|Year : 2015 | Volume
| Issue : 3 | Page : 364-368
Fasciolopsiasis: Endemic focus of a neglected parasitic disease in Bihar
A Achra1, P Prakash1, R Shankar2
1 Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Submission||25-Jul-2014|
|Date of Acceptance||20-Jan-2014|
|Date of Web Publication||12-Jun-2015|
Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: To describe a newly discovered, previously unreported endemic focus of fasciolopsiasis in the Phulwaria village, under tehsil Sugauli, East Champaran, Bihar. Materials and Methods: A study was conducted at village Phulwaria, following diagnosis of fasciolopsiasis in three children from the village. A total of 120 individuals, including all the children and adults who gave history of recent passage of red fleshy masses in their stool, were included in the study. The cases of fasciolopsiasis were treated with Praziquantel 25 mg/kg, three doses a day. Risk factors for the transmission of the parasite in the village were also studied. Results: Questionnaire revealed majority of the population suffering from abdominal discomfort and passage of red fleshy masses in stool. These fleshy masses were identified as Fasciolopsis buski. One hundred and eighteen individuals were presumably considered as cases of the parasitic infection. After treatment with Praziquantel, all of them passed the parasite in their stool for the next 2-3 days. On investigating, it was observed that all the conditions required for effective continuation of the life cycle of the parasite were present in this village. Conclusion: This study draws attention to a new endemic focus of fasciolopsiasis in Bihar, with a very high prevalence due to poverty, the lack of awareness about the parasite in villagers as well as ignorance among local medical practitioners. There is an urgent need for mass campaign around the region for its effective control.
Keywords: Fasciolopsis buski, fasciolopsiasis, flukes, metacercaria, praziquantel
|How to cite this article:|
Achra A, Prakash P, Shankar R. Fasciolopsiasis: Endemic focus of a neglected parasitic disease in Bihar. Indian J Med Microbiol 2015;33:364-8
|How to cite this URL:|
Achra A, Prakash P, Shankar R. Fasciolopsiasis: Endemic focus of a neglected parasitic disease in Bihar. Indian J Med Microbiol [serial online] 2015 [cited 2019 May 25];33:364-8. Available from: http://www.ijmm.org/text.asp?2015/33/3/364/158554
| ~ Introduction|| |
Fasciolopsis buski is the largest fluke parasitizing the human small intestine. It was described for the first time by English surgeon George Busk in 1843 following autopsy of an Indian sailor in London.  Its biology was studied in detail by Nakagawa in 1920. 
The monoecious adult worms live in the small intestine of humans and pigs. Man gets infected by ingestion of encysted infective metacercariae, which are found adhering to the surface of edible water plants. After ingestion, gastric juices help in the excystation of the metacercariae and release of a juvenile worm. This juvenile worm migrates to the small intestine, grows to maturity and produces operculated eggs which are passed in faeces. Eggs give rise to free-swimming miracidium which undergo further development in snails of the genus Segmentina and give rise to cercariae which encyst to form metacercariae and adhere to edible water plants such as water caltrop, water chestnuts, lotus and watercress. 
Clinical picture depends upon the number of infecting flukes in small intestine. Most of the patients with light infections are usually asymptomatic. Moderate and particularly heavy infections cause abdominal pain, diarrhoea, nausea, vomiting, fever and allergic reactions such as oedema of the face, lower extremities and ascites. Heavy infection can be fatal, as the flukes cause extensive intestinal inflammation, erosions, ulceration, haemorrhage and abscess formation. 
Diagnosis is established by demonstration of typical eggs in stool. However, as egg morphologies are similar for F. hepatica and F. buski, a definite diagnosis requires the examination of adult worms, which are passed in faeces and vomitus during symptomatic illness or can be obtained following expulsion chemotherapy with oral praziquantel 25 mg/kg, three doses a day. ,
F. buski is endemic to Bangladesh, China, India, Indonesia, the Lao People's Democratic Republic (PDR), Malaysia, Taiwan, Thailand and Vietnam.  In India, fasciolopsiasis has been reported with high prevalence from Assam, Uttar Pradesh and Maharashtra. ,, Sporadic cases have been reported from Bihar, West Bengal, Manipur, Odisha, Tamil Nadu and Karnataka. ,,,, But the data about population at risk and estimated number of people infected are lacking and the need for major epidemiological study has been emphasized time and again. , No epidemiological survey has been conducted since 1984. 
The present study reports a newly discovered endemic focus of the intestinal fluke from a village in Bihar.
| ~ Materials and Methods|| |
The study was conducted in village Phulwaria, tehsil Sugauli, district East Champaran, Bihar after the diagnosis of fasciolopsiasis in three children from the same village.
| ~ Patients|| |
The three children presented with history of abdominal pain, diarrhoea and occasional episodes of vomiting for last 2 years. After every 8-10 days, these symptoms worsened along with abdominal distension, bloating and relieved temporarily with passage of 5-10 fleshy reddish worms in stool and occasionally in vomitus.
