Iranian Hydatid Disease Registry: Establishment and Implementation of a Neglected Tropical Disease Registry

BACKGROUND

Cystic echinococcosis (CE) or hydatid disease is a global public health concern which imposes considerable economic costs on the communities in endemic regions. CE surveillance data are not adequately reliable. The present study reports the development and outcomes of a CE registry in Iran.

METHODS

Hydatid Registry (HydatidReg) was initially established as a single-center registry in 2014 after the ethical approval of KMU. Following a call from MoHME to promote registry of different diseases and health outcomes, a call for participation was announced and all the Iranian Universities of Medical Sciences were requested to contribute to the registry. Subsequently, a nation-wide registry of hydatid disease was established in 2016. With a global perspective, HydatidReg joined the European Register of Cystic Echinococcosis (ERCE). A data collection form based on minimum dataset was designed and standard operating procedures (SOPs) were prepared to ensure standardized patient enrolment in the registry. A biobank system with two-dimensional barcoding was established along with HydatidReg for management and organization of biological specimens.

RESULTS

As of March 2021, a total of 690 patients were enrolled in the registry. HydatidReg registered 362 (17.3%) out of the total 2097 patients enrolled in ERCE. Quality control (QC) of the data demonstrated 91.2% completeness and 80% timeliness. In the biobank, 322 biological specimens from 184 CE patients have been deposited including 70 blood, 96 sera and 156 parasite materials.

CONCLUSION

High-quality data in the HydatidReg registry provided opportunities for health professionals to improve quality of care and organize meaningful research.

Prospective collection of clinical data on cystic echinococcosis: experience with the European Registry of Cystic Echinococcosis in Pavia, Italy

BACKGROUND

Cystic echinococcosis (CE) is a chronic, complex and neglected infection that may cause serious disease in humans. Given its peculiar epidemiologic and clinical features, collection of clinical data is challenging. Notification systems, when available, fail to record important clinical features, available data are mostly retrospectively collected and no prospectively enrolled uniform surveillance systems exist. The European Register of Cystic Echinococcosis database (ERCE) is the first systematic attempt to address these issues.

METHODS

Here, we describe the demographics and clinical characteristics of 436 patients who accessed the CE clinic at the University of Pavia-San Matteo Hospital Foundation, in Pavia, Italy, from March 2012 to February 2020.

RESULTS

Overall, 436 patients, consisting of 204 (46.8%) males and 232 (53.2%) females were enrolled; the mean age at enrollment was 50 (range 4-88) y. Of the 436 patients, 248 (56.9%) were born in Italy while 188 (43.1%) were foreign-born. In total, 638 CE cysts were counted, most of them in the CE4 (230; 36.1%) and CE3b (131; 20.5%) stages.

CONCLUSIONS

This is the largest cohort of CE patients with detailed clinical and demographic data published to date. We strongly encourage colleagues caring for CE patients in the European Union to join the ERCE.

An integrated approach to control Cystic Echinococcosis in southern Italy

Cystic echinococcosis (CE) is a severe zoonosis, caused by the larval stage of the tapeworm Echinococcus granulosus. This helminth infection is of increasing public health and socio-economic concern due to the considerable morbidity rates that cause economic losses both in the public health sector and in the livestock industry. Control programmes against E. granulosus are considered long-term actions which require an integrated approach and high expenditure of time and financial resources. Since 2010, an integrated approach to control CE has been implemented in a highly endemic area of continental southern Italy (Campania region). Innovative procedures and tools have been developed and exploited during the control programme based on the following strategies: i) active and passive surveillance in livestock (using geospatial tools for georeferencing), ii) diagnosis in dogs (using the FLOTAC techniques and molecular analysis), iii) targeted treatment of farm dogs (using purpose-built confinement cages), iv) early diagnosis in livestock (by ultrasonography), v) surveillance in humans (through hospital discharge records analysis), vi) monitoring the food chain (analysing raw vegetables), vii) outreach activities to the general public (through dissemination material, e.g. brochures, gadgets, videos, virtual reality). Over eight years, the integrated approach and the new strategies developed have resulted in a noteworthy reduction of the parasite infection rates in livestock (e.g. up to 30 % in sheep). The results obtained so far highlight that using a one health multidisciplinary and multi-institution effort is of pivotal importance in preparing CE control programmes at regional level and could be extended to other endemic Mediterranean areas.

