Soil-transmitted helminth infections at very high altitude in Bolivia.

A cross-sectional study of soil-transmitted helminthiases in the Northern Bolivian Altiplano was carried out over the 6-year period 1992-97. Prevalences, intensities and associations were analysed from coprological results obtained in 31 surveys (28 in schools and 3 in individuals of all age-groups) performed in 24 Aymara communities located between the city of La Paz and Lake Titicaca, at an altitude of 3800-4200 m. Ascaris lumbricoides and Trichuris trichiura were detected, with local prevalences in the range 1.2-28.0% and 0.0-24.0%, respectively. Significant differences in prevalence rates of trichuriasis were detected, with highest prevalences in male schoolchildren and in subjects aged > 40 years. The global intensity ranged from 24 to 86,544 eggs per gram of faeces (epg) and from 24 to 4560 epg for ascariasis and trichuriasis, respectively. Higher intensities were noted in girls. A. lumbricoides egg counts were statistically significantly higher in the 5-8-years age-group. A positive association between A. lumbricoides and T. trichiura infections was detected. The proportion of heavy infections for A. lumbricoides was 0.1% and 1.0% in the school and community surveys, respectively. No heavy infection for T. trichiura was detected. The very high altitude and its severe environmental conditions may determine the relatively low prevalences and intensities in this area.

High endemicity of human fascioliasis between Lake Titicaca and La Paz valley, Bolivia.

Over a 6-year period, an epidemiological study of human infection by Fasciola hepatica in the Northern Bolivian Altiplano was carried out. Prevalences and intensities were analysed from coprological results obtained in 31 surveys performed in 24 localities and proved to be the highest known so far. The global prevalence was 15.4%, with local prevalences ranging from 0% to 68.2%. Significant differences between prevalence rates were detected and the highest prevalences were in subjects aged < 20 years. However, prevalences showed no gender difference. The global intensity (eggs per gram of faeces, epg) ranged from 24 to 5064 epg and showed arithmetic and geometric means respectively of 446 and 191 epg, with highest local arithmetic and geometric means of 1345 and 678 epg. Significant differences in mean egg output were detected between localities. The significantly higher F. hepatica egg counts shown by girls in school surveys is worth mentioning. Although the distributions of intensities according to age-groups did not show any significant difference, a decrease of egg output counts with an increase of age was detected. It is concluded that fascioliasis is a very important human health problem in this region.

The Northern Bolivian Altiplano: a region highly endemic for human fascioliasis.

The worldwide importance of human infection by Fasciola hepatica has been recognized in recent years. The endemic region between Lake Titicaca and the valley of La Paz, Bolivia, at 3800-4100 m altitude, presents the highest prevalences and intensities recorded. Large geographical studies involving Lymnaea truncatula snails (malacological, physico-chemical, and botanic studies of 59, 28 and 30 water bodies, respectively, inhabited by lymnaeids; environmental mean temperature studies covering a 40-year period), livestock (5491 cattle) and human coprological surveys (2723 subjects, 2521 of whom were school children) were conducted during 1991-97 to establish the boundaries and distributional characteristics of this endemic Northern Altiplano region. The endemic area covers part of the Los Andes, Ingavi, Omasuyos and Murillo provinces of the La Paz Department. The human endemic zone is stable, isolated and apparently fixed in its present outline, the boundaries being marked by geographical, climatic and soil-water chemical characteristics. The parasite distribution is irregular in the endemic area, the transmission foci being patchily distributed and linked to the presence of appropriate water bodies. Prevalences in school children are related to snail population distribution and extent. Altiplanic lymnaeids mainly inhabit permanent water bodies, which enables parasite transmission during the whole year. A confluence of several factors mitigates the negative effects of the high altitude.

Short report: Diagnosis of human fascioliasis: detection of anti-cathepsin L antibodies in blood samples collected on filter paper.

We have developed an ELISA for the diagnosis of human fascioliasis based on the detection of IgG4 antibodies to Fasciola hepatica cathepsin LI cysteine protease. Use of this assay in the Bolivian Altiplano, a region with a high prevalence of the disease, was hampered by the reluctance of the indigenous population to provide blood. To overcome this problem, we have investigated the method of collecting small quantities of blood from the finger onto filter paper, followed by the elution of antibodies for use in the diagnostic assay. Serum samples and blood samples collected onto filter paper were obtained from 57 individuals living in the village of Cutusuma in 1987 and from 11 individuals in Chijipata in 1996. Analysis of the IgG4-ELISA results revealed that there is highly significant linear relationship (P < 0.001) between the two methods of sampling. Most importantly, a reliable diagnosis was made with the blood-filter samples from Cutusuma, which had been stored for 10 years at 40 degrees C. While some deterioration of the blood-filter samples from Cutusuma had occurred over the 10-year storage period, no deterioration occurred with the Chijipata samples, which were stored for one year. Therefore, the method of collecting blood onto filter paper should prove useful for large-scale epidemiologic studies on human fascioliasis in the Bolivian Altiplano and in other regions where this disease is prevalent.

