Albendazole and ivermectin for the control of soil-transmitted helminths in an area with high prevalence of Strongyloides stercoralis and hookworm in northwestern Argentina: A community-based pragmatic study

Efficacy and Safety of Albendazole Versus Albendazole and Ivermectin in Reduction of Soil-Transmitted Helminth Infections in School-Age Children (DVERMIN): A Double-Blind, Randomized, Controlled Trial

BACKGROUND

Soil-transmitted helminth (STH) infections are endemic in India despite considerable improvements in hygiene conditions and regular deworming. This multicentric, double-blind, randomized controlled trial (Efficacy and Safety of Albendazole Versus AlbenDazole and IVERmectin in Reduction of Soil-Transmitted HelMINth Infections in School-Age Children (DVERMIN)) was conducted to evaluate the efficacy and safety of albendazole versus albendazole + ivermectin in the treatment of STH infections and to evaluate the prevalence of stool-positivity for STH in school-going children from 12 schools of Lucknow and Kolkata.

METHODS

This was a randomized controlled trial conducted from March 2022 to February 2023. The included children aged 6-15 years were administered single-dose oral suspension of albendazole (400 mg) or albendazole (400 mg) + ivermectin (3/6/12 mg based on body weight). The primary endpoint was the microbiological cure rate (proportion of infected children having egg-free stool samples post single-dose treatment) on Day 7. The secondary endpoints were egg reduction rate and clinical cure rate (proportion of children with symptom resolution) on Day 7, and the proportion of children in the regions of study conduct with stool positivity for STH at baseline. Safety was assessed based on adverse events (AEs).

RESULTS

Among the 1233 eligible children, stool samples from 1067 were evaluable at baseline. A total of 416 (38.99%) of these 1067 samples were egg-positive. Ascaris lumbricoides was the most prevalent STH (99.52% samples). Of the 416 samples, 304 were evaluable for post-dose analysis (albendazole, 146; albendazole + ivermectin, 158). In these samples, the microbiological cure rate achieved with albendazole (61.64%) was comparable to that achieved with albendazole + ivermectin (62.03%; p=0.95). The egg reduction rate obtained with albendazole was 90.61% compared to 93.22% achieved with albendazole + ivermectin. The rate of complete clinical cure on Day 7 was 66.95% with albendazole and 71.31% with albendazole + ivermectin (p=0.47). A moderate AE unrelated to antihelminthic medication was observed with albendazole; no AE was observed with albendazole + ivermectin.

CONCLUSIONS

Overall, both treatments were found to be effective and safe in school-age children. The rates of microbiological cure, egg reduction, and clinical cure were not significantly different between the groups; however, a clinical advantage was demonstrated in the albendazole + ivermectin group with respect to egg reduction and clinical cure.

Population Pharmacokinetics and Exposure-Response Analysis of a Fixed-Dose Combination of Ivermectin and Albendazole in Children, Adolescents, and Adults

Trichuris trichiura is a soil-transmitted helminth causing intestinal disease. Albendazole is the standard treatment despite its moderate efficacy, which is improved when co-administered with ivermectin. A fixed-dose combination adds practical advantages mainly for mass drug administration. The aim of this article is to define the population pharmacokinetic models and exposure-response of an innovative albendazole/ivermectin combination. Data were obtained from a phase I clinical trial in healthy adults and from a phase II trial in children and adolescents infected with T. trichiura. Nonlinear mixed-effects models were built for albendazole and ivermectin using NONMEM®. Area under the curve was calculated using the empirical Bayes estimates of the pharmacokinetic parameters of each individual and used for evaluation of exposure-response between cure rate and pharmacokinetic exposure. The pharmacokinetics of albendazole was described using a two-compartmental model with first-order absorption and the pharmacokinetics of ivermectin was described using a two-compartmental model with zero-order followed by first-order absorption. Clearance and volume of distribution increased with body weight for both albendazole and ivermectin. Day 1 area under the curve of albendazole and ivermectin from the children and adolescents treated with the combination regimens were similar to the healthy adults treated with control drugs. A flat exposure-response relationship was observed between the cure rate and drug exposure. Population pharmacokinetic of a combination of albendazole and ivermectin in children, adolescents, and adults, either healthy or infected by T. trichiura was described. The dosage selected in the phase II trial was appropriate for the subsequent phase III.

Seroprevalence of Strongyloides stercoralis, human T-lymphotropic virus, and Chagas disease in the Peruvian Amazon: a cross-sectional study

Strongyloides stercoralis infections, human T-lymphotropic virus (HTLV) infections, and Chagas diseases occur throughout many regions of Central and South America, including Peru. This study aimed to evaluate the seroprevalence of S. stercoralis, HTLV, and Chagas disease in Iquitos (Peruvian Amazon) and the associated epidemiological conditions for S. stercoralis seroprevalence in Iquitos. A population-based cross-sectional study was conducted from May 1 to June 15, 2020, to assess the seroprevalence of S. stercoralis [lysate antigen ELISA (enzyme linked immunosorbent assay)], HTLV (recombinant antigen ELISA), and Chagas disease (crude and recombinant antigen ELISAs). Of the 396 included individuals, 257 were seropositive for S. stercoralis (a 64.9% prevalence, 95% confidence interval [CI] 60.0% to 69.4%). In the multivariable analysis, seropositivity for S. stercoralis was higher in women (odds ratio [OR] 1.60, 95% CI 1.03 to 2.66) and residents of Punchana (OR 3.47, 95% CI 1.51 to 7.93), whereas residence in Iquitos was associated with lower positivity (OR 0.52, 95% CI 0.32 to 0.85). In total, four individuals were positive for HTLV (1.0% seroprevalence, 95% CI 0.3% to 2.7%), and none were positive for Chagas disease (0.0% seroprevalence, 95% CI 0.0% to 1.2%). The seroprevalence of S. stercoralis in Iquitos is high, particularly among women and residents of Punchana. The presence of HTLV infection indicates that the virus is circulating in Iquitos. This study found no cases of Chagas disease.

Systematic review and meta-analysis of soil-transmitted helminth infections in South America (2000-2024)

Soil-transmitted helminths (STHs) are parasitic nematodes commonly found in tropical and subtropical regions, where poor sanitation makes them a significant public health concern. This study provides a comprehensive review and meta-analysis of human STH infections across 13 South American countries from 2000 to 2023. It covers these infections' prevalence, distribution, and diagnosis, highlighting the environmental factors influencing transmission pathways. The review identified 134 studies on human STH infections, revealing Brazil as the most researched country. The meta-analysis found prevalence rates of Ascaris lumbricoides, Trichuris trichiura, hookworms, and Strongyloides stercoralis below 20 %, with notable heterogeneity across studies. Most studies used conventional microscopy for diagnosis, pointing out the need for implementing advanced diagnostic tools. Environmental and climatic factors, including temperature annual range, vegetation density, soil types, and properties were significant predictors of STH prevalence. The study calls for more research performing advanced diagnostic methods and broader geographical coverage to address existing data gaps. Furthermore, it emphasizes the need for holistic public health policies integrating biomedical and environmental approaches to ensure effective disease management.

The impact of community based interventions for the prevention and control of soil-transmitted helminths: A systematic review and meta-analysis

Soil-transmitted helminths (STHs) are among the most common human infections worldwide and a major cause of morbidity. They are caused by different species of parasitic worms and transmitted by eggs released in faeces or when hookworm larvae penetrate the skin. The main control strategy in endemic regions is periodic treatment with deworming medication. In the last 10 years, there has been a scale-up of prevention and control activities with a focus on community-based interventions (CBIs). This review aims to systematically analyse the impact of CBIs on the prevalence and infection intensity of STHs. A systematic review was published on this topic in 2014, but there have subsequently been several new studies published which are included in this review. Electronic database search of MEDLINE (Ovid), Global Health Online (Ovid), Cochrane Library, Embase (Ovid) and Web of Science was conducted. Titles, abstracts, and full texts were screened by two independent reviewers according to predefined eligibility criteria. Data were extracted and a meta-analysis of included studies was conducted. A total of 11,954 de-duplicated titles were screened, and 33 studies were included in the review. 14 focussed on community-wide treatment, 11 studies investigated school-based interventions, and 3 studies investigating both. Results suggest that CBIs are effective in reducing the prevalence of Hookworm, Trichuris trichiura and Ascaris lumbricoides. School-based treatment and community-wide treatment, as well as annual and semi-annual deworming, all reduce STH prevalence significantly. Mass drug administration was effective in reducing the infection intensity of Hookworm (Mean difference: -211.36 [95% CI: -519.12, 96.39]), Trichuris trichiura (-736.69 [-1349.97, -123.42]) and Ascaris lumbricoides (-2723.34 [-5014.85, -431.84]). The results suggest that CBIs are effective in reducing the prevalence and intensity of STH infections. While most studies delivered preventive chemotherapy (PC), few studies explored the impact of interventions such as water, sanitation, and hygiene (WASH) or health education, which may be essential in preventing reinfection after PC.

