Research Project

Incident Action Plan: Metagonimus yokogawai

Presented by:

Chayanan Anu-Ekjit (6261294)

Patreeya Janyasan (6261074)

Mingurn Chua (6261135)

Reported to:

Ms. Salinee Thamthavornvanich

Advanced Biology

Grade 11 Section C

Mahidol University International Demonstration School

Table of Contents

Executive Summary 2-6

Situation 7-8

Constraints & Restraints 9

Response Procedures 10-18

Prevention Steps 19-23

Conclusion 24

References 25-26

1
Executive Summary

Human metagonimiasis is caused by a trematode. Cats and dogs are also infected. Korea,

China, Taiwan, Japan, Siberia, Indonesia, Israel, and Spain are among the countries where it is

found. The major etiologic agents include; Metagonimus yokogawai, Metagonimus takahashii,

and Metagonimus miyatai. Metagonimus yokogawai are being dealt in the northern part of

Thailand due to its outbreak. This metagonimiasis are first found in Japan and Taiwan by Fujiro

Katsurada. It is known to be the smallest human fluke that has been discovered. It is classified in

the kingdom of animalia and the platyhelminthes phylum. It also occurs in the class trematoda

and the subclass of digenea. It is ordered in opisthorchiidae and in the genus of metagonimus.

Nearly every organism has its own life cycle and so does the M. yokogawai. The cycle

starts off with embryonated eggs being passed into an aquatic environment each containing a

fully developed larva, called a miracidium such as H. heterophyes. The development cannot

proceed past this stage unless the eggs are ingested by the first intermediate host, freshwater

snails. It does not hatch upon contact with water, but only after it is ingested by the appropriate

freshwater snail. After the snail host ingests the eggs, miracidia emerge and penetrate the snail’s

2
intestines. In the snail tissue, mircadia develop into sporocysts, then rediae, and finally emerge

from the snail as cercariae. The cercariae then penetrate the skin or go under the scale of a fresh

or brackish water fish and encyst as metacercariae in the tissue. The fish then serves as

secondary hosts varies based on location. The host then becomes infected by consuming

undercooked, raw, or pickled fish containing the infectious metacercariae. The metacercariae

then excyst in the small intestine of the host (human, mammal or bird), and develop into adults.

The metacercariae becomes infective to kittens at 15 days. In the small intestine, the adults attach

to the walls and develop new eggs.

Even though the M. yokogawai can infect people yet we sure know how to cure the

patient. The patient could be diagnosed through the recoveration of the eggs in the feces. The

patient could be diagnosed through symptoms that could be observed. The following symptoms

could be observed as follows; Peripheral eosinophilia, diarrhea, nausea, weight loss, abdominal

pain, lethargy, fatigue, anorexia, malaise and corresponding pains where the fluke goes (heart,

brain). Yet symptoms such as seizures, neurological defects, cardiac problems could be found in

extreme cases of patients.

There are different ways to test the patient if they were infected. Firstly, Merthiolate,

iodine, formalin (MIF) method. This method is known to be the most flexible and efficient

method to be able to detect the feces samples if it were to be infected. This method retains and

stain samples at the same time and allows them to be analyzed using a direct smear technique.

Secondly, Polymerase chain reaction (PCR) methods. This method takes the advantage of the

different types of DNA sequence by the different species of parasites within a specific genus.

The method for testing that has been useful so far is the polymerase chain reaction-restriction

fragment length polymorphism (PCR-RFLP). It is simply a sequence repeat anchored on the

3
PCR. This method is based on differences in restriction fragment length polymorphisms and

simple sequence repeats among the species. The data that can be collected involved the unique

sites in ribosomal RNA and mitochondrial cytochrome oxidase I (mtCOI) genes could help

distinguish M. yokogawai from other Metagonimus species.

