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Educational Workshop EW18: Human Parasites of the Gut: Epidemiology and Diagnostic Approaches in the Molecular Era

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Educational Workshop EW18: Human Parasites of the Gut: Epidemiology and Diagnostic Approaches in the Molecular Era Educational Workshop EW18: Human parasites of the gut: epidemiology and diagnostic approaches in the molecular era Arranged with the ESCMID Study Group for Clinical Parasitology (ESGCP) and the ESCMID Study Group for Molecular Diagnostics (ESGMD) Convenors: Titia M. Kortbeek (Bilthoven, NL) Paul Savelkoul (Maastricht, NL) Faculty: Marjan van Esbroeck (Antwerp, Belgium) Theo Mank (Haarlem, The Netherlands) Spencer Polley (London, United Kingdom) - no handout available Simone Caccio (Rome, Italy) 1 2 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Human parasites of the gut: epidemiology and diagnostic approaches in the molecular era General introduction and epidemiology of common parasites of the human gut Marjan van Esbroeck Institute of Tropical Medicine Antwerp, Belgium Influence of study population Protozoa • Giardia lamblia •E. histolytica • Cryptosporidium Helminths • warm t, humidity, poor sanitation, dirty nematodes water, substandard and crowded housing soil‐transmitted helminths •Sub‐Saharan Africa > Asia > Latin America • Ancylostoma duodenale •Behavior: more active in the environment, rarely employ good sanitation, crowd • Necator americanus together (schools, orphanages, slums) • Ascaris lumbricoides • helminths = immunomodulators • Trichuris trichiura 2 Influence of study population Distribution of intestinal parasites in internationally adopted children in ITM. Number of children: 120 ‐ Period: 1/1/2008‐30/6/2009 3 3 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Influence of study population • HIV/AIDS • solid/bone marrow transplantation • malnutrition • Cryptosporidium > Cyclospora > Cystoisospora • microsporidia •(Blastocystis) 4 Influence of study population Study of 2591 travelers ITM 4/2005 – 5/2006 Giardia lamblia 4,7% 6,0% Cryptosporidium 0,5% 1,3% E. histolytica 0,3% 0,5% Strongyloides 0,1% 0,8% 5 Influence of study population • Prolonged diarrhoea (> 14 days) •1‐3% of travellers • Protozoal parasites >> helminth parasites • Giardia lamblia • Cryptosporidium •E. histolytica 6 4 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Influence of study population Protozoa •E. histolytica Helminths • Giardia lamblia • Strongyloides •Cyclospora • Ascaris lumbricoides • Cryptosporidium • hookworms •Cystoisospora • Trichuris trichiura • microsporidia •tapeworms 7 Greater burden of intestinal protozoan infections globally Worldwide increase in • immunocompromised individuals •travel • medical tourism • immigration 8 Pathogenic Non‐pathogenic • Entamoeba histolytica • Entamoeba dispar, E. moshkovskii, • Giardia E. coli, E. polecki, E. hartmanni • Cyclospora cayetanensis • Iodamoeba butschlii • Endolimax nana • Cryptosporidium parvum • Chilomastix mesnili • Cystoisospora (Isospora) belli • Sarcocystis sp. • microsporidium • Dientamoeba fragilis • Blastocystis hominis 9 5 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Giardia lamblia (G. intestinalis, G. duodenalis) Developed regions of the world transmission via contaminated water Ubiquitous distribution person‐to‐person transmission in settings of poor fecal‐oral hygiene Food transmission is increasingly recognized Denmark, Norway, Finland, Sweden ‐ asymptomatic: 3% (2,6‐3,3%) ‐ symptomatic: 6% (5,3‐6,3%) 6% to 8% of children 15‐30% of stools in endemic areas Developing world: 200 M symptomatic infections 500.000 new cases each year ITM Antwerp: 4,6 (6%) 10 Giardia lamblia (G. intestinalis, G. duodenalis) Waterborne tranmission common agent identified in water‐borne outbreaks of diarrhea ‐ widely distributed in humans and other mammalian species contamination of surface water ‐ cysts can survive for weeks in cold, fresh water ‐ cysts are relatively resistant to chlorination ‐ few parasites are necessary to establish infection 11 Giardia lamblia (G. intestinalis, G. duodenalis) Person‐to‐person transmission Situations of poor fecal‐oral hygiene ‐ developing regions 15‐30% in children < 10 y ‐ day‐care centers 20‐50% ‐ oral‐anal sexual contact Transmission by food infected food handler > enviromental contamination of food Travel to areas of poor fecal‐oral hygiene 12 6 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Cryptosporidium Worldwide distribution ‐ developed countries sporadic outbreaks ‐ developing countries endemic infections southeast Asia (India) Species Major host Minor host C. parvum Cattle, sheep, goats, humans Deer, mice, pigs water and foodborne C. hominis Humans, monkeys Dugongs, sheep pathogen C. muris