The European Register of Cystic Echinococcosis, ERCE: state-of-the-art five years after its launch

BACKGROUND

The real burden of human cystic echinococcosis (CE) remains elusive, due to the peculiar characteristics of the disease and the heterogeneous and incomplete data recording of clinical cases. Furthermore, official notification systems do not collect pivotal clinical information, which would allow the comparison of different treatment outcomes, and thus circumvent the difficulty of implementing clinical trials for CE. The Italian Register of CE (RIEC) was launched in 2012 and expanded in 2014 into the European Register of CE (ERCE). The primary aim of the ERCE was to highlight the magnitude of CE underreporting, through the recording of cases that were not captured by official records. We present an overview of data collated in the ERCE and discuss its future, five years after its inception.

METHODS

The ERCE database was explored on March 31st 2019; data concerning participating centres and registered cases were descriptively analysed.

RESULTS

Forty-four centres from 15 countries (7 non-European) were affiliated to the ERCE. Thirty-four centres (77%) registered at least one patient; of these, 18 (53%) recorded at least one visit within the past 18 months. A total of 2097 patients were registered, 19.9% of whom were immigrants. Cyst characteristics were reported for at least one cyst at least in one visit in 1643 (78.3%) patients, and cyst staging was used by 27 centres. In total, 3386 cysts were recorded at first registration; mostly located in the liver (75.5%). Data concerning clinical management could be analysed for 920 "cyst stage-location-management" observations, showing great heterogeneity in the implementation of the stage-specific management approach recommended by the WHO.

CONCLUSIONS

The ERCE achieved its goal in showing that CE is a relevant but neglected public health problem in Europe and beyond, since a proportion of patients reaching medical attention are not captured by official notification systems. The ERCE may provide a valuable starting platform to complement hospital-derived data, to obtain a better picture of the epidemiology of clinical CE, and to collect clinical data for the issue of evidence-based recommendations. The ERCE will be expanded into the International Register of CE (IRCE) and restructured aiming to overcome its current criticalities and fulfil these aims.

Shortage of Albendazole and Its Consequences for Patients with Cystic Echinococcosis Treated at a Referral Center in Italy

Albendazole (ABZ) is the best drug available to treat cystic echinococcosis (CE), a neglected tropical disease. Cystic echinococcosis patients often receive a continuous course of the drug for 6-12 months. In Italy, ABZ shortages occur almost on a yearly basis. We searched clinical records at the World Health Organization Collaborating Center for the Clinical Management of CE in Pavia, Italy, to estimate the amount of ABZ prescribed to patients between January 2012 and February 2017. The cost of ABZ was estimated at €2.25 per tablet based on the current market price in Italy. Patients to whom ABZ had been prescribed were contacted to determine if they had experienced difficulties in purchasing the drug and to assess how such problems affected their treatment. Of 348 identified CE patients, 127 (36.5%) were treated with ABZ for a total of 20,576 days. This led to an estimated cost of €92,592. Seventy-five patients were available for follow-up, 42 (56%) reported difficulties in obtaining ABZ. Of these patients, four (9.5%) had to search out of their region and 10 (23.8%) had to go out of the country. A total of 27 patients (64%) had to visit more than five pharmacies to locate the drug and 10 patients (23.8%) interrupted treatment because of ABZ nonavailability. Shortages in ABZ distribution can disrupt CE treatment schedules and jeopardize patient health.

Severe chest allodynia as an unusual first presentation of hydatid disease: a case report

Background

Cystic echinococcosis (CE) is a worldwide zoonosis and the liver is the most commonly affected organ. Clinical manifestations range from completely asymptomatic cysts to a potential lethal cyst rupture and anaphylaxis.

Case presentation

Severe chest allodynia was an unusual clinical presentation of hepatic cyst rupture in the retroperitoneal space, without any other specific symptoms. CE diagnosis was confirmed by computed tomography scan and magnetic resonance. The patient underwent hepatectomy with complete resolution of the neuropathic pain.

Conclusions

Retroperitoneal hydatid cyst rupture is a rare event and its clinical manifestation may mimic other chest neuropathies.

