Human infections with liver and minute intestinal flukes in Guangxi, China: analysis by DNA sequencing, ultrasonography, and immunoaffinity chromatography

Environmental influence on abundance and infection patterns of snail intermediate hosts of liver and intestinal flukes in North and Central Vietnam

Liver and intestinal flukes (LIF) are important groups of foodborne zoonotic trematodes (FZTs) in Southeast Asia, including Vietnam. Their complex life cycles require specific freshwater snail species as the obligatory first intermediate hosts. In 2019, we conducted a longitudinal study in Yen Bai and Thanh Hoa provinces in North and Central Vietnam, respectively, to investigate the diversity of LIF and their infection prevalence in relation to snail host abundance and environmental factors. Using a combination of morphological and molecular identification techniques, we identified 10 LIF species infecting 11 snail host species. We observed significant seasonal variation in the mean abundance of several snail host species, with the majority of snails collected during the spring. We also detected seasonal changes in LIF species composition, with the highest species richness reported in the spring. Clonorchis sinensis and Fasciola gigantica, two medically important human liver flukes in Asia, were found only in the spring in Yen Bai. Our study revealed that not all snail host species have the same probability of becoming infected, and we recorded seasonal variations in the prevalence of LIF infection in different snail species in relation to water parameters.

Incidence of fish-borne trematode infections and associated factors: results from a cohort study in highly endemic communities in northern Vietnam

Fish-borne trematodes (FiBT) are an important group of zoonotic parasites negatively affecting human health, mainly in Asia. Most studies on FiBT have applied a cross-sectional design, which provides weaker evidence on potential risk factors for transmission than a cohort study. This cohort study aimed to estimate the incidence and identify associated risk factors for FiBT infection in Vietnam. Between April 2018 and May 2019, two communes in Yen Bai province, a highly endemic area for FiBT, were visited for sampling. Participants with a negative stool result for FiBT at baseline, were invited for follow-up and data collection, at months 4, 9, and 13. Stools were examined using Kato-Katz and formalin-ethyl acetate concentration techniques to detect FiBT eggs, whereas a questionnaire was used for interviewing participants to determine the risk factors for FiBT infection during each follow-up period. The incidence risk and the incidence rate were calculated, and univariate and multivariable models were run to identify the risk factors for FiBT. A total of 194 people, negative for FiBT eggs at the baseline survey, were invited to participate in the study, and 111 people agreed to enroll in the follow-up. The incidence risk at months 4, 9, and 13 was 9.0%, 6.4%, and 5.1%, respectively. We finally used data from 95 participants for the risk factor analysis, excluding 16 people lost for the follow-up. Overall, 20 people became infected with FiBT (IR = 21.1%). The incidence rate of FiBT infection was 21.4/100 person-year. In the univariate analysis, consumption of raw fish was the main risk factor (RR = 4.59, 95%CI = 1.95-10.82), followed by being male (RR = 3.41, 95%CI = 1.56-7.45) and drinking alcohol (RR = 3.25, 95%CI = 1.49-7.11). In the multivariable analysis, only consumption of raw-fish dishes was significantly associated with FiBT infection. The people who consumed raw fish were 3.44 (95%CI = 1.11-10.70) times more at risk of infection with FiBT as compared to individuals who did not consume raw fish. It can be concluded that the FiBT incidence is high in the study area. More awareness campaigns are needed to stop eating raw fish in these areas to reduce FBT infection.

Global prevalence of 4 neglected foodborne trematodes targeted for control by WHO: A scoping review to highlight the gaps

BACKGROUND

Foodborne trematodiases (FBTs) are a group of trematodes targeted for control as part of the World Health Organization (WHO) road map for neglected tropical diseases from 2021 to 2030. Disease mapping; surveillance; and capacity, awareness, and advocacy building are critical to reach the 2030 targets. This review aims to synthesise available data on FBT prevalence, risk factors, prevention, testing, and treatment.