There are 2 treatments in total that could effectively cure the patients. Praziquantel is one

of them. It is a praziniozoquinoline product that induces muscular paralysis and fluke detachment

by altering parasite tectum also known to be the calcium flux. Yet every medical drug has its side

effects but it is usually mild and occurs within the minors. Possible effects are as follows;

abdominal pain, allergy, diarrhea, headache, hepatic dysfunction/hepatitis, nausea or vomiting,

exacerbation of porphyries, pruritus, rash, somnolence, vertigo, or dizziness. The drug is

recommended to take with liquids during meals. The dose depends on the patient's age. In adults

they are required to take 75 mg/kg per day divided three times per day for 1-2 days. While

children under 4 years old it is recommended that this drug should not be taken due to their

health safety. Children 4 years old or older could take these drugs like other adults, 75 mg/kg

orally three times daily for 1-2 days.

Another treatment is the Tetrachloroethylene. It is made from chlorinated hydrocarbon,

yet its use has been replaced by new drugs such as the Praziquantel. In 1978 a study also looked

at the efficacy of several drugs on metagonimiasis infection, including bithionol, niclosamide,

and Praziquantel. All drugs showed lower prevalence of eggs in feces. However only

Praziquantel showed complete cure. Therefore the researchers concluded that Praziquantel was

the most highly effective and was very well-tolerated. It is known to be the most effective drug

against metagonimiasis.

Regarding this information, a concluded projection has been made to reduce the amount

4
of new cases as much as possible. Within 2 choices, either we wait or take action now. The costs

and time will sure be different. The treatment cost 1000 baht per person and more money is

needed to intervene if we waited for 3 months. This would help not only in reduction of the cure

cost yet also time and infected patients.

A prevention step has been planned to stabilize the situation. We put into consideration to

encourage people to consume fully cooked food especially when it comes to consuming a host of

the parasites such as fishes and snails. This will require a mass educational system to educate the

people of the north. Elimination of all snails in the area has also been recognized. Snails are

known to be the initial host of these flukes, by preventing other organisms from consuming

them, the elimination of the snails is a requirement. As the rural area does not have much in their

area, building a good pumping system is one of the importance we see to put an effort in. This

will help the area have a much better sanitation system of water they use everyday.

5
Situation

The outbreak of the Platyhelminthes parasite had been spreading across the area of

northern Thailand, especially in the rural part of Thailand. An approximate of 6.342 million

people are living in the area where there are several interconnected towns with 10,000 people in

the town’s population. Northern Thailand is an area full of mountains and forest with a number

of national parks. The climates are cooler than the rest of the part of Thailand. Yet they have a

total of 3 seasons; hottest season, rainy season and the season where they have warm and sunny

days and pleasant cool nights.

The rural area is surrounded by forest with a variety of organisms that could be found.

This includes a total of 3 species; mammals, reptiles and mollusks. Rats, dogs, bats, skinks,

snails and snakes could be found in the area. Within the forest various freshwater rivers and

streams could be observed. The local people rely heavily on these water as it runs through their

local towns. Various species of fishes and mollusks could also be found in the freshwater streams

and rivers.

The majority of the people in the area use the forest as their advantages of hunting

organisms for resources of food. About ⅓ of the population have animals farm for their source of

income. Farm animals includes; cows, sheeps and pigs. These meat of the animals are then

transported to the major cities. Some of the population are employed in the agriculture industry.

The population’s diet is typically the same as the other region of Thailand. Yet snails are

a common use in northern thai cooking and not so much in other parts of Thailand. It is used for

cooking with curries. Consequently, snails are known to be the number one host of these

parasites. Furthermore, their diet involves raw meat with blood and the cow’s guts itself. It is

also known as Phrae-style laap. It is well known especially in the rural part of this region.

6
 The outbreak started out with 202 known cases that have already been reported in 34

deaths. With no mass transportation between the major cities and the rural area. Yet individuals

will move and operate in all towns with no system of sanitation involved in any way. The law

enforcement are known to be great in the area. As the local hospitals are good but small and

cannot accommodate large numbers of people. Predictions are being given that the number of

people infected may be much higher. We hope and want to have changed the number of the

population’s death and decrease the rate of people getting infected.

7
Constraints & Restraints

For the most part, the purposes of constraints and restraints are to halt the life cycle of

Metagonimus yokogawai, stop the spread of the disease, and reduce rates of infection.

