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Epidemiology,transmission,andpreventionofcysticercosis

OfficialreprintfromUpToDate
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Epidemiology,transmission,andpreventionofcysticercosis
Author
AClintonWhite,Jr,MD,FACP,
FIDSA

SectionEditor
PeterFWeller,MD,FACP

DeputyEditor
ElinorLBaron,MD,DTMH

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Sep2015.|Thistopiclastupdated:Jun09,2015.
INTRODUCTIONCysticercosisiscausedbythelarvalstageofthetapewormTaeniasoliumclinical
syndromesincludeneurocysticercosisandextraneuralcysticercosis.Inendemicareas,neurocysticercosisisan
importantcauseofadultonsetseizures[16].
Theepidemiologyandtransmissionofcysticercosiswillbereviewedhere.Theclinicalmanifestations,diagnosis,
treatment,andpreventionofcysticercosisandthelifecycleofT.soliumarediscussedseparately.(See"Clinical
manifestationsanddiagnosisofcysticercosis"and"Treatmentofcysticercosis"and"Intestinaltapeworms".)
EPIDEMIOLOGYApproximately50millionpeopleworldwideareestimatedtohavecysticercosisinfection,
althoughestimatesareprobablylowsincemanyinfectionsaresubclinicalandtherearerelativelyfewpopulation
baseddataonprevalence[5,7].CysticercosisisendemicinmanyregionsofCentralandSouthAmerica,sub
SaharanAfrica,India,andAsia[16,8].Theprevalenceofcysticercosisvarieswithinthesecountriesandisoften
higherinruralorperiurbanareaswherepigsareraisedandsanitaryconditionsaresuboptimal[15,8].Insome
suchcommunities,therateofepilepsyapproaches3percent,and25to40percentofthesecaseshaveevidence
ofcysticercosis[24,6].
Individualswithcysticercosisalsopresentformedicalattentionoutsideofendemicareas,particularlywherethere
aresignificantnumbersofimmigrants[912].Areviewofanationaldatabaseestimatedthattherewere18,584
hospitalizationsforneurocysticercosisintheUnitedStatesbetween2003and2012[12].Inaprospectivestudyof
1800patientspresentingwithseizuresto11UnitedStatesemergencydepartmentsoveratwoyearperiod,
neurocysticercosiswastheetiologicagentinabout2percentofcases[10].Neurocysticercosiswasobserved
morefrequentlyinemergencydepartmentsofLosAngeles,Phoenix,andAlbuquerque(5.7percent),whichhada
higherproportionofimmigrantHispanicpatientsthantheotherhospitals.Travelerstoendemicareasrepresent
anothersourceofcysticercosis,althoughsuchinfectionaccountsforaminorityofcasesintheUnitedStates
[10,13,14].
Individualswithnohistoryofporkconsumptionortraveltoendemicareascanalsodevelopneurocysticercosis.In
areportoffourcasesinanOrthodoxJewishcommunity(whosedietarylawsstrictlyprohibitconsumptionofpork),
infectionwastransmittedbydomesticworkerswhohadrecentlyemigratedfromLatinAmericancountrieswhere
T.soliumisendemic[15].Epidemiologicstudieshavedemonstratedtightclusteringinhouseholdshousehold
contactsofpatientswithneurocysticercosishaveathreefoldhigherriskofpositiveserologyforcysticercosisin
comparisonwithcontrols[16].
LIFECYCLEANDTRANSMISSIONCysticercosisistransmittedbyingestionofT.soliumeggsshedinthe
stoolofahumantapewormcarrier(figure1).Followingingestion,embryos(oncospheres)hatchinthesmall
intestine,invadethebowelwall,anddisseminatehematogenouslytobrain,striatedmuscles,liver,and/orother
tissues.Overaperiodofthreetoeightweeks,tissuecysticercideveloptheseconsistofmembranouswallsfilled
