Information about Bilharzia

Transcription

1 FREQUENTLY-ASKED QUESTIONS BILHARZIA subsequent to bathing in South Corsica (Version last updated: 16 June 2014) Information about Bilharzia The current situation in South Corsica and action taken by the health authorities Healthcare recommendations for exposed persons Treatment for Bilharzia Recommendations for preventing Bilharzia Information about Bilharzia What is Bilharzia? Bilharzia (also known as schistosomiosis) is human disease caused by flatworms called Schistosomes. Schistosomes are parasites that live and develop in stagnant freshwater environments with little to no current (rivers, lakes, ponds, etc.). Several species are pathogenic to humans (Sch Haematobium, Sch mansoni and sch japonicum.). Several cases of uro-genital Bilharzia were reported in late April 2014 in people who had bathed in the Cavu River, in South Corsica, between 2011 and What is a parasite? A parasite is a living organism, animal or plant, which lives some or all of its life at the expense of another living organism, known as the host, which may be an animal, plant or human. The parasite depends on the host organism for shelter, food (tissues, blood or actual food) and reproductive ability. It lives under the skin or in the intestines, vessels, liver, kidneys, etc. of the host, causing damage and leading to what is referred to as a parasite disease (parasitosis). Examples of parasites include taenia, liver fluke, etc. What is the life cycle of the disease caused by Schistosoma haematobium? The eggs of mature worms laid in contaminated persons are passed out in the urine and thus contaminate the water. The eggs develop in an intermediate host mollusc, the Bulin snail, for a period of 4 weeks, and release larvae, furcocercous cercaria, into the freshwater. The larvae are 0.5 mm in length, move underwater and enter the human body through the skin upon even the briefest contact. Once inside the human body, the larvae reach maturity, mate and migrate into the vessels around the bladder, where the females lay their eggs from the 2 nd or 3 rd month following infection. When a contaminated person passes these eggs out through the urine and into the freshwater, given conducive temperatures, the eggs hatch and 1

2 release larvae that infest the Bulin snails, thus starting a new cycle of Bilharzia transmission. Contamination takes place most frequently during professional or recreational activities in freshwater (farming, fishing, bathing, canoeing, rafting, etc.). The worms longevity can exceed ten years. What are some signs of the disease? Bilharzia can occur in different forms, depending on the parasite species that caused it. The symptoms of S. haematobium include, during the invasion stage (worm migration), allergic reactions (fever, rash, cough) and during the stationary stage, the formation of granuloma that generate chronic lesions, which in turn cause urinary and genital symptoms. The infection can go unnoticed and spontaneous healing is sometimes possible. Complications can occur thereafter (where no treatment is adopted), to varying degrees of severity, in the urinary tract: bladder wall fibrosis, narrowing of the urinary tract, superinfection, gallstones, renal failure and, sometimes, in a subsequent stage, bladder cancer. The genital system can also be affected (infertility, sterility). Is Bilharzia dangerous? Bilharzia is a treatable disease. complications in the long term. However, if left untreated, it can lead to severe Can humans pass on Bilharzia? Bilharzia cannot be transmitted directly from human to human. In order for transmission to occur, the parasite must be passed from mollusc to human. However, an infected person can contaminate a freshwater source by excreting eggs during urination (in the urine) and thus indirectly transmit the disease to people in contact with the water. I am pregnant and have been diagnosed with Bilharzia. Can I transmit it to my infant? No, Bilharzia is not a maternal-foetal infection. Is there a vaccine to prevent Bilharzia? No vaccine is available to date. Is there medication to treat Bilharzia? Yes, there is effective, well-tolerated treatment, administrable in a single dose, which effectively treats the parasitosis. Can Bilharzia medication be taken preventively? No, the recommended treatment should not be taken unless the disease has been confirmed by biological tests. Furthermore, it should not be started until the stationary stage, meaning 2 months after the latest presumed contaminating contact with water, as it is active only when the parasite has reached maturity. In which regions of the world is Bilharzia found? Bilharzia is the world s second most common parasitic disease and is found in tropical and inter-tropical zones. For more information, see the WHO web site: WHO Fact Sheets: Bilharzia 2

