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The WHO Informal Working Group on Echinococcosis. Coordinating Board of the WHO-IWGE.

WHO Informal Working Groups on Echinococcosis were founded in 1985 and for 10 years, under the leadership of Prof. J. Eckert (Zurich, Switzerland), they contributed much to facilitate exchanges between interested scientists working in their respective areas. In 1995, the Veterinary Public Health Unit, at WHO, decided to modify the functioning of the Groups and to transform them into a single Group. The Working Group brings together all the scientists involved in research on Echinococcosis whatever their specialty, field of interest, or type of Echinococcosis studied. The aim of the Group is to establish international networks on relevant, up-to-date and/or important problems in Echinococcosis on the basis of i) international cooperation, ii) high scientific standards, and iii) accurate methodology. A Coordinator is designated by WHO and has a 4-year term. He/she is assisted by a Coordinating Board. This board is also proposed for a 4-year term, so that it can be regularly renewed. It, thus, will give an opportunity for closer association with the life of the Working Group to many scientists; the coordinator for the next term will be chosen from among the participants so that a continuity of action is ensured. The current networks deal with: "Standardization of the ultra-sound classification of hydatid cysts" (coordinator: C. Mcpherson); "Long-term follow-up of patients treated with PAIR" (coordinator: C. Filice); "Standardization of the staging/classification of patients with Alveolar Echinococcosis" (coordinator: P. Kern); "Vaccination of sheep for the prevention of Echinococcosis: pilot trials" (coordinator: M. Lightowlers); "Standardization of immunological tools for the detection of Echinococcus coproantigens in carnivores" (coordinator: P.S. Craig); "Educational material for Echinococcosis prevention/control" (coordinator: L. Garcia); and "Methodology for the evaluation of the economical cost of Echinococcosis" (coordinator: G. Battelli). Two new networks are activated at the beginning of 1997: "Long-term evaluation of chemotherapy in cystic echinococcosis" (coordinators: T. Todorov, A. Teggi), and "Natural history of small single hydatid cysts" (coordinator: Z. Pawlowski). People interested in participating in these networks or wanting to create a network, can send their name, the description of their research team, and the part they plan to take in the proposed network. All the proposals are submitted to the Coordinating Board and to Dr Meslin (WHO "Research on and promotion of zoonotic disease surveillance and control" team). If the work undertaken by a network leads to a proposal for international classification/standardization, it is submitted for formal approval by WHO. It must be understood by everyone, however, that neither WHO nor the Informal Working Group can give any financial support for these networks; however they can help in advising participants about other sources of funding, and organizing meetings on given subjects. In conclusion, the WHO Informal Working Group on Echinococcosis will continue to play a major role in information exchange and in stimulating public interest in the field. It does not exclude any active group or scientist but tries to integrate them on the basis previously defined. The coordinator designated for the 1995-1999 period is Prof. Dominique A. Vuitton, WHO Collaborating Center for Prevention and Control of Human Echinococcosis, University Hospital, F-25030 Besançon, France (Tel. xx33 3 81665572, Fax xx33 3 81665570).

Animals↗

[Surgical treatment of echinococcosis of the liver].

UNLABELLED: Echinococcosis is a parasitic disease which is most frequently located in the liver. The treatment of choice is surgery. METHODS: A total of 23 patients were hospitalised for liver echinococcosis during the period from January 1993 to September 1998. RESULTS: The diagnosis was in 20 cases (87%) cystic echinococcosis and in 3 patients (13%) alveolar echinococcosis. The regular intervention of cyst desinfection with cystectomy was carried out in 85% of the cases with cystic echinococcosis, whereas atypical or segmental liver resections were performed in 15%. Two patients with alveolar echinococcosis were operated upon by radical/extended liver resections, one was found intraoperatively inoperable. The mean hospital stay was 15.4 days with a mortality of 0% and a postoperative morbidity of 57%, including bile leaks in 30%. A perioperative antiparasitic chemotherapy with albendazole was prescribed in 91%. The apparent rate of recurrence was 7% for uncomplicated cystic echinococcosis. CONCLUSIONS: Cyst desinfection with cystectomy has been proved to be effective as the standard operative intervention for cystic echinococcosis. For alveolar echinococcosis, radical resections are required. Due to the risk of recurrence (especially in alveolar echinococcosis), the effectiveness of surgery should be improved by a perioperative chemotherapy with albendazole.

