International Journal for Parasitology xxx (2013) xxx–xxx

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International Journal for Parasitology

journal homepage: www.elsevier.com/locate/ijpara

Invited Review

The epidemiology and public health importance of toxocariasis:

A zoonosis of global importance
Calum N.L. Macpherson ⇑
Windward Islands Research and Education Foundation, St George’s University, Schools of Medicine and Veterinary Medicine, P.O. Box 7, Grenada

a r t i c l e i n f o a b s t r a c t

Article history: Toxocariasis, caused by infection with larvae of Toxocara canis, and to a lesser extent by Toxocara cati and
Received 27 June 2013 other ascaridoid species, manifests in humans in a range of clinical syndromes. These include visceral and
Received in revised form 16 July 2013 ocular larva migrans, neurotoxocariasis and covert or common toxocariasis. Toxocara canis is one of the
Accepted 18 July 2013
most widespread public health and economically important zoonotic parasitic infections humans share
Available online xxxx
with dogs, cats and wild canids, particularly foxes. This neglected disease has been shown through sero-
prevalence studies to be especially prevalent among children from socio-economically disadvantaged
Keywords:
populations both in the tropics and sub-tropics and in industrialised nations. Human infection occurs
Toxocariasis
Toxocara canis
by the accidental ingestion of embryonated eggs or larvae from a range of wild and domestic paratenic
Toxocara cati hosts. Most infections remain asymptomatic. Clinically overt infections may go undiagnosed, as diagnos-
Visceral larva migrans tic tests are expensive and can require serological, molecular and/or imaging tests, which may not be
Ocular larva migrans affordable or available. Treatment in humans varies according to symptoms and location of the larvae.
Neurotoxocariasis Anthelmintics, including albendazole, thiabendazole and mebendazole may be given together with
Covert toxocariasis anti-inflammatory corticosteroids. The development of molecular tools should lead to new and improved
Epidemiology strategies for the treatment, diagnosis and control of toxocariasis and the role of other ascaridoid species
in the epidemiology of Toxocara spp. Molecular technologies may also help to reveal the public health
importance of T. canis, providing new evidence to support the implementation of national control initia-
tives which have yet to be developed for Toxocara spp. A number of countries have implemented repro-
ductive control programs in owned and stray dogs to reduce the number of young dogs in the population.
These programs would positively impact upon T. canis transmission since the parasite is most fecund and
prevalent in puppies. Other control measures for T. canis include the regular and frequent anthelmintic
treatment of dogs and cats, starting at an early age, education and enforcement of laws for the disposal
of canine faeces, dog legislation and personal hygiene. The existence of wild definitive and paratenic
hosts complicates the control of T. canis. Increasing human and dog populations, population movements
and climate change will all serve to increase the importance of this zoonosis. This review examines the
transmission, diagnosis and clinical syndromes of toxocariasis, its public health importance, epidemiol-
ogy, control and current research needs.
Ó 2013 Australian Society for Parasitology Inc. Published by Elsevier Ltd. All rights reserved.

1. Introduction where dog treatment and population control is limited. Toxocara

Toxocariasis manifests itself in humans as a range of syn-
dromes. They are primarily caused by infection with larvae of the
ascardoid nematode Toxocara canis (Werner 1782) and to a lesser
extent by Toxocara cati (Schrank 1788) and related species.
Toxocara canis is one of the most widespread public health and eco-
nomically important zoonoses humans share with dogs, cats and a
range of wild definitive hosts, particularly foxes (Glickman and
Schantz, 1981; Schantz, 1989). Toxocariasis is particularly preva-
lent in the tropics and sub-tropics, in less industrialised nations
canis infection is also an important cause of morbidity in wealthier,
industrialised nations, especially in children and socio-economi-
cally disadvantaged populations (Torgerson and Budke, 2006;
Hotez, 2008; Hotez et al., 2013; Paul et al., 2010; Torgerson and
Macpherson, 2011). Other species of Toxocara contribute to the
global burden of toxocariasis, but their importance is less well
understood or defined. This includes T. cati, which has a similar
global distribution to T. canis. The importance of T. cati infection
to toxocariasis cannot be ignored (Fisher, 2003; Smith and Noor-
din, 2006). Other species include Toxocara malaysiensis (Gibbons

⇑ Tel.: +1 473 444 3997; fax: +1 473 444 3041.