Constraints Restraints

Eat fully-cooked fish or food in general Eat raw or under-cooked fish or food

Go see doctor immediately after notice Not seeing doctor immediately after notice

symptoms the symptoms

Properly dispose wastes (feces) Dispose wastes (feces) into water bodies

Keen to learn about the announcement and Ignore announcement and new information

new information

Drink clean water Drink unclean water

Wash hands regularly Wash hands rarely

Maintain good hygiene Not maintain good hygiene

8
Response Procedures

In light of the epidemic crisis in Northern Thailand, several measures must be taken to

handle the situation while contemplating general health, medical care, organism control, and

finance. The plan's goal is to direct organizations and staff in acting as promptly and efficiently

as possible in the situation, in order to minimize time and potential cost, as well as the total

number of infected people.

Care for Sick

1. Establishing additional patient support centers

The first move in handling the situation is to offer adequate care to those who have been

infected. To accommodate the increasing number of patients, local authorities must collaborate to

identify appropriate locations to serve as shelters and emergency centers. The locations must be

carefully calibrated and maintained to satisfy the expectations of the subsequent treatment

process while still attempting to limit infection rates.

2. Establishing disease examination units distributed in the village area

Examination units need to be distributed across the village area for the sake of reaching

and connecting people who are unable to go to the hospitals or are overburdened with household

responsibilities. This will also aid in the spread of information and announcements concerning

the disease and new measures.

9
 3. Establishing a temporary medical center distributed in the area of the village

Regarding the fact that the disease can be treated easily by the use of praziquantel,

temporary medical centers should be built to get to people in remote areas and others who are

unable to reach for medical care in hospitals. The medical centers will help to lower the number

of currently infected patients while still making space available for new cases.

4. Establishing a team of investigators to examine the area and the villager’s diet

A team of investigators will assist medical staff in estimating the extent of the infection

and the number of patients. It will help to narrow the field of study and expand awareness about

people's genuine lifestyles in order to foster connection and further the advancement of diagnosis

and medication.

5. Building a strong business chain for supplying Praziquantel

The availability of drugs is a critical factor in the process of disease prevention and

recovery. Adequate pharmaceutical availability ensures that medication can be performed

promptly and in proportion to the number of patients.

6. Training medical personnel so they are familiar with detection, communications, warning

and prevention systems.

In the event of an emergency, it is critical that personnel are familiar with the response

protocols, and therefore will respond promptly to the situation; however, it is also strongly

recommended to prepare them well before taking actions to ensure that they are up to date and

10
that new information is not overlooked, but is thoroughly considered, as this can facilitate the

diagnosis and medication operations.

7. Building an announcement unit for this outbreak and establishing an educational center.

People should be educated on new information and encouraged to practice hygienic

environments in order to raise awareness, minimize new cases, and prevent potential infections.

Furthermore, it would be preferable that people could receive news and announcements as soon

as practicable, so that they would not miss out on crucial information that is vital to their life or

health in general.

8. Dealing with local organizations in the sake of fundraising for medical purposes.

Money is one of the most key parameters driving the motor of overall response measures.

Initially, there may be sufficient funds to manage the situation; although as time passes, the

insufficient finances may necessitate additional funds to compensate. When there is enough

money, the process can operate easily and effectively, allowing the tasks to be completed.

11
Organism Control Measures

1. Work with public health systems and Municipalities to develop a better waste

management system.

The inefficient waste management system is a major issue that contributes to an epidemic

of Metagonimus yokogawai. The knowledge that Metagonimus yokogawai can lay eggs in our

bodies and release itself in feces allows it to maintain its life cycle. Therefore, We would be able

to control the spread by eliminating the egg site, which would halt the organism's life cycle.

2. Prohibiting villagers from eating raw or under-cooked fish.

The main factor that causes the disease in humans is the consumption of raw or

undercooked fresh or brackish water fish. The main factor that causes the disease in humans is

the consumption of raw or undercooked fresh or brackish water fish, meaning that in order to

prevent the organism from entering the human body, it needs to be killed beforehand. High

temperatures cause protein denaturation and organ destruction. Thus, eating well-cooked fish or

food in general is the best choice.

3. Encouraging farmers to raise ducks to kill snails.

The egg of Metagonimus yokogawai does not hatch when it comes into contact with

water, but only when it is ingested by the right freshwater snail, implying that if we could

eradicate or at least minimize the population of snails, we could halt its life cycle and prevent

spread of disease.

