Alveolar echinococcosis in humans: the current situation in Central Europe and the need for countermeasures.

Alveolar echinococcosis (AE) in humans is caused by a larval stage (metacestode) of Echinococcus multilocularis, which exhibits a tumor-like growth, initially in the liver, with the potential to induce serious disease. At the end of the 1980s, E. multilocularis was known to occur in four countries of Central Europe, but has now been identified in ten countries. Red foxes are the principal definitive hosts of E. multilocularis and sources of human infection, but dogs and cats can also be infected. Growing populations of foxes and their increasing immigration to urban areas are new risk factors. Human AE is rare but its potential high fatality rate, considerable costs of treatment and the persisting infection risk should be reasons for health authorities in European countries to establish coordinated systems of surveillance and risk assessment in combination with measures to reduce morbidity and mortality of AE in the human population. Here, J. Eckert and P. Deplazes outline the current epidemiological situation in Central Europe, and discuss options for surveillance, prevention and control.     

Echinococcosis: an emerging or re-emerging zoonosis?

The aim of this review is a critical discussion of factors actually or potentially contributing to persistence or emergence of echinococcosis in humans. Alveolar echinococcosis (AE), a life-threatening infection of humans, is caused by a larval stage of Echinococcus multilocularis. The adult parasite inhabits the intestine of foxes and other carnivores and has a wide distribution in the northern hemisphere (North America and northern and central Eurasia). Recent surveys in central Europe have extended the known geographical occurrence of E. multilocularis in foxes from four countries at the end of the 1980s to at least 11 countries in 1999. Cases of human AE previously regularly reported from only four countries are now recorded from seven countries, but the annual incidences are low. Since adequate information from earlier surveys is not available, it is not possible to conclude if the new findings reflect a recent extension of the parasite's range or just the first identification of hitherto unnoticed endemic areas. Evidence of parasite spreading has been reported from North America and Japan. Factors with the potential of enhancing the infection risk for humans in the future include increasing fox populations and parasite prevalences, progressing invasion of cities by foxes, the establishment of urban cycles of the parasite, and the spill-over of the E. multilocularis infection from wild carnivores to domestic dogs and cats. In view of the potential severity and fatality of AE in humans health authorities should initiate internationally coordinated countermeasures. Although control programmes against human cystic echinococcosis (CE), caused by E. granulosus, have been established in some countries and effective control strategies are available, the parasite has still a wide geographical distribution affecting many countries of all continents. Thus, human CE is persisting in many parts of the world with high incidences, and in some areas it is a re-emerging problem. For example, alarming increases of the number of human cases have been reported from Bulgaria and Kazakhstan, and the People's Republic of China. Progress in control can only be expected if health authorities attribute a higher priority to this disease and if all modern diagnostic and control options (for example vaccination of intermediate host animals) can be used.     

Wilderness in the city: the urbanization of Echinococcus multilocularis

A distinct increase in fox populations, particularly in urban areas, has been observed in Europe. This is of particular concern in endemic regions of the small fox tapeworm Echinococcus multilocularis, the aetiological agent of human alveolar echinococcosis. Novel tools have facilitated the investigation of the ecology of urban foxes and have demonstrated the urban wildlife cycle of E. multilocularis. Such studies are essential for estimating the risk of transmission to humans and to determine the basics for the development of control strategies.     

Helminths of red foxes (Vulpes vulpes) and raccoon dogs (Nyctereutes procyonoides) in Lithuania

