Chinese Liver Fluke, Clonorchis sinensis 
Outbreak Response Plan 
 

By 

Nichaporn Nattawut 

Pathitta Kittimongkolsuk 
Parinada Suriyaworakul 

Pemika Phatthanakittichai 

Wanwarisa Krittiyasrisumet 

Advanced Biology 1102 

Mr. Andrew James ​Filipczak 
Mahidol University International Demonstration 
School 
Semester 2 Academic Year 2017-2018  
 
BLUF: 
Chinese  Liver Fluke, also referred to as Clonorchis sinensis, is a disease that is commonly 
spreading  in  the  eastern  part  of  the  world,  especially  in  China,  Korea  and  Thailand.  At  this 
moment,  there  is  a  Platyhelminthes parasite outbreak in the northern part of Thailand. There are 
already 202 reported case on this outbreak, 34 of which are confirmed to be dead. Numbers have 
been  predicted  that  new  cases  will  increase  by  the  average  of  25  cases  per  month  and  will 
continuously rise if medications are still not provided. 
The  clonorchis  sinensis  will  enter  human’s body in the stage of ​Metacercaria which came 
with  the  consumption  of freshwater fish that is undercooked or not cooked properly. When they 
grow  up,  they  will  lay  eggs  which  come  out  with  the  feces  and  they  will  grow  up  to  be  a 
Miracidium  in  the  first  intermediate  host,  snail.  The  Miracidium  will  go  through  development 
stage  and  come  out  before  penetrating  under  fish  scales  and  later,  get  into  human when we eat 
undercooked fish.  
Once  the  ​clonorchis  sinensis  get  into  human,  mostly,  it  is  ​asymptomatic​.  In  some cases, 
they  may  have  ​indigestion,  abdominal  pain,  constipation  and  some  other  issues.  As  a treatment, 
we suggest the use of Praziquantel which is the the most recommended medicine for this disease. 
This medicine will help to get rid out of the ​clonorchis sinensis from our body.  
As  for  the  local  government,  we  want  them  to  ​help spreading the information about the 
Clonorchis  sinensis  for  the  villagers,  including  their  life  cycle,  how  they  grow,  where  they  come 
from,  how  to  prevent  them  and  how  to  deal  with  it  if  you  have  contracted  it.  The  government 
should improve the area and expand the hospital so that it can support the infected people​.  
Police  can  help  in  this  situation  by  ​helping  local  government  to  spread  the informations 
regarding  the  disease.  In  order  to  prevent  the  spread  of  ​Clonorchis  sinensis  to  other  places, 
police  can  enforce  law  in  checking  meal  before  exporting  them  out  of  the  area.  They  can  also 
support  the  local  hospital  by  help  sending  the  people  who  are  infected  to  the  hospital.  For  the 
last  part  which  is  local  hospital,  they  can  ….  The  prevention  of  this  can  be  divided  into  2 main 
parts  which  are  current  spread  and  future.  The  prevention  of  current  spread  can  be  as  follows: 
take  medicines  to exterminate the parasite, consume only  properly cooked meat and fish, build a 
quarantine  area,  and  sterilize  feces.  The  future  prevention  for  this  are  as  follows:  educating 
people  on  ​health  education,  environmental  construction,  and  improvement  of  sanitation.  The 
cost  of  medicine  is  1,000  baht  per  person,  which  will  be  253,000  baht  in  total  for  253  infected 
people. 
 
Current situation of Chinese liver fluke 
Chinese  liver  fluke  is  severely  spreading  all  over northern part of Thailand. According to 
figure  1.a)  the  first  case  is  reported  in  September  and  the  number  of  patient  increases 
enormously  in  each  month  as  shown  in  figure  1.b)  Amount  of  new  cases increase by average of 
25  cases  per  month  and  still  increasing  continuously  due  to  no  medication provided in that area 
yet.  Statistically,  the  situation  will  reach  a  critical  level  soon  which  may  spread  the  infection  to 
other part of Thailand due to citizen habit below. 
 
 There  are  10,000  citizens  in  this  series  of  interconnected  town  which  each  citizen  are 
usually  moving  all over to every single town in the series which cause the infection to spread into 
every  town  equally.  Their  food  source  are  forest and river which are major source of the carriers 
and  parasites.  One  third  of  citizens  are  closely  in  touch  with  carriers  and  host  due  to  the 
livestocks that they raise up for selling to the major towns in Thailand.  
 