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 4. Encouraging villagers to boil or put water under the sun in order to let the UV do the

work and kill the cercariae preventing them from entering the body.

UV fluences ranging from 3 to 60 mJ/cm2 have been shown to significantly degrade or

damage cercariae (The Effectiveness of Water Treatment Processes against Schistosome

Cercariae: A Systematic Review, 2018). As a result, in order to successfully interrupt the life

cycle, it is preferable that the villagers drink or use purified water to prevent any possibilities of

getting the disease.

5. Encouraging villagers to wash their hands regularly, especially after handling uncooked

food or feces.

This would preclude any possible contamination from developing into the organism's

implantation in the human body, as well as improve sanitation, which would help health and

quality of life, and prevent the transmission of other diseases that could worsen the symptoms.

13
Projections

Intervene Now

Months New Cases Total Cases Cost (1000/patient)

September 1 1 1000

October 3 4 4000

November 10 14 14000

December 25 39 39000

January 29 68 68000

February 35 103 103000

March 52 155 155000

April 47 202 202000

May 32 234 234000

June 17 251 251000

July 2 253 253000

August 0 253 253000

14
 Delay for three months

Month New Cases Total Cases Cost (1000/patient)

September 1 1 1000

October 3 4 4000

November 10 14 14000

December 25 39 39000

January 29 68 68000

February 35 103 103000

March 52 155 155000

April 47 202 202000

May (WAIT) 59.85714286 261.8571429 261857.1429

June (WAIT) 67.54761905 329.4047619 329404.7619

July (WAIT) 75.23809524 404.6428571 404642.8571

August 65.23809524 469.8809524 469880.9524

September 55.23809524 525.1190476 525119.0476

October 45.23809524 570.3571429 570357.1429

November 35.23809524 605.5952381 605595.2381

December 25.23809524 630.8333333 630833.3333

January 15.23809524 646.0714286 646071.4286

February 5.238095238 651.3095238 651309.5238

March 0 651.3095238 651309.5238

15
 As the information is shown in figure 1 and 2, the projected total cases of the event that

the intervention is suspended for three months are higher than the case of immediate

intervention. If we wait for three months, the total cases will reach up to 651 cases. On the other

hand, there will be 253 cases in total if we intervene immediately.

In order to reach 0 new cases as fast as possible, the intervention needs to be initiated

with all possible haste meaning that we should take action promptly without wasting any time

and it will take 4 months for the number of new cases to be reduced to zero. However, if we wait

for three months, it will double the time and triple the cost.

Figure 5 and 6 indicate the total amount of money that the whole treatment cost. In order

to cure the patients and return them to health, the cost is 1,000 baht per person. Regarding this

information, we can predict the total cost of both events. If we intervene now, it will cost us

253,000 baht in total. On the contrary, if we wait for three months, the cost will rise up to

651,309 baht and there is 398,309 baht difference in between.

From the calculation, it can be concluded that the local organizations and medical sector

should intervene the situation without delay for the sake of reducing time, cost and most

importantly; infected people.

16
Figure 1

Figure 2

Figure 3

17
Figure 4

Figure 5

Figure 6

18
Prevention Steps

There are 3 stages of life within this fluke’s life that can be identified and prevented, and

the first one we may possibly use to cut down the future possibilities of more widespread

infections is when the fluke has finally reached the state of metacercariae. In this stage, the fluke

has penetrated it’s secondary host already, and is ready to be consumed by humans in order to

reproduce sexually within their hosts. Other hosts include birds and other fish eating mammals,

but as they are not the main focus of this paper, the prevention of the infection of these hosts will

not be specifically discussed.

As we have researched the culture of the people, we found out that people of the north

have a tradition of eating raw food, whether it be raw beef, raw pork, raw innards, or raw blood,

hence there is a high chance of contracting the fluke. They believe that they are used to eating it,

hence they will not be affected by any physical ailments, despite many researches coming out

that it is detrimental to the health and that there has been past deaths before that has occured

from the diseases that stemmed from eating uncooked meat. When meat is eaten raw, this means

that there is no process of killing bacteria and parasites that might be infesting the meat. This is

part of the reason why there is a problem with the yokogawai fluke.