A T-cell diagnostic test for cystic echinococcosis based on Antigen B peptides

Cystic echinococcosis (CE) immunodiagnosis is still imperfect. We recently set-up a whole-blood test based on the interleukin (IL)-4 response to the native Antigen B (AgB) of Echinococcus granulosus. However, AgB is encoded by a multigene family coding for five putative subunits. Therefore, the aims of this study were to analyse the IL-4 response to peptides spanning the immunodominant regions of the five AgB subunits and to evaluate the accuracy of this assay for CE diagnosis. Peptides corresponding to each subunit were combined into five pools. A pool containing all peptides was also used (total pool). IL-4 evaluated by enzyme-linked immunosorbent assay was significantly higher in patients with CE compared to those without (NO-CE subjects) when whole-blood was stimulated with AgB1 and with the total pool. Moreover, IL-4 levels in response to the total pool were significantly increased in patients with active cysts. Receiver Operator Curve analysis identified a cut-off point of 0.59 pg/mL predicting active cysts diagnosis with 71% sensitivity and 82% specificity in serology-positive CE patients. These data, if confirmed in a larger cohort, offer the opportunity to develop new diagnostic tools for CE based on a standardized source of AgB as the peptides.

Increase of Vascular Endothelial Growth Factor and Decrease of MCP-1 and Some Updated Epidemiology Aspects of Cystic Echinococcosis Human Cases in Calabria Region

We aim to investigate some of the pathogenetic mediators of the human echinococcosis and to obtain updated epidemiological findings on cases of echinococcosis in Calabria, Southern Italy. Echinococcosis diagnosis was based on imaging, serological investigations, and molecular assay. Indeed, real-time PCR indicated the presence of G2/G3 genotypes of Echinococcus granulosus complex. Regarding pathogenesis, a relevant novel tool of immune depression should be deemed the reduced level of serum MCP-1. Also, we found a previously unreported VEGF, possibly associated with neovascularization requested by the parasite cyst metabolism. Cytokine profiles suggest a bias of the immunity toward Th2 and Treg responses. Nitric oxide levels exhibited a significant decrease one week after therapy versus basal level measured before surgery and/or chemotherapy. An increase of serum total IgE class and IgG4 subclass was found in Echinococcus-positive patients versus controls. Our data demonstrated an endemic spreading, at least in the province of Catanzaro and neighboring Calabria territories, for such parasitosis with the novel issue of the number of female overcoming male cases. In conclusion, the novel findings of this study were the increased VEGF and the reduced serum MCP-1 in the studied cases, as well as the number of Echinococcus-infected females overcoming the infected males.

Alveolar echinococcosis in Germany, 1992-2016. An update based on the newly established national AE database

PURPOSE

Alveolar echinococcosis is a rare disease caused by the parasite Echinococcus multilocularis. The newly established national database should enable us to determine high-risk areas and evaluate the endemic levels.

METHODS

The national database was implemented using SQL Workbench. We used EpiInfo™ software to display the prevalence of disease. Moran's I geodata analysis according to cluster and high risk areas was performed with GeoDa™. SAS Version 9.2 was used for the statistical analysis of the cases (n = 523).

RESULTS

The analysis showed a concentration of cases in Baden-Württemberg and Bavaria. Moran's I showed a heterogeneous case distribution throughout Germany (I = 0.208815, Z = 32.6175, p < 0.001). In the period from 1992 to 2016, the prevalence was 0.64/100,000 inhabitants in the whole of Germany, 2.18/100,000 inhabitants in Baden-Württemberg and 1.48/100,000 inhabitants in Bavaria. The analysis also revealed a difference between men and women, with a prevalence of 0.58/100,000 and 0.69/100,000, respectively. The analysis of spatial autocorrelation and possible risk areas showed that the southeast regions of Baden-Württemberg (I = 0.188514, Z = 11.3197, p < 0.001) and the southwest part of Bavaria (I = 0.176953, Z = 13.5144, p < 0.001) constitute the high risk areas.

CONCLUSIONS

The prevalence of disease is noticeably high in the Swabian Jura, the Bavarian Alps and the Alpine foothills. Raising awareness and educating doctors in high risk areas may prevent new cases and assist in earlier diagnosis.

