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      Strongyloides stercoralis: Global Distribution and Risk Factors


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          The soil-transmitted threadworm, Strongyloides stercoralis, is one of the most neglected among the so-called neglected tropical diseases (NTDs). We reviewed studies of the last 20 years on S. stercoralis's global prevalence in general populations and risk groups.

          Methods/Principal Findings

          A literature search was performed in PubMed for articles published between January 1989 and October 2011. Articles presenting information on infection prevalence were included. A Bayesian meta-analysis was carried out to obtain country-specific prevalence estimates and to compare disease odds ratios in different risk groups taking into account the sensitivities of the diagnostic methods applied. A total of 354 studies from 78 countries were included for the prevalence calculations, 194 (62.4%) were community-based studies, 121 (34.2%) were hospital-based studies and 39 (11.0%) were studies on refugees and immigrants. World maps with country data are provided. In numerous African, Asian and South-American resource-poor countries, information on S. stercoralis is lacking. The meta-analysis showed an association between HIV-infection/alcoholism and S. stercoralis infection (OR: 2.17 BCI: 1.18–4.01; OR: 6.69; BCI: 1.47–33.8), respectively.


          Our findings show high infection prevalence rates in the general population in selected countries and geographical regions. S. stercoralis infection is prominent in several risk groups. Adequate information on the prevalence is still lacking from many countries. However, current information underscore that S. stercoralis must not be neglected. Further assessments in socio-economic and ecological settings are needed and integration into global helminth control is warranted.

          Author Summary

          The soil-transmitted threadworm Strongyloides stercoralis is one of the most neglected helminth infections. It is endemic world-wide, yet more prevalent in hot and humid climates as well as resource poor countries with inadequate sanitary conditions. The difficult diagnosis and irregular excretion of larvae lead to an underreporting of infection rates. We reviewed the literature of the last 20 years reporting on infection rates of S. stercoralis. Including the sensitivity of diagnostic methods applied, we modeled and mapped for the first time country-wide prevalence estimates. The modeling was divided into studies reporting infection rates in the general population, in hospitals and on refugees & immigrants, respectively. We further summarized possible risk factors for S. stercoralis infection using meta-analysis. The most prominent risk factors include HIV-infection, HTLV-1 infection and alcoholism. Information on infection rates is missing in many countries. Our results show high prevalence estimates in many resource poor tropical and subtropical countries. We conclude that S. stercoralis should not be neglected and that further studies applying high sensitivity diagnostic methods are needed.

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          Most cited references101

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          Strongyloides hyperinfection syndrome: an emerging global infectious disease.

          The hyperinfection syndrome (HS) caused by Strongyloides stercoralis has a high mortality rate (15% to 87%). A variety of risk factors and predisposing conditions have been described, including new immunosuppressive therapies; HTLV-1 infection; cadaveric transplantation; immune reconstitution syndrome; haematological malignancies (especially lymphoma); tuberculosis; malnutrition secondary to chronic Strongyloides diarrhoea; international travel and immigration. Inhibition of Th2 cell-mediated, humoral or mucosal immunity is associated with HS. HS is more frequently seen in HTLV-1 than HIV patients. In AIDS, there is an increase in Th2 cytokines, while in HTLV-1 infection there is a decrease in the Th2 response, leading to an increased risk of autoinfection. Corticosteroid use remains the most frequent risk factor for HS. A number of ELISAs are useful for diagnosis and post-treatment evaluation. Once diagnosed, the disease may be managed effectively with anthelminthic drugs, including ivermectin. HS causes diverse symptoms and signs, with unusual manifestations leading to misdiagnosis and medical errors related to healthcare providers' lack of familiarity with the condition. HS is an example of an emerging tropical infection migrating to developed countries and requiring greater clinician awareness.
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            Intestinal strongyloidiasis and hyperinfection syndrome

            In spite of recent advances with experiments on animal models, strongyloidiasis, an infection caused by the nematode parasite Strongyloides stercoralis, has still been an elusive disease. Though endemic in some developing countries, strongyloidiasis still poses a threat to the developed world. Due to the peculiar but characteristic features of autoinfection, hyperinfection syndrome involving only pulmonary and gastrointestinal systems, and disseminated infection with involvement of other organs, strongyloidiasis needs special attention by the physician, especially one serving patients in areas endemic for strongyloidiasis. Strongyloidiasis can occur without any symptoms, or as a potentially fatal hyperinfection or disseminated infection. Th2 cell-mediated immunity, humoral immunity and mucosal immunity have been shown to have protective effects against this parasitic infection especially in animal models. Any factors that suppress these mechanisms (such as intercurrent immune suppression or glucocorticoid therapy) could potentially trigger hyperinfection or disseminated infection which could be fatal. Even with the recent advances in laboratory tests, strongyloidiasis is still difficult to diagnose. But once diagnosed, the disease can be treated effectively with antihelminthic drugs like Ivermectin. This review article summarizes a case of strongyloidiasis and various aspects of strongyloidiasis, with emphasis on epidemiology, life cycle of Strongyloides stercoralis, clinical manifestations of the disease, corticosteroids and strongyloidiasis, diagnostic aspects of the disease, various host defense pathways against strongyloidiasis, and available treatment options.
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              Global prevalence of strongyloidiasis: critical review with epidemiologic insights into the prevention of disseminated disease.

              R M Genta (2016)
              Opportunistic disseminated strongyloidiasis is an important cause of morbidity and mortality in immunocompromised patients. However, the worldwide prevalence of Strongyloides stercoralis is difficult to determine because adequate data are lacking. In this paper more than 100 epidemiologic studies reporting on the prevalence of S. stercoralis among various populations on five continents are critically reviewed. Analysis of this information indicates that the following groups of people may be at risk: residents of an emigrants from any developing country and southern, eastern, and central Europe; travelers and veterans returning from endemic areas; natives and residents of the Appalachian region in the United States and local endemic areas in other countries; and institutionalized persons. Because disseminated infections may be prevented by early treatment of asymptomatic chronic infections, screening programs are recommended to detect latent S. stercoralis infection before the initiation of chemotherapy or immunosuppression in patients at risk. Serologic tests are sensitive and specific but are not yet widely available. Thus strong suspicion based on clinical and epidemiologic clues in conjunction with repeated stool examinations remains the best way to rule out S. stercoralis infection in these groups.

                Author and article information

                Role: Editor
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, USA )
                July 2013
                11 July 2013
                : 7
                : 7
                : e2288
                [1 ]Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
                [2 ]University of Basel, Basel, Switzerland
                [3 ]National Center for Parasitology, Entomology and Malaria Control, Ministry of Health, Phnom Penh, Cambodia
                [4 ]Medical and Diagnostics Department, Swiss Tropical and Public Health Institute, Basel, Switzerland
                London School of Hygiene & Tropical Medicine, United Kingdom
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: UT PO. Performed the experiments: FS UT. Analyzed the data: FS FG PV. Contributed reagents/materials/analysis tools: VK SM HM PO. Wrote the paper: FS UT PO. Assisted with manuscript revisions: FG PV VK HM SM. Supervised first author in all aspects of the review: PO.

                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 21 November 2012
                : 14 May 2013
                Page count
                Pages: 17
                FS and VK received financial support from the UBS Optimus Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Infectious Diseases
                Parasitic Diseases
                Helminth Infection
                Neglected Tropical Diseases

                Infectious disease & Microbiology
                Infectious disease & Microbiology


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