Despite repeated consultations locally, the children had no relief. Home remedies including making the children drink kerosene oil, all were tried in a bid to seek relief. Children passed plenty of worms in stool and vomitus after kerosene consumption. But, these symptoms used to appear back after few weeks. They finally had to seek services of a tertiary care hospital located 500 km away from the village where the diagnosis was made.
General examination of children revealed pallor, facial oedema and mild ascites. Blood investigation revealed marked eosinophilia and anaemia [Table 1].
Macroscopic and microscopic examination of stool samples was performed. Stool microscopy showed large, oval eggs, measuring 130-140 μm × 80-85 μm, which were bile stained and unsegmented with a thin shell and an operculum at one end [Figure 1].
|Figure 1: Characteristic bile stained egg with operculum at one end in normal saline mount|
Click here to view
One of the three children passed a worm in his vomitus which was brought to us by his parents, this helped in identifying it. It was fleshy, reddish brown, dorsoventrally flattened, leaf-like, measuring 2 cm in length, 8 mm in breadth and 1.5 mm in thickness. The anterior end was narrower than the posterior. The ventral sucker was prominent and lying close to the oral sucker. There was no cephalic cone. The worm was identified as F. buski [Figure 2].  Thus, specific treatment for fasciolosiasis was started. All the three cases responded well to oral anthelminthic agent praziquantel (Distocide) 25 mg/kg, three doses a day.
On detailed inquiry, the parents of the children revealed that many children and a few adults in their village were suffering from similar illness for the last 4 years.
Therefore, a field visit was planned and one of the authors visited the village in October 2012 to conduct the study in the area where the three children belonged. The author carried compound microscope and other necessary consumables for onsite microscopic diagnosis of parasitic infection by stool microscopy. Blood examination could not be performed on other individuals of village. The objective of the study was to estimate the burden of the disease, to trace the source of the parasitic infection and other risk factors responsible for its transmission in the village, like common dietary habits, overall sanitation, mode of transmission, traditional treatment options, study of environment for presence of snails and water plants, presence of cattle and pigs as well as to look for availability of praziquantel and other anthelminthic drugs in local pharmacies.
The author asked all the persons, who had given the history of passing red fleshy masses in the last 4 weeks including all children of the locality, to collect stool samples. The samples were examined microscopically for the presence of F. buski eggs.
The next visit was planned and the author again visited the village with the recommended drug praziquantel (Distocide). All the individuals who gave the history of passing parasite in their stool, including stool-microscopy-positive, were treated with oral praziquantel (Distocide) 25 mg/kg, three doses a day.
| ~ Results|| |
On the first visit to the village, which had a population of 1,000 people, it was observed that people of different religion and caste lived in different sectors. The sector of the village where the three children belonged comprised 51 families with a total population of 262 individuals [Table 2]. Around 51% of the population was under 14 years of age. Majority of the people were poverty stricken and worked as labourers in farmlands. Some migrated to big cities in different states across the country for work.
According to the anganwadi worker, the disease had been prevailing in the village from the last 4 years. Number of individuals and severity of infections has gradually increased over these years. Maximum number of cases occurred in the post-monsoon period.
Of the 262 individuals, 120 gave history suggestive of fasciolopsiasis. Stool samples of 57 individuals were provided by the members of 51 families, which included at least one child from each family. Of the 57 samples, 55 were found to be positive for presence of F. buski eggs except for two children in the age-group <1 year.
All the 118 persons who gave the history of passing parasite in their stool, including 55 stool-microscopy-positive, were treated with oral praziquantel (Distocide) 25 mg/kg, three doses a day. All the praziquantel recipients passed large number of dead worms in their stool over the next 2-3 days. Most of the children in the age-group 5-14 year passed >300 worms [Figure 3] and [Figure 4]. One hundred and eighteen residents were confirmed as cases of the parasitic infection out of 262 people screened. Praziquantel at recommended dose was tolerated well by children in spite of heavy worm load, but a few complained of vague abdominal pain and bloating. Most of the adults suffered adverse reactions like dizziness, headache and nausea.
|Figure 3: Fleshy adult worms passed in stool by a child after first dose of praziquantel collected on a leaf by mother|
Click here to view
It was a common practice to defecate in open, especially along the banks of ponds, due to lack of in-house toilet facility. It was noted that in the village, cattle and pigs were fed on lotus roots after the harvesting of crop, thereby exposing them to infective metacercariae. Interaction with the villagers revealed their lack of awareness about the parasites' mode of transmission. Majority of children were malnourished due to poverty, as well as due to large parasite load causing malabsorption. Local medical practitioners often asked them to eat snails to increase their nutrition as it was an easily available protein source. This again increased the risk of acquisition of parasites due to lack of proper hand hygiene.
