Paragonimiasis Reemergence in Nigeria:

Predisposing Factors and Recommendations

for Early Intervention and Everlasting
Eradication
Reginald A. Eke, Udochi M. Nwosu, Ezinne E. Enwereji, and Chima V. Emerole

Presented by:

AVILA, K. | DELA CRUZ, R.G. | GO, D. | LOTERIO, L. | REYES, S. |

SUAREZ, E.

Introducti
on

Paragonimiasis
is a disease caused by an infection of a
number
of
species
of
trematodes
belonging to the genus Paragonimus
(WHO, 2012)
lung fluke disease
food-borne and zoonotic

LIFE CYCLE of
Paragonimus
Mode of
Transmissi
on
Eggs in
sputum or
in stool

Embryonat
ion
Miracidium

First
intermediate
host (snail)
Miracidium

Second
intermediate
host(crabs/crayf
shes)

Sporocyst

Metacercariae

Rediae
Cercariae

Defnitive
host
Ingestion of
metacercari
ae
Adults live
in the lungs

Chin
a

Koreas

Lao
s

Vietna
m

Thailan
d

P. westermani, P. heterotremus, and P. philippinensis in Asia(WHO,

Paragonimiasis

P. africanus and P. uterobilateralis in

western and central Africa (WHO,
2012)

Paragonimiasis

P. uterobilateralis resides in the dog

(Cameroun, mongoose and bush rats
(Liberia), and humans (Nigeria) (Eke,
2012)

Endemicity in Japan

Before 1950:
Endemic in
MiyazakiPrefecture,
Japan

1950-1960:
Mass screening
and Prevention
by Local
Government

1970:
Eradicated and
considered
disease of the
past

Endemicity in Japan
Late 1980s: new cases sporadically
emerged in previously endemic areas

re-

Endemicity in Nigeria

1964:
Recorded to be
endemic

1968-1970:
Civil war
caused the
disease to be a
major public
health concern

1980:
Reported to be
eradicated

Endemicity in Nigeria

1980 - September 2007: no case

reported for treatment

Endemicity in Nigeria

October 2007: re-emergence of

paragonimiasis was reported
January 2011:
5 other cases
reported

Endemicity in Nigeria

Shows similar trends to that of Japans

Goals of the Study

To determine predisposing factors

for re-emergence that would help
formulate
a
long
lasting
and
sustainable eradication plan

Method
s

Sample Population

12 endemic villages along Imo, River Bank

in Onu Imo Local Government Area of Imo
State, Nigeria
River Bank is the breeding place of
crabs with Paragonimus uterobilateralis
metacercariae

Sampling

Cross-sectional study
2760 households in total; 400 selected
using calculation for qualitative value
n=z^2Pq/d^2
Systematic sampling by sampling
interval of 7

Data Collection
household interview with interviewer
administered questionnaire
review of health facilities record books
interactive discussion with health
providers to assess level of awareness
on paragonimiasis (index of suspicion &
lab diagnosis)

Results

Knowledge/Awareness of
Paragonimiasis by Age
Age = significant factor
0% awareness (25-35 y.o.)
Possible reason:
Paragonimiasis was no longer
prevalent when they were
born/young.
Majority of those aware were of
the elderly age group.

Reasons for Eating Crab

Crabs as a Nigerian delicacy

= strongest factor
Crabs are readily available
and affordable - residence
along river bank

Identifed Cultural
Methods for Preparing
Crab
Unsafe cooking practices are
culturally accepted
Raw crab with alcohol
Alternatives to alcohol:
Pepper Sauce
Vinegar

Habit of Washing
Utensils

No washing of utensils more opportunities to

mechanically spread the
metacercariae of
Paragonimus from crabs
to other meals

Cultural Habit of
Disposing Excreta &
Sputum
Unhygienic disposal of
excreta and sputum
implication:
Constant discharge of greater
number of Paragonimus
uterobilateralis eggs into
the environment
Appropriate molluscs may then
become infected.