3 The Current Situation in South Corsica and Action Taken by the Health Authorities What is the current situation in South Corsica? In late-april, cases of Bilharzia were reported to the Health Authorities, involving people who had bathed in the Cavu River, in South Corsica, near Porto Vecchio, between 2011 and What action have the Health Authorities taken? The French Directorate General for Health (DGS) ordered the French High Council for Public Health (HCSP) and the French Agency for Food, Environmental and Occupational Health Safety (ANSES) to assess the risks connected with the infection and issue recommendations on how to respond to address exposed populations. Concurrent to this, the Corsican Regional Health Agency (ARS) informed the elected officials, local authorities and local healthcare professionals of the situation. Furthermore, investigations were initiated and continue presently, in order to determine whether other fresh waterways or water bodies have been contaminated. The HCSP issued an opinion and recommended that individuals having been in contact with the waters of the Cavu River in South Corsica between 2011 and 2013 during the period from June to September, even briefly, should see their doctor for possible diagnosis. The Ministry of Health further recommends that the population refrain from passing on excrement (urine, faeces) in the rivers, ponds, lakes and other fresh waterways/bodies, in order to prevent them from becoming contaminated. Measures have been taken locally to prohibit bathing in the Cavu River. Is there a way to destroy the molluscs responsible for Bilharzia in the Cavu River? What are the health authorities doing to prevent them from being proliferated? The fight against these molluscs is difficult as it can jeopardise the river s ecosystem; the molluscicides also affect fish. The molluscs are roving vectors and their habitat is constantly changing. An audit has been requested from the French Agency for Food, Environmental and Occupational Health Safety (ANSES) to determine the most appropriate response measures. Could other waterways be invested? In order to become infested, freshwater must: contain Bulin snails, contain schistosomes, sustain a specific temperature, show specific water salinity, ph levels, etc. To date, only the Cavu River has been identified as carrying a risk of Bilharzia transmission. Investigations are being carried out presently by specialised scientific teams to identify possible risks of infestation in other waterways. Have cases of Bilharzia been identified in other European countries? For the latest information about the number of cases in France and abroad, see the INVS or ECDC websites. 3

4 Healthcare recommendations for exposed persons Do I need to see my primary care physician for a check-up? If you have been exposed, meaning have had even brief skin contact with the waters (bathing, dipping a limb, etc.) of the Cavu River in South Corsica (near Porto-Vecchio) between 2011 and 2013 during the period from June to September, you should see your primary care physician. Exposed persons should see their primary care physician even if no emergency circumstances apply, as complications arise only in the long term. Bilharzia can be diagnosed using a blood sample alone. Exposed persons also showing symptoms (difficulty urinating, blood in the urine, etc.) and/or repeated contact with the waters of the Cavu River, during professional or recreational activity, should promptly see their primary care physician. What is the risk period for people who have been in contact with water from the Cavu River? The risk period lies between 2011 and 2013, from June to September. This is because the parasite can only survive when the water temperature has reached an adequate level. Do I need to promptly see my primary care physician? Exposed persons also showing symptoms (difficulty urinating, blood in urine, etc.) and/or repeated contact with the waters of the Cavu River, during professional or recreational activity, should promptly see their primary care physician. Which groups may have repeatedly been in contact with the waters of the Cavu River during the risk period? The groups include: - people adults and children who have been in contact with the waters of the Cavu River during recreation and bathing, for an extended or repeated period (while engaging in water sports, for instance); - those supervising or leading nautical, water or touristic sporting activities (canyoning, rafting, water trekking, etc.) or summer camps, outdoor recreation centres, recreational centres and ecological school trips, etc. - or other professionals: growers, freshwater fishermen, staff members of structures or administrative offices frequently in contact with water (maintenance workers at irrigation channels, water quality monitoring teams, etc.) How is urogenital bilharzia diagnosed? Uro-genital Bilharzia can be diagnosed on the basis of blood sample analysis alone. Are the Bilharzia diagnosis examinations reimbursed by French Public Health Insurance? Medical biology analyses are covered by the French Public Health Insurance system and supplementary coverage providers. 4

