Strongyloidiasis Important health problems in migrants? Important - PDF document

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 Strongyloidiasis 280.000 deaths) in sub-Saharian Africa Strongyloidiasis and schistosomiasis: screen, treat or forget? Zeno Bisoffi WHO Collaborating Center on strongyloidiasis and other Adapted from Colley, Lancet 2014 i t ti l iti i f ti Strongyloidiasis Important health problems in migrants? Important health problem? At least 370 million people infected Some 30–100 million people are estimated to be infected worldwide (probably an underestimate) Buonfrate Dora, Gobbi Federico, Marchese Valentina, Postiglione Chiara, Badona Monteiro Geraldo, Giorli Giovanni, Napoletano Giuseppina, Bisoffi Z, Buonfrate D, Montresor A, Requena‐Méndez A, et al. (2013) Strongyloides stercoralis: A Plea for Action. PLoS Negl Trop Dis 7(5): 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 e2214. doi:10.1371/journal.pntd.0002214http://www.plosntd.org/article/info:doi/10.1371/journal.pntd.0002214 Important health problems in migrants? Important health problems in migrants? 24.1% 14.3% 11.4% 17.4% Strongyloidiasis: pooled Schistosomiasis: pooled prevalence >10% EAP, prevalence >20% SSA SSA and LAC Accepted! Great job C. Greenaway et al. 2018. Prevalence of strongyloidiasis and Chris!!! schistosomiasis among migrants (Lancet GH, under review) C. Greenaway et al. 2018. Prevalence of strongyloidiasis and schistosomiasis among migrants (Lancet GH, accepted) 1

10/15/2018 Important health problems in migrants? Cicle of S. stercoralis Rome 2018, preliminary, unpublished data: Strongyloidiasis prevalence (IFAT): SSA 81/398 ( 20% ) LAC 37/248 ( 15% ) Schistosomiasis prevalence (ICT): SSA 66/400 ( 16.5% ) L. Marrone et al.,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 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 Symptoms of chronic, uncomplicated strongyloidiasis Symptoms of chronic, uncomplicated strongyloidiasis URTICARIA Anemia? Stunting? Other? DIARRHEA ITCHING F. Tamarozzi et al., TMIH 2018, under review F. Tamarozzi et al., TMIH 2018, under review Severe strongyloidiasis: 67% patients under steroids Immune depression Other conditions How to quantify the risk of X HTLV 1 hyperinfection/dissemination? We HIV need a stroke of genius! Alcoholism hyperinfection ‐ dissemination Malnutrition (accelerated autoinfection) (to ) Pregnancy? Fatality rate: 50‐86% Transplant Cancer Buonfrate D et al. BMC Infectious Diseases 2013 13(1):78 Buonfrate D et al. BMC Infectious Diseases 2013 13(1):78 2

10/15/2018 Diagnosis: is a satisfactory test available for screening? Is an Is an ef effective treatment nt a avail ailable? Ok Ok iv iverme ermectin…But how how many ma ny dose doses? s? 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% 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 Schistosomiasis ‐ Lifecycle Preliminary results… No difference!! WHO Collaborating Center on Adapted from Colley, Lancet, 2014 16 strongyloidiasis and other intestinal parasitic infections Important health problem? Important health problem? Schistosomiasis • S. mansoni ( japonicum ): This bladder “tumor” virtually disappeared in mild to moderate (if any) one month after pzq intestinal symptoms for years; treatment • Liver fibrosis, portal hypertension, death if untreated • S. haematobium : mild to moderate (if any) urogenital symptoms for years; Schistosoma in the mesenteric veins • Hydronephrosis, renal failure, class A carcinogen for bladder cancer Source o cambiare Source: F. Tamarozzi, CTD Negrar 3

10/15/2018 Patient 6 New insights: schistosomiasis and the lungs 90 days after treatment Patient 7 Gobbi F et al. Lancet Inf Dis 2017 Gobbi F et al. Lancet Inf Dis 2017 Diagnosis: is a satisfactory test available for screening? 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, • Presence of eggs in stools or in urine according to Latent Class Analysis (prev=35%) • Serology (type and cute‐off) • Circulating antigens (CCA/CAA) • Symptoms and eosinophilia • PCR? Urines? Stools? 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? 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 SYSTEMATIC REVIEW ON SCHISTOSOMIASIS TREATMENT IN NON‐ENDEMIC COUNTRIES doses? ses? 40 mg/kg single dose,but… • In non‐endemic countries  no existing 148 records included guidelines/recommendations on 92 (62.2%) management of (acute) and chronic standard treatment 56 (37.8%) schistosomiasis different treatment 25 3 2 12 1 different more than one 13 repeated dose dosage day and different more more than repeated and different dosage one day and than one dosage dose day repeated dose Cucchetto G et al., 2018 (to be submitted) 4

10/15/2018 We have a dream… SYSTEMATIC REVIEW ON SCHISTOSOMIASIS TREATMENT IN NON‐ENDEMIC COUNTRIES …A multi center RCT in non endemic countries to assess the efficacy of praziquantel One dose vs multiple doses Cucchetto G et al., 2018 (to be submitted) To screen or not to screen? Balance cost/benefits?? Is To screen or not to screen? presumptive treatment an option? 1. Important health problem 2. Natural history well understood 3. Detectable early stage 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 4. Early treatment more beneficial Helminth Infection among US-Bound Refugees from Asia. Maskery B 1 , Coleman MS 1 , Weinberg M 1 , Zhou W 1 , Rotz L 1 , Klosovsky A 2 , Cantey PT 3 , Fox LM 3 , Cetron MS 1 , Stauffer WM 1,4 . 5. Suitable test for early stage 6. Acceptable test Ivermectin: A Drug Worthy of a 7. Adequate intervals determined Nobel Prize, but Inaccessible for Those Who Need It 8. Adequate health services 22 October 2015 9. Risks less than benefits 10. Balance cost/benefits Wilson & Junger criteria WHO 1968 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? 5