FASCIOLA HEPATICA

PATHOGEN SAFETY DATA SHEET - INFECTIOUS SUBSTANCES

SECTION I - INFECTIOUS AGENT

NAME: Fasciola hepatica, Fasciola gigantica

SYNONYM OR CROSS REFERENCE: Fascioliasis, Human Fascioliasis, common liver fluke, trematode, sheep liver fluke disease.

CHARACTERISTICS: F. hepatica is a parasitic flatworm of the Fasciolidae family. Hermaphroditic adults are flat and leaf-like, ranging from 20-30 mm in length and 7-14 mm in width, with oral and ventral suckers that are the organs of attachment ^{(1, 2)}. F. gigantica are about double the size of F. hepatica. The eggs are ovoid, light yellow-brown, operculate and large, and range from 130 to 150 µm in length, and 60-90 µm in width.

SECTION II - HAZARD IDENTIFICATION

PATHOGENICITY/TOXICITY: F. hepatica induces pathology in the liver and biliary tracts ⁽³⁾, where it can survive up to 10-15 years in the infected host ⁽¹⁾. Infection consists of two stages, the hepatic stage and the biliary stage ⁽⁴⁾. The first hepatic stage is acute and invasive while flukes are in the liver parenchyma and can last for 2 to 4 months. This causes destruction of the hepatic tissue and hepatic lesions, resulting in fever, nausea and vomiting, urticaria, right upper quadrant abdonminal pain , hepatomegaly, hypergamma-globulinaemia, anaemia and marked eosinophilia. Other signs include mild hepatitis, severe subcapsular haemorrhage, and frank hepatic necrosis. The second biliary stage (chronic stage) occurs when flukes move into the biliary tract. Eggs appear in the stool after a prepatent period of 3 to 4 months. This can result in intermittent right upper quadrant pain, with or without cholangitis or cholestasis, chronic bile duct inflammation, and ectopic infections that may occur in the intestine, liver, and bile duct ⁽⁵⁾. Detection of absolute eosinophilia, fever, and infection of extrahepatic sites such as the heart, brain, intestines, lungs, and skin can also be attributed to F. hepatica infection ^{(4, 6)}. In addition, acute nasopharyngitis may occur in areas of high prevalence ⁽⁷⁾.

EPIDEMIOLOGY: Worldwide human infections have been reported in areas of high rainfall, poorly drained areas and irrigated pastures ⁽⁸⁾. Regions include South America, Southeast Asia, Africa, the Middle East, Europe, and the Pacific area. They are especially prevalent in areas inhabited by freshwater snails, since these are the intermediate host of this trematode ⁽⁹⁾, as well as areas where cattle or sheep are raised. F. gigantica is commonly found in tropical and subtropical areas, most notably in Africa, Asia, and western Pacific regions ⁽¹⁰⁾.

HOST RANGE: Humans are accidental hosts. The snails serve as intermediate hosts. Animal infections have been documented in rats, rabbits, chickens, ducks, cattle, horses, buffalo, goats, sheep, and other herbivore ruminants ^{(4, 9, 11, 12)}. Eggs are located in the bile duct of the host, and can be released into the environment along with excretion of faeces ⁽⁴⁾.

INFECTIOUS DOSE: Unknown for humans; however, chewing of encysted plants is sufficient to become infected ⁽⁸⁾. Rats aged 5 weeks or older showed symptoms of infection after ingesting 5 metacercariae ⁽¹³⁾.

MODE OF TRANSMISSION: Consumption of uncooked vegetation (commonly watercress) or raw parasitized liver of cattle or sheep containing metacercariae can lead to F. hepatica infection ⁽¹⁴⁾. It is also possible for the organism to break off of the foliage, so drinking unboiled water from pastures containing encysted plants can also lead to infection ^{(4, 12)}.

INCUBATION PERIOD: Onset of the first hepatic infection stage is 3 – 11 weeks after the metacercariae enters the body ⁽¹⁴⁾, followed by the chronic biliary stage which can occur after months or years following first ingestion ⁽⁴⁾. This period may vary depending on the infectious dose ⁽¹³⁾.

COMMUNICABILITY: Cannot be transmitted between humans.

