localization of alveolar echinococcosis in non-human primates. The animals lived in an indoor/outdoor housing facility, where the probable mode of contamination is by ingestion of food foraging around the enclosure which could be contaminated with fox feces. Serological survey in the facility should allow us to estimate the risk of human contamination and the zoonotic risk of monkey infection due to environmental contamination.

Echinococcus granulosus: Epidemiology and state-of-the-art of diagnostics in animals

Diagnosis and detection of Echinococcus granulosus (sensu lato) infection in animals is a prerequisite for epidemiological studies and surveillance of echinococcosis in endemic, re-emergent or emergent transmission zones. Advances in diagnostic approaches for definitive hosts and livestock, however, have not progressed equally over the last 20 years. Development of laboratory based diagnostics for canids using coproantigen ELISA and also coproPCR, have had a huge impact on epidemiological studies and more recently on surveillance during hydatid control programmes. In contrast, diagnosis of cystic echinococcosis (CE) in livestock still relies largely on conventional post-mortem inspection, despite a relatively low diagnostic sensitivity especially in early infections, as current serodiagnostics do not provide a sufficiently specific and sensitive practical pre-mortem alternative. As a result, testing of dog faecal samples by coproantigen ELISA, often combined with mass ultrasound screening programmes for human CE, has been the preferred approach for monitoring and surveillance in resource-poor endemic areas and during control schemes. In this article we review the current options and approaches for diagnosis of E. granulosus infection in definitive and animal intermediate hosts (including applications in non-domesticated species) and make conclusions and recommendations for further improvements in diagnosis for use in epidemiological studies and surveillance schemes.

Prion and prion-like diseases in animals

Transmissible spongiform encephalopaties (TSEs) are fatal neurodegenerative diseases characterized by the aggregation and accumulation of the misfolded prion protein in the brain. Other proteins such as β-amyloid, tau or Serum Amyloid-A (SAA) seem to share with prions some aspects of their pathogenic mechanism; causing a variety of so called prion-like diseases in humans and/or animals such as Alzheimer's, Parkinson's, Huntington's, Type II diabetes mellitus or amyloidosis. The question remains whether these misfolding proteins have the ability to self-propagate and transmit in a similar manner to prions. In this review, we describe the prion and prion-like diseases affecting animals as well as the recent findings suggesting the prion-like transmissibility of certain non-prion proteins.

Failure of heterogeneous amyloid-enhancing factor in geriatric squirrel monkeys (Saimiri boliviensis)

BACKGROUND

Cross-species transmission of AA amyloidosis between primates and other animals has not been previously reported.

METHODS

Eight geriatric squirrel monkeys were intravenously administered chimpanzee, bovine, or chicken amyloid fibrils and simultaneously received inflammatory stimulation.

RESULTS

AA amyloid deposition was not detected in any of the monkeys histopathologically or immunohistochemically.

CONCLUSIONS

These results suggest that heterogeneous AA amyloidosis may not be easily transmitted into primates.

First detection of Echinococcus multilocularis infection in two species of nonhuman primates raised in a zoo: a fatal case in Cercopithecus diana and a strongly suspected case of spontaneous recovery in Macaca nigra

The causative parasite of alveolar echinococcosis, Echinococcus multilocularis, maintains its life cycle between red foxes (Vulpes vulples, the definitive hosts) and voles (the intermediate hosts) in Hokkaido, Japan. Primates, including humans, and some other mammal species can be infected by the accidental ingestion of eggs in the feces of red foxes. In August 2011, a 6-year-old zoo-raised female Diana monkey (Cercopithecus diana) died from alveolar echinococcosis. E. multilocularis infection was confirmed by histopathological examination and detection of the E. multilocularis DNA by polymerase chain reaction (PCR). A field survey in the zoo showed that fox intrusion was common, and serodiagnosis of various nonhuman primates using western blotting detected a case of a 14-year-old female Celebes crested macaque (Macaca nigra) that was weakly positive for E. multilocularis. Computed tomography revealed only one small calcified lesion (approximately 8mm) in the macaque's liver, and both western blotting and enzyme-linked immunosorbent assay (ELISA) showed a gradual decline of antibody titer. These findings strongly suggest that the animal had recovered spontaneously. Until this study, spontaneous recovery from E. multilocularis infection in a nonhuman primate had never been reported.

