Strongyloidiasis Important health problems in migrants? Important - - PDF document

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Strongyloidiasis Important health problems in migrants? Important - - PDF document

Oct 20, 2022 220 likes •292 views

10/15/2018 Schistosomiasis:Important health problem? ICMH, Rome 2018 Global distribution of schistosomiasis Symposium, 3rd October 2018 >260 million infected. ~ 85% (over 200 million, Parasites: Malaria, Chagas, Schistosomiasis, and

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10/15/2018 1

Zeno Bisoffi

WHO Collaborating Center on strongyloidiasis and other i t ti l iti i f ti

ICMH, Rome 2018 Symposium, 3rd October 2018 Parasites: Malaria, Chagas, Schistosomiasis, and Strongyloidiasis

Strongyloidiasis and schistosomiasis: screen, treat or forget?

Global distribution of schistosomiasis

Schistosomiasis:Important health problem?

Adapted from Colley, Lancet 2014

>260 million infected. ~ 85% (over 200 million, 280.000 deaths) in sub-Saharian Africa Some 30–100 million people are estimated to be infected worldwide (probably an underestimate)

At least 370 million people infected

Bisoffi Z, Buonfrate D, Montresor A, Requena‐Méndez A, et al. (2013) Strongyloides stercoralis: A Plea for Action. PLoS Negl Trop Dis 7(5):

  • e2214. doi:10.1371/journal.pntd.0002214http://www.plosntd.org/article/info:doi/10.1371/journal.pntd.0002214

Strongyloidiasis

Important health problem?

Buonfrate Dora, Gobbi Federico, Marchese Valentina, Postiglione Chiara, Badona Monteiro Geraldo, Giorli Giovanni, Napoletano Giuseppina, Bisoffi Zeno. Extended screening for infectious diseases among newly arrived asylum seekers from Africa and Asia, Verona province, Italy, April 2014 to June 2015. Euro Surveill. 2018;23(16):pii=17-00527. https://doi.org/10.2807/1560-7917.ES.2018.23.16.17-00527

Important health problems in migrants? Important health problems in migrants?

Schistosomiasis: pooled prevalence >20% SSA

  • C. Greenaway et al. 2018. Prevalence of strongyloidiasis and

schistosomiasis among migrants (Lancet GH, under review)

24.1%

Accepted! Great job Chris!!!

Important health problems in migrants?

  • C. Greenaway et al. 2018. Prevalence of strongyloidiasis and schistosomiasis among migrants (Lancet GH, accepted)

Strongyloidiasis: pooled prevalence >10% EAP, SSA and LAC

17.4% 11.4% 14.3%

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10/15/2018 2 Important health problems in migrants?

Rome 2018, preliminary, unpublished data: Strongyloidiasis prevalence (IFAT): SSA 81/398 (20%) LAC 37/248 (15%) Schistosomiasis prevalence (ICT): SSA 66/400 (16.5%)

  • L. Marrone et al., September 2018

Cicle of S. stercoralis

Buonfrate D, Perandin F, Formenti F, Bisoffi Z. Novel approaches to the diagnosis of Strongyloides stercoralis infection. Clin Microbiol Infect. 2015 Jun;21(6):543-552.

ABDOMINAL PAIN DIARRHEA

  • F. Tamarozzi et al., TMIH 2018, under review

Symptoms of chronic, uncomplicated strongyloidiasis ITCHING URTICARIA Symptoms of chronic, uncomplicated strongyloidiasis

Anemia? Stunting? Other?

  • F. Tamarozzi et al., TMIH 2018, under review

Immune depression

hyperinfection ‐ dissemination

(accelerated autoinfection) (to )

Fatality rate: 50‐86%

X

Buonfrate D et al. BMC Infectious Diseases 2013 13(1):78

Severe strongyloidiasis: 67% patients under steroids

Buonfrate D et al. BMC Infectious Diseases 2013 13(1):78

Other conditions HTLV 1 HIV Alcoholism Malnutrition Pregnancy? Transplant Cancer

How to quantify the risk of hyperinfection/dissemination? We need a stroke of genius!

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Test Prevalence PPV NPV BORDIER ELISA 10,0% 85.4% 98.8% 20,0% 92.9% 97.4% IVD ELISA 10,0% 91.8% 99.0% 20,0% 96.2% 97.8%

Diagnosis: is a satisfactory test available for screening?