The disease burden of human cystic echinococcosis based on HDRs from 2001 to 2014 in Italy

Background

Cystic echinococcosis (CE) is an important neglected zoonotic parasitic infection belonging to the subgroup of seven Neglected Zoonotic Disease (NZDs) included in the World Health Organization’s official list of 18 Neglected Tropical Diseases (NTDs). CE causes serious global human health concerns and leads to significant economic losses arising from the costs of medical treatment, morbidity, life impairments and fatality rates in human cases. Moreover, CE is endemic in several Italian Regions. The aim of this study is to perform a detailed analysis of the economic burden of hospitalization and treatment costs and to estimate the Disability Adjusted Life Years (DALYs) of CE in Italy.

Methods and findings

In the period from 2001 to 2014, the direct costs of 21,050 Hospital Discharge Records (HDRs) belonging to 12,619 patients with at least one CE-related diagnosis codes were analyzed in order to quantify the economic burden of CE. CE cases average per annum are 901 (min—max = 480–1,583). Direct costs include expenses for hospitalizations, medical and surgical treatment incurred by public and private hospitals and were computed on an individual basis according to Italian Health Ministry legislation. Moreover, we estimated the DALYs for each patient. The Italian financial burden of CE is around € 53 million; the national average economic burden per annum is around € 4 million; the DALYs of the population from 2001 to 2014 are 223.35 annually and 5.26 DALYs per 10⁵ inhabitants.

Conclusion

In Italy, human CE is responsible for significant economic losses in the public health sector. In humans, costs associated with CE have been shown to have a great impact on affected individuals, their families and the community as a whole. This study could be used as a tool to prioritize and make decisions with regard to a surveillance system for this largely preventable yet neglected disease. It demonstrates the need of implementing a CE control program aimed at preventing the considerable economic and social losses it causes in high incidence areas.

CE is a neglected tropical disease that remains a considerable health problem in endemic regions and which leads to substantial economic losses for agriculture sectors and public health systems. The parasitic cycle requires a definitive host (canidae) and an intermediate host (livestock species), while humans are only occasionally hosts. CE is more prevalent in areas where extensive or semi-extensive farming of livestock (mostly sheep) is common. The study of prevalence and health expenditure at the national macro-regional and regional level is a prerequisite for creating awareness of the importance of this disease. The Italian Ministry of Health provides remuneration to its regions’ hospitals for treatment of illnesses. In this study 21,050 hospital discharge records with CE diagnosis from 2001 to 2014 related to 12,619 patients were analyzed. The median of CE hospitalizations per annum was 848. The direct costs of HDRs for echinococcosis were estimated to be € 53,175,934.34. The assessment of economic remuneration by Italian Regions grouped by Nomenclature of Territorial Units 1 (NUTS1) shows that Southern Italy and its major islands spent €13,523,999 and €15,171,739 respectively. The national annual average direct cost for 10⁵ inhabitants was € 6,398. The study of the National DALYs, a measure of social burden of disease, shows that 41% was correlated to Island patients DALYs per annum are 223.4. An analysis of direct costs and an estimate of DALYs are key factors for establishing how to prioritize control measures for CE, which is essentially a preventable disease.

Is there echinococcosis in West Africa? A refugee from Niger with a liver cyst

BACKGROUND

Italy is presently facing an increase in immigration from sub-Saharan Africa through the Mediterranean Sea. Case reports of human cystic echinococcosis (CE) have been reported from most sub-Saharan countries. Therefore, an increase in the number of patients with CE coming from these areas in the Italian and European centers for infectious diseases is expected. Unfortunately, the epidemiology of CE in sub-Saharan countries is poorly known, which makes clinical suspicion and diagnosis of such infection difficult in patients coming from these areas.

RESULTS

Here we report a case of hepatic CE in a patient from Niger who arrived in Italy through Libya and visited in a Tropical Medicine referral center in Northern Italy. The parasite was identified molecularly as the G6 "camel" strain of Echinococcus granulosus (E. canadensis). The diagnosis and management of a chronic and clinically complex infection like CE in such situation is difficult. Only 40 cases of CE from Niger have been reported; of these, 75% had extra-hepatic localization. To our knowledge, no strain characterization of human isolates from Niger has been reported so far. The CE cyst of the patient was in CE3a stage, indicating active transmission from the area in which the patient came. However, prevalence data from Niger, and from any other country in West Africa, are almost inexistent.