Knowledge & Awareness

of Health Workers
None of the health workers in the villages were
aware of paragonimiasis.
No suspected or diagnosed case in the health centers since the
eradication exercise in 1980.
All cases of cough and haemoptysis or rusty sputum had been
investigated for a possible of pulmonary tuberculosis or HIV
without the inclusion of paragonimiasis in the differential
diagnosis.

Discussion

Japan

Maruyama, et al. +
Nawa
reported reemergence of
paragonimiasis in areas
where it was previously
eradicated

Reemergence in
Japan

Enwereji + Eke
reported the
reemergence of
paragonimiasis in
Nigeria after almost 30
years

RISK OF SPREAD
*reemergence
elsewhere showed the
circle of transmission is
closed

ID: determinant
factors
contributing to the
reemergence of
paragonimiasis

SUSTAINABLE
ERADICATION PROGRAM

25-45 years old

less knowledgeable about
paragonimiasis mode of
transmission, prevention, and
control than the older age
group of 47 years and above

WHY???
most of them have not been
born at the time of
paragonimiasis eradication in
Nigeria; the few born were about
6 yo and were too young to
comprehend and use the
eradication measures

the breakdown shows that the discontinuation

of preventive and control activities after
eradication contributed to the group being less
apprehensive of paragonimiasis
FACTOR

AGE

FACTOR

crabs
as a delicacy in
custom of eating

Tables 2 and 3 created the

avenue for disease
reemergence

Pseudanautes africanus
an intermediate host of
Paragonimus uterobilateralis

from the research study of Abraham and Akpan, Vectors of Paragonimus uterobilateralis a Causative Fluke for Paragonimiasis in
Cross-River State-Nigeria
retrieved from http://www.ajol.info/index.php/afrrev/article/viewFile/64538/52320

eating crabs RAW also consistent with a previous report by Lucas and Gilles that
infection can occur by eating uncooked crabs and crayfish and also when encysted
cercariae are left on utensils
...as long as the chain of transmission was broken and later become closed,
FACTOR
the disease would certainly reemerge. -Enwereji and Eke

FACTOR

3
Unhygienic habit of

not washing utensils

properly after

preparing crab meals in Table 4 also created another chance of transmitting

metacercariae from crabs to man.
...as long as the chain of transmission was broken and later become closed,
the disease would certainly reemerge. -Enwereji and Eke

FACTOR

Insanitary
Disposal of
excreta and
sputum

Insanitary disposal of excreta

and sputum into the Imo River
and nearby bushes
fecal and sputum pollution of
water - breeding ground of
vectors transmission
maintenance

FACTOR

Lack of
Awareness

lack of awareness amongst

health workers at health centers
caused low level of index of
suspicion
Awareness high index of
suspicion lab confirmatory
tests for possible pulmonary
paragonimiasis cases (cough,
hemoptysis)

Recommendatio
ns
Health education
Health promotion
Provision of better health care services
Surveillance

Health Education

Health authorities and policy makers

how to check the indicators of
reemergence
All people at the village and
community levels
health information on a regular
basis
Diagnostic and treatment facilities
workers
periodic lectures, seminars, and
workshops

Health Promotion

People should be informed about

the consequences of eating
insufficiently cooked or uncooked
crabs as delicacies.
If crabs are the main source of
protein in that area, the government
should find an alternative source
(such as fish).

Health Care
Services

New diagnostic and treatment

procedures
better and more rapid diagnosis
(e.g. ELISA, modified ZiehlNeelsen technique)
avoid misdiagnosis

Surveillance

After complete eradication, routine

disease surveillance system and
notification should be established
AS IF AN ERADICATION PROGRAM IS
BEING IMPLEMENTED
Surveillance (case detection and
monitoring)
Notification (health education and
community mobilization)

In the Philippines
This journal article is a good reference if ever
paragonimiasis is eradicated in the Philippines
The mentioned recommendations may be done
to avoid reemergence of paragonimiasis.

The pre-disposing factors might be helpful in

integrating health promotion in the ongoing
surveillance