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1.  Human Alveolar Echinococcosis in Poland: 1990–2011 
Alveolar echinococcosis (AE) caused by Echinococcus multilocularis infections is a dangerous old disease in the Northern Hemisphere. The aim of the paper was to collect and analyze data on human AE in Poland in the last two decades.
Methodology/Principal Findings
The sources of data were both the cases officially registered and detected by an active field and laboratory surveillance. The cases were verified by clinical, epidemiological, and laboratory criteria. Altogether 121 human cases of AE were detected. Among these 83 (68,6%) cases were classified as confirmed, 16 as probable and 22 as possible. During the two decades a continuous increase in detection rate was noticed. The cases were 6–82 years old at the time of diagnosis (mean - 47.7 years). Sex ratio M/F was 0.86/1.0. The AE was fatal in 23 (19%) patients (mean age at death - 54.1 years). Family agglomeration of AE was found in 4 foci, involving 9 patients. Seventy six of the cases were diagnosed in an advanced stage of disease. In all cases the liver was the primary location of AE. In 30 (24.8%) patients a spread to other organs was observed. Ninety four of the patients were treated with albendazole. In 73 (60%) patients a surgical operation was performed, including 15 liver transplantations.
The studies confirmed that AE is an emerging disease in Poland, which is the fourth country in Europe with over 120 cases detected. The results also indicate the need of a wider national programme for implementation of screening in the highest AE risk areas (north-eastern Poland) with an effort to increase the public awareness of the possibility of contracting E. multilocularis, and above all, training of the primary care physicians in the recognition of the risk of AE to allow for an early detection of this dangerous disease.
Author Summary
Human alveolar echinococcosis (AE) is a consequence of accidental ingestion of the eggs of the tapeworm Echinococcus multilocularis. AE constitutes a serious and increasing medical and epidemiological problem in many countries including Poland. The natural environments with a high AE prevalence are the areas where the definitive hosts (foxes, raccoons) and the intermediate hosts (rodents) live. The increasing population of infected foxes that penetrate nearby the village and urban buildings and infected dogs poses a certain risk to human health. This report is a joint clinical and epidemiological analysis of 121 AE cases recorded in the years 1990–2011 in Poland. The highest percentage of E. multilocularis infected foxes in the north-eastern regions of Poland (about 40% of the examined population infected) bears a clear-cut relation to the highest incidence of detected AE human cases in those areas. An epidemiological and clinical survey of the local population conducted for over a dozen years has contributed to the discovery of several new AE cases. Alveolar echinococcosis in humans caused by Echinococcus multilocularis infection belongs to the emerging diseases in Poland where a continuous increase in the detection rate was noticed during the last two decades.
PMCID: PMC3536814  PMID: 23301116
2.  Dynamics of the Force of Infection: Insights from Echinococcus multilocularis Infection in Foxes 
Characterizing the force of infection (FOI) is an essential part of planning cost effective control strategies for zoonotic diseases. Echinococcus multilocularis is the causative agent of alveolar echinococcosis in humans, a serious disease with a high fatality rate and an increasing global spread. Red foxes are high prevalence hosts of E. multilocularis. Through a mathematical modelling approach, using field data collected from in and around the city of Zurich, Switzerland, we find compelling evidence that the FOI is periodic with highly variable amplitude, and, while this amplitude is similar across habitat types, the mean FOI differs markedly between urban and periurban habitats suggesting a considerable risk differential. The FOI, during an annual cycle, ranges from (0.1,0.8) insults (95% CI) in urban habitat in the summer to (9.4, 9.7) (95% CI) in periurban (rural) habitat in winter. Such large temporal and spatial variations in FOI suggest that control strategies are optimal when tailored to local FOI dynamics.
Author Summary
Human alveolar echinococcosis (AE) is caused by the fox tapeworm E. multilocularis and has a high fatality rate if untreated. The frequency of the tapeworm in foxes can be reduced through the regular distribution of anthelmintic baits and thus decrease the risk of zoonotic transmission. Here, we estimate the force of infection to foxes using a mathematical model and data from necropsied foxes. The results suggest that the frequency of anthelmintic baiting of foxes can be optimised to local variations in transmission that depend upon season and type of fox habitat.
PMCID: PMC3961194  PMID: 24651596
3.  A Systematic Review of the Epidemiology of Echinococcosis in Domestic and Wild Animals 
Human echinococcosis is a neglected zoonosis caused by parasites of the genus Echinococcus. The most frequent clinical forms of echinococcosis, cystic echinococcosis (CE) and alveolar echinococcosis (AE), are responsible for a substantial health and economic burden, particularly to low-income societies. Quantitative epidemiology can provide important information to improve the understanding of parasite transmission and hence is an important part of efforts to control this disease. The purpose of this review is to give an insight on factors associated with echinococcosis in animal hosts by summarising significant results reported from epidemiological studies identified through a systematic search.
Methodology and Principal Findings
The systematic search was conducted mainly in electronic databases but a few additional records were obtained from other sources. Retrieved entries were examined in order to identify available peer-reviewed epidemiological studies that found significant risk factors for infection using associative statistical methods. One hundred studies met the eligibility criteria and were suitable for data extraction. Epidemiological factors associated with increased risk of E. granulosus infection in dogs included feeding with raw viscera, possibility of scavenging dead animals, lack of anthelmintic treatment and owners' poor health education and indicators of poverty. Key factors associated with E. granulosus infection in intermediate hosts were related to the hosts' age and the intensity of environmental contamination with parasite eggs. E. multilocularis transmission dynamics in animal hosts depended on the interaction of several ecological factors, such as hosts' population densities, host-prey interactions, landscape characteristics, climate conditions and human-related activities.