Genetic diversity of Echinococcus spp. in Russia

In Russia, both alveolar and cystic echinococcoses are endemic. This study aimed to identify the aetiological agents of the diseases and to investigate the distribution of each Echinococcus species in Russia. A total of 75 Echinococcus specimens were collected from 14 host species from 2010 to 2012. Based on the mitochondrial DNA sequences, they were identified as Echinococcus granulosus sensu stricto (s.s.), E. canadensis and E. multilocularis. E. granulosus s.s. was confirmed in the European Russia and the Altai region. Three genotypes, G6, G8 and G10 of E. canadensis were detected in Yakutia. G6 was also found in the Altai region. Four genotypes of E. multilocularis were confirmed; the Asian genotype in the western Siberia and the European Russia, the Mongolian genotype in an island of Baikal Lake and the Altai Republic, the European genotype from a captive monkey in Moscow Zoo and the North American genotype in Yakutia. The present distributional record will become a basis of public health to control echinococcoses in Russia. The rich genetic diversity demonstrates the importance of Russia in investigating the evolutionary history of the genus Echinococcus.

The immunodiagnosis of Echinococcus multilocularis infection

Alveolar echinococcosis (AE) is a severe zoonotic disease caused by the metacestode stage of Echinococcus multilocularis. The infection can have fatal consequences in humans if treatment is not provided, so early diagnosis is fundamental for initiating treatment and reducing morbidity and mortality. In addition, detection of the parasite in the definitive host plays a central role in epidemiological studies and surveillance programmes for control of AE. This review presents an overview of the present situation regarding the immunodiagnosis of E. multilocularis infection. Special attention is given to the description of the native, partially purified and recombinant antigens available currently for immunodiagnostic purposes. Recent advances in the primary serodiagnosis and follow-up of AE patients are highlighted, including the detection of specific cytokine profiles. Progress in the immunodiagnosis of intestinal E. multilocularis infection in definitive hosts, particularly the detection of excretory-secretory and integument products of the worm in faeces (copro-antigens) by ELISA, is also discussed.

Echinococcus multilocularis--a zoonosis of anthropogenic environments?

Transmission of the fox tapeworm Echinococcus multilocularis, the causative agent of human alveolar echinococcosis, is known to depend on various environmental factors which are subject to human influence. Epidemiological data suggest that in most endemic regions anthropogenic landscape changes (e.g. deforestation and agricultural practices) have led to more favourable conditions for the parasite's animal hosts, especially arvicolid rodents, thereby increasing the risk for parasite transmission and human disease. Examples are the conversion of forests or crop fields into meadows and pastures in Europe, China and North America, and overgrazing of natural grassland in central Asia. Other anthropogenic factors include interference with host population densities by wildlife disease control, changing hunting pressure and provision of new habitats, e.g. in urban areas. Domestic dogs may, under certain conditions, get involved in the otherwise largely wildlife-based transmission, and thereby greatly increase the infection pressure to humans. The introduction of neozootic host species may increase transmission, or even initiate the parasite's life-cycle in previously non-endemic regions. Lastly, the parasite itself may be accidentally introduced into non-endemic areas, if suitable host populations are present (e.g. in northern Japan).

Recent advances in the immunology and diagnosis of echinococcosis

Echinococcosis is a cosmopolitan zoonosis caused by adult or larval stages of cestodes belonging to the genus Echinococcus (family Taeniidae). The two major species of medical and public health importance are Echinococcus granulosus and Echinococcus multilocularis, which cause cystic echinococcosis and alveolar echinococcosis, respectively. Both cystic echinococcosis and alveolar echinococcosis are serious diseases, the latter especially so, with a high fatality rate and poor prognosis if managed inappropriately. This review highlights recent advances in immunity to infection and vaccination against both parasites in their intermediate and definitive hosts and procedures for diagnosis of cystic echinococcosis and alveolar echinococcosis, including the value of immunodiagnostic and DNA approaches. There is discussion also of progress in genomics and related technologies that is providing valuable insights on the functional biology of the Echinococcus organisms. These studies will underpin future research that will reveal a better understanding of the Echinococcus-host interplay, and suggest new avenues for the identification of additional targets for diagnosis, vaccination and chemotherapy.