Rapid appraisal for Taenia solium and Cysticercosis cellulosae in ,

M.T. Correa,1* G.F. Catacora,2 J.L. Escobar, 2 L. Abbas2, and M. Levy.1 1College of Veterinary Medicine, North Carolina State University, USA 2Partners of America Farmer to Farmer Program Cochabamba, Bolivia-North Carolina Chapter, USA.

Summary—Taenia solium cysticercosis is a serious public health problem in Cochabamba, Bolivia. Our group conducted a rapid appraisal to determine the public health dimension of cysticercosis and to identify key areas to target in control programs. The current public and private infrastructure in Cochabamba would not support a large-scale control program. Local and tailored programs that integrate the rural population in the control efforts seem to be more appropriate for the socio- economic reality of the region and the complexity of the disease.

Introduction—Although mostly associated with rural areas, cysticercosis in humans is a public health threat to the urban population as well since people can be infected through contaminated pork and taenia carriers. Cysticercosis in humans is a condition closely related to the socio-cultural and economic fabric and hygiene standards of the society in question. Humans are the definitive host for the adult egg- laying tapeworm while pigs and humans are intermediate hosts for the larval stage or cysticercus. Humans become infected when ingesting cysticerci in undercooked pork. The eggs of the parasite shed in human feces may infect pigs and humans alike.1 Objectives— In response to a request from public and private organizations from the Department of Cochabamba, Bolivia, we conducted a rapid appraisal to determine the public health dimension of Taenia solium cysticercosis in the region. Rapid appraisal methods were used to determine problems and possible actions to be taken in areas related to a) swine production, transport, processing and transformation industries; b) food inspection, public health education, control programs; and, c) disease prevalence, diagnostic and treatment capabilities.2 Materials and Methods—Our efforts concentrated in the most populated provinces of the Department of Cochabamba (about 1 million inhabitants). Included were the major urban area in the region, the Cercado Province, and large portions of three neighboring provinces, , , and , where most of the pork consumed in the area is produced and processed. A total of three weeks were used to interview key informants from public and private organizations. Two weeks were dedicated to direct observation through a series of farm visits, slaughterhouse inspections, and open-market visits in urban and rural settings. A series of talks where delivered to a wide range of audiences, and community interviews were conducted. Results—Of interest to us were farms that were classified under these three broad categories: small confined farms, unconfined but with limited free-foraging range, or raised as rustic free-roaming pigs. The two later are the prevailing forms of pig raising in the rural or sub-urban areas studied. The number of farms and pigs in the

Proceedings of the 10th International Symposium on Veterinary Epidemiology and Economics, 2003 Available at www.sciquest.org.nz region are unknown, but pigs are seen everywhere. Human defecation in the open is a culturally accepted practice for a large segment of the population facilitating pigs access to Taenia solium-contaminated human feces. Municipal markets, which are loosely regulated and poorly inspected, are the places where free range and rustic pigs are sold at various times during the week at different points in the region. At the market, lay people known as the “trichina inspectors” check the tongues of pigs for cysticercosis. If no cysts are found the pig is rendered free of “trichina” (as cysticercosis is locally known). The price of a positive pig is low and the pig cannot be processed at the local municipal slaughterhouse. Most of the time when this occurs, the pig is taken to a clandestine facility for processing. At the slaughterhouse, after processing, butchers re-inspect the pig for “trichina.” If positive, the pig should be destroyed, but it is not clear if this is done at all. Although pigs are processed mainly on Fridays and Saturdays in preparation for the Sunday meal known as “chicharrón,” cows and sheep may also be processed concurrently. Butchers process pigs in the floor amidst a large contingent of women and children that wash entrails and carcasses with water of dubious quality and dirty rags. Veterinary inspection is precarious and done pre-mortem mainly for diseases of national interest and post-mortem for obvious macroscopic pathologies. Untreated slaughterhouse water run-offs reach water canals and rivers contaminating irrigation and drinking water sources. Transport from the slaughterhouse to the place of final sale is done in pick-up trucks, bicycles, bus, or carried in buckets out of the premises. Meat is not refrigerated and must be consumed immediately after processing. We speculate that most of the pork consumed in the region is processed in clandestine facilities since the processed pork at the three municipal slaughterhouses (150 pigs per slaughterhouse per week) is insufficient to cover the demand. There is a large unsupervised cottage sausage industry that uses the cyst- contaminated meat cut off from grossly contaminated pork that people would not consume otherwise. Municipal food inspectors are political appointees with no food safety background that may receive very basic on-the job training. At large markets these inspectors confiscate obviously contaminated meat or sausages—an event that it is usually accompanied of public outcry and a fine to the sales person. Although in place, the system fails more times than it works since the number of inspectors is insufficient to cover the large number of markets held in the region. A public health campaign to combat cysticercosis was initiated a decade ago, but was scantily funded and never completed. Two publications were produced at that time, one on the disease cycle and another on diagnostic procedures. Although cysticercosis is recognized as a serious public health problem, public funds and attention have been placed on Chagas and Foot and Mouth eradication efforts. The public, everywhere we conducted community interviews, showed total ignorance about the parasite cycle. The common belief was that Taenia solium and saginata were the same parasite and that the “trichina” from llamas or fish was also the pig’s “trichina.” People had no idea that a person with the tapeworm posed more risk to their own health and the health of those in the household, than a cyst in a piece of pork meat. Every where we went, we listened to testimonials of people with