Rodents, bactrian camels Humans, rock hyrax, moutain goats C. andersoni Cattle, bactrian camels Sheep selflimiting HIV/AIDS C. felis Cats Humans, cattle C. canis Dogs Humans C. meleagridis Turkeys Parrots, humans C. suis Domestic pigs Humans C. baileyi Chicken, turkeys Cockatiels, quails, ostriches, ducks C. galli Finches, chicken, capercalles C. serpentis Snakes, lizards C. wrairi Guinea pigs C. molnari Fish C. bovis Domestic cattle C. scophthalmi Fish C. varanii Lizards 13 Cryptosporidium Most common method of transmission: drinking and recreational water oral ingestion of oocysts ‐ the inoculum required to establish infection is very low (one ocoyst) ‐ excretion of large numbers of organisms into the environment 105‐7 oocysts per gram feces ‐ smal size escape common water filters ‐ outer shell: cysts can survive for months in the water soil cysts are relatively resistant to chlorine ‐ the oocyst is immediately infectious on ingestion 14 Cryptosporidium 15 7 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut E. histolytica • Globally distributed •Most morbidity/mortality in developing world –low hygienic standards, high population density – Indian subcontinent, Central/South America, Africa •50 M invasive amebiasis • 40.000‐100.000 deaths annually • Outbreaks –Mexico, Vietnam, Egypt –Chicago 1933, sewage and tap water mixed 800 cases • Amebic liver abscess <1% (potentially fatal illness) 16 E. histolytica E. histolytica/dispar, ITM, Belgium, 2005‐2013 2005 2006 2007 2008 2009 2010 2011 2012 2013 N % N %N N % % N %N% N%N %N % E. histolytica/dispar 152 189 194 214 214 212 248 248 266 E. histolytica 10 6,6 13 6,9 9 4,6 4 1,9 4 1,9 7 3,3 15 6 13 5,2 7 2,6 17 Strongyloides stercoralis •nematode • (sub)tropical areas (+ moderate climate) •global prevalence unknown • estimation 3 – 100 M infected persons – travel to endemic areas – consuming contaminated water –contact with infected soil (barefoot travel) •no intermediate host auto‐infection • cell mediated immunity defect hyperinfection (↑ Mt) –corticoƟ – organ transplantation –HTLV‐1 18 8 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Dientamoeba fragilis cosmopolitan distribution Prevalence 0,3%‐ 52% no consensus on ‐ age distribution ‐ gender distribution ITM: 2,8% 5 µm tot 15 µm 19 Dientamoeba fragilis •Cyststage? Bimodal age distribution in patients positive for D. fragilis •E. vermicularis as vector for transmission? – epidemiological link – higher incidence of coinfection than expected –DNA of Dientamoeba found in Enterobius Proportion of patients positive for E. vermicularis 20 Blastocystis species (B. hominis) • cosmopolitan distribution •> 1.000.000.000 colonized • genetic diversity Blastocystis sp. • unclear virulence factors, pathogenicity, risk factors • Significant difference in distribution of the ST – across host species – across geographical regions •virulence~ subtypes (~ species) (ST3) intrasubtype variation •virulence~ morpholigical forms ~ amoeboid forms 21 9 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Cystoisospora belli – Cyclospora cayetanensis •global distribution • predominance in (sub‐)tropical areas •ingestion of contaminated food or water • endemic areas: children • developed countries: outbreaks • travellers to endemic areas • immunocompromised individuals –more severe disease –disease may spread beyond the intestines Cystoisospora Cyclospora 22 Schistosoma fresh water contact poor sanitation school‐age children 23 S.mansoni S. haematobium •Southern and sub‐Saharan Africa •Southern and sub‐Saharan Africa the great lakes the great lakes • Nile River valley in Sudan and Egypt • Nile River valley in Egypt, Magreb •South America: Brazil, Suriname, region of North Africa Venezuela • Also found in areas of the Middle • Caribbean (low risk) East 24 10 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut S. japonicum S. intercalatum Indonesia and parts of China Parts of Central and West Africa and Southeast Asia 25 Schistosoma mekongi Cambodia, Laos 26 Soil transmitted helminth infections 27 11 Van Esbroeck - General introduction and epidemiology of common parasites of the human gut Ascaris lumbricoides • cosmopolitan distribution • (sub)tropical areas ‐ poor sanitation and personal hygiene • 807‐1221 M people infected Fertilized eggs Unfertilized eggs 28 Trichuris trichiura •whipworm • cosmopolitan distribution •more frequently in areas with tropical weather and poor sanitation • 604‐795 M people infected 29 Ancylostomidae • Hook worm • 576‐740 M people infected • cosmopolitan distribution, worldwide in areas with warm, moist climates • difficult differentiation no detailed numbers on the distribution ‐ Necator americanus: America, tropical Africa, Australia ‐ Ancylostoma duodenale: Mediterranean
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