METHODS

We searched the scientific literature and extracted prevalence data as well as qualitative data on the geographical and sociocultural risk factors associated with infection, preventive/protective factors, and methods and challenges of diagnostics and treatment. We also extracted WHO Global Health Observatory data representing the countries that reported FBTs during 2010 to 2019.

RESULTS

One hundred and fifteen studies reporting data on any of the 4 FBTs of focus (Fasciola spp., Paragonimus spp., Clonorchis sp., and Opisthorchis spp.) were included in the final selection. Opisthorchiasis was the most commonly reported and researched FBT, with recorded study prevalence ranging from 0.66% to 88.7% in Asia, and this was the highest FBT prevalence overall. The highest recorded study prevalence for clonorchiasis was 59.6%, reported in Asia. Fascioliasis was reported in all regions, with the highest prevalence of 24.77% reported in the Americas. The least data was available on paragonimiasis, with the highest reported study prevalence of 14.9% in Africa. WHO Global Health Observatory data indicated 93/224 (42%) countries reported at least 1 FBT and 26 countries are likely co-endemic to 2 or more FBTs. However, only 3 countries had conducted prevalence estimates for multiple FBTs in the published literature between 2010 to 2020. Despite differing epidemiology, there were overlapping risk factors for all FBTs in all geographical areas, including proximity to rural and agricultural environments; consumption of raw contaminated food; and limited water, hygiene, and sanitation. Mass drug administration and increased awareness and health education were commonly reported preventive factors for all FBTs. FBTs were primarily diagnosed using faecal parasitological testing. Triclabendazole was the most reported treatment for fascioliasis, while praziquantel was the primary treatment for paragonimiasis, clonorchiasis, and opisthorchiasis. Low sensitivity of diagnostic tests as well as reinfection due to continued high-risk food consumption habits were common factors.

CONCLUSION

This review presents an up-to-date synthesis on the quantitative and qualitative evidence available for the 4 FBTs. The data show a large gap between what is being estimated and what is being reported. Although progress has been made with control programmes in several endemic areas, sustained effort is needed to improve surveillance data on FBTs and identify endemic and high-risk areas for environmental exposures, through a One Health approach, to achieve the 2030 goals of FBT prevention.

Biology, Epidemiology, Clinical Features, Diagnosis, and Treatment of Selected Fish-borne Parasitic Zoonoses

Fish-borne parasites have been part of the global landscape of food-borne zoonotic diseases for many decades and are often endemic in certain regions of the world. The past 20 years or so have seen the expansion of the range of fish-borne parasitic zoonoses to new geographic regions leading to a substantial public health burden. In this article, we summarize current knowledge about the biology, epidemiology, clinical characteristics, diagnosis, treatment and control of selected fish-borne helminthic diseases caused by parasitic roundworm (Anisakis), tapeworm (Dibothriocephalus), and fluke (Metagonimus). Humans acquire infection via consumption of raw or improperly cooked fish or fish products. The burden from these diseases is caused by morbidity rather than mortality. Infected patients may present with mild to severe gastrointestinal (eg, abdominal pain, diarrhea, and indigestion) or allergic manifestations. Patients are often admitted to the hospital or clinic with acute symptoms and no prior health problems and no travel history. Diagnosis is often established based on the detection of the diagnostic parasite stages (eg, eggs or tapeworm segments) in the patient's feces. Sometimes imaging is required to exclude other causes and avoid unnecessary surgery. Dibothriocephalus and Metagonimus are mainly treated with praziquantel. Extraction of adult Dibothriocephalus or Anisakis larvae from the bowel ensures complete elimination of the parasites and prevents a relapse of infection. The development and implementation of more efficient food safety and public health strategies to reduce the burden of zoonotic diseases attributable to fish-borne parasites is highly desirable.

