An outbreak of An outbreak of Schistosomiasis Schistosomiasis

(Bilharzia) infection following (Bilharzia) infection following a school trip to Malawia school trip to Malawi

Scottish Public Health ConferenceScottish Public Health ConferenceNovember 2011November 2011

Ken Oates, Ola Blach, Steven Ken Oates, Ola Blach, Steven Bramwell, Grant FranklinBramwell, Grant Franklin

Case PresentationCase Presentation

• January 2011 , 17 year old male presented January 2011 , 17 year old male presented to urology with dysuria and visible to urology with dysuria and visible haematuriahaematuria

• Cystoscopy – severe inflammation of the Cystoscopy – severe inflammation of the bladder wall around blobs of parasitic eggs bladder wall around blobs of parasitic eggs – Diagnosis of urinary schistosomiasis ( S. – Diagnosis of urinary schistosomiasis ( S. Haematobium)Haematobium)

• History of swimming in Lake Malawi during History of swimming in Lake Malawi during a school trip previous summera school trip previous summer

Initial investigationInitial investigation

• Health Protection team notified by UrologistHealth Protection team notified by Urologist• Contacted Head teacher Secondary School Contacted Head teacher Secondary School

and Education Service Highland Counciland Education Service Highland Council• 21 people on school trip to Malawi in 21 people on school trip to Malawi in

June/July 2010 (17 pupils and 4 staff)June/July 2010 (17 pupils and 4 staff)• Canoeing trip on Lake Malawi (which Canoeing trip on Lake Malawi (which

included some swimming!)included some swimming!)• A full risk assessment was done in A full risk assessment was done in

advance! and school told by the adventure advance! and school told by the adventure company that particular area of the Lake company that particular area of the Lake was free from infection (Cape McLear and was free from infection (Cape McLear and Domwe Island)Domwe Island)

Further investigationFurther investigation

• Contacted all 21 people directly and Contacted all 21 people directly and advised them to have a screening testadvised them to have a screening test

• Arranged for blood tests – serology Arranged for blood tests – serology

• Informed local GPs – provided a Informed local GPs – provided a written briefingwritten briefing

• Agreed a lead local physician to see Agreed a lead local physician to see any positivesany positives

ResultsResults• 21 responded to our letters and saw 21 responded to our letters and saw

their GP or A&E (Glasgow, Dundee their GP or A&E (Glasgow, Dundee and Australia!)and Australia!)

• 21 were screened21 were screened• 13 tested positive for Schistosoma 13 tested positive for Schistosoma

infectioninfection• 2 were symptomatic (index and 1 2 were symptomatic (index and 1

other male)other male)• 11 were asymptomatic11 were asymptomatic

Results 2Results 2

• 10 were referred to Raigmore 10 were referred to Raigmore physicianphysician

• 3 seen by other specialists elsewhere3 seen by other specialists elsewhere

• All 13 treated with 2 doses of All 13 treated with 2 doses of PraziquantelPraziquantel

• All fully recoveredAll fully recovered

Schistosomiasis (Bilharzia)Schistosomiasis (Bilharzia)

• A blood fluke infection with adult male and A blood fluke infection with adult male and female worms living within the mesenteric female worms living within the mesenteric or vesical veins for many years.or vesical veins for many years.

The Illness:The Illness:• Initial infection is often asymptomatic but Initial infection is often asymptomatic but

itching can occur at the site of entry. Two itching can occur at the site of entry. Two to four weeks later fever, diarrhoea, to four weeks later fever, diarrhoea, cough, rash, abdominal pain and cough, rash, abdominal pain and hepato/splenomegaly may develop.hepato/splenomegaly may develop.

Schistosomiasis (Bilharzia)Schistosomiasis (Bilharzia)

3 types:3 types:• S. haematobiumS. haematobium causes haematuria. Long causes haematuria. Long

standing disease may cause ureteric standing disease may cause ureteric obstruction and renal failure. obstruction and renal failure.

• S. mansoniS. mansoni usually presents with anaemia due usually presents with anaemia due to blood loss and sometimes frank rectal to blood loss and sometimes frank rectal bleeding. Complications in long standing bleeding. Complications in long standing infection include diarrhoea, cirrhosis and portal infection include diarrhoea, cirrhosis and portal hypertension. hypertension.

• S. japonicumS. japonicum causes an illness similar to causes an illness similar to S.mansoniS.mansoni but is often more severe. Long term but is often more severe. Long term sequale includes bladder carcinoma, sequale includes bladder carcinoma, hepatosplenomegaly and portal hypertension. hepatosplenomegaly and portal hypertension.

Schistosoma cercariaeSchistosoma cercariae

Shistosoma haematobiumShistosoma haematobium

Schisto cases in ScotlandSchisto cases in Scotland59-84 cases each year between 2005 and 59-84 cases each year between 2005 and 20092009

Schisto and Bladder cancerSchisto and Bladder cancer

• FIGURE . Bladder Cancer: Prevalence of Active Schistosomiasis (AS) by Age and Age Distribution FIGURE . Bladder Cancer: Prevalence of Active Schistosomiasis (AS) by Age and Age Distribution of Bladder Cancer (BC) in Egypt. Ibrahim and Khaled of Bladder Cancer (BC) in Egypt. Ibrahim and Khaled National Cancer InstituteNational Cancer Institute. NIH Pub. No. 06-. NIH Pub. No. 06-5873. Bathesda; MD; 2006.5873. Bathesda; MD; 2006.

