Edmundo Larrieu

Long-term outcome of asymptomatic liver hydatidosis

BACKGROUND/AIMS The aim of this study was to determine the outcome of asymptomatic liver hydatid cysts in a cohort of 33 out of 59 carriers by evaluating clinical and ultrasonographic (US) changes 10-12 years after initial diagnosis. METHODS We compared US features and cyst size with the original descriptions from 1984-1986. Patients were questioned about hydatid-related symptoms and signs. RESULTS Thirty-three of the 59 carriers could be reevaluated, five (15.2%) of whom had undergone surgery without presenting symptoms, while of 28 unoperated cases, 21 (75%) remained asymptomatic. Of the unoperated cases evaluated by US, in 8/14 (57.1%) there were no modifications in cyst size during the 10-12-year period, in five (35.7%) growth was slight (<3 cm) and in one (7.1%) the cyst grew 4 cm. Mean cyst growth in all 14 cases was 0.7 cm. CONCLUSIONS Despite the limited number of cases, our results show that most asymptomatic liver hydatid cases (75%) remain symptom-free for more than 10 years, regardless of cyst size or type. We believe that such carriers are at low risk of developing complications, so that it is difficult to establish specific rules for their therapy, if any. Longitudinal follow-up of larger series of asymptomatic hepatic hydatidosis cases is essential to gain a deeper insight into the natural history of such patients, and to draw up comprehensive guidelines for treatment.

Ovine Echinococcus granulosus transmission dynamics in the province of Rio Negro, Argentina, 1980–1999

In this work, the impact of a hydatidosis control programme for dogs on the intermediate ovine host was specifically analysed to determine the levels of prevalence achieved and the dynamics of parasite transmission, as well as to evaluate the quality of diagnostic systems in slaughterhouses. A field study was conducted in four slaughterhouses (Valcheta, Los Menucos, Jacobacci, Bariloche) that process animals coming from all the departments within the work area. The control programme for dogs entailed treating dogs with 5 mg/kg praziquantel at 2-month intervals for 20 years. Sample size was determined with a 10% error margin and a 95% significance level. Harvested viscera (liver, lungs, kidneys) were preserved in 5% formaldehyde and sent to the laboratory for diagnostic confirmation of both positive and negative specimens. The 61% initial prevalence dropped to 18.3% at the end of the 10-year period, observed differences proving significant (Chi-square=15.454, P=0.00). There were statistically significant increases in infection prevalence with age (Pearsons Chi-square=133.61, P=0.00). Overall, 37.2% of hydatidosis cases diagnosed in slaughterhouses were considered non-hydatid by histological study. On the other hand, 1.1% of those diagnosed as healthy were found to be infected with hydatidosis. The number of hydatid cysts per animal increased with age: 0.04 in lambs and 1.22 in adults (linear regression equation, -0.0539+0.0127 x age), whereas the average for the whole period was 3.7% in lambs and 20.5% in adults. Viability studies indicated that 63.8% of parasitised animals had viable cysts, out of which 53.3% were fertile. Diagnosis of infection in sheep made by means of an adjusted statistical design and with histological confirmation of the presumptive diagnosis made in slaughterhouses demonstrated the flaws of the official systems for epidemic surveillance of hydatidosis. However, there was no overall significant difference in slaughterhouse and laboratory data.Ro was 0.53 and could imply a decrease in reproductive capacity of the parasite and steady state extinction.

Epidemiological surveillance of human hydatidosis by means of ultrasonography: its contribution to the evaluation of control programs

Epidemiological surveillance for hydatidosis is based on initial determination and follow-up of the infestation rate in man, sheep and dogs. The use of ultrasonography (US) as a screening method has demonstrated its usefulness in detecting asymptomatic human carriers of abdominal hydatidosis. To evaluate the contribution of US to epidemiological surveillance within the framework of disease control programs, we performed 719 US studies in school children from 7 to 13 years of age, in rural areas of Río Negro, Argentina, subjected to canine deparasitization during 1984/1986 and 1997/1998. In the first period, 15/268 (5.6%), while in the second, 5/451 (1.1%) carriers were detected (P < 0.0004). The average diameter of the cysts was 4.71 cm in 1984/1986 and 2.14 in 1997/1998. US as a mass screening method allows evaluation of early changes in human prevalence rates, closely related to infestation rates in sheeps and dogs, thus providing a sensitive indicator of the evaluation of control programs.