Month  New cases  Total cases 

September  1  1 

October  3  4 

November  10  14 

December  25  39 

January  29  68 

February  35  103 

March  52  155 

April  47  202 

 
figure 1.a ) chart of total cases and new cases since the start of the outbreak 
 

figure 1.b ) graph for infection of chinese liver fluke infection outbreak. 
for Equation for new cases:  
2.07E − 0.3x8 + (− 0.0405x7 ) + 0.175x6 + 1.33x5 + (− 14.9x4 ) + 51.1x3 + (− 69.6x2 ) + 33.9x + 1  
( R2 = 0. 999 ) 
Equation for total cases: − 0.146x3 + 5.67x2 + (− 3.68x) + 1.29 ( R2 = 0. 999 ) 
 
Area: 
The area that the parasite breakout takes place is in the northern part of Thailand. 
Statistically, there are a total of 10,000 people in the area. The geographical features of the area 
include mountains, thick forests and river valley. In addition, there are three main water sources 
that people rely on both agriculturally and daily, which are Nan river, Mekong river, and Salween 
river. As for the cultural aspect, 96.1% of the people are Buddhist, 3.4% are Christians, and 0.5% 
are made up of other religions. 

 
Constraints & Restraints: 
There are many constraints in this rural area. Firstly, killing livestocks are off limits. 
Because people in this area believe Buddhism, killing animals is prohibited and often frowned 
upon as it is considered to be a sin in one of the five precepts that shouldn’t be committed in 
Buddhism. Also, animals are one of the main sources of income for people in this area as they 
rely on animals to farm and sell them off. Secondly, killing infected people are also off limits 
because of religious beliefs and morals. Thirdly, chemicals of any kind couldn’t be released into 
the water sources as citizens mostly rely on them for daily uses and agricultural uses.  
As for restraints, there are three conditions that the local government should 
acknowledge and abide by. If any of these conditions are not met, further assistance in the area 
will be denied. Firstly, we will not kill infected people under any circumstances as it is inhumane 
and is on the extreme side. Secondly, we will not consume local food and water to endanger the 
health of by any means, due to the ongoing spread of parasite in this area. Lastly, we would like 
the local government to provide us these following accommodations: laboratories and motoring 
rooms to test the stool samples, and to observe the effects of the medicine and calculate the 
average duration of the disease after the ingestion of medicine. 
 
 
 
Life cycle: 
 

 
 
 

 
 
The cycle starts when human ingests in the parasite via uncooked fish or meat. The 
Metacercaria excysts in duodenum, then migrates to bile ducts. Onces the fluke s grow up, they 
release eggs which will go outside the host’s body through feces. Those embryonated eggs will 
later be ingested by the freshwater snails which is the first intermediate host. Those eggs will 
grow as a Miracidium and go through several development stages, namely sporocysts, rediae, and 
cercariae, in the host’s intestines.​ ​The cercariae free swimming exits the snails and penetrates into 
the second intermediate host, freshwater fish, as metacercariae. The metacercariae are ingested 
into human when undercooked, salted, pickled, or smoked freshwater fish, are consumed. Then, 
the cycle will continue and repeat. 
 
Symptoms: 
This parasite mostly cause no symptoms in light infection, which can also be referred to 
as asymptomatic. However, there might be some symptoms occur in weak cases including 
indigestion, abdominal pain, and constipation. In long term infections, the symptoms can be 
more severe, such as hepatomegaly and malnutrition may also be presented. Cholangitis, 
cholangiocarcinoma and cholecystitis can be developed in rare cases. 
 
Response and Procedure: 
Medical 
Praziquantel is the only medicine recommended. It should be administered at the dose of 
25 mg/kg 3 times daily for 2–3 consecutive days or of 40 mg/kg, single administration. The user 
should be aware of the food that they consume while using this medicine namely grapefruits. 
The common side effects of this medicine include headache, dizziness, stomach pain or upset, 
nausea, tiredness, ​weakness​, joint or ​muscle pain​, ​loss of appetite​, ​vomiting​, fever, skin rash, and 
sweating. 
Albendazole is the second choice for the treatment of Liver Fluke. For adults and 
children above 2 years old, the medicine should be administered at the dose of 10 mg/kg for 7 
consecutive days after meal. If it is the albemed brand, they should take at the dose of 400 mg 
twice a day for 3 days. The side effects are similar to Praziquantel which are headache, dizziness, 
stomach pain, vomiting, fever, sweating and some other symptoms. 
 
Local government 
We would need the local government to help us in spreading information about eating 
raw or undercooked fish and meat. We need to make sure that the parasite from fresh fish would 
not spread to the citizens. Government should consider in expanding hospital area, so that it 
would be able to provide and support all patients’ needs. Also, they need to improve the area 
sanitation, so that people in the area can have a better living quality.  
 
Police 
We need the police to take part in helping the government spread the information 
regarding the disease and ensure that there is no suffering people in the area. Police should be 
available for the needs of citizens in informing the hospital about the infected people and help 
bringing them in to the hospital for treatments. Police can also enforce a law such as checking 
the exporting meats for the contamination of liver fluke, so that the disease would not spread 
out into other cities. 
  
  
Local hospital 
We would need help from the local hospital to separate people who have the disease 
from those who don’t by ultrasounding liver and give medicine to those who are infected. 
Doctors and staffs should take care of infected citizens cautiously and to the best of their ability. 
 