CONCLUSIONS

We argue that population epidemiology surveys with ultrasound are warranted in Sahelian countries, including Niger. These studies could improve the knowledge of CE epidemiology, provide health authorities with important information for public health interventions targeting this zoonosis, and shed light on any difference between tissue tropism and clinical manifestations caused by the different E. granulosus strains.

Human cystic echinococcosis in Morocco: Ultrasound screening in the Mid Atlas through an Italian-Moroccan partnership

Background

Cystic echinococcosis (CE) is a neglected parasitic zoonosis with considerable socioeconomic impact on affected pastoral communities. CE is endemic throughout the Mediterranean, including Morocco, where the Mid Atlas is the most prevalent area for both human and animal infection. The highest hospital annual incidence of human CE is recorded in the provinces of Ifrane and El Hajeb. However, hospital-based statistics likely underestimate the real prevalence of infection, as a proportion of cases never reach medical attention or official records.

Methodology/Principal findings

In 2012, a project on clinical management of CE in Morocco was launched with the aims of estimating the prevalence of human abdominal CE in selected rural communes of the above mentioned provinces using ultrasound (US) screening and training local physicians to implement US-based focused assessment and rational clinical management of CE according to the WHO-IWGE Expert Consensus. A total of 5367 people received abdominal US during four campaigns in April-May 2014. During the campaigns, 24 local general practitioners received >24 hours of hands-on training and 143 health education sessions were organized for local communities. We found an overall CE prevalence of 1.9%, with significantly higher values in the rural communes of Ifrane than El Hajeb (2.6% vs 1.3%; p<0.001). CE cysts were predominantly in inactive stage, especially in older age groups. However, active cysts were present also in adults, indicating acquisition of infection at all ages. Province of residence was the only risk factor consistently associated with CE infection.

Conclusions/Significance

Our results show a high prevalence and on-going, likely environmental transmission of CE in the investigated provinces of Morocco, supporting the implementation of control activities in the area by national health authorities and encouraging the acceptance and divulgation of diagnosis and treatment algorithms based on imaging for CE at both national and local level.

Cystic Echinococcosis (CE) is a parasitic infection whose natural domestic cycle develops between dogs and sheep (and other livestock). Human infection is endemic in pastoral communities, where close contact with the dog-sheep cycle occurs. In humans, as well as in livestock, the parasite develops as fluid-filled cyst mainly in the liver. CE is a neglected disease, as it is a disabler without high mortality, it affects mainly poor communities, and requires complex and expensive clinical management and long-term integrated public health control strategies. The prevalence of infection in an area is often unknown or largely underestimated, therefore the problem is perceived as not important. In Morocco, the Mid Atlas is the most prevalent area for human and animal infection. We performed an ultrasound survey on 5,367 people in Ifrane and El Hajeb provinces, and found an overall prevalence of 1.9%. CE cysts were predominantly inactive, however, active cysts were present also in adults. Our results show a high prevalence and on-going transmission of CE, encouraging the prompt strengthening and complete implementation of control activities envisaged by Moroccan health authorities in the area and the adoption of diagnosis and treatment algorithms based on imaging at both national and local level, to avoid a risk-associated and expensive treatment of inactive cysts.

The Echinococcoses: Diagnosis, Clinical Management and Burden of Disease

The echinococcoses are chronic, parasitic diseases that are acquired after ingestion of infective taeniid tapeworm eggs from certain species of the genus Echinococcus. Cystic echinococcosis (CE) occurs worldwide, whereas, alveolar echinococcosis (AE) is restricted to the northern hemisphere, and neotropical echinococcosis (NE) has only been identified in Central and South America. Clinical manifestations and disease courses vary profoundly for the different species of Echinococcus. CE presents as small to large cysts, and has commonly been referred to as 'hydatid disease', or 'hydatidosis'. A structured stage-specific approach to CE management, based on the World Health Organization (WHO) ultrasound classification of liver cysts, is now recommended. Management options include percutaneous sterilization techniques, surgery, drug treatment, a 'watch-and-wait' approach or combinations thereof. In contrast, clinical manifestations associated with AE resemble those of a 'malignant', silently-progressing liver disease, with local tissue infiltration and metastases. Structured care is important for AE management and includes WHO staging, drug therapy and long-term follow-up for at least a decade. NE presents as polycystic or unicystic disease. Clinical characteristics resemble those of AE, and management needs to be structured accordingly. However, to date, only a few hundreds of cases have been reported in the literature. The echinococcoses are often expensive and complicated to treat, and prospective clinical studies are needed to better inform case management decisions.