Portadores asintomaticos de hidatidosis: epidemiologia, diagnostico y tratamiento

Until a short time ago, hydatidosis was considered a pathology that could only be resolved surgically. However, in recent years progress has been made with the epidemiology, diagnosis, and treatment of the disease, and new information on the natural history of hydatidosis has helped define new criteria for its treatment. It is now known that as many as 67% of the carriers of liver cysts who are asymptomatic remain so throughout their lives. This situation produces special results in immunologic testing. Enzyme-linked immunosorbent assay (ELISA) has a sensitivity of 63% and a specificity of 97% with asymptomatic carriers, while the double diffusion arc 5 test (DD5) achieves a sensitivity of only 31% with the same population. On the other hand, imaging studies based on ultrasonography have become the method of choice to detect asymptomatic carriers. Ultrasonography studies are 49% to 73% more sensitive than serological tests, and they can even be used as a part of epidemiological surveillance systems and to monitor control programs. Treatment schemes have also been modernized. Treating asymptomatic carriers chemotherapeutically with albendazole produces favorable results in as many as 69% of cases, while such minimally invasive surgical treatments as puncture-aspiration-injection-reaspiration (PAIR) reduce average cyst volume by as much as 66%. These factors have made it possible for hospital services in the province of Río Negro, Argentina, to establish a treatment scheme for asymptomatic carriers. It is based on the monitoring of small cysts (type Ia on the modified Gharbi scale); initial treatment with albendazole, followed by PAIR if there is no response, in larger or more complex cysts (types Ib, II, and III); and follow-up of inviable or dead cysts (types IV and V).

A case-control study of the risk factors for cystic echinococcosis among the children of Río Negro province, Argentina

Abstract In 1984 the prevalence of cystic echinococcosis (CE) in Río Negro province in central Argentina reached alarming levels, with almost 6% of children aged 7-13 years infected with the causative agent, Echinococcus granulosus . Although the control activities developed between 1980-2000 have now lowered the prevalence of infection in this age-group to 1.1%, transmission of E. granulosus has clearly not ceased. The aim of the present study was to identify possible flaws in the control programme and the risk factors associated with CE. The 24 cases and 66 controls used were identified during a survey of the 1070 schoolchildren attending 12 schools in Ingeniero Jacobacci, Río Negro province. In interviews based around a standardized questionnaire, the adult female with responsibility for each subject (usually the mother but sometimes a grandmother or guardian) was asked 70 questions about the child and his or her immediate family, their contact with dogs and relevant environmentmental factors, and their level of contact with the control programme. Univariate and multivariate analyses were used to determine odds ratios (OR) and their 95% confidence intervals (CI). The main risk factors found to be significantly associated with CE were having a family member with the disease (OR=3.11; CI=0.92-10.47), spending the first years of life surrounded by a large number of dogs (OR=2.11; CI=1.2-3.5), and having a father who slaughtered sheep at his workplace (OR=1.14; CI=1.04-1.24). Obtaining drinking water from a tap (OR=0.28; CI=0.08-1.01) also remained in the final model, as a protective factor.

SEROEPIDEMIOLOGY OF HUMAN HYDATIDOSIS: USE OF DRIED BLOOD SAMPLES ON FILTER PAPER

Programmes for the control of hydatidosis caused by Echinococcus granulosus in Argentina use an enzyme immunoassay (EIA) as a screening test for population surveys aimed at detecting asymptomatic patients. Persons thus selected are referred to health centres for the arc 5 double diffusion test and imaging techniques. One of the most costly procedures of these surveys is the collection of blood samples under field conditions; the possibility of collecting dry blood samples on filter paper was therefore investigated. In a survey of 497 rural inhabitants of an endemic area, the same number of hydatidosis cases (22) were identified by EIA using (i) serum samples and (ii) capillary blood samples obtained by finger prick and collected on filter paper. The latter system was both simpler and cheaper.

Control program of hydatid disease in the province of Río Negro Argentina.: 1980-1997

