Cystic echinococcosis (CE) is a neglected parasitic zoonosis prioritized by the WHO for control. Several studies have investigated potential risk factors for CE through questionnaires, mostly carried out on small samples, providing contrasting results. We present the analysis of risk factor questionnaires administered to participants to a large CE prevalence study conducted in Bulgaria, Romania and Turkey. A semi-structured questionnaire was administered to 24,687 people from rural Bulgaria, Romania and Turkey. CE cases were defined as individuals with abdominal CE cysts detected by ultrasound. Variables associated with CE at P < 0.20 in bivariate analysis were included into a multivariable logistic model, with a random effect to account for clustering at village level. Adjusted odds ratios (AOR) with 95% CI were used to describe the strength of associations. Data were weighted to reflect the relative distribution of the rural population in the study area by country, age group and sex. Valid records from 22,027 people were analyzed. According to the main occupation in the past 20 years, “housewife” (AOR: 3.11; 95% CI: 1.51–6.41) and “retired” (AOR: 2.88; 95% CI: 1.09–7.65) showed significantly higher odds of being infected compared to non-agricultural workers. “Having relatives with CE” (AOR: 4.18; 95% CI: 1.77–9.88) was also associated with higher odds of infection. Interestingly, dog-related and food/water-related factors were not associated with infection. Our results point toward infection being acquired in a “domestic” rural environment and support the view that CE should be considered more a “soil-transmitted” than a “food-borne” infection. This result helps delineating the dynamics of infection transmission and has practical implications in the design of specific studies to shed light on actual sources of infection and inform control campaigns.

Visceral leishmaniasis (VL) is a severe endemic disease with a fatal outcome if left untreated. The symptoms of patients are diverse and atypical. Against the background of anemia and pancytopenia, the condition of the patients gradually worsens with marked cachexia. Through sharing our experience, we aim to draw attention to this deadly disease. Clinical and laboratory data for 58 patients with VL treated over a forty-five-year period are presented. The diagnosis was established within a duration of 1 to 28 months of illness. Continuous fever (38–42 °C), splenomegaly, hepatomegaly, severe anemia (decreased hemoglobin to lowest values of 31 g/L), leucopenia (lowest values of leucocytes et 0.5 g/L), and thrombocytopenia (reduced thrombocyte count to 29 g/L) were observed. The diagnosis was made on the basis of microscopic evidence of amastigote forms in bone marrow smears and serological tests. The patients were treated with Glucantime for 17 to 21 days. Relapses were observed in seven patients (12.1%) and fatal outcome was observed in two patients (3.5%) during treatment, who developed acute respiratory and cardiovascular failure. In Bulgaria, Visceral leishmaniasis is primarily endemic in the southern regions and should be suspected not only in patients who have returned from tropical and subtropical countries, but also in those who have not traveled abroad. The challenges associated with VL stem from delayed diagnosis of patients, as this disease remains unrecognized by physicians.

Background: Cystic echinococcosis (CE) is a neglected parasitic zoonosis prioritized by the WHO for control. Hygiene education is included in CE control campaigns but appears of little impact, and the precise risk factors for human infection are still uncertain. Several works investigated potential risk factors for CE through questionnaires, mostly carried out on small samples, providing contrasting results. We present the analysis of risk factors questionnaires administered to participants to the largest prevalence study on CE conducted in Eastern Europe. Methodology/Principal Findings: A semi-structured questionnaire was administered to 24,687 people from rural Bulgaria, Romania, and Turkey. CE cases were defined individuals with abdominal CE cysts detected on ultrasound. Variables associated with CE infection at p<0.20 in bivariate analysis were included into a multivariable logistic model, with a random effect to account for clustering at village level. Adjusted odds ratio (AOR) with 95%CI were used to describe the strength of associations. Data were weighted to reflect the relative distribution of the rural population in the study area by country, age group and sex. Valid records from 22,027 people were analyzed. According to the main occupation in the past 20 years, “housewife” (AOR 3.11 [1.51-6.41]) and “retired” (AOR 2.88 [1.09-7.65]) showed significantly higher odds of being infected compared to non-agricultural workers. “Having relatives with CE” (AOR 4.18 [1.77-9.88]) was also associated with higher odds of infection. Dog-related and food/water-related factors were not associated with infection. Conclusions/Significance: Our results point to infection being acquired in a “domestic” rural environment and support the view that CE should be considered more a “soil-transmitted” than a “food-borne” infection, acquired through a “hand-to-mouth” mechanism. This result helps delineating the dynamics of infection transmission and have practical implications in the design of specific studies to shed light on actual sources of infection and inform control campaigns. AUTHOR SUMMARY: Cystic echinococcosis (CE) is a parasitic disease with high socio-economic impact, mostly affecting pastoral communities. The causative agent, Echinococcus granulosus sensu lato , is naturally transmitted between dogs and livestock; humans acquire infection through accidental ingestion of parasite eggs. Hygiene education is among the strategies of CE control campaigns, but appears of little impact. “Ingestion of contaminated food/water”, and “contact with dogs” are generally mentioned as the sources of human infection, however actual risk factors are still undefined. Several works investigated potential risk factors for human CE infection through questionnaires, mostly carried out on small samples, providing contrasting results. We analysed 22,027 risk factors questionnaires administered to the participants of the largest prevalence study on CE conducted in Eastern Europe. We found that being “housewife” and “retired” as the main occupation in the past 20 years, and “having relatives with CE” were associated with higher odds of CE infection, while dog-related and food/water-related factors were not associated with infection. Our results indicate that CE may be considered more a “soil-transmitted” than a “food-borne” infection, acquired through a “hand-to-mouth” mechanism in a domestic, rural environment. This may help designing specific studies on pathways of transmission of this neglected parasite.

Introduction: Cystic echinococcosis (CE) is a chronic disease in humans, usually asymptomatic, but in some cases could be very severe with fatal outcomes. This parasitosis is a health and economic problem in many areas of the world. The actual spread among people with CE in endemic regions is not known. The purpose of prophylactic ultrasound examinations of people in some areas was to clarify the real prevalence of CE and to detect undiagnosed asymptomatic cases and recurrences. Materials and methods: An abdominal ultrasound survey in four endemic regions in Bulgaria with the highest rate of registered patients with CE in Bulgaria for the last five years was conducted. For every patient with CE an epidemiological and clinical history, abdominal ultrasound examination, blood tests and ELISA IgG test for CE were performed. Results: From all 8602 people examined, in seventeen persons (0.2%), liver hydatid cysts were found for the first time. Ssixty five (0.8%) reported a history of previous surgical treatment for CE, of which 54 (83.1%) had passed surgery because of liver CE and 11 (16.9%) had extrahepatic CE (pulmonary, cardiac, bone, spleen). In three (5.6%) patients, who were operated years before for liver CE, recurrences were discovered. In 11 (64.7%) patients devitalized CE4 cysts were observed without any data for previous treatment. Three of the discovered patients with CE were treated with surgery, one with puncture-aspiration-injection-reaspiration, four only with Albendazole. The patients were successfully treated and followed for a period of five years. Conclusions: During the prophylactic ultrasound examinations, a higher percentage of people infected with liver cystic echinococcosis was found compared to the official information. It should be noted that these results are found in areas with the highest incidence of this disease in the country. US screenings give the opportunity for early detection, timely treatment of infected people and to prevent severe complications in patient with CE disease.