Cystic echinococcosis: Future perspectives of molecular epidemiology

Human cystic echinococcosis (CE) has been considered to be caused predominantly by Echinococcus granulosus sensu stricto (the dog-sheep strain). Molecular approaches on CE, however, have revealed that human cases are also commonly caused by another species, Echinococcus canadensis. All indices for classification and standardization of CE pathology including available images, epidemiology, diagnostics and treatment are currently based largely on a mixture of infections which include at least E. granulosus s.s. and E. canadensis. Involvement of other species of Echinococcus in CE including E. ortleppi or otherwise cryptic diversity demonstrated recently in Africa requires further elucidation. Molecular identification of the causative species in CE cases is essential for better understanding of pathogenesis and disease. This article stresses the importance of molecular species identification of human CE as a foundation for re-evaluation of evidence-based epidemiology.

Historical Aspects of Echinococcosis

Echinococcosis is a zoonosis whose history dates back to antiquity. This article provides an overview on the general history of echinococcosis, including the elucidation of Echinococcus life cycles and the long controversy on the aetiology of the cystic and alveolar forms of echinococcosis (CE and AE), lasting about 100years since the middle of the 19th century. Furthermore, selected historical aspects of some fields of echinococcosis research are discussed and compared with our current knowledge, such as geographic distribution and epidemiology of CE (Echinococcus granulosus) and AE (Echinococcus multilocularis), clinical aspects and pathology, diagnosis in humans and animals, treatment (with focus on chemotherapy), control and basic research. A short paragraph is devoted to the neotropical forms of echinococcosis, caused by Echinococcus vogeli and Echinococcus oligarthrus. In this context the achievements of some ancestral pioneers of echinococcosis research are particularly highlighted and appreciated. Finally, the role of associations, international organizations (World Health Organization and others) and international working groups in echinococcosis research and control is briefly outlined. The retrospective reveals both the admirable achievements of our ancestors and the scientific progress of more recent times. But, it also shows the gaps in our knowledge, skills and resources that we need to control or even eradicate echinococcosis.

Cystic Echinococcosis Epidemiology in Spain Based on Hospitalization Records, 1997-2012

BACKGROUND

Cystic echinococcosis (CE) is a parasitic disease caused by the tapeworm Echinococcus granulosus. Although present throughout Europe, deficiencies in the official reporting of CE result in under-reporting and misreporting of this disease, which in turn is reflected in the wrong opinion that CE is not an important health problem. By using an alternative data source, this study aimed at describing the clinical and temporal-spatial characteristics of CE hospitalizations in Spain between 1997 and 2012.

METHODOLOGY/PRINCIPAL FINDINGS

We performed a retrospective descriptive study using the Hospitalization Minimum Data Set (CMBD in Spanish). All CMBD's hospital discharges with echinococcosis diagnosis placed in first diagnostic position were reviewed. Hospitalization rates were computed and clinical characteristics were described. Spatial and temporal distribution of hospital discharges was also assessed. Between 1997 and 2012, 14,010 hospitalizations with diagnosis of CE were recorded, 55% were men and 67% were aged over 45 years. Pediatric hospitalizations occurred during the whole study period. The 95.2% were discharged at home, and only 1.7% were exitus. The average cost was 8,439.11 €. The hospitalization rate per 100,000 per year showed a decreasing trend during the study period. All the autonomous communities registered discharges, even those considered as non-endemic. Maximum rates were reached by Extremadura, Castilla-Leon and Aragon. Comparison of the CMBD data and the official Compulsory Notifiable Diseases (CND) reports from 2005 to 2012 showed that official data were lower than registered hospitalization discharges.