5 I was in contact with the waters of the Cavu River during the risk period, have trouble urinating and have blood in my urine. I am worried. Is it urgent that I seek diagnosis? Yes. Exposed persons also showing symptoms (difficulty urinating, blood in urine, etc.) and/or repeated contact with the waters of the Cavu River between June and September should promptly see their attending physician. I bathed in the Cavu River during the risk period, but have experienced no symptoms since that time. Do I need to seek diagnosis? In most cases, Bilharzia is asymptomatic, meaning that it does not cause any signs to appear. If you have had even brief skin contact with the waters of the Cavu River in South Corsica during the risk period, you should see your primary care physician, regardless of whether you have symptoms. You should promptly see your physician if you have repeatedly been in contact with the waters of the Cavu River (see question, Which groups may have repeatedly been in contact with the waters of the Cavu River? ). Otherwise, you should notify your primary physician, but do not need to do so urgently, in that complications arise only in the long term. I work near the Cavu River. Do I need to see my primary care physician? If, due to your profession, you were repeatedly in contact with the waters of the Cavu River between 2011 and 2013 during the period from June to September, you should promptly see your primary care physician, even if you are not showing any symptoms. I went canoe-kayaking/canyoning/rafting/water trekking in the Cavu between 2011 and Do I need to see my primary care physician? People having engaged in water activities on a one-time basis (canoekayaking/canyoning/rafting/water trekking, etc.) in the waters of the Cavu River between 2011 and 2013 during the period from June to September, should see their primary care physician, but do not need to seek diagnosis urgently. The professionals in charge of such activities or those engaging in them in the Cavu River on a regular and repeated basis should promptly see their primary care physician. I live in the Porto-Vecchio Region and have always bathed in the Cavu. Do I need to see my primary care physician? You should see your primary care physician only if you have had skin contact, even briefly, with the waters of the Cavu River between 2011 and 2013 during the period from June to September. I bathed in the Cavu with my children during the risk period. Are my children in danger? You should seek the opinion of your primary care physician for your children and yourself. Should Bilharzia be diagnosed, your physician will prescribe treatment for the disease. Effective, well-tolerated treatment is available. It prevents risk of further disease complications and will be prescribed to you by your physician based on the results of your blood tests. It is an anti-parasite treatment to be taken orally and is administered in a single dose. I bathed in the Cavu before 1 June Do I need to see my primary care physician? No. This alert does not apply to you. You should seek diagnosis of Bilharzia from your primary care physician only if you have had skin contact, even briefly, with the waters of the Cavu River between 2011 and 2013 during the period from June to September. 5

6 I did not fully immerse in the Cavu during the risk period; I only dipped my feet in. Do I need to see my primary care physician? Yes. Only a few minutes of contact with the water are enough to contract the infection. Regardless of the part of your body that came in contact with the Cavu River during the risk period, you need to see your primary care physician. I was not in contact with the waters of the Cavu, but show symptoms similar to those of Bilharzia. Do I need to see my primary care physician? You may see your primary care physician if you are sick to discuss your symptoms. Your physician will establish an appropriate analysis of your individual situation. I bathed in the Cavu River between 2011 and 2013, but only after 30 September. Do I need to see my primary care physician? No. This alert does not apply to you, in that you bathed during a non-exposure period. Could I have been contaminated while picking up an object that fell into the Cavu River during the risk period? If you have had even brief skin contact with the waters of the Cavu River in South Corsica between 2011 and 2013 during the period from June to September, you should see your primary care physician. I did not bathe in the Cavu, but drank water from the river during the risk period. Do I need to see my primary care physician? Yes. If you have had even brief skin contact with the waters of the Cavu River in South Corsica between 2011 and 2013 during the period from June to September, you should see your primary care physician Does exposure to the infection depend on the time of day at which bathing took place? Do I need to see my primary care physician if I bathed in the Cavu only at night? If you were in contact with the waters of the Cavu River during the risk period, you should see your primary care physician, regardless of the time of day you were in contact with the waters. I spend my holidays in South Corsica, but near a river other than the Cavu. Is this river contaminated? Do I need to see my primary care physician? No. Only the Cavu River shows risk of Bilharzia transmission to date. Investigations have been initiated and continue today to determine whether other freshwater waterways or bodies may have been contaminated. For the time being, none have been identified. These health recommendations therefore do not apply to you. I bathed in a swimming pool in South Corsica during the risk period. Could I have been contaminated? No. Bathing in chlorine pools does not hold any risk of Bilharzia transmission. These health recommendations therefore do not apply to you. I bathed in the sea in South Corsica during the risk period. Could I have been contaminated? No. Sea bathing does not hold any risk of Bilharzia transmission. These health recommendations therefore do not apply to you. I contracted Bilharzia during a stay abroad and was treated upon returning to France. Should I see my primary care physician again if I was in contact with the Cavu River during the risk period? 6

7 Yes, you should see your primary care physician, as repeat infection is possible, even following Bilharzia treatment. If you have had even brief skin contact with the waters of the Cavu River in South Corsica between 2011 and 2013 during the period from June to September, you should see your primary care physician. I heard that Bilharzia was very common in certain regions of the world. I bathed in freshwaters during a stay in a country with high transmission risk. Do I need to see my primary care physician? These health recommendations do not apply to you. You may nonetheless see your physician, who will be able to diagnose your exact situation. 7

