Advance Biology

Research Project- Platyhelminthes Medical Response Plan

Mr.Andrew Filipczak

Fall Semester 2
Made by:

Ronnakit Taninpaisal (Series) ID6161064 1108

Kankamol Bongkot-Olarn (Fen) ID6161083 1107
Arinda Khampanich (Eve) ID6161044 1108
Burin Intachuen (Burin) ID6161015 1108
Suchanun Chantrapimol (Earn) ID6161028 1108
Table of content Page
Bluf 2
Situation 3
Constraint and Restraint 5
Response Procedure 6
Prevention Steps 8
Conclusion 9
Reference 10

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Bluff

An outbreak of the Clonorchis sinensis or Chinese liver fluke has occurred in the
Northern part of Thailand. The part of Northern Thailand that is most affected by this is small
towns with bad sanitation, small hospital aid, limited number of people, bad transit and limited
space. The villagers relied on freshwater from the river as their primary source of survival.
Clonorchis sinensis is a liver fluke that can affect mammals that eat uncooked fish, which
include humans too. It is classified in class Trematoda, phylum Platyhelminthes. Snails that eat
Clonorchis sinensis’ eggs from freshwater are infected by them. Once the Clonorchis sinensis’
eggs hatched, small larvae will come out. Later, these larvae will be eaten by fish. There are two
ways that humans can be infected by Clonorchis sinensis. The first way is that humans consume
uncooked fish that is infected by the parasite. The second way is from humans drinking
freshwater from the river that isn’t sanitized (boil or filtrate). After a period of time, Clonorchis
sinensis that lives in the infected patient will begin to cause damage to their digestive system.
There are 202 reported cases including 34 deaths. However, the number is believed to be much
higher.
The response procedures that we must take are the following. Since the symptoms of
Clonorchis sinensis can vary from no symptom to mild stomach ache. To deal with this, we need
to contact the public center and the district chef for a stool test. The district chef will contact the
village head of the respected areas to gather people in the village for stool tests each week.
People that are infected by the parasite will be given Praziquantel and they will be questioned on
where the fish that they eat came from. Once, we conclude the potential area that the parasite
comes from. We’ll contact the police force to close off the area. Then, the district chef spread the
news and warned the people about eating uncooked fish and snails as ingredients.

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Situation

We found the area of an outbreak of the ​Clonorchis sinensis or Chinese liver fluke in ​the
Northern region of Thailand. The area of infection are rural areas with small towns containing
approximately 10,000 people with a few transit areas. The sanitation system does not reach these
areas the same as the hospital that can only accommodate a small number of patients with limited
space. The forest surrounding the towns contains freshwater rivers and streams that the locals
heavily rely on. The surrounding forest also includes habitats of mammals, reptile and mollusk
species; snails and freshwater fish are found in large quantities. People in the areas also fed on
both plants and animals in the surrounding forest

Clonorchis sinensis, the Chinese liver fluke, is a liver fluke belonging to the class
Trematoda, phylum Platyhelminthes. It infects fish-eating mammals including humans. In
humans, it infects the common bile duct and gallbladder, feeding on human bile.The lifespan of
this parasite is about 25-30 years.Clonorchis Sinensis or Chinese liver fluke’s eggs are in
freshwater and continue spreading via snails that ingest Clonorchis eggs. The eggs in infected
snails will hatch and release small larvae that fishes in freshwater consume and enter to the fish.
Then people can continue the spread of chinese liver fluke by consuming uncooked fish that
contains parasites. The liver flukes will grow inside the human bile duct system, It takes 3
months to complete one life cycle of the Clonorchis Sinensis in humans.

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 This Clonorchis can be infected by eating uncooked fish or only salted or smoked which
cannot kill the flukes. People can also be infected by drinking river water or drinking low quality
which are not suitable for drink or cook can also lead to infection.
Patient will not show any symptoms at first, but liver fluke will damage the liver and
gallbladder in humans and cause severe illness after a period of time. There are more than 300
cases of infection and the number are most likely to increase because of Northern people’s eating
habits. To be detailed, People in some parts of Northern and Eastern of Thailand have a regular
habit of eating fermented fish or son dried fish. From the information about the fluke, only salt
cannot kill the eggs of the fluke in fish which causes more people to be infected.
Prognosis - ​Long exposure to Chinese liver fluke can lead to Clonorchiasis, which
according to MSD Manual is described as infection with liver fluke Clonorchis sinensis.
Clonorchiasis symptoms include fever, chills, upper abdomen pain, hepatomegaly becoming
tender, diarrhea and a mild case of Jaundice. Jaundice is when the skin and the white area of a
person’s eye turn yellow. The symptom of Jaundice depends on the waste material found in the
body called Bilirubin. Bilirubin is an orange-yellow substance made during normal breakdown
of red blood cells. Jaundice is usually associated with liver problems. Normally bilirubin would
bond with other chemicals once it reaches the liver and become conjugated bilirubin. Conjugated
bilirubin is the substance that gives feces the brown color. In the case that there’s too much
bilirubin, known as hyperbilirubinemia, it would result in yellowing of the mentioned organs.

