Cystic echinococcosis in Bulgaria 1996-2013, with emphasis on childhood infections.

The objective of this study was to determine some features of cystic echinococcosis among children and adolescents, such as epidemiology, diagnosis, organ localization, treatment, and social and environmental factors favoring transmission of the disease. The 18-year study period (1996-2013) includes officially registered primary cases treated surgically, and/or with drug therapy, and/or with the puncture, aspiration, injection, reaspiration technique. Organ localization of the cysts and the most common diagnostic procedures were studied from the patients' medical records. Groups of diseased and healthy children were surveyed to outline some of the environmental and social factors influencing morbidity. From 1996 to 2013, the average annual incidence of cystic echinococcosis in the country was 6.7 per 100,000, but with significant variations in the incidence between different age groups. The hydatid cysts in children aged 0 to 9 years may most frequently be found in the lungs, in contrast to patients from other age groups. Almost 90% of the affected children had sustained contact with dogs. At present, among the countries of the European Union, Bulgaria holds the highest incidence and prevalence of cystic echinococcosis. Childhood echinococcosis remains a serious health problem for the country. Therefore, the study of cystic echinococcosis in children has important epidemiological significance concerning the intensity of transmission.

Epidemiology and epizootology of cystic echinococcosis in Romania 1862-2007.

Infections with cestodes from genus Echinococcus are usually acquired by oral ingestion of eggs, direct contact with carriers, and contaminated food (especially vegetables) or water. Echinococcosis, previously characterized as a malady of medical importance only, depends upon veterinary solutions and faces political obstacles; it is considered the most important zoonotic disease in Romania. As a result of the increased number of human and animal cases, Romania was framed in the forefront of the European countries and among the first countries worldwide in 1995. The present paper is the first international systematized review concerning echinococcosis in Romania. It covers a period of 146 years, beginning in 1862, when the first case of human hydatid disease was mentioned in medical annals, until 2007 and aims at overviewing and analyzing data provided by major studies from different fields of human and veterinary medicine. Authors also present unpublished data of a 37-year surveillance performed in a reference infectious disease hospital. During the period 1979-1988, 8557 patients were hospitalized for hydatid disease requiring 210,057 days of health care, and 516 fatalities (6.03%) were registered. The prevalence of the disease in livestock during the period 1983-1994 varied between 24.3% and 92.9% in sheep, 31.2% and 43.6% in cattle, and 20.4% and 73.8% in swine. The economic losses in animals are very high due not only to increased mortality rates but also to weight loss and decreased productivity. Epidemiological data available showed that at least one person from 45.5% of Romanian localities underwent surgery for cystic echinococcosis. The information presented outlines the severity of the situation from human- and livestock-associated cystic echinococcosis in Romania. Control programs based on combinations of animal vaccination, dehelmintization of dogs, and education programs should be implemented to achieve effective prevention of disease transmission.

A 13th-century cystic echinococcosis from the cemetery of the monastery of Badia Pozzeveri (Lucca, Italy).

OBJECTIVE: To differentially diagnose a calcified formation recovered from a 13th century AD grave from the Tuscan monastery of Badia Pozzeveri, Lucca, Italy. MATERIALS: A calcified formation from the thoraco-abdominal region of a skeleton buried in the monastery cemetery. METHODS: Cone Beam Computed Tomography, Scanning Electron Microscope and Energy Dispersive X-Ray Spectroscopy. RESULTS: A hollow, calcified ovoid formation was identified as typical of a hydatid cyst, permitting the diagnosis of cystic echinococcosis in a 35-45year-old female. CONCLUSIONS: The study reveals the circulation of the parasite Echinococcus granulosus in the region of Lucca in late medieval Tuscany. SIGNIFICANCE: This finding is the fourth case of cystic echinococcosis from an archaeological context in Italy and provides insight into environmental conditions that appear to have affected members of a community, irrespective of social status. LIMITATIONS: Caution and the application of multiple analyses must be exercised in the differential diagnosis to discriminate among calcified formations. SUGGESTIONS FOR FURTHER RESEARCH: Analysis of stable isotopes of the calcified formation, such as 15N and 13C, in order to compare them with isotopic values of the host individual and to further confirm the parasitic origin of the find.

