Edoardo Pozio

Epidemiology, Diagnosis, Treatment, and Control of Trichinellosis

SUMMARY Throughout much of the world, Trichinella spp. are found to be the causative agents of human trichinellosis, a disease that not only is a public health hazard by affecting human patients but also represents an economic problem in porcine animal production and food safety. Due to the predominantly zoonotic importance of infection, the main efforts in many countries have focused on the control of Trichinella or the elimination of Trichinella from the food chain. The most important source of human infection worldwide is the domestic pig, but, e.g., in Europe, meats of horses and wild boars have played a significant role during outbreaks within the past 3 decades. Infection of humans occurs with the ingestion of Trichinella larvae that are encysted in muscle tissue of domestic or wild animal meat. Early clinical diagnosis of trichinellosis is rather difficult because pathognomonic signs or symptoms are lacking. Subsequent chronic forms of the disease are not easy to diagnose, irrespective of parameters including clinical findings, laboratory findings (nonspecific laboratory parameters such as eosinophilia, muscle enzymes, and serology), and epidemiological investigations. New regulations laying down rules for official controls for Trichinella in meat in order to improve food safety for consumers have recently been released in Europe. The evidence that the disease can be monitored and to some extent controlled with a rigorous reporting and testing system in place should be motivation to expand appropriate programs worldwide.

Sequence analysis of the β-giardin gene and development of a polymerase chain reaction-restriction fragment length polymorphism assay to genotype Giardia duodenalis cysts from human faecal samples

The flagellate parasite Giardia duodenalis is a major cause of diarrhoea in humans and in animals worldwide. Molecular techniques are particularly useful for studying the taxonomy, the population structure, the zoonotic potential of animal isolates, and the correlation between the genetic variability of the parasite and the range of clinical symptoms observed in humans. In this work, a new PCR assay that targets the beta-giardin gene was tested on 21 Giardia duodenalis reference strains representing Assemblages A, B and E, which are associated with infections of humans and other mammals. The assay was then applied to 30 faecal samples collected from Italian persons. The sequence analysis of 31 PCR products from both reference strains and clinical samples showed that each Assemblage is clearly distinct from the others on the basis of specific substitutions; the sequence diversity was approximately 5%, and all substitutions occurred at the third codon positions of the gene. The analysis of the intra-Assemblage variability allowed for the identification of three genotypes within Assemblage A, and of four genotypes within Assemblage B. Interestingly, two genotypes were identified only in the clinical samples and not in reference strains. Finally, a simple PCR-restriction fragment length polymorphism method was developed for the rapid discrimination of Assemblages and applied for the direct genetic analysis of cysts present in human faecal samples.

Systematics and epidemiology of trichinella.

In this review, we describe the current knowledge on the systematics, ecology and epidemiology of Trichinella and trichinellosis, and the impact of recent research discoveries on the understanding of this zoonosis. The epidemiology of this zoonosis has experienced important changes over the past two decades, especially with regard to the importance of the sylvatic cycle and the sylvatic species. Outbreaks of trichinellosis due to Trichinella spiralis from domestic swine, while still frequent, increasingly are caused by other Trichinella spp. infecting hosts such as horses, dogs, wild boars, bears and walruses. The latter revelations have occurred as a result of a series of discoveries on the systematics of Trichinella spp., facilitated by new molecular tools. As a consequence, the genus is now composed of two clades, an encapsulated group (five species and three genotypes) and a non-encapsulated one (three species). This has sparked renewed investigations on the host range of these parasites and their epidemiological features. Most dramatic, perhaps, is the recognition that reptiles may also serve as hosts for certain species. This new knowledge base, in addition to having an important relevance for food safety policies and protection measures, is raising important questions on the phylogeny of Trichinella spp., the ecological characteristics of the species and their geographic histories. Answers to these questions may have great value for the understanding of the evolutionary biology for other parasitic helminths, and may increase the value of this genus as models for research on parasitism in general.

