SummaryThe worldwide importance of human infection by Fasciola hepatica has been recognized in recent years. The endemic region between Lake Titicaca and the valley of La Paz, Bolivia, at 3800-4100 m altitude, presents the highest prevalences and intensities recorded. Large geographical studies involving Lymnaea truncatula snails (malacological, physico-chemical, and botanic studies of 59, 28 and 30 water bodies, respectively, inhabited by lymnaeids; environmental mean temperature studies covering a 40-year period), livestock (5491 cattle) and human coprological surveys (2723 subjects, 2521 of whom were school children) were conducted during 1991-97 to establish the boundaries and distributional characteristics of this endemic Northern Altiplano region. The endemic area covers part of the Los Andes, Ingavi, Omasuyos and Murillo provinces of the La Paz Department. The human endemic zone is stable, isolated and apparently fixed in its present outline, the boundaries being marked by geographical, climatic and soil-water chemical characteristics. The parasite distribution is irregular in the endemic area, the transmission foci being patchily distributed and linked to the presence of appropriate water bodies. Prevalences in school children are related to snail population distribution and extent. Altiplanic lymnaeids mainly inhabit permanent water bodies, which enables parasite transmission during the whole year. A confluence of several factors mitigates the negative effects of the high altitude.

We detected 10 protozoan and nine helminth species in surveys of 338 5-15 year-old Quechua schoolchildren in three communities of the Asillo zone of the Puno region, located at a very high altitude of 3910 m in the Peruvian Altiplano. The area proved to be hyperendemic for human fascioliasis with a 24.3% overall mean prevalence of Fasciola hepatica, local prevalences ranging between 18.8 and 31.3%, and infection intensities of up to 2496 eggs per gram of faeces (epg), with 196-350 epg (mean: 279 epg) and 96-152 epg (123 epg) as arithmetic and geometric means, respectively. Prevalences did not significantly vary between schools and in relation to sex. No statistical differences were found in intensities between schools, nor according to sex or age groups between and within schools, although the highest overall egg counts were detected in girls and in the youngest age group. Asillo zone is a man-made irrigation area built only recently to which both liver fluke and lymnaeid snails have quickly adapted. The region appears to be isolated from the Northern Bolivian Altiplano natural endemic area. Such man-made water resources in high altitude areas of Andean countries pose a high fascioliasis risk. Significant positive association of F. hepatica with protozooses following a one host life cycle, such as Giardia intestinalis, suggests that human infection mainly occurs through drinking water. This is supported by additional evidence such as the absence of typical aquatic vegetation in the drainage channels inhabited by lymnaeid snails, the absence of aquatic vegetables in the traditional nutrition habits of the Quechua inhabitants, and the lack of potable water systems inside dwellings, which requires inhabitants to obtain water from irrigation canals and drainage channels.

Over a 6-year period, an epidemiological study of human infection by Fasciola hepatica in the Northern Bolivian Altiplano was carried out. Prevalences and intensities were analysed from coprological results obtained in 31 surveys performed in 24 localities and proved to be the highest known so far. The global prevalence was 15.4%, with local prevalences ranging from 0% to 68.2%. Significant differences between prevalence rates were detected and the highest prevalences were in subjects aged < 20 years. However, prevalences showed no gender difference. The global intensity (eggs per gram of faeces, epg) ranged from 24 to 5064 epg and showed arithmetic and geometric means respectively of 446 and 191 epg, with highest local arithmetic and geometric means of 1345 and 678 epg. Significant differences in mean egg output were detected between localities. The significantly higher F. hepatica egg counts shown by girls in school surveys is worth mentioning. Although the distributions of intensities according to age-groups did not show any significant difference, a decrease of egg output counts with an increase of age was detected. It is concluded that fascioliasis is a very important human health problem in this region.

Cathepsin L1 (CL1), an immunogenic cysteine proteinase secreted by juvenile and adult Fasciola hepatica, was assessed for its potential as a diagnostic agent for the serologic detection of human fascioliasis. Using ELISAs, we compared the ability of liver fluke homogenates (LFH), excretory/secretory (ES) products, and CL1 to discriminate between seropositive (infected) and seronegative (noninfected) individuals within a population of 95 patients from the Bolivian Altiplano. A high prevalence of human fascioliasis has been reported in this region. The division between the seropositive and seronegative individuals was poorly defined when LFH was used as the antigen. A greater discrimination between these populations was achieved with both ES and CL1. A K-means cluster analysis using the combined ES and CL1 ELISA data identified a cluster of seropositive individuals. Cathepsin L1 detected a subset (20) of these seropositive individuals while ES detected all 26; however, ES detected nine additional individuals that were in the seronegative cluster. The ratio of the mean absorbance readings between seropositive and seronegative individuals was markedly improved by using conjugated second antibodies to IgG4, the predominant isotype elicited by infection. In these IgG4-ELISAs, CL1 again identified fewer individuals as seropositive than did ES, but improved the discrimination between the seropositive and seronegative individuals and thus provided a more conclusive diagnosis. Sera obtained from patients infected with schistosomiasis mansoni, cysticercosis, hydatidosis, and Chagas' disease were negative in these assays, which demonstrated the specificity of the IgG4-ELISA for detecting fascioliasis. Twenty of the 95 patients (21%) were seropositive for fascioliasis by the CL1 IgG4-ELISA, confirming the earlier reports of the high prevalence of disease in this region. A standardized diagnostic test for human fascioliasis, based on an ELISA that detects IgG4 responses to CL1, could be available to all diagnostic centers if sufficient quantities of recombinant CL1 can be produced.

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