Canadian Society of Internal Medicine Annual Meeting 2018 Banff, AB

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1 Canadian Society of Internal Medicine Annual Meeting 2018 Banff, AB Prevalence of strongyloidiasis and schistosomiasis among migrants: A systematic review and meta-analysis Xing Jian Liu Division of General Internal Medicine, McGill University, Montreal, Canada

2 Prevalence of strongyloidiasis and schistosomiasis among migrants: A systematic review and meta-analysis Archana Asundi, Alina Beliavsky, Xing Jian Liu, Arash Akaberi, Guido Schwarzer, Zeno Bisoffi, Ana Requena-Méndez, Ian Shrier, Christina Greenaway Division of Infectious Diseases, Boston Medical Center, Boston, USA (A Asundi MD) Division of Infectious Diseases, University of Toronto, Toronto, Canada (A Beliavsky MD) Division of General Internal Medicine, McGill University, Montreal, Canada (XJ Liu MD) Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, McGill University, Montreal, Canada (A Akaberi MSc, I Shrier PhD, C Greenaway MD) Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center University of Freiburg, Freiburg, Germany (G Schwarzer PhD) Centre for Tropical Diseases (CTD), Sacro Cuore Don Calabria Hospital, Negrar, Verona, and Department of Diagnostics and Public Health, University of Verona, Verona, Italy (Z Bisoffi PhD) Barcelona Institute for Global Health (ISGlobal CRESIB), Universitat de Barcelona Hospital Clinic, Barcelona, Spain (A Requena-Méndez MD) Division of Infectious Diseases and Clinical Epidemiology, SMBD-Jewish General Hospital, McGill University, Montreal, Canada. (C Greenaway MD) Lancet Global Health. In Press

3 CSIM Annual Meeting 2018 Conflict Disclosures I have no conflicts to declare

4 Outline Introduction Methods Data analysis Results Discussion

5 Introduction Strongyloides stercoralis larvae Schistosoma mansoni eggs Source: CDC

6 Introduction Significant morbidity and mortality can be prevented by prompt diagnosis and treatment (Requena-Mendez 2017, Buonfrate 2017)

7 Introduction Rising global migration has increased their public health impact (Bisoffi 2013, Requena-Mendez 2017) Screening for strongyloidiasis and schistosomiasis Older guidelines: targeted screening based on region of origin (CDC 2013, Pottie 2011) Newer guidelines : broader migrant screening (Boggild 2016, Requena-Mendez 2017)

8 Methods Primary study outcomes The prevalence of Strongyloides larvae in the stool or seroprevalence The prevalence of Schistosoma eggs found in the stool or urine or seroprevalence Population Migrants originating from endemic countries and living in non-endemic countries

9 Methods Prepared and reported in accordance with PRISMA guidelines Three electronic databases (Medline & Medline in-process, PubMed, and EMBASE) were searched from inception until July 28 th, 2018 Authors contacted for missing information No funding source

10 Methods - Eligible studies Reported on the primary study outcomes Included migrants originating from endemic countries arriving/living in low endemic host countries, defined as the United States, Canada, Australia, New Zealand, Western Europe, and Israel In English or French

11 Methods - Exclusion criteria Only selected individuals at a study site were screened <70% of eligible persons underwent screening Subjects are symptomatic had eosinophilia had received potentially effective anti-helminthic therapy The study population that focused on migrants with particular medical co-morbidities Except HIV - stratified

12 Data analysis Stratification (if possible) by age (children 19 years old vs general population) immigrant status region of origin immigrant status within region of origin study setting host country decade of publication

13 World Bank classifications Source: Wikipedia

14 Data analysis Pooled proportion and its 95% CI R function metaprop from R package meta Random-effects model with arcsin transformed proportions Heterogeneity of estimates I 2 statistics

15 PRISMA flow sheet: Number of records identified, inclusions/exclusions and reasons for exclusions

17 Pooled and stratified strongyloidiasis prevalence

18 Pooled and stratified strongyloidiasis prevalence

19 Pooled and stratified schistosomiasis prevalence

20 Pooled and stratified schistosomiasis prevalence

21 Limitations High heterogeneity despite stratification Significant residual effect of unmeasured variables Missing data for variables Number of stool sample collected

22 Key points All migrants from all regions are at risk for strongyloidiasis Migrants from Sub-Saharan Africa are at highest risk for schistosomiasis, followed by Middle East and North Africa Poor sensitivity of stool diagnostic tests Serological testing is the preferred screening method for strongyloidiasis

23 Thank you! Questions?

24 Supplementary slides

25 Pooled and stratified Strongyloides and Schistosomiasis prevalence

26 Persistence of seroprevalence Schistosomiasis Detects both cleared and active infection Strongyloides serology May be limited by cross-reactivity with other helminth co-infections Serology is useful for the follow-up of patients infected with strongyloidiasis and determining test of cure (Buonfrate 2015)

27 Studies of patients with HIV Infection with HIV/AIDS has not been shown to be a risk factor to develop strongyloidiasis (CDC 2018)

28 Prevalence of schistosomiasis Highest in childhood and early adolescence Children tend to swim or bath in water containing freshwater snails We found that stool prevalence was higher in the studies with the general population compared to studies that included only children Only a few studies on children General population may include children

29 Random-effects model For series of studies that had been performed by researchers operating independently I 2 statistic measures the percentage of variation that is not due to chance

30 Less than a third of all studies documented collection of more than one stool sample

31 Abbreviations for regions of origin EAP SA CAs MENA SSA CAf LAC EEC East Asia & Pacific South Asia Combined Asia Middle East & North Africa Sub-Saharan Africa Combined Africa Latin America & Caribbean Eastern Europe & Central Asia

32 Forest plot of strongyloidiasis seroprevalence stratified by region of origin and sorted by year of publication

33 Forest plot of prevalence of strongyloidiasis larvae detected by stool microscopy stratified by region of origin and sorted by year of publication

35 Forest plot of schistosomiasis seroprevalence stratified by region of origin and sorted by year of publication

36 Forest plot of prevalence of schistosomiasis eggs detected by stool microscopy stratified by region of origin and sorted by year of publication

10/15/2018. Strongyloidiasis Important health problem? Important health problems in migrants? Important health problems in migrants?

10/15/2018. Strongyloidiasis Important health problem? Important health problems in migrants? Important health problems in migrants? ICMH, Rome 2018 Symposium, 3rd October 2018 Parasites: Malaria, Chagas, Schistosomiasis, and Strongyloidiasis Strongyloidiasis and schistosomiasis: screen, treat or forget? Schistosomiasis: Global distribution