Echinococcus multilocularis: an emerging pathogen in Hungary and Central Eastern Europe?

Helminth diversity of nutria (Myocastor coypus) across the Morava basin in the Czech Republic

The nutria was introduced to Europe from South America and kept for the fur industry. This semiaquatic rodent became a well-established species in the Czech Republic; however, it still poses a significant threat to the native fauna, not only as a natural competitor but also as a vector of non-indigenous parasites. Our research aimed to investigate the diversity of endoparasitic helminths in nutria, with a particular focus on assessing the risk posed by helminth species with zoonotic potential. A total of 46 nutria cadavers were collected at 8 locations in the Morava River basin and examined using standard parasitological post-mortem procedures. Additionally, coprological and molecular methods were used to identify the parasites. The presence of 6 helminth species was revealed. The highest prevalence was observed for Strongyloides myopotami (78.3%) and Trichuris myocastoris (37.0%), both of which are host-specific nematodes of nutria. Only 2 trematode taxa were recorded (Echinostoma sp. and a representative of the family Psilostomidae). The presence of alveolar hydatid cysts of Echinococcus multilocularis in the livers of 5 nutria specimens was also recorded. Herein, we provide novel molecular data for each parasite species collected, which is valuable for future phylogenetic analyses. Our findings also demonstrate that nutria in the Czech Republic serve as a carrier of helminths with zoonotic potential, particularly E. multilocularis and S. myopotami. Although the nutria is a relatively new species in local fauna, its synanthropic behaviour raises concerns about potential threats to human health, underscoring the importance of exercising caution when handling these animals.

Retrospective multidisciplinary analysis of human alveolar echinococcosis in Hungary using spatial epidemiology approaches

Human alveolar echinococcosis (HAE), which is caused by the larval stage of the Echinococcus multilocularis tapeworm, is an increasing healthcare issue in Hungary. Among the 40 known cases in the country, 25 were detected in the last five years. Our study aimed to reveal the geographically underlying risk factors associated potentially with these cases. We investigated the spatial pattern and the impact of potential risk factors of HAE by cluster analysis, and local and global regression models. Also, a questionnaire survey on the patients' lifestyle was implemented. We found two HAE hyperendemic foci in the country with very dissimilar biotic and climatic features, and controversial impact of different environmental factors. Four factors, viz. forest cover (β = 0.291, p < 0.0001), surface soil wetness (β = - 0.157, p = 0.033), fox infection rate (β = 0.369, p < 0.0001) and socio-economic development (β = - 0.216, p = 0.009), proved important countrywide. The most forested and the least developed districts showed the highest HAE risk. Among the patients, kitchen gardening (67.86%) and dog ownership (67.86%) seemed the riskiest activities. Our models detected an anomaly in one of the poorest regions of Hungary where all risk factors behaved contrary to that of the neighboring areas. This phenomenon was supposed to be the result of under-detection of the disease, and it called attention to the urgent priority of knowledge dissemination to the public and the healthcare professionals.

Suitability of red fox (Vulpes vulpes) and golden jackal (Canis aureus) as hosts of Echinococcus multilocularis based on egg production characteristics and literature data on the intestinal ecosystems of carnivores

Echinococcus multilocularis is the most important food-borne parasite in Europe. Its natural definitive host is the red fox (Vulpes vulpes) while other canid species play a secondary role in the maintenance of its endemics. However, recent studies call attention to the potential of golden jackal (Canis aureus) as a suitable definitive host for E. multilocularis. Our study aimed to evaluate the quantitative and qualitative egg production traits of adult E. multilocularis in different hosts as an indicator of reproductive success. Investigation of 111 and 82 parasites from 33 red foxes and 29 golden jackals, respectively, we ascertained that the proportion of worms with mature eggs was significantly lower in golden jackals than in red foxes. Those worms, which produced mature eggs in golden jackal hosts, originated from less crowded infrapopulations than their fox-originated counterparts. Other characteristics of the parasite's reproductive ability, such as the proportion of fertile worms, and mean egg production were similar in the two hosts. Comparing these findings to evolutionary data on different canid taxa, we hypothesised that the mutual presence of red fox and a differently evolved host of E. multilocularis might contribute to the formation of stable parasite circulation in these multi-host systems.

Emergence of Echinococcus multilocularis in Central Continental Croatia: A Human Case Series and Update on Prevalence in Foxes

Human alveolar echinococcosis (HAE), caused by the metacestode stage of Echinococcus multilocularis, has emerged in many European countries over the last two decades. Here, we report the first data on the new HAE focus with increasing incidence in central Croatia, describe its clinical presentation and outcomes in diagnosed patients, and provide an update on the prevalence and geographic distribution of Echinococcus multilocuaris in red foxes. After the initial case in 2017 from the eastern state border, from 2019 to 2022, five new autochthonous HAE cases were diagnosed, all concentrated in the Bjelovar-Bilogora County (the county incidence in 2019 and 2021: 0.98/10⁵, in 2022: 2.94/10⁵/year; prevalence for 2019-2022: 4.91/10⁵). The age range among four female and two male patients was 37-67 years. The patients' liver lesions varied in size from 3.1 to 15.5 cm (classification range: P2N0M0-P4N1M0), and one patient had dissemination to the lungs. While there were no fatalities, postoperative complications in one patient resulted in liver transplantation. In 2018, the overall prevalence of red foxes was 11.24% (28/249). A new focus on HAE has emerged in central continental Croatia, with the highest regional incidence in Europe. Screening projects among residents and the implementation of veterinary preventive measures following the One Health approach are warranted.

