The Nature and Prevalence of Intestinal Parasites in the United States and its Refugees

H. Alicic, R. Sharar, B. Tarcea

Introduction: Despite the common notion that intestinal parasites--organisms that live in the intestine of a host species and negatively impacts hosts--are a health issue limited to third world nations, the United States experiences a relatively high occurrence of parasite-related illness. In fact, many of the poorest Americans are suffering from similar parasitic infections that affect people in Africa, Asia and Latin America. [1] Over one third of the worlds population is infected by intestinal parasites, including an estimated 65 million people in the United States. [2] These infections often cause significant morbidity and mortality and one of the most consequential effects of both symptomatic and asymptomatic infections is transmission to new hosts. Intestinal parasites are most commonly transmitted from anus to mouth, with the ingestion of contaminated water being a prominent method of transmission. Consequently, populations in countries with poor sanitation standards are highly susceptible to parasitic infection. Common symptoms of intestinal parasitic infections include abdominal pain, diarrhea, nausea, vomiting, gas, dysentery, stomach pain, fatigue, and anorexia, though they can have a wide variety of physical effects. [3] Intestinal parasites are classified into two main types: helminths and protozoa. Helminths consist of the Nematoda (roundworms) and Platyhelminths (flatworms) while flatworms are further divided into trematodes (flukes) and cestodes (tapeworms). [2] In our study we will consider intestinal parasites from each of these classifications. 1

Because we live in a world of escalating global movement, will parasitic infections spread as people spread? To do this we can look at the common intestinal parasites that affect Americanborn individuals and compare them to the intestinal parasites that commonly infect refugees, an

incoming population to the United States. We will examine treatment

Figure 1: Classification of intestinal parasites: Protozoa and Helminths

protocol in the two groups to help determine: 1. if refugees to America could be responsible for transmission of intestinal parasites to American-born individuals and 2. the social implications of who is treated and not. Materials and Methods Refugees from Southeast Asia and Sub-Saharan Africa were studied because of the wealth of information available concerning these groups. Refugee groups make good study subjects because their background and health is methodically examined and recorded by the United States Centers of Disease Control and Prevention in conjunction with the United States Department of Immigration and Citizenship. [4] Also, parasite prevalence is high in Southeast Asia and Sub-Saharan Africa, which makes these refugee populations particularly relevant for this study.

Parasite prevalence was measured in percent (%) of individuals infected by a parasite. This accounts for differences in population size that would be problematic if the total number of infected individuals were measured rather than the percent infected. Results/Findings Intestinal parasite prevalence among incoming refugees to the United States: Individuals wishing to seek asylum in the United States must be screened for a wide variety of infectious diseases including tuberculosis, human immunodeficiency virus (HIV) and other sexually transmitted diseases, hepatitis, and intestinal and other parasites. Between 1989 and 2002, the number of refugees admitted into the United States was above 1.2 million. Depending on a variety of factors, such as age, place of origin, intermediate countries of residence, living conditions, dietary habits or restrictions, etc., the infection rates of intestinal parasites among refugees can vary from 8% to 86%. Different methods of sampling and analysis of stool samples can also attribute to the wide breadth of prevalence rates. [2] In 1999, 22% of 2,545 refugees were positive for gastrointestinal parasitic infections among individuals screened in Minnesota. Meanwhile, 56% of the 1,254 African refugees in Massachusetts (screened between 1999 and 2001) tested positive for parasites. [5] Two intestinal parasites that are commonly found in refugees that are known to cause chronic infections are Strongyloides stercoralis (a round worm) and various Schistosoma species (blood flukes). Both infections carry a strong risk of morbidity and mortality, even years after emigrating away from the country of origin, and thus are promptly treated upon entry to the US. Strongyloides, while found in regions all over the globe, is widespread in Southeast Asia. Around 100 million people are infected with Strongyloides. For example, 42% of Cambodian refugees are infected, while only 24% of Laotian and 11% of East African refugees

