Data Analysis
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Results of fecal examinations for helminth eggs were analyzed for prevalence and intensity of infection (epg), as measured by enumeration of eggs per gram of feces. Species infection rates (number of expelled worms) were descriptively analyzed by using SPSS version 11.0 software (SPSS Inc., Chicago, IL, USA) and χ2 and Student t tests.
Results
Parasite Diversity, Prevalence, and Intensity
A total of 615 persons, 563 men (91.5%) and 52 women (8.5%), were selected and submitted stool for examination. Fecal egg examinations showed that 554 persons (90.1%) were positive for helminth parasites (Table 1). Trichuris trichiura (whipworm) nematode eggs were found in 58.2% of the stool samples. A total of 64.9% were infected with small trematode eggs (<50 μm long), and 39.5% were infected with Ascaris lumbricoides (roundworm). Hookworm eggs (3.1%) and large (>50 μm long) trematode eggs (0.8%) were infrequently seen (Table 1). Multiparasitism was common in this community, with 65.1% of the persons expelling eggs having >2 species or types of eggs. Small trematode eggs, all <50 μm long, were presumed to be either those of C. sinensis or of intestinal trematodes of the family Heterophyidae. However, differentiation was not considered reliable by light microscopy, and selected persons were treated to expel their helminth parasites.
On the basis of egg count data, small trematode infection prevalence differed significantly between men (68.7%) and women (23.1%) (χ2 43.56, p<0.05). The infection rate for small trematode infection in men also differed significantly between age groups; it was significantly higher for those >40 years of age (χ2 7.95, p<0.05). In contrast, women did not show a significant difference in infection rates between age groups (χ2 0.85, p>0.05).
Most persons with small trematode eggs showed low infection intensity (epg); 344 (86.2%) of 399 shed <1,000 epg, and 55 (13.8%) of 399 shed 1,000–9,999 epg. Infection intensity differed significantly between those <40 years of age and those >40 years of age (χ2 4.17, p<0.05) (Table 2).
The prevalence of A. lumbricoides was 39.3% in men and 42.3% in women. There was a significant increase in prevalence with age only in women (χ2 6.4, p<0.05). Infection with T. trichiura infection did not differ significantly by sex or age (p>0.05).
FZT Species Identification
Trematodes responsible for releasing small eggs were identified by using morphologic characterization of adult stages expelled from patients. A total 15,185 adult worms were collected from 33 patients. The number and prevalence of individual species of expelled trematodes are shown in Table 3. C. sinensis and 4 species of intestinal fishborne zoonotic flukes were identified (Figure 3); C. sinensis was isolated from 51.5% of patients. Intestinal fluke species identified (mean body length × width measurements in μm) were Haplorchis pumilio (632 × 291), H. taichui (756 × 421), H. yokogawai (760 × 400), and Stellantchasmus falcatus (468 × 298). Prevalence of intestinal flukes was H. pumilio, 100%; H. taichui, 69.7%; H. yokogawai, 6.1%; and S. falcatus, 3.0%. H. pumilio was the most common trematode (90.4%) of all worms isolated; 13,734 adult worms were isolated from 33 persons (mean 416.2); 1 patient expelled 4,525 worms. The plantborne intestinal pig trematode Fasciolopsis buski was isolated from 1 patient.
Multiple infections with FZTs were common (Figure 4): 54.5% of patients were infected with 2 trematode species, 33.3% with 3 species. A total of 9% were infected with only 1 species. One person (3%) was infected with 4 FZT species and F. buski.
Discussion
Our results demonstrate that zoonotic fishborne intestinal trematodes are endemic in Vietnam. These trematodes represent, to our knowledge, a new and previously unrecognized public health problem. To our knowledge, in the many publications on human parasites originating in Vietnam since the 19th century colonial era, no reports on these intestinal fishborne parasites have appeared (11). Whether this zoonosis is newly emerging in Vietnam because of changes in agriculture/aquaculture, demographics, social, or environmental changes or if it has been overlooked because of diagnostic problems is not known. However, snail vectors (e.g., Melanoides tuberculata) and suitable vertebrate intermediate (fish) and reservoir hosts (fish-eating birds, dogs, cats, pigs) for FZTs are common in this country (1,4,11,19,21). Furthermore, H. taichui, H. pumilio, H. yokogawai, and S. falcatus are endemic in neighboring countries such as Thailand (14), Lao People's Democratic Republic (10,15), and the People's Republic of China (16).