Analysis of Enteric Parasites Found in Refugees in Texas, 2000-2005

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

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

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/photocontest/photos/SP04%20photo%20contest/Newly%20Arrived%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.radiocayman.gov.ky/servlet/page?_pageid=3471&_dad=portal30&_schema=PORTAL30&_mode=3 http://www.irrawaddy.org/aviewer.asp?a=3788&z=9

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

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 A B C D 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 A B C D 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/darfur041213.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

45. Similar Studies

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. 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 Future studies http://www.humanrightsfirst.org/images/refugees/intl_refs/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