The yokogawai fluke’s secondary host is typically a sweet fish, and it can become pig

feed or simply eaten by human beings. When the fish is not cooked thoroughly, or is left

uncooked at all, then there is a possibility that the yokogawai fluke would enter the digestive

system and reproduce within the human host.

A definite way of curing this, is by educating the people. In this, we can organize a small

party to make expeditions through the Northern provinces and educate them about the dangers of

eating raw fish, and the ways they can consume them in a safe way. We cannot simply tell them

19
to quit their tradition of eating raw, as this would counteract and cause unhappiness among the

people, but we can suggest other alternatives as to how to eat them safely. There are 2

alternatives that we can suggest in this situation, which is to either freeze the fish under -35 C for

2 days, or cook the fish over 60C for more than 1 minute. While educating people, we should

focus more in areas where there are a lot of children, as we can instill good food practices in

children, which in turns allows them to pressure their parents. That is not to say that we cannot

educate adults, and we can hold a general class for housewives/ people in the village to attend as

a representative of each family.

The second way we can intercept the fluke’s infestation is to kill their primary host, the

snails. In this stage, the flukes enter their first intermediate host as an egg, and grow within the

snails from egg to cercariae before it is released into the water. By killing the snails, we are able

to eliminate snails that are already carrying fluke eggs as well as snails that are potential hosts of

the flukes.

If we were to kill snails, a good way of doing the first round of exterminations is through

using chemicals. This ensures that a large number of adult snails and young snails will be

exterminated, and as for other remnants of snails, the villagers can raise the more of the snail’s

natural predators, like ducks or other animals to keep doing the job for them.

The cost of this method is lower compared to other methods, but can possibly have long

term consequences for the environment.

Naturally, this way of doing things can possibly be damaging to the natural environment

of the north as snails are typically creatures on the lower rungs of the food chain, and their

absence can lead to the food chain collapsing. They are an important part of the diet of birds,

fishes, and other species in the area. As it is, many species of snails are already going extinct, as

20
they are hard to simulate a habitable environment for them in captivity, and for the fact that they

are extremely susceptible to parasites and flukes that are harmful towards humans which leads to

humans killing them.

The third method that can be used instead of the second method is through establishing a

plumbing system in the north. This will be a single solution that can solve and prevent future

problems related to diseases. This can also improve the lifestyle and quality of life of the people

in the north immensely.

As the flukes are excreted in egg form from the body of humans, this means that within

an infected host, they will constantly be generating eggs. Without a good plumbing system, this

would mean that the villagers would excrete into bodies of water, and that is not a hygienic way

of living, nor is it very good for preventing further growth of the flukes. With the infested feces

out in the wild, snails will naturally come in contact with them, and they would too be infested,

hence starting the cycle of infection once more.

As the point about hygiene that is mentioned above, the people from the north relies on

these fresh water streams for day-to-day activities like drinking, bathing, washing clothes, etc.

With feces in the water, this can lead to other diseases to be transferred through the stream, and

can lead to other problems regarding pollution in the river area. If a good plumbing system is

created in the village, this would help modernize and systemize the rural area.

There might be some point in contention as in the possible repercussions in land usage

though. Most rural areas of northern Thailand have an agriculture-based economy, and in

developing a plumbing system, a lot of land would be taken up and ruined to create it, and it can

generate discourse among the villagers and the authorities. Also, a lot of rural northern Thailand

are located in mountainous areas, which may make the planning and funding a lot harder than an

21
average village situated in an area with lower elevation.

This is a large scale infrastructure project, and though it is beneficial long term, a large

amount of funding and coordination is required to complete this. It can take up to 70 million baht

in budget to create a plumbing system, and can take many years of planning and execution in

order to create a fully functioning system for a single village, much less for a lot of villages in

steep areas. Anyhow, this is a project that is bound to be completed in the future, so having the

health of the villagers as an incentive to start is a good way to speed the process up.

But as we can see from the prevention steps above, a lot of the reason why the flukes are

rampant in the rural areas is because of how behind these areas are in terms of technology and

education. Modernized and urban areas do not face these kinds of infectious diseases often

compared to rural areas. This means that the transmission of diseases are related to

socio-economical and sanitary conditions.