Results derived from epidemiological studies provide a better understanding of the behavioural, biological and ecological factors involved in the transmission of this parasite and hence can aid in the design of more effective control strategies.
Author Summary
Echinococcosis is considered a neglected zoonotic disease caused by the larval form of Echinococcus spp. tapeworms. Humans become infected through the accidental intake of parasitic eggs excreted by the faeces of definitive hosts (dogs, foxes and other canids). Infection involves the development of cysts, primarily in the lungs and liver, causing damage as they enlarge like a slowly growing tumor. Transmission is facilitated by the general lack of awareness of infection factors and epidemiological models can identify them. Nevertheless, there has never been a systematic review summarizing the significant determinants for echinococcosis in animals. One hundred publications were included in the results after evaluating 1,935 entries and screening the references lists of the eligible papers. Principal factors associated with canine infection included the access of dogs to infected offal, allowing dogs to roam free, being a young and/or male dog and social behaviours linked with poor health conditions and poor living environments of dog owners. Ecological factors influencing E. multilocularis transmission encompassed population densities of foxes and rodents, predator-prey relationships, geographical characteristics, climate conditions and the movement of foxes towards urban areas. These findings are important, as intervention to control echinococcosis requires intervention in animal populations.
PMCID: PMC3674998  PMID: 23755310
4.  Survey of public knowledge about Echinococcus multilocularis in four European countries: Need for proactive information 
BMC Public Health  2008;8:247.
Public information about prevention of zoonoses should be based on the perceived problem by the public and should be adapted to regional circumstances. Growing fox populations have led to increasing concern about human alveolar echinococcosis, which is caused by the fox tapeworm Echinococcus multilocularis. In order to plan information campaigns, public knowledge about this zoonotic tapeworm was assessed.
By means of representative telephone interviews (N = 2041), a survey of public knowledge about the risk and the prevention of alveolar echinococcosis was carried out in the Czech Republic, France, Germany and Switzerland in 2004.
For all five questions, significant country-specific differences were found. Fewer people had heard of E. multilocularis in the Czech Republic (14%) and France (18%) compared to Germany (63%) and Switzerland (70%). The same effect has been observed when only high endemic regions were considered (Czech Republic: 20%, France: 17%, Germany: 77%, Switzerland: 61%). In France 17% of people who knew the parasite felt themselves reasonably informed. In the other countries, the majority felt themselves reasonably informed (54–60%). The percentage that perceived E. multilocularis as a high risk ranged from 12% (Switzerland) to 43% (France). In some countries promising measures as deworming dogs (Czech Republic, Switzerland) were not recognized as prevention options.
Our results and the actual epidemiological circumstances of AE call for proactive information programs. This communication should enable the public to achieve realistic risk perception, give clear information on how people can minimize their infection risk, and prevent exaggerated reactions and anxiety.
PMCID: PMC2522376  PMID: 18644138
5.  Biological, Epidemiological, and Clinical Aspects of Echinococcosis, a Zoonosis of Increasing Concern 
Clinical Microbiology Reviews  2004;17(1):107-135.
Echinococcosis in humans is a zoonotic infection caused by larval stages (metacestodes) of cestode species of the genus Echinococcus. Cystic echinococcosis (CE) is caused by Echinococcus granulosus, alveolar echinococcosis (AE) is caused by E. multilocularis, and polycystic forms are caused by either E. vogeli or E. oligarthrus. In untreated cases, AE has a high mortality rate. Although control is essentially feasible, CE remains a considerable health problem in many regions of the northern and southern hemispheres. AE is restricted to the northern hemisphere regions of North America and Eurasia. Recent studies have shown that E. multilocularis, the causative agent of AE, is more widely distributed than previously thought. There are also some hints of an increasing significance of polycystic forms of the disease, which are restricted to Central and South America. Various aspects of human echinococcosis are discussed in this review, including data on the infectivity of genetic variants of E. granulosus to humans, the increasing invasion of cities in Europe and Japan by red foxes, the main definitive hosts of E. multilocularis, and the first demonstration of urban cycles of the parasite. Examples of emergence or reemergence of CE are presented, and the question of potential spreading of E. multilocularis is critically assessed. Furthermore, information is presented on new and improved tools for diagnosing the infection in final hosts (dogs, foxes, and cats) by coproantigen or DNA detection and the application of molecular techniques to epidemiological studies. In the clinical field, the available methods for diagnosing human CE and AE are described and the treatment options are summarized. The development of new chemotherapeutic options for all forms of human echinococcosis remains an urgent requirement. A new option for the control of E. granulosus in the intermediate host population (mainly sheep and cattle) is vaccination. Attempts are made to reduce the prevalence of E. multilocualaris in fox populations by regular baiting with an anthelmintic (praziquantel). Recent data have shown that this control option may be used in restricted areas, for example in cities, with the aim of reducing the infection risk for humans.
PMCID: PMC321468  PMID: 14726458
6.  Rapid Urbanization of Red Foxes in Estonia: Distribution, Behaviour, Attacks on Domestic Animals, and Health-Risks Related to Zoonotic Diseases 
PLoS ONE  2014;9(12):e115124.
