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A comparison of helminth infections in urban and rural areas of Addis Ababa
540 Sabry, M., Gamal, H., El-Masry, N. & Kilpatrick, M. E. (1991). A placebo-controlled double-blind trial for the treatment of Bancroftian filariasis with ivermectin or dietbylcarbamazine. Transactions of the Royal Society of Tropical Medicine and Hygiene, 85,640-643. Schwartz, D. (1981). MCthodes Statistiques b PUsage desMJdecins et Biologistes, 3rd edition. Paris: Flammarion MCdecine
Sciences.
Wijers, D. J. B:, Kaleli, N. & Ngindu, A. H. (1988). Dietbylcarbamazme prophylaxis against bancroftian filariasis given by a member of the local community in Kenya. AnnaZs of Tropical Medicine and Parasitology, 82,411-412.
Received 16 January March I992
1992; accepted for publication 31
TRANSACTIONSOF THE ROYAL SOCIETYOF TROPICALMEDICINE AND HYGIENE (1992) 86, 54C-541
A comparison of helminth infections in urban and rural areas of Addis Ababa I. de Carneril, L. Di Matte01 and Shibru Tedlaz ‘Department of Preventive, Occupational and Community Medicine, University of Pavia, Italy; Vnstitute of Pathobiology, University of Addis Ababa, Ethiopia
Ethiopia, togetherwith Eritrea, measures1 251 282 km2 and lies between latitudes 3” and 18”N and longitudes 33” and 48”E. By mid-1990 it had 50.9 million inhabitants living between 100 m below sea level and at over 4000 m altitude in the mountains. With its broad variety of climate, and the general poverty of its inhabitants, this area appears tailor-made for studies on human hehninthology (ZEIN & KLOOS,1988). Worms are the main reason (TEKA, 1984), or the second one (TEDLA, 1989), why the people seek medical aid, and traditionally each village has its ‘koussowoman’ who uses herbal remedies for Taenia saginata infections. 89% of the population live in the countryside, but the population of Addis Ababa is rising at a rate of 4% a year, compared to 29% in the rest of the country. Between November and January 1991we started a study in Addis Ababa and its surroundings. From our experience in Italy since 1962 (see DE CARNERI,lVVO),we expected that in a homogeneousendemic area both the prevalence and the worm burden of geohehninthiases would be inversely proportional to the socio-economic standard. Addis Ababa (2408 m above sealevel) now officially has 1 917 900 inhabitants. We examined schoolchildren, mostly aged V-10 years, in 3 different parts of the city. Kolfe is a poor district on the western fringe of the city, built on red clay, with 13 583 inhabitants of various nationalities, mostly Christians, 2186 of them schoolchildren. Most of the inhabitants gave their occupation as ‘street merchants’, a euphemism that in most casesmight be translated as ‘no specific profession’. Their homes are huts, with sanitary facilities consisting of defaecation fields between the houses. We examined 75 children aged V-10 years arid 9 aged eight years (total 84), attending the local public school (public schools are at the same level as government schools and are set up when the government schools have no room for all the children of a given borough). Kechene is a northern borough! again on red earth, with 8500 inhabitants, mostly Christians. Economica.lly it is one step up the scale from Kolfe. Many of the inhabitants are weavers, but there are also numerous ‘merchants’, as before. Excreta disposal is still based on defaecation fields. We examined 84 children aged V-10 years, from a public school. Bole is another suburb, built on volcanic black earth, to the south near the airport. It has 11 000 inhabitants of mixed nationalities, mostly Christians, living in small, well-kept houses, each with a water closet, built 25 years ago by an American Company for government employees. We examined 84 children aged V-10 years, from a public school. In the countryside 30 km west of Addis Ababa,
at 2580 m above sea level on the road to Addis Alem, Menagesha is a village with about 3000 inhibitants, Christians of Amhara origin, mostly merchants, some government employees and a few farmers. We examined 87 children from the local government schools; 13 of them came from a small farming settlement, Kolobo, 500 m away. Collection of faecal samples and data was greatly facilitated by the co-operation of teachersand the children themselves. Examinations of faeces (Kato method on 20 mg and Ridley formol-ether sedimentation on 1 g) were done, after storage at 4°C for not more than 48 h, at the Institute of Pathobiology in Addis Ababa. The results showed that in Addis Ababa and its surrounding boroughs ascariasiswas the main problem (Fig. 1). At Kolfe the prevalence was 83%. One-quarter of the
children had between 20 000 and 368 500 eggs/g. At Kechene (68% prevalence), 15% had between 20 000 and 60 000 eggs/g. In the more modern Bole borough (18% prevalence),only 2 children had 20 000 and 45 000 eggs/g respectively. All the differences between pughs were highly significant (e.g., for pre_vglence,x =79.988; degreesof freedom (df)=2; P
_12978 10--
5553 0
13098
1
T
8018
1 Mena~ePh~-KOiObO
bsesnene
KOI te
Fig. 2. Ascaris lumbricoides: arithmetic mean worm burden in Addis Ababa,with 95%confidence limits.