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Constraints & Restraints

The limitation needed inorder to prevent Chinese liver fluke which can happen by people
excreting all over the place into the river with the eggs of the liver fluke contaminated. The
larvae of this period will live in the flesh of the freshwater fish, while people and animals would
consume raw fishes with living larvae inside, which would only be killed at 70 degree celsius or
up. However, killing or any kinds of inaction that would result as animal death should be illegal
to do.
The constraints or the condition that someone tells you not to do, would be to not kill or
to do any harmful actions that would result in the animal's death. Fish that are suspected to have
the infections should be separated from the others while people who suspect to have a parasitic
infection, early treatment by using Albendazole which is an anti-worm medication which
prevents newly hatched insects or larvae and an appointment to the doctor would be helpful.
While the restraint or what you will not do yourself, is to not eat any kind of raw or uncooked
food. Food must be clean and well cooked before being consumed.

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 Response Procedures

Health
As the first means to respond to the Chinese Liver Fluke we must find out who is infected
with the fluke. From the statistics we can conclude that there are about 10,000 people who are
infected with the platyhelminthes. To deal with the current spread of the liver fluke. We need to
know who is infected with liver fluke. Since the common symptoms can range from no
symptoms to mild stomach ache. It is best that we contact the public health centre and the district
chief to gather people for a stool test. Each week the district chief will contact the village head in
the respected area to gather people from their village to come to the hospital in order to gather
the stool samples without overcrowding them.Then the sample will be sent to be tested. People
who are infected with the fluke worm will then be given Praziquantel. Dosage for children older
than 4 years old and adults is 25 mg per 1kg of weight 3 times/day for 1 day. The people who are
infected will be asked where the fish that they consume came from. We then contact the police
force to close down the water source that the potential host came from. We asked the district
chelf to spread the news about the water sources being closed down to the civilians and to avoid
eating dishes with uncooked fermented fish or freshwater snails as ingredients. For citizens that
need a water source for hydration we will now offer 2 packs of 1500 litre of drinking water in
each household.

Projection

If we interfere now there will be a lower case for us to handle in the long term compared to
interfering three months after the first case. If there is an influx of patients coming into the
hospital it could potentially lead to the hospital to have too many patients which would impact
the treatment. The faster we can detect the outbreak, the easier we can control the situation.
Since we are confident that we can slow the rate of infection by 15 people per month if we
interfere now, it deems to be a better option compared to waiting until the number of people
infected in 3 months increases and reduces the infected by 10 per month. As the graph below
suggests if we choose to respond now a new case would likely to stop appearing in August the
year after. If we choose to respond 3 months after, new cases would most likely stop appearing
in March 2 years after the case started. As suggested by the total case graph if we choose to
respond now, the total number of cases would stop increasing by August the following year. If
we choose to respond in 3 month the number of total cases would stop increasing by April 2
years after the start of the spread. So our best decision is to respond right away.

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Cost

First we need to calculate the price of the medicine for 10,000 people. The cost of a
single 600-mg tablet is about 4.11 baht and an average treatment is estimated to be between
6.32-9.48 baht. And we know that the treatment lasts for 3 times for 1 day. So the cost for the
medicine would be 4.11 x 3 = 12.33 per person. This added with the average treatment would be
9.48 + 12.33 = 21.81 per person. To treat the whole population of 10,000 people would cost
218100 baht.
According to research Thailand has approximately 3 people per household. This average
down to 3333 households that are in need of water which is not available for them due to the
outbreak. Since the amount of water can vary from individual we would collect how much water
each family drinks in a week. The rough cost of this would be derived from estimations. On
average people drink around 1.5-2 litres of water per day. Which means for a household it would
require 42 litres per week. The cost of one pack of 1.5 l with 6 bottles is 55 baht. So for one
household, the cost would be 275 baht per week for 5 packs of water and for 3333 households it
would be around 916575 baht per week.