E-mail address: cmacpherson@sgu.edu

0020-7519/$36.00 Ó 2013 Australian Society for Parasitology Inc. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijpara.2013.07.004

Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
2 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx

et al., 2001) which occurs in cats in Malaysia and China (Li et al.,
2006; Gasser, 2013; Mohd Zain et al., 2013), Toxocara vitulorum
of cattle, buffalo and other ruminants (Rast et al., 2013; Woodbury
et al., 2012), Baylisascaris procyonis from raccoons in the USA, Eur-
ope and Japan (Chavez et al., 2012), other Baylisascaris spp. (Gavin
et al., 2005; Bauer, 2013) and Ascaris suum of pigs (Pinelli et al.,
2011). Many other ascaridoids including Toxocara pteropodis (bats)
and members of the genera Lagochilascaris (opossums), Porrocae-
cum sp. (birds of prey) and Ophidascaris, Polydelphis, Travassoascaris
(snakes), have zoonotic potential but their importance is likely to
be very limited due, inter alia, to the lack of human exposure to
these parasites (Lloyd and Morgan, 2011). Toxascaris leonina, which
occurs in dogs, cats and various wild canids and felids throughout
the world, is also considered to have limited zoonotic potential
(Morgan, 2013).
7 years (Beaver et al., 1952; Salem and Schantz, 1992; Taira
et al., 2004; Lloyd, 2006; Choi et al., 2012; Strube et al., 2013).
L3s may also be found in a range of invertebrate hosts including
earthworms. Dogs which ingest paratenic hosts can develop adult
worms but there is no tracheal migration (Overgaauw and van
Knapen, 2013). L3s ingested by omnivorous or carnivorous parate-
nic hosts can migrate to the tissues of a new paratenic host.
Ingestion of paratenic hosts plays an important role in T. cati
infection for adult cats. Transmission of the parasite from infected
rodents may be facilitated by behavioral changes induced in ro-
dents infected with T. canis, which may impair survival and fitness
relative to the intensity of infection (Cox and Holland, 2001). Post
mortem examination of rats (Rattus norvegicus) which had been
experimentally infected with T. canis revealed L3s in muscle, eye,
liver, kidney, brain and lung (Santos et al., 2009). The same situa-
tion may apply to T. cati.

