Geographic distribution and epidemiology of Oesophagostomum bifurcum and hookworm infections in humans in Togo

Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

Generalists at the interface: Nematode transmission between wild and domestic ungulates

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Nematodes vary in host range, affecting potential for cross-species transmission.

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Host-specific parasites account for <50% of the parasite species infecting a host.

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Goats are most and horses are least liable to nematodes carried by wildlife.

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Plains zebra and mouflon are most liable to nematodes carried by livestock.

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Existing knowledge is biased, 84% of references are from Africa, Europe, North America.

Many parasitic nematode species are generalists capable of infecting multiple host species. The complex life cycle of nematodes, involving partial development outside of the host, facilitates transmission of these parasites between host species even when there is no direct contact between hosts. Infective nematode larvae persist in the environment, and where grazing or water sources are shared ingestion of parasite larvae deposited by different host species is likely. In this paper we examine the extent to which nematode parasite species have been observed in sympatric wild and domestic ungulates. First, using existing host–parasite databases, we describe expected overlap of 412 nematode species between 76 wild and 8 domestic ungulate host species. Our results indicate that host-specific parasites make up less than half of the nematode parasites infecting any particular ungulate host species. For wild host species, between 14% (for common warthog) and 76% (for mouflon) of parasitic nematode species are shared with domestic species. For domestic host species, between 42% (for horse) and 77% (for llamas/alpacas) of parasitic nematode species are shared with wild species. We also present an index of liability to describe the risk of cross-boundary parasites to each host species. We then examine specific examples from the literature in which transmission of nematode parasites between domestic and wild ungulates is described. However, there are many limitations in the existing data due to geographical bias and certain host species being studied more frequently than others. Although we demonstrate that many species of parasitic nematode are found in both wild and domestic hosts, little work has been done to demonstrate whether transmission is occurring between species or whether similar strains circulate separately. Additional research on cross-species transmission, including the use of models and of genetic methods to define strains, will provide evidence to answer this question.

Morphological variability withinOesophagostomum bifurcumamong different primate species from Ghana

AdultOesophagostomum bifurcum(Nematoda: Strongylida) from human and non-human primates from Ghana were compared in order to investigate the extent of morphological variability within the species. Using analysis of variance and principal component analysis, significant differences in morphological characters (such as parasite length, width, length of the oesophagus and length of spicules) were demonstrated betweenO. bifurcumworms from humans, the Mona, Patas or Green monkey and/or Olive baboons. These findings suggest thatO. bifurcumfrom different species of primate host represent distinct population variants, also supported by recent epidemiological and genetic studies ofO. bifurcumfrom such hosts.

Impact of repeated mass treatment on human Oesophagostomum and hookworm infections in northern Ghana

Oesophagostomum bifurcum is a common parasite of humans causing disease in parts of northern Ghana and northern Togo. The impact of repeated mass treatment with albendazole on infection with O. bifurcum and hookworm is analysed and the results compared with those in a control area where no treatment was given. At baseline, O. bifurcum and hookworm prevalences were 53.0% and 86.9%, respectively (n=1011). After 12 months, following two rounds of albendazole treatment, prevalences decreased significantly to 5.4% for O. bifurcum and 36.8% for hookworm (n=535). Twenty-four months after the baseline survey and following a total of four rounds of treatment, prevalences were further reduced to 0.8% and 23.4% for O. bifurcum and hookworm, respectively (n=478). Overall, there was a significant decrease in the larval counts, measured as geometric mean larval count per 4 g of stool of O. bifurcum from 3.0 to 0.1 and of hookworm from 47.2 to 1.8. The fourth mass treatment was carried out in April 2003 by the Lymphatic Filariasis Elimination Programme. Overall, compliance to treatment varied from 70% to 80%. In the control area, Oesophagostomum prevalence increased from 18.5% to 37.0% and the intensity from 0.4 to 1.4. For hookworm, both prevalence (86.1-91.3%) and intensity (54.8-74.3) increased but not to a significant level. The prospects of eliminating human oesophagostomiasis from the intervention area, while simultaneously achieving an important reduction of hookworm prevalences by albendazole mass treatment, are discussed.

