[LIVER CYSTIC ECHINOCOCCOSIS LAPAROSCOPIC TREATMENT EFFECTIVENESS].

The main goal of the research was to study echinococcosis liver cyst laparoscopic treatment's effectiveness. The retrospective analysis of liver echinococcosis cyst surgical treatment in the period from 2003 to 2013 years was conducted. 348 patients underwent surgical treatment, among them 283 patients - laparoscopic procedure, 65 - open surgery. Medial age was 42,3±7,9 years. Female - 214, male - 134. 249 patients underwent laparoscopic partial (conservative) cystectomy, 34 - laparoscopic radical cystectomy with liver resection, 3 (1%) - conversion. 47 patients underwent partial (conservative) cystectomy using open approach. 18 - radical cystectomy using either typical or atypical hemihepatectomy. A long term analysis of 226 (79,8%) patients in a period from 6 month to 7 years was conducted. Comparison of the results revealed the advantage of laparoscopic operations. It was manifested in less blood loss, duration of the procedure, pain syndrome, and a smaller number of bed-days. Infections of the residual cavity after open surgery were twice as much comparing to ones after laparoscopic surgery. Complications after open surgery were significantly higher than after laparoscopic procedures due to postoperative wound infections. After open surgery frequency of echinococcosis recurrence was higher than after laparoscopic one (8,5% vs 2,5%) (р<0,05). Nowadays it is possible to say that treatment of choice of noncomplicated liver echinococceal cysts is laparoscopic one. Correctly made laparoscopical procedure has a good long term results, few postoperative compications, less frequent recurrences and the excellent cosmetic effect. From the principles of radical surgical treatment's point of view laparoscopic approach is the same as an open surgery.

Simulating control of a focal wildlife outbreak of Echinococcus multilocularis.

The parasitic tapeworm Echinococcus multilocularis is the causative agent of alveolar echinococcosis, a serious zoonotic infection present in Europe that can be fatal. The United Kingdom currently has E. multilocularis free status but the possibility of introduction exists, most likely via an imported or returning dog or other deliberately introduced animal that has not had anthelmintic treatment. We have developed a model to predict the probability of successfully eliminating a focal outbreak of E. multilocularis using a programme of anthelmintic bait distribution. We investigated three different potential control programmes, each with 36 monthly campaigns commencing five, ten or 15 years after disease introduction over an area of 2827km2. We assumed equilibrium disease prevalence of 30%, 40% and 55% based on the range of values reported across Europe. However, for all of these scenarios, equilibrium had not been reached at five to 15 years after introduction and simulated local prevalence values were between 0.5% and 28%. We found that it is possible to eliminate the disease with a 38%-86% success rate if control is started five years after introduction, dropping to 0% to 56% if control is delayed until 15 years after introduction, depending upon the prevalence equilibrium. We have also estimated the costs involved in these programmes to be from €7 to €12 million (2013 prices).

Echinococcosis: Control and Prevention.

Human cystic echinococcosis (CE) has been eliminated or significantly reduced as a public health problem in several previously highly endemic regions. This has been achieved by the long-term application of prevention and control measures primarily targeted to deworming dogs, health education, meat inspection, and effective surveillance in livestock and human populations. Human CE, however, remains a serious neglected zoonotic disease in many resource-poor pastoral regions. The incidence of human alveolar echinococcosis (AE) has increased in continental Europe and is a major public health problem in parts of Eurasia. Better understanding of wildlife ecology for fox and small mammal hosts has enabled targeted anthelmintic baiting of fox populations and development of spatially explicit models to predict population dynamics for key intermediate host species and human AE risk in endemic landscapes. Challenges that remain for echinococcosis control include effective intervention in resource-poor communities, better availability of surveillance tools, optimal application of livestock vaccination, and management and ecology of dog and wildlife host populations.

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

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

Public Health Follow-up of Suspected Exposure to Echinococcus multilocularis in Southwestern Ontario.

In the 3 years since the first report of canine alveolar echinococcosis (AE) in Ontario, three additional cases have been diagnosed in the province. Of the four cases reported to date, three have had no known history of travel outside the province. It is possible that this development is an indication of previously unrecognized environmental contamination with Echinococcus multilocularis eggs in some areas of the province. If so, there is the potential for an emerging threat to human health. This article describes a local public health department's investigation of the possible exposure to E. multilocularis of a number of individuals who had had contact with the latest of the four cases of canine AE, and summarizes a comprehensive decision process that can be used by public health departments to assist in the follow-up of such exposures.

