Helminthozoonoses in India – a

resurgent problem
M. B. Chhabra and K.M.L.Pathak
Journal of parasitic diseases,
December 2008, Vol. 32, No.2 77-86
 Introduction
• Parasitic zoonoses constitute an important
group of animal borne human diseases

• Transmissions associated with poverty, lack of

sanitary practices and a proximity to animal
sources
 Introduction
• Several factors have led to resurgence of
parasitic zoonoses in the recent years
– Environmental changes
– Ecological disturbances
– Increased urbanization
– Lifestyle changes
– Increased travel
– Emergence of AIDS
 Trematode zoonoses

• Cercarial dermatitis
• Fascioliasis
• Fasciolopsiasis
• Gastrodiscoidiasis
 Cercarial dermatitis
• Cercariae of several species of mammalian and
avian schistosomes are responsible for causing
dermatitis in man, during the act of skin
penetration
• Also known as swimmers itch or paddy field
dermatitis
• Condition rampant in rural India
• Most cases seem to involve cercariae of
mammalian schistosomes, most commonly
Schistosoma spindale
• Recent reports deal with cases from Assam,
Madhya Pradesh and Karnataka
• Muraleedharan et al reported case of a person
who collected snails with bare hands from an
irrigation pond.
• Minutes after collecting the snails, he
experienced itching and erythema on the
dorsum of hands which went on to become
macules and then papules.
• Agarwal et al recorded Cercarian Hullen
Reaction positivity in 51% of human
dermatitis cases not responding to benzyl
benzoate as against 20% positivity in those
responding to the drug
 Fascioliasis
• Good example of an emerging/reemerging
parasitic disease in many countries
• Caused by Fasciola hepatica and Fasciola
gigantica.
• Definitive host range is very broad, including
many herbivorous animals but occasionally
man
• Although human fascioliasis infection should
be related to animal endemicity, reports of
human fascioliasis in India have been very
rare.
• Case reports dealing with hepato biliary
symptoms and obstructive jaundice in children
attributable to F.hepatica are on record from
Uttar Pradesh
• Similar report from Assam was also of a child
with adult flukes in his gall bladder, which
were detected by ultrasonography
 Fasciolopsiasis
• Fasciolopsis buski is a large digenean which
inhabits the intestinal tract, particularly the
duodenum and jejunum.
• Pigs are the main reservoir but rabbits were
also found susceptible
• In India a high infection rate has been
recorded among people in the north east,
particularly Assam.
• Infections in pigs and humans were reported in
Calcutta whereas Bombay city had 29%
presence in humans in the absence of F. buski
in pigs.
• Human foci were also detected in other parts of
Maharashtra
• In Assam, Segmentina spp were the snail
intermediate hosts and Indoplanorbis exustus
elsewhere
• In endemic areas the disease in underreported
and is most prevalent in remote rural places and
semi urban areas.
• Asthenia, pallor, malnutrition and protuberant
abdomen in human infections were observed in a
series in India.
• Therapeutic options found to be successful
include praziquantel, triclabendazole, rafoxanide
• There have been reports of a re-emergence of
human fasciolopsiasis in Uttar Pradesh despite
programs in the control of food borne
trematode infections
 Gastrodiscoidiasis
• Gastrodiscoides hominis inhabits the caecum
and colon of pigs and humans
• In India it has a large distribution in the north
eastern and central states of Assam, Bengal,
Orissa, Bihar, Uttar Pradesh and Madhya
Pradesh.
• Follows a diheteroxenous life cycle, using an
aquatic snail species as its intermediate host.
• Juvenile flukes released from metacercariae
reach the cecum and colon where they mature
and live attached to the mucosa
• Pig is the main reservoir and prevalence in
pigs is of epidemiological interest
• Concomitant infection with F. buski is high in
India
• In Shillon (Meghalaya) where rearing of pigs is
a common household practice, G. hominis
showed a seasonal occurrence similar to that of
F. buski.
• Owing to similarities in intermediate and
reservoir hosts, as well as in transmission and
contamination characteristics, measures useful
against F. buski may also be applied against G.
hominis
 Other trematodes
• Isolated foci of human paragonimiasis exist in
Madras, bengal, Assam and Manipur
• From Manipur 39 cases among young persons
of 11-30yrs were reported die to eating of raw
crabs.
• Reports of a new focus of paragonimiasis from
Arunachal Pradesh exist.
• ELISA using ES Ag of the parasite has been
developed.
 CESTODE ZOONOSES
• Cysticercosis