8 Treatment for Bilharzia Is medication available to treat Bilharzia? Yes, effective, well-tolerated treatment is available. It prevents risk of further disease complications and will be prescribed to you by your physician based on the results of your blood test. It is an anti-parasite treatment to be taken orally and is administered in a single dose. Should I be worried if my diagnostic test comes out positive, showing that I have been infected for years without knowing it? If your test comes out positive, your physician will prescribe you anti-parasite treatment which you will take orally. The treatment is effective and well-tolerated. If necessary, additional exams may be carried out to look for further complications. Is Bilharzia treatment eligible for reimbursement by the French Public Health Insurance system? Yes, treatment is reimbursed by the French Public Health Insurance system. Can Bilharzia treatment be taken even when no diagnosis has been made? Bilharzia treatment cannot be prescribed unless biological tests have confirmed the diagnosis. It is not recommended except during parasite invasion stages, meaning 8 weeks after presumed contact with the water. Is Bilharzia medication preventive? No. The treatment is only effective on mature parasites. It thus has no effect during the invasion phase or on the eggs. Is Bilharzia treatment hazardous? No. The treatment is generally well-tolerated and is subject to only a small number of counter-indications. Your physician will advise you based on your exact situation. Seek the opinion of your physician or pharmacist. Will enough medication be available if it turns out that a large number of people have been infected? The health authorities have taken the action necessary to provide for the needs of all individuals possibly contaminated with Bilharzia during contact with the waters of the Cavu. The French Agency for Drug and Healthcare Product Safety (ANSM) has adopted contingency measures to guarantee that medication will be available in adequate quantities. 8

9 Recommendations for Preventing Bilharzia How can I protect myself from the disease if residing in or visiting Corsica? It is vital that you avoid any contact with the waters of the Cavu River. Do not bathe in the river, even briefly; do not dip any part of your body in the water. There is no way to protect from the disease, whether by vaccine or preventive medication. Should I avoid contact with waters from rivers other than the Cavu, in France? How can I find out whether other bodies of water or waterways have been infested? To date, only the Cavu River has been identified as carrying a risk of Bilharzia transmission. You may bathe or engage in recreational, sporting or professional activities in all other rivers in France. Should the health authorities identify other contaminated bodies of water or waterways, the population will be informed and further preventive and diagnostic recommendations will be issued. This is not the case for the time being. Is it possible to prevent spreading the disease? What kind of action can I take? Some people can carry the disease without showing any of the related symptoms, and thus pass on parasites without knowing it, when they defecate or urinate in another river. By doing so, they may trigger or sustain the parasite s cycle in other rivers and thus cause the disease to be transmitted to other people. The French Ministry of Health recommends that individuals refrain from passing on excrement (urine, stool) in bodies of water or waterways (lakes, ponds, rivers, etc.) in order to prevent any risk of contamination of the Bulin snails that live there and thus the disease s potentially being transmitted to others. Can any action be taken to prevent Bilharzia when travelling to countries with high risk of transmission? Yes. To limit the risk of contracting Bilharzia when travelling to a region with high transmission risk, you must: - Avoid contact with freshwater believed to be contaminated. - Consume only drinking water. Non-drinking water must be boiled for at least one minute or filtered before consumption. Important: water purification using iodine is not enough to ensure decontamination. - Bring bathwater to a full boil for at least one minute, if it comes from a source believed to be contaminated. The water can be stored for one to two days without risk. - In the event of accidental exposure, even a few minutes with infested water, do not wait for possible clinical signs and see a physician, either on-site, or upon your return to France, specifying your country of stay, so that you can be given an appointment if the physician deems necessary. Who can I ask about this subject? The Ministry of Social Affairs and Health s website contains a Question and Answer section. Your primary care physician can also answer your questions, particularly those of medical nature. An information hotline has also been set up at (from Monday to Friday, 9 AM to 7 PM, toll free from landline) 9

10 Where can I find more information about Bilharzia? If you are interested in finding out more about Bilharzia, go to the following sites: - Ministry of Social Affairs and Health: - Corsican Regional Health Agency: - World Health Organization (WHO): - French Institute for Public Health Surveillance: - French Agency for Food, Environmental and Occupational Health & Safety: - French Higher Council on Public Health: - French National Agency for Drug and Health Product Safety: 10