Urban areas are becoming increasingly important for wildlife as diminishing natural habitats no longer represent a suitable environment for many species. Red foxes (Vulpes vulpes) are nowadays common in many cities worldwide, and in recent years they have colonized urban areas in Estonia. We used a public web-based questionnaire approach to evaluate the distribution and behaviour of Estonian urban foxes, to detect related problems and to assess health risks to humans and domestic animals. In total, 1205 responses were collected throughout the country. Foxes have colonized the majority of Estonian towns (33 out of 47) in a relatively short period of time, and have already established breeding dens in several towns. Despite their recent arrival, the behaviour of Estonian urban foxes is similar to that reported in longer-established urban fox populations: they are mostly active during night-time, often visit city centres and some also have dens in such locations. Certain characteristics of urban foxes serve as a basis for conflict with humans: foxes have entered houses and attacked domestic animals, killing cats and poultry. About 8% of reported foxes exhibited symptoms of sarcoptic mange, a disease that also infects domestic animals, especially dogs. The proportion of mange-infected foxes was higher in large urban areas. In addition to mange, a substantial fraction of red foxes in Estonia are known to be infected with the life-threatening tapeworm Echinococcus multilocularis, the causative agent of alveolar echinococcosis. Therefore, urban foxes may represent a source of serious infectious disease for pets and humans.
PMCID: PMC4274007  PMID: 25531399
7.  Genetic Diversity of the Cestode Echinococcus multilocularis in Red Foxes at a Continental Scale in Europe 
Alveolar echinococcosis (AE) is a severe helminth disease affecting humans, which is caused by the fox tapeworm Echinococcus multilocularis. AE represents a serious public health issue in larger regions of China, Siberia, and other regions in Asia. In Europe, a significant increase in prevalence since the 1990s is not only affecting the historically documented endemic area north of the Alps but more recently also neighbouring regions previously not known to be endemic. The genetic diversity of the parasite population and respective distribution in Europe have now been investigated in view of generating a fine-tuned map of parasite variants occurring in Europe. This approach may serve as a model to study the parasite at a worldwide level.
Methodology/Principal Findings
The genetic diversity of E. multilocularis was assessed based upon the tandemly repeated microsatellite marker EmsB in association with matching fox host geographical positions. Our study demonstrated a higher genetic diversity in the endemic areas north of the Alps when compared to other areas.
The study of the spatial distribution of E. multilocularis in Europe, based on 32 genetic clusters, suggests that Europe can be considered as a unique global focus of E. multilocularis, which can be schematically drawn as a central core located in Switzerland and Jura Swabe flanked by neighbouring regions where the parasite exhibits a lower genetic diversity. The transmission of the parasite into peripheral regions is governed by a “mainland–island” system. Moreover, the presence of similar genetic profiles in both zones indicated a founder event.
Author Summary
Echinococcus multilocularis is a tapeworm of the red fox, which represents a considerable health threat to respectively infected humans. Main endemic areas are located in China, Siberia, and central Europe. Alarmed by an emerging or reemerging situation in Europe, the question of how the parasite gets spatially and temporally spread and transmitted becomes essential to prepare appropriate control programs. The question was tackled by using genetic data on a large sample size of E. multilocularis adult stage tapeworms, combined with geographical site location data input. The historically documented endemic area, represented by the northern Alpine arch, was shown to harbour the highest genetic richness and diversity, as compared to surrounding areas in northern and eastern Europe. The spatial and temporal spread of different E. multilocularis genotypes in Europe seems to be ruled by a founder event, linked to exportation of parasites from the central core to newly identified (western and eastern) areas or subregions, where these parasites could subsequently disseminate under geographical separation from the original foci.
PMCID: PMC2685985  PMID: 19513103
8.  Anthelmintic Baiting of Foxes against Urban Contamination with Echinococcus multilocularis 
Emerging Infectious Diseases  2003;9(10):1266-1272.
In recent years, increases in the urban fox population have been observed in many countries of the Northern Hemisphere. As a result, Echinococcus multilocularis has entered the urban environment. Because of a possible increased risk for alveolar echinococcosis, intervention strategies need to be evaluated. In Zürich, Switzerland, 50 praziquantel-containing baits per km2 were distributed monthly in six 1-km2 bait areas and one 6-km2 bait area from April 2000 through October 2001. The proportion of E. multilocularis coproantigen–positive fox fecal samples collected remained unchanged in six control areas but decreased significantly in the 1-km2 bait areas (from 38.6% to 5.5%) and in the 6-km2 bait area (from 66.7% to 1.8%). E. multilocularis prevalence in the intermediate host Arvicola terrestris also decreased significantly in baited areas. This controlled baiting study shows that a pronounced reduction of E. multilocularis egg contamination is feasible in urban areas where the organism is highly endemic.
PMCID: PMC3033062  PMID: 14609462
9.  Subcutaneous Infection Model Facilitates Treatment Assessment of Secondary Alveolar Echinococcosis in Mice 
Alveolar echinococcosis (AE) in humans is a parasitic disease characterized by severe damage to the liver and occasionally other organs. AE is caused by infection with the metacestode (larval) stage of the fox tapeworm Echinococcus multilocularis, usually infecting small rodents as natural intermediate hosts. Conventionally, human AE is chemotherapeutically treated with mebendazole or albendazole. There is, however still the need for improved chemotherapeutical options. Primary in vivo studies on drugs of interest are commonly performed in small laboratory animals such as mice and Mongolian jirds, and in most cases, a secondary infection model is used, whereby E. multilocularis metacestodes are directly injected into the peritoneal cavity or into the liver. Disadvantages of this methodological approach include risk of injury to organs during the inoculation and, most notably, a limitation in the macroscopic (visible) assessment of treatment efficacy. Thus, in order to monitor the efficacy of chemotherapeutical treatment, animals have to be euthanized and the parasite tissue dissected. In the present study, mice were infected with E. multilocularis metacestodes through the subcutaneous route and were then subjected to chemotherapy employing albendazole. Serological responses to infection were comparatively assessed in mice infected by the conventional intraperitoneal route. We demonstrate that the subcutaneous infection model for secondary AE facilitates the assessment of the progress of infection and drug treatment in the live animal.