Adolescent↗

A hospital-based retrospective survey of human cystic and alveolar echinococcosis in Ningxia Hui Autonomous Region, PR China.

A retrospective study of in-patient records for the period 1985-2001 collected from 11 hospitals in Ningxia Hui Autonomous Region (NHAR), China revealed a total of 2216 cases of echinococcosis. The survey showed that cystic echinococcosis (CE) occurs throughout NHAR but that human alveolar echinococcosis (AE) cases were only located in a confluence area of three counties, Xiji, Haiyuan and Guyuan. Incidence rates between counties within southern NHAR showed a highly heterogeneous distribution of cases, suggestive of different echinococcal transmission patterns. There was a significant difference in incidence between males and females, and farm labourers accounted for the majority of cases. Radical surgery with or without albendazole/mebendazole drug treatment was the major method of treatment for CE and repeat surgery was common; drug treatment alone was used mainly for AE. Epigastric pain was the main reason for patients seeking medical advice, the liver was the primary location of echinococcosis lesions and the majority of echinococcosis cases were diagnosed by ultrasound. Over a 12 year period, the average bed utilization rate in the Second Provincial Hospital of NHAR for patients with echinococcosis was 78% and echinococcosis cases accounted, on average, for 0.7% among the total hospital in-patients. Taking inflation into account, charges for echinococcosis hospitalization and treatment increased three-fold over the period 1994-2002. This study indicates that echinococcosisis is a significant public health problem in NHAR, especially in the south. The data from the hospital retrospective study are clearly underestimates and community surveys are required to determine the true echinococcosis prevalence levels, especially in the more remote areas of NHAR.

China↗

Interleukin-5 is the predominant cytokine produced by peripheral blood mononuclear cells in alveolar echinococcosis.

An involvement of cellular immunity in alveolar echinococcosis is strongly suggested by the intense granulomatous infiltrations observed around the hepatic parasite lesions. However, the basis of cellular immunoregulation in patient with alveolar echinococcosis is poorly understood. The present report shows a comparative analysis of lymphoid cell function in peripheral blood mononuclear cells (PBMC) of 16 patients with alveolar echinococcosis and of healthy individuals. Our in vitro restimulation studies with crude Echinococcus multilocularis antigen demonstrated that PBMC from patients with alveolar echinococcosis were responsive to challenge with parasitic antigen as measured by lymphoid cell proliferation. In this system, we also evaluated cytokine expression at the gene and protein levels after stimulation with E. multilocularis antigen. Analysis of cytokine mRNA expression revealed distinct patterns of cytokine expression in patients and normal donors. By using reverse transcriptase PCR, we could demonstrate that the TH1 cytokine transcripts interleukin-2 (IL-2) and gamma interferon (IFN-gamma) are present in PBMC from patients with alveolar echinococcosis. Moreover, it was found that stimulation with E. multilocularis antigen induced or enhanced the expression of the TH2 cytokine IL-3, IL-4, IL-10, and especially IL-5 mRNAs in PBMC from 13 of 16 patients with alveolar echinococcosis. Two patients who were examined after radical surgery, as well as another patient with a stable course of the disease under continuous chemotherapy, were not able to generate the same pattern of cytokine response and had no evidence of IL-5 mRNA synthesis. In contrast to the frequent expression of TH2 cytokine mRNAs observed in patients with alveolar echinococcosis, PBMC cultures from normal donors showed prominent IL-2 and IFN-gamma mRNA expression but weak IL-3, IL-4, and IL-10 mRNA expression. Most interestingly, IL-5 mRNA was substantially absent in PBMC from healthy individuals. In accordance with the mRNA studies, it was found that E. multilocularis antigen induced the secretion of large amounts of IL-5 and intermediate amounts of IFN-gamma in patients with alveolar echinococcosis, whereas large amounts of IFN-gamma and no or threshold amounts of IL-5 were detected in supernatants from healthy individuals. Collectively, the present study provides the first evidence that a TH2 immune response is gradually activated during the course of E. multilocularis infection, indicating a critical role for IL-5 in the manifestation of human alveolar echinococcosis.

