1. Brian Lassen Estonian University of Life Sciences Zoonoses in Estonia - an overview Journal Club 20 th December 2011

2. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Small selection of parasites * Echinococcus * Toxoplasma gondii * Giardia * Cryptosporidium * Other investigations of concern Further data: http:/sbsp.eu (links)

3. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Method * Refreshing of parasite ecology * Knowledge on Human cases (Estonia) * Knowledge on Animal Hosts (Estonia) * Situation in Near Countries (Sweden, Finland, Latvia, Lithuania)

4. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Echinococcus

5. Echinococcosis (hydatidosis, or hydatid disease) Images: http://dpd.cdc.gov/dpdx/html/Echinococcosis.htm, http://www.constipation-remedies.co.uk/parasite-echinococcocis.php, http://www.human-healths.com/echinococcosis/echinococcosis.phphttp://dpd.cdc.gov/dpdx/html/Echinococcosis.htmhttp://www.constipation-remedies.co.uk/parasite-echinococcocis.php Echinococcus granulosus Echinococcus multilocularis alveolar echinococcosis cystic echinococcosis (Echinococcus vogeli) polycystic echinococcosis

6. Echinococcosis (Primary Hosts) Echinococcus granulosus Echinococcus multilocularis (Echinococcus vogeli) Image life cycle: http://dpd.cdc.gov/dpdx/html/Echinococcosis.htm, http://completedogfood.net/, http://animals.nationalgeographic.com/animals/mammals/red-fox/, http://www.agefotostock.com/en/Stock-Images/Rights-Managed/K97-1258787, http://true-wildlife.blogspot.com/2011/02/coyote.html, http://www.sobi.org/photos/Cat/Mottle/index.html, http://www.cosmosmith.com/european_gray_wolves.asp, http://www.brazilianfauna.com/bushdog.phphttp://dpd.cdc.gov/dpdx/html/Echinococcosis.htmhttp://completedogfood.net/http://animals.nationalgeographic.com/animals/mammals/red-fox/ http://www.agefotostock.com/en/Stock-Images/Rights-Managed/K97-1258787http://true-wildlife.blogspot.com/2011/02/coyote.html http://www.sobi.org/photos/Cat/Mottle/index.htmlhttp://www.cosmosmith.com/european_gray_wolves.asp Primary hosts

7. TerviseametVeterinaar ja Toidulaboratoorium Echinococcosis human cases, Estonia

8. Echinococcus granulosus infections in humans, Finland

9. Echinococcus human cases, Sweden Sweden, human 20042005200620072008200920102011 Total111481714153018 Per 100.000 inhabitants 0.120.150.090.190.150.160.320.19 Smittskyddinstitutet (Smi)

10. Veterinaar ja Toidulaboratoorium Statistics on animals with Echinococcus worms or cysts found during routine diagnostics 2006-2011: 0 cases

11. Meat inspection and monitoring: E. granulosus infection in reindeer and elk 2000-2010 (Source: Evira) Echinoccocus granulosus findings in each The incidence of reindeer parasite positive / 10000 slaughter animals Per year positive elkpositive deer

12. Echinococcus multilocularis in Finland Annual studies of voles, raccoon dogs and foxes (Source: Zoonoses monitoring programs, Evira) Raccoon dogFoxVoles Studied individuals