[ULTRASOUND MONITORING FEATURES OF POSTOPERATIVE HEPATIC ECHINOCOCCOSIS].

The aim of the study was to investigate ultrasound features (US) of liver after post operative anti-parasite recurrence treatment of patients with echinococcosis. The clinical analyses of 50 patients were carried out. It was concluded that the use of ultrasound can provide valuable data to the clinician to assess and monitor anti parasitic therapy echinococcosis of liver in post operative period. During the monitoring the positive dynamics of disease was observed in 94,5% of cases, in 5% оf cases toxic hepatites with septic complication was diagnosed, and in 0,5% of cases the disease recurrence was revealed. Ultrasound semiotics of liver after post operative anti-parasite recurrence treatment of patients with echinococcosis was presented. Control and monitoring of patients in the postoperative period echinococcosis with appropriate antirelapse antiparasitic therapy should be held not less than 1-5 years.

Alveolar echinococcosis: how knowledgeable are primary care physicians and pharmacists in the Franche-Comté region of France?

BACKGROUND: Alveolar echinococcosis (AE) is a parasitic disease resulting from the intrahepatic growth of Echinococcus multilocularis larva. This zoonotic helminthic disease is rare but, if left untreated or treated too late, can be severe or even fatal. In France, endemic areas containing infected foxes have become larger, spreading towards western regions of the country and leading to an increased risk of environmental contamination. An observational survey was undertaken in 2014 to assess the level of knowledge of AE among primary care physicians (PCPs) and pharmacists in the Franche-Comté region. METHODS: Standardized questionnaires were sent to a random sample of 183 PCPs and 236 pharmacists practicing in the Franche-Comté region (eastern France), requesting their voluntary and anonymous participation. The questionnaires collected socio-demographic details, self-evaluation and asked multiple choice questions (MCQs) about epidemiology, prevention, diagnosis and management of AE. RESULTS: The crude response rate was 37.5% of the PCPs and pharmacists questioned. Responses to MCQs showed that most of the participating PCPs and pharmacists had acceptable basic knowledge of AE, especially concerning epidemiology and prevention of the disease. However, a serious lack of knowledge was observed concerning the management of AE. CONCLUSION: PCPs are often the first health professionals to suspect latent AE, which is still a rural disease in France. Both PCPs and pharmacists play an important role in informing and referring patients potentially exposed to AE. This study shows that although AE is rare, PCPs and pharmacists of the Franche-Comté region have a satisfactory level of knowledge of AE.

Threat of alveolar echinococcosis to public health--a challenge for Europe.

Alveolar echinococcosis (AE) is a neglected 'malignant' parasitic disease. The European endemic area of Echinococcus multilocularis in foxes is larger than previously anticipated, and there is new evidence that both fox populations and the prevalence of E. multilocularis have increased in many areas, indicating increased pressure for infection with E. multilocularis eggs in intermediate and accidental hosts, including humans. This may result in more human AE cases within the next decades. Current numbers of both immunocompetent and immunocompromised AE patients, and the anticipated future increase, call for scaling-up research to rapidly improve the development and implementation of prevention measures, early diagnosis, and curative treatment of human AE.

Prevention and Immunotherapy of Secondary Murine Alveolar Echinococcosis Employing Recombinant EmP29 Antigen.