Adult↗

Immunodiagnosis of polycystic hydatid disease/polycystic echinococcosis due to Echinococcus vogeli.

A crude antigenic metacestode extract from Echinococcus vogeli was assessed by enzyme-linked immunosorbent assay (ELISA) and showed strong binding activity with serum antibodies from patients with polycystic echinococcosis. Major cross-reactions occurred with serum antibodies from patients with cystic and alveolar echinococcosis and from patients infected with other species of helminths. An E. vogeli antigen fraction, Ev2, was subsequently purified by immunosorption. The respective Ev2 ELISA demonstrated improved specificity, allowing discrimination of non-Echinococcus infections from polycystic echinococcosis. Based upon the calculation of a comparative (Ev-crude ELISA versus Ev2 ELISA) reactivity index, it became possible to discriminate all cystic echinococcosis cases, but only some alveolar echinococcosis cases, from polycystic echinococcosis. Immunoblot analyses revealed an antibody banding pattern highly conserved among polycystic, cystic, and alveolar echinococcosis. However, immunoblotting reliably distinguished between echinococcosis and all non-Echinococcus infections.

Animals↗

[Epidemiology of echinococcosis in Bavaria].

OBJECTIVE: There are few and incomplete data about the epidemiology of echinococcosis in Germany. The aim of this retrospective study was to collect informations about frequency and distribution of this parasitosis in one of the main endemic regions (Bavaria). PATIENTS AND METHODS: Standardized questionnaires were sent to all Bavarian hospitals, requesting (anonymous) information about all patients with echinococcosis seen between 1985 and 1989. In addition, hospital statistics and archives were searched for echinococcosis cases. A total of 216 cases were found; sufficient data were available for 181 (87 males, 94 females; mean age 41 [4-79] years). There were 123 patients with cystic echinococcosis (infection with the larval stage of Echinococcus granulosus), 58 with the alveolar form (larval stage of Echinococcus multilocularis). In the remaining 35 the available information was inadequate for reliable differentiation. RESULTS: The data indicate a prevalence of echinococcosis in Bavaria of 1.9 per 100,000 inhabitants, 1.1 for Echinococcus granulosus and 0.5 for Echinococcus multilocularis. The mean annual incidence was 0.22 (Echinococcus granulosus 0.15; Echinococcus multilocularis 0.03). Dividing the patients by country of origin, 86.2% of those with Echinococcus multilocularis were German, while 68.3% of those with Echinococcus granulosus originated from outside Germany, mostly the Mediterranean area. The prevalence of Echinococcus multilocularis infection was highest in the District of Swabia (2.4/100,000) and Upper Bavaria (0.6/100,000). These are regions in which there is a proven significantly higher infestation of echinococcosis in foxes. Farmers were most at risk of being infected with alveolar echinococcosis.

Adolescent↗

Echinococcosis and allergy.

The larval stages of Echinococcus granulosus and E. multilocularis are involved in parasitic diseases in humans: cystic echinococcosis (CE) ("hydatid disease") and alveolar echinococcosis (AE), respectively. Both diseases and parasites have tight links with allergy because of the immunological characteristics that contribute to maintain the larvae in their human host as well as their potential in inducing clinical anaphylactic reactions in some patients. Clinical observations in patients and data obtained from mass screenings in various countries have identified both forms of echinococcosis as "polar diseases," i.e., diseases where immunological background of the patients was related to the clinical presentation and course. In particular, abortive cases (i.e., spontaneous cures) have been found in many subjects in endemic areas. On the other hand, immune suppression was associated with severe disease. AE especially might be considered as an opportunistic infection. Experimental and clinical studies have shown that Th1-related immune response was associated with protection and Th2-related response was associated with parasite growth. Genetic characteristics of the host are related to both occurrence and severity of AE and are associated with the extent of IL-10 secretion, which is a major feature of chronic progressing echinococcosis. Anaphylactic reactions, including urticaria, edema, respiratory symptoms, and anaphylactic shock due to spontaneous or provoked rupture of the parasitic cyst, are well known in CE. Anaphylactic reactions in AE are far less frequent, and have been observed in rare cases at time of metastatic dissemination of the parasitic lesions. Echinococcus-specific IgE is present in most of the patients and associated with severity. Specific histamine release by circulating basophils stimulated with E. granulosus antigens is present in all patients with CE and AE. Echinococcus allergens include (1) AgB 12-kDa subunit, a protease inhibitor and a potent Th2 inducer; (2) Ag5, a serine protease; (3) EA 21, a specific cyclophilin, with a homology with other types of cyclophilins; (4) Eg EF-1 beta/delta an elongation factor, with a homology with Strongyloides stercoralis EF that shares the same IgE epitope. A clinical cross-reaction with Thiomucase, a mucopolysaccharidase used in arthritis treatment, has recently been published. However, despite the potential risk of allergic reactions, the dogma "never puncture a hydatid cyst" is no longer valid. International experience of therapeutic technique of "puncture, aspiration, injection, re-aspiration" of hydatid cysts developed at the beginning of the 1980s has proved to be successful in a variety of selected indications that have been reviewed by WHO recommendations. A better understanding of the immunological background of echinococcosis in humans has led to new therapeutic developments, such as immunomodulation using interferon alpha. Th2-driven immunological response and IL-10-related tolerance state are common characteristics of atopic allergy and echinococcosis. The example of echinococcosis stresses the ambiguous links that exist between parasitic and allergic diseases, and show the usefulness of comparing these diseases to better understand how immune deviation may lead to pathological events and to find new therapeutic and.or preventive agents.

