Combating Taenia solium cysticercosis in Southeast Asia an opportunity for improving human health and livestock production.

Cysticercosis caused by the zoonotic pork tapeworm Taenia solium is emerging as a constraint for the nutritional and economic well-being of small-holder farming communities in many underdeveloped areas of Southeast Asia. It occurs mainly in impoverished regions with inadequate sanitation, poor pig management practices and lack of meat inspection and control. Neurocysticercosis, the most serious form of the disease, is considered the most common parasitic infection of the human nervous system and the most frequent preventable cause of epilepsy in the developing world. Although theoretically easy to control and declared eradicable, T. solium taeniosis/cysticercosis remains a neglected disease. There is a lack of information and awareness of the burden and transmission of the disease at the regional and global level, partially explained by the unavailability of good quality diagnostic tools in field-applicable formats. These factors are further compounded by a lack of validated simple and sustainable intervention packages as part of integrated helminth control programmes. To date, T. solium taeniosis/cysticercosis has not been eliminated from any region by a specific programme in Southeast Asia, and no national control programmes are yet in place except in parts of the People's Republic of China. The presence, distribution, public health importance and economic relevance of cysticercosis need to be better documented in Southeast Asia in order to bring it to the attention of affected communities, decision-makers and funding bodies. A number of proven cost-effective intervention tools for combating cysticercosis appear to be available but need to be field validated. The Regional Network for Asian Schistosomiasis and Other Helminth Zoonoses (RNAS(+)) serves as an important regional 'driving force' for managing research, capacity building, knowledge and stakeholder engagement essential for controlling cysticercosis in the Southeast Asian region while ensuring that research efforts are integrated with regional needs for surveillance and control.

Accuracy of serological testing for the diagnosis of prevalent neurocysticercosis in outpatients with epilepsy, Eastern Cape Province, South Africa.

BACKGROUND: Few studies have estimated prevalence of neurocysticercosis (NCC) among persons with epilepsy in sub-Saharan Africa. While the limitations of serological testing in identification of NCC are well known, the characteristics of persons who are misdiagnosed based on serology have not been explored. The first objective of this pilot study was to estimate the prevalence of NCC in epilepsy outpatients from an area of South Africa endemic for cysticercosis. The second objective was to estimate the accuracy of serological testing in detecting NCC in these outpatients and characterize sources of disagreement between serology and neuroimaging. METHODOLOGY/PRINCIPAL FINDINGS: All out-patients aged 5 or older attending the epilepsy clinic of St. Elizabeth's Hospital in Lusikisiki, Eastern Cape Province, between July 2004 and April 2005 were invited to participate. Epidemiological data were collected by local study staff using a standardized questionnaire. Blood samples were tested by ELISA for antibody and antigen for Taenia solium. Four randomly chosen, consenting participants were transported each week to Mthatha for brain CT scan. The proportion of persons with epilepsy attending St. Elizabeth clinic with CT-confirmed NCC was 37% (95% CI: 27%-48%). Using CT as the gold standard, the sensitivity and specificity of antibody testing for identifying NCC were 54.5% (36.4%-71.9%) and 69.2% (52.4%-83.0%), respectively. Sensitivity improved to 78.6% (49.2%-95.3%) for those with active lesions. Sensitivity and specificity of antigen testing were considerably poorer. Compared to false negatives, true positives more often had active lesions. False positives were more likely to keep pigs and to have seizure onset within the past year than were true negatives. CONCLUSIONS/SIGNIFICANCE: The prevalence of NCC in South African outpatients with epilepsy is similar to that observed in other countries where cysticercosis is prevalent. Errors in classification of NCC using serology alone may reflect the natural history of NCC.

Multi-host transmission dynamics of Schistosoma japonicum in Samar province, the Philippines.

BACKGROUND: Among the 6.7 million people living in areas of the Philippines where infection with Schistosoma japonicum is considered endemic, even within small geographical areas levels of infection vary considerably. In general, the ecological drivers of this variability are not well described. Unlike other schistosomes, S. japonicum is known to infect several mammalian hosts. However, the relative contribution of different hosts to the transmission cycle is not well understood. Here, we characterize the transmission dynamics of S. japonicum using data from an extensive field study and a mathematical transmission model. METHODS AND FINDINGS: In this study, stool samples were obtained from 5,623 humans and 5,899 potential nonhuman mammalian hosts in 50 villages in the Province of Samar, the Philippines. These data, with variable numbers of samples per individual, were adjusted for known specificities and sensitivities of the measurement techniques before being used to estimate the parameters of a mathematical transmission model, under the assumption that the dynamic transmission processes of infection and recovery were in a steady state in each village. The model was structured to allow variable rates of transmission from different mammals (humans, dogs, cats, pigs, domesticated water buffalo, and rats) to snails and from snails to mammals. First, we held transmission parameters constant for all villages and found that no combination of mammalian population size and prevalence of infectivity could explain the observed variability in prevalence of infection between villages. We then allowed either the underlying rate of transmission (a) from snails to mammals or (b) from mammals to snails to vary by village. Our data provided substantially more support for model structure (a) than for model structure (b). Fitted values for the village-level transmission intensity from snails to mammals appeared to be strongly spatially correlated, which is consistent with results from descriptive hierarchical analyses. CONCLUSIONS: Our results suggest that the process of acquiring mammalian S. japonicum infection is more important in explaining differences in prevalence of infection between villages than the process of snails becoming infected. Also, the contribution from water buffaloes to human S. japonicum infection in the Philippines is less important than has been recently observed for bovines in China. These findings have implications for the prioritization of mitigating interventions against S. japonicum transmission.