SECTION III - DISSEMINATION

RESERVOIR: Eggs are released into the environment by infected hosts. In water with optimal temperatures, miracidia hatch from the eggs and then enter into a snail for developmental stages ⁽⁸⁾. The mature cercariae emerge from the snail and encyst onto aquatic plants (watercress are the most common), where they develop into the infectious metacercariae stage in a matter of a few hours – the maturity process may be accelerated by irrigation and washing of the plants ⁽¹¹⁾. The mature metacercariae can infect cattle, sheep, humans (accidental hosts), and other mammal hosts.

ZOONOSIS: Yes – humans can become infected through ingestion of metacercariae or indirectly through cattle, sheep, and other herbivore ruminants ⁽⁸⁾.

VECTORS: F. hepatica develops into its infectious stage (metacercariae) in the freshwater snail (usually lymnaeid) ⁽⁸⁾.

SECTION IV – STABILITY AND VIABILITY

DRUG SUSCEPTIBILITY: Triclabendazole, a benzimidazole, is the current drug of choice ^(15-17). Bithionol is an alternative drug for the treatment of fascioliasis ^{(4, 15)} .

DRUG RESISTANCE: Immature F. hepatica displays resistance to clorsulon, closantel, nitroxynil, and albendazole fasciolocides. Resistance to triclabendazole is also developing in isolated strains from Australia and Spain ⁽¹⁸⁾.

SUSCEPTIBILITY TO DISINFECTANTS: Flukes are susceptible to 1000-5000 ppm sodium hypochlorite, formaldehyde – most effective at above 20°C ⁽¹²⁾, and 2% glutaraldehyde ⁽¹⁹⁾.

PHYSICAL INACTIVATION: Sensitive to heat, sterilize by autoclave.

SURVIVAL OUTSIDE HOST: Freshly hatched cercariae from the snail can survive about one hour to encyst on a suitable object ⁽²⁰⁾. If the water in which the snails live dries up, the snails can still be infected for months and in the presence of water the snails emerge and shed many cercariae. Metacercariae can survive prolonged periods (up to one year) on aquatic plants or even on hay grown in infested meadows, as they are resistant to drying ⁽²¹⁾. They can also be found free-floating in shallow, still water ^{(4, 22)}.

SECTION V – FIRST AID / MEDICAL

SURVEILLANCE: Serological techniques (ELISA, immunoblotting, complement fixation, indirect hemagglutination) can detect antibodies against antigens secreted from adult flukes 2 – 4 weeks after infection ^{(23, 24)}. Evidence of infection can be obtained using radiographic techniques such as computed tomography (CT), ultrasonography, magnetic resonance imaging, and the indirect hemagglutination test ⁽²⁵⁾. Stool examination for F. hepatica ova can confirm infection after 2 months. Other techniques include percutaneous cholangiography, endoscopic retrograde cholangiography, and liver biopsy, which can be used but are invasive and not essential in most cases ⁽⁴⁾.

FIRST AID/TREATMENT: Administer appropriate drug therapy. A single oral dose or two dose 12 hours apart of 10 mg/kg body weight of Triclabenazole can clear infection in a few months for humans (may require a second round of treatment in some cases) ⁽¹⁶⁾. Bithionol can be used with a 50% cure rate in one month ⁽¹⁵⁾.

IMMUNIZATION: None to date.

PROPHYLAXIS: None to date. Avoid oral exposure to uncooked plants growing in moist grounds or in flooded areas, or drinking unboiled or unfiltered surface water ⁽⁸⁾.

SECTION VI - LABORATORY HAZARDS

LABORATORY-ACQUIRED INFECTIONS: None reported to date.

SOURCES/SPECIMENS: Infected specimens including faeces, liver tissues, and the bile tract which can contain mature flukes and eggs ^{(5, 14, 24)}.

PRIMARY HAZARDS: Ingestion ⁽²⁶⁾ and accidental parenteral inoculation (i.e. of culture medium containing metacercariae) ⁽²⁷⁾.

SECONDARY HAZARDS: None.

SECTION VII – EXPOSURE CONTROLS / PERSONAL PROTECTION

RISK GROUP CLASSIFICATION: Risk Group 2 ⁽²⁸⁾.

CONTAINMENT REQUIREMENTS: Containment Level 2 facilities, equipment, and practices are required for work with F. hepatica and F. gigantica. Exposure hazards include ingestion, inoculation, and through mucous membrane. Avoid the production of aerosols or splashes, although it cannot be transmitted while airborne, it may set on bench tops where it can become an ingestion hazard by coming in contact with hands ⁽²⁹⁾.