Albendazole reduces hepatic inflammation and endoplasmic reticulum-stress in a mouse model of chronic Echinococcus multilocularis infection

BACKGROUND

Echinococcus multilocularis causes alveolar echinococcosis (AE), a rising zoonotic disease in the northern hemisphere. Treatment of this fatal disease is limited to chemotherapy using benzimidazoles and surgical intervention, with frequent disease recurrence in cases without radical surgery. Elucidating the molecular mechanisms underlying E. multilocularis infections and host-parasite interactions ultimately aids developing novel therapeutic options. This study explored an involvement of unfolded protein response (UPR) and endoplasmic reticulum-stress (ERS) during E. multilocularis infection in mice.

METHODS

E. multilocularis- and mock-infected C57BL/6 mice were subdivided into vehicle, albendazole (ABZ) and anti-programmed death ligand 1 (αPD-L1) treated groups. To mimic a chronic infection, treatments of mice started six weeks post i.p. infection and continued for another eight weeks. Liver tissue was then collected to examine inflammatory cytokines and the expression of UPR- and ERS-related genes.

RESULTS

E. multilocularis infection led to an upregulation of UPR- and ERS-related proteins in the liver, including ATF6, CHOP, GRP78, ERp72, H6PD and calreticulin, whilst PERK and its target eIF2α were not affected, and IRE1α and ATF4 were downregulated. ABZ treatment in E. multilocularis infected mice reversed, or at least tended to reverse, these protein expression changes to levels seen in mock-infected mice. Furthermore, ABZ treatment reversed the elevated levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α and interferon (IFN)-γ in the liver of infected mice. Similar to ABZ, αPD-L1 immune-treatment tended to reverse the increased CHOP and decreased ATF4 and IRE1α expression levels.

CONCLUSIONS AND SIGNIFICANCE

AE caused chronic inflammation, UPR activation and ERS in mice. The E. multilocularis-induced inflammation and consecutive ERS was ameliorated by ABZ and αPD-L1 treatment, indicating their effectiveness to inhibit parasite proliferation and downregulate its activity status. Neither ABZ nor αPD-L1 themselves affected UPR in control mice. Further research is needed to elucidate the link between inflammation, UPR and ERS, and if these pathways offer potential for improved therapies of patients with AE.

Emerging human alveolar echinococcosis in Hungary (2003-2018): a retrospective case series analysis from a multi-centre study

Background

Human alveolar echinococcosis (AE) caused by Echinococcus multilocularis is an underreported, often misdiagnosed and mistreated parasitic disease mainly due to its low incidence. The aim of this study was to describe the epidemiological and clinical characteristics of human AE patients in Hungary for the first time.

Method

Between 2003 and 2018, epidemiological and clinical data of suspected AE patients were collected retrospectively from health database management systems.

Results

This case series included a total of 16 AE patients. The mean age of patients was 53 years (range: 24–78 years). The sex ratio was 1:1. Four patients (25%) revealed no recurrence after radical surgery and adjuvant albendazole (ABZ) therapy. For five patients (31.3%) with unresectable lesions, a stabilization of lesions with ABZ treatment was achieved. In seven patients (43.8%), progression of AE was documented. The mean diagnostic delay was 33 months (range: 1–122 months). Three AE related deaths (fatality rate 18.8%) were recorded.

Conclusions

AE is an emerging infectious disease in Hungary with a high fatality rate since based on our results, almost every fifth AE patient died in the study period. Differential diagnosis and appropriate surgical and medical therapy for AE is an urging challenge for clinicians in Hungary, as well as in some other European countries where E. multilocularis is prevalent.

Prevalence and genetic characterization of Echinococcus spp. in cattle, sheep, and swine in Hungary

A study was conducted to investigate genetic diversity of Echinococcus isolates collected in Hungarian slaughterhouses between 2015 and 2018. Organs of 219 animals with suspected hydatidosis were collected during routine meat inspection and sent to our laboratory. Echinococcus infection was confirmed in 65 animals. These results indicate that prevalence data based on reporting of slaughterhouses are not reliable without the appropriate training of the people responsible for meat inspection. The genetic diversity was evaluated by the DNA sequence analysis of the cytochrome c oxydase subunit 1 (cox1) mitochondrial gene. Echinococcus intermedius (n = 31), Echinococcus granulosus s.s. (n = 2), and Echinococcus multilocularis (n = 3) was identified in swine. In cattle, only E. granulosus s.s. (n = 20) was detected. E. granulosus s.s. (n = 7) was the dominant species in sheep; nevertheless, E. intermedius was also identified in two animals. E. granulosus s.s. (n = 29) and E. intermedius (n = 33) were classified in 13 and three haplotypes, respectively. The genetic diversity and haplotype network of E. granulosus s.s. were similar to that observed in some other countries of Eastern Europe. The genetic diversity of E. intermedius was low with a single dominant haplotype. Cysts were fertile in nine sheep (100%), 22 swine (61%), and three cattle (15%) indicating that all three species play a role in some extent in the epidemiology of cystic echinococcosis in Hungary. Based on the number of animals killed in the slaughterhouses involved in the present study, the rate of infection was 0.013% in sheep, 0.007% in cattle, and 0.001% in swine. As animals with hydatidosis originated from family farms, control programs should mainly focus on these facilities.

Impact of disposing stray dogs on risk assessment and control of Echinococcosis in Inner Mongolia

Echinococcosis has been recognized as one of the most important helminth zoonosis in China. Available models always consider dogs as the mainly definitive hosts. However, such models ignore the distinctions between domestic dogs and stray dogs. In this study, we propose a 10-dimensional dynamic model distinguishing stray dogs from domestic dogs to explore the special role of stray dogs and potential effects of disposing stray dogs on the transmission of Echinococcosis. The basic reproduction number R₀, which measures the impact of both domestic dogs and stray dogs on the transmission, is determined to characterize the transmission dynamics. Global dynamic analysis of the model reveals that, without disposing the stray dogs, the Echinococcosis becomes endemic even the domestic dogs are controlled. Moreover, due to the difficulties in estimating the parameters involved in R₀ with real data and the limitation of R₀ in real-world applications, a new risk assessment tool called relative risk index I_risk is defined for the control of zoonotic diseases, and the studies of the risk assessment for Echinococcosis infection show that it is essential to distinguish stray dogs from domestic dogs in applications.