Distribution and clustering ofOesophagostomum bifurcumand hookworm infections in Northern Ghana

HumanOesophagostomuminfections are locally common in northern Ghana. The present study describes the results of a cross-sectional survey involving 1011 subjects, selected by a compound-based random sampling method from 1227 compounds in 24 villages. Selected persons were examined by both Kato and coproculture methods. Hookworm-like eggs, representing ova ofOesophagostomum bifurcumand hookworm were detected in 87·5% of the Kato smears. The geometric mean egg count of the infected subjects was 1018. Upon coproculture, third-stage larvae ofO. bifurcumand hookworm were detected in 53·0% and 86·9% of subjects respectively. Oesophagostomum infections were clustered but no clear explanation for aggregation of infections could be found as yet. Subjects infected with hookworm had a 5-fold higher risk of being infected withO. bifurcum. Infection rates in adult women were higher than in adult men. No association was found with family size, level of hygiene or with the presence of animals in the compounds. Representatives of the Bimoba-tribe were significantly more infected than those of the other tribes. It appears, however, that this tribal association is a geographical phenomenon: Bimoba are mostly living in villages with the highest infection rates.

Insights into the epidemiology and genetic make-up ofOesophagostomum bifurcumfrom human and non-human primates using molecular tools

The nodule wormOesophagostomum bifurcum(Nematoda: Strongylida) is a parasite of major human health importance predominantly in northern Togo and Ghana. Currently, it is estimated that 0·25 million people are infected with this nematode, and at least 1 million people are at risk of infection. Infection with this parasite causes significant disease as a consequence of encysted larvae in the wall of the large intestine. In spite of the health problems caused byO. bifurcum, there have been significant gaps in the knowledge of the biology, transmission and population genetics of the parasite. This review provides an account of some recent insights into the epidemiology and genetics of the parasite from human and non-human primate hosts in specific regions of Africa using molecular tools. Recent research findings are discussed mainly in relation to non-human primates being reservoirs of infection, and the consequences for the prevention and control of oesophagostomiasis in humans are briefly discussed.

Oesophagostomum bifurcum in non-human primates is not a potential reservoir for human infection in Ghana

In northern Togo and Ghana, human infection with the parasitic nematode Oesophagostomum bifurcum is of major health importance. Elsewhere, oesophagostomiasis is considered a zoonotic infection, non-human primates being the natural host. We examined 349 faecal samples of the olive baboon, mona monkey and black and white colobus monkey from two geographically distinct areas in Ghana, outside the region endemic for O. bifurcum in humans. Using both microscopy and species-specific PCR, we found a high prevalence of O. bifurcum (75-99%) in olive baboons and mona monkeys. The majority of the test-positive faecal samples contained large numbers of larvae after copro-culture (>100). No O. bifurcum was detected in the faeces of the black and white colobus monkeys. Observational studies on the behaviour of the non-human primates, focusing on defecation, food consumption and the sharing of habitat with the local human population, indicated favourable conditions for zoonotic transmission. Given that no human infection with O. bifurcum has been reported from either study area, the present findings support the hypothesis that O. bifurcum from humans in the north of Ghana, and O. bifurcum from olive baboons and/or mona monkeys are distinct.

Oesophagostomum bifurcum-induced nodular pathology in a highly endemic area of Northern Ghana

Human infection with Oesophagostomum bifurcum is rare globally, but focally endemic and common in Ghana and Togo. Two clinical presentations are identified: uni-nodular disease, which may be recognized as a 'Dapaong Tumour', and multi-nodular disease. Here, we describe the prevalence of O. bifurcum infection and the association with nodular pathology in northern Ghana. The study was performed in October 2002. Out of a well-defined population of approximately 18000, 928 subjects of all ages were randomly selected for parasitological and ultrasound examination. In stool cultures, 44% had detectable third-stage O. bifurcum larvae present. Females were more often infected than males (P<0.05). In 34% of the samples, nodules were detected along the colon wall, with the ascending and the transverse colon being the most affected regions. Significant correlations existed between the intensity of infection and the presence of nodules, both at the village and the individual level (P<0.001 for both). Patients with multi-nodular pathology had significantly higher larval counts than patients with uni-nodular pathology. The present data suggest that nodular pathology, and probably the severity of the disease, are directly related to intensity of the infection.