Malnutrition and intestinal parasitosis: Current prevalences and risk factors among schoolchildren in Misiones (Argentina)

OBJECTIVES

To assess the current prevalences of nutritional status and intestinal parasites, and their potential association with socio-environmental conditions among schoolchildren in Aristóbulo del Valle, Misiones.

METHODS

We measured body weight and height in 444 schoolchildren aged 3-14 years and evaluated their nutritional status following WHO criteria. We examined fecal samples and anal swabs from 234 schoolchildren and collected socio-environmental data through questionnaires.

RESULTS

The prevalence of undernutrition was 4.5% and excess of weight was 24.1%. The prevalence of stunting and of being overweight reached 2.3% and 12.4%, respectively. About 42% of the schoolchildren were infected with at least one of the 12 species identified. The most prevalent species were Blastocystis sp., Enterobius vermicularis, and Giardia lamblia. Entamoeba dispar was recorded for the first time in the locality. The multiple correspondence analysis identified peri-urban, urban, and rural groups. Underweight, stunting and obesity were highest in the peri-urban group, while overweight, wasting and parasitism rates were highest in the rural group. The urban group showed the lowest parasitic prevalences. Bed-sharing, mother's education, and animal husbandry were associated with parasitic infections.

CONCLUSIONS

The study highlights a decrease in undernutrition but a rise in overweight and obesity, indicating an ongoing nutritional transition. The association between socio-environmental risk factors and parasitic infections underscore the need for comprehensive interventions addressing both nutritional and socio-environmental conditions to improve the population's life quality.

Persistent transmission of soil-transmitted helminths despite 16 years of uninterrupted Mebendazole- and ivermectin-based preventive chemotherapy in the Lomie Health District (East Region, Cameroon): The emergency of complementary control strategies

BACKGROUND

The control of the Soil-Transmitted Helminths (STH) infections primarily relies on the school-based Preventive Chemotherapy (PCT) with mebendazole. Given the efficacy of ivermectin on STH, the control of the latter is expected to be potentialized in areas where ivermectin is also distributed for onchocerciasis and/or lymphatic filariasis control/elimination. This study aimed to assess the prevalence and intensity of STH in the Lomie Health District where annual school-based deworming campaigns and community-directed treatments with Ivermectin have been underway for almost two decades.

METHODOLOGY/PRINCIPAL FINDINGS

A quantitative cross-sectional study was conducted in 10 schools of the Lomie Health District, East Region, Cameroon. Stool samples were collected from school-aged children and analysed using the Kato-Katz technique. Semi-structured questionnaires were administered to enrolees to assess compliance with water, sanitation, and hygiene (WASH). Of the 491 children (median age: 9 years; IQR: 7-10) enrolled, 83.9% (95% CI: 80.3-87.1) were infected with at least one STH species. Trichuris trichiura was the predominant species (78.5%), and no hookworm was found. The prevalence trend slightly decreased between 1987 and 2010 (~8%) and remained unchanged since 2010 (p-value = 0.05). Overall, 46.8% and 41.8% of children were heavy-to-moderately infected with Ascaris lumbricoides and T. trichiura. Poor hand hygiene (OR: 2.24, 95% IC: 1.4-3.4, p-value = 0.0002) and the use of river as a source of drinking water (OR: 14.8, 95% IC: 6.9-33.3, p-value = 0.0001) were the main risk factors associated with the STH infection in Lomie Health District.

CONCLUSIONS/SIGNIFICANCE

The persistent high prevalence and intensity of STH infection despite 16 years of mebendazole-based PCT and expected collateral impact of ivermectin mass distribution, points to plausible implementation gaps, poor compliance to WASH or sub-optimal efficacy of the anthelminthics used. This study highlights the need to further assess the cause of the persistent high prevalence and implement context-adapted control measures in order to curb STH transmission.

Effectiveness of ivermectin mass drug administration in the control of soil-transmitted helminth infections in endemic populations: a systematic review and meta-analysis

BACKGROUND

Current soil-transmitted helminth (STH) control guidelines endorse the use of albendazole or mebendazole for school-based targeted preventive chemotherapy (PC), yet their reduced efficacy against Strongyloides stercoralis and Trichuris trichiura presents significant limitations. Emerging evidence indicates that community-wide PC [or mass drug administration (MDA)] using ivermectin, commonly used in other neglected tropical disease (NTD) control programs, may play an important role in controlling these parasites. We conducted a systematic review and meta-analysis to evaluate the effectiveness of ivermectin PC in reducing STH prevalence in endemic populations.

METHODS

We searched Pubmed, EMBASE, and Web of Science on February 14, 2023, for studies that investigated the effectiveness of ivermectin PC, either alone or in combination with other anthelmintic drugs, on STH infections, and provided a measure of STH prevalence before and after PC. We calculated pooled prevalence reductions for each STH using random-effects meta-analyses. Our protocol is available on PROSPERO (registration number CRD42023401219).

RESULTS

A total of 21 were eligible for the systematic review, of which 15 were eligible for meta-analysis. All studies delivered ivermectin through MDA. The pooled prevalence reduction of S. stercoralis following MDA with ivermectin alone was 84.49% (95% CI 54.96-94.66) across five studies and 81.37% (95% CI 61.62-90.96) across seven studies with or without albendazole. The prevalence reduction of T. trichiura was 49.93% (95% CI 18.23-69.34) across five studies with ivermectin alone, and 89.40% (95% CI 73.66-95.73) across three studies with the addition of albendazole. There was high heterogeneity for all syntheses (I2 > 65%).

CONCLUSIONS

This study underscores the key role of ivermectin-based MDA in addressing limitations in current global STH guidelines in terms of limited efficacy against S. stercoralis and T. trichiura. Based on these findings, revising international STH guidelines to include ivermectin is a promising option to progress the control and eventual elimination of STHs and other NTDs.

Intestinal parasites in children from native communities of Salta, Argentina

Introduction

Intestinal parasites particularly affect vulnerable populations, making their management crucial in endemic areas.

Objective

To evaluate the relationship between intestinal parasites, socioeconomic characteristics, and anthropometric nutritional status.

Methods

This is an observational, cross-sectional study conducted on children aged 1 to 15 years in Tartagal, Argentina, for a year. Intestinal parasitic infections were determined through fecal analysis using sedimentation techniques (Teleman), Kato-Katz, and the Baerman method. Demographic and socioeconomic data were collected using a standardized survey. Height, weight, and mid-upper arm and head circumference were measured in the participants.

Results

Of the 588 participants who provided fecal samples, 55.4% had intestinal parasites, with G. lamblia and H. nana being the most prevalent species. Additionally, 31.9% of participants were found to have malnutrition due to excess weight. Risk factors for intestinal parasite presence included age, overcrowding, and walking barefoot, while owning a refrigerator, having an animal corral, adequate water storage, and belonging to the Guaraní ethnic group were protective factors. High vulnerability areas were observed regarding housing conditions and access to public services.

Conclusions

An association between socioeconomic conditions and the risk of intestinal parasite presence was observed. However, no association was found between anthropometric nutritional status and the presence of intestinal parasites.

The Relationship Between Soil-Transmitted Helminth Infections and Environmental Factors in Puerto Iguazú, Argentina: Cross-Sectional Study

BACKGROUND

Soil-transmitted helminths (STHs) are widely distributed throughout the world. Various factors, including the environment, socioeconomic characteristics, and access to water and sanitation, play an important role in the spread and persistence of these parasites within communities. They, in turn, affect the growth and development of members of the community, especially children. Studies in the northern provinces of Argentina have shown variable prevalence of STHs, but the factors associated with their presence have not been completely elucidated.

OBJECTIVE

This cross-sectional study aimed to identify the socioeconomic and environmental factors related to STH infection in indigenous villages located in Puerto Iguazú (Misiones), Argentina.

METHODS

Between 2018 and 2019, stool samples were collected from individuals ≥1 year residing in 3 villages: Mini-Marangatú, Yriapú, and Fortín Mbororé. Standard parasitological methods were used to determine STH prevalence. Standardized questionnaires were used to assess participants' habits, customs, and household characteristics, and environmental data were obtained through satellite imagery. Multilinear regression with Akaike information criterion stepwise variables was used to explore relevant associations.

