Cystic Echinococcosis in the Early 2020s: A Review
Abstract
:1. Introduction
2. Materials and Methods
3. Results
3.1. Taxonomy
3.2. Epidemiology
- Transmission and Life Cycle.
- Epidemiological Data.
3.3. Current Guidelines
3.3.1. Prevention and Control
3.3.2. Treatment
- Surgery:Surgery was the preferred course of treatment in the past, as it may be curative by the complete removal of the cyst (total cystectomy) [3,32]. Other surgical approaches are sub-total cystectomy and hepatectomy. Total cystectomy avoids cyst opening and therefore prevents recurrence and is the preferred option if possible. Surgery is still used for particular scenarios such as liver cysts that are secondarily infected or cysts that are located in critical areas like the brain, lungs, or kidneys. It is also the elective choice of treatment for large liver cysts, particularly those over 7.5 cm, which are likely to have biliary communication [3]. It is recommended to associate albendazole to prevent relapses.
- Chemotherapy:Over 2000 documented cases [1,3,4,8,12,46,56,57] have been treated with benzimidazoles. The optimal course of treatment includes albendazole (10–15 mg/kg/day or 400 mg q12h) taken after a fatty meal, alone or in association with mebendazole (40–50 mg/kg/day divided into three doses during fat-rich meals) or praziquantel (40 mg/kg once a week), with variable treatment outcomes [1,4,27,56]. Chemotherapy results in cyst disappearance (free from disease) in 10–30% of patients, improvement in 50–70%, and no change in 20–30%. It is generally more effective in younger patients and against specific cyst types. Chemotherapy is indicated in inoperable patients with primary liver echinococcosis, patients with multiple cysts in multiple organs, and in secondary echinococcosis prevention. However, chemotherapy is not recommended for large cysts at risk of rupture, inactive or calcified cysts, compromised patients with severe chronic hepatic diseases, or in early pregnancy. It can be administered before surgery for the safe manipulation of cysts, since it inactivates protoscolices, alters the integrity of cystic membranes, and reduces cyst turgidity [3,32].Chemotherapy can be given before surgery, and many regimens have been tested employing both monotherapy and drug associations. These range from treatment with albendazole administrated 1 week before surgery (continued for 2 months after surgery) and 10 mg/kg/day albendazole and 25 mg/kg/day of praziquantel for 1 month prior to surgery to facilitate the safe manipulation of cysts. It inactivates protoscolices, alters the integrity of cyst membranes, and reduces cyst turgidity [3,4,27].
- Puncture, Aspiration, Injection, and Re-aspiration (PAIR):PAIR [11,46,58] is a minimally invasive, ultrasound-guided cyst puncture, followed by the aspiration of cyst fluid, injection of a protoscolicidal substance (preferably 95% ethanol), and re-aspiration of the fluid after a specified time. It is used as a last resort for treating inoperable patients, relapsing instances after surgery, or non-responders to chemotherapy. A modified procedure of PAIR may also be useful as an alternative to surgery for non-complicated CE2 and CE3b cysts. The “modified catheterization technique” (MoCAT) uses sonographic and fluoroscopic guidance to aspirate both the cyst content and the parasitic membranes and to place a catheter for a period of time after the intervention [59]. Even if this method is suitable for a variety of cysts, it should not be used for lung cysts [1,3].
- “Watch-and-wait” Approach:The observation that some CE cysts may spontaneously become inactive leads to the withholding of treatment, as these cysts remain stable over time. The use of albendazole or other treatment options in asymptomatic patients is not recommended on a standard basis [40,47]. However, it may be an option in highly selected cases referred to specialized centers. In 2010, the WHO-IWGE published their recommendation of this approach for uncomplicated, asymptomatic, inactive (CE4-CE5 stages of the WHO-IWGE classification) CE cysts [40,47].
3.4. Projects and Initiatives Related to the WHO Road Map
3.4.1. The HERACLES Project
Objectives and Results
- Ultrasound screening of CE within the Eastern European population and the ERCE register.
- 2.
- New molecular-based tools for detection, diagnosis, and follow-up of CE.
- 3.
- Host–parasite interplay.
- 4.
- The increasing bioavailability of albendazole and a new enantiomeric drug synthesis.
- 5.
- Training and dissemination of information.
Correlation with the WHO Road Map
- The establishment of an international patient surveillance network for cystic echinococcosis (ERCE);
- The implementation of screening programs in rural parts of the countries that are at risk, as well as the execution of a study aimed at determining the prevalence rates in these specific regions;
- Reporting to both national and international authorities tasked with the responsibility to control and prevent infectious diseases, and thereafter engaging in collaborative efforts to formulate recommendations that are targeted at managing the endemic situation;
- Improving diagnostic techniques by identifying novel biomarkers that can be employed in the molecular diagnosis of CE.
3.4.2. The mEmE Project
Objectives and Results
- Standard operating procedures (SOPs) for sampling.
- 2.
- Validation of multiplex PCRs.
- 3.
- Sequencing of samples using RSE and NGS.
- 4.
- The prevalence of Em/Eg in dogs from selected geographical areas [87].
- 5.
- A quantitative assessment of the impact of human CE in Europe.
- 6.
- Training and Dissemination of information.