Differentiation between hepatic alveolar echinococcosis and primary hepatic malignancy with diffusion-weighted magnetic resonance imaging

PURPOSE

To determine the value of diffusion-weighted magnetic resonance imaging (DW-MRI) in discriminating between hepatic alveolar echinococcosis (AE) and hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

METHODS

We included 49 patients (27 men, 22 women; mean age: 52.02±9.76 [SD] years; range: 25-72years) with 57 histopathologically confirmed hepatic AE lesions. Fifty patients (18 men, 32 women; mean age: 58.93±8.42 [SD] years; range: 42-71years) with 61 histopathologically confirmed hepatocellular carcinoma and 50 patients (24 men, 26 women; mean age: 50.11±7.70 [SD] years; range: 38-69years) with 54 histopathologically confirmed intrahepatic cholangiocarcinoma lesions were used as control groups. All patients had MRI examination of the liver that included conventional MRI sequences and DW-MRI using b values of 50, 400 and 800s/mm². Two radiologists evaluated conventional MRI and DW-MRI images and calculated ADC values of hepatic lesions.

RESULTS

The mean ADC value of solid components of hepatic AE lesions was 1.34±0.41×10^-3 mm²/s (range: 0.9-1.59×10^-3 mm²/s) and was significantly higher than that of the solid components of hepatocellular carcinoma lesions (mean ADC value, 0.99±0.29×10^-3 mm²/s; range: 0.7-1.15×10^-3 mm²/s) and of intrahepatic cholangiocarcinoma lesions (mean ADC value, 1.05±0.22×10^-3 mm²/s; range: 0.86-1.18×10^-3 mm²/s) (P<0.001).

CONCLUSION

In general ADC values can help discriminate between AE and hepatocellular carcinoma and intrahepatic cholangiocarcinoma. However, the use of ADC values cannot help differentiating Type 4 AE from hepatocellular carcinoma or intrahepatic cholangiocarcinoma.

The geographical distribution and prevalence of Echinococcus multilocularis in animals in the European Union and adjacent countries: a systematic review and meta-analysis

BACKGROUND

This study aimed to provide a systematic review on the geographical distribution of Echinococcus multilocularis in definitive and intermediate hosts in the European Union (EU) and adjacent countries (AC). The relative importance of the different host species in the life-cycle of this parasite was highlighted and gaps in our knowledge regarding these hosts were identified.

METHODS

Six databases were searched for primary research studies published from 1900 to 2015. From a total of 2,805 identified scientific papers, 244 publications were used for meta-analyses.

RESULTS

Studies in 21 countries reported the presence of E. multilocularis in red foxes, with the following pooled prevalence (PP): low (≤ 1 %; Denmark, Slovenia and Sweden); medium (> 1 % to < 10 %; Austria, Belgium, Croatia, Hungary, Italy, the Netherlands, Romania and the Ukraine); and high (> 10 %; Czech Republic, Estonia, France, Germany, Latvia, Lithuania, Poland, Slovakia, Liechtenstein and Switzerland). Studies from Finland, Ireland, the United Kingdom and Norway reported the absence of E. multilocularis in red foxes. However, E. multilocularis was detected in Arctic foxes from the Arctic Archipelago of Svalbard in Norway.

CONCLUSIONS

Raccoon dogs (PP 2.2 %), golden jackals (PP 4.7 %) and wolves (PP 1.4 %) showed a higher E. multilocularis PP than dogs (PP 0.3 %) and cats (PP 0.5 %). High E. multilocularis PP in raccoon dogs and golden jackals correlated with high PP in foxes. For intermediate hosts (IHs), muskrats (PP 4.2 %) and arvicolids (PP 6.0 %) showed similar E. multilocularis PP as sylvatic definitive hosts (DHs), excluding foxes. Nutrias (PP 1.0 %) and murids (PP 1.1 %) could play a role in the life-cycle of E. multilocularis in areas with medium to high PP in red foxes. In areas with low PP in foxes, no other DH was found infected with E. multilocularis. When fox E. multilocularis PP was >3 %, raccoon dogs and golden jackals could play a similar role as foxes. In areas with high E. multilocularis fox PP, the wolf emerged as a potentially important DH. Dogs and cats could be irrelevant in the life-cycle of the parasite in Europe, although dogs could be important for parasite introduction into non-endemic areas. Muskrats and arvicolids are important IHs. Swine, insectivores, murids and nutrias seem to play a minor or no role in the life-cycle of the parasite within the EU and ACs.

Autochthonous human alveolar echinococcosis in a Hungarian patient

BACKGROUND

Alveolar echinococcosis is a zoonotic parasitic disease causing a severe clinical condition and is known as the most deadly of all helminth infections. Moreover, this disease is also an increasing concern in Northern and Eastern Europe due to its spread in the wildlife animal host.

CASE PRESENTATION

An asymptomatic 70-year-old woman from south-western Hungary was diagnosed with multiple liver lesions. Imaging techniques (ultrasound, computed tomography and magnetic resonance imaging), serology (ELISA, indirect hemagglutination and Western blot), and conventional staining methods (hematoxylin-eosin and periodic acid-Schiff) were used for the detection of the disease. A histopathological re-evaluation of formalin-fixed paraffin block by immunohistochemical staining with the monoclonal antibody Em2G11 definitively confirmed the diagnosis of alveolar echinococcosis.