are. When not found in the initial pre-departure screening, the average time before migration and diagnosis of strongyloidiasis is 61 months. Hyperinfection/disseminated strongyloidiasis carries a mortality rate of above 50%, especially when the individual is positive for another pathogen that causes suppression of the immune system (such as HIV). [2] Schistosomiasis, or infection with any one of the various Schistosoma blood fluke parasites, is most commonly found in immigrants and refugees from sub-Saharan Africa. The Centers for Disease Prevention and Control (CDC) reports that 46% of Sudanese refugees were positive for the infection. Other groups with a seroprevalence greater than 40% include Somali and Liberian refugees. These blood flukes are known to cause or increase the risk of a range of health issues, such as liver cirrhosis, bladder cancer, renal failure. Perhaps the most severe is when the eggs are deposited into the circulatory system, which can deposit them anywhere in the body. This includes the brain and spinal cord, which can cause paralysis. [2] Pre-Departure Treatment of Refugees: The current protocol for addressing helminth and other intestinal parasite infections among refugees is to give refugees a pre-departure treatment of anti-parasitic drugs For most helminth infections, a single 600 mg dose of albendazole is adequate treatment, taken 3 days before coming into the US. Of 1,254 African refugees sampled in 1997, 56% tested positive for intestinal parasites. 175 (14%) were specifically infected with at least one helminth, while 2% had multiple. [6] 38% of a Somali refugee group were found to be infected with parasites. After the CDC implemented a pre-departure treatment protocol in 1999, intestinal helminth population in African refugees was reduced from 24% to under 4%. It lowered the chances of being infected by common intestinal parasites such as hookworm, Trichuris, and Ascaris by 90%, as well as a few protozoan parasites. [2]

The anti-parasite albendazole alone, however, is not adequate for eliminating Strongyloides and Schistosoma infections. It is used in concert with ivermectin in order to eliminate the Strongnyloides. [7] Protocols are in place for special groups, such as children, pregnant/breastfeeding women, and immunocompromised indiviuals. In individuals coming from sub-Saharan Africa, praziquantel is used as well as albendazole to treat Schistosoma infections. [2] These specific treatments, with relatively inexpensive drugs, are given to refugees who test positive for Strongyloides or Schistosoma after they arrive in the United States. In both tests, screening for eosinophilia (increased eosiniphils, parasite-fighting white blood cells) is used to decide whether more treatment is needed. [2] In conclusion, the CDC takes many active and effective steps to ensure that refugees to the United States do not carry parasites. Intestinal parasite prevalence among American-born individuals: Much like the poorest individuals in developing nations, many of the 40 million impoverished Americans suffer from parasitic infections. [1] The common parasites toxocariasis (a roundworm), cysticercosis (a tapeworm), and toxoplasmosis (a protozoan) have become major public health concerns in the United States. 14% of the US population is currently infected with Toxocara (medscape). Among the poor, the seroprevalence of toxocariasis is 23%; socioeconomically disadvantaged African American children experience an especially high rate of 30%. [1] [9] Normally, infection with Toxocara occurs following the ingestion of eggs; children are more prone to infection as they are most likely to be in the sandboxes and playgrounds where the rate of contamination is high. [10] Ingested eggs are hatched in the small intestine and then spread to the abdominal organs, central nervous system and eyes, where they cause symptoms such as abdominal pain, respiratory failure, vision impairment and seizures. [11] Nelson et al. have shown that there may be a

relationship

between

infection

with the parasite and decreased cognitive development and mental retardation. [12] A positive

relationship between Toxocariassi and asthma has also been found, suggesting that the parasite may contribute to the manifestation of the illness and the increase of
Figure 2: Distribution of common intestinal parasites in the United States

asthma among inner-city children. [11] Though treatment of ocular toxocariasis can be difficult, most manifestations of the illness can be treated by albendazole or mebendazole, usually in combination with anti-inflammatory medications, and result in a favorable prognosis. [13] Accounting for 10% of all emergency room visits for seizures, cysticercosis causes neurological complications. [1] Of the approximately 1,000 new cases of cysticercosis that are reported each year, 62% occur in Mexican immigrants while most other cases are observed in Asian or African immigrants or children of immigrants. [14] The parasite constitutes the leading cause of seizures among Hispanic individuals. [15] Cases are generally concentrated in the Southwestern United States. [16] The parasite is spread after the ingestion of an egg, which then develops into larva that enters the soft tissues of a host and forms an adult that ultimately resides in the intestinal tract. [15] The adult then produces eggs that can lodge into soft tissues such as muscle tissue and central nervous system tissue. [15] Transmission often occurs after contact with a family member, friend, or housekeeper from an endemic country. Treatment with