Correlation with WHO Road Map
- The establishment of SOPs on sample collection in cases of CE suspicion, particularly in animals, which has played a significant role in contributing to disease control and prevention efforts;
- The basis for an epidemiological study within the present context;
- Confirmation of the efficacy of molecular diagnostic techniques;
- A wide distribution of project findings, targeting both the general public and experts in human and veterinary disciplines.
4. Discussion
4.1. Prospects for Prevention and Control
4.2. Limitations of the Study
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
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Continent | Information Regarding Data | Mean Prevalence | |
---|---|---|---|
Africa | Number of studies included | 4 | 0.0114 (CI 95%, 0.0089–0.0139) |
Time frame of the included studies (publishing date) | 2013–2022 | ||
Number of patients included | 7002 | ||
Number of identified CE patients | 80 | ||
South America | Number of studies included | 6 | 0.0342 (CI 95%, 0.0296–0.0389) |
Time frame of the included studies (publishing date) | 2014–2022 | ||
Number of patients included | 5845 | ||
Number of identified CE patients | 200 | ||
Asia | Number of studies included | 7 | 0.0177 (CI 95%, 0.0169–0.0185) |
Time frame of the included studies (publishing date) | 2011–2022 | ||
Number of patients included | 98,751 | ||
Number of identified CE patients | 1747 | ||
Europe | Number of studies included | 3 | 0.0027 (CI 95%, 0.0020–0.0035) |
Time frame of the included studies (publishing date) | 2018–2020 | ||
Number of patients included | 18,495 | ||
Number of identified CE patients | 50 | ||
Total | Number of patients included | 130,093 | 0.0160 (CI 95% 0.0153–0.0166) |
Number of identified CE patients | 2077 |
WHO Road Map Required Actions | HERACLES Project | mEmE Project | |
---|---|---|---|
Scientific understanding | Map health and economic burden | International patient surveillance network for cystic echinococcosis (ERCE) | A systematic review focused on the quantitative assessment of the impact of CE in Europe [82] |
Estimate prevalence in sheep and other relevant livestock | - | Prevalence of Em/Eg in dogs from selected geographical areas | |
Research to quantify resources needed to control the disease | 56 publications with implications on how to better understand and consequently control the disease | 18 publications, including epidemiological trends, diagnostic methods, and others | |
Diagnostics | Define target product profile and develop optimal diagnostic for humans | The discovery of new biomarkers, with the possibility of further research on the topic Evaluation of commercial serological tests and the identification of their limits Efforts towards implementation of POC-LOC devices | - |
Effective intervention | Conduct efficacy trials in humans to understand optimal treatment courses of albendazole | Novel antihelmintic compounds have been discovered, evaluated, and patented The new molecules were defined as salts with a benzimidazole structure, e.g., albendazole | - |
Operational and normative guidance | Develop guidelines for implementation of optimized prevention and control methods | - | The establishment of SOPs on sample collection in cases of CE suspicion, particularly for dogs, sheep, foxes, and others |
Planning governance and program implementation | Implement systematic use of population ultrasound screening for early diagnosis | A cross-sectional ultrasound-based study in rural parts of the countries involved, aimed at determining the prevalence rates in these specific regions | - |
Mandate segregated reporting of CE and AE in all endemic countries | International patient surveillance network for cystic echinococcosis (ERCE) | - | |
Capacity and awareness building | Develop training courses for medical personnel on diagnosis and clinical management of CE and AE in rural areas of affected countries | The projects have successfully disseminated the acquired information among the local communities of partner nations through several channels: (1) Publishing their research to communicate novel discoveries to the scientific community; (2) Implementing public health initiatives aimed at healthcare professionals, utilizing research outcomes as a basis; (3) Disseminating information to the general population through various means, such as social events, brochures, or journals. | |
Provide community education based on the local values to improve the effectiveness of interventions |
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Hogea, M.-O.; Ciomaga, B.-F.; Muntean, M.-M.; Muntean, A.-A.; Popa, M.I.; Popa, G.L. Cystic Echinococcosis in the Early 2020s: A Review. Trop. Med. Infect. Dis. 2024, 9, 36. https://doi.org/10.3390/tropicalmed9020036
Hogea M-O, Ciomaga B-F, Muntean M-M, Muntean A-A, Popa MI, Popa GL. Cystic Echinococcosis in the Early 2020s: A Review. Tropical Medicine and Infectious Disease. 2024; 9(2):36. https://doi.org/10.3390/tropicalmed9020036
Chicago/Turabian StyleHogea, Mihai-Octav, Bogdan-Florin Ciomaga, Mădălina-Maria Muntean, Andrei-Alexandru Muntean, Mircea Ioan Popa, and Gabriela Loredana Popa. 2024. "Cystic Echinococcosis in the Early 2020s: A Review" Tropical Medicine and Infectious Disease 9, no. 2: 36. https://doi.org/10.3390/tropicalmed9020036
APA StyleHogea, M. -O., Ciomaga, B. -F., Muntean, M. -M., Muntean, A. -A., Popa, M. I., & Popa, G. L. (2024). Cystic Echinococcosis in the Early 2020s: A Review. Tropical Medicine and Infectious Disease, 9(2), 36. https://doi.org/10.3390/tropicalmed9020036