2. Veterinary aspects
2.3. Survival and distribution of eggs of Toxocara spp.

2.1. Definitive hosts

Once expelled, T. canis eggs require 2–6 weeks at temperatures
of 10–30 °C before the eggs are fully embryonated and contain
Toxocara canis is transmitted predominantly among canids
infective L3s. Increasing temperature accelerates the development
(dogs, foxes, wolves and coyotes) and T. cati by felids through a
as well as the degradation of T. canis eggs while temperatures
wide variety of routes. These include vertical transmission, trans-
colder than 10 °C or warmer (>37 °C) are inimical to the matura-
placental (not cats) and/or trans-mammary (lactogenic) as well
tion or survival of eggs (Gamboa, 2005; Azam et al., 2012). Embry-
as horizontal transmission through the ingestion of embryonated
onation is therefore seasonal in temperate climates but year-round
eggs from the environment or ingestion of larvae via vertebrate
in tropical areas. Toxocara canis eggs do not embryonate in dark-
and/or invertebrate paratenic hosts (Overgaauw and van Knapen,
ness (Feney-Rodriguez et al., 1988), and infections have yet to be
2000). It is the ability of T. canis to survive for many years in the
reported from the Arctic (Jenkins et al., 2013).
tissues of a substantial number of vertebrate species, as well as
Eggs are very resistant and survive well over most winters in tem-
to develop to sexual maturity in the intestinal tract of its definitive
perate climates, surviving for 6–12 months. Some eggs may be able
canid hosts, especially dogs, that has facilitated its global
to survive in moist, cool conditions for 2–4 years or longer (Azam
distribution.
et al., 2012). Soil type, pH and percentage of vegetation cover impact
Pups are infected in utero by reactivated, somatic larvae of
upon contamination and viability with clay soils negatively impact-
T. canis from the mother from day 42 of gestation (Lloyd et al.,
ing on egg viability (Trejo et al., 2012). In sandy soils in Perth, Austra-
1983). This efficient trans-placental infection route results in egg
lia, eggs disappeared over 6 months, despite favorable conditions
excretion 16 days after parturition (Lloyd, 1993). More limited,
(Dunsmore et al., 1984). In Poland, 1 year after deposition in sandy
lactogenic transmission continues to occur for 5 weeks. Kittens
soils a few eggs were recovered with 60–90% viability and >94% were
are infected by vertical, lactogenic transmission of T. cati and com-
found in the top centimeter (Mizgajska-Wiktor and Uga, 2006). The
mence fecal egg excretion 47 days after birth (Overgaauw and
substrate, light, temperature, humidity, pH and vegetation cover
van Knapen, 2013). Once infected, pups shed millions of eggs per
are important factors for egg availability, development and survival;
day into the environment, depending on the intensity of T. canis
the proportion of deposited eggs that survive and/or are available to
infection and host immune status (Glickman and Schantz, 1981).
hosts is unknown. Eggs can be physically dispersed by movements of
Dogs and other canids also become infected by ingesting embry-
definitive hosts, rainfall, birds, beetles, earthworms, slugs and flies.
onated eggs from the environment. Toxocara canis undergoes a tra-
The role of water-borne transmission of eggs of Toxocara spp. is un-
cheal migration and has a prepatent period of 4–5 weeks. In cats,
known (Beer et al., 1999) and requires further investigation.
the prepatent period is 8 weeks. Toxocara canis infections can be
Studies have concentrated on assessing egg contamination of
acquired at any age, although adult worm infections are generally
playgrounds, parks, sandpits, and backyards/gardens and have shown
less common in dogs less than 6 months of age, and fecal egg counts
contamination to be prevalent (Manini et al., 2012; reviewed by
are much lower than in pups (Claerebout et al., 2009). Paradoxically,
Lloyd and Morgan, 2011; Manini et al., 2012). Although such areas
low levels of egg exposure are more successful for the establish-
seem to provide opportunities for infection, the role of different
ment of patent infections in juvenile/adult dogs than large numbers
domestic and wild definitive hosts in the contamination of these
of eggs. This finding may have long term implications for control
areas is unclear. One issue has been the inability to unequivocally
programs (Overgaauw and van Knapen, 2013).
identify eggs to species using a microscope; even though the eggs
Toxocara spp. do not usually cause pathological changes in
of T. canis are usually larger than those of T. cati (74.8  86.0 lm ver-
definitive host species, although high infection intensities in trans-
sus 62.3  72.7 lm), it is difficult and time consuming to distinguish
placentally infected puppies can result in a pot-bellied appearance,
Toxocara eggs at a species level. Fortunately, PCR utilising the second
failure to thrive and, in some instances, death (Lloyd and Morgan,
internal transcribed spacer (ITS-2) of rDNA allows specific identifica-
2011; Overgaauw and van Knapen, 2013).
tion (Jacobs et al., 1997). A recent study (Fahrion et al., 2011), in
which eggs shed by dogs were identified by PCR, showed that 24
2.2. Paratenic hosts (68.5%) were T. canis and 11 (31.5%) were T. cati. Coprophagy was
suggested as a possible explanation for this finding. The development
Mammals (rodents, lagomorphs, birds and domestic livestock) of molecular techniques to identify and differentiate Toxocara spp.
are susceptible to infection by embryonated eggs containing infec- eggs from, for example, playgrounds may now be carried out using
tive L3s (Araujo, 1972), which migrate to the tissues, where they a high throughput, quantitative real-time PCR (qPCR) assay, which
undergo no further development and remain infective for up to should help to evaluate environmental contamination (Durant

Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx
et al., 2012). Molecular techniques can also be useful in identifying
Toxocara spp. in paratenic hosts (Marucci et al., 2013).
2.4. Diagnosis in definitive hosts
Ante mortem diagnosis of adult Toxocara spp. infections are
routinely conducted by faecal flotation techniques using solutions
with a high specific gravity (1.2–1.3) and the identification of the
characteristic eggs. Such techniques are sensitive for diagnosis in
young animals shedding large numbers of eggs, but lack sensitivity
in older animals which shed eggs intermittently and/or in low
numbers.
2.5. Treatment of companion animals
Dogs and cats can be effectively treated by administration of
any of a wide variety of commercially available anthelmintics
including milbemycin, nitroscanate, piperazine and pyrantel, all
of which kill or paralyse adult worms. Emodepside, ivermectin,
moxidectin, elamectin and fenbendazole are all effective in treat-
ing both adult worms and larvae (Ramsey, 2011). Fenbendazole,
moxidectin and the avermectins can be used to prevent vertical
transmission of Toxocara in pregnant and lactating females. How-
ever, there are no drugs that are effective against arrested, somatic
larvae. Puppies should be treated at 2, 4, 6 and 8 weeks of age, fol-
lowed by a monthly regimen until the age of 6 months and then
followed by annual, biannual or tri-annual treatment, depending
on the individual animal’s exposure to risk factors. The recommen-
dation for cats is that kittens are treated at 3, 5, 7 and 9 weeks of
age (www.cdc.gov/healthypets/diseases/toxocariasis.htm).
3. Epidemiology
3.1. Human infection and risk factors
Humans become infected with L3s of Toxocara spp. through the
accidental ingestion of embryonated eggs shed by definitive hosts
and through the consumption of L3s in raw or undercooked parate-
nic hosts.
Many biological factors inherent to the parasite’s life cycle suc-
cessfully facilitate the perpetuation of Toxocara spp. These include
the numerous advantages of vertical transmission, ensuring the
early onset of egg production in young definitive hosts, the fecun-
dity of the adult female, the prolonged survival of eggs in the envi-
ronment and the diversity of its domestic and wild definitive and
paratenic host species. These factors, coupled with the ubiquitous
distribution of definitive hosts, have resulted in Toxocara spp. being
one of the world’s most widespread and prevalent parasitic
zoonoses.
The global prevalence of Toxocara spp. in humans is influenced
by a wide and complex number of variables which are linked at a
population level to environmental, geographic, cultural and socio-
economic factors and at the individual level by the heterogeneity
of susceptibility to infection influenced by immunity, co-infection,
genetics, age, gender, nutrition and behavior of the (human and
definitive) hosts (Macpherson, 2013; Viney and Graham, 2013).
These factors, together with the increasing human population, glo-
bal migration and rural:urban migration with more than 50% of the
global population now residing in urban areas and the ever closer
and denser human-definitive host interactions suggest that, for the
majority of the world’s population, Toxocara/toxocariasis is an ever
changing public health problem.
Transmission and risk factors will vary considerably in different
parts of the world. Poverty, a lack of education and problems with
uncontrolled and untreated definitive host populations will lead to
heavily contaminated environments which, under warm climatic
Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
3
conditions, will provide ideal transmission opportunities, particu-
larly if coupled with poor hygiene and geophagia or pica. Such risk
factors are widely appreciated and documented for many parts of
the world (Dunsmore et al., 1984; Overgaauw, 1997; Won et al.,
2008; Lee et al., 2010). A recent study in the USA, where there
are more than 77 million dogs and 93 million cats (Esch and Peter-
sen, 2013), assessed the risk factors associated with poverty, geog-
raphy and demographics, and confirmed that both individual-level
risk factors and geographic factors affected the transmission of tox-
ocariasis (Congdon and Lloyd, 2011). Children, due to their behav-
ior and their close contact with dogs, eating soil, putting objects in