Alveolar echinococcosis (AE) is caused by infection with the larval stage of the tapeworm Echinococcus multilocularis. An increasing understanding of immunological events that account for the metacestode survival in human and murine AE infection prompted us to undertake explorative experiments tackling the potential of novel preventive and/or immunotherapeutic measures. In this study, the immunoprotective and immunotherapeutic ability of recombinant EmP29 antigen (rEmP29) was assessed in mice that were intraperitoneally infected with E. multilocularis metacestodes. For vaccination, three intraperitoneal injections with 20µg rEmP29 emulsified in saponin adjuvants were applied over 6 weeks. 2 weeks after the last boost, mice were infected, and at 90 days post-infection, rEmP29-vaccinated mice exhibited a median parasite weight that was reduced by 75% and 59% when compared to NaCl- or saponin-treated control mice, respectively. For immunotherapeutical application, the rEmP29 (20µg) vaccine was administered to experimentally infected mice, starting at 1 month post-infection, three times with 2 weeks intervals. Mice undergoing rEmP29 immunotherapy exhibited a median parasite load that was reduced by 53% and 49% when compared to NaCl- and saponin-treated control mice, respectively. Upon analysis of spleen cells, both, vaccination and treatment with rEmP29, resulted in low ratios of Th2/Th1 (IL-4/IFN-γ) cytokine mRNA and low levels of mRNA coding for IL-10 and IL-2. These results suggest that reduction of the immunosuppressive environment takes place in vaccinated as well as immunotreated mice, and a shift towards a Th1 type of immune response may be responsible for the observed increased restriction of parasite growth. The present study provides the first evidence that active immunotherapy may present a sustainable route for the control of AE.

Epidemiology and control of echinococcosis in central Asia, with particular reference to the People's Republic of China.

At least 270 million people (58% of the total population) are at risk of cystic echinococcosis (CE) in Central Asia including areas of Mongolia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, Afghanistan, Iran, Pakistan and western China. The annual surgical incidence rate in Uzbekistan and Tadjikistan has been estimated to be as high as 25-27 cases/100,000 with the highest prevalence reaching 10% (range from 0.8 to 11.9%) in some Tibetan communities in western China. Echinococcus transmission in the region is largely associated with social factors including limited community knowledge of echinococcosis, small-scale household animal production, home killing of livestock, and the feeding of dogs with uncooked offal. Alveolar echinococcosis (AE) is also endemic in Central Asia and is recognized as a major problem in some Tibetan communities with up to 6% of villagers infected in some villages. In western China, 5-30% of the population are seropositive against E. granulosus antigens, indicating that a large number of individuals have been exposed to the parasite. Although echinococcosis control programs have been initiated in some countries in Central Asia, control efforts are generally fragmented and uncoordinated. Monthly deworming of dogs with praziquantel (PZQ), as a key measure to control the Echinococcus parasites, has been used in western China. However, the approach has proven difficult in local semi-nomadic communities. Additional control measures including health education, domestic livestock animal treatment/vaccination and dog vaccination are needed in CE-endemic areas to accelerate progress.

[Reduction of the recurrences and postoperative complications in surgical treatment of hepatic echinococcosis].

Results of examination and treatment of 326 patients, suffering hepatic echinococcosis, in whom 449 surgical interventions were performed, were analyzed. In 123 of them the disease recurrence was diagnosed, and laparoscopic, laparotomy and puncture interventions were applied. Conduction of active screening examination of population in the regions, endemic for echinococcosis, application of effective intraoperative methods for prophylaxis of abdominal dissemination of invasive material, usage of antiparasitic chemical and thermal processing of cystic contents and its walls, left after echinococcectomy performance, postoperative prophylactic application of antiparasitic medicinal therapy have had permitted to lower the hepatic echinococcosis recurrence rate (down to 1.3% in last 5 yrs).

Radical versus conservative surgical treatment of liver hydatid cysts.

BACKGROUND: The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts. METHODS: Data from all patients with liver hydatid cyst treated in a hepatobiliary surgical unit, between January 1990 and December 2010, were retrieved from a retrospective database. To minimize selection bias, propensity score matching was performed, based on 17 variables representing patient characteristics and operative risk factors. The primary outcome measure was hydatid cyst recurrence. RESULTS: One hundred and seventy patients were matched successfully, representing 85 pairs who had either a radical or a conservative approach to surgery. At a median (i.q.r.) follow-up of 106 (59­135) and 87 (45­126) months in the radical and conservative groups respectively, the recurrence rate was 4 per cent in both groups (odds ratio (OR) 1.00, 95 per cent confidence interval 0.19 to 5.10). There were no statistically significant differences between conservative and radical surgery in terms of operative mortality (1 versus 0 per cent; P=0.497), deep abdominal complications (12 versus 16 per cent; OR 1.46, 0.46 to 3.49), overall postoperative complications (15 versus 19 per cent; OR 1.28, 0.57 to 2.86), reinterventions (0 versus 4 per cent; P=0.246) and median hospital stay (7 (i.q.r. 5­12) days in both groups; P=0.220). CONCLUSION: This study could not demonstrate that radical surgery reduces recurrence and no trend towards such a reduction was observed.