Proceedings of the 10th International Symposium on Veterinary Epidemiology and Economics, 2003 Available at www.sciquest.org.nz cysticercosis or stories about family members or neighbors that had been diagnosed or died of neurocysticercosis. Estimations of the prevalence of taenia and cysticercosis in humans in Cochabamba vary between 10 and 20% depending on the source of information.3 In a study involving 48 women that cooked and sold “chicharrón” in stands by the side of the road in a small town, it was reported that 17% of the women had cysticercosis. The seroprevalence of cysticercosis in school-age children in rural areas varied between 1 and 10%. Information on the prevalence for T. solium in Bolivia is scant. Unpublished data from a small coprologic study of women selling food at markets found that 10% had taenia spp. In pigs, cysticercosis is expected to be two times higher than in humans; data from the Department of Santa Cruz indicates that cysticercosis in pigs is in the order of 20 to 40%.4 Laboratory personnel from official laboratories could not identify the parasite’s eggs in fecal samples and diagnostic procedures focused mainly on cysticercosis. Research efforts on taenia and cysticercosis were isolated, scarce, and not published. At the major regional tertiary hospital, it was estimated that 60% of the adult onsets of seizures seen in the emergency room could be associated with neurocysticercosis. Although 20 patients were treated at this hospital in 2002, it is estimated that private neurologists in the region see 100 or more patients a year at their practices. Patients with persistent headaches and other associated neurological signs associated with the disease may go undiagnosed or untreated if they cannot afford the cost of the MRI or drugs. Neurocysticercosis seems to be so prevalent in the rural areas of Cochabamba that the disease has a name in Quechua, the local native language. Discussion—Data from other parts of the country indicate that teniasis and cysticercosis are a widespread problem in Bolivia. We believe that a national program may not work at this moment due to the socio-cultural economical and infrastructure of the public health system. Local and tailored programs that integrate the rural population in the control efforts seem to be more appropriate. We have started working on public health education targeting pig producers and the public in collaboration with international, regional and local public and private institutions. Other phases of the study will integrate different aspects of the food chain.

References 1. EP Hoberg. 2002. Taenia tapeworms: their biology, evolution and socioeconomic significance. Microbes and Infection, Vol.4, pgs. 859-866. 2. Rapid Appraisal methods for the assessment, design, and evaluation of food security programs. 1999. Technical Guide #6, International Food Policy Research Institute, Washington, DC. 3. HS Jafri, F Torrico, JC Noch, et al. 1998. Application of the enzyme-linked immunoelectrotransfer blot to filter paper blood spots to estimate seroprevalence of cysticercosis in Bolivia. The American journal of tropical medicine and hygiene, 1998 Mar, 58(3):313-315. 4. Proceedings from First National Swine Production Meeting. February 20-21, 2003, Santa Cruz, Bolivia.

Proceedings of the 10th International Symposium on Veterinary Epidemiology and Economics, 2003 Available at www.sciquest.org.nz