Discovery of Carcinogenic Liver Fluke Metacercariae in Second Intermediate Hosts and Surveillance on Fish-Borne Trematode Metacercariae Infections in Mekong Region of Myanmar

Countries of lower Mekong regions are highly alarmed by the spread of fish-borne trematode infections, i.e., small liver flukes and minute intestinal flukes especially in Thailand, Lao People’s Democratic Republic (Lao PDR), Vietnam, Cambodia and Myanmar. Moreover; the incidence of cholangiocarcinoma has also been increasing in the endemic area of liver fluke infections. Only a few reports have been published concerning the fish-borne trematodes infections in the central region of Myanmar. However; there is still a lack of information regarding the status of trematodes infections in second intermediate hosts in the Mekong region of Myanmar. Therefore, we conducted surveillance on the distribution of trematode metacercariae in small cyprinoid fishes collected from the Mekong region of Myanmar. A total of 689 fishes (12 different species of cyprinoid fishes) have been collected and examined by pepsin digestion methods. We discovered four species of fish-borne trematode metacercariae infections, i.e., carcinogenic liver fluke, Opisthorchis viverrini; minute intestinal flukes, Haplorchis taichui; Haplorchis pumilio and Haplorchoides sp. in Tachileik, the Mekong Region of Myanmar. The outcome of this study could be a useful index for the fish-borne zoonotic trematode epidemiology in the Mekong area. Besides, the results of our study contribute to filling the gap of information necessary for the control and prevention of fish-borne trematode zoonotic infections in the Mekong region.

Current status of Opisthorchis viverrini, minute intestinal fluke and Taenia spp. infections among inhabitants in the Kenethao district of northern Lao PDR

Background

This study reports the prevalence of Ov/minute intestinal fluke (MIF) and Taenia infections among inhabitants of the Kenethao district, northern Lao PDR.

Methods

Fecal samples from 580 inhabitants were examined using the formalin-ethyl acetate concentration technique.

Results

The prevalence of Ov/MIF, Taenia spp. and coinfection was 45.3, 11.9 and 6.1%, respectively. There was no significant difference between males and females for Ov/MIF (p=0.813) and Taenia infection (p=0.759). The prevalence of Ov/MIF was significantly associated with age (p=0.005), but not for Taenia infection (p=0.836). Consumption of raw fish (p=0.001) and raw meat (p=0.046) was significantly associated with parasitic infections.

Conclusions

The results suggest that Ov/MIF and Taenia spp. are highly endemic in this area and there is a need for projects to eliminate these parasites.

Prevalence, Species Distribution, and Related Factors of Fish-Borne Trematode Infection in Ninh Binh Province, Vietnam

Background. Clonorchis sinensis/Opisthorchis viverrini and minute intestinal flukes (MIF) such as Haplorchis pumilio and H. taichui are fish-borne trematodes (FBT) that may coexist in regions where local people have a habit of eating raw fish like Vietnam. Responses to FBT should be verified according to the data on the distribution of these flukes. This study aims to explore the prevalence of different species of FBT and related factors among local people in a northern province of Vietnam. Methods. A cross-sectional study was conducted in Kim Son and Yen Khanh districts, Ninh Binh province, between March 2016 and March 2017. Four hundred people aged 15 years or older were interviewed and gave stool samples. The FBT eggs in faecal samples were enumerated by modified formalin-ether technique and identified by sequencing of the second internal transcribed spacer (ITS2) region. Result. Among the 400 persons, 19.5% were infected with FBT. On univariate analysis, eating raw fish was the main risk factor (odds ratios (OR)) of 6.769 (95% confidence interval (CI) of 2.655-17.259) followed by being of male gender (3.994 (CI95% 2.117-7.536)) and drinking alcohol (2.680 (CI95% 1.440-4.986)), respectively. There was no risk of increased infection among those living at home without hygienic latrines, those living close to rivers or having ponds, or those raising cats or dogs. By multivariate analysis, FBT infection was only related to the consumption of raw fish and gender. Seventy stool samples with a sufficient amount of faecal matter were subjected to DNA extraction, 42.85% of them yielded DNA production, and all were of Clonorchis sinensis. Conclusion. Results of the study showed the high prevalence of infection of fish-borne trematode, mostly C. sinensis among humans in Ninh Binh province. The prevention of FBT should be strengthened with programs detailed according to the distribution of FBT in different endemic areas.