Prevent current spread: 
To prevent the current spread of Clonorchis Sinensis, the simplest way is to start by 
taking the medicines called Praziquantel to exterminate the parasite and let parasite out from the 
infected people. Secondly, citizens should not eat raw or undercooked fish. According to the life 
cycle of Chinese liver fluke, they can penetrate fish scales into the fish’s body and reside there. 
Therefore, people who eat raw fish can be infected easily from this parasite. Next, the creation of 
quarantine area is required to separate people who have the disease from those who don’t. As the 
eggs of Chinese liver fluke can be released into the human feces, we need to make sure that the 
parasite do not migrate anywhere else. In addition, to cut the life cycle of the parasite, the feces 
should be sterilized so snails cannot be infected by the eggs of this parasite.  
 
Future Prevention: 
There are many ways to prevent Clonorchis Sinensis from spreading in the future. Firstly, 
the health education aspect. A TV program or a short film educating about the disease could be 
broadcasted on the national TV program. By doing this, citizens in rural area would also get the 
information about the disease, how it can be transmitted, and how to prevent it as well. 
Alternatively, inviting a medical professor or a local health service in those areas to educate 
children in school about the disease and how it can be prevented, for instance, avoiding the 
consumption of raw or undercooked meat and fish as fish acts as the second intermediate host 
for liver flukes, would also be effective as well. Also, promoting the use of clean water, for 
instance, water filtering and water purification, could also be beneficial to the citizens as well 
seeing as liver flukes often reside in water sources.  
Secondly,  the  environmental  construction  aspect.  Firstly,  a  bigger  hospital  could  be 
constructed  because  the  existing  one  is  small  and  simply  not  enough  to  accommodate  a  large 
quantity  of people. Also, the division of livestocks could be planned. In order to cut the life cycle 
of  liver  flukes,  the  pigsty  area  should  be  separated  from  the  fish  pond  as  liver  flukes  lay  eggs in 
stools  and  those  parasite  could  penetrate  through  the  fish’s  skin  if  they  get  into  the  water. 
Thirdly,  the sanitation aspect. Another way to prevent the liver flukes from getting into the water 
sources is to schedule a weekly drains disinfection.  

Financial aids: 

In financial, we came up with two types of costs we needed to consider; fixed costs and 
variable costs. For the fixed costs, we would need money to buy materials in order to build 
toilets, and improve sanitation in this area. We would help them install some water filter in public 
area, so we would need an amount of budget to buy and install water filters. Money is also 
needed to relocate the place for raising livestocks and fish ponds and rebuild some stalls. 

It would cost 1,000 baht per person to cure and get them back to health. Therefore, the 
total cost of the medication needed to cure every infected person would vary upon the number 
of infected people. If we intervene the infection now, it would cost around 253,000 baht, but if 
we wait three month later, the total medication cost would be around 1,177,000 baht. Another 
variation cost that we have to consider is the amount of money needed to cure infected animals 
(hosts). 

 
Conclusion: 

In conclusion, we choose to intervene now, so that the number of the infected people 
will decrease faster, which is by the rate of 15 person per month. It also costs less comparing to 
if we choose to intervene three months later; only 253,000 baht comparing to 1,177,000 baht, 
respectively. In addition, if we choose to intervene now, the maximum number of infected 
people would only reach up to 253 people in August and would reduce to zero if we follow our 
response plan by using Praziquantel as our medicine to help cure the disease.  

References: 
Tang, Z., Huang, Y., & Yu, X. (2016, July 6). ​Current status and perspectives of Clonorchis 
sinensis and clonorchiasis: Epidemiology, pathogenesis, omics, prevention and control. Retrieved 
March 28, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933995/ 

CDC. (2018, March 7). Clonorchis FAQs. Retrieved March 19, 2018, from 
https://www.cdc.gov/parasites/clonorchis/faqs.html 
 
WHO. (n.d.). ​Clonorchiasis. Retrieved March 19, 2018, from 
http://www.who.int/foodborne_trematode_infections/clonorchiasis/en/ 
 
Clonorchiasis - Chinese or Oriental Liver Fluke Disease. (n.d.). Retrieved March 20, 2018, from 
http://web.stanford.edu/class/humbio103/ParaSites2001/clonorch/ClonorchiasisWebsite.html 

Seo, BS., Lee, SH., Chai, JY., & Hong, ST. (n.d.). Praziquantel(Distocide(R)) In Treatment Of 
Clonorchis Sinensis Infection. Retrieved March 20, 2018, from 
https://www.ncbi.nlm.nih.gov/pubmed/12902655  
Klase, G. L., (2013). ​The Chinese liver fluke Clonorchis sinensis​: ​an environmental investigation 
into a foodborne parasite. Retrieved March 20, 2018, from 
https://etd.ohiolink.edu/rws_etd/document/get/osu1366378549/inline