RESULTS

A total of 342 individuals from the 3 villages participated in this study. The prevalence of STHs varied across villages: 89.6% (43/48), in Mini-Marangatú, 80.8% (101/125) in Yriapú, and 68.5% (115/169) in Fortín Mbororé. Notably, there was a significant difference in hookworm infection among the villages (P=.02). The analysis highlighted the significant influence of specific environmental factors on STH presence and spatial distribution, particularly in relation to hookworm infection. Vegetation patterns represented by the Vegetation Heterogeneity Index, created ad hoc for this study, emerged as a critical factor, with 2 significant predictors related to it (P=.002 and P=.004) alongside impervious surface density with a significant predictor (P<.001). The multilinear regression model yielded a high F test score (F108=4.75, P<.001), indicating a strong fit (R2=0.5465). Furthermore, socioeconomic factors, including walking barefoot in houses with dirt floors and overcrowding, were significantly correlated with hookworm infection intensity (P<.001 and P=.001, respectively). We also used the multilinear regression model to calculate hookworm infection intensity (F110=21.15, P<.001; R2=0.4971).

CONCLUSIONS

Our study underscores the complexity of STH transmission, as villages with similar living conditions and environmental characteristics displayed varied STH prevalence and spatial distribution. Specific environmental factors, such as vegetation pattern and impervious surface density, played major roles in STH presence, demonstrating the crucial relationship between environmental factors and hookworm infection distribution. Moreover, our findings emphasize the significant influence of socioeconomic factors on hookworm infection intensity. By gaining insights into this complex interplay, our research contributes to a better understanding of STH transmission characteristics, thereby informing targeted public health interventions for effective control.

Impact of preventive chemotherapy on Strongyloides stercoralis: A systematic review and meta-analysis

BACKGROUND

Strongyloides stercoralis is a neglected soil-transmitted helminth (STH) that leads to significant morbidity in endemic populations. Infection with this helminth has recently been recognised by the World Health Organization (WHO) as a major global health problem to be addressed with ivermectin preventive chemotherapy, and therefore, there is now, the need to develop guidelines for strongyloidiasis control that can be implemented by endemic countries. This study aimed to evaluate the impact of ivermectin preventive chemotherapy (PC) on S. stercoralis prevalence in endemic areas to generate evidence that can inform global health policy.

METHODOLOGY/PRINCIPAL FINDINGS

This study was a systematic review and meta-analysis. We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and LILACS for literature published between 1990 and 2022 and reporting prevalence of S. stercoralis before and after PC with ivermectin, administered either at school or at community level. The search strategy identified 933 records, eight of which were included in the meta-analysis. Data extraction and quality assessment were carried out by two authors. Meta-analysis of studies based on fecal testing demonstrated a significant reduction of S. stercoralis prevalence after PC: prevalence Risk Ratio (RR) 0.18 (95% CI 0.14-0.23), I2 = 0. A similar trend was observed in studies that used serology for diagnosis: RR 0.35 (95% CI 0.26-0.48), I2 = 4.25%. A sensitivity analysis was carried out for fecal tests where low quality studies were removed, confirming a post-intervention reduction in prevalence. The impact of PC could not be evaluated at different time points or comparing annual vs biannual administration due to insufficient data.

CONCLUSIONS/SIGNIFICANCE

Our findings demonstrate a significant decrease of S. stercoralis prevalence in areas where ivermectin PC has taken place, supporting the use of ivermectin PC in endemic areas.

Intestinal parasitic infections in a community from Pampa del Indio, Chaco (Argentina) and their association with socioeconomic and environmental factors

Neglected tropical diseases are a group of 20 disabling diseases, which, in particular, are the most common chronic infections in the most vulnerable people. This study aimed to characterize the infection by intestinal parasites (IPs) in dwellings from a peri-urban neighborhood in Pampa del Indio, Chaco (Argentina), and its association with socioeconomic and environmental variables. Single stool samples were collected from all individuals older than 1 year through household visits and processed using coprological sedimentation and flotation techniques. Standardized questionnaires were used at the household level to collect socio-economic information. Environmental variables were obtained from the Planetscope image, Landsat 8 images and remote sensors, while land-use layers were obtained through the use of a maximum likelihood algorithm. Stool samples were provided by 314 individuals. The prevalence of IPs found was 30.6% (n = 96), with a predominance of Giardia lamblia (12.7%, n = 40) and Hymenolepis nana (7.6%, n = 24). The only soil-transmitted helminth found was Strongyloides stercoralis with a 2.5% prevalence (n = 8). Individuals of adult age (> 18 years) were 0.65 times less likely to present parasitic infections with respect to children and adolescents. The only environmental variable that was closely associated with the presence of IPs, was the Normalized Difference Water Index (NDWI), a measure of humidity; being higher around houses with positive individuals. Most of the IPs found in this study were of water-borne transmission and those transmitted directly from person-to-person, therefore fecal contamination is present. We believe that the low prevalence of STH in this area, which requires a passage through the soil, is related to the environmental characteristics, which are unsuitable for the development/permanence of the infective stages of these parasites. The geospatial data and tools used herein proved to be useful for the study of the relationship between the different factors that influence the presence of IPs in a community, from an eco-health approach.

Ivermectin systemic availability in adult volunteers treated with different oral pharmaceutical formulations

Ivermectin (IVM) is currently approved as an antiparasitic agent for human use in the treatment of onchocerciasis, lymphatic filariasis, strongyloidiasis, scabies, and pediculosis. Recent findings indicate that IVM may reach other pharmacological targets, which accounts for its proven anti-inflammatory/immunomodulatory, cytostatic, and antiviral effects. However, little is known about the assessment of alternative drug formulations for human use.

OBJECTIVE

To compare the systemic availability and disposition kinetics of IVM orally administered as different pharmaceutical formulations (tablet, solution, or capsule) to healthy adults.

EXPERIMENTAL DESIGN/MAIN FINDINGS

Volunteers were randomly assigned to 1 of 3 experimental groups and orally treated with IVM as either, a tablet, solution, or capsules at 0.4 mg/kg in a three-phase crossover design. Blood samples were taken as dried blood spots (DBS) between 2 and 48 h post-treatment and IVM was analyzed by HPLC with fluorescence detection. IVM Cmax value was higher (P < 0.05) after the administration of the oral solution compared to treatments with both solid preparations. The oral solution resulted in a significantly higher IVM systemic exposure (AUC: 1653 ng h/mL) compared to the tablet (1056 ng h/mL) and capsule (996 ng h/mL) formulations. The simulation of a 5-day repeated administration for each formulation did not show a significant systemic accumulation.

CONCLUSION

Beneficial effects against systemically located parasitic infections as well as in any other potential therapeutic field of IVM application would be expected from its use in the form of oral solution. This pharmacokinetic-based therapeutic advantage without the risk of excessive accumulation needs to be corroborated in clinical trials specifically designed for each purpose.

Iron deficiency and soil-transmitted helminth infection: classic and neglected connections

Beyond participating in the oxygen transport by red blood cells, iron is an essential micronutrient and contributes to different physiological pathways and processes, such as cell proliferation, DNA repair, and other homeostatic functions. Iron deficiency affects millions of people, especially children and pregnant women. The consequences of iron deficiency are diverse, including inadequate child development, impaired cognition, and reduced productivity. Several factors contribute to iron deficiency, such as iron-poor diet, genetic factors, and infection with soil-transmitted helminths (STHs), especially roundworms (Ascaris lumbricoides), hookworms (Necator americanus and Ancylostoma duodenale), and whipworms (Trichuris trichiura). This review updates and summarizes the role of STHs as drivers of iron deficiency. Also, the poorly explored connections between STH infection, geophagia (a pica manifestation), immune response, and iron deficiency are discussed, highlighting how iron deficiency may act as a risk factor for infections by STHs, in addition to being a consequence of intestinal parasitic infections. Finally, strategies for control and management of iron deficiency and STH infection are described.

Factors associated with variation in single-dose albendazole pharmacokinetics: A systematic review and modelling analysis

BACKGROUND

Albendazole is an orally administered anti-parasitic medication with widespread usage in a variety of both programmatic and clinical contexts. Previous work has shown that the drug's pharmacologically active metabolite, albendazole sulfoxide, is characterised by substantial inter-individual pharmacokinetic variation. This variation might have implications for the efficacy of albendazole treatment, but current understanding of the factors associated with this variation remains incomplete.