Opinion on the diagnosis and treatment of human trichinellosis

The clinical diagnosis of trichinellosis is difficult because there are no pathogenic signs or symptoms and in diagnosing the infection epidemiological data are of great importance. Trichinellosis usually begins with a sensation of general discomfort and headache, increasing fever, chills and sometimes diarrhoea and/or abdominal pain. Pyrexia, eyelid or facial oedema and myalgia represent the principal syndrome of the acute stage, which can be complicated by myocarditis, thromboembolic disease and encephalitis. High eosinophilia and increased creatine phosphokinase activity are the most frequently observed laboratory features and the parasitological examination of a muscle biopsy and the detection of specific circulating antibodies will confirm the diagnosis. The medical treatment includes anthelmintics (mebendazole or albendazole) and glucocorticosteroids. Mebendazole is usually administered at a daily dose of 5 mg/kg but higher doses (up to 20 – 25 mg/kg/day) are recommended in some countries. Albendazole is used at 800 mg/day (15 mg/kg/day) administered in two doses. These drugs should be taken for 10 – 15 days. The use of mebendazole or albendazole is contraindicated during pregnancy and not recommended in children aged < 2 years. The most commonly used steroid is prednisolone, which may alleviate the general symptoms of the disease. It is administered at a dose of 30 – 60 mg/day for 10 – 15 days.

Worldwide occurrence and impact of human trichinellosis, 1986-2009.

To assess the global incidence and clinical effects of human trichinellosis, we analyzed outbreak report data for 1986-2009. Searches of 6 international databases yielded 494 reports. After applying strict criteria for relevance and reliability, we selected 261 reports for data extraction. From 1986 through 2009, there were 65,818 cases and 42 deaths reported from 41 countries. The World Health Organization European Region accounted for 87% of cases; 50% of those occurred in Romania, mainly during 1990-1999. Incidence in the region ranged from 1.1 to 8.5 cases per 100,000 population. Trichinellosis affected primarily adults (median age 33.1 years) and about equally affected men (51%) and women. Major clinical effects, according to 5,377 well-described cases, were myalgia, diarrhea, fever, facial edema, and headaches. Pork was the major source of infection; wild game sources were also frequently reported. These data will be valuable for estimating the illness worldwide.

Giardia Cysts in Wastewater Treatment Plants in Italy

ABSTRACT Reductions in annual rainfall in some regions and increased human consumption have caused a shortage of water resources at the global level. The recycling of treated wastewaters has been suggested for certain domestic, industrial, and agricultural activities. The importance of microbiological and parasitological criteria for recycled water has been repeatedly emphasized. Among water-borne pathogens, protozoa of the genera Giardia and Cryptosporidium are known to be highly resistant to water treatment procedures and to cause outbreaks through contaminated raw or treated water. We conducted an investigation in four wastewater treatment plants in Italy by sampling wastewater at each stage of the treatment process over the course of 1 year. The presence of the parasites was assessed by immunofluorescence with monoclonal antibodies. While Cryptosporidium oocysts were rarely observed, Giardia cysts were detected in all samples throughout the year, with peaks observed in autumn and winter. The overall removal efficiency of cysts in the treatment plants ranged from 87.0 to 98.4%. The removal efficiency in the number of cysts was significantly higher when the secondary treatment consisted of active oxidation with O2 and sedimentation instead of activated sludge and sedimentation (94.5% versus 72.1 to 88.0%; P = 0.05, analysis of variance). To characterize the cysts at the molecular level, the β-giardin gene was PCR amplified, and the products were sequenced or analyzed by restriction. Cysts were typed as assemblage A or B, both of which are human pathogens, stressing the potential risk associated with the reuse of wastewater.