Author Summary
Alveolar echinococcosis is a disease which affects humans and inflicts severe damage to the liver and other organs. It is caused by a parasite whose definitive host is the fox. Despite being a relatively rare disease, an increasing number of new cases has been reported in central and eastern European countries more recently. The current therapy in human AE patients consists of benzimidazoles. The treatment has to be taken on a daily basis for very long periods of time, or even lifelong. New options are currently being searched for, mainly based on compounds that show efficacy in experimental animal infection models. The infection is commonly done by injecting parasites directly into the peritoneal cavity of the animals, with risk of damage to the surrounding organs. The efficacy of applied treatments can only be evaluated at the end of the studies by dissection of the animals. In this study we show that the subcutaneous infection model can be applied for drug treatment trials and enables the direct monitoring of treatment effects during the entire study period.
PMCID: PMC3662659  PMID: 23717701
10.  European Echinococcosis Registry: Human Alveolar Echinococcosis, Europe, 1982–2000 
Emerging Infectious Diseases  2003;9(3):343-349.
Surveillance for alveolar echinococcosis in central Europe was initiated in 1998. On a voluntary basis, 559 patients were reported to the registry. Most cases originated from rural communities in regions from eastern France to western Austria; single cases were reported far away from the disease-“endemic” zone throughout central Europe. Of 210 patients, 61.4% were involved in vocational or part-time farming, gardening, forestry, or hunting. Patients were diagnosed at a mean age of 52.5 years; 78% had symptoms. Alveolar echinococcosis primarily manifested as a liver disease. Of the 559 patients, 190 (34%) were already affected by spread of the parasitic larval tissue. Of 408 (73%) patients alive in 2000, 4.9% were cured. The increasing prevalence of Echinococcus multilocularis in foxes in rural and urban areas of central Europe and the occurrence of cases outside the alveolar echinococcosis–endemic regions suggest that this disease deserves increased attention.
PMCID: PMC2958541  PMID: 12643830
alveolar echinococcosis; alveolar hydatid disease; Echinococcus multilocularis; epidemiology; geographic distribution; risk factors; clinical characteristics; case registry; research
11.  Detection of Echinococcus multilocularis in Carnivores in Razavi Khorasan Province, Iran Using Mitochondrial DNA 
Echinococcus multilocularis is the source of alveolar echinococcosis, a potentially fatal zoonotic disease. This investigation assessed the presence of E. multilocularis infection in definitive hosts in the Chenaran region of Razavi Khorasan Province, northeastern Iran.
Methodology/Principal Findings
Fecal samples from 77 domestic and stray dogs and 14 wild carnivores were examined using the flotation/sieving method followed by multiplex PCR of mitochondrial genes. The intestinal scraping technique (IST) and the sedimentation and counting technique (SCT) revealed adult Echinococcus in the intestines of five of 10 jackals and of the single wolf examined. Three jackals were infected only with E. multilocularis but two, and the wolf, were infected with both E. multilocularis and E. granulosus. Multiplex PCR revealed E. multilocularis, E. granulosus, and Taenia spp. in 19, 24, and 28 fecal samples, respectively. Echinococcus multilocularis infection was detected in the feces of all wild carnivores sampled including nine jackals, three foxes, one wolf, one hyena, and five dogs (6.5%). Echinococcus granulosus was found in the fecal samples of 16.9% of dogs, 66.7% of jackals, and all of the foxes, the wolf, and the hyena. The feces of 16 (21.8%) dogs, 7 of 9 (77.8%) jackals, and all three foxes, one wolf and one hyena were infected with Taenia spp.
The prevalence of E. multilocularis in wild carnivores of rural areas of the Chenaran region is high, indicating that the life cycle is being maintained in northeastern Iran with the red fox, jackal, wolf, hyena, and dog as definitive hosts.
Author Summary
Echinococcus multilocularis causes alveolar echinococcosis, a serious zoonotic disease present in many areas of the world. The parasite is maintained in nature through a life cycle in which adult worms in the intestine of carnivores transmit infection to small mammals, predominantly rodents, via eggs in the feces. Humans may accidentally ingest eggs of E. multilocularis through contact with the definitive host or by direct ingestion of contaminated water or foods, causing development of a multivesicular cyst in the viscera, especially liver and lung. We found adult E. multilocularis in the intestine and/or eggs in feces of all wild carnivores examined and in some stray and domestic dogs in villages of Chenaran region, northeastern Iran. The life cycle of E. multilocularis is being maintained in this area by wild carnivores, and the local population and visitors are at risk of infection with alveolar echinococcosis. Intensive health initiatives for control of the parasite and diagnosis of this potentially fatal disease in humans, in this area of Iran, are needed.
PMCID: PMC3222634  PMID: 22132245
12.  Detection of Echinococcus multilocularis in the Definitive Host: Coprodiagnosis by PCR as an Alternative to Necropsy 
Journal of Clinical Microbiology  1998;36(7):1871-1876.