Anaphylaxis↗

Present situation of echinococcosis in the Middle East and Arabic North Africa.

Echinococcosis is one of the major zoonotic parasitic diseases in the Middle East and Arabic North Africa from Morocco to Egypt. Both cystic and alveolar echinococcosis has been reported from these areas. However, cystic echinococcosis is more prevalent and has been reported from all countries in the Middle East and Arabic North Africa. Alveolar echinococcosis is less prevalent and has been reported only from Iran, Turkey, Iraq and Tunisia. Present situation of echinococcosis in dogs and other definitive hosts, animal intermediate hosts and humans in the Middle East and Arabic North Africa has been reviewed. Echinococcus granulosus is highly prevalent in Iran, Turkey, Iraq, Morocco, Tunisia, and Libya. In the Levant countries, the cystic echinococcosis is also highly endemic. In Oman, it is endemic with low prevalence and a very low level in Cyprus. Various surveys have indicated that hydatid cysts are commonly found in sheep, cattle, goats and camels throughout the Middle East and Arabic North Africa. Sheep are the most infected animals of these regions. Most of studies on human have been focused on surgical reports although several population studies have been performed using serological and imaging techniques. Human cystic echinococcosis (CE) is prevalent in the Middle East and Arabic North Africa. It is hyper endemic in Iran, Turkey, Iraq, Jordan, Morocco, Libya, Tunisia, and Algeria, and endemic in Egypt. Studies on the strain specificities of E. granulosus in the Middle East revealed sheep strain (G1) present in sheep, goats, cattle, camels and humans, and the camel strain (G6) in camels, sheep, cattle as well as humans. Dog/sheep strain seems to be more prevalent in the foregoing regions in documented reports from Iran and Jordan. However, a strain of E. granulosus, which resembles the horse strain (G4) strain, has been reported from Jordan. Strain specifications of E. granulosus in Arabic North Africa showed that sheep/dog strain (G1) have been reported from Tunisia and Libya both from humans and animals. However, in Egypt the human cases reported are of camel/dog strain.

Africa, Northern↗

Recent advances in the immunology and diagnosis of echinococcosis.

Echinococcosis is a cosmopolitan zoonosis caused by adult or larval stages of cestodes belonging to the genus Echinococcus (family Taeniidae). The two major species of medical and public health importance are Echinococcus granulosus and Echinococcus multilocularis, which cause cystic echinococcosis and alveolar echinococcosis, respectively. Both cystic echinococcosis and alveolar echinococcosis are serious diseases, the latter especially so, with a high fatality rate and poor prognosis if managed inappropriately. This review highlights recent advances in immunity to infection and vaccination against both parasites in their intermediate and definitive hosts and procedures for diagnosis of cystic echinococcosis and alveolar echinococcosis, including the value of immunodiagnostic and DNA approaches. There is discussion also of progress in genomics and related technologies that is providing valuable insights on the functional biology of the Echinococcus organisms. These studies will underpin future research that will reveal a better understanding of the Echinococcus-host interplay, and suggest new avenues for the identification of additional targets for diagnosis, vaccination and chemotherapy.