Red foxes and raccoon dogs are hosts for a wide range of parasites including important zoonotic helminths. The raccoon dog has recently invaded into Europe from the east. The contribution of this exotic species to the epidemiology of parasitic diseases, particularly parasitic zoonoses is unknown. The helminth fauna and the abundance of helminth infections were determined in 310 carcasses of hunted red foxes and 99 of raccoon dogs from Lithuania. Both species were highly infected with Alaria alata (94·8% and 96·5% respectively) and Trichinella spp. (46·6% and 29·3%). High and significantly different prevalences in foxes and raccoon dogs were found for Eucoleus aerophilus (97·1% and 30·2% respectively), Crenosoma vulpis (53·8% and 15·1%), Capillaria plica (93·3% and 11·3%), C. putorii (29·4% and 51·5%), Toxocara canis (40·5% and 17·6%) and Uncinaria stenocephala (76·9% and 98·8%). The prevalences of the rodent-transmitted cestodes Echinococcus multilocularis, Taenia polyacantha, T. crassiceps and Mesocestoides spp. were significantly higher in foxes than in raccoon dogs. The abundances of E. multilocularis, Mesocestoides, Taenia, C. plica and E. aerophilus were higher in foxes than those in raccoon dogs. A. alata, U. stenocephala, C. putorii and Echinostomatidae had higher abundances in raccoon dogs. The difference in prevalence and abundance of helminths in both animals may reflect differences in host ecology and susceptibility. The data are consistent with red foxes playing a more important role than raccoon dogs in the transmission of E. multilocularis in Lithuania.     

Infection of red foxes with Echinococcus multilocularis in western Switzerland

In the Jura mountains, Plateau and Alps of western Switzerland important variations in the prevalence of Echinococcus multilocularis infection in red foxes were observed between geographical areas from 1990 to 1995. The Jura mountains and the Plateau had higher mean prevalence levels than the Alps with 30.6, 32.4 and 18.8%, respectively. The highest rate was recorded in the Plateau in the canton of Fribourg with a prevalence of 52.3%. The prevalence of E. multilocularis infection in foxes in the alpine canton of Valais was the lowest (7.1%). Juvenile foxes were found to be more susceptible to E. multilocularis than adults. Adult foxes were less heavily infected in summer and autumn, while the prevalence in juveniles (less than 1 year old) increased between the spring and winter, when they are more than 6 months old. The retrospective data relate to the beginning of the 1990s, since when a drastic prevalence increase of E. multilocularis infection in foxes has occurred in several regions of Europe. Nevertheless, the study is a major contribution to the epidemiological situation of E. multilocularis in central Europe, in that it contains valuable information on spatial distribution and seasonal differences in different age groups of foxes.     

Echinococcus multilocularis in carnivores from the Klatovy district of the Czech Republic

A unique human case of alveolar echinococcosis was described in 1979 from the Klatovy district of the Czech Republic. However, there were no previous epidemiological studies in this area focusing on detection of the source of infection--Echinococcus multilocularis adults producing eggs. During the period June 1997 to April 1999, 29 out of a total of 46 (63.3%) red foxes (Vulpes vulpes) in the Klatovy district and one of four foxes (25.0%) in the Pilsen South district were found to be infected with adult worms of E. multilocularis. No E. multilocularis adults were found in other animals from the Klatovy district (i.e. three specimens of Martes martes, two Martes foina, one Mustela erminea, two Meles meles and one Felis catus f. domestica). An examination of faecal samples from 55 dogs (Canis familiaris) from the Klatovy district resulted in the detection of E. multilocularis DNA in one (1.8%) sample. The present results support the possibility that human alveolar echinococcosis previously described in the Czech Republic had the character of an autochthonous infection. There are also indications of a potential risk of infection to humans.     

Reproductive potential of Echinococcus multilocularis in experimentally infected foxes, dogs, raccoon dogs and cats

A total of 15 red foxes, 15 raccoon dogs, 15 domestic dogs and 15 domestic cats were each infected with 20,000 protoscolices of Echinococcus multilocularis. At 35, 63, and 90 days post inoculation (dpi), five animals from each group were necropsied and the worm burdens determined. The highest worm burdens in foxes (mean of 16,792) and raccoon dogs (mean of 7930) were found at 35 dpi. These declined to a mean of just 331 worms in foxes and 3213 worms in raccoon dogs by day 63 with a further decline to 134 worms in foxes and 67 worms in raccoon dogs by day 90. In dogs, there was no significant difference between worm burdens recovered at days 35 (mean of 2466) and day 90 (mean of 1563), although reduced numbers were recovered on day 63 (mean of 899). In cats, worms were found in four animals 35 dpi (mean of 642), in three at 63 dpi (mean of 28) and in two at 90 dpi (mean of 57). Faecal egg counts were determined at 3 day intervals from 25 dpi. A mathematical model of egg excretion dynamics suggested that the mean biotic potential per infected animal was high in foxes (346,473 eggs); raccoon dogs (335,361 eggs) and dogs (279,910 eggs) but very low for cats (573 eggs). It also indicated that approximately 114, 42 and 27 eggs per worm were excreted in the faeces of dogs, raccoon dogs and foxes, respectively. The fecundity of worms in cats was low with an average of less than one egg per worm. The peak levels of coproantigen were detected earlier in foxes and raccoon dogs than in dogs. Eggs recovered from foxes, raccoon dogs and dogs resulted in massive infections in experimental mice. However, metacestodes did not develop from eggs originating from infected cats. It is concluded that foxes, raccoon dogs and dogs are good hosts of E. multilocularis. In contrast, the low worm establishment, the very few excreted eggs and the lack of infectivity of eggs strongly indicate that cats play an insignificant role in parasite transmission.     