La hidatidosis constituye un serio problema de Salud Publica en la Provincia de Rio Negro, Argentina. Los factores que han motivado esta situacion incluyen una economia rural basada en la ganaderia ovina extensiva, bajas condiciones socioculturales en una porcion importante de la poblacion rural, habitos de faenamiento domiciliario de ovinos adultos para consumo humano con entrega de las visceras resultantes del acto para consumo de los perros e infraestructura de faena en pequenas comunidades rurales altamente deficiente. Esta situacion ha promovido la instrumentacion de un programa de control basado en la desparasitacion canina sistematica con praziquantel, la vigilancia con arecolina, la educacion sanitaria, el control de faena, la legislacion y la atencion de las personas. El programa, puesto en marcha en 1980, cubrio inicialmente con acciones sistematicas 51.479 km2, alcanzandose en 1992 120,013 km2 bajo control. 11.915 canes rurales han recibido 1,870,423 comprimidos de praziquantel con coberturas que en promedio fueron del 65%. Se efectuaron 21.444 controles de materia fecal canina mediante la dosificacion con bromhidrato de arecolina, (control anual del 11,2% de los canes bajo programa). La prevalencia equinococcosica inicial era de 41,5%, siendo en 1996 del 2,9%. La hidatidosis ovina, por su parte, presenta una disminucion acentuada de la prevalencia, ubicandose en 1996 en el 5,5%. En relacion a hidatidosis humana, 1,720 casos nuevos fueron diagnosticados en toda la provincia en el periodo 1980/1996, el 31,4% de los cuales correspondieron a infectados asintomaticos, mediante encuestas serologicas o ecograficas (48.826 encuestas serologicas a poblacion escolar y a pobladores rurales adultos y 2.762 encuestas ultrasonograficas). El numero de casos humanos nuevos en el grupo de edad 0-10 anos presenta una disminucion del 77% desde la puesta en marcha del programa. Por el contrario, zonas no tratadas muestran una tendencia estable en la aparicion de casos humanos nuevos. En el periodo 1980/1986 se produjeron 581 casos nuevos en las areas bajo programa, mientras que en el periodo 1990/1996 el numero de casos nuevos fue de 275. Las encuestas ultrasonograficas en poblacion asintomatica, por su parte, arrojaron tasas de positividad del 5,5% (1984), 4,1% (1986) y 2,1% (1996). El modelo desarrollado, basado en una estructura de ejecucion descentralizada, con activa participacion comunitaria, seleccion de tecnologias sencillas y enfoque de riesgo; sustentado en el tiempo sobre la base de una firme decision politica de continuidad programatica y a su bajo costo operativo habria en tal sentido, modificado la capacidad de reproduccion del parasito.

Critical analysis of cystic echinococcosis control programs and praziquantel use in South America, 1974-2010

Cystic echinococcosis (CE) is one of the most prevalent zoonoses in Argentina, Brazil, Chile, Peru, and Uruguay. Control programs in South America were originally modeled after programs developed in insular territories, such as Tasmania and New Zealand. The advent and proven effectiveness of praziquantel, plus the experience of insular models, produced high expectations for rapid advances; however, after 30 years of praziquantel use, no endemic area in South America has obtained eradication. In fact, only modest gains in CE control have been made and impact on prevalence among humans has been slight. A major impediment has been the infrastructure needed to administer praziquantel to dogs in rural areas 8 times per year over numerous years, a requirement for rapid attack stage 1. Such an infrastructure has not been financially or politically sustainable in endemic areas, which tend to be the poorest. On the other hand, certain areas in Argentina have had success with simple and economically viable alternatives. Based primarily on continuous field work supported by the local community, these strategies have significantly decreased transmission to humans, the health sectors main objective. In addition, new possibilities and tools, such as the EG95 vaccine, are being evaluated; as are early detection and treatment of asymptomatic carriers.

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 vaccines 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.

Early diagnosis, treatment and follow-up of cystic echinococcosis in remote rural areas in Patagonia: impact of ultrasound training of non-specialists.

Cystic echinococcosis (CE) is a chronic, complex and neglected disease caused by the larval stage of Echinococcus granulosus. The effects of this neglect have a stronger impact in remote rural areas whose inhabitants have no chances of being diagnosed and treated properly without leaving their jobs and travelling long distances, sometimes taking days to reach the closest referral center. Background In 1980 our group set up a control program in endemic regions with CE in rural sections of Rio Negro, Argentina. Since 1997, we have used abdominopelvic ultrasound (US) as a screening method of CE in school children and determined an algorithm of treatment. Objectives To describe the training system of general practitioners in early diagnosis and treatment of CE and to evaluate the impact of the implementation of the field program. Materials and Methods In 2000, to overcome the shortage of radiologists in the area, we set up a short training course on Focused Assessment with Sonography for Echinococcosis (FASE) for general practitioners with no previous experience with US. After the course, the trainees were able to carry out autonomous ultrasound surveys under the supervision of the course faculty. From 2000 to 2008, trainees carried out 22,793 ultrasound scans in children from 6 to 14 years of age, and diagnosed 87 (0.4%) new cases of CE. Forty-nine (56.4%) were treated with albendazole, 29 (33.3%) were monitored expectantly and 9 (10.3%) were treated with surgery. Discussion The introduction of a FASE course for general practitioners allowed for the screening of CE in a large population of individuals in remote endemic areas with persistent levels of transmission, thus overcoming the barrier of the great distance from tertiary care facilities. The ability of local practitioners to screen for CE using US saved the local residents costly travel time and missed work and proved to be an efficacious and least expensive intervention tool for both the community and health care system.