METHODOLOGY/PRINCIPAL FINDINGS

We carried out a systematic review to identify references containing temporally disaggregated data on the plasma concentration of albendazole and/or (its pharmacologically-active metabolite) albendazole sulfoxide following a single oral dose. These data were then integrated into a mathematical modelling framework to infer albendazole sulfoxide pharmacokinetic parameters and relate them to characteristics of the groups being treated. These characteristics included age, weight, sex, dosage, infection status, and whether patients had received a fatty meal prior to treatment or other drugs alongside albendazole. Our results highlight a number of factors systematically associated with albendazole sulfoxide pharmacokinetic variation including age, existing parasitic infection and receipt of a fatty meal. Age was significantly associated with variation in albendazole sulfoxide systemic availability and peak plasma concentration achieved; as well as the clearance rate (related to the half-life) after adjusting for variation in dosage due to differences in body weight between children and adults. Receipt of a fatty meal prior to treatment was associated with increased albendazole sulfoxide systemic availability (and by extension, peak plasma concentration and total albendazole sulfoxide exposure following the dose). Parasitic infection (particularly echinococcosis) was associated with altered pharmacokinetic parameters, with infected populations displaying distinct characteristics to uninfected ones.

CONCLUSIONS/SIGNIFICANCE

These results highlight the extensive inter-individual variation that characterises albendazole sulfoxide pharmacokinetics and provide insight into some of the factors associated with this variation.

Pharmacokinetic Characterization and Comparative Bioavailability of an Innovative Orodispersible Fixed-Dose Combination of Ivermectin and Albendazole: A Single Dose, Open Label, Sequence Randomized, Crossover Clinical Trial in Healthy Volunteers

Soil-transmitted helminths are intestinal worm diseases transmitted through the soil. Available treatments are albendazole and/or ivermectin. The co-administration of existing drugs is an appropriate strategy. A fixed-dose combination adds practical advantages mainly considering mass drug administration. The aim is to characterize pharmacokinetics and to evaluate the comparative bioavailability of an innovative fixed-dose combination of ivermectin/albendazole 18/400 mg compared with the marketed references. Seventy-eight healthy volunteers were included in this laboratory-blinded, randomized, three-treatment, three-period crossover study. Each subject received a single dose of ivermectin/albendazole 18/400 mg (1 tablet); ivermectin 3 mg (6 tablets); and albendazole 400 mg (1 tablet). Serial blood samples for the pharmacokinetic analysis were obtained pre-dose and up to 72 h post-dose. Plasma concentrations of ivermectin H2B1a, ivermectin H2B1b, albendazole, and albendazole sulfoxide were analyzed by LC-MS/MS. Pharmacokinetic parameters were estimated by a non-compartmental analysis and bioavailability compared through a bioequivalence analysis. Safety and tolerability were assessed throughout the study. Main pharmacokinetic parameters of the fixed combination were estimated for both, ivermectin [Cmax (mean, confidence interval): 86.40 (30.42-39.23) ng/ml; AUC0-72 (mean, CI): 1,040 (530-1,678) ng·h/mL; tmax (median, min., and max.); 4.50 (2.50-5.50)] and albendazole [Cmax (mean, CI): 22.27 (1.89-111.78) ng/ml; AUC0-72 (mean, CI): 94.65 (11.65-507.78) ng·h/mL; tmax (median, min., and max.): 2.50 (1.00-12.00) h]. The 90% confidence interval of the geometric mean ratios demonstrated the bioequivalence in the case of ivermectin (Cmax: 110.68%-120.49%; AUC0-72: 110.46%-119.60%) but not in the case of albendazole (Cmax: 53.10%-70.34%; AUC0-72: 61.13%-76.54%). The pharmacokinetic profile of a new fixed-dose combination of ivermectin and albendazole was characterized. The bioequivalence versus the reference ivermectin was demonstrated, though bioequivalence versus albendazole was not shown. The three medications analyzed were well tolerated. The results allow the advancement to the next phase of the clinical program to demonstrate efficacy and safety in patients affected by soil-transmitted helminths. Clinical Trial Registration: https://www.clinicaltrialsregister.eu/ctr-search/search/, identifier Nr. 2020-003438-19.

Strongyloides stercoralis and Trypanosoma cruzi coinfections in a highly endemic area in Argentina

Background

Strongyloidiasis and Chagas disease are endemic in northern Argentina. In this study we evaluate the association between S. stercoralis and T. cruzi infections in villages with diverse prevalence levels for these parasites. Further understanding in the relationship between these Neglected Tropical Diseases of South America is relevant for the design of integrated control measures as well as exploring potential biologic interactions.

Methodology

Community based cross-sectional studies were carried in different villages of the Chaco and Yungas regions in Argentina. Individuals were diagnosed by serology for S. stercoralis and T. cruzi. The association between S. stercoralis and T. cruzi, and between anemia and the two parasites was evaluated using two approaches: marginal (Ma) and multilevel regression (Mu).

Results

A total of 706 individuals from six villages of northern Argentina were included. A total of 37% were positive for S. stercoralis, 14% were positive for T. cruzi and 5% were positive for both. No association was found between infection with S. stercoralis and T. cruzi in any of the models, but we found a negative correlation between the prevalence of these species in the different villages (r = -0.91). Adults (> 15 years) presented association with S. stercoralis (Ma OR = 2.72; Mu OR = 2.84) and T. cruzi (Ma OR = 5.12; Mu OR = 5.48). Also, 12% and 2% of the variance of infection with S. stercoralis and T. cruzi, respectively, could be explained by differences among villages. On the other hand, anemia was associated with infection with S. stercoralis (Ma OR = 1.73; Mu OR = 1.78) and was more prevalent in adults (Ma OR = 2.59; Mu OR = 2.69).

Conclusion

We found that coinfection between S. stercoralis and T. cruzi is not more frequent than chance in endemic areas. However, the high prevalence for both parasites, raises the need for an integrated strategy for the control of STH and Chagas disease.

Infections with S. stercoralis and T. cruzi belong to the group of neglected tropical diseases (NTDs). NTDs are influenced by climate and the presence of their vectors and host reservoirs in areas with structural poverty. S. stercoralis and T. cruzi have high prevalence in northern Argentina. Due to the high prevalence and chronicity of infections by these parasites, coinfection with both is possible. We conducted a cross sectional study in six villages in the north of Argentina. These villages have different prevalence for the two parasites and are located in different ecoregions (Chaco, Yungas and the border between these two). We found that coinfection between S. stercoralis and T. cruzi occurs only by chance; and the most affected groups for S. stercoralis and T. cruzi infection are adults. We also found that adults or individual with infection with S. stercoralis were more likely to have anemia. In addition, each village represents a different setting for infection with S. stercoralis and T. cruzi, and individuals in different villages presented differences in the probability of infection.

Prevalence and risk factors of strongyloidiasis among schoolchildren in Sabach Sanjal and Upper Badibou districts in the North Bank East Region of The Gambia

Background

Strongyloidiasis is a parasitic disease that mainly affects humans and is caused by a roundworm called Strongyloides stercoralis. It is endemic in humid tropical regions that include Africa, Latin America and Southern Asia. Among the public health important soil-transmitted helminths (STHs) classified as neglected tropical diseases, S. stercoralis is the most neglected. A study of schistosomiasis and STHs mapping was conducted and S. stercoralis larvae were detected using the utilized diagnostic method; thus, this current study described the prevalence and risk factors of S. stercoralis infection in districts of Sabach Sanjal and Upper Badibou in The Gambia.

Methods

The cross-sectional study enrolled 851 schoolchildren, ages 7 to 14 years old. The participants were enrolled from 17 schools in Sabach Sanjal and Upper Badibou Districts. The WHO random sampling technique n/50 (25 boys and 25 girls) was used. Stool samples were collected from each participant and Kato-Katz smear method was used to screen for S. stercoralis infection.

Results

Out of the total 851 pupils, 76 pupils (8.9%) were positive for S. stercoralis infection. The mean age of infected persons was 10.1 years (±2.2). The prevalence of infection was higher among females (9.2%) than males (8.7%). Rates of infection for age categories 7–10 years and 11–14 years were 12.4% and 4.2%, respectively. Rates of infection by districts were 12.3% for Sabach Sanjal and 7.1% for Upper Badibou. Schoolchildren from Sabach Sanjal were 1.6 times more likely to have strongyloidiasis compared to those from Upper Badibou (aOR = 1.64, p-value = 0.058). Schoolchildren aged 7–10 years were 3.2 times more likely to have strongyloidiasis infection compared to the 11–14-year-olds (aOR = 3.20, p-value <0.001). Schoolchildren who ‘sometimes’ have water or tissue after defaecation have more infection rate compared to those who ‘always’ have water or tissue after defaecation. However, this difference was not statistically significant (aOR = 1.36, p-value = 0.308).

Conclusion

The study revealed the prevalence of strongyloidiasis in Sabach Sanjal and Upper Badibou districts of The Gambia. Kato-Katz technique might be inadequate for detecting S. stercoralis; thus, more studies are needed to determine the true prevalence of the disease in these two districts through the combined use of highly sensitive techniques such as Baermann, Koga Agar Culture and polymerase chain reaction.

