Amoebiasis

Disease Trends in the U.S.: April 2002, an outbreak of gastroenteritis in 59 people occurred in Palau. Entamoeba histolytica was isolated in 9 of the 30 stool specimens. All of the cases reported consuming untreated drinking water from the same water tank that collected water from a stream. The water tested positive for fecal matter [21]. From July through September of 1998, 177 suspected cases of Entamoeba histolytica were identified in Tbilisi, Republic of Georgia. The outbreak was a result of contaminated water; fruits and vegetables purchased at an unofficial market and dairy products from an official market were also implicated in the outbreak [22]. In February of 1996, two institutions for the mentally retarded reported an Entamoeba histolytica outbreak. Thirteen residents from the first institution and twenty-nine residents from the second institution tested positive for the Entamoeba histolytica cyst. No cysts were found in the parents of the residents; none of the employees from the first institution tested positive, one employee from the second institution tested positive. The risk of infection for the parents and the employees was very low [23]. Amebiasis (intestinal) is caused by a single-celled parasite, Entamoeba histolytica. Most infections are asymptomatic. E. dispar infection and E. moshkovkii infections and 90 percent of Entamoeba histolytica infections are asymptomatic [8, 10, 16]. Symptoms of Amebiasis include bloody stool, abdominal cramps, chills, fever, prostration, nausea, headache and tenesmus [8, 15]. Entamoeba histolytica exist in two forms, the cyst stage, which is the infective form, and the trophozoite stage, which is the invasive form of the disease [16]. Reservoir of Infection: Humans are the reservoir and they are usually identified as a chronically ill or asymptomatic cyst passer [1, 6, 8]. Mode of Transmission: Primarily through ingestion of focally contaminated food or water containing amebic cysts (chlorine resistant). Transmission can occur sexually through oral-anal contact [6, 8, 14, 17]. Amebiasis is usually spread by a chronically ill or asymptomatic cyst shedder [1]. Amebiasis can also be transmitted through the unwashed hands of food handlers and fresh vegetables contaminated by human excrement [8]. A study which reviewed symptomatic amoebic patients between 2000 and 2001 in the big cities of Japan, found that 95% were male and over half of these male patients were homosexual [19]. Attack Rates: specific information was unavailable in the literature reviewed. Infectious Dose: the ingestion of one viable cyst can cause an infection [24]. Incubation Period: Can range from days to years; commonly lasts 2-4 weeks [6, 8, 18]. Infectious Period: Cysts may be passed for years [6, 8]. Untreated individuals may be

intermittently infectious for years [8]. Asymptomatic Carrier State: Intestinal Amebiasis can have a clinical presentation of chronic, nondysenteric diarrhea, weight loss, and abdominal pain, which can persist for years [16]. A study on adult carriers found that the vast majority of carriers remained asymptomatic during a 15 months observation period [13]. Diagnosis: An enzyme immunoassay kit to specifically detect E. histolytica in fresh stool specimens is commercially available. Polymerase chain reaction (PCR)-based diagnosis is not readily available [18]. Antigen detection assays are the best method for diagnosing intestinal Amebiasis [16]. Preventive Measures: Exclusions: Symptomatic
1. According to an article published in Communicable Disease and Public Health

(2004) Symptomatic individuals can return to work 48 hours after first normal stool; people whose work involves preparing or serving unwrapped foods not subjected to further heating and clinical and social care staff who have direct contact with highly susceptible patients or persons whom gastrointestinal infection would have particularly serious consequences require microbiological clearance...one stool obtained at least one week after the end of treatment should be examined for E. histolytica cysts [1]. Guidelines and Consensus Document {Grade III-A}
2. Bolyard et al (1998) states, Restriction from patient care and the patient

environment or from food handling is indicated for personnel with diarrhea or acute gastrointestinal symptoms, regardless of causative agent [2]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}
3. The American Academy of Pediatrics American Public Health Association and

the National Resource Center for Health and Safety in Child Care (2004) state, Children and caregivers who excrete intestinal pathogens but no longer have diarrhea may be allowed to return to child care once diarrhea resolves [3]. Guidelines and Consensus Document {Grade III-A}
4. According to the American Academy of Pediatrics American Public Health

Association and the National Resource Center for Health and Safety in Child Care (2004) Children with diarrheal illness of infectious origin generally may be allowed to return to child care once the diarrhea resolves [4]. Guidelines and Consensus Document {Grade III-A}

5. According to Guerrant et al (2001)because food-handlers and health care

workers can transmit bacterial and parasitic diseases even if they are asymptomatic, it is recommended that before returning to their jobs, these persons have 2 consecutive negative stools samples taken 24 hours apart and at least 48 h after resolution of symptoms [5]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}
6. According to Allason-Jones et al (1988) To determine the natural course of

infections with E. histolytica we did not treat the patients but reassessed them at three month intervals. At each visit we recorded details of any gastrointestinal symptoms and coincidental treatment and carried out a general examination; at least one fresh stool sample was examined for presence of parasites. The patients were considered to be clear of E. histolytica if three consecutive stool specimens gave negative results [17]. Review of Outbreaks and Epidemiology {Grade III-A}
7. According to the Communicable Disease Management Protocol (2001)

Exclusion of persons infected with E. histolytica from food handling and from direct contact of hospitalized and institutionalized patients for the duration of antimicrobial therapy [8]. Microscopic examination of feces of household members and other suspected contacts is recommended [8]. The Communicable Disease Management Protocol also recommends that symptomatic carriers should be treated the same as cases [8]. Guidelines and Consensus Document {Grade III-A}
8. Petri and Singh (1999) state, Since Amebiasis often spreads through a

household; it is prudent to screen family members of an index case for intestinal (Entamoeba) histolytica infection [9]. Evidence Based Literature {Grade III-A} Asymptomatic
1. According to Van Hal et al., (2007) Generally, asymptomatic patients never

become symptomatic. They may excrete cysts for a short period of time, but the majority of these patients will clear the infection within 12 months. Patients with confirmed (Entamoeba) histolytica should be treated to eliminate the organism and prevent further transmission [11]. Evidence Based Literature {Grade III-A}
2. According to Guerrant et al., (2001)because food-handlers and health care

workers can transmit bacterial and parasitic diseases even if they are asymptomatic, it is recommended that before returning to their jobs, these persons have 2 consecutive negative stools samples taken 24 hours apart and at least 48 hours after resolution of symptoms [5]. Evidence based reviews with guidelines formed out of reviewed literary sources {Grade III-A}

3. Gatti et al (1995) state, Our report confirms the importance of asymptomatic

carriers of pathogenic amoebic strains in the dissemination of disease and the epidemiological risk presented by such carriers. In the outbreak we described, it is almost certain that the Philippino maid represented the primary source of infection, probably transmitted via food or beverages [7]. Review of Outbreaks and Epidemiology {Grade III-A}
4. According to Gatti et al. (1999), Case 1 was infected during repeated food-

exchanges with his North African workmates, although it was not possible to test his colleagues for overt disease or asymptomatic infection. The asymptomatic male partner of the second couple most likely acquired his amoebic infection, along with his giardiasis, during a visit to India. Thus, it was the male partner in each couple who probably brought the parasite into their households. Their female partners are then assumed to have ingested amoebic cysts excreted by the men, by an indirect fecal-oral route, probably through handling contaminated house furnishings or by ingesting food handled and contaminated by the men [12]. Review of Outbreaks and Epidemiology {Grade III-A}