Recently, extensions of the range of Echinococcus multilocularis in Europe and North America and drastic increases in fox populations in Europe put an increasing proportion of the human population at risk of alveolar echinococcosis. To obtain data on the local infection pressure, studies of the prevalence of the parasite in the animals that transmit the parasite, foxes, dogs, and cats, are urgently required. Such investigations, however, have been hampered by the need for necropsy of the host animal to specifically diagnose infection with the parasite. In this study, a nested PCR and an improved method for DNA extraction were developed to allow the sensitive and specific diagnosis of E. multilocularis infections directly from diluted fecal samples from foxes. The target sequence for amplification is part of the E. multilocularis mitochondrial 12S rRNA gene. The specificity of the method was 100% when it was tested against 18 isolates (metacestodes and adult worms) of 11 cestode species, including E. granulosus. The sensitivity of the method was evaluated by adding egg suspensions and individual eggs to samples of diluted feces from uninfected foxes. The presence of one egg was sufficient to give a specific signal. To confirm the PCR results, an internal probe which hybridized only with E. multilocularis amplification products but not with the DNA of other cestodes was constructed. In order to investigate the applicability of this method for epidemiological studies, 250 wild foxes from a area in southern Germany where echinococcosis is highly endemic were examined by both necropsy and PCR of rectal contents. The sensitivity correlated with the parasites’ number and stage of maturity. It ranged from 100% (>1,000 gravid worms) to 70% (<10 nongravid worms). On the basis of positive PCR results for 165 foxes, the sensitivity of the traditional and widely used necropsy method was found to be not higher than 76%. We therefore present this PCR system as an alternative method for the routine diagnosis of E. multilocularis in carnivores.
PMCID: PMC104943  PMID: 9650927
13.  The Global Burden of Alveolar Echinococcosis 
Human alveolar echinococcosis (AE) is known to be common in certain rural communities in China whilst it is generally rare and sporadic elsewhere. The objective of this study was to provide a first estimate of the global incidence of this disease by country. The second objective was to estimate the global disease burden using age and gender stratified incidences and estimated life expectancy with the disease from previous results of survival analysis. Disability weights were suggested from previous burden studies on echinococcosis.
Methodology/Principal Findings
We undertook a detailed review of published literature and data from other sources. We were unable to make a standardised systematic review as the quality of the data was highly variable from different countries and hence if we had used uniform inclusion criteria many endemic areas lacking data would not have been included. Therefore we used evidence based stochastic techniques to model uncertainty and other modelling and estimating techniques, particularly in regions where data quality was poor. We were able to make an estimate of the annual global incidence of disease and annual disease burden using standard techniques for calculation of DALYs. Our studies suggest that there are approximately 18,235 (CIs 11,900–28,200) new cases of AE per annum globally with 16,629 (91%) occurring in China and 1,606 outside China. Most of these cases are in regions where there is little treatment available and therefore will be fatal cases. Based on using disability weights for hepatic carcinoma and estimated age and gender specific incidence we were able to calculate that AE results in a median of 666,434 DALYs per annum (CIs 331,000-1.3 million).
The global burden of AE is comparable to several diseases in the neglected tropical disease cluster and is likely to be one of the most important diseases in certain communities in rural China on the Tibetan plateau.
Author Summary
Human alveolar echinococcosis (AE), caused by the larval stage of the fox tapeworm Echinococcus multilocularis, is amongst the world's most dangerous zoonoses. Transmission to humans is by consumption of parasite eggs which are excreted in the faeces of the definitive hosts: foxes and, increasingly, dogs. Transmission can be through contact with the definitive host or indirectly through contamination of food or possibly water with parasite eggs. We made an intensive search of English, Russian, Chinese and other language databases. We targeted data which could give country specific incidence or prevalence of disease and searched for data from every country we believed to be endemic for AE. We also used data from other sources (often unpublished). From this information we were able to make an estimate of the annual global incidence of disease and disease burden using standard techniques for calculation of DALYs. Our studies suggest that AE results in a median of 18,235 cases globally with a burden of 666,433 DALYs per annum. This is the first estimate of the global burden of AE both in terms of global incidence and DALYs and demonstrates the burden of AE is comparable to several diseases in the neglected tropical disease cluster.
PMCID: PMC2889826  PMID: 20582310
14.  Human Echinococcosis Mortality in the United States, 1990–2007 
Despite the endemic nature of Echinococcus granulosus and Echinococcus multilocularis infection in regions of the United States (US), there is a lack of data on echinococcosis-related mortality. To measure echinococcosis-associated mortality in the US and assess possible racial/ethnic disparities, we reviewed national-death certificate data for an 18-year period.
Methodology/Principal Findings
Echinococcosis-associated deaths from 1990 through 2007 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. A total of 41 echinococcosis-associated deaths occurred over the 18-year study period. Mortality rates were highest in males, Native Americans, Asians/Pacific Islanders, Hispanics and persons 75 years of age and older. Almost a quarter of fatal echinococcosis-related cases occurred in residents of California. Foreign-born persons accounted for the majority of echinococcosis-related deaths; however, both of the fatalities in Native Americans and almost half of the deaths in whites were among US-born individuals.
Although uncommon, echinococcosis-related deaths occur in the US. Clinicians should be aware of the diagnosis, particularly in foreign-born patients from Echinococcus endemic areas, and should consider tropical infectious disease consultation early.
Author Summary
Human echinococcosis is a parasitic disease that affects an estimated 2–3 million people and results in an annual monetary loss of over $750,000,000 worldwide. It results in the development of life threatening tissue cysts, primarily in the liver and lung, following accidental ingestion of eggs in infected dog, fox or wild canine feces. Echinococcus parasites have a complex, two-host lifecycle (such as in dogs and sheep) in which humans are an aberrant, dead-end host. The vast majority of cases of human echinococcosis occur outside of the United States (US); however, cases within the US do occur. In this study, the authors examined death certificate data of US residents from 1990–2007 in which echinococcosis was listed as one of the diagnoses at death. The analysis demonstrated 41 echinococcosis-related deaths over the 18-year study period with foreign-born persons accounting for the majority of the deaths. This study helps quantify echinococcosis deaths among US residents and adds further support to the importance of funding echinococcosis prevention research.