Infection of foxes by Echinococcocus multilocularis in urban and suburban areas of Nancy, France: influence of feeding habits and environment

This study evaluated the impact of biological and environmental factors on the infection of red foxes (Vulpes vulpes) by Echinococcus multilocularis in an endemic area of north-east France. From January 2004 to April 2006, 127 foxes were examined for E. multilocularis and their stomach contents analysed. The effect of year, season, age, sex and urbanisation level on E. multilocularis presence was estimated using a General Linear Model (GLM) with logit link, (i.e. logistic regression). Urbanisation level was the only influencing factor, with a decreasing gradient from rural [54%, CI 95% (40-68)] to peri-urban [31%, CI 95% (15-52)] and urban area [4%, CI 95% (0.7-15)]. The consumption of Arvicola terrestris and Microtus sp., grassland species, the main presumed intermediate hosts of E. multilocularis, was studied by the same approach. The two species were consumed less in the urban area and more in autumn than in spring. Anthropogenic food consumption was linked to urbanisation and to age. The frequency of anthropogenic food consumption decreased in the rural area. A global model explaining the presence of E. multilocularis and including urbanisation level and diet was then elaborated. Independently of urbanisation, there was a suggestion of less E. multilocularis infection with anthropogenic food consumption. Red foxes consuming Microtus sp. and A. terrestris had higher worm burden than those that did not. The results suggest that the decreasing gradient observed from rural to urban area is linked to behaviour and feeding habits.     

Echinococcus multilocularis coproantigen detection by enzyme-linked immunosorbent assay in fox, dog, and cat populations

A sandwich enzyme-linked immunosorbent assay (ELISA) for the detection of Echinococcus multilocularis coproantigens (EM-ELISA) was developed with polyclonal rabbit (solid phase) and chicken egg (catching) antibodies that were directed against E. multilocularis coproantigens and somatic worm antigens, respectively. In experimentally infected dogs and cats, coproantigens were first detectable 6-17 days postinfection (PI) in samples of 8 dogs (worm burdens at necropsy: 6,330-43,200) and from 11 days PI onward in samples of 5 cats infected with 20-6,833 worms. After anthelmintic treatment of 4 dogs and 5 cats at day 20 PI, coproantigen excretion disappeared within 3-5 days. The sensitivity of the ELISA was 83.6% in 55 foxes infected with 4-60,000 E. multilocularis, but reached 93.3% in the 45 foxes harboring more than 20 worms. The EM-ELISA was used in surveys of "normal" dog and cat populations in Switzerland. Among 660 dogs and 263 cats, 5 dogs and 2 cats exhibited a positive reaction. In 2 of these dogs (0.30%) and 1 cat (0.38%), intestinal E. multilocularis infections were confirmed by necropsy, polymerase chain reaction PCR, or both. The specificites of the ELISA in these groups were found to be 99.5% and 99.6%, respectively, if positive ELISA results that could not be confirmed by other methods were classified as "false positive" reactions.     