In spite of clear-cut presentation, this disease has not been treated properly by local practitioners. Drugs like albendazole, ivermectin, diloxanide, piperazine were commonly prescribed by local practitioners. But the drug praziquantel was never prescribed by local practitioners. Children are frequently forced by parents to drink kerosene oil to get rid of worms. This puts the children at risk of kerosene poisoning.
The author tried to study the members of families in other sectors of the village, but was faced with stiff resistance and opposition as neither the stool examination nor treatment with praziquantel was accepted by them.
| ~ Discussion|| |
On assessing the risk factors for the transmission of the parasite in the village, it was observed that all the conditions required for effective continuation of the life cycle of the parasite were found in the village. Every year during rainfall, there is flooding of low-lying areas and shallow ponds. Various plants like water caltrop and lotus are cultivated in these ponds. These ponds and paddy fields abound with snails. Snails and lotus tubers are a major source of food for the villagers. These ponds are a site of recreation for children where they also consume raw lotus flower buds, thereby consuming the infective metacercariae [Figure 5].
Till date, various studies from India estimated the prevalence rate of 60% from Assam, 22.4% from Uttar Pradesh and 63% from Maharashtra. ,, In the present study, 45.8% residents of a sector of a village in Bihar was found to be infected with F. buski. The actual prevalence could be more as only symptomatic individuals were included in the study. Highest worm burden was found in children 5-14 year of age due to the high risk practice of eating raw lotus flower buds and tubers, which was also documented in previous studies. ,,
The parasite, owing to its high egg laying capacity (average 16,000 eggs/day)  and high worm load in majority of infected individuals will infect more and more individuals in the locality. Travel and migration of individuals with such heavy worm load in their intestine can easily spread the parasite to other contiguous and far flung areas of the country where conditions may be favourable for transmission. Risk of spread is also due to distribution of aquatic products like water caltrop and chestnut that are contaminated with large number of infective metacercariae due to lack of food inspection facilities in country. And finally, along with other food-borne trematodiases, there is risk for spread to other countries due to increasing travel and consumption of exotic foods. 
Though most of the infections are asymptomatic or with minimal symptoms, there are few case reports from India in recent past with major morbidity like small bowel stricture, intestinal perforation, acute kidney injury and death. ,,, As per anganwadi worker, one of the 11-year-old female who used to pass many worms in her diarrhoeal stool was diagnosed as a case of intestinal tuberculosis on the basis of ultrasound findings of distended bowel loops, fluid collection between gut and pelvis with ascites. This patient was treated with antitubercular drugs for 9 months without any relief and ultimately died probably due to parasites. This is just the tip of iceberg as majority of such cases remain unreported. These individuals are at risk of co-infection by multiple helminths and indeed suffer clinically significant morbidity even at low intensity infections. , Despite the considerable public health impact and the emerging nature of fasciolopsiasis and other food-borne trematodiases, these diseases are among the most neglected of the so-called neglected tropical diseases. 
The patients were followed up by telephonic conversation with anganwadi worker and some parents. They were enquired about clinical features suggestive of infection and passage of worms after 3 months, 6 months, 12 months and 18 months of treatment. Though the first three follow-ups did not reveal any disease activity, but some children have started passing worms again after 18 months.
The control of the disease can be achieved by chemotherapy for human and animals, improved access to adequate sanitation, use of chemical fertilizers, food inspections, destruction of snails and information, education and communication (IEC) campaigns. Further, the ultimate aim must be to change human behaviour, especially children who are at highest risk of acquiring disease. Therefore, to start a campaign to control this disease, we have to change the mind-set of people by consistent educational programmes as experienced in the present study.
Praziquantel is the drug of choice and should be prescribed once the diagnosis is made as other anti-helmintic drugs are less effective.  But this drug was never prescribed by local practitioners, major obstacle seems to be lack of availability of this drug in local pharmacies, as well as ignorance among the local practitioners that might have led to misdiagnosis and mistreatment. This also emphasizes the need of continuing medical education in areas of emerging and re-emerging diseases.
While chemotherapy-based morbidity control should serve as the backbone of the disease control programme, integrated control approach with intersectoral collaboration between public health and veterinary medicine is required.
Major lacuna of our study was that we could not perform stool examination of the animals, especially pigs for their possible role in disease transmission and also could not speciate snails recovered from village.
| ~ Conclusion|| |
present study indicates the existence of endemic focus of F. buski, and considering the intensity of parasite burden in the community, it is time to conduct major epidemiological survey to assess the extent of the burden of the disease in and around this village. There is also an urgent need to start mass chemotherapy for all affected individuals, which needs strong will at all administrative levels to control this neglected disease. At the time when we have come too far in treating major killer diseases, there are still thousands of people suffering from easily treatable diseases like fasciolopsiasis.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]