1. Analysis of Enteric Parasites Found in Refugees in Texas, 2000-2005 Bethany Dalene Blackstone School of Biological Sciences The University of Texas at Austin Mentors: Jeff Taylor, MPH Katherine Von Alt, M(ASCP)

2. Introduction http://news.bbc.co.uk/2/hi/south_asia/4269507.stm

3. Estimated Worldwide Prevalence of Parasitic Infections InfectionPrevalence Toxoplasmosis1-2 billion Ascaris1 billion Hookworm disease800-900 million Amebiasis200-400 million Schistosomiasis200-300 million Malaria200-300 million Filariasis250 million Giardiasis200 million Pinworm infection60-100 million Strongyloidiasis50-80 million Guinea worm infection20-40 million Trypanosomiasis15-20 million Leishmaniasis1-2 million taken from Table 51-1, Schaechter's Mechanisms of Microbial Disease, fourth edition

4. Overview of Parasitology Parasites: helminths and protozoa  Blood and tissue parasites malaria  Enteric parasites tapeworm  Arthropods A: thick blood smear of malaria; B: T. solium; images from CDC’s DPDx A B

5. Helminths

6. Model Helminth: Trichuris trichiura

7. Protozoa

8. Model Protozoan: Giardia lamblia

9. A Risk for Populations Developing countries Tropics Southern United States Institutional settings (e.g. daycares) Newly arrived persons  Travelers  Immigrants  Refugees http://www.internationalstudies.villanova.edu/students/pho tocontest/photos/SP04%20photo%20contest/Newly%20A rrived%20Refugees%20Peter%20Dweyer,%20Tibet.jpg

10. Refugees Immigration and Nationality Act: person forced to leave home country and unable to return because of persecution Refugees are not  Immigrants  Internally displaced persons http://www.npr.org/templates/story/story.php?storyId=1976090 http://news.bbc.co.uk/2/hi/south_asia/4269507.stm

11. The world as you are used to seeing it http://www.sasi.group.shef.ac.uk/worldmapper/display.php?selected=1

12. Where are refugees commonly from? http://www.sasi.group.shef.ac.uk/worldmapper/display.php?selected=14

13. And where are they going? http://www.sasi.group.shef.ac.uk/worldmapper/display.php?selected=13

14. Resettlement to the United States Pre-departure  health screening Arrival in US  results of screening sent to state health departments Arrival in Texas  screening at refugee clinics http://www.irrawaddy.org/aviewer.asp?a=3788&z=9 http://www.radiocayman.gov.ky/servlet/page?_pageid=347 1&_dad=portal30&_schema=PORTAL30&_mode=3

15. Refugees entering Texas Amarillo Austin Dallas Houston San Antonio Abilene

16. Purpose To analyze the enteric parasites found in refugees entering the state of Texas between 2000 and 2005 Determine prevalence, demographic characteristics http://www.interaction.org/media/photo2005/DR.html

17. Materials and Methods http://www.respecteurope.org/Refugees/tabid/58/Default.aspx

18. Study Population Official refugees entering Texas between January 1, 2000 and December 31, 2005 Database of 14,540 specimen entries Analysis carried out using Access, Excel http://www.respecteurope.org/Refugees/tabid/58/Default.aspx

19. Specimen submission and screening procedure Clinics collect stool samples  Formalin vial  PVA vial Samples sent to Medical Parasitology Section at TDSHS Process, ID, and enter in database

20. Texas Department of State Health Services: Medical Parasitology Section

21. Laboratory Identification Formalin  wet mounts for cysts and trophs PVA  trichrome for ova

22. Helminth ID  A. lumbricoides  C. sinensis  D. latum  E. vermicularis  F. buski/F. hepatica  Hookworm species  H. nana  S. mansoni  S. stercoralis  Taenia species  T. orientalis  T. trichiura  Other eggs AB CD A: A. lumbricoides eggs; B: T. trichiura egg; C: F. buski fluke; D: T. saginata adult; images from CDC’s DPDx