Characterization of a surface glycoprotein from Echinococcus multilocularis and its mucosal vaccine potential in dogs.

Alveolar echinococcosis is a refractory disease caused by the metacestode stage of Echinococcus multilocularis. The life cycle of this parasite is maintained primarily between foxes and many species of rodents; thus, dogs are thought to be a minor definitive host except in some endemic areas. However, dogs are highly susceptible to E. multilocularis infection. Because of the close contact between dogs and humans, infection of dogs with this parasite can be an important risk to human health. Therefore, new measures and tools to control and prevent parasite transmission required. Using 2-dimensional electrophoresis followed by western blot (2D-WB) analysis, a large glycoprotein component of protoscoleces was identified based on reactivity to intestinal IgA in dogs experimentally infected with E. multilocularis. This component, designated SRf1, was purified by gel filtration using a Superose 6 column. Glycosylation analysis and immunostaining revealed that SRf1 could be distinguished from Em2, a major mucin-type antigen of E. multilocularis. Dogs (n=6) were immunized intranasally with 500 µg of SRf1 with cholera toxin subunit B by using a spray syringe, and a booster was given orally using an enteric capsule containing 15 mg of the same antigen. As a result, dogs immunized with this antigen showed an 87.6% reduction in worm numbers compared to control dogs (n=5) who received only PBS administration. A weak serum antibody response was observed in SRf1-immunized dogs, but there was no correlation between antibody response and worm number. We demonstrated for the first time that mucosal immunization using SRf1, a glycoprotein component newly isolated from E. multilocularis protoscoleces, induced a protection response to E. multilocularis infection in dogs. Thus, our data indicated that mucosal immunization using surface antigens will be an important tool to facilitate the development of practical vaccines for definitive hosts.

Pilot field trial of the EG95 vaccine against ovine cystic echinococcosis in Rio Negro, Argentina: early impact and preliminary data.

Cystic echinococcosis is endemic in the Rio Negro province of Argentina. After 30 years of control using praziquantel in dogs the transmission rate to humans and sheep has decreased significantly, however transmission persists. The objective of the study is to assess the impact of the inclusion of the EG95 vaccine for sheep in the control programme, including analysis of the vaccine's operative feasibility in field conditions. The vaccine was applied in an area comprising four communities of native people including 79 farms with 3146 lambs and 311 dogs in total. Seventy one farms were designated as control areas where no vaccinations were undertaken while vaccinations of lambs undertaken on 91 farms. Lambs received two vaccinations with the EG95 vaccine followed by a single booster injection when the animals were 1-1.5 years of age. Farm locations were defined using GPS coordinates for the houses. Evidence for Echinococcus granulosus transmission was monitored by coproantigen ELISA on samples of dog faeces, by E. granulosus-specific PCR using soil samples, and anti-E. granulosus antibody assessments in sera from 2 to 4 teeth lambs, purgation of dogs to detect E. granulosus worms and necropsy on adult sheep. Before the vaccine was introduced, 26.2% of sheep with 2-4 teeth were positive using ELISA/WB, the prevalence decreased to 7.8% at the third year following use of the vaccine. Necropsy of animals older than 6 years (not vaccinated) showed that 66.1% of animals were infected with E. granulosus. In dogs, 4% was found positive for E. granulosus using arecoline purgation and 24.7% of the farms were infected using coproELISA/WB. During the first year of vaccination 2721 lambs received the first vaccine dose and 2448 received a booster. In the second year 2138 lambs were initially vaccinated and 1745 received a booster, and 1308 animals received the third dose. During the third year 1110 lambs received the first dose from which 539 received a booster and 723 animals received the third dose. An analysis of advantages and limitations of the diagnostic techniques used and the ability of the geospatial analysis to detect risk area are included. Based in the immunodiagnostic techniques, the EG95 vaccine has been able to prevent the infection in animals up to 3 years old. Also, the difficulties in the field for the correct vaccine administration and the social features and habits that may impact on echinococcosis control are included in the analysis.