Strongyloides stercoralis seropositivity is not associated with increased symptoms in a remote Aboriginal community

BACKGROUND

Strongyloides stercoralis is a soil-transmitted helminth, endemic in remote Aboriginal and Torres Strait Islander communities in northern Australia with estimates of prevalences up to 60%. Hyperinfection in the setting of immunosuppression is a rare, but well recognised cause of significant morbidity and mortality. However, the morbidity associated with chronic uncomplicated infection is less well characterised.

AIMS

To measure the prevalence of symptoms potentially attributable to S. stercoralis infection and their association with seropositivity.

METHODS

This retrospective matched case-control study reviewed records of primary healthcare presentations for symptoms in the 12 months before and after an ivermectin mass drug administration (MDA) in a remote Aboriginal community.

RESULTS

One hundred and seventy-five S. stercoralis seropositive cases were matched with 175 seronegative controls. The most frequently reported symptom overall in the 12 months prior to the MDA was cough followed by abdominal pain, weight loss/malnutrition, diarrhoea and pruritis. Seropositive cases were not more likely than matched controls to have symptoms typically attributed to strongyloidiasis. In the seropositive cohort, we found no difference in symptoms in the 12 months before and after an ivermectin MDA despite a reduction in seroprevalence.

CONCLUSION

We found no evidence to suggest that S. stercoralis seropositivity was associated with increased symptoms when compared to matched seronegative controls. Treatment with ivermectin did not reduce symptoms in seropositive cases. Without evidence to support that population-based screening or treatment programmes reduce symptoms, the emphasis must remain on identifying and managing those few individuals with immunosuppression that predisposes them to potentially life-threatening hyperinfection.

Albendazole and Mebendazole as Anti-Parasitic and Anti-Cancer Agents: an Update

The use of albendazole and mebendazole, i.e., benzimidazole broad-spectrum anthelmintics, in treatment of parasitic infections, as well as cancers, is briefly reviewed. These drugs are known to block the microtubule systems of parasites and mammalian cells leading to inhibition of glucose uptake and transport and finally cell death. Eventually they exhibit ovicidal, larvicidal, and vermicidal effects on parasites, and tumoricidal effects on hosts. Albendazole and mebendazole are most frequently prescribed for treatment of intestinal nematode infections (ascariasis, hookworm infections, trichuriasis, strongyloidiasis, and enterobiasis) and can also be used for intestinal tapeworm infections (taeniases and hymenolepiasis). However, these drugs also exhibit considerable therapeutic effects against tissue nematode/cestode infections (visceral, ocular, neural, and cutaneous larva migrans, anisakiasis, trichinosis, hepatic and intestinal capillariasis, angiostrongyliasis, gnathostomiasis, gongylonemiasis, thelaziasis, dracunculiasis, cerebral and subcutaneous cysticercosis, and echinococcosis). Albendazole is also used for treatment of filarial infections (lymphatic filariasis, onchocerciasis, loiasis, mansonellosis, and dirofilariasis) alone or in combination with other drugs, such as ivermectin or diethylcarbamazine. Albendazole was tried even for treatment of trematode (fascioliasis, clonorchiasis, opisthorchiasis, and intestinal fluke infections) and protozoan infections (giardiasis, vaginal trichomoniasis, cryptosporidiosis, and microsporidiosis). These drugs are generally safe with few side effects; however, when they are used for prolonged time (>14-28 days) or even only 1 time, liver toxicity and other side reactions may occur. In hookworms, Trichuris trichiura, possibly Ascaris lumbricoides, Wuchereria bancrofti, and Giardia sp., there are emerging issues of drug resistance. It is of particular note that albendazole and mebendazole have been repositioned as promising anti-cancer drugs. These drugs have been shown to be active in vitro and in vivo (animals) against liver, lung, ovary, prostate, colorectal, breast, head and neck cancers, and melanoma. Two clinical reports for albendazole and 2 case reports for mebendazole have revealed promising effects of these drugs in human patients having variable types of cancers. However, because of the toxicity of albendazole, for example, neutropenia due to myelosuppression, if high doses are used for a prolonged time, mebendazole is currently more popularly used than albendazole in anti-cancer clinical trials.

Efficacy and safety of albendazole and high-dose ivermectin co-administration in school-aged children infected with Trichuris trichiura in Honduras: A Randomized Controlled Trial

BACKGROUND

The efficacy of currently available anthelminthics against Trichuris trichiura infections is significatively lower than for other soil-transmitted helminths (STH). The combination of ivermectin (IVM) and albendazole (ALB) has shown significant improvements in efficacy.

METHODS

Safety and efficacy randomized controlled clinical trial comparing 3 experimental regimens against ALB monotherapy for the treatment of T. trichiura infections in northern Honduras. Infected children were randomized to one of the following treatments: (Arm 1) single-dose ALB 400 mg; (Arm 2) single-dose ALB 400 mg/IVM 600 μg/kg; (Arm 3) ALB 400 mg for 3 consecutive days; or (Arm 4) ALB 400 mg/IVM 600 μg/kg for 3 consecutive days. Efficacy was measured through egg reduction rate (ERR) and cure rate (CR), both assessed 14-21 days after treatment using the Kato-Katz method. Safety was evaluated by analyzing the frequency and severity of adverse events.

RESULTS

A total of 176 children were randomized to one of the 4 treatment arms, 117 completed treatment and follow-up. The ERR for Arms 1 to 4 were: 47.7%, 96.7%, 72.1% and 100%, respectively; with p-values <0.001 between IVM groups and ALB only arms. The CRs were 4.2%, 88.6%, 33.3% and 100%, respectively. A total of 48 (85.4% mild) AEs were reported in 36 children.

CONCLUSIONS

The combined use of ALB and high-dose IVM is a highly effective and well tolerated treatment for the treatment of T. trichiura infections offering a significantly improved treatment for the control of this infection.

Preventive chemotherapy for the control of strongyloidiasis in school-age children: Estimating the ivermectin need

BACKGROUND

Strongyloides stercoralis is a soil-transmitted helminth (STH) that affects approximately 600 million people worldwide. Interventions targeting S. stercoralis have not been implemented yet. Specific treatment (ivermectin) could be included in already ongoing preventive chemotherapy (PC) campaigns targeting other STHs. The aim of this study was to estimate the quantity of ivermectin needed for an integrated STH/S. stercoralis control program.

METHODODOLOGY/PRINCIPAL FINDINGS

Our study estimates the number of school- age children (SAC) (the main focus of STH deworming campaigns) in need of PC with ivermectin. The normal approximation of the binomial distribution was adopted to calculate the hypothetical prevalence distribution in each endemic country. Considering prevalence thresholds for PC equal to 10%, 15%, and 20%, we estimated the number of SAC in need of treatment. We adjusted the estimates accounting for ivermectin distributed in lymphatic filariasis and onchocerciasis elimination programs and excluded from our calculation areas where Loa loa is endemic. The global number of SAC that should be targeted in PC campaigns was estimated at 283.9 M (95% CI: 163.4-368.8), 207.2 M (95% CI: 160.9-380.7), and 160.7 M (95% CI: 86.6-225.7) when the threshold for intervention was set to 10%, 15%, and 20%, respectively. India, China, Indonesia, Bangladesh, and Nigeria accounted for about 50% of the global SAC would have to be covered by PC intervention.

CONCLUSIONS/SIGNIFICANCE

Our analysis may support endemic countries to evaluate the ivermectin quantity needed for integrating strongyloidiasis in the existing STH programs. These estimates might also show to generic drug manufacturers the size of the potential market for ivermectin and encourage its production.

A systematic review and an individual patient data meta-analysis of ivermectin use in children weighing less than fifteen kilograms: Is it time to reconsider the current contraindication?

BACKGROUND

Oral ivermectin is a safe broad spectrum anthelminthic used for treating several neglected tropical diseases (NTDs). Currently, ivermectin use is contraindicated in children weighing less than 15 kg, restricting access to this drug for the treatment of NTDs. Here we provide an updated systematic review of the literature and we conducted an individual-level patient data (IPD) meta-analysis describing the safety of ivermectin in children weighing less than 15 kg.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for IPD guidelines by searching MEDLINE via PubMed, Web of Science, Ovid Embase, LILACS, Cochrane Database of Systematic Reviews, TOXLINE for all clinical trials, case series, case reports, and database entries for reports on the use of ivermectin in children weighing less than 15 kg that were published between 1 January 1980 to 25 October 2019. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017056515. A total of 3,730 publications were identified, 97 were selected for potential inclusion, but only 17 sources describing 15 studies met the minimum criteria which consisted of known weights of children less than 15 kg linked to possible adverse events, and provided comprehensive IPD. A total of 1,088 children weighing less than 15 kg were administered oral ivermectin for one of the following indications: scabies, mass drug administration for scabies control, crusted scabies, cutaneous larva migrans, myiasis, pthiriasis, strongyloidiasis, trichuriasis, and parasitic disease of unknown origin. Overall a total of 1.4% (15/1,088) of children experienced 18 adverse events all of which were mild and self-limiting. No serious adverse events were reported.