PMCID: PMC3274497  PMID: 22347516
15.  Echinococcus multilocularis: An Emerging Pathogen in Hungary and Central Eastern Europe? 
Emerging Infectious Diseases  2003;9(3):384-386.
Echinococcus multilocularis, the causative agent of human alveolar echinococcosis, is reported for the first time in Red Foxes (Vulpes vulpes) in Hungary. This parasite may be spreading eastward because the population of foxes has increased because of human interventions, and this spread may result in the emergence of alveolar echinococcosis in Central Eastern Europe.
PMCID: PMC2958538  PMID: 12643838
Echinococcus multilocularis; red fox; Hungary; Central Eastern Europe; alveolar echinococcosis; emerging zoonosis; dispatch
16.  Rudolf Virchow and the Recognition of Alveolar Echinococcosis, 1850s 
Emerging Infectious Diseases  2007;13(5):732-735.
Virchow proved that the disease “alveolar colloid” was caused by an Echinococcus sp.
Alveolar echinococcosis, which is caused by the larval stage of the fox tapeworm Echinococcus multilocularis, is one of the most dangerous parasitic diseases. It is endemic in many parts of the Northern Hemisphere and an emerging health problem in the People’s Republic of China. In Europe and North America, human cases are rare, but concomitant with an increase in the population of the final host, the red fox, an increase of human infections is expected. Rudolf Virchow, the father of the concept of cellular pathology, determined in the 1850s that an Echinococcus sp. was the causative agent of this enigmatic emerging disease. In his famous publication in 1855, he described the clinical course of the disease, its macroscopic aspects, and histopathologic findings in detail. He also identified the disease formerly known as alveolar colloid of the liver to be an infection with the larval stage of an Echinococcus sp.
PMCID: PMC2738454  PMID: 17553252
Rudolf Virchow; alveolar echinococcosis; Echinococcus multilocularis; pathology; infectious diseases; historical review
17.  Effect of Amphotericin B on Larval Growth of Echinococcus multilocularis 
Alveolar echinococcosis is caused by the parasitic cestode Echinococcus multilocularis. Benzimidazoles, namely, mebendazole and albendazole, are the only drugs available for the treatment of inoperable alveolar echinococcosis. At present, no therapeutic alternative is available for patients with progressive disease under treatment or for patients who are unable to tolerate the side effects of the benzimidazoles. In addition, benzimidazoles are only parasitostatic for E. multilocularis. Thus, new therapeutic options are of paramount importance. In the present study we examined the in vitro effect of amphotericin B on E. multilocularis larvae. E. multilocularis metacestodes grown in the peritoneal cavities of Mongolian gerbils were transferred into a culture system. Vesicles budded from the tissue blocks and increased in number and size during the first 5 weeks. After 6 weeks drugs were added and deleterious effects on the vesicles were observed macroscopically and microscopically. By use of this in vitro tissue culture model we demonstrated that amphotericin B effectively inhibits the growth of E. multilocularis metacestodes. This destructive effect was significantly more rapid with amphotericin B than with the benzimidazoles. Cyclic treatment was effective in suppressing parasite growth. However, amphotericin B appears to be parasitostatic for E. multilocularis larvae, and regrowth occurs even after extended periods. In summary, amphotericin B constitutes the first promising alternative for the treatment of alveolar echinococcosis in cases of intolerance or resistance to benzimidazoles. It holds promise as an effective treatment option for otherwise fatal courses of disease.
PMCID: PMC151734  PMID: 12543669
18.  Landscape Composition and Spatial Prediction of Alveolar Echinococcosis in Southern Ningxia, China 
Alveolar echinococcosis (AE) presents a serious public health challenge within China. Mass screening ultrasound surveys can detect pre-symptomatic AE, but targeting areas identified from hospital records is inefficient regarding AE. Prediction of undetected or emerging hotspots would increase detection rates. Voles and lemmings of the subfamily Arvicolinae are important intermediate hosts in sylvatic transmission systems. Their populations reach high densities in productive grasslands where food and cover are abundant. Habitat availability is thought to affect arvicoline population dynamic patterns and definitive host–intermediate host interactions. Arvicoline habitat correlates with AE prevalence in Western Europe and southern Gansu Province, China.
Methods and Findings
Xiji County, Ningxia Hui Autonomous Region, borders southern Gansu. The aims of this study were to map AE prevalence across Xiji and test arvicoline habitat as a predictor. Land cover was mapped using remotely sensed (Landsat) imagery. Infection status of 3,205 individuals screened in 2002–2003 was related, using generalised additive mixed models, to covariates: gender; farming; ethnicity; dog ownership; water source; and areal cover of mountain pasture and lowland pasture. A Markov random field modelled additional spatial variation and uncertainty. Mountain pasture and lowland pasture were associated with below and above average AE prevalence, respectively.
Low values of the normalised difference vegetation index indicated sub-optimality of lowland pasture for grassland arvicolines. Unlike other known endemic areas, grassland arvicolines probably did not provide the principal reservoir for Echinococcus multilocularis in Xiji. This result is consistent with recent small mammal surveys reporting low arvicoline densities and high densities of hamsters, pikas and jerboas, all suitable intermediate hosts for E. multilocularis, in reforested lowland pasture. The risk of re-emergence is discussed. We recommend extending monitoring to: southern Haiyuan County, where predicted prevalence was high; southern Xiji County, where prediction uncertainty was high; and monitoring small mammal community dynamics and the infection status of dogs.