Fox baiting against Echinococcus multilocularis: contrasted achievements among two medium size cities.

In Europe, most cities are currently colonized by red foxes (Vulpes vulpes), which are considered to be the main definitive host of the zoonotic cestode Echinococcus multilocularis. The risk of transmission to humans is of particular concern where high fox populations overlap with high human populations. The distribution of baits containing praziquantel has successfully reduced the infection pressure in rural areas and in small plots within large cities. The purpose of this study was to assess its efficiency in two medium size cities (less than 100,000 inhabitants) in areas of high human alveolar echinococcosis incidence. From August 2006 to March 2009, 14 baiting campaigns of praziquantel treatment were run in Annemasse and Pontarlier (Eastern France), each of which encompassed 33 km(2), with a density of 40 baits/km(2). The bait consumption appeared to be lower in strictly urban context compared to suburban areas (78.9% vs. 93.4%) and lower in Annemasse than in Pontarlier (82.2% vs. 89.5%). During our study, the prevalence of E. multilocularis, as assessed by EM-ELISA on fox faeces collected in the field in Annemasse, was lower within the treated area than in the rural control area. A "before/during" treatment comparison revealed a significant decrease of spring prevalence from 13.3% to 2.2%. No significant change in prevalence was detected in Pontarlier (stable prevalence: 9.1%) where the contamination of the treated area followed the temporal trend observed in the control area. There, a greater resilience of the parasite's life cycle, probably due to a strong pressure of recontamination from outside the treated area, may have counteracted the prophylaxis treatment. These contrasted outcomes suggest that the frequency of fox anthelmintic treatment should be adapted to the local situation.

A pilot study on developing mucosal vaccine against alveolar echinococcosis (AE) using recombinant tetraspanin 3: Vaccine efficacy and immunology.

BACKGROUND: We have previously evaluated the vaccine efficacies of seven tetraspanins of Echinococcus multilocularis (Em-TSP1-7) against alveolar echinococcosis (AE) by subcutaneous (s.c.) administration with Freund's adjuvant. Over 85% of liver cyst lesion number reductions (CLNR) were achieved by recombinant Em-TSP1 (rEm-TSP1) and -TSP3 (rEm-TSP3). However, to develop an efficient and safe human vaccine, the efficacy of TSP mucosal vaccines must be thoroughly evaluated. METHODOLOGY/PRINCIPAL FINDINGS: rEm-TSP1 and -TSP3 along with nontoxic CpG ODN (CpG oligodeoxynucleotides) adjuvant were intranasally (i.n.) immunized to BALB/c mice and their vaccine efficacies were evaluated by counting liver CLNR (experiment I). 37.1% (p < 0.05) and 62.1% (p < 0.001) of CLNR were achieved by these two proteins, respectively. To study the protection-associated immune responses induced by rEm-TSP3 via different immunization routes (i.n. administration with CpG or s.c. immunization with Freund's adjuvant), the systemic and mucosal antibody responses were detected by ELISA (experiment II). S.c. and i.n. administration of rEm-TSP3 achieved 81.9% (p < 0.001) and 62.8% (p < 0.01) CLNR in the liver, respectively. Both the immunization routes evoked strong serum IgG, IgG1 and IgG2α responses; i.n. immunization induced significantly higher IgA responses in nasal cavity and intestine compared with s.c. immunization (p < 0.001). Both immunization routes induced extremely strong liver IgA antibody responses (p < 0.001). The Th1 and Th2 cell responses were assessed by examining the IgG1/IgG2α ratio at two and three weeks post-immunization. S.c. immunization resulted in a reduction in the IgG1/IgG2α ratio (Th1 tendency), whereas i.n. immunization caused a shift from Th1 to Th2. Moreover, immunohistochemistry showed that Em-TSP1 and -TSP3 were extensively located on the surface of E. multilocularis cysts, protoscoleces and adult worms with additional expression of Em-TSP3 in the inner part of protoscoleces and oncospheres. CONCLUSIONS: Our study indicated that i.n. administration of rEm-TSP3 with CpG is able to induce both systemic and local immune responses and thus provides significant protection against AE.

Ambispective comparative study of two surgical strategies for liver hydatidosis.