Bisoffi Z, Buonfrate D, Sequi M, Mejia R, Cimino RO, Krolewiecki AJ, et al. (2014) Diagnostic Accuracy of Five Serologic Tests for Strongyloides stercoralis Infection. PLoS Negl Trop Dis 8(1): e2640. https://doi.org/10.1371/journal.pntd.0002640

Is Is an an ef effective treatment nt a avail ailable? Ok Ok iv iverme ermectin…But how how ma many ny dose doses? s?

Preliminary results…

WHO Collaborating Center on strongyloidiasis and other intestinal parasitic infections

No difference!!

Schistosomiasis ‐ Lifecycle

Adapted from Colley, Lancet, 2014

16

Schistosoma in the mesenteric veins

Source o cambiare

Schistosomiasis

  • S. mansoni (japonicum):

mild to moderate (if any) intestinal symptoms for years;

  • Liver fibrosis, portal

hypertension, death if untreated

  • S. haematobium: mild to

moderate (if any) urogenital symptoms for years;

  • Hydronephrosis, renal failure,

class A carcinogen for bladder cancer

Important health problem?

Source: F. Tamarozzi, CTD Negrar

Important health problem?

This bladder “tumor” virtually disappeared in

  • ne month after pzq

treatment

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10/15/2018 4

Gobbi F et al. Lancet Inf Dis 2017

New insights: schistosomiasis and the lungs

Patient 6 Patient 7

90 days after treatment Gobbi F et al. Lancet Inf Dis 2017

Diagnosis: is a satisfactory test available for screening?

  • Presence of eggs in stools or in urine
  • Serology (type and cute‐off)
  • Circulating antigens (CCA/CAA)
  • Symptoms and eosinophilia
  • PCR? Urines? Stools?

Table 3. Predictive values of a combination of positive ICT (Se 96% Sp 79%, PPV 72%, NPV 97%) and a positive (PPV) or a negative (NPV) second test, according to Latent Class Analysis (prev=35%)

Beltrame A, Guerriero M, Angheben A, Gobbi F, Requena-Mendez A, et al. (2017) Accuracy of parasitological and immunological tests for the screening of human schistosomiasis in immigrants and refugees from African countries: An approach with Latent Class Analysis. PLOS Neglected Tropical Diseases 11(6): e0005593 Diagnosis: is a satisfactory test available for screening?

  • In non‐endemic countries  no existing

guidelines/recommendations on management of (acute) and chronic schistosomiasis

40 mg/kg single dose,but… Is Is an an ef effect ectiv ive treatme ment nt a availa ailable? e? Ok Ok pr praziqu aziquant antel…B l…But how how many many doses? ses?

92 (62.2%) standard treatment 148 records included 56 (37.8%) different treatment 25 different dosage 12 more than one day 13 repeated dose

1 more than

  • ne day and

repeated dose 2 repeated dose and different dosage 3 more than one day and different dosage

SYSTEMATIC REVIEW ON SCHISTOSOMIASIS TREATMENT IN NON‐ENDEMIC COUNTRIES

Cucchetto G et al., 2018 (to be submitted)

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10/15/2018 5

SYSTEMATIC REVIEW ON SCHISTOSOMIASIS TREATMENT IN NON‐ENDEMIC COUNTRIES

Cucchetto G et al., 2018 (to be submitted)

We have a dream…

…A multi center RCT in non endemic countries to assess the efficacy of praziquantel One dose vs multiple doses

To screen or not to screen?

  • 1. Important health problem
  • 2. Natural history well understood
  • 3. Detectable early stage
  • 4. Early treatment more beneficial
  • 5. Suitable test for early stage
  • 6. Acceptable test
  • 7. Adequate intervals determined
  • 8. Adequate health services
  • 9. Risks less than benefits
  • 10. Balance cost/benefits

Wilson & Junger criteria WHO 1968

To screen or not to screen? Balance cost/benefits?? Is presumptive treatment an option?

PLoS Negl Trop Dis. 2016 Aug 10;10(8):e0004910. doi: 10.1371/journal.pntd.0004910. eCollection 2016 Aug. Economic Analysis of the Impact of Overseas and Domestic Treatment and Screening Options for Intestinal Helminth Infection among US-Bound Refugees from Asia. Maskery B1, Coleman MS1, Weinberg M1, Zhou W1, Rotz L1, Klosovsky A2, Cantey PT3, Fox LM3, Cetron MS1, Stauffer WM1,4.

Ivermectin: A Drug Worthy of a Nobel Prize, but Inaccessible for Those Who Need It 22 October 2015

Conclusions and an unanswered last question

  • Relevant health problems
  • Screening recommended (e.g. new Italian MOH guidelines)

Is screening feasible considering the current political mainstream in many countries?