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Prevention Steps

It’s as important to stop Chinese liver fluke from spreading as it is to prevent any new
Chinese liver fluke from spreading in the future. To prevent future spread firstly, farmers will
have to follow a set of tasks. Firstly pig and cattle farms are to isolate their waste in a safe
container away from water sources and snails habitat. The waste would be used as fertilizers
once free of chinese liver fluke. Pigs and cattle are to be vaccinated and treated with flukicide if
symptoms of infections are found. Diagnosis of ​Clonorchis sinensis in cattles and pigs includes
faecal egg counts, and antibody detection test. By performing faecal egg counts, the presence of
adult liver fluke can be identified in a specific organism. Antibody detection tests can be
performed by sending milk and blood samples to a local vet to analyse. Symptoms of livestocks
being infected usually include reduction in milk production, reduced muscle mass and damaged
liver. ​Pisciculture is to regularly undergo strict inspections of water sources and fish quality in
order to be able to send out fish conducted by FDA (Food and drug administration) and
DOA(Department of agriculture). Local food businesses are to undergo inspections and receive
qualifications provided by us following the FDA and DOA regulation in order to be able to serve
fish and snail menus. Our inspection includes the cleanliness of food storage and kitchen,
employees hygiene and service hygiene. Local businesses are to undergo inspections on a cycle
of once per 2 weeks. To be able to sell foods in markets, the market has to undergo regulation
and has to follow the health expectation set by the FDA. Expectations would include the cleaness
of each stalls, proper separation of fresh food and cooked food, and proper equipment
maintenance. Food stalls are to either operate in markets or in their own land. Conducting
business on the pavement would be considered unhealthy and beyond the local government's
reach to inspect. Any food business conducted on the pavement is to either move to the market or
conduct business on own land. EPA is to be carried out in order to regulate water quality.
Businesses and locals are to manage their waste and avoid disposing of water sources without
water treatment. Anyone who were to oppose these tasks will be charged accordingly and food
related businesses that violate their responsibility in the community will have their qualification
taken and have to under a new regulation after a 3 month suspension. As these tasks are being
carried out it is important to educate the community. As a way to reach the majority, students
will be reached out to first. Schools are to teach students about the danger of eating raw fish in
health class and to promote eating cooked fish. After a month local news providers are to include
facts about chinese liver fluke in their sites and newspaper. A month later, we would be
providing free basic courses for farmers to be educated about responses to ​Clonorchis sinensis.

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Conclusion

To conclude the project, an outbreak of the Clonorchis sinensis or Chinese liver fluke has
occurred in the Northern part of Thailand. Due to their eating habits, the outbreak has worsened
because Northern people like to eat uncooked foods.. Clonorchis sinensis is a liver fluke that
affects mammals that eat uncooked fish. There have been about 202 reported cases including 34
deaths. We came up with a response procedure to contact the public health center and district
chef. The distinct chef will contact the head of the village and invite the villagers of the respected
village to take a stool test each week. People that are infected will be given ​Praziquantel and they
will be questioned on where they ate the fish. Once, we narrowed down a specific place that the
infected fish came from. We will contact the police force to close down that area and spread the
news/warnings of the parasite.

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Reference
https://www.who.int/schistosomiasis/strategy/en/
https://www.cdc.gov/parasites/clonorchis/biology.html
https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007214
https://www.bigc.co.th/sigha-water-1-5-l-pack-6.html
https://www.sciencedirect.com/topics/immunology-and-microbiology/clonorchis-sinensis
https://www.scops.org.uk/internal-parasites/liver-fluke/lifecycle/
https://www.cattleparasites.org.uk/liver-fluke-and-rumen-fluke/
https://www.cattleparasites.org.uk/app/uploads/2018/04/COWS-guide-to-liver-fluke.pdf
https://www.uptodate.com/contents/liver-flukes-clonorchis-opisthorchis-and-metorchis
https://www.scops.org.uk/internal-parasites/liver-fluke/detection-treatment-and-control/
https://www.healthline.com/health/liver-fluke#treatment
https://www.medicalnewstoday.com/articles/165749
https://www.msdmanuals.com/professional/infectious-diseases/trematodes-flukes/clonorchiasis
http://www.infectionlandscapes.org/

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