23. Protozoan ID  B. hominis (rare to few, moderate to many)  C. mesnili  C. parvum  C. cayetanensis  D. fragilis  E. nana  E. coli  E. hartmanni  E. histolytica  E. polecki  G. lamblia  I. butschlii  I. belli  T. hominis AB CD A: E. nana cyst; B: E. polecki cyst; C: E. histolytica trophozoite ; D: G. lamblia trophozoites; images from CDC’s DPDx

24. Refugee Databases

25. Demographic Variables  Overall prevalence  Country of origin  Area of origin  Gender  Age  Multiple infections  City of arrival http://www.cbc.ca/world/story/2004/12/13/darf ur041213.html

26. Results http://ec.europa.eu/echo/information/library/refugees/03.htm

27. Countries of Origin for Refugees in Texas

28. Percent of Refugees by Area of Origin

29. Percent of Refugees by Country of Origin

30. Which refugees are going where?

31. Refugees entering Texas…

32. …are not just adults.

41. Conclusions http://saindarfur.org/darfur_photos/albums/uploads/May/2/refugees_food_line_AFP_5_12_05.jpg

42. Conclusions Refugees who entered Texas came from all areas of the world  Africa  Gender  Age http://www.lnsart.com/JachRefugeeCampSudan.jpg

43. Most commonly seen parasites Helminths  H. nana—2.22% (317)  T. trichiura—1.86% (266)  S. mansoni—1.30% (186) Protozoa (pathogens)  G. lamblia—8.99% (1283)  B. hominis (moderate to many)—8.92% (1272)  E. histolytica—5.82% (830)

44. Similar Studies State (author) Texas (current study) California (Garg et al.) Illinois (Peterson et al.) Year Jan 2000- Dec 2005Oct 2001-Jan 2004July 1998-June 1999 Helminths H. nana (2.2%) T. trichiura (1.9%) Hookworm (2%) A. lumbricoides (1.3%) S. stercoralis (1.3%) N/A Protozoa G. lamblia (9.0%) B. hominis (moderate to many) (8.9%) G. lamblia (6%) D. fragilis (3%) N/A

45. Similar Studies State (author) Texas (current study) California (Garg et al.) Illinois (Peterson et al.) Area of Origin Helminths: East Asia (18.3%) Protozoa: Latin America (70.8%) Helminths: South Central Asia (10.8%) Protozoa: Middle East (12.9%) Overall: Middle East (56.5%) Southeast Asia (48.9%) Africa (48.9%) Gender Helminths: males Protozoa: females Both: males Helminths: no association Protozoa: males (p=0.14) N/A Age Helminths: 7  17 Protozoa: 18  34 Both: 7  17 Helminths: no association Protozoa: under age 18 (p=0.01) N/A

46. Statistically Significant Differences  Gender Males: Helminths (p≤0.01) Both helminths and protozoa (p≤0.01) Females: Protozoa (p≤0.025)  Age 7 to 17 years: Helminths (p≤0.001) Both helminths and protozoa (p≤0.001) 18 to 34 years: Protozoa (p≤0.001)

47. Limitations Significant portion of refugee database missing information (e.g. country of origin) Number of specimens not equal to total number of refugees who entered Texas during study period Country of origin may not be country where infection acquired Only reflects data from refugees tested

48. Study Impact Medical clinics across Texas  Refugees  General population http://www.ams.usda.gov/cotton/OfficePages/CO%20images/texas.jpg

49. Future studies Demographic data: ensure that all possible data is gathered from every submission clinic Multiple infections: analyze by specific organisms Transit history: determine more accurate transit history for sample of refugees http://www.humanrightsfirst.org/images/refugees/intl_ref s/intl_ref_1.jpg

50. Acknowledgements Mr. Jeff Taylor Ms. Katherine Von Alt Dr. Leanne Field Ms. Cathy Snider Mr. Stephen Murchison Mr. Sam Householder Ms. Nancy Elder Ms. Sandra Cranek Mr. Jim Schuermann Everyone in TDSHS Infectious Disease Control Unit

51. Questions?