Author Summary
In humans, larvae of the fox tapeworm Echinococcus multilocularis typically infect the liver where metastasis, calcification and necrosis cause the zoonotic disease alveolar echinococcosis (AE). Treatment is difficult. Early detection greatly increases patient life expectancy but under-detection is a problem. Understanding the ecological conditions that elevate AE risk would help identify at-risk communities. Voles and lemmings of the subfamily Arvicolinae are important intermediate hosts in most AE endemic areas, and arvicoline habitat has been proposed as a predictor of AE risk. Using a model of spatial autocorrelation with land cover identified from satellite remote sensing imagery, we identified AE hotspots in southern Ningxia Hui Autonomous Region (NHAR), China. Hotspots were not located near optimal arvicoline habitats. Thus, non-arvicolines provide principal reservoirs in NHAR and the range of ecological conditions sustaining E. multilocularis transmission in China is greater than previously thought. We also show: social factors explain higher prevalence in females than males; dogs increase infection risk; and we argue that water source quality is important via interaction with other environmental variables. Our map of AE prevalence represents the current state-of-the-art regarding the spatial distribution of AE in southern NHAR and provides an important baseline for future monitoring programs there.
PMCID: PMC2565701  PMID: 18846237
19.  Alveolar Echinococcosis Infection in a Monkey (Ateles geoffroyi) In Mashhad, Iran 
Iranian Journal of Public Health  2012;41(2):111-116.
Alveolar echinococcosis (AE), which is caused by ingestion of eggs of the fox tapeworm Echinococcus multilocularis, is the most potentially lethal parasitic infection because of its tendency to invade and proliferate in the liver and the difficulty in treatment. This article describes a case of alveolar echinococcosis found in Ateles geoffroyi in Mashhad, Iran. The cysts were characterized as an alveolar structure, composed of numerous small vesicles in liver, abdominal cavity, retroperitoneum and lungs. A characteristic feature of these vesicles was its exogenous tumor-like proliferation. These cysts were filled with numerous protoscoleces suggesting a potential role of this monkey in cycle of transmission. Up to now, this is probably the first report of alveolar echinococcosis in A. geoffroyi in the world.
PMCID: PMC3481672  PMID: 23113143
Alveolar echinococcosis; Ateles geoffroyi; Iran
20.  Natural Infection of the Ground Squirrel (Spermophilus spp.) with Echinococcus granulosus in China 
Echinococcus granulosus is usually transmitted between canid definitive hosts and ungulate intermediate hosts.
Methodology/Principal Findings
Lesions found in the livers of ground squirrels, Spermophilus dauricus/alashanicus, trapped in Ningxia Hui Autonomous Region, an area in China co-endemic for both E. granulosus and E. multilocularis, were subjected to molecular genotyping for Echinococcus spp. DNA. One of the lesions was shown to be caused by E. granulosus and subsequently by histology to contain viable protoscoleces.
This is the first report of a natural infection of the ground squirrel with E. granulosus. This does not provide definitive proof of a cycle involving ground squirrels and dogs or foxes, but it is clear that there is active E. granulosus transmission occurring in this area, despite a recent past decline in the dog population in southern Ningxia.
Author Summary
Echinococcus granulosus and E. multilocularis are important zoonotic pathogens that cause serious disease in humans. E. granulosus can be transmitted through sylvatic cycles, involving wild carnivores and ungulates; or via domestic cycles, usually involving dogs and farm livestock. E. multilocularis is primarily maintained in a sylvatic life-cycle between foxes and rodents. As part of extensive investigations that we undertook to update available epidemiological data and to monitor the transmission patterns of both E. granulosus and E. mulilocularis in Ningxia Hui Autonomous Region (NHAR) in northwest China, we captured small mammals on the southern slopes of Yueliang Mountain, Xiji, an area co-endemic for human alveolar echinococcosis and cystic echinococcosis. Of 500 trapped small mammals (mainly ground squirrels; Spermophilus dauricus/alashanicus), macroscopic cyst-like lesions (size range 1–10 mm) were found on the liver surface of approximately 10% animals. One of the lesions was shown by DNA analysis to be caused by E. granulosus and by histology to contain viable protoscoleces. This is the first report of a natural infection of the ground squirrel with E. granulosus. We have no definitive proof of a cycle involving ground squirrels and dogs/foxes but it is evident that there is active E. granulosus transmission occurring in this area.
PMCID: PMC2737643  PMID: 19771151
21.  Age, season and spatio-temporal factors affecting the prevalence of Echinococcus multilocularis and Taenia taeniaeformis in Arvicola terrestris 
Taenia taeniaeformis and the related zoonotic cestode Echinococcus multilocularis both infect the water vole Arvicola terrestris. We investigated the effect of age, spatio-temporal and season-related factors on the prevalence of these parasites in their shared intermediate host. The absolute age of the voles was calculated based on their eye lens weights, and we included the mean day temperature and mean precipitation experienced by each individual as independent factors.
Overall prevalences of E. multilocularis and T. taeniaeformis were 15.1% and 23.4%, respectively, in 856 A. terrestris trapped in the canton Zürich, Switzerland. Prevalences were lower in young (≤ 3 months: E. multilocularis 7.6%, T. taeniaeformis 17.9%) than in older animals (>7 months: 32.6% and 34.8%). Only 12 of 129 E. multilocularis-infected voles harboured protoscoleces. Similar proportions of animals with several strobilocerci were found in T. taeniaeformis infected voles of <5 months and ≥5 months of age (12.8% and 11.9%). Multivariate analyses revealed strong spatio-temporal variations in prevalences of E. multilocularis. In one trapping area, prevalences varied on an exceptional high level of 40.6-78.5% during the whole study period. Low temperatures significantly correlated with the infection rate whereas precipitation was of lower importance. Significant spatial variations in prevalences were also identified for Taenia taeniaeformis. Although the trapping period and the meteorological factors temperature and precipitation were included in the best models for explaining the infection risk, their effects were not significant for this parasite.