withfluidandaninvaginatedscolex.Cystslocatedinthebrainresultinneurocysticercosishumanswith
cysticercosisareincidentaldeadendhosts.
HumansbecomeT.soliumtapewormcarriersbyingestingundercookedporkcontainingcysticerciinmuscle
tissue.Onceingested,thescolexevaginatesandattachestothehumansmallintestinebyitssuckersandhooks.
Proglottids(segments)arisefromthebaseofthescolex,graduallyenlargeandaredisplacedfromtheneckby
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newproglottids.Theproglottidsmatureoveraperiodoftwotofourmonths.Adulttapewormscanresideinthe
smallintestineforyearstheymaydevelopupto7minlengthwitheachproglottidsegmentcontaining50,000to
100,000eggs.
Somepatientswithcysticercosisaretapewormcarriers,andmostindividualswithintestinaltapeworminfectiondo
notdevelopsymptomaticcysticercosis[17].However,humantapewormcarriersareatriskforfecaloral
autoinoculationofeggsandsubsequentdevelopmentofcysticercosis.
Pigsacquireinfectionthroughingestionoffoodorwatercontaminatedbyinfectedhumanfeces.Ratesof
transmissionarehighinruralcommunitieswherepigsroamfreeandhumanfecalcontaminationofsoilis
common.Pigtopigtransmissionalsooccurs,althoughthemagnitudeandeffectofthistransmissiononratesof
humaninfectionisnotfullyunderstood[18].
Acommonmisconceptionisthatcysticercosisisacquiredbyeatingpork.However,astheabovelifecycle
illustrates,ingestionofinfectedporkonlycausesadulttapeworminfestation(taeniasis)becauseinfectedpork
containsthelarvalcyststhatdevelopintoadultwormsinhumanintestinebutdoesnotcontaintheeggsthat
causecysticercosis[19].
Transmissionofcysticercosiswaspreviouslythoughttooccurbyindirectmeans,suchasbytheingestionof
produceirrigatedwithwatercontaminatedwithhumanfecescontainingT.soliumeggs.However,epidemiological
evidencesuggeststhatthemostcommonsourceofinfectiveeggsisanasymptomatichouseholdtapeworm
carrier[20,21].Therefore,cysticercosisshouldbeviewedasadiseaselargelytransmittedfrompersontoperson,
withinfectedpigsasperpetuatorsofinfection.
TheTaenialifecycleisdiscussedinfurtherdetailseparately.(See"Intestinaltapeworms",sectionon'Taeniasis'.)
PREVENTIONThereareseveralstagesoftransmissionthatcanbetargeted,anderadicationprogramswill
likelyrequireimplementationofallofthesestrategies[22].
TapewormsinhumansPreventinghumantapeworminfectionisimportantforreducingthereservoirofegg
carriersandcanbedonebyeliminatinghumanconsumptionofporkcontaminatedwithviablecysticerci.Methods
include:
Inspectionofporkforcysticerci,whicharevisibleinrawmeat("measlymeat").Thismethodhasbeen
successfulincountrieswiththeappropriateresourcesbutnotinresourcelimitedsettingsinwhichinspection
canbebypassedandtheeconomicconsequencesofpigcondemnationaresevere.
Freezingoradequatelycookingmeattodestroycysticercipicklingandsaltingarenotadequatetechniques.
Administeringantiparasiticagentstopigsmaydecreaseparasiteburdenbutisnotreliableenoughtomake
theporksafe.
CysticercosisinpigsPreventingthetransmissionofcysticercalinfectionstopigscanbeaccomplishedby
eliminatingaccessofpigstohumanfecalmaterial.Methodsincludeimprovingsanitaryconditionsforproper
disposalofhumanwaste(usinglatrinesorsewagesystems)andconfiningpigssotheyarenotallowedtoroam
freelyinareaswithhumanwaste.
ReducingtransmissionMechanismsforinterruptingthetransmissionofeggsbetweenhumansinclude:

Communityeducationregardingroutesoftransmission
Goodpersonalhygieneandhandwashingpriortofoodpreparation
Targetedtreatmentforhumantapewormcarriers(perhapsidentifiedbyhistoryofproglottidpassage)
Masscommunityanthelminthicprogramstotreattapewormcarriers

ThetreatmentofchoiceforT.soliumtapewormsinmasschemotherapyisniclosamide.Thiscanbegivenasa
singledoseof2g(fourchewabletablets)inadults,1.5ginchildrenover34kg,and1ginchildrenbetween11
and34kg.NiclosamideisnolongermarketedintheUnitedStates.Praziquantelcanbeusedasanalternativeat
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adoseof10mg/kginasingledose.Thereisalowriskofseizuresinpatientswithoccultneurocysticercosis.
VaccinationThereisnovaccineforhumanprotectionagainstT.solium.However,vaccinesareavailableto
preventT.saginatainfectionincattleandT.ovisinsheep.Severalgroupsareworkingtodevelopvaccinesfor
porcineT.soliuminfection,andinitialresultssuggestthatvaccinationshouldbefeasible[23].
SUMMARY
CysticercosisiscausedbythelarvalstageofthetapewormTaeniasolium.(See'Introduction'above.)
Approximately50millionpeopleworldwideareestimatedtohavecysticercosisinfection,whichisendemicin
manyregionsofCentralandSouthAmerica,subSaharanAfrica,India,andAsia.Theprevalenceof
cysticercosisvariesandisoftenhigherinruralorperiurbanareas,especiallywherepigsareraisedand
wheresanitaryconditionsaresuboptimal.(See'Epidemiology'above.)
Themostcommonsourceofinfectiveeggsisanasymptomatichouseholdtapewormcarrier.Household
contactsofpatientswithneurocysticercosishaveathreefoldhigherriskofpositiveserologyforcysticercosis
incomparisonwithcontrols.(See'Epidemiology'above.)
CysticercosisistransmittedbyingestionofT.soliumeggsshedinthestoolofahumantapewormcarrier.
Followingingestion,embryos(oncospheres)hatchinthesmallintestine,invadethebowelwall,and
disseminatehematogenouslytobrain,striatedmuscles,liver,and/orothertissues.(See'Lifecycleand
transmission'above.)
HumansbecomeT.soliumtapewormcarriersbyingestingundercookedporkcontainingcysticerciinmuscle
tissue.About5to10percentofpatientswithcysticercosisaretapewormcarriers,andmostindividualswith
intestinaltapeworminfectiondonotdevelopsymptomaticcysticercosis.(See'Lifecycleandtransmission'
above.)
Acommonmisconceptionisthatonecanacquireneurocysticercosisbyeatingpork.However,ingestionof
infectedporkcausesadulttapeworminfestation(taeniasis)butnotcysticercosis.Thisisbecauseinfected
porkcontainsthelarvalcyststhatdevelopintoadultwormsinhumanintestinebutdoesnotcontaintheeggs
thatcausecysticercosis.(See'Lifecycleandtransmission'above.)
Eradicationprogramswilllikelyrequireimplementationofstrategiestoreducetransmissionatseveral
stages,includingpreventinghumantapeworminfectionduetoporkconsumption,improvingsanitary
conditionstopreventtransmissionofcysticercalinfectionsfromhumanstopigs,andmeasurestointerrupt
transmissionofeggsbetweenhumans.(See'Prevention'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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diseases?PLoSNeglTropDis20093:e319.
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10. OngS,TalanDA,MoranGJ,etal.NeurocysticercosisinradiographicallyimagedseizurepatientsinU.S.
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12. O'NealSE,FleckerRH.Hospitalizationfrequencyandchargesforneurocysticercosis,UnitedStates,2003
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13. DelBruttoOH.Neurocysticercosisamonginternationaltravelerstodiseaseendemicareas.JTravelMed
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hospitalizedcases.PLoSNeglTropDis20126:e1480.
15. SchantzPM,MooreAC,MuozJL,etal.NeurocysticercosisinanOrthodoxJewishcommunityinNew
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16. GoodmanKA,BallaghSA,CarpioA.CasecontrolstudyofseropositivityforcysticercosisinCuenca,
Ecuador.AmJTropMedHyg199960:70.
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GRAPHICS
Taeniasoliumlifecycle

Cysticercosisisaninfectionofbothhumansandpigswiththelarvalstagesof
thecestodeTaeniasolium.Thisinfectioniscausedbyingestionofeggsshed
inthefecesofahumantapewormcarrier(1).Pigsandhumansbecome
infectedbyingestingeggsorgravidproglottids(2,7).Humansareinfectedby
ingestionofeggsspreaddirectlyfromanothertapewormcarrier,fromthe
environment,orbyautoinfection.Inthelattercase,humansinfectedwith
adultT.soliumcaningesteggsproducedbythattapeworm,mostlikelyby
adherenceofeggstothehandsandsubsequentspreadfromhandtomouth.
Onceeggsareingested,oncosphereshatchintheintestine(3,8),invadethe
intestinalwall,andmigratetostriatedmusclesaswellasthebrainandother
tissues,wheretheydevelopintocysticerci(9).Inhumans,cystsmaycause
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serioussequellaeiftheylocalizeinthebrain,resultinginneurocysticercosis.
Theparasitelifecycleiscompleted,resultinginhumantapeworminfection,
whenhumansingestundercookedporkcontainingcysticerci(4).Cysts
evaginateandattachtothesmallintestinebytheirscolex(5).Adult
tapewormsdevelop,(upto2to7minlengthandproducelessthan1000
proglottids,eachwithapproximately50,000eggs)andresideinthesmall
intestineforyears(6).
Cysticercosis.http://www.dpd.cdc.gov/dpdx/HTML/Cysticercosis.htm.
Graphic75531Version2.0

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Disclosures
Disclosures:AClintonWhite,Jr,MD,FACP,FIDSANothingtodisclose.PeterFWeller,MD,FACPGrant/Research/ClinicalTrial
Support:NIH[EGPA(Mepolizumab)].Consultant/AdvisoryBoards:GSK[EGPA(Mepolizumab)].ElinorLBaron,MD,DTMHNothingto
disclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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