CONCLUSIONS

Hospitalizations distribution was uneven by year and autonomous region. Although CE hospitalization rates have decreased considerably due to the success of control programs, it remains a public health problem due to its severity and economic impact. Therefore, it would be desirable to improve its oversight and surveillance, since officially reported data are underestimating the real burden of CE in Spain.

Retrospective study of human cystic echinococcosis over the past decade in France, using a nationwide hospital medical information database

No specific surveillance system of cystic echinococcosis infections in humans exists in France. The incidence and trends over time have not been documented since the last decade of the twentieth century. We performed the current analysis to assess human cystic echinococcosis epidemiology over a 10-year period in France (including the island of Corsica but excluding the overseas territories) using a nationwide hospital medical information database. A total number of 2629 patients were identified in this database between 2005 and 2014. The average annual incidence rate was 0.42 hospitalized cases/100,000 inhabitants. It was highest in the Island of Corsica (1.76 cases/100,000) and in the region Provence-Alpes-Côte d'Azur (0.85 cases/100,000). This retrospective analysis of hospital records provides a population-based estimate of cystic echinococcosis incidence and trends over a 10-year period at a national level. It indicates a significant decrease of the incidence between 2005 and 2014 at the national level and in the area that reported the highest incidence. It stresses the fact that in France, cystic echinococcosis is not re-emerging and that the incidence remains low in comparison with similar studies in other Mediterranean countries.

The first meeting of the European Register of Cystic Echinococcosis (ERCE)

Cystic echinococcosis (CE) is a zoonotic parasitic disease endemic in southern and eastern European countries. The true prevalence of CE is difficult to estimate due to the high proportion of asymptomatic carriers who never seek medical attention and to the underreporting of diagnosed cases, factors which contribute to its neglected status. In an attempt to improve this situation, the European Register of Cystic Echinococcosis (ERCE), was launched in October 2014 in the context of the HERACLES project. ERCE is a prospective, observational, multicentre register of patients with probable or confirmed CE. The first ERCE meeting was held in November 2015 at the Italian National Institute of Health (Istituto Superiore di Sanita, ISS) in Rome, to bring together CE experts currently involved in the Register activities, to share and discuss experiences, and future developments.Although the Register is still in its infancy, data collected at the time of writing this report, had outnumbered the total of national cases reported by the European endemic countries and published by the European Centre for Disease Prevention and Control in 2015. This confirms the need for an improved reporting system of CE at the European level. The collection of standardized clinical data and samples is expected to support a more rational, stage-specific approach to clinical management, and to help public authorities harmonize reporting of CE. A better understanding of CE burden in Europe will encourage the planning and implementation of public health policies toward its control.

Screening of the Open Source Malaria Box Reveals an Early Lead Compound for the Treatment of Alveolar Echinococcosis

The metacestode (larval) stage of the tapeworm Echinococcus multilocularis causes alveolar echinococcosis (AE), a very severe and in many cases incurable disease. To date, benzimidazoles such as albendazole and mebendazole are the only approved chemotherapeutical treatment options. Benzimidazoles inhibit metacestode proliferation, but do not act parasiticidal. Thus, benzimidazoles have to be taken a lifelong, can cause adverse side effects such as hepatotoxicity, and are ineffective in some patients. We here describe a newly developed screening cascade for the evaluation of the in vitro efficacy of new compounds that includes assessment of parasiticidal activity. The Malaria Box from Medicines for Malaria Venture (MMV), comprised of 400 commercially available chemicals that show in vitro activity against Plasmodium falciparum, was repurposed. Primary screening was carried out at 10 μM by employing the previously described PGI assay, and resulted in the identification of 24 compounds that caused physical damage in metacestodes. Seven out of these 24 drugs were also active at 1 μM. Dose-response assays revealed that only 2 compounds, namely MMV665807 and MMV665794, exhibited an EC₅₀ value below 5 μM. Assessments using human foreskin fibroblasts and Reuber rat hepatoma cells showed that the salicylanilide MMV665807 was less toxic for these two mammalian cell lines than for metacestodes. The parasiticidal activity of MMV665807 was then confirmed using isolated germinal layer cell cultures as well as metacestode vesicles by employing viability assays, and its effect on metacestodes was morphologically evaluated by electron microscopy. However, both oral and intraperitoneal application of MMV665807 to mice experimentally infected with E. multilocularis metacestodes did not result in any reduction of the parasite load.