[Historical aspects of echinococcosis--an ancient but still relevant zoonosis]. / Historische Aspekte der Echinococcose--einer uralten, aber noch immer relevanten Zoonose.

The history of echinococcosis in Europe includes a period of over 2000 years. Already in antiquity metacestodes (hydatids) of Echinococcus granulosus, the causative agents of Cystic Echinococcosis (CE), were observed in animals and humans. Alveolar Echinococcosis (AE), caused by metacestodes of E. multilocularis, was identified as a disease entity only in the middle of the 19th century. It took about 100 years until it was undoubtedly clarified and accepted that CE and AE are not caused by a single Echinococcus species, but by E. granulosus and E. multilocularis, respectively. In the 20th century significant progress has been achieved in echinococcosis research, including diagnosis, epidemiology, therapy, immunology, molecular biology and other fields. However, CE and AE remain actual problems as in many endemic regions resources and structures are lacking for effective surveillance and control of these zoonoses threatening humans.

[A challenge to Peronism's social justice: hydatidosis in the province of Buenos Aires, 1946-1952]. / Un desafío a la justicia social peronista: la hidatidosis en la provincia de Buenos Aires, 1946-1952.

This analysis of the sanitary policies enforced in the province of Buenos Aires by Domingo Alfredo Mercante--Juan Domingo Perón's right-hand man--focuses on one of his most fascinating efforts: the eradication of hydatidosis. In exploring an issue largely forgotten by historiography, the article describes how the Mercante administration (1946-52) used statistical, socioeconomic, and symbolic legitimization to place hydatidosis on the State agenda. The administration's strategies are also pinpointed: the passing of regulatory laws against this endemic disease; the creation of specific state anti-hydatidosis institutions; the creation of space for information and for interdisciplinary, interministerial, and even supranational education aimed at achieving greater knowledge of the disease and at the exchange of experiences; and, lastly, the definition of initiatives focused on relief, treatment, and prevention in animals and people.

A possible Echinococcus granulosus calcified cyst found in a medieval adult female from the churchyard of Santo Domingo de Silos (Prádena del Rincón, Madrid, Spain).

Calcification, or mineralisation, can occur as part of a natural process, or by pathological processes. The purpose of this work is to examine an unidentified semi-spherical and perforate hollow mass, found near the pelvis of an adult female, dated 12th-13th century AD, exhumed of the Church of Santo Domingo de Silos (Prádena del Ricón, Madrid, Spain). The mass was examined by SEM and Energy Dispersive X-Ray Spectroscopy. These procedures revealed a heterogeneous inner surface with both smooth and irregular areas. A larger spherical and several smaller crescent-shaped perforations were noticed. X-ray microanalysis revealed the presence of the elements C, K, P, Ca, Al, Si, Fe, and Mg. The co-localisation of Ca and P suggests that they may be combined in a mineral matrix, likely formed in vivo. Other minerals probably came from the soil, although Fe could be related to the presence of blood. The macroscopic and microscopic appearances, chemical composition, and location of the calcified mass point to a possible hydatid cyst from Echinococcus granulosus, common in agricultural populations. This study used a suite of analytical techniques that are useful in the diagnosis of unknown calcified masses and can, therefore, be recommended for use in future analytical work.

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.

Control of cystic echinococcosis/hydatidosis: 1863-2002.

Echinococcosis/hydatidosis, caused by Echinococcus granulosus, is a chronic and debilitating zoonotic larval cestode infection in humans, which is principally transmitted between dogs and domestic livestock, particularly sheep. Human hydatid disease occurs in almost all pastoral communities and rangeland areas of the underdeveloped and developed world. Control programmes against hydatidosis have been implemented in several endemic countries, states, provinces, districts or regions to reduce or eliminate cystic echinococcosis (CE) as a public health problem. This review assesses the impact of 13 of the hydatid control programmes implemented, since the first was introduced in Iceland in 1863. Five island-based control programmes (Iceland, New Zealand, Tasmania, Falklands and Cyprus) resulted, over various intervention periods (from <15 to >50 years), in successful control of transmission as evidenced by major reduction in incidence rates of human CE, and prevalence levels in sheep and dogs. By 2002, two countries, Iceland and New Zealand, and one island-state, Tasmania, had already declared that hydatid disease had been eliminated from their territories. Other hydatid programmes implemented in South America (Argentina, Chile, Uruguay), in Europe (mid-Wales, Sardinia) and in East Africa (northwest Kenya), showed varying degrees of success, but some were considered as having failed. Reasons for the eventual success of certain hydatid control programmes and the problems encountered in others are analysed and discussed, and recommendations for likely optimal approaches considered. The application of new control tools, including use of a hydatid vaccine, are also considered.