Animals↗

The reconsideration of natural history of echinococcosis at Rebun Island.

It has been believed that the outbreak of echinococcosis at Rebun Island had ceased by 1970. The first patient was diagnosed in 1936 and 131 patients have been authorized as echinococcosis so far. The conference of measures against the outbreak had been organized in 1948 and started to eradicate Echinococcus multilocularis from the Island. Medical examination to detect the patients and the capture and autopsy of dogs and cats had been carried out hard till 1970. At that time, foxes imported from Simusiru Island in the middle Kuriles during the years 1924 to 1926 had already disappeared and it has seemed to be sure that stray dogs and cats might carry E. multilocularis and excrete infectious eggs in stead of foxes. Since we have had no real data concerning the natural history of patients with echinococcosis without any treatments, it can not be recognized the time of infection and the role of dogs or cats on the spread of echinococcosis at Rebun Island. From the new data, it is concluded that the active life cycle of E. multilocularis between foxes and vole might be closed by 1940, since the last patient infected with E. multilocularis was born in 1940 and died in 1945. Furthermore, it is estimated that more than 200 patients (3 to 4% of people at the island) might die from echinococcosis, because of the fact of the unusual increase of mortality of liver disorders and oldness observed during the years of 1940 to 1960. 81 patients with the high possibility of echinococcosis detected from 1937 to 1963 can be added to 131 authorized patients. Surprisingly, it is noticed that the standard deviations of ages of death of 94 patients born in Meiji era (1880-1912) and 59 in Taisho and Showa eras (1912-1940) are 63.16 +/- 11.68, and 34.32 +/- 11.87, respectively. It means that both old and young people might be infected simultaneously but for the long period. There was no difference between the susceptibility of young and old men to E. multilocularis. The numbers of male patients died were more than those of female patients at the ages from 30s to 60s while the number of female died was predominant after 70s. All 13 familial cases of echinococcosis represent that men might bring the infectious eggs into their houses and died earlier by the infection. Thus, the sexual difference might be due to the life style of men who preferred hunting beside fishing. From these results, it is conceivable that the heavy infection of E. multilocularis excreted from foxes might occur from 1925 to 1940 and the peak of the death might be formed during 1940 to 1965. The eradication of foxes might be done by poachers after 1935 and the adaptation of E. multilocularis from fox to dog or cat might not occur readily at Rebun Island.

Adult↗

Primary echinococcosis of the sternocleidomastoid muscle.

Muscular echinococcosis accounts for 0.5% to 5.4% of all hydatid disease cases, with very little data on the incidence of muscular echinococcosis of the head and neck. We report a unique case of primary echinococcosis of the right sternocleidomastoid muscle in a 56-year-old man. Preoperative assessment by ultrasound and fine needle aspiration did not point to echinococcosis. We suspected the right diagnosis intraoperatively and confirmed it postoperatively by pathohistology and serologic tests. Echinococcosis of the liver and the lungs was also excluded postoperatively. Combination of operative treatment and postoperative albendazole herapy in two 28-day cycles one month apart resulted in complete regression of the disease. Echinococcosis should be considered as differential diagnosis of a multicystic mass in neck, particularly if it is of longstanding duration. Serologic tests for echinococcosis should be included in differential diagnostic procedures for each multicystic formation on the neck, especially in endemic areas.

Albendazole↗

Use of disability adjusted life years in the estimation of the disease burden of echinococcosis for a high endemic region of the Tibetan plateau.