541
Trichutis infections had a lower prevalence and worm burden everywhere, especially in the city (Fig. 1). We found a maximum of 14 000 eggs/gin Menageshaand an overall averageof 805& 1935 eggs/g.In Addis Ababa and surroundings we found 7 children with Fasciola eggs (this needs to be rechecked becauseof the possibility of spurious infection), one with Schistosoma-mansoni,- 10 with Hvmenoleais nana. one with H. diminuta. onlv one with Taenia (children rarely eat meat!), 6 withancyiostomiasis, one with Trichostrongylus, and 4 with strongyloidiasis (together with the Kato technique, we used the Ridley sedimentation method in order to detect scanty eggsand Strongyloides larvae). In conclusion, the most serious hehninthological problem around Addis Ababa is due to Ascaris: with a prevalence of more than 60% the corresponding worm burden may be dangerously high (see GUYATT et al., 1990). The prevalence and worm burden of Trichuris seemsto be a relatively minor problem (seethe report of our experience in Italy: BIAGI et al., 1970). However, nothing is known about possible pathogenic synergism with other helminths; nowadays we have broad spectrum anthehnintics and appropriate associationsof anthelmintics can be chosen for every local situation. The urban situation of Addis Ababa (only 7% of homes have toilets), apart from needing urgent amelioration, makes this megalopolis-to-be an ideal place for
quantitative integrated demographic, socioeconomic and hehninthological studies. References
Biagi, F.. de Carneri. I. & Gazzola, E. 119701.Valutazione de1 &&cato patologico della tricocefalbsi idfantile in un ambiente rurale lombardo caratterizzato da alta prevalenza dell’elmintiasi e bassacarica parassitaria. Rivistu Parussitologia, 31, 183-194.
De Carneri, I. (1990). Impact of the socioeconomic development on human helminthiases: an Italian experience. In:
Basic Research in Helminthiases, Ehrlich, R., Nieto, A. &
Yarzabal, J. (editors). MonteGideo, U;ugGay: Ediciones Logos, pp. 31-44. Guyatt, H. L., Bundy, D. A. P., Medley, G. F. & Grenfell, B. T. (1990). The relationship between the frequency distribution of Ascaris lumbricoides and the prevalence and intensity of infections in human communities. Parasitology, 101, 1391 143. Tedla, S. (1989). Hehninthiasis in Ethiopia: a review. Ethiopian Journal of Science,12,25-48. Teka, G. M. (1984). Human Wastes Disposal. Addis Ababa: Planning and Programming Bureau, Ministry of Health. Zein, Z. A. & Kloos, H. (1988). The Ecolog) of Health and Diseasein Ethiopia. Addis Ababa: Ministry of Health. Received 28 October 1991; revised 8 January acceptedfor publication 9Januay 1992
1992;
TRANSACTIONS OFTHEROYALSOCIETY OFTROPICAL MEDICINE ANDHYGIENE (1992)86, 541
1I Short Report I1 Chronic persistent strongyloidiasis cured by ivermectin M. Lyagoubil, A. Datryl, R. Mayorgal, G. Bruckerl, I. Hilmarsdottirl, P. Gaxottel, D. Neu2, M. Danis’ and IDepartement de Mbdicine Tropicale et M. Gentilinil Parasitologie, Groupe Hospitalier ‘Piti&Salp&ridre, 47 Boulevard de l’H@ital, 75651 Paris CLdex 13, France; Vnfectious Disease Clinical Research, Merck Sharp & Dohme Research Laboratories, West Point, Pennsylvania, USA
We hereby report a patient with chronic intestinal strongyloidiasis resistant to different treatment regimens and drug schedules who was finally cured with 3 dosesof ivermectin. This drug has already been reported to be useful for strongyloidiasis in uncontrolled studies (TESTA etal., 1990; NAQUIRA~~~~.,1989). A 45 years old man from Zaire, living in France since 1977, had attended regularly at the Departement de Medecine tropicale et Parasitologie in Paris since 1979 for pruritus and watery diarrhoea. Raised blood eosinophilia and Strongyloides stercoralis larvae in the stools were constant findings during the 14 years period, despite 20 treatments with thiabendazole (total dose 90 g). Different dosagesand drug schedules were tried, to no avail. He was also treated 6 times with flubendazole (3600 mg), 6 times with albendazole (7200 mg), once with mebendazole (600 mg), and once with praziquantel (1200 mg). In December 1989 ivermectin was administered as a single dose of 12 mg, with a reduction of the