CONCLUSIONS

To our knowledge, this is the first confirmed autochthonous case of human alveolar echinococcosis in Hungary. To what extent diagnostic difficulties may contribute to underestimate this zoonosis in Eastern Europe is unknown. Differential diagnosis with alveolar echinococcosis should be considered for patients with multiple, tumor-like cystic lesions of the liver, in countries where this parasite is emerging.

Environmental determinants of the spatial distribution of Mesocestoides spp. and sensitivity of flotation method for the diagnosis of mesocestoidosis

Mesocestoides spp. are zoonotic cestodes of wild and domesticated carnivores. Although the adult stages are relatively harmless intestinal parasites, the metacestode stages (tetrathyridia) can be responsible for life-threatening peritonitis and pleuritis in several species including dogs, cats, non-human primates and probably man. The aim of the present study was to reveal the spatial distribution pattern of Mesocestoides spp. in the most important final hosts, red foxes (Vulpes vulpes), to analyse the relationship of these patterns with landscape and climate by geographical information systems and to evaluate faecal flotation method for the detection of infection in the final host. Fox carcasses, representing 0.5% of the total fox population were randomly selected out of all the foxes of Hungary. The intestinal tract was examined by sedimentation and counting technique. The sensitivity of the flotation method was evaluated by the testing of the faecal samples of 180 foxes infected with Mesocestoides spp. The prevalence of infection was high in foxes (45.8%; 95% CI=41.0-50.6%), and the parasite was detected in all areas of Hungary. The high prevalence of the parasite in foxes suggests that the infection might also be common in outdoor dogs and cats. Mesocestoides infection could not be detected in any of the foxes by flotation method indicating that the sensitivity of the method is less than 0.6%. Therefore, almost all canine and feline infections remain undetected in the veterinary practice. Based on the statistical analysis, the altitude was the only determinant of the spatial distribution of Mesocestoides spp. indicating that infections in carnivores including dogs and cats can be expected mainly in midland regions (150-750 m above sea level). It might be attributed to the altitude-dependent species richness and abundance of the intermediate and final hosts of the parasite.

Environmental determinants of the spatial distribution of Angiostrongylus vasorum, Crenosoma vulpis and Eucoleus aerophilus in Hungary

Angiostrongylus vasorum, Crenosoma vulpis and Eucoleus aerophilus (syn. Capillaria aerophila) are the most important lungworm species infecting wild and domesticated canids in Europe. To investigate the spatial distribution of these parasites and the factors influencing their circulation in the fox populations, 937 red foxes (Vulpes vulpes) were tested for lungworm infection in Hungary. The prevalence of A. vasorum, C. vulpis and E. aerophilus infection was high (17.9, 24.6 and 61.7%). The distribution pattern of infection in foxes and the relationship of this pattern with landscape and climate was analyzed by geographic information system. Based on the analysis, the annual precipitation was the major determinant of the spatial distribution of A. vasorum and C. vulpis and E. aerophilus. Nevertheless, the mean annual temperature also influenced the distribution of A. vasorum and E. aerophilus. The positive relationship with annual precipitation and the negative relationship with mean annual temperature can be attributed to the sensitivity of larvae, eggs and intermediate hosts (snails and slugs) of lungworms for desiccation. Based on the highly clumped distribution of A. vasorum and C. vulpis, the indirect life cycle (larvae, slugs and snails) of these parasites seems to be particularly sensitive for environmental effects. The distribution of E. aerophilus was considerably less clumped indicating a lower sensitivity of the direct life cycle (eggs) of this parasite for environmental factors. Based on these results, lungworm infections in canids including dogs can be expected mainly in relatively wet and cool areas.

Stability of the southern European border of Echinococcus multilocularis in the Alps: evidence that Microtus arvalis is a limiting factor

The known range of the zoonotic fox tapeworm Echinococcus multilocularis has expanded since the 1990s, and today this parasite is recorded in higher abundances throughout large parts of Europe. This phenomenon is mostly attributed to the increasing European fox populations and their invasion of urban habitats. However, these factors alone are insufficient to explain the heterogeneous distribution of the parasite in Europe. Here, we analysed the spatial interrelationship of E. multilocularis with the known distribution of seven vole species in Ticino, southern Switzerland. Among 404 necropsied foxes (1990-2006) and 79 fox faecal samples (2010-2012), E. multilocularis was consistently found in the north of the investigated area. No expansion of this endemic focus was recorded during the 22 years of the study period. This stable endemic focus is coincident with the known distribution of the vole species Microtus arvalis but not, or only partly, with the distribution of the other autochthonous vole species. Our results give evidence that this vole species plays a crucial role in the maintenance of the parasite's life cycle and that its absence could be a limiting factor for the spread of E. multilocularis in this region.

Evaluation of faecal flotation methods followed by species-specific PCR for detection of Echinococcus multilocularis in the definitive hosts

Echinococcus multilocularis is one of the most pathogenic zoonotic parasites in the temperate and arctic region of the Northern Hemisphere. For estimating the potential risk of human infection in endemic areas, reliable antemortem methods are needed to detect the parasite in carnivore definitive hosts. The sensitivity of routine flotation techniques for detection of E. multilocularis eggs was found to be low (3-33%) depending on the flotation solution used (specific gravities = 1.3-1.4). An improved faecal flotation followed by a species-specific PCR is described with a sensitivity of 74% (95% CI = 62-84%) and a specificity of 100% (95% CI = 94-100%). These parameters are similar to those of the intestinal scraping technique (sensitivity = 78%, specificity = 100%). The sensitivity of the improved flotation was significantly higher (P < 0.0001) than that of routine flotation techniques. The costs of the method are similar or lower than those of other antemortem diagnostic methods. Based on these data, the method is suitable for surveys of domesticated and wild carnivores.