Research approaches for improved pro-poor control of zoonoses.

BACKGROUND: Developing countries face difficulties in sustainably utilizing tools to effectively implement control measures for zoonoses. This is mainly due to dispersed and heterogeneous smallholder livestock systems, predominance of informal markets, poor infrastructure and lack of resources to deliver information, interventions, and regulations. In addition, developing countries lack an evidence base for planning and targeting control efforts. Zoonotic infections are receiving more and more international attention as diseases of neglected and impoverished communities, at the intersection between livestock production, human health, and poverty. OBJECTIVE: To review research innovations and trends that can help identify and test targeted control strategies for zoonoses tailored to poor communities, focusing particularly on Africa. METHODS: Review of recommendations of relevant working groups and scientific literature. RESULTS: New and innovative research approaches promise to better capture the impact of zoonoses from a societal perspective and the perspective of poor livestock owners through more comprehensive frameworks that consider benefits of the control of zoonoses to the public health, livestock, and private sectors. It is challenging to better assure food safety in informal markets. Risk-based approaches with participatory elements provide a framework in which stakeholders can decide an appropriate level of protection to balance the needs for safe food, cheap food, and pro-poor economic growth. Appropriate information for all stakeholders and capacity-building of national and regional authorities is an important element of this process. New diagnostic tools that are accurate and easily used in developing-country health centers and markets can assist in reporting of cases, detection of patients, and testing of control strategies. CONCLUSIONS: A research agenda on zoonoses of the livestock sector should be interdisciplinary and participatory and include intersectoral collaborations, notably between the livestock and public health sectors.

Methods for assessing the burden of parasitic zoonoses: echinococcosis and cysticercosis.

Cysticercosis and echinococcosis cause illness and productivity losses in human and agricultural animal populations. Recent studies suggest that these diseases have large societal impacts on endemic areas. Estimates of burden provide essential, evidence-based data for conducting cost-benefit and cost-utility analyses that will secure political will, and financial and technical resources. To evaluate the burden, the monetary and non-monetary impacts of these zoonoses on human health, agriculture and society must be considered comprehensively. In this article, we review the framework used to assess the burden of cysticercosis and echinococcosis, and the data needed to estimate the extent of the problem for societies.

Estimating and modeling the dynamics of the intensity of infection with schistosoma japonicum in villagers of leyte, Philippines. Part II: Intensity-specific transmission of S. japonicum. The schistosomiasis transmission and ecology project.

A dynamic model of Schistosoma japonicum transmission is presented that incorporates effects of infection intensity, age, and sex. We use four infection intensity classes to investigate the impact of ecologic changes and public health interventions on the burden of infection within communities. Age- and sex-specific infection data from three disease-endemic villages in the Philippines are used to estimate the parameters of the model. The model gives good qualitative agreement with observed fecal egg counts adjusted for the accuracy of the Kato-Katz examination. Our results suggest that differences in infection burden between villages are caused by differences in both the infection process and the recovery process in humans. We describe the potential impact of mass treatment of all humans on the numbers with high infection. Furthermore, we show that a sudden reduction in snail population size would affect high prevalence and low prevalence communities in different ways.

Current status of cysticercosis in Vietnam.

This English review concerning the current status of cysticercosis in Vietnam has been compiled from various reports of studies conducted over the past 15 years, which have appeared in national publications in Vietnamese, in order to make the information available to the international community. Hospital surveys indicate that cysticercosis is emerging as a serious health problem in the country though most of the information comes from the Hanoi area. Many more men than women are being treated for cysticercosis with most patients being young to middle-aged adults though several juvenile cases have been seen in the south. Clinical manifestations of the disease in humans include subcutaneous nodules, epileptic seizures, severe headache, impaired vision and memory loss. Albendazole has been found to be the best drug for treating cysticercosis though it does not appear to be totally effective for curing cerebral cysts. Information concerning porcine and bovine cysticercosis is very limited and based mostly on passive surveillance at Hanoi slaughterhouses. Surveys for human taeniasis in central and northern provinces indicate a prevalence of 0.2-7.2%. However, techniques of low sensitivity were used and the results are inconclusive since it is unknown with which species of tapeworm the people were infected. In addition to Taenia solium which causes human cysticercosis, T. saginata and T. asiatica are also known to be present in Vietnam. Risk factors investigated thus far with regard to transmission of T. solium suggest that consumption of raw pork, inadequate or absent meat inspection and control, poor sanitation in some areas, and the use of untreated human waste as fertilizer for crops may play important roles in Vietnam but this remains to be validated. The evidence thus far collected suggests that a national surveillance program for cysticercosis is a great need for Vietnam. The authors recommend further research on the epidemiology and impact of cysticercosis in both human and pig hosts in order to determine whether a prevention and control program in Vietnam would be merited and cost effective.