their mouths, eating earthworms and/or their poor hygiene, are
most at risk of toxocariasis.
Less understood is the relative contribution of infective eggs
and their spatial distribution in the environment by different sym-
patric definitive host species (Luty, 2001; Mizgajska et al., 2001;
Morgan et al., 2013). A recent case study in the city of Bristol in
the UK (Morgan et al., 2013) found that although pups less than
12 weeks of age dominated total egg excretion, their lack of access
to public areas and the removal of their faeces resulted in foxes
being the primary source of eggs. In many cities in Europe, public
environments including parks and playgrounds pose the main area
for risk of human exposure to eggs (Deplazes et al., 2011).
Embryonated Toxocara spp. eggs have been recovered from the
hair of dogs, which demonstrates that direct human-dog contact
could also be a route of infection for humans (Wolfe and Wright,
2003; Roddie et al., 2008; Aydenizoz-Ozkayhan et al., 2008; Amaral
et al., 2010; El-Tras et al., 2011). One study (Tavassoli et al., 2012)
implicated contact with sheepdog pups as a potential source of di-
rect transmission of embryonated eggs. Other authorities in the
field rarely, if ever, find embryonated eggs on the hair of dogs
and believe that this route of transmission is rare (Nagy et al.,
2011). A recent study showed that embryonation is slower on
the hair of dogs but can occur and the authors suggest that trans-
mission by direct contact, even for well-groomed dogs, should not
be ruled out (Keegan and Holland, 2013).
The importance of human infection via ingestion of paratenic
hosts has yet to be determined. Meat-borne transmission through
the consumption of raw or undercooked viscera or meat has been
incriminated (Salem and Schantz, 1992; Yoshikawa et al., 2008;
Antolova et al., 2013; Strube et al., 2013). The use of molecular
techniques and the rapid identification of larvae in paratenic hosts
will aid in identifying the range and epidemiological importance of
such hosts (Gasser, 2013; Marucci et al., 2013). Some well-docu-
mented instances of ingestion of paratenic hosts have provided
valuable information on the incubation period of visceral larva mi-
grans (VLM) (Cianferoni et al., 2006), and infection rates in small
rodents may provide shared indicators for Toxocara spp. (Reperant
et al., 2009).
3.1.1. Risk of infection with other ascaridoids
In the USA, the risk of infection with B. procyonis relates mainly
to the contact with embryonated eggs passed by raccoons, which
are sometimes kept as pets, or contact with ‘raccoon latrines’ in
wooded areas.
Toxocara vitulorum eggs are likely to occur in soil and water in
tropical environments as cattle and water buffalo calves are fre-
quently infected (e.g., Rast et al., 2013).
4. Clinical manifestations in humans
The clinical syndromes of human toxocariasis are caused by the
migration of L3s of Toxocara spp. via the bloodstream to the inter-
nal organs including muscle, liver, brain and eye. Such migration
may be asymptomatic or can lead to a wide variety of clinical
symptoms, depending on the organs invaded, the duration of
4 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx
migration, the intensity of infection, and age- and immune-medi-
ated host responses. The long-term survival of T. canis larvae has
been attributed to two molecular strategies evolved by the para-
site. The larvae release significant quantities of ‘excretory–secre-
tory’ products including lectins, mucins and enzymes that
interact with and modulate host immunity, and secondarily the
larvae produce a specialised mucin-rich surface coat, loosely at-
tached to the parasite epicuticle. This ‘coat’ permits the parasite
to escape, when host antibodies and cells adhere, resulting in an
inflammatory reaction around a newly vacated focus (Maizels,
2013). Toxocariasis is rarely fatal but the inflammatory responses
to the migrating larvae have been associated with generalised lym-
phadenopathy, granulomatous hepatitis, endomyocarditis,
endophthalmitis, asthma and leukocytosis including high eosino-
philia (>30% or >2  109/L) is often seen (Despommier, 2003; Men-
donça et al., 2012; Fan et al., 2013). Many patients have IgG/IgE
hyper-gamma-globulinaemia; cutaneous manifestations and,
rarely, meningoencephalitis can occur. Infections are usually self-
limiting and larvae become encapsulated in the musculature and