Echinococcosis in wild carnivorous species: epidemiology, genotypic diversity, and implications for veterinary public health

Echinococcosis is a zoonosis caused by helminths of the genus Echinococcus. The infection, one of the 17 neglected tropical diseases listed by the World Health Organization, has a cosmopolitan distribution and can be transmitted through a variety of domestic, synanthropic, and sylvatic cycles. Wildlife has been increasingly regarded as a relevant source of infection to humans, as demonstrated by the fact that a significant proportion of human emerging infectious diseases have a wildlife origin. Based on available epidemiological and molecular evidence, of the nine Echinococcus species currently recognized as valid taxa, E. canadensis G8-G10, E. felidis, E. multilocularis, E. oligarthrus, E. shiquicus, and E. vogeli are primarily transmitted in the wild. E. canadensis G6-G7, E. equinus, E. granulosus s.s., and E. ortleppi are considered to be transmitted mainly through domestic cycles. We summarize here current knowledge on the global epidemiology, geographical distribution and genotype frequency of Echinococcus spp. in wild carnivorous species. Topics addressed include the significance of the wildlife/livestock/human interface, the sympatric occurrence of different Echinococcus species in a given epidemiological scenario, and the role of wildlife as natural reservoir of disease to human and domestic animal populations. We have also discussed the impact that human activity and intervention may cause in the transmission dynamics of echinococcosis, including the human population expansion an encroachment on shrinking natural habitats, the increasing urbanization of wildlife carnivorous species and the related establishment of synanthropic cycles of Echinococcus spp., the land use (e.g. deforestation and agricultural practices), and the unsupervised international trade and translocation of wildlife animals. Following the 'One Health' approach, we have also emphasized that successful veterinary public health interventions in the field of echinococcosis requires an holistic approach to integrate current knowledge on human medicine, veterinary medicine and environmental sciences.

Amino ozonides exhibit in vitro activity against Echinococcus multilocularis metacestodes

Artemisinin is an antimalarial sesquiterpene lactone that contains a 1,2,4-trioxane heterocycle. Dihydroartemisinin and artesunate demonstrated activity against Echinococcus multilocularis metacestodes in vitro but were not effective in a mouse model. In this study, the in vitro effects of a small library of synthetic ozonides (1,2,4-trioxolanes) were investigated. Initial compound screening against E. multilocularis metacestodes was performed at 20μM, and selected ozonides were further assessed in dose-response studies in metacestode cultures and mammalian cells. Transmission electron microscopy (TEM) was employed to characterise compound-induced structural alterations. At 20μM, the most potent ozonides (OZ401, OZ455, OZ491 and OZ494) led to death of ca. 60-100% of the parasites. Subsequent dose-response experiments demonstrated that OZ401, OZ455 and OZ491, which contain an aminopropylether substructure, were the most potent, with 50% inhibitory concentrations ranging from 11μM to 14μM. Cytotoxicity for these three ozonides, assessed in human foreskin fibroblasts, rat hepatoma cells and green monkey epithelial kidney (Vero) cells, was evident only at high concentrations. TEM demonstrated that OZ401 and OZ491 treatment induced considerable metabolic impairment in metacestodes at 1 day post exposure. At Day 3 post exposure, the germinal layer was severely distorted, although some intact cells were still visible, demonstrating that not all cell types in the parasite tissue were equally affected. Complete destruction of the germinal layer was noted at 5 days post exposure. Synthetic ozonides could represent interesting leads that will be further investigated in a suitable in vivo model of E. multilocularis infection.

Echinococcus multilocularis and Trichinella spiralis in golden jackals (Canis aureus) of Hungary

Over the last decades the distribution area of the golden jackal (Canis aureus) has increased significantly in Europe, particularly in the Balkan Peninsula and in Central Europe. Vagrant individuals were described in many European countries. Herein, we report Echinococcus multilocularis (total worm count: 412) and Trichinella spiralis (101 larvae/g for muscles of the lower forelimb) infections in two golden jackals shot in Hungary. It is a new host record of E. multilocularis and T. spiralis in Europe and Hungary, respectively. As jackals migrate for long distances through natural ecological corridors (e.g., river valleys), they may play a significant role in the long distance spread of zoonotic parasites into non-endemic areas of Europe. Therefore, monitoring zoonotic parasites in this host species can be recommended in the European Union.

Environmental changes impacting Echinococcus transmission: research to support predictive surveillance and control

Echinococcosis, resulting from infection with tapeworms Echinococcus granulosus and E. multilocularis, has a global distribution with 2-3 million people affected and 200,000 new cases diagnosed annually. Costs of treatment for humans and economic losses to the livestock industry have been estimated to exceed $2 billion. These figures are likely to be an underestimation given the challenges with its early detection and the lack of mandatory official reporting policies in most countries. Despite this global burden, echinococcosis remains a neglected zoonosis. The importance of environmental factors in influencing the transmission intensity and distribution of Echinococcus spp. is increasingly being recognized. With the advent of climate change and the influence of global population expansion, food insecurity and land-use changes, questions about the potential impact of changing temperature, rainfall patterns, increasing urbanization, deforestation, grassland degradation and overgrazing on zoonotic disease transmission are being raised. This study is the first to comprehensively review how climate change and anthropogenic environmental factors contribute to the transmission of echinococcosis mediated by changes in animal population dynamics, spatial overlap of competent hosts and the creation of improved conditions for egg survival. We advocate rigorous scientific research to establish the causal link between specific environmental variables and echinococcosis in humans and the incorporation of environmental, animal and human data collection within a sentinel site surveillance network that will complement satellite remote-sensing information. Identifying the environmental determinants of transmission risk to humans will be vital for the design of more accurate predictive models to guide cost-effective pre-emptive public health action against echinococcosis.