Fishborne zoonotic heterophyid infections: An update

Fishborne heterophyid trematodes infecting humans are at least 29 species worldwide and belong to 13 genera. Its global burden is much more than 7 million infected people. They include Metagonimus (M. yokogawai, M. takahashii, M. miyatai, M. minutus, and M. katsuradai), Heterophyes (H. heterophyes, H. nocens, H. dispar, and H. aequalis), Haplorchis (H. taichui, H. pumilio, H. yokogawai, and H. vanissimus), Pygidiopsis (P. summa and P. genata), Heterophyopsis (H. continua), Stellantchasmus (S. falcatus), Centrocestus (C. formosanus, C. armatus, C. cuspidatus, and C. kurokawai), Stictodora (S. fuscata and S. lari), Procerovum (P. varium and P. calderoni), Acanthotrema (A. felis), Apophallus (A. donicus), Ascocotyle (A. longa), and Cryptocotyle (C. lingua). Human infections are scattered around the world but the major endemic areas are located in Southeast Asia. The source of human infection is ingestion of raw or improperly cooked fish. The pathogenicity, host-parasite relationships, and clinical manifestations in each species infection are poorly understood; these should be elucidated particularly in immunocompromised hosts. Problems exist in the differential diagnosis of these parasitic infections because of close morphological similarity of eggs in feces and unavailability of alternative methods such as serology. Molecular diagnostic techniques are promising but they are still at an infant stage. Praziquantel has been proved to be highly effective against most of the patients infected with heterophyid flukes. Epidemiological surveys and detection of human infections are required for better understanding of the geographical distribution and global burden of each heterophyid species. In this review, the most updated knowledge on the morphology, biology, epidemiology, pathogenesis and pathology, immunology, clinical manifestations, diagnosis and treatment, and prevention and control of fishborne zoonotic heterophyid infections is provided.

Application of Ultrasonography in the Diagnosis of Infectious Diseases in Resource-Limited Settings

Ultrasound (US) has vast potential in the field of infectious diseases, especially so in resource-limited settings. Recent technological advances have increased availability and access to ultrasound in low-resource settings, where the burden of infectious diseases is greatest. This paper collates the evidence for the utilization of ultrasound and evaluates its effectiveness in the diagnosis and management of a range of infectious diseases. This paper explores the role of ultrasound in population-based screening for specific diseases as well as highlights its benefits for individual patient management. We describe the common diagnostic signs seen on US for common and neglected parasitic, bacterial, and viral diseases. We proceed to document the emerging field of chest US which is proving to be a superior imaging modality for the diagnosis of specific pulmonary conditions. We conclude by discussing the efforts needed to formalize and rigorously evaluate the role of ultrasound in infectious diseases.

Point-of-Care Ultrasound Assessment of Tropical Infectious Diseases--A Review of Applications and Perspectives

The development of good quality and affordable ultrasound machines has led to the establishment and implementation of numerous point-of-care ultrasound (POCUS) protocols in various medical disciplines. POCUS for major infectious diseases endemic in tropical regions has received less attention, despite its likely even more pronounced benefit for populations with limited access to imaging infrastructure. Focused assessment with sonography for HIV-associated TB (FASH) and echinococcosis (FASE) are the only two POCUS protocols for tropical infectious diseases, which have been formally investigated and which have been implemented in routine patient care today. This review collates the available evidence for FASH and FASE, and discusses sonographic experiences reported for urinary and intestinal schistosomiasis, lymphatic filariasis, viral hemorrhagic fevers, amebic liver abscess, and visceral leishmaniasis. Potential POCUS protocols are suggested and technical as well as training aspects in the context of resource-limited settings are reviewed. Using the focused approach for tropical infectious diseases will make ultrasound diagnosis available to patients who would otherwise have very limited or no access to medical imaging.