Shiqu County, located on the Tibetan plateau of western China, has an extremely high prevalence of both human alveolar echinococcosis (AE), and cystic echinococcosis (CE). The short form 12 version 2 quality of life survey, which was used to evaluate the extent to which morbidity associated with echinococcosis should be accounted, verified that there was a significant reduction in the mean health scores in all categories for individuals diagnosed with abdominal echinococcosis compared with an age and sex cross-matched population. Results of a larger ultrasound survey, which screened 3135 subjects, demonstrated that the prevalence rates of AE and CE were both approximately 6% with a combined prevalence rate of 11.4%. Prevalence rates adjusted for the age and sex structure of Shiqu County were 4.6% for AE and 4.9% for CE with an estimated overall adjusted prevalence rate of 9.5%. The burden of disease associated with echinococcosis was calculated using disability adjusted life years (DALYs) based on these estimated prevalence rates. Monte-Carlo techniques were used to model the uncertainty in the prevalence estimates and the disability weights. Using these methods, we estimated that the total numbers of DALYs lost due echinococcosis was 50,933 (95% confidence interval [CI] = 41,995-61,026). The DALYs lost consisted of approximately 32,978 (95% CI = 25,019-42,422) due to AE and 17,955 (95% CI = 14,268-22,128) due to CE and suggests an average of approximately 0.81 DALY lost per person. This study has clearly shown that the impact of DALYs lost due to echinococcosis, in terms of medical treatment costs, lost income, and physical and social suffering, is likely to be substantial in this highly endemic region of China.

Adolescent↗

[Imaging methods in the diagnosis and therapy of cystic echinococcosis].

Imaging studies, ultrasonography, play a central role for the diagnosis and follow-up of cystic echinococcosis (hydatid disease) due to the non-specific clinical symptoms and still inadequate sensitivity and specificity of currently available serological tests. Due to the increasing number of people immigrating to central Europe from countries with a high incidence of cystic echinococcosis, cystic echinococcosis has become an important differential diagnosis of cystic lesions. The imaging modality to localize and stage the disease depends on the organs affected. Ultrasonography is the most important imaging technique to screen for abdominal lesions (more than 75 % of the cases). Therefore, an expert committee of the WHO Working Group on echinococcosis has recently suggested a standardized ultrasonographic classification of hepatic cystic echinococcosis. This classification proofs to be very useful for staging echinococcal cysts with respect to parasite activity. Ultrasonography is not only an excellent tool for the primary diagnosis and therapeutic decision but also for follow-up of patients treated for cystic echinococcosis. Indications for computed tomography or magnetic resonance tomography are restricted to extra abdominal disease, patients not suited for ultrasonography because of obesity or meteorism, complicated cysts and planning of surgery or interventional therapy. Apart from surgery three other treatment options are well established: (1) chemotherapy with albendazole or mebendazole, (2) percutaneous drainage and sterilization (PAIR) and (3) observation of inactive echinococcal stages ("watch and wait" approach).

Albendazole↗

[Comparison of serum immunoglobulin levels in patients with alveolar and cystic echinococcosis].

Serum IgG, IgA and IgM levels of 91 patients with alveolar echinococcosis and 83 patients with cystic echinococcosis were compared with 104 healthy adults as controls by single radial immunodiffusion. The mean IgG, IgA and IgM concentrations in patients with alveolar echinococcosis and the mean IgG and IgM levels in patients with cystic echinococcosis were found to be significantly higher than those of the normal controls. The mean IgG, IgA and IgM levels in patients with alveococcosis were 510 +/- 413.06, 389.45 +/- 433.42 and 313.48 +/- 255.19, while those in cystococcosis were 308.36 +/- 339.24, 329.61 +/- 319 and 266.68 +/- 255.68 respectively. The geometric mean of IgG and IgM levels in patients with alveococcosis was 1.67 and 1.25 times that in cystococcosis. 76.9% of alveococcosis patients had IgG levels reaching 200 IU/ml or above, being significantly higher than that in the cystic hydatidosis (50.6%). 93.4% of alveolar echinococcosis cases showed elevated IgM levels up to 100 IU/ml or more, being also significantly higher than that of cystic echinococcosis cases (78.3). Statistically, there was significant correlation between IgG concentration and ELISA antibody titre.

Echinococcosis↗

Epidemiology of alveolar echinococcosis in southern Germany (Bavaria).