The impact of globalisation on the distribution of Echinococcus multilocularis

In the past three decades, Echinococcus multilocularis, the cause of human alveolar echinococcosis, has been reported in several new countries both in definitive hosts (canids) as well as in people. Unless treated, infection with this cestode in people is fatal. In previously endemic countries throughout the Northern Hemisphere, geographic ranges and human and animal prevalence levels seem to be increasing. Anthropogenic influences, including increased globalisation of animals and animal products, and altered human/animal interfaces are thought to play a vital role in the global emergence of this pathogenic cestode. Molecular epidemiological techniques are a useful tool for detecting and tracing introductions, and differentiating these from range expansions.

Willingness to pay for compulsory deworming of pets entering Sweden to prevent introduction of Echinoccoccus multilocularis

To investigate if the Swedish entry rules for pets to prevent the introduction of Echinococcus multilocularis (EM) are proportional (i.e. that their costs do not exceed the value of their benefits), a dichotomous-choice contingent valuation study was conducted. The study was performed before the first case of EM was detected in Sweden in February 2011. About 5000, randomly selected, Swedish citizens were invited to participate and 2192 of them (44%) accepted to do so. Missing information on whether or not one would accept to pay for keeping the rules for 143 respondents resulted in 2049 observations (41%) available for the estimation of willingness to pay (WTP), and missing information on personal characteristics for another 274 respondents reduced the number of observations available for sensitivity analysis to 1775 (36%). Annual expected WTP for keeping the rules ranged between € 54.3 and € 99.0 depending on assumptions about compensations demanded by respondents not willing to pay. The estimates are conservative since only answers from respondents that were absolutely certain they would pay the suggested bid were regarded as yes-responses. That WTP is positive implies that Swedish citizens perceived the benefits of the rules to be larger than their costs.

Combining information from surveys of several species to estimate the probability of freedom from Echinococcus multilocularis in Sweden, Finland and mainland Norway

Background

The fox tapeworm Echinococcus multilocularis has foxes and other canids as definitive host and rodents as intermediate hosts. However, most mammals can be accidental intermediate hosts and the larval stage may cause serious disease in humans. The parasite has never been detected in Sweden, Finland and mainland Norway. All three countries require currently an anthelminthic treatment for dogs and cats prior to entry in order to prevent introduction of the parasite. Documentation of freedom from E. multilocularis is necessary for justification of the present import requirements.

Methods

The probability that Sweden, Finland and mainland Norway were free from E. multilocularis and the sensitivity of the surveillance systems were estimated using scenario trees. Surveillance data from five animal species were included in the study: red fox (Vulpes vulpes), raccoon dog (Nyctereutes procyonoides), domestic pig, wild boar (Sus scrofa) and voles and lemmings (Arvicolinae).

Results

The cumulative probability of freedom from EM in December 2009 was high in all three countries, 0.98 (95% CI 0.96-0.99) in Finland and 0.99 (0.97-0.995) in Sweden and 0.98 (0.95-0.99) in Norway.

Conclusions

Results from the model confirm that there is a high probability that in 2009 the countries were free from E. multilocularis. The sensitivity analyses showed that the choice of the design prevalences in different infected populations was influential. Therefore more knowledge on expected prevalences for E. multilocularis in infected populations of different species is desirable to reduce residual uncertainty of the results.

The first finding of Echinococcus multilocularis in dogs in Slovakia: an emerging risk for spreading of infection

Alveolar echinococcosis, caused by the metacestode Echinococcus multilocularis, is a zoonosis of public health significance. Apart from red foxes, other carnivore species can also serve as definitive hosts of this parasite. This study aimed to determine the occurrence of E. multilocularis in dogs in the Slovak Republic and identify risk factors for acquiring the infection. Out of 289 dogs examined, E. multilocularis was detected in eight samples (2.8%). Positive results were observed in shepherd dogs (12.5%), guard dogs (7.1%), hunting dogs (2.4%) and in one dog with unknown usage (2.5%). Catching rodents and feeding with raw viscera were confirmed to be the most important risk factors for E. multilocularis infection. On the contrary, the way of dog use, frequency of going to the rural areas, the age and gender of animals seem not to be risk factors for infection. No significant association was observed between the positivity of dogs coming from high endemic or non-endemic regions. This is the first report of E. multilocularis in dogs in the Slovak Republic that confirms substantial contribution of dogs to the transmission of the tapeworm in this territory and urges the necessity of prophylactic measures for dog owners.

Echinococcosis in China, a review of the epidemiology of Echinococcus spp

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are highly significant infectious diseases occurring worldwide and caused by metacestodes of tapeworms Echinococcus granulosus and E. multilocularis, respectively. Both human CE and AE have highest prevalence rates in western and northwestern China. Livestock is the main intermediate host of E. granulosus, and wild small mammal are the main intermediate hosts of E. multilocularis. Since they range freely in pastoral areas, prey on wild small mammals and offal of livestock after slaughter, and have close relationships with humans, domestic dogs are the most important definitive host of both Echinococcus spp. with the highest risk of transmitting CE and AE to humans. Pastoralism is the occupation with the highest risk of being infected with the both kinds of echinococcosis due to the proximity of livestock, dogs, and wildlife host species. In this review, we summarize the epidemiology of human echinococcosis, the situation of parasite transmission in animal hosts, and possible transmission patterns in China. In addition, human activities and their potential influence on the transmission of echinococcosis are also discussed.

