Intestinal Parasites in Immigrants and Refugees

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Intestinal Parasites in Immigrants and Refugees

• Pat Walker, M.D., D.T.M.H.
• Director
• Center for International Health and International
  Travel Clinic
• Michelle Weinberg, M.D., M.P.H.
• Acting Branch Chief
• Immigrant, Refugee and Migrant Health Branch
• Division of Global Migration and Quarantine

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Intestinal parasites in refugees and immigrants
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An interesting email

• Sent Monday, April 04, 2005 432 PM
• To Patricia.F.Walker_at_HealthPartners.Com
• Subject health needs
• I got your email address from my mother-
  Linda  A.
• I am an ELL teacher and have many students from
  Liberia.  I had a student complain about coughing
  up a long white worm as he was eating a lemon at
  lunch.  I sent him to the nurse at school, as he
  said this was the second time it has happened to
  him.  She sent him back to class saying there
  wasn't enough to tell anything at this point.  Is
  there anything you can suggest, or anywhere I can
  direct his parents?
• Thanks for your help!
• Michelle R  

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Laboratory screening for refugees

• CBC with WBC differential and platelets
• Urinalysis
• Infant metabolic screening in newborns according
  to state guidelines
• HBsAb, HBsAG
• VDRL or RPR,HIV
• Blood lead level for children ages 6 months 16
  years
• Stool OP

http//www.cdc.gov/ncidod/dq/refugee/rh_guide/in
dex.htm
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Domestic screening pitfallsIntestinal parasites

• Providers may not have information about
  presumptive treatment of refugees given overseas
• Initial screening may not include differential
  WBC count, may only include 1 stool specimen
• Providers assume patients who have been in the US
  for a significant length of time cannot have
  pathogenic parasites
• Providers assume negative stools for OP means
  the patient is not infected
• Evaluation management of eosinophilia is
  inadequate

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Pitfalls in new arrival screening eosinophilia
not pursued

• 128 Southeast Asian patients with eosinophilia
  unexplained after initial stool for ova
  parasites (OP) x 3
• Subsequent evaluation with O P or serology
• 55 Hookworm
• 38 Strongyloides stercoralis
• 2 Entamoeba histolytica
• 95

TB Nutman et al Eosinophilia in Southeast Asian
refugees evaluation at a referral center. JID.
1987 Feb155(2)309-13.
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Strongyloides clinical presentation

• Asymptomatic eosinophilia
• Dermatitis - larva currens
• Abdominal pain
• Pulmonary infiltrates with eosinophilia
• Dissemination with sepsis

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Natural history of untreated infection

• Hookworm
• Once removed from an environment where
  re-infection can occur, adult A. duodenale life
  span averages 5-7 years. (Necatur americanus up
  to 15 years)

• Strongyloides
• Auto-infection possible via several routes
• Male/female larva
• Perianal re-infection
• Infection can persist for decades

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Strongyloides by ethnicityRegions Hospital, St.
Paul, MN, 1/1988 - 9/1998

Microbiology Lab Regions Hospital, St Paul,
Minnesota Positive stool specimens
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Strongyloides stercoralisRegions Hospital, St
Paul, MN 1988-1998

• Diagnosed by OP 161
• Disseminated 5
• Deaths 3

Source Walker PF, Jaranson J. Refugee and
Immigrant Health Care. Med Clin N Am 83(4) 1999
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Disseminated Strongyloides,Minneapolis / St
Paul, 1993-2002

• N9
• All Southeast Asian
• All received steroids prior to dissemination
• 2/9 AEC gt 500/uL
• 8/9 presented with GI complaints
• 2/9 presented with pulmonary complaints
• 3/9 died

Newberry AM, Williams DN, Stauffer WS, Walker PF
et al Chest.2005128(5)3681-4
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Disseminated StrongyloidesTeaching Points

• Avoid steroid use in refugees immigrants until
  knowing results of eosinophil count stools for
  O P.
• Vigorously pursue the evaluation of even mild
  eosinophilia in refugees immigrants.
• Check stools for O P on all newly arriving
  refugees immigrants, on refugees, immigrants
  and travelers with GI symptomatology, regardless
  of length of stay in U.S. (carriers documented
  after 60 years away from endemic areas).
  
  P.F. Walker, MD, DTMH 5/97

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Pre-departure treatment for intestinal parasites
in U.S.-bound refugees

• Since May 1999, CDC has implemented empiric
  treatment with single dose albendazole 600 mg for
  all refugees departing from sub Saharan Africa,
  and for selected groups, such as Hmong arriving
  from Thailand

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Enhanced screening of Barawan Somali refugees,
1997

• Cross sectional survey of 10 during standard
  pre- departure screening 39 intestinal
  parasites
• Mass therapy for Barawan refugees 1-2 days before
  resettlement
• 600 mg albendazole for those gt2 yo non-pregnant
• Estimated US cases avoided 1,500 (38) cases of
  intestinal parasites

Miller JM, Boyd HA, et al. AJTMH
62(1),2000,pp.115-121
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Intestinal parasites among African refugees
resettled in Massachusetts impact of an overseas
pre-departure treatment program, 1995-2001,
N1,254

• 56 - intestinal parasites
• 52 - protozoan infection
• Post treatment odds ratios
• Any parasite 0.61
• Helminths 0.15
• E. histolytica 0.47
• Empiric treatment resulted in fewer helminths
  possibly some protozoans

Geltman P,Cochran J, Hedgecock C. AJTMH 69 (6)
2003657-662
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Results of serologic testing for strongyloides
schistosomiasis for Lost Boys and Girls of Sudan
Somali Bantu refugees resettled to the US, 2004
Posey, DL et al High Prevalence and Presumptive
Treatment of schistosomiasis strongyloidiasis
among African refugees, Clin Infec
Dis.2007Nov1545(1)1316-8
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Short report persistent untreated tropical
infectious diseases among Sudanese refugees in
the U.S.

• Lost Boys of Sudan living in Atlanta treated at
  Tropical Medicine Clinic, Emory University,
  7/2005 12/2006, N44
• Serology () S mansoni 78
• Serology () S haematobium 22
• Serology () Strongyloides 25
• HBsAg () 32

Franco-Paredes, C et al. AJTMH
77(4),2007633-635
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Current recommended presumptive treatment
regimens for U.S.-bound refugees
http//www.cdc.gov/ncidod/dq/refugee/rh_guide/ip
/index.htm, as of 06/2009 1 for children 12 23
mos, use 200 mg no treatment for children lt 12
mos 2 no treatment for children who weigh lt 15
kg 3 no treatment for children lt 4 years of age
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Cost effectiveness of strategies for the
treatment of intestinal parasites in immigrants

• As compared with watchful waiting, presumptive
  treatment with albendazole of all immigrants at
  risk for parasitosis would avert at least 870
  DALYs, prevent 33 deaths and 374 hospitalizations
  and save at least 4.2M per year.
• Compared with watchful waiting, screening would
  cost 159,236 per DALY.
• Universal screening with treatment of positive
  stools would save lives but is less cost
  effective.
• Presumptive treatment saves lives and money.
• Muenning P, Pallin D, Sell R, et al.
• NEJM 1999, 340(10)773-779

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