parasite burden but not complete clearance by the follow-up one week later. Repeated administration of this same dose on 2 consecutive days resulted in a definite cure. During 14 months follow-up, 16 stool sampleswere examined, all by wet mount, formalin-ether sedimentation technique, and Baermann’s technique; no parasite was seen. The patient’s eosinophil count returned to normal 3 months after ivermectin treatment. This caseindicates that ivermectin is a potential therapeutic alternative in the treatment of chronic strongyloidiasis resistant to conventional, and even to unconventional, therapies. Moreover, this drug is generally well tolerated (GREENEet al., 1989). In this case, treatment failure with a single dose was overcome after a second treatment course of two doses. Controlled clinical trials are necessaryto confirm this observation. The potentially beneficial effect of ivermectin in the treatment of disseminated or hyperinvasive strongyloidiasis should also be determined. References
Greene, B. M., Brown, K. R. & Taylor, H. R. (1989). Use of ivermectiu in humans. In: Zvermectin and Avamectin, Campbell, ___ W. C. (editor). New York: Springer-Verlag, pp. 311jzj. Naquira, C., Jimenez, G., Guerra, J. G., Bernal, R., Nalin, D. R., Neu, D. & Aziz, M. (1989). Ivermectin for human strongyloidiasis and other intestinal hehninths. American Journal of Tropical Medicine and Hygiene, 40,30&309. Testa, J., Kizimandji-Coton, G., Delmont, J., Di Constanzo, B. & Gaxotte, P. (1990). Traitement de l’anguillulose, de l’ascaridiose et de l’ankylostomiase par l’ivermectine (Mectizan@) B Bangui (RCA). Mtdecine d’Aftique Noire, 37, 283-284.
Received 13 February March 1992
1992; accepted for publication 4
Sciences.
Wijers, D. J. B:, Kaleli, N. & Ngindu, A. H. (1988). Dietbylcarbamazme prophylaxis against bancroftian filariasis given by a member of the local community in Kenya. AnnaZs of Tropical Medicine and Parasitology, 82,411-412.
Received 16 January March I992
1992; accepted for publication 31
TRANSACTIONSOF THE ROYAL SOCIETYOF TROPICALMEDICINE AND HYGIENE (1992) 86, 54C-541
A comparison of helminth infections in urban and rural areas of Addis Ababa I. de Carneril, L. Di Matte01 and Shibru Tedlaz ‘Department of Preventive, Occupational and Community Medicine, University of Pavia, Italy; Vnstitute of Pathobiology, University of Addis Ababa, Ethiopia
Ethiopia, togetherwith Eritrea, measures1 251 282 km2 and lies between latitudes 3” and 18”N and longitudes 33” and 48”E. By mid-1990 it had 50.9 million inhabitants living between 100 m below sea level and at over 4000 m altitude in the mountains. With its broad variety of climate, and the general poverty of its inhabitants, this area appears tailor-made for studies on human hehninthology (ZEIN & KLOOS,1988). Worms are the main reason (TEKA, 1984), or the second one (TEDLA, 1989), why the people seek medical aid, and traditionally each village has its ‘koussowoman’ who uses herbal remedies for Taenia saginata infections. 89% of the population live in the countryside, but the population of Addis Ababa is rising at a rate of 4% a year, compared to 29% in the rest of the country. Between November and January 1991we started a study in Addis Ababa and its surroundings. From our experience in Italy since 1962 (see DE CARNERI,lVVO),we expected that in a homogeneousendemic area both the prevalence and the worm burden of geohehninthiases would be inversely proportional to the socio-economic standard. Addis Ababa (2408 m above sealevel) now officially has 1 917 900 inhabitants. We examined schoolchildren, mostly aged V-10 years, in 3 different parts of the city. Kolfe is a poor district on the western fringe of the city, built on red clay, with 13 583 inhabitants of various nationalities, mostly Christians, 2186 of them schoolchildren. Most of the inhabitants gave their occupation as ‘street merchants’, a euphemism that in most casesmight be translated as ‘no specific profession’. Their homes are huts, with sanitary facilities consisting of defaecation