Occurrence of Echinococcus multilocularis (Cestoda, Taeniidae) in red foxes (Vulpes vulpes) from Western Ukraine

Echinococcus multilocularis was found for the first time in red foxes in the L’vivska and Volynska regions (Western Ukraine). Prevalence was 36% and intensity was 11–731 parasites. The material was identified as E. multilocularis on morphological characters. It is presumed that this infection of foxes with E. multilocularis occurred locally and, probably, can be considered as a consequence of the expansion of the range of the parasite.

Emerging zoonoses and vector-borne infections affecting humans in Europe

The purpose of this study was to assess and describe the current spectrum of emerging zoonoses between 2000 and 2006 in European countries. A computerized search of the Medline database from January 1966 to August 2006 for all zoonotic agents in European countries was performed using specific criteria for emergence. Fifteen pathogens were identified as emerging in Europe from 2000 to August 2006: Rickettsiae spp., Anaplasma phagocytophilum, Borrelia burgdorferi, Bartonella spp., Francisella tularensis, Crimean Congo Haemorrhagic Fever Virus, Hantavirus, Toscana virus, Tick-borne encephalitis virus group, West Nile virus, Sindbis virus, Highly Pathogenic Avian influenza, variant Creutzfeldt-Jakob disease, Trichinella spp., and Echinococus multilocularis. Main risk factors included climatic variations, certain human activities as well as movements of animals, people or goods. Multi-disciplinary preventive strategies addressing these pathogens are of public health importance. Uniform harmonized case definitions should be introduced throughout Europe as true prevalence and incidence estimates are otherwise impossible.

Spatial spreading of Echinococcus multilocularis in Red foxes (Vulpes vulpes) across nation borders in Western Europe

The occurrence of the fox tapeworm Echinococcus multilocularis in Red foxes was studied in Belgium and a neighbouring region in The Netherlands. A total number of 1202 foxes were analysed (1018 in Belgium and 184 in The Netherlands) of which 179 were infected with E. multilocularis (164 in Belgium and 15 in The Netherlands). Further, the spatial distribution of infection among sampled foxes was analysed with an ellipsoidal gradient, demonstrating a decreasing prevalence in northwestern direction. Using this gradient, we showed that the spatial patterns of infection in Belgium and the neighbouring region in The Netherlands correspond, indicating a continuous distribution of E. multilocularis across the nation borders. Part of the Belgian data allowed investigating temporal changes in the spatial distribution of E. multilocularis. This revealed a northwestern spread of E. multilocularis.

Parasitic diseases of the respiratory tract

PURPOSE OF REVIEW

The human pulmonary system can be affected by a variety of parasites. This review focuses on the most common parasitic infestations involving the lung, except for protozoon disease.

RECENT FINDINGS

In many parasitic lung conditions, the clinical manifestations and the imaging findings are non-specific and can make diagnosis challenging. Hydatid disease and paragonimiasis involve the lung directly. Chronic schistosomiasis can lead to pulmonary hypertension. Strongyloides stercoralis infestation is capable of transforming into a fulminant fatal disease. In many types of nematode infestations, the pulmonary phase can cause acute eosinophilic pneumonia. Chest radiographs of patients with paragonimiasis and dirofilariasis can cause diagnostic confusion. Cases of tropical pulmonary eosinophilia typically present with refractory bronchial asthma. Most of these diseases are initially diagnosed by detecting eggs or larvae in stool, sputum, pleural fluid or tissue, and are confirmed by serologic testing. Cystic hydatid disease generally requires surgical treatment, whereas almost all other parasitic lung conditions can be treated medically.

SUMMARY

Although most parasites that affect the lung are endemic to tropical and subtropical regions, immigration and travel practices have resulted in transfer of these diseases to other areas. It is important for physicians to know the epidemiologic characteristics, clinical presentations, and treatments of choice for these conditions.

Echinococcus multilocularis in Austrian foxes from 1991 until 2004

The prevalence rates of Echinococcus multilocularis in foxes (n=5600) evaluated in several Austrian surveys conducted between 1991 and 2004 were analysed for spatial and temporal differences. Data from early studies (1993-1997) in which the intestinal scraping technique (IST) was utilized were compared with data from recent (1999-2004) investigations, which made use of the shaking in a vessel technique (SVT), and it was assessed whether or not the infection rates of Austrian foxes had increased between the investigated intervals. In total, data from 85 districts are presented and both the retrospective and recent data are available from 39 of these districts. A Bayesian hierarchical model of parasite prevalences is presented which (i) accounts for differences in the sensitivity of IST and SVT, (ii) incorporates spatial auto-correlation between neighbouring districts, (iii) investigates the possibility of a temporal shift in the infection status of foxes, and (iv) quantifies uncertainty at each level of the model. The national average prevalence rates in the mid-1990s and at the turn of the millennium were 2.4% (95% confidence intervals 1.1-4.8) and 3.9% (95% confidence intervals 1.5-8.4) respectively. Above average prevalence rates were observed in the western and the northern parts of the country. Evidence is also presented for a temporal augmentation of the prevalence rates in some districts in the northern and eastern parts of the country. These findings are in concordance with several investigations in other European states where both newly emerged areas and elevated levels of transmission in existing endemic areas have been found. None of the districts investigated here showed significant evidence of a drop in prevalence.