Analysis of climatic data and forecast indices for human fascioliasis at very high altitude.

Human infection with Fasciola hepatica has recently been recognized as an important health problem worldwide, and particularly at very high altitudes in South America. The highest prevalences and intensities of human fascioliasis known are those of the northern Bolivian Altiplano, where infected Lymnaea truncatula occur at altitudes of 3800-4100 m. In the present study, the climatic data for this area of the Altiplano, which differ markedly from those of endemic areas in the lowlands, were analysed. There is no marked seasonality in temperature but there are large variations in temperature within a daily, 24-h period. Rainfall is seasonal, with a long dry season, coinciding with the lowest minimum temperatures, and a long wet season. The rate of evapotranspiration is very high, and temporary water bodies dry out very quickly. Solar radiation at ground level is intense, not only because of the altitude but also because of the lack of trees and shrubs. Two climatic indices for forecasting fascioliasis, Mt and Wb-bs, were calculated. Modifications in these forecast indices are proposed, to reflect the environment at high altitude and low latitude. Estimates, based on climadiagrammes, of the durations of the wet and dry seasons were greatly effected by the inclusion of an aridity-index modification. The usefulness of the modified indices was examined using prevalence data for human and cattle fascioliasis collected in the neighbourhoods of the stations providing the meteorological data. Values for both indices indicated that conditions were optimum for transmission between December and March. The results were statistically significant for the modified Wb-bs index when the data for a meteorological station in which no lymnaeids were found were excluded. The modified Mt index did not appear sufficiently accurate to be useful. The values for the modified Wb-bs index permitted the study areas to be designated low-, moderate- or high-risk areas for the transmission of fascioliasis to man and domestic animals.

Immunodiagnosis of Fasciola hepatica infection (fascioliasis) in a human population in the Bolivian Altiplano using purified cathepsin L cysteine proteinase.

Cathepsin L1 (CL1), an immunogenic cysteine proteinase secreted by juvenile and adult Fasciola hepatica, was assessed for its potential as a diagnostic agent for the serologic detection of human fascioliasis. Using ELISAs, we compared the ability of liver fluke homogenates (LFH), excretory/secretory (ES) products, and CL1 to discriminate between seropositive (infected) and seronegative (noninfected) individuals within a population of 95 patients from the Bolivian Altiplano. A high prevalence of human fascioliasis has been reported in this region. The division between the seropositive and seronegative individuals was poorly defined when LFH was used as the antigen. A greater discrimination between these populations was achieved with both ES and CL1. A K-means cluster analysis using the combined ES and CL1 ELISA data identified a cluster of seropositive individuals. Cathepsin L1 detected a subset (20) of these seropositive individuals while ES detected all 26; however, ES detected nine additional individuals that were in the seronegative cluster. The ratio of the mean absorbance readings between seropositive and seronegative individuals was markedly improved by using conjugated second antibodies to IgG4, the predominant isotype elicited by infection. In these IgG4-ELISAs, CL1 again identified fewer individuals as seropositive than did ES, but improved the discrimination between the seropositive and seronegative individuals and thus provided a more conclusive diagnosis. Sera obtained from patients infected with schistosomiasis mansoni, cysticercosis, hydatidosis, and Chagas' disease were negative in these assays, which demonstrated the specificity of the IgG4-ELISA for detecting fascioliasis. Twenty of the 95 patients (21%) were seropositive for fascioliasis by the CL1 IgG4-ELISA, confirming the earlier reports of the high prevalence of disease in this region. A standardized diagnostic test for human fascioliasis, based on an ELISA that detects IgG4 responses to CL1, could be available to all diagnostic centers if sufficient quantities of recombinant CL1 can be produced.

High Cryptosporidium prevalences in healthy Aymara children from the northern Bolivian Altiplano.

The prevalence of Cryptosporidium infection was determined in four Aymara communities in the Bolivian Altiplano, between the city of La Paz and Lake Titicaca, at an altitude of 3,800-4,200 meters. Single stool specimens were randomly collected from 377 5-19-year-old students, all apparently asymptomatic. The total prevalence (31.6%) is possibly the highest reported among healthy humans (a maximum of 9.8% and 2.0% in coprologic surveys in underdeveloped and developed countries, respectively) and one of the highest even in symptomatic subjects. No significant age and sex differences were observed. Such an infection prevalence is probably related to the poor sanitation conditions, contaminated water supplies, overcrowding, and close contact with domestic animals. Continuous exposure to the parasite could be associated with protection against parasite-related symptoms in the children examined.

Balantidiasis in Aymara children from the northern Bolivian Altiplano.

