An outbreak of Schistosomiasis (Bilharzia) infection following a school trip to Malawi Scottish Public Health Conference November 2011 Ken Oates, Ola Blach, Steven Bramwell, Grant Franklin

Case Presentation January 2011, 17 year old male presented to urology with dysuria and visible haematuria January 2011, 17 year old male presented to urology with dysuria and visible haematuria Cystoscopy – severe inflammation of the bladder wall around blobs of parasitic eggs – Diagnosis of urinary schistosomiasis ( S. Haematobium) Cystoscopy – severe inflammation of the bladder wall around blobs of parasitic eggs – Diagnosis of urinary schistosomiasis ( S. Haematobium) History of swimming in Lake Malawi during a school trip previous summer History of swimming in Lake Malawi during a school trip previous summer

Initial investigation Health Protection team notified by Urologist Health Protection team notified by Urologist Contacted Head teacher Secondary School and Education Service Highland Council Contacted Head teacher Secondary School and Education Service Highland Council 21 people on school trip to Malawi in June/July 2010 (17 pupils and 4 staff) 21 people on school trip to Malawi in June/July 2010 (17 pupils and 4 staff) Canoeing trip on Lake Malawi (which included some swimming!) Canoeing trip on Lake Malawi (which included some swimming!) A full risk assessment was done in advance! and school told by the adventure company that particular area of the Lake was free from infection (Cape McLear and Domwe Island) A full risk assessment was done in advance! and school told by the adventure company that particular area of the Lake was free from infection (Cape McLear and Domwe Island)

Further investigation Contacted all 21 people directly and advised them to have a screening test Contacted all 21 people directly and advised them to have a screening test Arranged for blood tests – serology Arranged for blood tests – serology Informed local GPs – provided a written briefing Informed local GPs – provided a written briefing Agreed a lead local physician to see any positives Agreed a lead local physician to see any positives

Results 21 responded to our letters and saw their GP or A&E (Glasgow, Dundee and Australia!) 21 responded to our letters and saw their GP or A&E (Glasgow, Dundee and Australia!) 21 were screened 21 were screened 13 tested positive for Schistosoma infection 13 tested positive for Schistosoma infection 2 were symptomatic (index and 1 other male) 2 were symptomatic (index and 1 other male) 11 were asymptomatic 11 were asymptomatic

Results 2 10 were referred to Raigmore physician 10 were referred to Raigmore physician 3 seen by other specialists elsewhere 3 seen by other specialists elsewhere All 13 treated with 2 doses of Praziquantel All 13 treated with 2 doses of Praziquantel All fully recovered All fully recovered

Schistosomiasis (Bilharzia) A blood fluke infection with adult male and female worms living within the mesenteric or vesical veins for many years. A blood fluke infection with adult male and female worms living within the mesenteric or vesical veins for many years. The Illness: Initial infection is often asymptomatic but itching can occur at the site of entry. Two to four weeks later fever, diarrhoea, cough, rash, abdominal pain and hepato/splenomegaly may develop. Initial infection is often asymptomatic but itching can occur at the site of entry. Two to four weeks later fever, diarrhoea, cough, rash, abdominal pain and hepato/splenomegaly may develop.

Schistosomiasis (Bilharzia) 3 types: S. haematobium causes haematuria. Long standing disease may cause ureteric obstruction and renal failure. S. haematobium causes haematuria. Long standing disease may cause ureteric obstruction and renal failure. S. mansoni usually presents with anaemia due to blood loss and sometimes frank rectal bleeding. Complications in long standing infection include diarrhoea, cirrhosis and portal hypertension. S. mansoni usually presents with anaemia due to blood loss and sometimes frank rectal bleeding. Complications in long standing infection include diarrhoea, cirrhosis and portal hypertension. S. japonicum causes an illness similar to S.mansoni but is often more severe. Long term sequale includes bladder carcinoma, hepatosplenomegaly and portal hypertension. S. japonicum causes an illness similar to S.mansoni but is often more severe. Long term sequale includes bladder carcinoma, hepatosplenomegaly and portal hypertension.

