Foodborne trematodiases (Source :

http://www.who.int/mediacentre/factsheets/fs
368/en/ )
Fact sheet N368
Updated May 2015

Key facts

At least 56 million people globally suffer from one or more foodborne trematodiases.

People become infected through the consumption of raw fish, crustaceans or vegetables
that harbour the parasite larvae.

Foodborne trematodiases are most prevalent in East Asia and South America.

Foodborne trematodiases result in severe liver and lung disease.

Safe and effective medicines are available to prevent and treat foodborne trematodiases.

Foodborne trematodiases are estimated to affect more than 56 million people throughout the
world.
They are caused by trematode worms (flukes), of which the most common species affecting
humans are Clonorchis, Opisthorchis, Fasciola and Paragonimus.
People become infected through the consumption of raw or poorly cooked food: fish, crustaceans
and vegetables that harbour the minute larval stages of the parasites (see Table 1).

Transmission
Foodborne trematodiases are zoonoses, i.e. they are naturally transmissible from vertebrate
animals to people and vice versa. Direct transmission is however not possible, as the relevant
causative parasites become infective only after having completed complex life-cycles that
usually involve stages in intermediate, non-human hosts.
The first intermediate host is in all cases a freshwater snail, while the second host differs: in
clonorchiasis and opisthorchiasis it is a freshwater fish, in paragonimiasis it is a crustacean,

while fascioliasis does not require a second intermediate host. The final host is always a
mammal.
People get the infection when they ingest the second intermediate host that is infected with larval
forms of the parasite. In the case of fascioliasis, people become infected when the larvae are
ingested together with the aquatic vegetables to which they are attached (see Table 1 for details).

Table 1. Epidemiological characteristics of foodborne trematodiases

Disease

Infectious agent

Acquired through
consumption of

Clonorchis
Fish
sinensis
Opisthorchis
Opisthorchiasis viverrini,
Fish
O. felineus
Fasciola hepatica,
Fascioliasis
Aquatic vegetables
F. gigantica
Crustaceans (crabs and
Paragonimiasis Paragonimus spp.
crayfish)
Clonorchiasis

Natural final hosts of the infection

Dogs and other fish-eating
carnivores
Cats and other fish-eating
carnivores
Sheep, cattle and other herbivores
Cats, dogs and other crustaceaneating carnivores

Epidemiology and burden

In 2005, more than 56 million people worldwide were estimated to be infected with foodborne
trematodes, and over 7000 people died from infection.
Cases of foodborne trematodiases have been reported from over 70 countries worldwide.
However, East Asia and South America are the most affected areas. In these regions, infections
with foodborne trematodes represent a significant public health problem.
Within countries, transmission is often restricted to limited areas and reflects behavioural and
ecological patterns, such as peoples food habits, methods of food production and preparation,
and the distribution of the intermediate hosts. Information on the epidemiological status of
foodborne trematode infections in Africa is largely missing.
The economic impact of foodborne trematodiases is significant, and is linked to losses in
livestock and aquaculture industries due to reduced animal productivity, as well as to restrictions
on exports and reduced consumer demand.

Symptoms
The public health burden attributable to foodborne trematodiases is predominantly due to
morbidity rather than mortality.

Early and light infections often pass unnoticed, as they are asymptomatic or only scarcely
symptomatic. Conversely, if the worm load is high, general malaise is common and severe pain
can occur, especially in the abdominal region, and this occurs most frequently in the case of
fascioliasis.
Chronic infections are invariably associated with severe morbidity. Symptoms are mainly organspecific and reflect the final location of the adult worms in the body.
In clonorchiasis and opisthorchiasis, the adult worms lodge in the smaller bile ducts of the liver,
causing inflammation and fibrosis of the adjacent tissues and eventually cholangiocarcinoma, a
severe and fatal form of bile duct cancer. Both C. sinensis and O. viverrini, but not O. felineus,
are classified as carcinogenic agents.
In fascioliasis, the adult worms lodge in the larger bile ducts and the gall bladder, where they
cause inflammation, fibrosis, blockage, colic pain and jaundice. Liver fibrosis and anaemia are
also frequent.
In paragonimiasis, the final location of the worms is the lung tissue. They cause symptoms that
can be confounded with tuberculosis: chronic cough with blood-stained sputum, chest pain,
dyspnoea (shortness of breath) and fever. Migration of the worms is possible: cerebral locations
are the most severe.

Prevention and control

Control of foodborne trematodiases aims to reduce the risk of infection and at controlling
associated morbidity.
Veterinary public health measures and food safety practices are recommended to reduce the risk
of infection, while, to control morbidity, WHO recommends improved access to treatment using
safe and effective anthelminthic medicines (drugs that expel the worms).
Treatment can be offered through preventive chemotherapy or individual case management.
Preventive chemotherapy involves a population-based approach where everyone in a given
region or area is given medicines, irrespective of their infection status. It is recommended in
areas where large numbers of individuals are infected.
Individual case-management involves the treatment of people with confirmed or suspected
infection (see Table 2): this approach is more appropriate where cases are less clustered and
where health facilities are available.

Table 2. Recommended treatments and strategies

Disease

Recommended drug and dosage

Clonorchiasis and Individual case management

Recommended strategy

Disease

Praziquantel:
Recommended
25 mg/kg three
drug
times
anddaily
dosage
for
23 consecutive days
Preventive chemotherapy

opisthorchiasis
Praziquantel:
40 mg/kg in single
administration

Treat all confirmed cases

Recommended strategy
In endemic areas: treat all suspect cases
In districts where the prevalence of
infection is
20%, treat all residents every 12 months
In districts where the prevalence of
infection is
< 20%, treat all residents every 24 months,
or treat only those individuals reporting
the habit of eating raw fish, every 12
months

Individual case management

Fascioliasis

Triclabendazole:
10 mg/kg in single
Treat all confirmed cases
administration (a double dose of
In endemic areas: treat all suspect cases
20 mg/kg can be administered in
case of treatment failure)
Preventive chemotherapy
Triclabendazole:
10 mg/kg in single
administration

In sub-districts, villages or communities

where cases of fascioliasis appear to be
clustered: treat all school-age children (5
14 years) or all residents, every 12 months

Individual case management

Triclabendazole:
2 x 10 mg/kg in the same day or

Paragonimiasis

Praziquantel:
25 mg/kg three times daily for
three days
Preventive chemotherapy
Triclabendazole:
20 mg/kg in single
administration

Treat all confirmed cases

In endemic areas: treat all suspect cases

In sub-districts, villages or communities

where cases of paragonimiasis appear to
be clustered: treat all residents every 12
months

WHO response
WHOs work on foodborne trematodiases is part of an integrated approach to the control of
neglected tropical diseases, and includes:

development of strategic directions and recommendations;

support for mapping in endemic countries;

support for pilot interventions and control programmes in endemic countries;

support for monitoring and evaluation of implemented activities; and

documentation of the burden of foodborne trematodiases and the impact of implemented

interventions.

WHO promotes the inclusion of foodborne trematodiases among the targets of preventive
chemotherapy interventions, with the aim of ensuring that their worst consequences (cancer of
the bile duct and others) are fully prevented.
WHO has also negotiated an agreement with Novartis Pharma AG whereby the company donates
triclabendazole for the treatment of human fascioliasis and paragonimiasis. The medicines are
shipped free of charge to ministries of health that apply for them. WHO invites all endemic
countries to take advantage of this donation programme.
In 2013, about 300 000 individuals were reported to have received treatment for foodborne
trematodiases worldwide. The largest programmes for the control of foodborne trematodiases are
being implemented in Bolivia, Cambodia, Peru and Viet Nam