Failure to identify alveolar echinococcosis in trappers from South Dakota in spite of high prevalence of Echinococcus multilocularis in wild canids

Echinococcus multilocularis causes a rare but potentially lethal zoonotic disease in humans. This tapeworm has been known to be endemic in foxes (Vulpes vulpes) and coyotes (Canis latrans) within the northern United States since the 1960s. One purpose of this study was to provide recent data on the prevalence of E. multilocularis in foxes and coyotes from eastern South Dakota. In a survey conducted from 1987 to 1991 and involving 137 foxes and 9 coyotes from this area, 74.5% of the foxes and 4 of the coyotes were infected. To assess the possible prevalence of alveolar echinococcosis in a group at presumptive high risk, we also conducted a serological survey of members of the South Dakota Trappers Association in 1990 and 1991. Serum samples from 115 trappers were evaluated for the presence of E. multilocularis antibodies using enzyme-linked immunosorbent assay tests involving a purified antigen called Em2, a crude E. multilocularis antigen, and a recombinant E. multilocularis antigen called II/3-10. None of the trappers showed antibody evidence for the presence of E. multilocularis. Roughly half of the surveyed individuals had trapped more than 50 foxes during their life, and almost one-fourth had trapped more than 1,000 foxes.     

Observations on the development of Echinococcus multilocularis in cats

The development of a European isolate of Echinococcus multilocularis was compared in cats and dogs at the end of the prepatent period. Echinococcus multilocularis established in all dogs and cats, but worm recovery was significantly greater from dogs than from cats. Overall, worms in cats were not as advanced as those in dogs in terms of development and maturation, but there was no evidence of retarded development or stunted forms. These results confirm that dogs are highly susceptible to E. multilocularis, whereas cats have lower and more variable recovery rates. However, because cats produce thick-shelled eggs of E. multilocularis after experimental and natural infections, they have to be regarded as potential sources of infection both for intermediate and accidental hosts, including humans. However, their general role in the epidemiology of the infection has yet to be determined.     

Towards global control of cystic and alveolar hydatid diseases

Control programmes against Echinococcus granulosus in its dog-sheep transmission cycle (Fig. 1) have been successful in many parts of the world'. In contrast, the related E. multilocularis presents a much more complex problem for control authorities. Unlike E. granulosus, the life cycle of E. multilocularis predominantly involves sylvatic hosts (e.g. rodents and foxes) (Fig. 2) and the control of wild life echinococcosis presents a formidable challenge to ecologists and epidemiologists. This review contrasts the two parasites, explaining why E. granulosus in its domestic dog-sheep life cycle has been so responsive to control, and examines the prospects for control of E. multilocularis.     

Recurrent hepatic alveolar echinococcosis: report of the first case in Korea with unproven infection route

Human alveolar echinococcosis (AE), a hepatic disorder that resembles liver cancer, is a highly aggressive and lethal zoonotic infection caused by the larval stage of the fox tapeworm, Echinococcus multilocularis. E. multilocularis is widely distributed in the northern hemisphere; the disease-endemic area stretches from north America through Europe to central and east Asia, including northern parts of Japan, but it has not been reported in Korea. Herein, we represent a first case of AE in Korea. A 41-year-old woman was found to have a large liver mass on routine medical examination. The excised mass showed multinodular, necrotic, and spongiform appearance with small irregular pseudocystic spaces. Microscopically, the mass was composed of chronic granulomatous inflammation with extensive coagulation necrosis and parasite-like structure, which was revealed as parasitic vesicles and laminated layer delineated by periodic acid-Schiff (PAS) stain. Clinical and histologic features were consistent with AE. After 8 years, a new liver mass and multiple metastatic pulmonary nodules were found and the recurred mass showed similar histologic features to the initial mass. She had never visited endemic areas of AE, and thus the exact infection route is unclear.     

Echinococcus multilocularis identified in Michigan with additional records from Ohio

Echinococcus multilocularis was identified in a coyote in Indiana in January 1990, prompting an investigation of the distribution and prevalence of the parasite in wild canids in Indiana and surrounding states. In 1990-1991, the parasite was found throughout northern and central Indiana, in northwestern Ohio, and in east-central Illinois. In 1993-1994, 162 wild canids (97 red foxes, 54 coyotes, 11 gray foxes) were collected from Michigan, and an additional 75 (55 red foxes, 7 coyotes, 13 gray foxes) from Ohio, and examined for this parasite. Of these, 15 wild canids (6.3%) were found to be infected with E. multilocularis , including 4 of 97 (4.1%) red foxes from Michigan and 9 of 55 (16.4%) red foxes and 2 of 7 (28.6%) coyotes from Ohio. In Michigan, all infected animals were from the central and southwestern parts of the state. No infected animals were found in northern Michigan, including the Upper Peninsula. In Ohio, infected animals were limited to the northwestern and west-central portions of the state. These findings constitute new state and distribution records for E. multilocularis in the midwestern United States and indicate that the parasite continues to spread eastward and into Michigan from the south.     