Schistosoma cercariae

Shistosoma haematobium

Schisto cases in Scotland cases each year between 2005 and 2009

Schisto and Bladder cancer FIGURE. Bladder Cancer: Prevalence of Active Schistosomiasis (AS) by Age and Age Distribution of Bladder Cancer (BC) in Egypt. Ibrahim and Khaled National Cancer Institute. NIH Pub. No Bathesda; MD; FIGURE. Bladder Cancer: Prevalence of Active Schistosomiasis (AS) by Age and Age Distribution of Bladder Cancer (BC) in Egypt. Ibrahim and Khaled National Cancer Institute. NIH Pub. No Bathesda; MD; 2006.

Discussion High infection rate 13/21 (62%) High infection rate 13/21 (62%) Even following limited exposure Even following limited exposure Majority asymptomatic Majority asymptomatic Other Scottish outbreaks 25-33% infected Other Scottish outbreaks 25-33% infected Between 2005 and 2009, 23% of Scotland’s new cases of schisto were from freshwater exposure in Malawi. ( 42% of these in year olds) Between 2005 and 2009, 23% of Scotland’s new cases of schisto were from freshwater exposure in Malawi. ( 42% of these in year olds)

Discussion 2 Scotland and Malawi “ Cooperation Agreement” 2005 Scotland and Malawi “ Cooperation Agreement” 2005 Many school trips to Malawi Many school trips to Malawi High risk country/area High risk country/area Lack of awareness amongst pupils and staff and schools Lack of awareness amongst pupils and staff and schools

Actions – local Highland Council now has a new policy on school trips overseas – “HC strongly advises that all staff, pupils and volunteers should avoid direct contact with water in or from Lake Malawi.” Highland Council now has a new policy on school trips overseas – “HC strongly advises that all staff, pupils and volunteers should avoid direct contact with water in or from Lake Malawi.” Also provide advice re screening in those who have been exposed and seeking early help from GP if symptomatic on return Also provide advice re screening in those who have been exposed and seeking early help from GP if symptomatic on return

Travax – Malawi page Advice to travellers Advice to travellers Travellers should avoid contact with fresh water in lakes, streams and rivers. Water for washing can be treated by heating water to 50°C for five minutes or leaving to stand for 48 hours. Travellers should avoid contact with fresh water in lakes, streams and rivers. Water for washing can be treated by heating water to 50°C for five minutes or leaving to stand for 48 hours. If travellers are concerned that they may have been exposed to schistosomiasis, they should seek medical help on their return. If travellers are concerned that they may have been exposed to schistosomiasis, they should seek medical help on their return. Further information can be found on the Schistosomiasis Page. Further information can be found on the Schistosomiasis Page. Schistosomiasis Page Schistosomiasis Page

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

Scotland Malawi Partnership Swimming 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 HPS Travax HPS Travax Scotland Malawi Partnership national schools and volunteers guidance will be amended shortly Scotland Malawi Partnership national schools and volunteers guidance will be amended shortly Publication Publication

References 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 Redman C, Spence G, Smith H, Smith K. Travel medicine: Schistosomiasis in Scotland HPS: Surveillance Report 2010; 44: Travax 4. Scotland Malawi Partnership

Acknowledgements Ola Blach, Stephen Bramwell, Urology Dept, Raigmore Hospital, Inverness Ola Blach, Stephen Bramwell, Urology Dept, Raigmore Hospital, Inverness Grant Franklin, Dept of Medicine, Grant Franklin, Dept of Medicine, Raigmore Hospital, Inverness Scottish Parasite Diagnostic Laboratory Stobhill Scottish Parasite Diagnostic Laboratory Stobhill Health Protection Scotland Travel team Health Protection Scotland Travel team HP team NHS Highland HP team NHS Highland