Vaccines against cysticercosis and hydatidosis: foundations in taeniid cestode immunology.

Recombinant oncosphere antigens have been used in the development of effective vaccines for the prevention of cysticercosis caused by Taenia ovis, Taenia saginata, Taenia solium and hydatid disease caused by Echinococcus granulosus. These vaccines were developed utilizing information gathered from numerous researchers over some 60 years which had established many of the principals concerning immunity to taeniid cestodes in their intermediate hosts. Australian scientists, or scientists with close Australian connections, made seminal early contributions to the understanding of cestode immunology that provided the foundations for more recent application of recombinant DNA methods and the development of practical vaccines. Here, some particular contributions to the field are highlighted from Drs. Michael Gemmell, Michael Rickard, David Heath and Graham Mitchell together with a précis of the recent progress in vaccine development, particularly for prevention of cysticercosis due to T. solium.

Australasian contributions to an understanding of the epidemiology and control of hydatid disease caused by Echinococcus granulosus--past, present and future.

For several years after Echinococcus granulosus was introduced into Australasia from Europe, its life cycle was unknown. Before the end of the 19th century, however, Cystic Hydatid Disease (CHD) was recognized in humans as an important cause of death, although its magnitude was not quantified. During the first 50 years of the 20th century, the urban component declined, but CHD remained a serious source of ill-health. During the second half of the 20th century major research contributions have included: (i) differentiation of pastoral from wildlife Echinococcus and (ii) breaking the 'epidemiological code' of the family Taeniidae, thereby defining the conditions under which transmission occurs. Based on this research and concurrent surveys, it is concluded that the present geographical distribution of E. granulosus in domestic animals and CHD in the rural population is determined by climate; being uncommon where hot dry seasons continue beyond a few months. The parasite's range may be extended in its wildlife cycle through a highly susceptible definitive host--the dingo. The ease with which blowflies transfer taeniid eggs from dog faeces to animal and human foodstuffs implies that in Australasia, CHD can sometimes be regarded as foodborne. A perceived decline in autochthonus cases in the rural community during the second half of the 20th century may be accounted for by increased standards of living generated by economic advancement. Where a decline has not occurred or incidence is unusually high, CHD may be acting as an indicator of social disadvantage. Field trials and control programmes demonstrated that pastoral echinococcosis readily responded to intervention. Indeed, in both New Zealand and Tasmania, using different administrative structures and methods of funding, E. granulosus was driven from endemic towards extinction status. The really convincing result was the rapid decline in CHD in all age groups. The problem still to be solved is to identify methods for eliminating foci where high levels of CHD still exist but, continent- or even state-wide intervention may not be considered to be cost-effective using current tools. Here, mathematical modelling and cost-benefit analysis can be regarded as powerful methods to assist the decision-making process.

An evolving pattern of human hydatid disease transmission in the United States.

Echinococcus granulosus infection was being acquired in the contiguous United States by Virginia sharecroppers and small-holders by the turn of the century. The last recorded human infection from that general area was diagnosed in 1947. By 1920 human infections were also being acquired in the lower Mississippi valley. Apparently, infection in both of these areas was maintained chiefly in swine. By 1940 a third transmission area definitely existed in the Central Valley of California, with its reservoir intermediate host sheep. Seemingly, infection has been disseminated from these California foci into Utah and more recently into northern New Mexico and Arizona. Human populations now at unusual risk in the western United States are transhumant sheep ranchers, including Basque-Americans in California, Mormons in central Utah, and Navajo and Zuni Indians in New Mexico and Arizona. Conditions highly favorable to E. granulosus transmission, intensification and spread now exist throughout relatively large areas of the American West.