The fox tapeworm Echinococcus multilocularis causes a deadly disease in humans that is characterized by cancer-like parasite growth in the liver of patients. Hence E. multilocularis is ideally removed by radical resection. However, as this is not always possible, patients are treated by chemotherapy to stop further parasite growth. To date, the drugs in use cannot kill the parasite E. multilocularis and they also induce side-effects, therefore new options for treatment are needed. We here screened a library of 400 compounds with proven activity against Plasmodium falciparum, the cause of malaria, for their effects against E. multilocularis in vitro. We developed and refined an in vitro screening cascade and developed an assay that can identify compounds with parasiticidal effects against E. multilocularis cells. We here show that MMV665807 acts parasiticidal as demonstrated by in vitro viability tests and by electron microscopy. In the mouse infection model the drug was not active, but work will focus on the evaluation of derivatives with improved bioavailability and pharmacokinetic properties to achieve parasiticidal activity not only in vitro, but also in vivo.

Surveillance of Human Echinococcosis in Castilla-Leon (Spain) between 2000-2012

BACKGROUND

Cystic echinococcosis (CE) is an important health problem in many areas of the world including the Mediterranean region. However, the real CE epidemiological situation is not well established. In fact, it is possible that CE is a re-emerging disease due to the weakness of current control programs.

METHODOLOGY

We performed a retrospective observational study of inpatients diagnosed with CE from January 2000 to December 2012 in the Western Spain Public Health-Care System.

PRINCIPAL FINDINGS

During the study period, 5510 cases of CE were diagnosed and 3161 (57.4%) of the cases were males. The age mean and standard deviation were 67.8 ± 16.98 years old, respectively, and 634 patients (11.5%) were younger than 45 years old. A total of 1568 patients (28.5%) had CE as the primary diagnosis, and it was most frequently described in patients <45 years old. Futhermore, a secondary diagnosis of CE was usually found in patients >70 year old associated with other causes of comorbidity. The period incidence rate was 17 cases per 105 person-years and was significantly higher when compared to the incidence declared through the Notifiable Disease System (1.88 cases per 105 person-years; p<0.001).

CONCLUSIONS

CE in western Spain is an underestimated parasitic disease. It has an active transmission, with an occurrence in pediatric cases, but has decreased in the recent years. The systematic search of Hospital Discharge Records of the National Health System Register (HDR) may be a more accurate method than other methods for the estimation of the incidence of CE in endemic areas.

[Epidemiological update of hydatid disease in hospitals in the public health system of Extremadura (2003-2012)]

INTRODUCTION

Echinococcosis is a zoonotic infection with a worldwide distribution, and is still an important health problem in many areas of the world, including the Mediterranean basin. At present the epidemiological situation is unclear in certain regions of Spain. The aim of this study was to update the epidemiological situation in Extremadura through an analysis of hospitalised patients in the public health system diagnosed with hydatid disease.

METHODS

A longitudinal retrospective study was conducted between 2003 and 2012 on hospitalised patients with a diagnosis of hydatidosis (ICD 122.0-122.9) in hospitals of the public health service of Extremadura.

RESULTS

During the period of study, 876 patients were diagnosed with hydatid disease. Of these 536 (61%) of cases were male, with a mean age of 65.53±17.8 years. More importantly, 19 (2.2%) of patients were 19 years old, with 17 cases between 2003-2007 versus 2 cases between 2008-2012 (OR=7.83; 95%CI: 1.79-34.11; P=.001). A total of 141 (16.0%) were younger than 45 years. The primary diagnosis was most frequently reported in the younger population <45 years, whereas the secondary diagnosis was usually found in the elderly population >70 years (P<.05). The incidence rate of hydatid disease obtained from Hospital Discharge Records (HDRs) was significantly higher compared to the incidence that was declared in the Notifiable Disease System of Extremadura (8.02 cases per 10(5) person-years vs. 1.88 cases per 10(5) person-years [P<.05]).

CONCLUSION

In Extremadura hydatid disease is still frequent. With a clear decrease in the number of paediatric cases. The number of cases obtained from HDRs regarding Notification System Diseases Extremadura suggests the need for modifications to improve surveillance and control of hydatid disease.