22
Conclusion

The wave of Human metagonimiasis is caused by the trematode, Metagonimus

yokogawai via the ingestion of infected, inadequately cooked, freshwater fish that is a large part

of the diet of the people of Northern Thailand.

The infection started during the month September, and was recognized as a problem

during April. Our decision is to take action immediately, and by doing so, we are able to shorten

the time of infection and the costs of treating and rehabilitating patients.

Our first course of action is to create a system to care for the patients who were already

infected. These people are of highest priority, as they are at risk, and an adequate system must be

created in caring for these people. The actions within here include establishing patient support

centers, examination units, temporary medical centers, investigators to investigate the area and

diet, a business chain to supply medicine, trained medical personnels, an announcement unit for

education, and lastly fundraising for financially supporting the measures.

Running concurrently to the care of patients is the organism control measures. This is an

important step because it relates to the eradication of the fluke. The actions within these

measures include working with the public health system to develop a better waste system,

prohibiting the consumption of raw/ inadequately cooked fish, encouraging farmers to raise

ducks to kill snails, encouraging the sterilization of water, and encourage them to have hygienic

habits like washing their hands regularly.

23
References

PubMed Central (PMC). (April 1, 2018). The effectiveness of water treatment processes
against schistosome cercariae: A systematic review. Retrieved from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903662/#:%7E:text=UV%20fluences%
20between%203%E2%80%9360,been%20shown%20to%20remove%20cercariae

Stanford. (n.d.). Metagonimiasis. Retrieved from:

https://web.stanford.edu/group/parasites/ParaSites2001/metagonimiasis/meta.htm

ScienceDirect. (n.d.). Flukes: Overview. Retrieved from:

https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/flukes

Chinnawat S. (November 15, 2016). Bangkok Post: Freezing kills liver flukes in popular
Thai fermented fish. Retrieved from:
https://www.bangkokpost.com/thailand/general/1135924/freezing-kills-liver-flukes-in-popular-th
ai-fermented-fish#:~:text=Producers%20of%20fermented%20fish%20can,announced%20the%2
0discovery%20on%20Tuesday.&text=Producers%20of%20fermented%20fish%20can,announce
d%20the%20discovery%20on%20Tuesday.

Fish Parasites | Food Safety Authority of Ireland. (n.d.). Food Safety Authority of
Ireland. Retrieved from: https://www.fsai.ie/faq/fish_parasites.html

Northern Thailand. (2018, December 11). The Wild Planet. Retrieved form:
https://www.thewildplanet.com/northern-thailand-2/

North Thailand - To do & see - History. (n.d.). RenownTravel. Retrieved from:

https://www.renown-travel.com/northernthailand.html

Iverson, K. (2017, January 25). An Insider’s Guide to Thai Food, Region by Region.
Culture Trip. Retrieved from:
https://theculturetrip.com/asia/thailand/articles/a-brief-guide-to-thai-food-region-by-region/

Bush, A. (2014, June 3). Northern Thailand’s Raw Food Movement Involves Blood and
Guts. VICE. Retrieved from:
https://www.vice.com/en/article/qkxyqp/northern-thailands-raw-food-movement-involves-blood-
and-guts

J. (2020, July 11). How to Cook Chiang Mai Snail Curry. Jackie M. Retrieved from:
https://jackiem.com.au/2015/08/13/how-to-cook-chiang-mai-snail-curry/#:%7E:text=Snail%20is
%20common%20in%20northern,are%20cooked%20in%20the%20shell.

Metagonimus yokogawai | American Association of Veterinary Parasitologists. (n.d.).

AAVP. Retrieved from:
https://www.aavp.org/wiki/trematodes-2/trematodes-small-intestine/heterophyidae/metagonimina

24
e/metagonimus-yokogawai/

Praziquantel: Side Effects, Dosages, Treatment, Interactions, Warnings. (2017, July 24).
RxList. Retrieved from:
https://www.rxlist.com/consumer_praziquantel_biltricide/drugs-condition.htm

D., D., & D. (2017, February 22). Metagonimus yokogawai infection - MediGoo - Health
Tests and Free Medical Information. MediGoo - Health Medical Tests and Free Health Medical
Information. Retrieved from:
https://www.medigoo.com/articles/metagonimus-yokogawai-infection/

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