albendazole and corticosteroids has proven to be beneficial though surgical excision may be necessary at times. Toxoplasmosis in pregnant Hispanic and African American women causes approximately 400-4,000 cases of congenital toxoplasmosis (characterized by mental retardation and vision and hearing loss) each year despite studies showing that antiparastic drugs taken during pregnancy could prevent these cases. [1] Humans are infected with toxoplasma gondii after ingesting cysts in undercooked meat or ingesting oocysts shed in the feces of a cat. [17] In pregnant women, the infection can spread to the fetus and cause neurological or eye damage. [17] Among individuals with AIDS, toxoplasmosis is the most frequent cause of severe neurological infection. [17] In the general population, Pyrimethamine and Sulfadiazine can be used to treat Toxoplasmosis while spiramycin is sometimes used in pregnant women. [13] Global Africa
Schistosoma mansoni haematobium intercalatum Taenia saginata (especiall y Ethiopia and Eritrea)

Asia
Fasciolopsis buski Southeast Asia: Opisthorchis viverrini

Latin America
Taenia solium

Middl e East
Echinococcus Giardia

Eastern Europe
Diphyllobothriu m latum Opisthorchis felineus

United States
Enterobius vermicularis

Ascaris lumbricoides Trichuris trichiura Hookworm Strongyloides stercoralis Enterobius vermicularis Fasciola Hymenolepis Most protozoa, especially Giardia intestinalis (lamblia)

Schistosoma mansoni Opisthorchis guayaquilensis(Ecuador )

Giardia lamblia

Ancylostom Clonorchis sinensis Necator Schistosom a japonicum mekongi South Asia: Taenia solium Entamoeba histolytica americanus a duodenale

Table 1: Most common intestinal parasites found in refugee populations compared to most common intestinal parasites found in Americans [19]

[20]

Discussion and Concluding Remarks: The fact that the most common intestinal parasites in the United States are not the same as the common intestinal parasites in incoming refugee populations does not support our original idea that the influx of foreigners into the United States causes the spread of intestinal parasites. The intestinal parasites associated with Southeast Asian and Sub-Saharan African populations are not commonly found in the United States, which indicates that the treatment protocol mandated by the CDC is effective in eradicating these parasites. Some parasites afflicting native-born Americans and refugees from areas such as Southeast Asia and Sub-Saharan Africa do overlap, but the most common differ between the areas. The screening and treatment that refugees undergo before entering America for the large part prevents parasites from crossing into the United States. Treatments, therefore, are effective and commonly used. Why, then, do parasites still exist in America? Calculations have shown that as many as 2.8 million impoverished African Americans and tens of millions of Americans in general may be infected. [9] Lifestyles of the poor and underrepresented make them especially vulnerable: they have less access to clean water, they experience more direct skin contact be it in small, crowded homes or overburdened daycare facilities, they are less able to take their pets to veterinarians, and they live in less sanitary conditions. The problem does not seem to be an ability to treat these ailments but rather a lack of political will to study an issue that primarily affects impoverished people and minorities. [1] Disease of poverty are more easily neglected. Living with parasites can have devastating consequences. Multiple studies have shown a negative relationship between infection and cognitive performance: one study showed significant differences in the neuropsychological health of children with and without infection by Toxocara.

Infected children were more hyperactive and had poorer performance of measures of cognitive ability. [18] During the early 20th century, hookworm was highly endemic in the United States south and negatively influenced child development, school performance and school attendance and was perhaps responsible for a 43% future reduction in wage earning. [1] A similar trend may be seen in impoverished and parasite-infected populations today. Thus, if anti-parasite treatment is relatively easy and inexpensive, why does the government not put more effort into treating its own population that is clearly debilitated by common infections? While our study culminated in some new and interesting ideas, it would be a reasonable idea to conduct the study again with newer data. Most of our data came from the 1990s and there could be significant differences between the data we used and current data, especially as populations spread and globalization makes the world smaller. Furthermore, our results led us to consider new questions including the impact of illegal immigration on of parasite spread. Could the influx of undocumented individuals be causing or potentially cause an increase in the prevalence of certain parasites in the United States because these people do not undergo treatment for parasite infections? Also, these people are frequently poorer, and as indicated by this study, that makes them more susceptible to parasitic infections than other Americans. Finally, it would be interesting to consider whether the spread of people is associated with spread of parasites in countries that do not impose mandatory parasite treatment and screening in incoming populations. Further time and resources could help us determine how to best treat intestinal parasite infections and transmission in the United States.