CONCLUSIONS/SIGNIFICANCE

Existing limited data suggest that oral ivermectin in children weighing less than 15 kilograms is safe. Data from well-designed clinical trials are needed to provide further assurance.

Asymptomatic Strongyloidiasis among Latin American Migrants in Spain: A Community-Based Approach

Strongyloides stercoralis infection is frequently underdiagnosed since many infections remain asymptomatic. Aim: To estimate the prevalence and characteristics of asymptomatic S. stercoralis infection in Latin American migrants attending a community-based screening program for Chagas disease in Spain. Methodology: Three community-based Chagas disease screening campaigns were performed in Alicante (Spain) in 2016, 2017, and 2018. Serological testing for S. stercoralis infection was performed using a non-automatized IVD-ELISA detecting IgG (DRG Instruments GmbH, Marburg, Germany). Results: Of the 616 migrants from Central and South America who were screened, 601 were included in the study: 100 children and adolescents (<18 years of age) and 501 adults. Among the younger group, 6 participants tested positive (prevalence 6%, 95% confidence interval [CI] 2.5% to 13.1%), while 60 adults did so (prevalence 12%, 95% CI 9.3% to 15.3%). S. stercoralis infection was more common in men than in women (odds ratio adjusted [ORa] 2.28, 95% CI 1.289 to 4.03) and in those from Bolivia (ORa 2.03, 95% CI 1.15 to 3.59). Prevalence increased with age (ORa 1.02, 95% CI 0.99 to 1.05). In contrast, a university education had a protective effect (ORa 0.29, 95% CI 0.31 to 0.88). Forty-one (41/66; 62.1%) of the total cases of S. stercoralis infection were treated at the health care center. Positive stool samples were observed in 19.5% of the followed-up positive cases. Conclusion: Incorporating serological screening for S. stercoralis into community-based screening for Chagas disease is a useful intervention to detect asymptomatic S. stercoralis infection in Central and South American migrants and an opportunity to tackle neglected tropical diseases in a transversal way. The remaining challenge is to achieve patients’ adherence to the medical follow-up.

Epidemiology of intestinal helminthiases in a rural community of Ethiopia: Is it time to expand control programs to include Strongyloides stercoralis and the entire community?

BACKGROUND

Soil transmitted helminths are highly prevalent worldwide. Globally, approximately 1.5 billion people are infected with Ascaris lumbricoides, Trichuris trichiura or hookworm. Endemic countries carry out periodic mass treatment of at-risk populations with albendazole or mebendazole as a control measure. Most prevalence studies have focused on school aged children and therefore control programs are implemented at school level, not at community level. In this study, the prevalence of intestinal helminths, including Strongyloides stercoralis, was examined using a comprehensive laboratory approach in a community in north-western Ethiopia.

METHODS

A cross-sectional survey was conducted on 792 individuals ≥5 years old in randomly selected houses in a rural district. Stools were examined using three techniques: a formol-ether concentration, the Baermann technique and a real time polymerase chain reaction test (these last two specific for S. stercoralis). Statistical analyses were performed between two large age groups, children (≤14 years old) and adults (≥15 years old).

RESULTS

The prevalence of helminths was 91.3%; (95% CI: 89.3-93.3%). Hookworm was the most prevalent, 78.7% (95% CI 75.6-81.4%), followed by S. stercoralis 55.7% (95% CI 52.2-59.1%). Co-infection with both was detected in 45.4% (95% CI 42.0-49.0%) of the participants. The mean age of hookworm-infected individuals was significantly higher than non-infected ones (p = 0.003). Also, S. stercoralis infection was significantly associated with age, being more prevalent in adults (p = 0.002).

CONCLUSIONS

This is the highest prevalence of S. stercoralis detected in Ethiopia so far. Our results highlight the need of searching specifically for infection by this parasite since it usually goes unnoticed if helminth studies rely only on conventional diagnostic techniques, i.e. Kato-Katz. Moreover, the focus of these programs on children undermines the actual prevalence of hookworm. The adult population acts as a reservoir for both hookworm and S. stercoralis and this fact may negatively impact the current control programs in Ethiopia which only target treatment of school aged children. This reservoir, together with a lack of adequate water, sanitation and hygiene, increases the probability of re-infection in children. Finally, the high prevalence of S. stercoralis found calls for a comprehensive diagnostic approach in endemic areas in addition to a revision of control measures that is, adding ivermectin to current albendazole/mebendazole, since it is the drug of choice for S. stercoralis.

Seroprevalence of the Strongyloides stercoralis Infection in Humans from Yungas Rainforest and Gran Chaco Region from Argentina and Bolivia

The threadworm, Strongyloides stercoralis, is endemic in tropical and subtropical areas. Data on the prevalence and distribution of infection with this parasite species is scarce in many critical regions. We conducted a seroprevalence study of S. stercoralis infection in 13 locations in the Gran Chaco and Yungas regions of Argentina and Bolivia during the period 2010-2016. A total of 2803 human serum samples were analyzed by ELISA-NIE which has a sensitivity of 75% and specificity of 95%. Results showed that 551 (19.6%) of those samples were positive. The adjusted prevalence was 20.9%, (95% confidence interval (CI) 19.4%-22.4%). The distribution of cases was similar between females and males with an increase of prevalence with age. The prevalence in the different locations ranged from 7.75% in Pampa del Indio to 44.55% in Santa Victoria Este in the triple border between Argentina, Bolivia, and Paraguay in the Chaco region. Our results show that S. stercoralis is highly prevalent in the Chaco and Yungas regions, which should prompt prospective surveys to confirm our findings and the design and deployment of control measures.

Mapping the Prevalence of Strongyloides stercoralis Infection in Ecuador: A Serosurvey

Data on the prevalence of strongyloidiasis in Ecuador are patchy. The aim of this study was to document the presence of Strongyloides stercoralis infection in rural communities of different provinces of Ecuador. We tested 1,418 serum samples stored at the biobank of the Central University of Ecuador, Quito, with an ELISA test for Strongyloides. The samples had been collected in eight different provinces of Ecuador. Two hundred ninety-four samples (20.7%) were positive, and Jipijapa, Manabí Province, was the site with the largest proportion of positive samples (66.7%). Further surveys aimed at estimating the prevalence of the infection should be carried out in areas where the infection seems highly prevalent, and ad hoc control measures should be adopted.

A Cross-Sectional Study of Seroprevalence of Strongyloidiasis in Pregnant Women (Peruvian Amazon Basin)

Strongyloidiasis is a soil-transmitted helminthiasis with a high global prevalence. Objectives: We aimed to evaluate the prevalence of Strongyloides stercoralis infection and assess strongyloidiasis serology as a screening technique in the Peruvian Amazon. Material and Methods: We performed a cross-sectional study of strongyloidiasis in 300 pregnant women in Iquitos (Peru) from 1 May 2019 to 15 June 2019. Women were tested using serology (Strongyloides IgG IVD-ELISA kit) as an index test and the modified Baermann technique and/or charcoal fecal culture as the parasitological reference standard. Results: The reference tests showed S. stercoralis in the stool of 30 women (prevalence: 10%; 95% confidence interval [CI] 7.1% to 13.9%), while 101 women tested positive on the blood test (prevalence: 33.7%; 95% CI 28.6% to 39.4%). Fourteen of the 15 women (93.3%) with positive results according to the modified Baermann technique, and 14 of the 23 women (56.5%) with positive charcoal cultures also had positive serological results. Serology showed a sensitivity of 63.3% and a negative predictive value of 94.4%. Conclusion: In Iquitos, pregnant women have a high prevalence of S stercoralis. S. stercoralis ELISA could be an excellent tool for population-based screening, as it has a high negative predictive value that can help to rule out the presence of active infection.

Safety of high-dose ivermectin: a systematic review and meta-analysis

BACKGROUND

Ivermectin is a key anthelmintic for the control of neglected tropical diseases. The main indications for population-level control with ivermectin through mass drug administration are onchocerciasis and lymphatic filariasis; however, there is interest in using higher, fixed-dose regimens for the control of scabies, soil-transmitted helminths and malaria. Safety data for these higher-dose regimens are needed.

METHODS

A systematic literature review and meta-analysis on the safety and doses of ivermectin was conducted. Eligible studies reported patient-level data and, for the meta-analysis, clinical trials reporting data on doses ≥200 and ≥400 μg/kg were included. Incidence ratios were used to compare adverse events by severity and organ system affected.