Past to present: echinococcosis in Turkey.

Echinococcosis is a zoonotic infection caused by Echinococcus spp. and is one of the most important helminthic diseases worldwide. Two forms of echinococcosis occur in Turkey, i.e. Echinococcus granulosus and E. multilocularis. The life cycle of E. granulosus is predominantly in dogs and sheep, and most sheep farmers in Turkey keep a dog or two. Stray dogs are numerous and prevention or treatment of infection in these dogs is very difficult. Cystic echinococcosis (CE) occurs throughout Turkey whereas alveolar echinococcosis (AE) predominantly occurs in the eastern Anatolian region of the country. Both CE and AE are known to be endemic but few surveys have been performed. Most data on human CE and AE have been collected from hospital records. The first reference of echinococcosis, "Kyste hydatique multiloculaire", in Turkey dates as far back to 1872 by an Ottoman Physician, C.R. Katibian. The results of the first Turkish study on E. granulosus were published in 1928. According to Ministry of Health records, 21303 patients had operations to treat or confirm CE in the period 1987-1994 which corresponds to approximately 2663 patients per year. The estimated surgical case rate of CE is 0.87-6.6 per 100000 in Turkey. The prevalence of E. granulosus infection in dogs in Turkey is between 0.32 and 40% and varies widely with geographical location. The reported prevalence of CE in domestic animals in Turkey has ranged from 11.2 to 50.7% and has varied widely with geographical location. Although no detailed information has been published on AE in domestic and wild animals in Turkey, the main definitive and intermediate hosts of E. multilocularis are assumed to be rodents and red foxes, respectively. However, there has been only a single published report of E. multilocularis in a wild animal (fox) in the northwest in 1965 by Merdivenci. The first human case of AE in Turkey was reported by Mutlu in 1939, and total cumulative reported case number is 202 between 1980 and 1998.

Human cystic echinococcosis in Sardinia during the 20th century.

At the beginning of the 20th century in Sardinia human Cystic Echinococcosis was considered a highly endemic disease by all the health operators. In the early twenties the number of reported cases was 429, but incidence appeared rising due to increase in availability of data and to improvements in diagnosis. The fall of personal and public hygienic conditions together with the drift from urban to rural areas during the second world war, had in fact facilitated the possibilities of infection, causing a strong growth of surgical cases during the post war years, so that incidence rate remains high and almost unvaried until the end of the eighties. Comparative analysis of young and probably old cysts indicates that this high rate of surgical cases was attributable to treated hepatic cysts in elderly. On the contrary the continuous reduction in the number of young cysts clearly shows a slow but constant decrease of the infection rate.

[Parasitoses and development: malaria and echinococcosis]. / Parassitosi e sviluppo: la malaria e l'echinococcosi.

After having placed emphasis on the cyclic oscillations characterizing the interest of the scientific and political world for parasitology, the author analyzes the various standpoints from which parasitic diseases, and above all malaria, have been dealt with ever since the beginning of this century. Specific criticism is addressed to the military model, which has provided the basis for many eradication campaigns. The author also analyzes the "vicious circle theory", which labelled the activity of the WHO in its first decade of life, and which assumed that breaking the disease and underdevelopment circle was possible by acting mainly or even exclusively on endemic and debilitating diseases. Both these models were tested with success in Sardinia with the 1947-49 antimalaria campaign. However, socio-economic development of the island did not occur as expected, and attempts to export the same approaches to other parts of the world soon disclosed their limitations, leading to major failures. The experience on the fight against echinococcosis is subsequently examined. The conclusions drawn are that many successes may be obtained through a systemic rather than a sectorial approach; and that a "conflicting cohabitation" with diseases is foreseen as a long-lasting reality, and must thus be controlled with the appropriate means.

Cystic echinococcosis in Italy from the 1950s to present.