AIM: To investigate the morbidity, mortality, recurrence and technical aspects of two distinct surgical strategies that were implemented in successive periods. METHODS: Ninty-two patients with 113 cysts underwent surgical procedures. The study was divided into 2 periods. Data from first period (P1) were compiled retrospectively. The surgical strategy was conservative surgery. The second period (P2) included a prospective study conducted according to a protocol following the criterion that radical procedures should be performed whenever it is technically feasible. RESULTS: Patients of both periods showed no statistically significant differences in age, gender, cyst location or mortality. Among the P2 group, patients exhibited more preoperative jaundice, and cyst size was smaller (P < 0.05). Changes in surgical strategy increased the rate of radical surgery, decreases morbidity and in-hospital stay (P < 0.001). A negative result in P2 was the death of two old patients (4.8%) who had undergone conservative treatments. The rate of radical surgery in P2 was around 75%. CONCLUSION: Radical surgery should be the technique of choice whenever it is feasible, because it diminishes morbidity and in-hospital stay. Conservative surgery must be employed only in selected cases.

Hidatidosis poliquística autóctona en dos pacientes Yanomami en el Alto Orinoco, Amazonas, Venezuela / Polycystic hydatid disease in two patients indigenous Yanomami in the Upper Orinoco, Amazonas, Venezuela

La infección por Echinococcus sp. es hipoendémica en Venezuela. Sólo cuatro casos de hidatidosis autóctona por E. vogeli han sido reportados, tres de ellos en la región de la Guayana venezolana. En Febrero del año 2009 se realizó el diagnóstico clínico-sero-epidemiológico de hidatidosis poliquística en una paciente femenina de la etnia Yanomami, procedente de Parima B, Alto Orinoco, en la Amazonía venezolana. Se resolvió con tratamiento médico y quirúrgico por laparoscopia y se evidenció en el quiste la presencia de ganchos rostelares compatibles con E. vogeli. En Abril del 2009 en una segunda paciente Yanomami de igual procedencia, se le diagnosticó hidatidosis por E. vogeli siendo operada exitosamente por cirugía laparoscópica asistida por robot. Dos casos humanos en una misma población y la presencia de factores de riesgo como la tenencia de perros domésticos y la comunicación por informantes indígenas del hallazgo de quistes en hígados de animales de cacería (Cuniculus paca o lapa y Dasyprocta sp. o picure), hacen pensar en transmisión activa en la cuenca del Alto Orinoco y en zonas selváticas de la Guayana venezolana. El presente, es el primer registro de casos de hidatidosis poliquística en indígenas de la etnia Yanomami.

Infection by Echinococcus sp. is hypoendemic in Venezuela. Only four cases of autochthonous E. vogeli hydatidosis have been reported, including three in the Venezuelan region of Guayana. In February 2009, based on epidemiological data, signs and symptoms and serological tests, a female patient of the Yanomami ethnic group, was diagnosed with a polycystic hydatid disease in Parima B, Alto Orinoco, in the Venezuelan Amazon. Rostellar hooks compatible with E. vogeli were found in the cyst. It was resolved with medical and surgical treatment by laparoscopy. A second Yanomami patient from the same location was diagnosed with E. vogeli hydatidosis in April 2009, being successfully operated with robot-assisted laparoscopy. Two human cases in the same population and the presence of risk factors such as domestic dog ownership and findings of cysts in livers of hunted animals (such as Cuniculus and Dasyprocta sp.) reported by indigenous informants, suggest active transmission in the Upper Orinoco basin and forested areas of the Venezuelan Guayana. These are the first reported cases of polycystic hydatid disease of the Yanomami ethnic group.

Disease awareness and knowledge in caregivers of children who had surgery for cystic hydatid disease in Lima, Peru.

Cystic hydatid disease (CHD) is a common cause of lung and liver disease worldwide. Despite Peru being highly endemic, information about the level of knowledge is scarce and poor. A telephone survey was applied to assess the knowledge in the caregivers of patients treated for CHD at a paediatric hospital at Lima, Peru. Of the 26 contacted families, only 5 (20%) answered correctly all seven questions. A higher education degree was associated with correct answers (P = 0.002). Most respondents (17, 65%) incorrectly identified the etiologic agent and mode of transmission. Lact of knowledge is likely a major contributor to maintain the endemicity of disease in Peru.