• Hydatidosis

• Sparganosis
 Cysticercosis
• Infection caused by metacestodes of Taenia
solium.
• In India the incidence of human taeniasis,
which averages 0.5-0.75% among general
population, may go as high as 12-16% in
selected groups such as backyard pig keepers
and persons associated with pig slaughter
• Surveys in the past decade have indicated that
India is among the countries where
cysticercosis is a serious emerging problem
• Neurocysticercosis has been regarded as the
most frequent parasitosis of the CNS
• A serological and MRI study in Lucknow found
existence of large number of asymptomatic
cases, which indicated high prevalence.
• It is also the most common cause of epilepsy in
India
• Accounted for 5-20% of all epilepsy cases
• Sporadic cases of ocular cerebral and extra cranial
foci have been reported from all parts of the
country
• A study in Goa found eosinophilic granulomas in
superficial muscles and subcutaneous tissues as a
common presentation
• Swine cysticercosis, usually established at post
mortem tissue inspection, has been recorded as
ranging from 2-28.8% in India
• Detections by immunological tests, usually
counterimmunoelectrophoresis or by ELISA
and its variants have given higher positivity
• Treatment with Albendazole in experimentally
infected pigs was highly effective in a study
• For implementing effective control,
collaboration between medical and veterinary
services at ground level, as well as a
combination of rational control strategies, have
been envisaged
 Hydatidosis
• Echinococcus multilocularis – single report
from Chandigarh in 1978
• E. granulosus – Major zoonoses
• Widespread prevalence, ranging from 2-30%
in sheep, goat and pig, and a much higher 12-
62% in cattle and buffalo, as reported from
several parts of India
• As regards fertility of cysts, it was recorded s
high as 90% in both sheep and goats which
indicated the suitability of these animals as
intermediate hosts
• It is also in accord with the observation that in
India, it is mainly the sheep strain (and the
cattle strain to a lesser extent) that is infectious
for humans.
• Presentation highly variable as recorded in
many reports
• Most frequent – hepatic and pulmonary
• Others – cardiac, nephrotic, cerebral, spinal,
mediastinal, ocular, bilateral ovarian and even
an unusual breast lump
• Detection of canine echinococcosis can be
facilitated by finding coproantigens in faeces
by sensitive assays such as ELISA
• Overall control would probably require
measures such as vaccination of intermediate
hosts
 Sparganosis
• Infection my tapeworm larvae of the genus
Spirometra which invade humans as accidental
hosts and persis as so called spargana for some
time in various tissues
• Final hosts are dogs, cats and other carnivores
• In India sparganosis has been reported
involving the subcutaneous tissues and
muscles of various parts of the body
• Uncommon presentations such as invasion of
the anterior chamber of the eye, brain and
spinal cord in two cases and cerebrum are also
in record
• Brain involvement was seen as a granuloma or
abscess
 Nematode zoonoses
• Larva migrans –
– Cutaneous larva migrans (creeping eruptions)
– Visceral larva migrans – larvae of mainly the dog
ascarid Toxocara canis
• In South Asian countries, due to rampant
contamination of soil and opportunities for its
contact with children as well as many kinds of
workers, both these conditions are highly
prevalent
• Screening for worm eggs detected in soil samples
and dog faeces at various centres in India has
found positivity for Ancylostoma ranging from 3-
93% and for Toxocara from 3.6 – 58.2%
• Stray dogs were found more likely to be infected
than the pet dogs just as soil samples from
playgrounds which were more likely to be
frequented by stray dogs were found to have
greated positivity than soil around houses
• Magnitude of problem greater than detected by
conventional methods of detection
• Using molecular epidemiological tools in
addition to the conventional ones in a remote
community in North East India, Traub et al
found 72% dogs harbouring A.caninum, 60%
A. braziliense and 37% having mixed
infecetions with both hookworms
 Other nematode infections
• Gnathostomiasis – caused by the migrating larvae
of Gnathostoma spinigerum of which carnivorous
animals like cats and dogs are definitive hosts
• The larvae may migrate in the skin or in visceral
organs
• Two cases with intraocular parasites with
resultant loss of vision and one case of
intracranial invasion have been reported from
India
• Dirofilariasis – there seems to be a focus of
human dirofilariasis in Kerala with Dirofilaria
repens, normally a parasite of dogs and cats.
• Increased occurrence of the worms in the
subcutaneous tissues and subconjunctival
space of humans in different parts of Kerala
with incidence of microfilariae in dog blood
smears, spells enhanced risk of humans who
acquire infection
• Thelaziasis – also known as eye worm
infection
• Two cases have been reported from India