References:
1. Hotez, P.J. 2007. Neglected Diseases and Poverty in The Other America: The Greatest Health Disparity in the United States? PLoS Neglected Tropical Diseases 2. Center For Disease Control. Refugee Health Guidelines: Domestic Guidelines. http://www.cdc.gov/immigrantrefugeehealth/pdf/intesti nal-parasites-domestic.pdf 3. Ehrlich, S. 2010. Intestinal Parasites. University of Maryland Medical Center. http://www.umm.edu/altmed/articles/intestinalparasites-000097.htm 4. Refugee Health Guidelines: Domestic Guidelines. Centers for Disease Control and Prevention. http://www.cdc.gov/immigrantrefugeehealth/pdf/intesti nal-parasites-domestic.pdf 5. Barnett, Elizabeth D. 2004. Infectious Disease Screening for Refugees Resettled in the United States. Travel Medicine. CID 2004:39 6. Geltman, Paul L., Jennifer Cochran, et al. 2003. Intestinal Parasites Among African Refugees Resettled In Massachusetts and the Impact of an Overseas PreDeparture Treatment Program. The American Society of Tropical Medicine. Vol. 69. No. 6. Pp. 657-662. 7. Chandrasekar, Pranatharthi Haran. Strongyloides Treatment And Management. Medscape Reference. 8. Toxocariasis. Medscape Reference. http://emedicine.medscape.com/article/229855overview 9. Hotez, P.J., Wilkins, P.P. 2009. Toxocariasis: America's Most Common Neglected Infection of Poverty and a Helminthiasis of Global Importance? PLoS Neglected Tropical Diseases. 10. Shargi, N., Schantz, P.M., Caramico, L., Ballas, K., Teague, B.A., Hotez, P.J. 2001. Environmental exposure to Toxocara as a possible risk factor for asthma: a clinic-based case-control study. Clinical Infectious Diseases 32: 111-116. Sharghi, N., Schantz, P., Hotez, P.J. 2000. Toxocariasis: An occult cause of childhood neuropsychological deficits and asthma? Seminars in Pediatric Infectious Diseases 257260. Nelson, S., Greene, T., Ernhart, C.B. 1996. Toxocara canis infection in preschool age children: Risk factors and the cognitive development preschool children. Neurotoxicology and Teratology. Toxocariasis (also known as Roundworm Infection). CDC. http://www.cdc.gov/parasites. Mansur, M.M., Montes, M., Yancey, L. Cysticerosis. Medscape . http://emedicine.medscape.com DeGiorgio, C.M., Sorvillo, F., Escuenta, S.P. 2005. Neurocysticerosis in the United States: review of an important emerging infection. Neurology. Richards, R.O., Schantz.P.M., Ruiz-Tiben E., Sorvillo, F.J. 1985. Cysticercosis in Los Angeles County. JAMA 254: 3444-3448. Jones, J., Kruszon-Moran, D., Wilson, M. 2003. Toxoplasma gondii Infection in the United States, 19992000. Emerging Infectious Diseases 1371-1374. Marmor, M., Glickman, L., Shofer, F., Faich, L.A., Rosenberg, C., Cornblatt, B., Friedman, S. 1987. Toxocara canis infection of children: epidemiologic and neuropsychologic findings. American Journal of Public Health 77: 554-559. Domestic Intestinal Parasite Guidelines. 2009. Centers for Disease Control and Prevention. http://www.cdc.gov/immigrantrefugeehealth/guidelines/ domestic/intestinal-parasites-domestic.html#table1 Kucik, C., G. Martin and B. Sortor. 2004. Common Intestinal Parasites. American Family Physician. 5: 1161-1169.

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