In Italy the epidemiological pattern of cistic echinococcosis (CE) is incomplete and the information for most regions is out of date, contradictory, and almost exclusively limited to the intermediate hosts. The disease is found most frequently in particular social and economic conditions: widespread use of extensive or semi-extensive sheep farming, illegal slaughtering, and high numbers of sheepdogs and other types of dogs. The highest incidence in sheep is found in Sardinia (70.6-92.8%), Sicily (6.5-36.5%), Basilicata (5-28%), Abruzzo (22%) and Tuscany (47%). It North Italy, it is never higher than 0.5% in slaughtered sheep. No data are available on the biomolecular characterization of the strains of E. granulosus in Italy, apart from Sardinia and recently Lazio. G1 (Sheep strain), G7 (Pig strain) G2 (Tasmanian sheep strain) have been identified in Sardinia and G1 and G3 (Buffalo strain) have been recently isolated in Lazio. In Italy, CE has was also found in buffaloes (2.63-9.8%) and horses (<1%). However, further epidemiological surveys and genotyping study are necessary. The small quantity of up to date information on the diffusion of E. granulosus in dogs (Abruzzo 4%, Sardinia 6-10% and Sicily 19.3%) highlights the need for modern, fast, sensitive and low risk diagnostic methods which would provide a true picture of the pattern of the infection in this host.

Samuel Charles Fitzpatrick.

Samuel Fitzpatrick, MBE, CBE, was an outstanding general practitioner and surgeon in the Western District of Victoria for 50 years. He became a world authority on the surgical management of hydatid disease. He is also an accomplished and prolific painter, especially in watercolours. Many of his works are displayed in the Hamilton Art Gallery, Victoria.

[Cystic hydatidosis--its occurrence and prevention in Japan].

The history of cystic hydatidosis (CH) in Japan is reviewed on the basis of case reports and other references during the period from 1881 to 2003. A total of 76 cases were identified as CH patients in Japan of which 47 were reported prior to 1945 and 29 thereafter. The occurrence was divided into 2 stages before and after the Slaughterhouse Act that was brought into force in 1906. The presence of endemic foci of CH was suggested before the Act was introduced in Japan, especially in southwestern prefectures, and the development of cattle breeding and unsanitary small slaughterhouses in the areas were thought to be cause. Japan emphasized cattle as a dietary protein source and also for various military accouterments such as shoes and rucksacks for soldiers. China was a transit port to Japan from Europe and also a big endemic area of CH. Japan had sent a huge number of soldiers and citizens to China in the Japanese-Sino and Japanese-Russian War and a number of cattle, pet dogs and people have also came to Japan from China. After enforcement of the Slaughterhouse Act in 1906, the number of CH cases decreased dramatically, and only 2 cases were reported for the 30 years between 1920 and 1950 in Japan. The situation regarding CH in Japan thus suggested the existence of endemic foci in southwestern prefectures, although direct evidence was lacking because no one had found E. granulosus in dogs of the area. Almost all of the patients recently presenting with CH appear to have been infected in overseas endemic countries. The available information strongly suggest that sanitary control of slaughterhouses is essential for preventing CH in endemic areas. Diagnostic laboratory examinations and appropriate medical intervention are clearly important. An animal quarantine system against echinococcal infestation of pet dogs should also be established urgently in Japan, because hundreds of pet dogs are being imported annually from endemic countries in Europe and Asia.

[Life and work of Dr. Bozo Pericic (1865-1947), genius of our medicine]. / Zivot i djelo Dr. Boze Pericica (1865-1947), velikana nase medicine.

The paper describes the life and work of on of our most distinguished physicians--Dr Bozo Pericic. Togheter with another young physician Dr Nikola Lalic the Sibenik hospital became a sort of Meca for medical people. Dr Pericic succeded to clarify an unknown disease--so called "Skrljevo disease", paved the path of to the knowledge about achinococcus etc. He published also number of valuable medical articles and books and avarded a number af aknowledgements. One of the biggest was his nomination for membership of the Supreme Haelth Council in Wienna. He contributed e lot to the medical journals, especially to the "Physician's Journal". As person of wide culture, famous linguist and polyglot Dr Pericic published the "Medical dictionary of Croatian and German Language". He lay foundation of the craniology, quite a new branch of arheology at the time. His accounts of travels, reviews on famous writers, translation of Hamlet, etc--are valuable literary works.