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Travel-Associated Parasitological Infections Travel-associated parasitological infections Cândida Abreu Infectious Diseases Depart. HSJoão Travel Medicine Clinic, HSJoão Faculty of©Medicine, by author Porto - Portugal Technical Workshop for ESCMIDBasic Online and Clinical Lecture Parasitology Library Porto, 21 June 2013 OUTLINE Burden of parasitic diseases in travellers - overview Gastroentestinal diseases Dermatological diseases Sistemic diseases Prevention © by author Take home messages ESCMID Online Lecture Library PARASITIC DISEASES IN TRAVELLERS Asymetrical world: Parasitic pathogens distribution Safe water distribution Sanitation Agricultural conditions Animal health Vectors distribution© by author TheESCMID less developed worldOnline has a higherLecture burden Libraryof parasitic diseases Globalization can make things worse BURDEN OF PARASITIC DISEASE IN TRAVELLERS The incidence and risk of parasitic disease in returned travellers is not easy to determine The published studies are generally from samples of ill travellers only proportionated morbidity or the rate of ill travellers with a subset of diagnoses to all ill returned travellers for a given country can© be calculatedby author sample size is often small ESCMID many variables Online: destination Lecture, duration Libraryof travel, type of traveller,… BURDEN OF PARASITIC DISEASES AND PURPOSE OF TRAVEL Sample: ill returned patients: 2275 canadian travellers and © by1213 author new immigrants Study: from November,97 to June,03 MoreESCMID parasitic infections Online diagnosed Lecture in immigrants Library(21.1% vs 7.1%, p < 0.001), and VFR (17.9% vs 11.8%, p < 0.001) Andrea K . Boggild Prospective Analysis of Parasitic Infections in Canadian Travelers and Immigrants. Journal of Travel Medicine, 2006 Volume 13, Issue 3,, 138–144 PARASITIC DISEASES AND PURPOSE OF TRAVEL IN CANADIANS Comparing with other travellers Tourists : more likely to acquire cutaneous larva migrans (OR=10.8) Immigrants and VFR more likely to have: malaria (OR=1.5, 2.4) schistosomiasis (OR=3.4, 1.5) filariasis (OR=4.6, 2.6) strongyloidiasis (OR=2.1, 3.9) echinococcosis© by author (OR=4.3, 4.8) Immigrants more like to have: ESCMID Onlineamebiasis Lecture ( R=2.6) Library giardiasis (OR=1.9) Andrea K . Boggild Prospective Analysis of Parasitic Infections in Canadian Travelers and Immigrants. Journal of Travel Medicine, 2006,Volume 13, Issue 3, 138–144 PARASITIC DISEASES IN CANADIAN TRAVELLERS AND IMMIGRANTS From 3528 returned Canadian (2275 travellers , 1213 new immigrants ) between November,97 -June, 03 1010 (29%) had a parasitic infection diagnosed - 209 nonhistolytica amebiasis - 143 malaria - 105 cutaneous larva migrans - 74 giardiasis © by author - 48 schistosomiasis -- 43 strongiloidiasis ESCMID- 41 amebiasis Online (E.histolytica Lecture) Library - 38 echinococcosis Andrea K . Boggild et al. Journal of Travel Medicine, 2006, Volume 13, (3) , 138–144. PARASITIC DISEASE: DESTINATION AND EXPATRIATES VERSUS NON EXPATRIATES From 2883 expatriates compared with 11910 non -expatriates* Those returning from Africa had higher rates of malaria, filariasis and schistosomiasis Those returning from Asia-Pacific region had higher rates of strongyloidiasis Those returning from Latin America had higher rates of© giardiasis by author ESCMIDFrom all regions Online: expatriates Lecture had higher ratesLibrary of amebiasis and gastrointestinal infections *non-expatriates: business or missionary/volunteers patients Lim et al. BMC Infectious Diseases 2012, 12:386. PARASITIC DISEASES AND IMMUNOCOMPROMISED TRAVELLERS Cryptosporidium, Microsporidium ongoing and debilitating symptoms Strongyloides infections in patients with a cell mediated immunity defect (high dose corticosteroid use, organ transplantation, HTLV-1, HIV infection, …) can result in hyperinfection syndrome Transmission of S stercoralis through transplantation of solid organs: a single donor was© the by source author for 3 of 4 organ recipients* Reactivation of Strongyloides, Trypanosoma and Leishmania in transplantESCMID recipients Online from endemic Lecture areas; infections Library donor-derived A Slack. Aust Fam Physician 2012;41:782-786 *Transmission of Strongyloides stercoralis Through Transplantation of Solid Organs — Pennsylvania, 2012 MMWR / April 12, 2013 / Vol. 62 / No. 14 LONG TIME CONSEQUENCES OF PARASITIC DISEASES Intestinal infections protein losing enteropathy postinfectious fatigue posinfectious irritable bowel syndrome (Cryptosporidium) posinfectious lactase deficiency (Giardia ) In children: growth/cognitive impairment (deficiencies of iron & micronutrients) Blood infections (Schistosomiasis)© by author Fibrosis and chronic diseases (hepatic, ureters , bladder) BladderESCMID cancer (squamous Online cell Lecture carcinoma) Library Cerebral malaria: retinopathy, encephalopathy Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 A. Slack. Aust Fam Physician 2012;41:782-786 COMMON PARASITIC DISEASES IN TRAVELLERS Helminth infections Gastrointestinal (strongyloidiasis, toxocariasis); Protozoarial (amebiasis; giardiasis; cryptosporidiosis) Dermatologic Larva cutaneous © by authormigrans , myasis, tungyasis ESCMID Online Lecture Library Blood Malaria, schistosomiasis, tripanossomiasis, filariasis RISK OF ENTEROPATHOGENIC INFECTIONS* ACQUIRED DURING TRAVEL 1996-2005 (25 867 travellers) N=7442 (travellers with confirmed gastrointestinal disease) From the 2902 © by author pathogens isolated 65% were parasitic ESCMID Online Lecture Library31% bacterial * Clinical symptoms appearing > 14 days after exposure Swaminathan A, et al. J Infect 2009;59:19-27. Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 PARASITIC ENTEROPATHOGENS IN RETURNED TRAVELLERS © by author ESCMID Online Lecture Library •Adapted from: Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 GIARDIASIS IN TRAVELLERS Giardia lamblia (or G. intestinalis or G. duodenalis) The most likely pathogen to infect travellers by ingestion of cysts in contaminated food or water; person to person transmission also possible Highly contagious (10-25 cysts may cause disease) © by author Rotavirus may work synergistically with GiardiaESCMID to enhance Online pathogenesis Lecture Library (attachment of trophozoites to epithelium) A Slack. Aust Fam Physician 2012;41:782-786 Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 AMEBIASIS E.histolytica and E moshkovski causes amebiasis: ingestion of food or water contamined with fecal cysts trophozoites invasion: days to years after initial infection: fever, abdominal pain, bloody diarrhea 90% of cases are asymptomatic and self-limiting © by author 1% of clinical cases of amebiasis envolve the liver AuranofinESCMID may be a betterOnline therapeutic Lecture option thanLibrary metronidazole* Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 * Debnath A et al. NatMed 2012;18:956-60 STRONGILOIDIASIS Autoinfection can result in persistent infection for decades (rhabditiform larvae transform in filariform) 50% of patients with chronic infection are asymptomatic if eosinophilia or elevated Ig E in travellers strongyloidiasis should be considered © by author possible symptoms: skin eruptions, pruritus, larva currens , abdominal painESCMID, diarrhea Online Lecture Library hyperinfection syndrome (owing to reprodutive capacity of the parasite) has a mortality rate up to 90% Ross AGP et al. N Engl J Med 2013;368:1817-25.DOI: 10.1056/NEJMra1207777 ANALITICAL/CLINICAL FEATURES THAT HELP PREDICT PARASITIC/BACTERIAL INTESTINAL INFECTION? 509 cases included; parasitic aetiology in 51/428 (11.9%) bacterial© byin 55/440 author (12.5%). Symptoms ≤ 14 days: bacterial more likely than parasitic dis. (p<0.001) Travellers to South and Southeast Asia: more ESCMIDlikely to have parasitic Online infection Lecture(p=0.041) Library A.C. McGregor et al. Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 549– 553 TRAVEL RELATED HELMINTIC INFECTIONS AND EOSINOPHILIA A prospectively study for the occurrence of clinical or subclinical schistosomiasis, strongyloidiasis, filariasis and toxocariasis and the screening value of eosinophilia 1207 travellers included ; serology for parasites + eosinophil counts Samples were tested before and after travel (median travel duration: 21d) Previous infection: 112 travellers; recent: largely contracted in Asia Schistos. Strongil. filariasis toxocariasis Previous infection ©2.7% by 2.4%author3.4% 1.8% Recent infection 0.51% 0.25% 0.09% 0.08% PositiveESCMID preditive value Onlineof eosinophilia Lecture for diagnosis: Library 15% for previous infection; 0% for recent infection (short-term journey) Baaten et al. BMC Infectious Diseases 2011, 11:84 DIAGNOSIS OF INTESTINAL PARASITOSIS IN TRAVELLERS Stool examination – gold standard Detection of trophozoites, cysts, eggs and larvae by microscopic stool examination Enzyme immunoassays and direct fluorescent-antibodie assays (Giardia and Cryptosporidium in stools) © by author PCR (E. histolytica, G lamblia, C hominis/C parvum; S stercoralisESCMID) in faeces; Online PCR multiplex Lecture Library R. Hove. Eur J Clin Microbiol Infect Dis (2009) 28:1045–1053 DOI 10.1007/s10096-009-0745-1 DIAGNOSIS OF INTESTINAL PARASITOSIS IN TRAVELLERS 2591 stool samples from 2591 returned travellers with and without symptoms Multiplex real-time PCR on Entamoeba histolytica, Giardia, Cryptosporidium and Strongyloides stercoralis © by author ESCMID Online Lecture Library R. Hove. Eur J Clin Microbiol Infect Dis (2009) 28:1045–1053
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