Distribution of human Oesophagostomum bifurcum, hookworm and Strongyloides stercoralis infections in northern Ghana

A cross-sectional study was carried out in 216 randomly selected, representative rural villages in the northeastern part of Ghana from March 1995 to May 1998. Inhabitants of randomly selected households, stratified by age and gender, were included. The geographical position of villages was recorded with a global positioning system (GPS). The prevalence of Oesophagostomum, hookworm and Strongyloides stercoralis infections in a study population of 20250 people was determined by microscopic examination of larvae in stool cultures. The overall prevalence was 10.2, 50.6 and 11.6% for the three nematodes, respectively. Hookworm infections were seen in all but one (99.5%) and S. stercoralis in 88.4% of the 216 villages, while Oesophagostomum infections were found to be common in a limited area with prevalences varying from 0 to 75%. An association was found between Oesophagostomum and hookworm infection, both at the individual and at the village level. Spatial analysis of the prevalence data indicated that the endemic area is relatively clearly demarcated to the south of the study area.

High resolution DNA fingerprinting by AFLP to study the genetic variation among Oesophagostomum bifurcum (Nematoda) from human and non-human primates from Ghana

An AFLP approach was established to investigate genetic diversity within Oesophagostomum bifurcum (order Strongylida) from human and non-human primates. Evaluation of different combinations of restriction enzymes (n = 8) and primers (n = 29) demonstrated that the use of HindIII/BglII digested templates and primers with the selective nucleotides + AG/ +AC, respectively, was the most effective for the analysis of O. bifurcum DNA. A total of 63 O. bifurcum adults from human, Patas monkey, Mona monkey and Olive baboon hosts from different geographical regions in Ghana were subjected to analysis using this method. Cluster analysis revealed 4 genetically distinct groups, namely O. bifurcum from the Patas monkey (I), from the Mona monkey (II), from humans (III) and from the Olive baboon (IV). These findings were concordant with those achieved previously using RAPD analysis and supports population genetic substructuring within O. bifurcum according to host species. The results demonstrated the effectiveness of the present AFLP method for establishing genetic variation within O. bifurcum, and indicates its applicability to other parasitic nematodes of human and/or veterinary health importance.

Screening for haplotypic variability within Oesophagostomum bifurcum (Nematoda) employing a single-strand conformation polymorphism approach

Genetic markers in the mitochondrial genome have proven useful for population genetic studies because of their maternal inheritance and relatively high evolutionary rates. In this study, we exploited the high resolution capacity of PCR-coupled single-strand conformation polymorphism (SSCP) to screen for sequence variation in part of the cytochrome c oxidase subunit 1 gene (p cox 1) among individuals of the parasitic nematode, Oesophagostomum bifurcum from human or Mona monkey hosts from Africa. SSCP analysis revealed distinct profiles among some of the individuals, and subsequent sequence analysis of representative samples defined 10 different haplotypes. For comparative purposes, the p cox 1 sequences for representatives of four other species of Oesophagostomum from livestock were included. While there were high levels (11.5-13.7%) of sequence difference among the latter species, there was no fixed nucleotide difference between O. bifurcum individuals from humans and those from monkeys. The data support the proposal that O. bifurcum from the two primate hosts represents a single species and that the haplotypic variability in p cox 1 represents population variation. The results reinforce the usefulness of the SSCP-sequencing approach for studying genetic variation in nematode populations using mitochondrial markers.

Emerging helminth zoonoses

As our ability to recognise and diagnose human disease caused by helminth parasites has improved, so our understanding of the epidemiology and clinical manifestations of these diseases has improved. Humans can develop patent infection with a wide range of helminth parasites, whose natural host is another vertebrate. Rather than focusing on a comprehensive review of zoonotic helminth infections, this review describes in detail examples of zoonotic helminth infections that have newly appeared in human populations, or have existed but are increasing in incidence or geographic range. Examples include intestinal capillariasis, anisakidosis, eosinophilic enteritis, oesophagostomiasis and gnathostomiasis. Potential reasons for the emergence of these infections, including changes in social, dietary or cultural mores, environmental changes, and the improved recognition of heretofore neglected infections often coupled with an improved ability to diagnose infection are discussed.