Zoonotic helminths parasites in the digestive tract of feral dogs and cats in Guangxi, China

BACKGROUND

In Guangxi, a province of southern China, an important number of dogs and cats roam freely in rural settings, and the presence of these animals in proximity of people may represent a risk of parasitic zoonoses. The objective of the present study was to investigate the presence and identify gastrointestinal helminths in feral carnivores in Guangxi province. Therefore, post mortem examination was performed in 40 dogs and in 39 cats.

RESULTS

The Gastrointestinal helminths were found in all the necropsied dogs and in 37 out of 39 cats. Fifteen species were identified including 7 trematodes, 3 cestodes and 5 nematodes. Most of them may be responsible for zoonotic infections.

CONCLUSIONS

Major zoonotic gastrointestinal helminths, including liver and intestinal flukes, Toxocara spp., and Ancylostoma spp., are present in feral dogs and cats in Guangxi, and may represent a significant risk for public health.

Correlation between clonorchiasis incidences and climatic factors in Guangzhou, China

BACKGROUND

Human infection with Clonorchis sinensis is still a big public health problem in Guangzhou. To investigate the correlation between clonorchiasis and climatic factors, we analyzed the clonorchiasis reported cases and simultaneous meteorological data during 2006-2012 in Guangzhou City, China.

FINDINGS

Annual incidence rate of clonorchiasis from 2006 to 2012 was 166.76, 191.55, 247.37, 213.82, 246.03, 274.71, and 239.63 (per 100 000), respectively. Each 1°C rise of temperature corresponded to an increase of 1.18% (95% CI 0.88% to 1.48%) in the monthly number of cases, and a one millimeter rise of rainfall corresponded to increase of 0.03% (95% CI 0.01% to 0.04%). Whereas each one percent rise of relative humidity corresponded to a decrease in the number of cases by 1.51% (95% CI -1.75% to -1.27%).

CONCLUSIONS

We reported incidence rates of clonorchiasis showed an increasing trend by years. Temperature and rainfall were positively associated with clonorchiasis incidence, while relative humidity was inversely associated with clonorchiasis incidence. Our study provided evidence that climatic factors affect the occurrence of clonorchiasis in Guangzhou city, China.

Complete mitochondrial genome of Haplorchis taichui and comparative analysis with other trematodes

Mitochondrial genomes have been extensively studied for phylogenetic purposes and to investigate intra- and interspecific genetic variations. In recent years, numerous groups have undertaken sequencing of platyhelminth mitochondrial genomes. Haplorchis taichui (family Heterophyidae) is a trematode that infects humans and animals mainly in Asia, including the Mekong River basin. We sequenced and determined the organization of the complete mitochondrial genome of H. taichui. The mitochondrial genome is 15,130 bp long, containing 12 protein-coding genes, 2 ribosomal RNAs (rRNAs, a small and a large subunit), and 22 transfer RNAs (tRNAs). Like other trematodes, it does not encode the atp8 gene. All genes are transcribed from the same strand. The ATG initiation codon is used for 9 protein-coding genes, and GTG for the remaining 3 (nad1, nad4, and nad5). The mitochondrial genome of H. taichui has a single long non-coding region between trnE and trnG. H. taichui has evolved as being more closely related to Opisthorchiidae than other trematode groups with maximal support in the phylogenetic analysis. Our results could provide a resource for the comparative mitochondrial genome analysis of trematodes, and may yield genetic markers for molecular epidemiological investigations into intestinal flukes.

Molecular cloning and characterization of taurocyamine kinase from Clonorchis sinensis: a candidate chemotherapeutic target

Background

Adult Clonorchis sinensis lives in the bile duct and causes endemic clonorchiasis in East Asian countries. Phosphagen kinases (PK) constitute a highly conserved family of enzymes, which play a role in ATP buffering in cells, and are potential targets for chemotherapeutic agents, since variants of PK are found only in invertebrate animals, including helminthic parasites. This work is conducted to characterize a PK from C. sinensis and to address further investigation for future drug development.