The emergence of Taenia solium cysticercosis in Eastern and Southern Africa as a serious agricultural problem and public health risk.

Pig production has increased significantly in the Eastern and Southern Africa (ESA) region during the past decade, especially in rural, resource-poor, smallholder communities. Concurrent with the increase in smallholder pig keeping and pork consumption, there have been increasing reports of porcine cysticercosis in the ESA region. This article reviews the findings concerning the presence and impact of porcine cysticercosis in seven of the ESA countries. Most of the reported findings are based on surveys utilising lingual palpation and post-mortem examination, however, some also used serological assays. In Tanzania, community-based studies on porcine cysticercosis indicate a prevalence of 17.4% in the northern highlands district of Mbulu and a prevalence range of 5.1-16.9% in the southern highlands. In Kenya recent surveys in the southwestern part of the country where smallholder pig keeping is popular indicate that 10-14% of pigs are positive for cysticercosis by lingual examination. Uganda has the most pigs in Eastern Africa, most of which are kept under smallholder conditions. Preliminary surveys in 1998 and 1999 at slaughterhouses in Kampala indicated a prevalence of porcine cysticercosis between 0.12 and 1.2%, however, a rural survey in northern Uganda in 1999 indicated 34-45% of pigs slaughtered in selected villages were infected. Additionally, a new survey of 297 pigs slaughtered in Kampala in 2002 indicated that pigs from the central region of the country were negative for cysticercosis while 33.7% of the pigs coming from the rural Lira district in the north were positive. Interestingly 8 piglet foetuses removed from an infected slaughtered sow coming from Lira district were all found to harbour cysts of T. solium providing evidence of congenital transmission of porcine cysticercosis. In Mozambique, abattoir records indicate that porcine cysticercosis is present in all provinces of the country. A serological survey on pigs in rural Tete Province found 15% of pigs positive. In Zimbabwe, a retrospective study in official abattoirs around the country from 1994 to 2001 reported a mean prevalence of 0.34% which is in contrast to a post-mortem survey in 1999, which showed that the prevalence of porcine cysticercosis in rural west Zimbabwe where smallholder pig keeping is popular was 28.6%. In Zambia, abattoir records reported porcine cysticercosis in six of the nine provinces. Routine meat inspection of 1316 pigs at a slaughter slab in Lusaka showed that 20.6% of the pigs had cysticercosis whereas serological testing of 874 pigs at the same abattoir indicated that 56.6% were found to have circulating antigens of Taenia solium. Field surveys based on lingual palpation in Southern and Eastern Provinces of Zambia revealed prevalences of 8.2-28.4 and 5.2%, respectively. South Africa has the largest number of pigs in Southern Africa and cysticercosis has been recognised as a problem in the country for many decades. There is strong evidence supporting the high prevalence of neurocysticercosis infecting humans from resource-poor areas of the country where pigs are being raised under smallholder conditions. In spite of this community-based surveys on porcine cysticercosis have never been conducted in South Africa and the last slaughterhouse survey was conducted nearly 40 years ago. The prevalences of porcine cysticercosis found in these ESA countries rank among the highest in the world and the disease is emerging as an important constraint for the nutritional and economic well being of resource-poor smallholder farming communities. The current findings suggest the widespread presence of human tapeworm carriers and thus a high risk of human cysticercosis in both rural areas and urban centres in the ESA region. More research is required in the region to assess the extent and public health and economic impact of T. solium infection in order to determine whether and what prevention and control efforts are needed.

Experimental Schistosomiasis japonica in the pig: immunohistology of the hepatic egg granuloma.

Use of the pig as an animal model in schistosomiasis research is increasing, but knowledge of the porcine immune response to schistosome infection is still very limited. We investigated the immunohistology of different maturation stages of the Schistosoma japonicum egg granuloma in pigs. Liver sections from pigs experimentally infected with S.japonicum for 9, 12 or 21 weeks were examined by immunohistochemistry using a three-step streptavidin-biotin-complex/immunoperoxidase method or a two-step alkaline phosphatase-mediated system. All granulomas showed marked expression of major histocompatibility complex (MHC) class II in epithelioid macrophages and were dominated by T lymphocytes, comprising both CD4+ and CD8+ phenotypes, with consistently higher proportions noted for CD8+ cells. B lymphocytes, as identified by expression of CD21, were confined to lymphoid nodular structures primarily associated with mature granulomas. Early and mature granulomas contained numerous immunoglobulin (Ig)G+ plasma cells. Significant differences in immunohistology related to duration of infection were not observed. The results indicate that all stages of the hepatic S.japonicum egg granuloma in the pig manifests MHC class II-dependent CD4+ T cell activity concomitant with infiltration of CD8+ T cells. B cell activity preceding the effector cell stage appears to occur in granuloma-associated lymphoid nodules, whereas antibody, mainly IgG, is produced within the granuloma.