DiscussionDiscussion

• High infection rate 13/21 (62%)High infection rate 13/21 (62%)• Even following limited exposureEven following limited exposure• Majority asymptomaticMajority asymptomatic• Other Scottish outbreaks 25-33% Other Scottish outbreaks 25-33%

infectedinfected• Between 2005 and 2009, 23% of Between 2005 and 2009, 23% of

Scotland’s new cases of schisto were Scotland’s new cases of schisto were from freshwater exposure in Malawi. from freshwater exposure in Malawi. ( 42% of these in 15-24 year olds) ( 42% of these in 15-24 year olds)

Discussion 2Discussion 2

• Scotland and Malawi “ Cooperation Scotland and Malawi “ Cooperation Agreement” 2005Agreement” 2005

• Many school trips to MalawiMany school trips to Malawi

• High risk country/areaHigh risk country/area

• Lack of awareness amongst pupils Lack of awareness amongst pupils and staff and schoolsand staff and schools

Actions – local Actions – local

• Highland Council now has a new policy on Highland Council now has a new policy on school trips overseas – “school trips overseas – “HC HC strongly strongly advisesadvises that all staff, pupils and that all staff, pupils and volunteers should avoid direct contact volunteers should avoid direct contact with water in or from Lake Malawiwith water in or from Lake Malawi.”.”

• Also provide advice re screening in those Also provide advice re screening in those who have been exposed and seeking who have been exposed and seeking early help from GP if symptomatic on early help from GP if symptomatic on returnreturn

Travax – Malawi pageTravax – Malawi page

• Advice to travellersAdvice to travellers• Travellers should avoid contact with fresh Travellers should avoid contact with fresh

water in lakes, streams and rivers.  Water water in lakes, streams and rivers.  Water for washing can be treated by heating for washing can be treated by heating water to 50°C for five minutes or leaving to water to 50°C for five minutes or leaving to stand for 48 hours.stand for 48 hours.

• If travellers are concerned that they may If travellers are concerned that they may have been exposed to schistosomiasis, they have been exposed to schistosomiasis, they should seek medical help on their return.should seek medical help on their return.

• Further information can be found on the Further information can be found on the SchistosomiasisSchistosomiasis Page Page..

Travax - Schisto pageTravax - Schisto page

• Recommendations for TravellersRecommendations for Travellers• Avoid skin contact with fresh water in Avoid skin contact with fresh water in

endemic areas e.g. ponds, lakes and rivers. endemic areas e.g. ponds, lakes and rivers. Swim only in protected swimming pools or Swim only in protected swimming pools or safe sea water. Avoid drinking infected safe sea water. Avoid drinking infected water. Wear protective footwear when water. Wear protective footwear when walking in soil, especially if it is damp or walking in soil, especially if it is damp or water logged. Those who have been water logged. Those who have been knowingly exposed can be screened after knowingly exposed can be screened after return but if there are no symptoms this return but if there are no symptoms this should be delayed for 6 weeks after the should be delayed for 6 weeks after the last possible exposure so as to allow the last possible exposure so as to allow the time for the development of antibodies.time for the development of antibodies.

Scotland Malawi PartnershipScotland Malawi PartnershipSwimming• Infection from bilharzia (also known as schistosomiasis)

occurs when travellers paddle, swim or shower in fresh water which has invasive larva. The risk of infection at Cape McLear is about 80%, but other beaches on the west coast of the Lake, and islands also constitute a serious risk. Slow moving rivers and other lakes in Malawi are also infected with this parasite. The risk may still be present in the main beach hotels if shower water is drawn straight from the Lake and not filtered or stored in holding tanks. The snails that are the intermediate hosts are not confined to reedy areas.

Chinteche beach in the north appears safe.

Treatment does not work until the parasite has matured in the body about 3 months after infection and first time treatment is not always successful. If you do swim in the Lake you should apply 50% DEET to all exposed areas after your shower in the evening since this kills the parasites in the skin before they migrate. Hotel pools are also to be avoided as there is uncertainty over chlorination of the water.

Actions – national Actions – national

• HPS TravaxHPS Travax

• Scotland Malawi Partnership national Scotland Malawi Partnership national schools and volunteers guidance will schools and volunteers guidance will be amended shortlybe amended shortly

• PublicationPublication

ReferencesReferences

• 1. An outbreak of Schistosomiasis in travellers returning from endemic areas – the importance of rigorous tracing in peer groups exposed to risk of infection. Journal of Public Health. IN PRESS November 2011.

• 2. Redman C, Spence G, Smith H, Smith K. Travel medicine: Schistosomiasis in Scotland 2005-2009. HPS: Surveillance Report 2010; 44: 24-26.

• 3. Travax www.Travax.nhs.uk• 4. Scotland Malawi Partnership

www.scotland-malawipartnership.org

AcknowledgementsAcknowledgements

• Ola Blach, Stephen Bramwell, Urology Ola Blach, Stephen Bramwell, Urology Dept, Raigmore Hospital, InvernessDept, Raigmore Hospital, Inverness

• Grant Franklin, Dept of Medicine, Grant Franklin, Dept of Medicine,

Raigmore Hospital, InvernessRaigmore Hospital, Inverness

• Scottish Parasite Diagnostic Laboratory Scottish Parasite Diagnostic Laboratory StobhillStobhill

• Health Protection Scotland Travel teamHealth Protection Scotland Travel team

• HP team NHS HighlandHP team NHS Highland