Echinococcus multlocularis infections of rural, residential and urban foxes (Vulpes vulpes) in the canton of Geneva, Switzerland

We examined 267 red foxes (Vulpes vulpes) from the canton of Geneva, Switzerland, for intestinal infections with Echinococcus multilocularis. This region is situated in the core area of the endemic range of this zoonotic cestode in Central Europe. Several factors were taken into account and urbanisation level appeared to be the most explicative to describe observed differences. The prevalence decreased significantly from rural and residential areas (prevalence of 52%, CI 43-62%, and 49%, CI 38-59 %, respectively) to the urban area (prevalence of 31%, CI 19-42%). A few juvenile foxes harboured very high burdens up to more than 120,000 worms and were significantly more heavily infected than adults. The intensity of infection decreased from rural and residential areas to the city, suggesting a lower contamination of the urban environment.     

Echinococcus multilocularis in the red fox Vulpes vulpes from the East Carpathian region of Poland and the Slovak Republic

The occurrence of Echinococcus multilocularis in the Poland-Slovak frontier zone of the East Carpathian region was assessed, for comparison with that in adjacent regions in both countries. A total of 392 red foxes from Poland and 427 red foxes from the Slovak Republic were examined from 2001 to 2004. Significant differences in prevalences were observed in foxes captured from the borderland and adjacent zones in both countries. The mean prevalence of E. multilocularis in the Polish borderland reached 45.7+/-18.6% and in the Slovak border 35.0+/-10.7%. In both countries, the prevalence of E. multilocularis in red foxes from adjacent districts, outside the frontier Carpathian region, was considerably lower (18.9+/-9.2% in Poland and 20.8+/-9.0% in Slovakia). These differences are probably due to geomorphological and ecological factors, which contribute to the survival of the tapeworm eggs and the subsequent spread of infection. The Carpathian regions of northeast Slovakia and southeast Poland are characterized by specific climatic conditions such as low mean annual air temperatures, low temperatures in active soil surfaces, high soil humidities and a high mean annual rainfall.     

Epidemiology of alveolar echinococcosis in southern Cantal, Auvergne region, France

Alveolar echinococcosis (AE) is a helminth zoonosis which is encountered only in the northern hemisphere. In central France, the Auvergne region represents the most western and southern extension of this helminthiasis. In 1999, a human case of AE was diagnosed in the southern part of the Cantal department, where AE was supposed absent, and an epidemiological survey was subsequently carried out. The transmission of the zoonosis in the sylvatic and peridomestic definitive hosts was studied, as well as that in the rodent and human intermediate hosts. Eleven red foxes (Vulpes vulpes) were shot, and 50 fox faecal deposits were collected. Twelve farm dogs had their faeces taken by rectal touch, and four were checked after arecoline purgation. Optical detection of Echinococcus multilocularis worms was achieved on fox intestines after scraping, and also on dog stools after arecoline therapy. Coproantigen ELISA assay was performed for the 11 scraping products, for the 50 fox faeces, and for the 12 dog faecal samples. No adult AE agent was observed by microscopy, and the ELISA assay yielded positive results in one of 11 fox intestines, one of 50 fox faeces, and 2 of 12 dog faecal samples. Twenty-five small mammals were trapped, of which 19 were Arvicola terrestris water voles. One rodent liver exhibited a hepatic lesion consistent with AE. An epidemiological questionnaire was completed in 85 human volunteers, who were also serologically tested for AE. Only one (the case's husband) exhibited a Western-blotting pattern indicative of a low-grade AE infection. The results of this preliminary study suggested a slow AE extension to the south of Cantal department from the northern focus.     