PROTECTIVE CLOTHING: Lab coat. Gloves when direct skin contact with infected materials or animals is unavoidable. Eyes protection must be used where there is known or potential risk of exposure to splashes ⁽²⁹⁾.

OTHER PRECAUTIONS: All procedures that may produce aerosols, or involve high concentrations or large volumes should be conducted in a biological safety cabinet (BSC). The use of needles, syringes, and other sharp objects should be strictly limited. Additional precautions should be considered with work involving animals or large scale activities ⁽²⁹⁾ .

SECTION VIII – HANDLING AND STORAGE

SPILLS: Allow aerosols to settle and, wearing protective clothing, gently cover spill with paper towels and apply an appropriate disinfectant, starting at the perimeter and working towards the centre. Allow sufficient contact time before clean up.

DISPOSAL: Decontaminate all wastes that contain or have come in contact with the infectious organism by autoclave, chemical disinfection, gamma irradiation, or incineration before disposing ⁽¹⁹⁾.

STORAGE: The infectious agent should be stored in leak-proof containers that are appropriately labelled.

SECTION IX – REGULATORY AND OTHER INFORMATION

REGULATORY INFORMATION: The import, transport, and use of pathogens in Canada is regulated under many regulatory bodies, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment Canada, and Transport Canada. Users are responsible for ensuring they are compliant with all relevant acts, regulations, guidelines, and standards.

UPDATED: June 2010

PREPARED BY: Pathogen Regulation Directorate, Public Health Agency of Canada

Although the information, opinions and recommendations contained in this Pathogen Data Sheet are compiled from sources believed to be reliable, we accept no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information. Newly discovered hazards are frequent and this information may not be completely up to date.

Copyright ©
Public Health Agency of Canada, 2010
Canada

REFERENCES:

1. Ryan, K.J. and Ray, C.G. (Ed.). (2004). Medical Microbiology (4th ed.). United States of America: The McGraw-Hill Companies.
2. Smith, M. C., & Sherman, D. M. (2009). Goat Medicine (2nd ed.). Ames, Iowa: Wiley-Blackwell.
3. Fried, B., & Abruzzi, A. (2010). Food-borne trematode infections of humans in the United States of America. Parasitology Research, 106(6), 1263-1280. doi:10.1007/s00436-010-1807-0
4. Aksoy, D. Y., Kerimoglu, U., Oto, A., Erguven, S., Arslan, S., Unal, S., Batman, F., & Bayraktar, Y. (2005). Infection with Fasciola hepatica. Clinical Microbiology and Infection : The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, 11(11), 859-861. doi:10.1111/j.1469-0691.2005.01254.x
5. Murray, P. R., Baron, E. J., Jorgensen, J. H., Landry, M. L., Pfaller, M. A., & Yolken, R. H. (Eds.). (2003). Manual of Clinical Microbiology (8th ed.). Herdon, VA, United States of America: American Society for Microbiology.
6. Keiser, J., & Morson, G. (2008). Fasciola hepatica: Surface tegumental responses to in vitro and in vivo treatment with the experimental fasciolicide OZ78. Experimental Parasitology, 119(1), 87-93. doi:10.1016/j.exppara.2007.12.015
7. Advances in Parasitology (2007). In Muller R., Rollinson D. and Hay S. I. (Eds.), . San Diego, CA: Elsevier.
8. Krauss, H., Weber, A., Appel, M., Enders, B., Isenberg, H. D., Schiefer, H. G., Slenczka, W., von Graevenitz, A., & Zahner, H. (2003). Zoonosis – Infectious Diseases Transmissible from Animals to Humans (3rd ed.) American Society for Microbiology.
9. Kaplan, R. M. (2001). Fasciola hepatica: a review of the economic impact in cattle and considerations for control. Veterinary Therapeutics : Research in Applied Veterinary Medicine, 2(1), 40-50.
10. Keyyu, J. D., Monrad, J., Kyvsgaard, N. C., & Kassuku, A. A. (2005). Epidemiology of Fasciola gigantica and amphistomes in cattle on traditional, small-scale dairy and large-scale dairy farms in the southern highlands of Tanzania. Tropical Animal Health and Production, 37(4), 303-314.
11. Farag, H. F. (1998). Human fascioliasis in some countries of the Eastern Mediterranean Region.4, 156-160.
12. Collins, P. R., Stack, C. M., O'Neill, S. M., Doyle, S., Ryan, T., Brennan, G. P., Mousley, A., Stewart, M., Maule, A. G., Dalton, J. P., & Donnelly, S. (2004). Cathepsin L1, the major protease involved in liver fluke (Fasciola hepatica) virulence: propetide cleavage sites and autoactivation of the zymogen secreted from gastrodermal cells. The Journal of Biological Chemistry, 279(17), 17038-17046. doi:10.1074/jbc.M308831200
13. Rajasekariah, G. R., & Howell, M. J. (1977). Fasciola hepatica in rats: effects of age and infective dose. International Journal for Parasitology, 7(2), 119-121.
14. Aroonroch, R., Worawichawong, S., Nitiyanant, P., Kanchanapitak, A., & Bunyaratvej, S. (2006). Hepatic fascioliasis due to Fasciola hepatica: a two-case report. Journal of the Medical Association of Thailand = Chotmaihet Thangphaet, 89(10), 1770-1774.
15. Apt, W., Aguilera, X., Vega, F., Miranda, C., Zulantay, I., Perez, C., Gabor, M., & Apt, P. (1995). Treatment of human chronic fascioliasis with triclabendazole: drug efficacy and serologic response. The American Journal of Tropical Medicine and Hygiene, 52(6), 532-535.
16. Lecaillon, J. B., Godbillon, J., Campestrini, J., Naquira, C., Miranda, L., Pacheco, R., Mull, R., & Poltera, A. A. (1998). Effect of food on the bioavailability of triclabendazole in patients with fascioliasis. British Journal of Clinical Pharmacology, 45(6), 601-604.
17. Millan, J. C., Mull, R., Freise, S., Richter, J., & Triclabendazole Study Group. (2000). The efficacy and tolerability of triclabendazole in Cuban patients with latent and chronic Fasciola hepatica infection. The American Journal of Tropical Medicine and Hygiene, 63(5-6), 264-269.
18. Keiser, J., Utzinger, J., Vennerstrom, J. L., Dong, Y., Brennan, G., & Fairweather, I. (2007). Activity of artemether and OZ78 against triclabendazole-resistant Fasciola hepatica. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(12), 1219-1222. doi:10.1016/j.trstmh.2007.07.012
19. Laboratory Safety Manual (1993). (2nd ed.). Geneva: World Health Organization.
20. Jutzi, S. C., Haque, I., McIntire, J., & Stares, J. E. S. (1988). Management of Vertisols in Sub-Saharan Africa. ILCA, Addis, Ababa, Ethiopia.
21. Bowman, D. D. (2009). Geogis' Parasitology for Veterinarians (9th ed.). St. Louis, Missouri: Elsevier Inc.
22. Nouri, J., Mahvi, A. H., Saeedi, R., & et al. (2008). Purification and removal of Ascaris and Fasciola hepatica eggs from drinking water using roughing filters.25(3), 501-504.
23. Salimi-Bejestani, M. R., McGarry, J. W., Felstead, S., Ortiz, P., Akca, A., & Williams, D. J. (2005). Development of an antibody-detection ELISA for Fasciola hepatica and its evaluation against a commercially available test. Research in Veterinary Science, 78(2), 177-181. doi:10.1016/j.rvsc.2004.08.005
24. Hillyer, G. V., De Galanes, M. S., & Azanero, E. D. (2001). Immune diagnosis of human fasciolosis in children from Cahamerca, Peru.25, 3-4.
25. Bautista-Garfias, C. R., Lopez-Arellano, M. E., & Sanchez-Albarran, A. (1989). A new method for serodiagnosis of sheep fascioliasis using helminth excretory-secretory products. Parasitology Research, 76(2), 135-137.
26. Kistner, T. P., & Koller, L. D. (1975). Experimentally induced Fasciola hepatica infections in black-tailed deer. Journal of Wildlife Diseases, 11(2), 214-220.
27. O'Neill, S. M., Mills, K. H., & Dalton, J. P. (2001). Fasciola hepatica cathepsin L cysteine proteinase suppresses Bordetella pertussis-specific interferon-gamma production in vivo. Parasite Immunology, 23(10), 541-547.
28. Human Pathogens and Toxins Act. S.C. 2009, c. 24. Government of Canada, Second Session, Fortieth Parliament, 57-58 Elizabeth II, 2009, (2009).
29. Best, M., Graham, M. L., Leitner, R., Ouellette, M., & Ugwu, K. (Eds.). (2004). The Laboratory Biosafety Guidelines (3rd ed.). Ottawa: Public Health Agency of Canada.