RESULTS

The systematic search identified six studies for inclusion, revealing no differences in the number of individuals experiencing adverse events. A descriptive analysis of these clinical trials for a variety of indications showed no difference in the severity of the adverse events between standard (up to 400 μg/kg) and higher doses of ivermectin. Organ system involvement only showed an increase in ocular events in the higher-dose group in one trial for the treatment of onchocerciasis, all of them transient and mild to moderate in intensity.

CONCLUSIONS

Although within this review the safety of high-dose ivermectin appears to be comparable to standard doses, there are not enough data to support a recommendation for its use in higher-than-approved doses. Ocular adverse events, despite being transient, are of concern in onchocerciasis patients. These data can inform programme managers and guide operational research activities as new approaches for the use of ivermectin are evaluated.

Morbidity Associated with Chronic Strongyloides stercoralis Infection: A Systematic Review and Meta-Analysis

Strongyloides stercoralis, a worldwide-distributed soil-transmitted helminth, causes chronic infection which may be life threatening. Limitations of diagnostic tests and nonspecificity of symptoms have hampered the estimation of the global morbidity due to strongyloidiasis. This work aimed at assessing S. stercoralis-associated morbidity through a systematic review and meta-analysis of the available literature. MEDLINE, Embase, CENTRAL, LILACS, and trial registries (WHO portal) were searched. The study quality was assessed using the Newcastle-Ottawa scale. Odds ratios (ORs) of the association between symptoms and infection status and frequency of infection-associated symptoms were calculated. Six articles from five countries, including 6,014 individuals, were included in the meta-analysis-three were of low quality, one of high quality, and two of very high quality. Abdominal pain (OR 1.74 [CI 1.07-2.94]), diarrhea (OR 1.66 [CI 1.09-2.55]), and urticaria (OR 1.73 [CI 1.22-2.44]) were associated with infection. In 17 eligible studies, these symptoms were reported by a large proportion of the individuals with strongyloidiasis-abdominal pain by 53.1% individuals, diarrhea by 41.6%, and urticaria by 27.8%. After removing the low-quality studies, urticaria remained the only symptom significantly associated with S. stercoralis infection (OR 1.42 [CI 1.24-1.61]). Limitations of evidence included the low number and quality of studies. Our findings especially highlight the appalling knowledge gap about clinical manifestations of this common yet neglected soil-transmitted helminthiasis. Further studies focusing on morbidity and risk factors for dissemination and mortality due to strongyloidiasis are absolutely needed to quantify the burden of S. stercoralis infection and inform public health policies.

Soil-Transmitted Helminthiasis in Children from a Rural Community Taking Part in a Periodic Deworming Program in the Peruvian Amazon

Children in the Peruvian Amazon Basin are at risk of soil-transmitted helminths (STH) infections. This study aimed to determine the prevalence of STH infection in children from a rural Amazonian community of Peru and to elucidate epidemiological risk factors associated with its perpetuation while on a school-based deworming program with mebendazole. Stool samples of children aged 2-14 years and their mothers were analyzed through direct smear analysis, Kato-Katz, spontaneous sedimentation in tube, Baermann's method, and agar plate culture. A questionnaire was administered to collect epidemiological information of interest. Among 124 children, 25.8% had one or more STH. Individual prevalence rates were as follows: Ascaris lumbricoides, 16.1%; Strongyloides stercoralis, 10.5%; hookworm, 1.6%; and Trichuris trichiura, (1.6%). The prevalence of common STH (A. lumbricoides, T. trichiura, and hookworm) was higher among children aged 2-5 years than older children (31.6% versus 12.8%; P = 0.01). In terms of sanitation deficits, walking barefoot was significantly associated with STH infection (OR = 3.28; CI 95% = 1.11-12.07). Furthermore, STH-infected children more frequently had a mother who was concomitantly infected by STH than the non-STH-infected counterpart (36.4% versus 14.1%, P = 0.02). In conclusion, STH infection is highly prevalent in children from this Amazonian community despite routine deworming. Institutional health policies may include hygiene and sanitation improvements and screening/deworming of mothers to limit the dissemination of STH. Further studies are needed to address the social and epidemiological mechanics perpetuating these infections.

Strongyloides stercoralis: Spatial distribution of a highly prevalent and ubiquitous soil-transmitted helminth in Cambodia

Background

Strongyloides stercoralis is a neglected soil-transmitted helminth that occurs worldwide, though it is particularly endemic in tropical and subtropical areas. It can cause long-lasting and potentially fatal infections due to its ability to replicate within its host. S. stercoralis causes gastrointestinal and dermatological morbidity. The objective of this study was to assess the S. stercoralis infection risk and, using geostatistical models, to predict its geographical distribution in Cambodia.

Methodology / Principal findings

A nation-wide, community-based parasitological survey was conducted among the Cambodian population, aged 6 years and older. S. stercoralis was diagnosed using a serological diagnostic test that detects IgG antibodies in urine. Data on demography, hygiene and knowledge about helminth infection were collected. S. stercoralis prevalence among 7,246 participants with a complete data record was 30.5%, ranging from 10.9% to 48.2% across provinces. The parasite was ubiquitous in Cambodia; only five south-eastern provinces had prevalence rates below 20%. Infection risk increased with age for both men and women, although girls under the age of 13 and women aged 50 years and over had lower odds of infection than their male counterparts. Open defecation was associated with higher odds of infection, while having some knowledge of the health problems caused by worms was a protective factor. Infection risk was positively associated with nighttime maximum temperature, minimum rainfall, and distance to water; it was negatively associated with land occupied by rice fields.

Conclusions / Significance

S. stercoralis infection is rampant in Cambodia. Control programs delivering ivermectin are needed to manage the parasite. However, the high cost of this drug in Cambodia currently precludes the implementation of control initiatives. Donations, subsidies or affordable generics are needed so that S. stercoralis, which infects almost a third of the Cambodian population, can be addressed through an adequate control program.

The threadworm, Strongyloides stercoralis, is a highly neglected worm infection, transmitted through infective larvae in the soil. Threadworms occur worldwide, particularly in tropical climates. It may cause long-lasting and potentially fatal infections due to the parasite’s ability to replicate within its host. This study aimed to assess the risk of threadworm infection at national level in Cambodia. We conducted a nation-wide, community-based parasitological survey of the Cambodian population, aged 6 years and over. The threadworm was diagnosed using a serological diagnostic test that detects antibodies in urine. Data on demography, hygiene and knowledge about helminth infection were collected. The purpose of this study was to predict the risk of S. stercoralis infection in unsurveyed locations, assess risk factors for infection, and map its geographical distribution in Cambodia. About one third (30.5%) of the enrolled study participants (n = 7,246) were infected with threadworms. At provincial level, the lowest and highest infection rates were 10.9% and 48.2%, respectively. Prevalence rates below 20% were found in just five south-eastern provinces. The risk of a threadworm infection increased with age for both men and women. Open defecation was associated with higher risk of infection, while having some knowledge of the health problems caused by worms was a protective factor. Infection risk was positively associated with environmental factors, such as nighttime maximum temperature, minimum rainfall, and distance to water; it was negatively associated with land occupied by rice fields. Threadworm infection is highly prevalent in Cambodia and adequate control measures, including access to treatment, are warranted to address the burden of this Neglected Tropical Disease (NTD) in Cambodia.

Characterization of a non-sexual population of Strongyloides stercoralis with hybrid 18S rDNA haplotypes in Guangxi, Southern China

Strongyloidiasis is a much-neglected but sometimes fatal soil born helminthiasis. The causing agent, the small intestinal parasitic nematode Strongyloides stercoralis can reproduce sexually through the indirect/heterogonic life cycle, or asexually through the auto-infective or the direct/homogonic life cycles. Usually, among the progeny of the parasitic females both, parthenogenetic parasitic (females only) and sexual free-living (females and males) individuals, are present simultaneously. We isolated S. stercoralis from people living in a village with a high incidence of parasitic helminths, in particular liver flukes (Clonorchis sinensis) and hookworms, in the southern Chinese province Guangxi. We determined nuclear and mitochondrial DNA sequences of individual S. stercoralis isolated from this village and from close by hospitals and we compared these S. stercoralis among themselves and with selected published S. stercoralis from other geographic locations. For comparison, we also analyzed the hookworms present in the same location. We found that, compared to earlier studies of S. stercoralis populations in South East Asia, all S. stercoralis sampled in our study area were very closely related, suggesting a recent common source of infection for all patients. In contrast, the hookworms from the same location, while all belonging to the species Necator americanus, showed rather extensive genetic diversity even within host individuals. Different from earlier studies conducted in other geographic locations, almost all S. stercoralis in this study appeared heterozygous for different sequence variants of the 18S rDNA hypervariable regions (HVR) I and IV. In contrast to earlier investigations, except for three males, all S. stercoralis we isolated in this study were infective larvae, suggesting that the sampled population reproduces predominantly, if not exclusively through the clonal life cycles. Consistently, whole genome sequencing of individual worms revealed higher heterozygosity than reported earlier for likely sexual populations of S. stercoralis. Elevated heterozygosity is frequently associated with asexual clonal reproduction.