Disappearance rate of praziquantel-containing bait around villages and small towns in southern Bavaria, Germany

In recent years, the red fox (Vulpes vulpes) has increasingly occupied urban areas in central Europe. Meanwhile, prevalence of infection in foxes with the small fox tapeworm (Echinococcus multilocularis) has increased, thereby increasing the human risk of infection with the parasite, which causes alveolar echinococcosis. Baiting strategies to counteract E. multilocularis have been implemented in cities and the open countryside, but there are few data on the situation in villages and small towns (<10,000 inhabitants). We recorded disappearance rates of praziquantel-containing bait within villages and small towns and on settlement edges for 7 days after distribution. Disappearance rates were 89.2% in villages, 88.8% in small towns, and 91.8% in settlement edges. More than 75% of the bait was consistently taken within the first three nights. There were no significant differences in disappearance rates between years or among seasons (Cox proportional hazard model). The survival time of the bait in small towns (P=0.021) and villages (P=0.026) depended on the zone (zone 1, first row of houses bordering on open countryside; zone 2, second to fourth rows, zone 3; beyond the fifth row) in which bait was distributed. In villages, the probability of bait being eaten in zone 1 was 119% higher than it was in zone 3 (P=0.007). In small towns, the probability was 60% higher (P=0.006).     

Ecological and biological factors involved in the transmission of Echinococcus multilocularis in the French Ardennes

In order to identify the respective importance of the ecological and biological factors involved in the transmission of Echinococcus multilocularis, we estimated grassland vole intermediate host (Microtus sp. and Arvicola terrestris) population densities, in relation to the diet of the definitive host (red fox, Vulpes vulpes) and with the prevalence of E. multilocularis in the fox population. The study was conducted in the Ardennes, north-eastern France, which is an area with a high incidence of alveolar echinococcosis. Surface index methods showed that Microtus was the most abundant intermediate host in the area. Furthermore, Microtus was present in one-third of the 144 faeces and 98 stomach content samples examined and represented more than two-thirds of the rodent occurrences. Red fox predation on Microtus was significantly correlated with Microtus relative abundance. In contrast, the relative abundance of A. terrestris was very low. This species, as well as Clethrionomys glareolus and Apodemus sp., was little consumed. E. multilocularis prevalence in foxes was determined from carcasses and reached 53% (95% confidence interval 45-61%). Intensity of infection varied from 2 to 73,380 worms per fox, with 72% of the sampled worm burden harboured by 8% of the sampled foxes. The selected explanatory variables (sex, year, age class, health and nutritional condition, and season) failed to predict prevalence rate and worm burden. The high prevalence rate in foxes indicates the possibility of intense E. multilocularis transmission, apart from periods, or in landscapes, favourable to large population outbreaks of grassland rodents.     

Role of dog behaviour and environmental fecal contamination in transmission of Echinococcus multilocularis in Tibetan communities

On the Eastern Tibetan Plateau region (Sichuan province, China) dogs are regarded as important definitive hosts of Echinococcus multilocularis. We studied dog spatial behaviour in 4 Tibetan villages in order to determine the role of dogs in environmental contamination and their potential interactions with small mammal intermediate hosts. We identified definitive host species and Echinococcus spp. infection status of feces collected in the field by PCR methods and analysed the spatial distribution of canid feces. Nocturnal space utilization of GPS collared dogs in and around villages was also undertaken. E. multilocularis DNA was amplified in 23% of dog feces (n=142) and in 15% of fox feces (n=13) but this difference was not significant. However, dog feces were more frequently observed (78% of collected feces) than fox feces and are therefore assumed to largely contribute to human environment contamination. Feces were mainly distributed around houses of dog owners (0-200 m) where collared dogs spent the majority of their time. Inside villages, the contamination was aggregated in some micro-foci where groups of dogs defecated preferentially. Finally, small mammal densities increased from the dog core areas to grasslands at the periphery of villages occasionally used by dogs; male dogs moving significantly farther than females. This study constitutes a first attempt to quantify in a spatially explicit way the role of dogs in E. multilocularis peri-domestic cycles and to identify behavioural parameters required to model E. multilocularis transmission in this region.