• Trichuris vulpis – normally parasitic in dogs,

its occurrence has been reported in an Indian
tribal population
 Conclusion
• Global agencies have recommended continued
and greater surveillance of parasitic zoonoses
in man and animals
• Critical issues in implementation of control
where active transmission causes substantial
morbidity and mortality are the political will,
social support, financing and organizational
framework.
Redemption of professional
ethics
J. S. Bajaj
Ann Natl Acad Med Sci (India)
46(1): 1-3, 2010
• The editor describes the promulgation of the
“Indian Medical Council (professional
conduct, etiquette and ethics)(amendment)
Regulations, 2009- part-I” as an act of
redemption of professional values.
• Over the last several decades – growing
impact of pharmaceutical industry’s effort to
transform physician behavior
• While physicians capacity of independent
decision making has declined, the retail prices
of drugs and products have shown a steep
increase
• From 1997-2005, drug manufacturers have
paid at least $57 million to doctors, nurses and
other health care workers in Minnesota alone
• In addition $40 million was provided to clinics
and research centers
• Apart from individual-centered approach, a
more subtle way to produce a ‘mass’ effect is
through industry’s endeavor to subsidize
continuing medical education programmes
• Dissemination of ‘appropriate’ information through
professional publications notably journal
supplements is another source of major expenditure
• Number of credit hours of accredited CME
programmes has become mandatory for the
purpose of maintaining license to practice and this
is helping create a captive marketplace for
industry’s products as they usually subsidize such
programmes
• Strong and consistent evidence that industry sponsored
research tends to favour pro-industry inferences
• Bias in drug trials is common and generally favors the
sponsor’s product
• Compounding these aberrations is the fact that peer
reviewers may themselves show bias in so far as they
may approve or reject an rticle simply because it
favours or contradicts their own interests
 Example of misconduct
• An internationally acclaimed diabetes
investigator, while reviewing a confidential
study for the NEJM, sent a copy of the
manuscript by fax to GlaxoSmithKline (the
manufacturer of the drug under study), thus
tipping the company to the imminent
publication of safety concerns in relation to
antidiabetes drug Rosiglitazone
• The same expert acknowledged having
received $75000 in consulting and speaking
fees from the company since 1999
• High time that nefarious activities of such
physicians who travel luxuriously to promote
specific drugs or biomedical devices
manufactured by their sponsors, who
enthusiastically join advisory boards of
pharma companies and who create industry
supported clinical practice guidelines be
curbed by imposing laws like MCI amendment
and also penalties