Emergence/re-emergence of Echinococcus spp.--a global update

This review provides an update of the biological aspects of the genus Echinococcus and focuses on newly recognized endemic areas. Infection with the intermediate cystic stage of all species of Echinococcus causes disease and incapacity in animals and humans, and in the most serious cases, death of the host. Transmission of Echinococcus to new continents has occurred during European colonisation and the parasite has often taken advantage of Echinococcus-naive wildlife populations in these new environments, incorporating them into its transmission pattern. Echinococcus granulosus consists of a complex of 10 strains. Host specificities of these strains have important implications for transmission and control. As a result of human behaviour and/or political instability in a number of countries Echinococcus is re-emerging as an important public health issue. The importance of wildlife reservoirs in perpetuating transmission and as a source of infection for domestic animals and humans is addressed. The review also refers to the transmission pattern of a recently described new species, Echinococcus shiquicus, from China.

Comparative development of Echinococcus multilocularis in its definitive hosts

The comparative development of Echinococcus multilocularis was studied in its definitive hosts, the fox, dog, cat and raccoon dog, beyond the pre-patent period to 90 days post-infection. All host species, apart from cats were susceptible to infection and capable of supporting substantial worm burdens. Although worms in cats matured and produced thick-shelled eggs, their overall development was retarded compared to that in other species in which the parasite matured rapidly producing large populations of gravid worms. E. multilocularis matured rapidly in foxes and raccoon dogs and this was sustained in raccoon dogs but not in foxes in which maturation of worms declined during the later stages of infection, in contrast to that in both raccoon dogs and dogs. These populations were sustained for longer in raccoon dogs and dogs compared to foxes. Cats would appear to have only a minor role in the maintenance of E. multilocularis in endemic areas, and infections in cats may be of minimal public health significance. In contrast, foxes, dogs and the recently recognized definitive host the raccoon dog, are all capable of playing significant roles in the epidemiology of alveolar echinococcosis. This study also demonstrated that the developmental processes of growth, segmentation, proglottization and maturation in adult Echinococcus are independent and can be influenced by environmental factors thus confirming earlier in vitro observations.

The present situation of echinococcosis in Europe

The taxonomy of Echinococcus is presently undergoing major changes, the paraphyletic Echinococcus granulosus being split into several distinct species. In this review, an attempt is made to assess the present epidemiological situation in Europe separately for each species (Echinococcus multilocularis, Echinococcus granulosus sensu stricto, Echinococcus equinus, Echinococcus ortleppi, and Echinococcus sp.). For E. multilocularis, an increasing density of infected host animals is apparent in central Europe, and, possibly, a range increase has occurred. Prevalence rates in foxes have risen in many agriculturally dominated landscapes of France, The Netherlands, Germany, Austria, Slovakia and Poland, but the lifecycle is now also established in many urban areas, where red foxes occur with high population densities. E. granulosus s. s. (the former 'sheep strain') is still frequent and a public health problem in many parts of the Mediterranean region and re-emergence after failed control campaigns is observed or suspected in Bulgaria and Wales. No recent data on the cattle-transmitted E. ortleppi and the horse-transmitted E. equinus are available, but their relevance for human health seems to be minor. The same may apply to the 'pig strain' and the newly described 'European cervid strain', which both belong to a cluster of genotypes whose taxonomy is not yet resolved (Echinococcus sp.).

Echinococcus multilocularis in red foxes (Vulpes vulpes) of the Italian Alpine region: is there a focus of autochthonous transmission?

Alveolar echinococcosis, caused by the metacestode of Echinococcus multilocularis, is a zoonosis with a wider distribution area than described in the past. Fox populations living in the Alpine regions of Italy had been considered free from this parasite until 2002, when two infected foxes (Vulpes vulpes) were detected in the Bolzano province (Trentino Alto Adige region) near the Austrian border. The aim of this work was to evaluate the prevalence of infection in red fox populations from five Italian regions. A modified nested PCR analysis was used to detect E. multilocularis DNA in faecal samples. Amplicons were confirmed by sequencing. Of 500 faecal samples from foxes shot in Valle d'Aosta (n=57), Liguria (n=44), Lombardy (n=102), Veneto (n=56), and Trentino Alto Adige (n=241) regions, 24 animals, all from the Trentino Alto Adige region, were found positive. Twenty-two positive animals originated from the Bolzano province and two positive animals from the Trento province. Several localities of the Bolzano province, in which positive foxes were detected, are the same as those where alveolar echinococcosis had been described in humans in the second half of the 19th century, suggesting an old endemicity for the investigated area, which is adjacent to endemic areas of Austria. Therefore, the question arises if we are observing an increase and expansion of foci, or if the new records are due to the more sensitive and specific methods used to detect the worm DNA.

Echinococcal disease in Alberta, Canada: more than a calcified opacity

Background

Most cases of echinococcal disease (ED) acquired in Canada are thought to be due to the sylvatic form of Echinococcus granulosus, which may be more benign than ED due to either Echinococcus multilocularis or the pastoral form of E. granulosus. There are limited descriptions of the clinical course and outcome of Canadian patients with ED in the modern era.

Methods

A retrospective chart review was performed of patients hospitalized with echinococcal disease (ED) from 1991 to 2001 in Edmonton, Alberta.

Results

Forty-two cases of ED were identified of which 19 were definite, 3 probable, and 20 possible. Further analysis was limited to the 22 definite and probable cases, of which 77% were female and 41% aboriginal, with an age range of 5 to 87 years. Nine patients (40%) had pulmonary involvement and 11 (50%) hepatic involvement. One patient had an intracardiac mass presenting as a cerebrovascular event and one had a splenic cyst. Seven of the 22 patients had combined surgical resection and medical treatment, six had surgical resection of the cyst alone, four had cyst aspiration, one had medical treatment alone and four had no specific treatment. There was no mortality attributable to ED but three patients died of unrelated illnesses.

Conclusion

Echinococcal disease in northern Alberta has a marked diversity of clinical presentations, and generally has a good prognosis despite a wide variety of therapeutic interventions.