Prevalence of abdominal cystic echinococcosis in rural Bulgaria, Romania, and Turkey: a cross-sectional, ultrasound-based, population study from the HERACLES project

Tamarozzi, Francesca; Akhan, Okan; Creţu, Carmen; Vutova, K.; Akıncı, Devrim; Chipeva, Rossitza; Çiftçi, Türkmen; Constantin, Corina; Fabiani, Massimo; Golemanov, Branimir; Janţă, Denisa; Mihăilescu, P; Muhtarov, M.; Örsten, Serra; Petruţescu, Marius Septimiu; Pezzotti, Patrizio; Popa, Alexandru; Popa, Loredana Gabriela; Popa, Mircea Ioan; Velev, Valeri; Siles-Lucas, Mar; Brunetti, Enrico; Casulli, Adriano

doi:10.1016/s1473-3099(18)30221-4

Cited by 123 publications

(135 citation statements)

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“…For instance, the Human CE ReseArch in CentraL and Eastern Societies (HERACLES) project ( http://www.heracles-fp7.eu/index.html) screened around 25,000 people by ultrasound surveys in the rural area of Bulgaria, Romani and Turkey in 2014–2015. The authors of this study estimated that about 45,000 people (7,872 in Bulgaria, 37,229 in Romania) living in these European rural areas might be infected with abdominal CE, a third of whom had active infection (Tamarozzi et al., ). The authors of this study, estimated that official statistics might underestimate the true value by 700‐fold for Romania and 10‐fold in Bulgaria.…”

Section: Discussionmentioning

confidence: 88%

The European Union One Health 2018 Zoonoses Report

2019

EFS2

589

325

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Section: Discussionmentioning

confidence: 88%

The European Union One Health 2018 Zoonoses Report

2019

EFS2

589

325

View full text Add to dashboard Cite

show abstract

“…A detailed description of the US surveys has been published [19]. Briefly, abdominal ultrasound screening sessions were performed in 2014-2015 on 24,687 people in 50 villages of Bulgaria, Romania, and Turkey, in areas of mid-range endemicity for human CE.…”

Section: Methodsmentioning

confidence: 99%

“…Cysts were identified and staged based on the visualization of pathognomonic signs of CE etiology, according to the WHO-IWGE Expert Consensus [20]; more stringent conditions were, however, applied to unilocular cysts, which where ascribed to parasitic etiology only if a double wall was clearly visible. Lesions suspect of CE, including CL, were investigated as per protocol to define the nature of the lesion [19]. Due to logistic constraints, only patients visiting the project’s referral hospitals for treatment of CE cysts received chest X-ray for the detection of possible lung CE; none resulted positive [19].…”

Section: Methodsmentioning

confidence: 99%

“…Lesions suspect of CE, including CL, were investigated as per protocol to define the nature of the lesion [19]. Due to logistic constraints, only patients visiting the project’s referral hospitals for treatment of CE cysts received chest X-ray for the detection of possible lung CE; none resulted positive [19]. “CE cases” were defined as all individuals with abdominal CE cysts detected on ultrasound, independently of whether they reported having received previous treatment for CE.…”

Section: Methodsmentioning

confidence: 99%

“…In 2014-2015, we carried out the largest research-based field survey on human CE in the context of the project “Human cystic Echinococcosis ReseArch in CentraL and Eastern Societies” (HERACLES [18]) funded by the European Commission in 2013. We examined by abdominal ultrasound 24,687 people from rural areas of Romania, Bulgaria, and Turkey, estimating that 151,000 people with abdominal CE may be currently present in the rural areas on these countries, a third of them potentially requiring treatment [19]. Here we present the analysis of risk factors questionnaires administered to participants during the HERACLES ultrasound population-based surveys.…”

Section: Introductionmentioning

confidence: 99%

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Potential risk factors associated with human cystic echinococcosis: a semi-structured questionnaire from a large population-based ultrasound cross-sectional study in Eastern Europe and Turkey

Tamarozzi

Akhan

Creţu³

et al. 2019

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BackgroundCystic echinococcosis (CE) is a neglected parasitic zoonosis prioritized by the WHO for control. Hygiene education is included in CE control campaigns but appears of little impact, and the precise risk factors for human infection are still uncertain. Several works investigated potential risk factors for CE through questionnaires, mostly carried out on small samples, providing contrasting results. We present the analysis of risk factors questionnaires administered to participants to the largest prevalence study on CE conducted in Eastern Europe.Methodology/Principal FindingsA semi-structured questionnaire was administered to 24,687 people from rural Bulgaria, Romania, and Turkey. CE cases were defined individuals with abdominal CE cysts detected on ultrasound. Variables associated with CE infection at p<0.20 in bivariate analysis were included into a multivariable logistic model, with a random effect to account for clustering at village level. Adjusted odds ratio (AOR) with 95%CI were used to describe the strength of associations. Data were weighted to reflect the relative distribution of the rural population in the study area by country, age group and sex. Valid records from 22,027 people were analyzed. According to the main occupation in the past 20 years, “housewife” (AOR 3.11 [1.51-6.41]) and “retired” (AOR 2.88 [1.09-7.65]) showed significantly higher odds of being infected compared to non-agricultural workers. “Having relatives with CE” (AOR 4.18 [1.77-9.88]) was also associated with higher odds of infection. Dog-related and food/water-related factors were not associated with infection.Conclusions/SignificanceOur results point to infection being acquired in a “domestic” rural environment and support the view that CE should be considered more a “soil-transmitted” than a “food-borne” infection, acquired through a “hand-to-mouth” mechanism. This result helps delineating the dynamics of infection transmission and have practical implications in the design of specific studies to shed light on actual sources of infection and inform control campaigns.AUTHOR SUMMARYCystic echinococcosis (CE) is a parasitic disease with high socio-economic impact, mostly affecting pastoral communities. The causative agent, Echinococcus granulosus sensu lato, is naturally transmitted between dogs and livestock; humans acquire infection through accidental ingestion of parasite eggs. Hygiene education is among the strategies of CE control campaigns, but appears of little impact. “Ingestion of contaminated food/water”, and “contact with dogs” are generally mentioned as the sources of human infection, however actual risk factors are still undefined. Several works investigated potential risk factors for human CE infection through questionnaires, mostly carried out on small samples, providing contrasting results. We analysed 22,027 risk factors questionnaires administered to the participants of the largest prevalence study on CE conducted in Eastern Europe. We found that being “housewife” and “retired” as the main occupation in the past 20 years, and “having relatives with CE” were associated with higher odds of CE infection, while dog-related and food/water-related factors were not associated with infection. Our results indicate that CE may be considered more a “soil-transmitted” than a “food-borne” infection, acquired through a “hand-to-mouth” mechanism in a domestic, rural environment. This may help designing specific studies on pathways of transmission of this neglected parasite.

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