Alveolar echinococcosis is considered to be the most dangerous endemic parasitic disease for man in Central Europe. In Germany, unlike the neighbouring countries of Switzerland, Austria and France, only limited data on the prevalence and incidence of echinococcosis are available. Therefore, a retrospective cross-sectional study was conducted in order to investigate the epidemiology of echinococcosis in Bavaria, one of the two southern states of Germany. A standardised questionnaire was sent to all hospitals in Bavaria requesting information about patients seen from 1985 to 1989. In a second step a team of reviewers was sent to all relevant hospitals for active case finding in hospital statistics and medical records. A total of 216 patients with echinococcosis were detected of whom 58 had alveolar echinococcosis. According to these data, the prevalence in Bavaria was calculated to be 0.5 per 100,000 inhabitants with peak values in the counties of Swabia (2.4) and Upper Bavaria (0.6). The annual mean incidence of newly diagnosed cases amounted to 0.03 per 100,000. The distribution of prevalence in man was closely correlated to the infection rates in foxes throughout Bavaria (p < 0.05). Farmers are the occupational group with the highest risk to acquire echinococcosis with a prevalence/odds ratio of 14.6 for Swabia and 8.8 for Upper Bavaria, when compared to the general rural population.

Adult↗

Peritoneal echinococcosis.

Peritoneal echinococcosis is rare, even in areas where hydatid disease is endemic. Although the liver and lungs are the organs most commonly involved, peritoneal echinococcosis, either primary or secondary, represents an uncommon but significant manifestation of the disease. We reviewed the medical records of 121 patients with abdominal echinococcosis operated on in our department over the past 12 years. Peritoneal echinococcosis was found in 17 patients, usually combined with liver disease. The presenting symptoms were mostly atypical, and a few cases were discovered accidentally during routine follow-up after operations for hepatic echinococcosis. Surgery remains the best curative or palliative treatment for peritoneal echinococcosis, although anthelmintics can be an effective alternative for the treatment of small and asymptomatic cysts.

Adult↗

Hospital and community surveys reveal the severe public health problem and socio-economic impact of human echinococcosis in Ningxia Hui Autonomous Region, China.

A comprehensive study of human echinococcosis (caused by Echinococcus granulosus or E. multilocularis), including assessment of hospital records, community surveys and patient follow-up, was conducted in Ningxia Hui Autonomous Region (NHAR), China. In contrast to hospital records that showed 96% of echinococcosis cases were caused by cystic echinococcosis (CE), 56% of cases detected in active community surveys were caused by alveolar echinococcosis (AE). The AE and CE cases co-existed frequently in the same village, even occurring in the same patient. A serious public health problem caused by echinococcosis was evident in southern NHAR, typified by: a long diagnostic history for both AE and CE (7.5 years) compared with a shorter treatment history (4.7 years); a significant mortality rate (39%) caused by AE in one surveyed village, where patients had no previous access to treatment; family aggregation of CE and AE cases; a high proportion of both AE (62.5%) and CE (58%) in females; a high rate of recurrent surgery (30%) for CE demonstrated by surgical records; and frequent symptomatic recurrences (51%) because of discontinuous or sporadic access to chemotherapy for AE. The disease burden for both human AE and CE is thus very severe among these rural communities in NHAR, and this study provides the first attempt to determine the costs of morbidity and surgical intervention of human CE and AE cases both at the hospital and community level in this setting. This information may be useful for assessing the cost effectiveness of designing effective public health programs to control echinococcosis in this and other endemic areas in China and elsewhere.

Adolescent↗

Endemic alveolar echinococcosis in Southern Belgium?

Until now, Belgium has been considered as a low-risk country for alveolar echinococcosis. However it was recently demonstrated by necropsy series that, in some parts of southern Belgium (Wallonia), up to 51% of the red foxes (Vulpes vulpes) may be infected by E. multilocaris. The authors, working in a university hospital in southern Belgium, described in 2002 the first autochthonous Belgian case of hepatic alveolar echinococcosis. More importantly, in 2004, they diagnosed three other patients with alveolar echinococcosis. One underwent surgical resection, but two others had bilateral pulmonary involvement at time of definite diagnosis. Palliative albendazole therapy was initiated. These patients had been diagnosed with hepatic mass from unknown origin for several months. The previous experience with the first case allowed the authors to consider and to confirm alveolar echinococcosis diagnosis, made by pathology and/or serological tests and imaging. These four patients with alveolar echinococcosis were living either in the Liege or the Luxembourg province. Considering the high prevalence of E. multilocaris infection of red foxes and the recent increase of the fox population due to rabies vaccination in southern Belgium, and also the presence of E. multilocaris infection of red foxes in northern Belgium, it is likely that not only Wallonia, but also maybe the whole Belgium, may face endemic alveolar echinococcosis in the next years.

Aged↗