Diagnosis and drug resistance of human soil-transmitted helminth infections: A public health perspective

Soil-transmitted helminth (STH) infections represent a major public health problem globally, particularly among socio-economically disadvantaged populations. Detection of STH infections is often challenging, requiring a combination of diagnostic techniques to achieve acceptable sensitivity and specificity, particularly in low infection-intensity situations. The microscopy-based Kato-Katz remains the most widely used method but has low sensitivity in the detection of, for instance, Strongyloides spp. infections, among others. Antigen/antibody assays can be more sensitive but are parasite species-specific. Highly sensitive PCR methods have been developed to be multiplexed to allow multi-species detection. Novel diagnostic tests for all STH species are needed for effective monitoring, evaluation of chemotherapy programmes, and to assess the potential emergence of parasite resistance. This review discusses available diagnostic methods for the different stages of STH control programmes, which vary in sensitivity and spectrum of detection requirements, and tools to evaluate drug efficacy and resistance.

Prevalence of intestinal parasites and the absence of soil-transmitted helminths in Añatuya, Santiago del Estero, Argentina

BACKGROUND

Intestinal parasites (IP) have been reported in point studies from different provinces of Argentina. The presence of soil-transmitted helminths (STH) was detected in many of these studies, including varied prevalences of all five species of STH in the north were the climate is more appropriate for transmission. Nonetheless, Argentina lacks a comprehensive prevalence map of STH. Therefore, the objective of this study was to determine the prevalence of intestinal parasites, focusing on STH, in rural and peri-urban areas of Añatuya, Santiago del Estero Province and identifying risk factors for their transmission.

METHODS

We conducted a cross-sectional survey in the entire population of three rural lots located on the outskirts of the city between March and June of 2015 and among children in a peri-urban neighbourhood of Añatuya city in July 2016. Socio-economic variables, characteristics of the house and stool samples were collected from each household.

RESULTS

A total of 470 stool samples were analysed. The prevalence of STH was extremely low, with only 2 people being positive for hookworm and no detection of other STH. The prevalence of IP was 11.7% for protozoans and 11.1% for helminths. IP were significantly more prevalent in pre-school and school-aged children than in adults (P < 0.05). The level of education of adults was also significantly associated with infection (P = 0.001), as well as the practice of informal slaughter of animals (P = 0.002) and the presence of unimproved walls (P = 0.046) and unimproved floors (P = 0.021) in the household. Nonetheless, the only significant predictors of IP in the logistic regression analysis were age (P < 0.001) and main source of electricity (P = 0.026).

CONCLUSIONS

The total prevalence of intestinal parasites in the study population was 22.6%. The intestinal parasites detected are transmitted mostly through water (Giardia lamblia) and close contact (Hymenolepis nana), evidencing the need to improve quality control in water facilities and access to improved sanitation to avoid contamination of stored water. The presence of IP was significantly associated with age (with children being more susceptible), households containing unimproved walls and those that did not have access to an electricity network.

Knowledge, attitude and practice with respect to soil contamination by Soil-Transmitted Helminths in Ibadan, Southwestern Nigeria

Ancylostoma duodenale, Necator americanus, Ascaris lumbricoides and Trichuris trichiura, the four major Soil-transmitted helminths (STHs) and also Strongyloides stercoralis infect humans worldwide. Most studies on Soil-transmitted helminths (STHs) carried out in Ibadan were faecal examination based while relatively few soil examination based studies were carried out mostly around school premises using limited number of sampling locations. This study was therefore designed to assess the level of soil contamination with STH and associated risk factors in the eleven local government areas of Ibadan. A total of 1980 soil samples were purposively collected monthly, between January and December 2017, from toilet areas, refuse dump sites, house vicinities, playgrounds, roadsides/walk ways, and examined for the presence of parasite eggs or larvae using automated analysis of light microscopy images by computer. Well-structured questionnaires were administered to 620 consenting participants to obtain information on the Knowledge of STH infections, Attitudes and Practices towards the infections. Data were analyzed using SPSS version 21, Chi-square and ANOVA were used in the analysis at p < 0.05. Out of soil samples examined, 1087 (54.9%) had at least one species of parasite. The prevalence of hookworm was 74.5% followed by 50.2% and 37.2% for Strongyloides species larvae and adult respectively, and 25.1% for Ascaris species. The highest prevalence was observed in the refuse dump (74.2%) followed by toilet area (36.5%) while the lowest was at house vicinities (1.6%). Fifty-seven percent of the respondents use pit latrine while 20.6% still practice open defecation. A high transmission risk was observed as large percentage (66.8%) of the respondents showed inadequate knowledge of how to avoid STH infections. Moreover, 64.0% and 25.2% reported that they often walk barefooted and suck fingers respectively. The high prevalence of parasitic contamination of soil observed in the present study and the high proportion of respondent with inadequate knowledge of how to prevent transmission of STH pose a high risk of re-infections in the study area even after treatment. Therefore there is a need for proper education on parasite transmission in the area.

Misconceptions and paradoxes in soil-transmitted helminthiases control as a public health problem

Soil-transmitted helminthiases (STHs) constitute a public health problem that requires immediate action to resolve the morbidity of those harboring the parasites in their guts, to prevent infection in all those at risk, and to interrupt the vicious circle of poverty and disease in the affected communities, structural poverty being the main determinant of this group of infectious diseases. Since the times of the Rockefeller initiatives over a hundred years ago, the strategy has been viewed as one requiring community-wide efforts rather than pure individual case management. The World Health Organization (WHO) and its regional offices, as the governing institutions endorsed by the countries and their governments, have been the leaders in stating the actual executive measures to reach the goals and endpoints for the management of the problem. With the task of setting a group of activities that could be launched, monitored, and measured, these actions were established with the available resources since this public health problem had to be launched immediately, resources were those available at the moment and not those appearing on a wish list. Considerable progress has been made in the establishment of policies for the achievement of the Millennium Development Goals (MDGs), later followed by the Sustainable Development Goals (SDGs) through WHO-lead actions for the control of neglected tropical diseases (NTDs). With an initial goal of morbidity control, there are already discussions and proposals for elimination of STH if support is sustained and empiric facts confirm data emerging from modeling and small-scale studies. The aim of these comments is to describe and question instances of currently accepted concepts, theories, and practices that conform to the dogmatic status quo that serves as the foundation on top of which the new elimination aspirations are supposed to be built on, which might not be serving the desired purpose if taken unrevised.

Species specific RNA A-to-I editing of mosquito RDL modulates GABA potency and influences agonistic, potentiating and antagonistic actions of ivermectin

The insect GABA receptor, RDL, is the target of several classes of pesticides. The peptide sequences of RDL are generally highly conserved between diverse insects. However, RNA A-to-I editing can effectively alter amino acid residues of RDL in a species specific manner, which can affect the potency of GABA and possibly insecticides. We report here that RNA A-to-I editing alters the gene products of Rdl in three mosquito disease vectors, recoding five amino acid residues in RDL of Aedes aegypti and six residues in RDLs of Anopheles gambiae and Culex pipiens, which is the highest extent of editing in RDL observed to date. Analysis of An. gambiae Rdl cDNA sequences identified 24 editing isoforms demonstrating a considerable increase in gene product diversity. RNA editing influenced the potency of the neurotransmitter, GABA, on An. gambiae RDL editing isoforms expressed in Xenopus laevis oocytes, as demonstrated by EC₅₀s ranging from 5 ± 1 to 246 ± 41 μM. Fipronil showed similar potency on different editing isoforms, with IC₅₀s ranging from 0.18 ± 0.08 to 0.43 ± 0.09 μM. In contrast, editing of An. gambiae RDL affected the activating, potentiating and inhibiting actions of ivermectin. For example, ivermectin potentiated currents induced by GABA at the EC₂₀ concentration in the unedited isoform but not in the fully edited variant. Editing of a residue in the first transmembrane domain or the cys-loop influenced this potentiation, highlighting residues involved in the allosteric mechanisms of cys-loop ligand-gated ion channels. Understanding the interactions of ivermectin with molecular targets may have relevance to mosquito control in areas where people are administered with ivermectin to treat parasitic diseases.