liver, and symptoms subside. The syndromes of infection with Tox-
ocara spp. are thus related to the migration of larvae and the im-
mune response to them (Despommier, 2003; Gavignet et al.,
2008; Lopez Mde et al., 2010; Salvador et al., 2010; Damasceno
and Damasceno, 2012; Caldera et al., 2013; Fan et al., 2013; Mai-
zels, 2013). Originally, two classifications of toxocariasis were de-
fined: VLM or visceral toxocariasis (VT) and ocular larva migrans
(OLM) or ocular toxocariasis (OT) (Fan et al., 2013). Our under-
standing of the variability in the clinical signs and symptoms of
toxocariasis has evolved over the last 30 years. With the introduc-
tion of improved diagnostic tests and seroepidemiological screen-
ing surveys there is a greater understanding of the molecular
basis of immune recognition and evasion. Therefore, additional
major syndromes have been described, including common or cov-
ert toxocariasis (CT) (Taylor et al., 1988; Nathwani et al., 1992) and
neurotoxocariasis (NT) (Finsterer and Auer, 2007; Smith et al.,
2009; Salvador et al., 2010).
Other parasites are involved in the spectrum of toxocariasis,
including T. cati, which are known to cause both VLM and OLM,
but the importance of these species awaits clarification (Fisher,
2003; Lee et al., 2010). In addition, B. procyonis infections may be
severe due to the aggressive migrations of the L3s, which increase
in size as they migrate slowly through the brain and spinal chord,
and encapsulate slowly (Gavin et al., 2005). The L3s of T. vitulorum
are likely only to have a short-lived migration, but infection could
induce cross-reactive-antibody and eosinophilia and, in repeated
infections, disease. Clinical cases of VLM suspected to be caused
by A. suum have been described (Izumikawa et al., 2011). Molecu-
lar diagnosis may provide the best opportunity to evaluate the
importance of T. cati and other ascaridoids in human toxocariasis
(Chen et al., 2012; Gasser, 2013).
4.1. Visceral larva migrans (VLM)/visceral toxocariasis (VT)
VLM is most commonly diagnosed in children less than 8 years
of age and is associated with high intensity or repeated larval
infection by T. canis which can persist for weeks or months (Kayes,
1997). Classical signs include fever, hepatosplenomegaly, abdomi-
nal pain, vomiting, diarrhoea, respiratory signs (cough/wheeze),
asthma, anorexia, weight loss, fatigue, neurological manifestations,
pallor and, occasionally, urticaria (Despommier, 2003).
A serological survey of sera from VLM and OLM suspected pa-
tients in the Netherlands using IgG-ELISA suggested that human
exposure to A. suum may occur in those countries where pig slur-
ry/sludge is used as a fertiliser on farms and gardens (Pinelli et al.,
2011). The importance of A. suum as a zoonosis needs to be as-
Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
sessed; it is likely to occur where pig slurry is used as fertiliser or
in countries where there are free-roaming pigs and poor hygiene.
4.2. Ocular larva migrans (OLM)/ocular toxocariasis (OT)
OLM is considered to be rare compared with VLM, is thought to
result from low intensity of infection with T. canis and, similar to
VLM, is most frequently reported in children (Despommier,
2003). The clinical consequences of OLM elicit emotive reactions
from those involved, which increases the awareness of the public
health importance of toxocariasis. Cases of OLM are usually unioc-
ular and are caused by the migration of L3s in the eye and resultant
immune reactions. Visual impairment occurs over days or weeks,
and the level of impairment is dependent on the location of the lar-
vae, the eosinophilia and later the fibrotic granulomatous response
as granulomatas create a distortion, heterotopia and/or detach-
ment of the macula, which can result in blindness (CDC, 2011). Vi-
sual impairment depends on the specific area involved (CDC, 2011;
Woodhall et al., 2012). OLM can also cause diffuse endophthalmitis
or papillitis. Long-term infection with Toxocara spp. may lead to
choroidal neovascular membrane formation following chorioreti-
nitis (Despommier, 2003).
Baylisascaris procyonis has also been implicated in subacute uni-
lateral neuroretinitis (Goldberg et al., 1993).
Co-infection of T. canis with other parasites that may impair vi-
sion is not uncommon. One study using multivariate analysis to