Our results demonstrate that, besides temporal and spatial factors, low temperatures contribute to the risk of infection with E. multilocularis. This suggests that the enhanced survival of E. multilocularis eggs under cold weather conditions determines the level of infection pressure on the intermediate hosts and possibly also the infection risk for human alveolar echincoccosis (AE). Therefore, interventions against the zoonotic cestode E. multilocularis by deworming foxes may be most efficient if conducted just before and during winter.
PMCID: PMC3033848  PMID: 21247427
22.  Interleukin-5 is the predominant cytokine produced by peripheral blood mononuclear cells in alveolar echinococcosis. 
Infection and Immunity  1995;63(5):1688-1697.
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.
PMCID: PMC173211  PMID: 7729873
23.  Frequency distribution of Echinococcus multilocularis and other helminths of foxes in Kyrgyzstan 
Veterinary parasitology  2010;171(3-4):286-292.
Echinococcosis is a major emerging zoonosis in central Asia. A study of the helminth fauna of foxes from Naryn Oblast in central Kyrgyzstan was undertaken to investigate the abundance of Echinococcus multilocularis in a district where a high prevalence of this parasite had previously been detected in dogs. A total of 151 foxes (Vulpes vulpes) were investigated in a necropsy study. Of these 96 (64%) were infected with E. multilocularis with a mean abundance of 8669 parasites per fox. This indicates that red foxes are a major definitive host of E. multilocularis in this country. This also demonstrates that the abundance and prevalence of E. multilocularis in the natural definitive host are likely to be high in geographical regions where there is a concomitant high prevalence in alternative definitive hosts such as dogs. In addition Mesocestoides spp., Dipylidium caninum, Taenia spp., Toxocara canis, Toxascaris leonina, Capillaria and Acanthocephala spp. were found in 99 (66%), 50 (33%), 48 (32%), 46 (30%), 9 (6%), 34 (23%) and 2 (1%) of foxes, respectively. The prevalence but not the abundance of E. multilocularis decreased with age. The abundance of Dipylidium caninum also decreased with age. The frequency distribution of E. multilocularis and Mesocestoides spp. followed a zero inflated negative binomial distribution, whilst all other helminths had a negative binomial distribution. This demonstrates that the frequency distribution of positive counts and not just the frequency of zeros in the data set can determine if a zero inflated or non-zero inflated model is more appropriate. This is because the prevalences of E. multolocularis and Mesocestoides spp. were the highest (and hence had fewest zero counts) yet the parasite distribution nevertheless gave a better fit to the zero inflated models.
PMCID: PMC2903646  PMID: 20434845
Fox; intestinal helminths; Echinococcus multilocularis; Kyrgyzstan; epidemiology; zero inflated; negative binomial
24.  Echinococcus multilocularis Alkaline Phosphatase as a Marker for Metacestode Damage Induced by In Vitro Drug Treatment with Albendazole Sulfoxide and Albendazole Sulfone 
Alveolar echinococcosis (AE) is caused by the metacestode stage of the fox tapeworm Echinococcus multilocularis. The disease affects the human liver and occasionally other organs and is fatal if treatment is unsuccessful. The present chemotherapy of AE is based on the administration of benzimidazole carbamate derivatives, such as mebendazole and albendazole. Albendazole treatment has been found to be ineffective in some cases, parasitostatic rather than parasiticidal, and the recurrence rate is rather high. Therefore, chemotherapy usually involves the lifelong uptake of massive doses of albendazole and new treatment options are urgently needed. In order to avoid costly and time-consuming animal experimentation, a first step in searching for novel parasiticidal compounds could be the in vitro drug screening of novel compounds by employing metacestode cultivation. However, presently used techniques (e.g., transmission electron microscopy) for determination of parasite viability involve costly equipment and time-consuming preparation of rather large amounts of parasite material. We therefore searched for a parasite marker which can be easily traced and the presence or absence of which is indicative of parasite viability. In this study we show that the increase of E. multilocularis alkaline phosphatase activity in culture supernatants during in vitro drug treatment with albendazole derivatives correlates with the progressive degeneration and destruction of the metacestode tissue. The inexpensive and rapid assay presented here will serve as an ideal tool for performing first-round in vitro tests on the efficacy of a large number of antiparasitic compounds.
PMCID: PMC90639  PMID: 11451682
25.  Alveolar hydatid cyst mimicking cerebellar metastatic tumor 
Echinococcus multilocularis is a rare infestation in the world with a particularly increased incidence mainly in South America, Central Europe and Asia. Progression of alveolar Echinococcosis is more aggressive that can metastasize to lungs, brain and bones however brain involvement is usually rare with an incidence about 1%.
Case Description:
We report a 23-year-old man with a cerebellar Echinococcosis multilocularis mimicking a metastatic cerebellar tumor. Suboccipital craniotomy was performed for gross total removal of the tumor. Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis.
Radical surgical excision should be recommended for single Echinococcosis multilocularis lesions particularly at infratentorial localization.
PMCID: PMC3046418  PMID: 21427774
Alveolar hydatid cysts; cerebellum; echinococcus; surgery; tumor

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