Genotyping of Giardia duodenalis From Humans and Dogs From Mexico Using a β-Giardin Nested Polymerase Chain Reaction Assay

Cysts of Giardia duodenalis were collected in Mexico from symptomatic children (n = 9) and from pet dogs (n = 5), and they were directly characterized by nested polymerase chain reaction (PCR) amplification of the β-giardin gene. Eight isolates of human origin established as in vitro cultures and 2 reference strains, representing assemblages A and B of G. duodenalis, were also analyzed. PCR–restriction fragment length polymorphism showed that all isolates belonged to assemblage A. Sequence analyses indicated that the large majority of isolates were of the A1 genotype; interestingly, 2 human isolates displayed the A3 genotype, which has been previously identified in human isolates from Italy. The presence of cysts of the A1 and A3 genotypes in isolates from pet dogs is consistent with their role as reservoirs for human infection, although further studies are needed to confirm the occurrence of zoonotic transmission. Remarkably, cysts of assemblage B have not been found in any of the Mexican isolates studied to date.

Molecular taxonomy, phylogeny and biogeography of nematodes belonging to the Trichinella genus

Studying parasites of the genus Trichinella provides scientists of today many advantages. This is a group of zoonotic nematodes that circulates freely among wildlife hosts with one in particular, Trichinella spiralis that is exceptionally well adapted to domestic swine. Recent reports suggest that human infections from hunted animals are on the rise worldwide and numerous countries still experience problems with T. spiralis in their domestic food supplies. Trichinella is a genus whose members are easily propagated in the laboratories, have been used as models to investigate host-parasite relationships and parasitism among clade I organisms, and represent a poorly investigated link between the phylum Nematoda and other Metazoans. The importance of T. spiralis in better understanding the tree of life was so recognized that in 2004, its genome was carefully selected as one of only nine key non-mammalian organisms to be sequenced to completion. Since it was first discovered in 1835, this genus has expanded from being monospecific to eight species including four other genotypes of undetermined taxonomic rank. Inasmuch as discriminating morphological data have been scant, our understanding of the genus has been relegated to a compilation of molecular, biochemical and biological data. Herein, we provide a collection of information and up-to-date interpretations on the taxonomy, diagnostics, systematics, micro- and macroevolution, and the biogeographical and biohistorical reconstruction of the genus Trichinella.

Hosts and habitats of Trichinella spiralis and Trichinella britovi in Europe

Trichinella spiralis and Trichinella britovi are the two most common species of Trichinella circulating in Europe. Based on data provided to the International Trichinella Reference Centre over the past 20 years (data referring to 540 isolates of T. spiralis and 776 isolates of T. britovi), we describe the host species and habitat characteristics for these two pathogens in Europe. A Geographical Information System was constructed using administrative boundaries, a Corine Land Cover (CLC) map, and an elevation map. In most countries, T. britovi is more widespread (62.5-100% of the isolates) than T. spiralis (0.0-37.5%), although in Finland, Germany, Poland and Spain, T. spiralis is more prevalent (56.3-84.2% of the isolates). Trichinella britovi is more widespread than T. spiralis in sylvatic carnivores (89% versus 11%), whereas T. spiralis is prevalent in both wild boars (62% versus 38%) and domestic swine (82% versus 18%), as well as in rodents (75% versus 25%). Trichinella spiralis and T. britovi circulate in the same environments: 41.1% and 46.0%, respectively, in agricultural areas, and 45.5% and 46.6% in forested and semi-natural areas. Although both pathogens can be transmitted by domestic and sylvatic cycles, their epidemiology is strongly influenced by the higher adaptability of T. spiralis to swine and of T. britovi to carnivores. These results are important because they include information on the countries at risk for these pathogens, the role played by specific species as reservoirs, the role of the pathogens in domestic and sylvatic cycles, and the role of the habitat in their circulation. The results can also be used to identify the most suitable animal species for the monitoring of these pathogens in Europe.

Human Infection with Cryptosporidium felis: Case Report and Literature Review

An infection with Cryptosporidium felis in an HIV-positive man from Italy was successfully treated with paromomycin, despite the patient’s having a CD4+ cell count of 31/mL. Fourteen cases of human infection with C. felis have been described, all in the past 3 years, emphasizing the public health importance of Cryptosporidium parasites other than C. parvum.