Methology/Principal findings

A cDNA clone encoding a putative polypeptide of 717 amino acids was retrieved from a C. sinensis transcriptome. This polypeptide was homologous to taurocyamine kinase (TK) of the invertebrate animals and consisted of two contiguous domains. C. sinensis TK (CsTK) gene was reported and found consist of 13 exons intercalated with 12 introns. This suggested an evolutionary pathway originating from an arginine kinase gene group, and distinguished annelid TK from the general CK phylogenetic group. CsTK was found not to have a homologous counterpart in sequences analysis of its mammalian hosts from public databases. Individual domains of CsTK, as well as the whole two-domain enzyme, showed enzymatic activity and specificity toward taurocyamine substrate. Of the CsTK residues, R58, I60 and Y84 of domain 1, and H60, I63 and Y87 of domain 2 were found to participate in binding taurocyamine. CsTK expression was distributed in locomotive and reproductive organs of adult C. sinensis. Developmentally, CsTK was stably expressed in both the adult and metacercariae stages. Recombinant CsTK protein was found to have low sensitivity and specificity toward C. sinensis and platyhelminth-infected human sera on ELISA.

Conclusion

CsTK is a promising anti-C. sinensis drug target since the enzyme is found only in the C. sinensis and has a substrate specificity for taurocyamine, which is different from its mammalian counterpart, creatine.

The food-borne clonorchiasis imposes public health problems on inhabitants in endemic areas. Praziquantel has been employed as an efficacious anthelminthic in large-scale campaigns as well as for individual treatment of Clonorchis sinensis human infections. Although praziquantel continues to have good efficacy, new drug development for this parasite has been recognized as a crucial issue to be investigated intensively. Clonorchis sinensis adults generate energy through glycolysis, actively utilizing exogenous glucose, and produce a large amount of eggs each day. Taurocyamine kinase (CsTK) is distributed abundantly in the locomotive and reproductive organs, and is an important enzyme in energy generation and homeostasis in adult C. sinensis. Enzymes of the glycolytic pathway are also expressed abundantly in these organs and in tegument, implying these organs play central roles which are essential for survival and reproduction of C. sinensis. The TK enzymes, including CsTK, are found only among invertebrate organisms and have substrate specificity for taurocyamine, which are significantly different from phosphagen kinases of vertebrate animals. With these molecular biological, enzymatic, and evolutionary characteristics, we propose here that CsTK could be a target for development of chemotherapeutic agents against C. sinensis and be a biomolecular model for other human-infecting trematodes.

Accuracy of the Kato-Katz method and formalin-ether concentration technique for the diagnosis of Clonorchis sinensis, and implication for assessing drug efficacy

Background

Clonorchiasis is a chronic neglected disease caused by a liver fluke, Clonorchis sinensis. Chemotherapy is the mainstay of control and treatment efficacy is usually determined by microscopic examination of fecal samples. We assessed the diagnostic accuracy of the Kato-Katz method and the formalin-ether concentration technique (FECT) for C. sinensis diagnosis, and studied the effect of diagnostic approach on drug efficacy evaluation.

Methods

Overall, 74 individuals aged ≥18 years with a parasitological confirmed C. sinensis infection at baseline were re-examined 3 weeks after treatment. Before and after treatment, two stool samples were obtained from each participant and each sample was subjected to triplicate Kato-Katz thick smears and a single FECT examination.

Results

Thirty-eight individuals were still positive for C. sinensis according to our diagnostic ‘gold’ standard (six Kato-Katz thick smears plus two FECT). Two FECT had a significantly lower sensitivity than six Kato-Katz thick smears (44.7% versus 92.1%; p <0.001). Examination of single Kato-Katz and single FECT considerably overestimated cure rates.

Conclusions

In settings where molecular diagnostic assays are absent, multiple Kato-Katz thick smears should be examined for an accurate diagnosis of C. sinensis infection and for assessing drug efficacy against this liver fluke infection.