fields between the houses. We examined 75 children aged V-10 years arid 9 aged eight years (total 84), attending the local public school (public schools are at the same level as government schools and are set up when the government schools have no room for all the children of a given borough). Kechene is a northern borough! again on red earth, with 8500 inhabitants, mostly Christians. Economica.lly it is one step up the scale from Kolfe. Many of the inhabitants are weavers, but there are also numerous ‘merchants’, as before. Excreta disposal is still based on defaecation fields. We examined 84 children aged V-10 years, from a public school. Bole is another suburb, built on volcanic black earth, to the south near the airport. It has 11 000 inhabitants of mixed nationalities, mostly Christians, living in small, well-kept houses, each with a water closet, built 25 years ago by an American Company for government employees. We examined 84 children aged V-10 years, from a public school. In the countryside 30 km west of Addis Ababa,
at 2580 m above sea level on the road to Addis Alem, Menagesha is a village with about 3000 inhibitants, Christians of Amhara origin, mostly merchants, some government employees and a few farmers. We examined 87 children from the local government schools; 13 of them came from a small farming settlement, Kolobo, 500 m away. Collection of faecal samples and data was greatly facilitated by the co-operation of teachersand the children themselves. Examinations of faeces (Kato method on 20 mg and Ridley formol-ether sedimentation on 1 g) were done, after storage at 4°C for not more than 48 h, at the Institute of Pathobiology in Addis Ababa. The results showed that in Addis Ababa and its surrounding boroughs ascariasiswas the main problem (Fig. 1). At Kolfe the prevalence was 83%. One-quarter of the
children had between 20 000 and 368 500 eggs/g. At Kechene (68% prevalence), 15% had between 20 000 and 60 000 eggs/g. In the more modern Bole borough (18% prevalence),only 2 children had 20 000 and 45 000 eggs/g respectively. All the differences between pughs were highly significant (e.g., for pre_vglence,x =79.988; degreesof freedom (df)=2; P
_12978 10--
5553 0
13098
1
T
8018
1 Mena~ePh~-KOiObO
bsesnene
KOI te
Fig. 2. Ascaris lumbricoides: arithmetic mean worm burden in Addis Ababa,with 95%confidence limits.
541
Trichutis infections had a lower prevalence and worm burden everywhere, especially in the city (Fig. 1). We found a maximum of 14 000 eggs/gin Menageshaand an overall averageof 805& 1935 eggs/g.In Addis Ababa and surroundings we found 7 children with Fasciola eggs (this needs to be rechecked becauseof the possibility of spurious infection), one with Schistosoma-mansoni,- 10 with Hvmenoleais nana. one with H. diminuta. onlv one with Taenia (children rarely eat meat!), 6 withancyiostomiasis, one with Trichostrongylus, and 4 with strongyloidiasis (together with the Kato technique, we used the Ridley sedimentation method in order to detect scanty eggsand Strongyloides larvae). In conclusion, the most serious hehninthological problem around Addis Ababa is due to Ascaris: with a prevalence of more than 60% the corresponding worm burden may be dangerously high (see GUYATT et al., 1990). The prevalence and worm burden of Trichuris seemsto be a relatively minor problem (seethe report of our experience in Italy: BIAGI et al., 1970). However, nothing is known about possible pathogenic synergism with other helminths; nowadays we have broad spectrum anthehnintics and appropriate associationsof anthelmintics can be chosen for every local situation. The urban situation of Addis Ababa (only 7% of homes have toilets), apart from needing urgent amelioration, makes this megalopolis-to-be an ideal place for
quantitative integrated demographic, socioeconomic and hehninthological studies. References
Biagi, F.. de Carneri. I. & Gazzola, E. 119701.Valutazione de1 &&cato patologico della tricocefalbsi idfantile in un ambiente rurale lombardo caratterizzato da alta prevalenza dell’elmintiasi e bassacarica parassitaria. Rivistu Parussitologia, 31, 183-194.