Balantidium coli infection was coprologically studied in 2,124 Aymara children 5-19 years of age from the schools of 22 communities of the northern Bolivian Altiplano over a five-year period. Infection with B. coli was found in 11 of the communities surveyed, with prevalences of 1.0-5.3% (overall prevalence=1.2%). The prevalences observed are some of the highest reported and did not differ significantly among the various age groups or between boys and girls. These prevalences, the apparent absence of symptoms or signs of illness due to this parasite in the schoolchildren surveyed at the time of stool sampling, and the consistency of stool samples of the infected students suggest that they are apparently asymptomatic carriers. Infection with B. coli must be considered as an endemic anthropozoonosis in the area studied. A relationship between B. coli infection and Altiplanic pigs is suggested.

A population-based coprological study of human fascioliasis in a hyperendemic area of the Bolivian Altiplano.

The community of Chijipata Alta, at an altitude of 3850 m, near the southern coast of Lake Titicaca in the northern Altiplano of Bolivia, was surveyed for human fascioliasis. The global prevalence (66.7%) and intensity (eggs per gram of faeces--epg: range: 24-4440; arithmetic mean: 1001; geometric mean: 390) proved to be the highest known in the world by means of coprological techniques. These results suggest the existence of highly hyperendemic subzones among the large human fascioliasis-endemic zone of the Bolivian northern Altiplano. Despite the decrease in prevalence and intensity from children (75.0%, 24-4440 epg) to adults (41.7%, 144-864 epg), our findings show that in an hyperendemic zone adult subjects either maintain the parasites acquired when young or are newly infected as the consequence of inhabiting a zone of high infection risk.

Presence of very high prevalence and intensity of infection with Fasciola hepatica among Aymara children from the Northern Bolivian Altiplano.

Coprological studies of school children from four communities in the Northern Bolivian Altiplano were carried out in order to estimate the prevalences and intensities of Fasciola hepatica infection. Single stool specimens were collected at random from 558 school children (308 boys and 250 girls) aged 5-19 years old. Nineteen different parasite species (13 protozoan and six helminths) were detected. Of the children examined, 98.7% (96.5-100%) presented infection with at least one parasite species. The mean prevalence of 27.6% by Fasciola hepatica (range, 5.9-38.2%) was the highest not only with respect to the helminth species found in the Northern Bolivian Altiplano but also among the fasciolosis prevalences reported in children in other parts of the world to date. Prevalences were significantly different among the communities surveyed and was significantly higher in the 9-12 years age group. There were, however, no significant differences between sexes. Among the 154 children presenting F. hepatica eggs in stools, intensities ranged from 24-5064 eggs per gram of faeces (epg), with arithmetic and geometric means of 474 and 201 epg, respectively. Significant differences in mean egg output were detected between communities, sexes and age groups. Individual fasciolosis infections coexisting with other pathogenic parasite species (Entamoeba histolytica and/or E. dispar, Giardia intestinalis, Balantidium coli, Dientamoeba fragilis, Cryptosporidium sp., Hymenolepis nana, Taenia spp., Trichuris trichiura, Ascaris lumbricoides and Enterobius vermicularis) were detected. A significant positive association with F. hepatica was only found in the case of G. intestinalis. This coprological study not only verifies the existence of high prevalences of F. hepatica among humans in the Northern Bolivian Altiplano, but also demonstrates the need to expand the Southern boundaries of this high endemic zone to include the Southeastern region of Lake Titicaca.

Phylogeography and genetic divergence of some lymnaeid snails, intermediate hosts of human and animal fascioliasis with special reference to lymnaeids from the Bolivian Altiplano.

A population genetic study using starch gel electrophoresis was performed on populations of several species of lymnaeid snails acting as intermediate hosts for Fasciola hepatica (Trematoda, Plathyhelminth). Lymnaea viatrix was collected in 16 sites from the Bolivian Northern Altiplano. L. cubensis were obtained in one site from Venezuela, one site from Guadeloupe, three sites from Cuba and one site from the Dominican Republic. L. truncatula were collected in one site from France, one from Portugal and one from Morocco. Multilocus enzyme electrophoresis (MEE) were determined for 282 snails at 18 loci. A complete monomorphism was encountered at each geographic site. However, among these 18 loci, 13 are polymorphic and low and high levels of genetic divergence were observed between samples. Two genotypic groups can be differentiated by their multilocus genotypes. The western genotypic group associates together samples from Venezuela, Guadeloupe, Cuba and Dominican Republic (L. cubensis) while samples from France, Portugal and Morocco (L. truncatula) belong to the eastern genotypic group. Surprisingly, the Northern Bolivian Altiplano populations (L. viatrix) do not present any genetic divergence with the Portuguese sample. Therefore, the Bolivian snails belong entirely to the eastern genetic group. Within each group slight genetic divergences were observed. These results strongly support the European origin of the lymnaeid snails from the Northern Bolivian Altiplano.