13. Echinococcosis (Relevance) Echinococcus granulosus Echinococcus multilocularis Images:http://www.iom.int/jahia/Jahia/nordic-and-baltic-countries, http://completedogfood.net/, http://animals.nationalgeographic.com/animals/mammals/red-fox/, http://www.agefotostock.com/en/Stock-Images/Rights-Managed/K97-1258787, http://true-wildlife.blogspot.com/2011/02/coyote.html, http://www.sobi.org/photos/Cat/Mottle/index.html, http://www.cosmosmith.com/european_gray_wolves.asp, http://www.brazilianfauna.com/bushdog.phphttp://completedogfood.net/http://animals.nationalgeographic.com/animals/mammals/red-fox/ http://www.agefotostock.com/en/Stock-Images/Rights-Managed/K97-1258787http://true-wildlife.blogspot.com/2011/02/coyote.html http://www.sobi.org/photos/Cat/Mottle/index.htmlhttp://www.cosmosmith.com/european_gray_wolves.asp Fox: 29% Fox: 0-1.5% (Davidson et al. 2011) Fox: 0.1% (Osterman-Lind et al. 2011) Fox: 0.3% (Saeed et al. 2006) Wolf: ~30% (Hirvelä-Koski et al. 2003) Wolf: 4% (Moks et al. 2008) Dog: 4% (Bruzinskaite et al. 2009) Dog: 1% Fox: 59%Raccoon dog: 8% (Bružinskaitė et al. 2011)

14. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Toxoplasma

15. Toxoplasma gondii (Toxoplasmosis) Images: http://drugster.info/ail/pathography/3456/, http://www.aafp.org/afp/2003/0515/p2131.html, http://www.teara.govt.nz/en/diseases-of- sheep-cattle-and-deer/5/2, http://www.thepregnancyzone.comhttp://drugster.info/ail/pathography/3456/http://www.aafp.org/afp/2003/0515/p2131.htmlhttp://www.teara.govt.nz/en/diseases-of- sheep-cattle-and-deer/5/2

16. Toxoplasma gondii (Hosts) Images: http://www.dpd.cdc.gov/dpdx/html/Toxoplasmosis.htm, http://en.wikipedia.org/wiki/Felidae http://www.dpd.cdc.gov/dpdx/html/Toxoplasmosis.htm Felids

17. Toxoplasmosis, human cases, Estonia Studied Cases Years

18. Toxoplasmosis in humans, Latvia (Source: Infectology Center of Latvia) Humans20062007200820092010 Cases91066 Per 100.000 people??0.260.30.44

19. Infectious Disease Registry reported toxoplasmosis in humans (Source: THL) The incidence in the population The cases reported in humans Number of toxoplasmosis cases / year Incidence / million. inhabitant / year

20. Toxoplasma gondii (Relevance) Images: http://drugster.info/ail/pathography/3456/, http://www.aafp.org/afp/2003/0515/p2131.html, http://www.teara.govt.nz/en/diseases-of- sheep-cattle-and-deer/5/2, http://www.thepregnancyzone.comhttp://drugster.info/ail/pathography/3456/http://www.aafp.org/afp/2003/0515/p2131.htmlhttp://www.teara.govt.nz/en/diseases-of- sheep-cattle-and-deer/5/2 Tartu: 55% (Birgisdóttir et al. 2006) Uppsala: 23% (Birgisdóttir et al. 2006) Reykjavik: 10% (Birgisdóttir et al. 2006) Copenhagen*: 28% (Lebech et al. 1999) Uppsala: 23% (Birgisdóttir et al. 2006) Stockholm+Skaane*: 18% (Evengard et al. 2001) Warsaw*: 41% (Nowakowska et al. 2006) * pregnant women World ~33% (Montoya & Liesenfeld 2004)

21. Fig. 1. Global status of Toxoplasma gondii seroprevalence. Source: Pappas et al. 2009. >60% 40-60% 20-40% 10-20% <10% Unknown Tartu: 55% (Birgisdóttir et al. 2006)

22. Cats20062007200820092010 Tested (N) (serology test) 23587 Positive (%)00000 Veterinaar ja Toidulaboratoorium Toxoplasmosis cats, Estonia

23. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Giardia

24. Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Giardia lamblia (Giardiasis)

25. Not listed among zoonotic infections in Estonia! Cases per 100.000 people Years

26. Giardiasis in humans in Latvia and Lithuania Absence of data!

27. Sweden199719981999200020012002200320042005200620072008200920102011 Total23281710173015621426142913541331114912911414152912071311970 Per 100.000 people 26.3119.3119.5217.6016.0216.0115.1114.7712.7014.1715.4116.5312.9313.9310.31 Smittskyddinstitutet (Smi) Reported cases of giardiasis in humans

28. Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Giardia Dogs infected General: ~30% Estonia: ~50% (REGISTERED cases) Humans: 291 cases/year Humans: 5.4 cases/100.000/year (Rimhanen-Finne et al., 2011) Outbreaks: 2007 (water) (Rimhanen-Finne et al., 2010) Risk: Travelling (east) (Jokipii et al., 1985) (REGISTERED cases) Humans: 350-500 cases/year Humans: 26-37 cases/100.000/year (Terviseamet, 2011) Lost work hours: 42.000—60.000/year Lost full time workers: 21-30/year Second highest infected European country (Lujan, 2011)

29. Veterinaar ja Toidulaboratoorium Estonia20062007200820092010 Pets %pos (N)00000 Sheep %pos (N) 00000 Cattle %pos (N)0100 (1) 43 (14) Studies ~50%* ~85% Reported cases of Giardia in animals and study prevalences

30. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Cryptosporidium

31. Cryptosporidium parvum (Cryptosporidiosis) Images: http://en.wikipedia.org/,http://en.wikipedia.org/

33. Cryptosporidiosis in humans in Latvia and Lithuania Absence of data!

34. Reported cryptosporidiosis in humans (Source: Infectious Disease Registry, THL)

35. Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Estonia20062007200820092010 Pets %pos (N)00? (2)00 Sheep %pos (N)00? (2)00 Cattle %pos (N)0100 (1) 00 Studies ~27% ~30 Reported cases of Cryptosporidium in animals and study prevalences Cryptosporidium not considered present in Latvian in cattle to noteworthy extent (46% positive)!

36. Cryptosporidium (C. hominis, C. parvum) Images: http://en.wikipedia.org/,http://en.wikipedia.org/ (REGISTERED cases) Humans: 0 or ? (REGISTERED cases) Humans: 11 cases/year Humans: 0.2 cases/100.000/year (Rimhanen-Finne et al., 2011) Outbreaks: 2008 (food) (Pönka et al., 2009) Outbreaks: 1986 (vets, cows) (Pohjola et al., 1986) Nordic countries (humans) UNREGISTERED cases per REGISTERED case Giardia: 254-867 cases Cryptosporidium: 4.072-15.181 cases (Hörman et al., 2004) Estonian projection (humans) Giardia: 6.604-32.079 cases/year Cryptosporidium: ? ECDC

37. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Other concerns

38. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Terviseamet

39. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Diphyllobothrium latum

40. Dupouy-Camet and Peduzzi 2004, http://www.eurosurveillance.org/viewarticle.aspx?articleid=467

42. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Terviseamet

43. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/

44. Images: http://en.wikipedia.org/,http://en.wikipedia.org/Images: http://en.wikipedia.org/,http://en.wikipedia.org/ Dilemmas

45. Awareness [knowledge] Detection [Methods] Identification [Microscopy] Assesment [Epidemiology] Expertise [Interpretation] Molecular tools [Details] 1 2 3 4 5 6 5 1 2 6 3 4 5 1 2 6 3 4 IDEAL DISTRIBUTION ACTUAL DISTRIBUTION The Dilemma of Synergy and The Weakest Chain

46. Awareness [knowledge] Detection [Methods] Identification [Microscopy] Assesment [Epidemiology] Expertise [Interpretation] Molecular tools [Details] Figure: Registered human cases ( Terviseamet ) No registered cases of Cryptosporidiosis and Echinococcosis! The Dilemma of Awareness It is amazing what we do not know about zoonotic parasites in Estonia! Cases of cryptosporidiosis in Estonia diagnosed in Finland or refused diagnosis in Estonia

47. Take home message: „Absence of data does not mean absence of pathogens or problems!“

48. Thank You Brian.Lassen@gmail.com Background artwork: sensitivelight.com Further data: http:/sbsp.eu (links) http://ecdc.europa.eu