De Carneri, I. (1990). Impact of the socioeconomic development on human helminthiases: an Italian experience. In:
Basic Research in Helminthiases, Ehrlich, R., Nieto, A. &
Yarzabal, J. (editors). MonteGideo, U;ugGay: Ediciones Logos, pp. 31-44. Guyatt, H. L., Bundy, D. A. P., Medley, G. F. & Grenfell, B. T. (1990). The relationship between the frequency distribution of Ascaris lumbricoides and the prevalence and intensity of infections in human communities. Parasitology, 101, 1391 143. Tedla, S. (1989). Hehninthiasis in Ethiopia: a review. Ethiopian Journal of Science,12,25-48. Teka, G. M. (1984). Human Wastes Disposal. Addis Ababa: Planning and Programming Bureau, Ministry of Health. Zein, Z. A. & Kloos, H. (1988). The Ecolog) of Health and Diseasein Ethiopia. Addis Ababa: Ministry of Health. Received 28 October 1991; revised 8 January acceptedfor publication 9Januay 1992
1992;
TRANSACTIONS OFTHEROYALSOCIETY OFTROPICAL MEDICINE ANDHYGIENE (1992)86, 541
1I Short Report I1 Chronic persistent strongyloidiasis cured by ivermectin M. Lyagoubil, A. Datryl, R. Mayorgal, G. Bruckerl, I. Hilmarsdottirl, P. Gaxottel, D. Neu2, M. Danis’ and IDepartement de Mbdicine Tropicale et M. Gentilinil Parasitologie, Groupe Hospitalier ‘Piti&Salp&ridre, 47 Boulevard de l’H@ital, 75651 Paris CLdex 13, France; Vnfectious Disease Clinical Research, Merck Sharp & Dohme Research Laboratories, West Point, Pennsylvania, USA
We hereby report a patient with chronic intestinal strongyloidiasis resistant to different treatment regimens and drug schedules who was finally cured with 3 dosesof ivermectin. This drug has already been reported to be useful for strongyloidiasis in uncontrolled studies (TESTA etal., 1990; NAQUIRA~~~~.,1989). A 45 years old man from Zaire, living in France since 1977, had attended regularly at the Departement de Medecine tropicale et Parasitologie in Paris since 1979 for pruritus and watery diarrhoea. Raised blood eosinophilia and Strongyloides stercoralis larvae in the stools were constant findings during the 14 years period, despite 20 treatments with thiabendazole (total dose 90 g). Different dosagesand drug schedules were tried, to no avail. He was also treated 6 times with flubendazole (3600 mg), 6 times with albendazole (7200 mg), once with mebendazole (600 mg), and once with praziquantel (1200 mg). In December 1989 ivermectin was administered as a single dose of 12 mg, with a reduction of the
parasite burden but not complete clearance by the follow-up one week later. Repeated administration of this same dose on 2 consecutive days resulted in a definite cure. During 14 months follow-up, 16 stool sampleswere examined, all by wet mount, formalin-ether sedimentation technique, and Baermann’s technique; no parasite was seen. The patient’s eosinophil count returned to normal 3 months after ivermectin treatment. This caseindicates that ivermectin is a potential therapeutic alternative in the treatment of chronic strongyloidiasis resistant to conventional, and even to unconventional, therapies. Moreover, this drug is generally well tolerated (GREENEet al., 1989). In this case, treatment failure with a single dose was overcome after a second treatment course of two doses. Controlled clinical trials are necessaryto confirm this observation. The potentially beneficial effect of ivermectin in the treatment of disseminated or hyperinvasive strongyloidiasis should also be determined. References
Greene, B. M., Brown, K. R. & Taylor, H. R. (1989). Use of ivermectiu in humans. In: Zvermectin and Avamectin, Campbell, ___ W. C. (editor). New York: Springer-Verlag, pp. 311jzj. Naquira, C., Jimenez, G., Guerra, J. G., Bernal, R., Nalin, D. R., Neu, D. & Aziz, M. (1989). Ivermectin for human strongyloidiasis and other intestinal hehninths. American Journal of Tropical Medicine and Hygiene, 40,30&309. Testa, J., Kizimandji-Coton, G., Delmont, J., Di Constanzo, B. & Gaxotte, P. (1990). Traitement de l’anguillulose, de l’ascaridiose et de l’ankylostomiase par l’ivermectine (Mectizan@) B Bangui (RCA). Mtdecine d’Aftique Noire, 37, 283-284.
Received 13 February March 1992
1992; accepted for publication 4