control for demographic and risk factors (Jones et al., 2008)
showed that persons infected with Toxocara spp. were also more
likely to be infected with Toxoplasma gondii (Odds Ratio
(OR) = 1.93, 95% Confidence Limits (CL) = 1.61–2.31), and similarly,
persons infected with T. gondii were more likely to be infected with
Toxocara spp. (OR = 1.91, 95% CL = 1.59 2.28). Other parasites that
may impact on vision include Plasmodium falciparum, Taenia soli-
um, Echinococcus granulosus and Onchocerca volvulus (Benazzou
et al., 2010; Ziaei et al., 2011; Ejere et al., 2012; Postels et al., 2013).
4.3. Covert or common toxocariasis (CT)
As with most other parasitic infections, the vast majority may
go undiagnosed due to the asymptomatic, mild or non-specific
clinical nature of their features. The same appears to be the case
for many Toxocara spp. infections. Cross-sectional community-
based seroepidemiological surveys often detect individuals who
test positive for anti-Toxocara antibodies, but who are asymptom-
atic or only have non-specific or mild symptoms (Taylor et al.,
1988). These findings prompted the terms ‘covert’ or ‘common’
toxocariasis (Taylor et al., 1987, 1988; Magnaval et al., 1994; Paw-
lowski, 2001). Magnaval et al. (1994) characterised CT in children
by fever, anorexia, headache, abdominal pain, nausea, vomiting,
lethargy, sleep and behavioral disorders, pulmonary symptoms,
limb pains, cervical lymphadenitis and hepatomegaly, and com-
mon toxocariasis in adults by weakness, pruritus, rash, pulmonary
symptoms and/or abdominal pain.
4.4. Neurotoxocariasis (NT)
NT arises from the invasion of L3s of T. canis to the brain and
spinal cord (Ruttinger and Hadidi, 1991; Finsterer and Auer,
2007; Caldera et al., 2013), causing meningitis, encephalitis, mye-
litis, cerebral vasculitis and seizures.
4.5. Toxocara canis associated with other clinical manifestations
Toxocara canis infection has also been associated with asthma
and may be linked to the rise in asthma observed in inner city chil-
dren in cities in the USA (Sharghi et al., 2001; Busse and Mitchell,
 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx
2007; Walsh and Haseeb, 2012) and other countries (Cobzaru et al.,
2012; Kanobana et al., 2013). There is also growing evidence that
implicates Toxocara spp. infection in epilepsy (Nicoletti et al.,
2007; Quattrocchi et al., 2012). One small cohort of children with
a diagnosis of OLM also had a strong association with seizures
(Good et al., 2004). The aetiological connection between Toxocara
spp. infection and epilepsy requires additional studies (Holland
and Hamilton, 2013) particularly in areas with other sympatrically
occurring infections that also cause epilepsy. In a large study in five
countries in sub-Saharan Africa (where epilepsy is common), epi-
lepsy in children (<18 years) was associated with difficulties in
feeding or breathing after birth, crying, abnormal antenatal periods
and head injury, whilst in adults (P18 years), risk factors included
malaria or fever, exposure to T. canis, T. gondii, O. volvulus, T. solium
or hypertension (Ngugi et al., 2013).
Children seropositive for T. canis have been linked in a few stud-
ies to impaired cognitive development (Stewart et al., 2005; Jarosz
et al., 2010; Holland and Hamilton, 2013). Walsh and Haseeb
(2012) reported statistically lower cognitive scores on both the
Wechsler Intelligence Scale for Children-Revised (WISC-R) and
the Wide Range Achievement Test-Revised (WRAT-R) in the USA
compared with seronegative children. This finding was indepen-
dent of socio-economic status, ethnicity, gender, rural residence,
cytomegalovirus infection and lead levels in blood. These results
require additional longitudinal data to confirm an aetiological con-
nection between toxocariasis and cognitive function.
5. Diagnosis in humans
Direct microscopic diagnosis of Toxocara spp. larval infection
in humans is difficult and rarely attempted. PCR-based sequenc-
ing of ITS-1 and ITS-2 sequences of nuclear rDNA enables the
identification of T. canis, T. cati and other ascaridoids which
can occur in human tissue biopsies (Jacobs et al., 1997; Zhu
et al., 2001; Li et al., 2007, 2008; Norhaida et al., 2008).
Diagnosis of VLM and CT is problematic, particularly in trop-
ical countries where polyparasitism is common. Diagnosis is
based on clinical presentation, history and serological antibody
tests. Immunodiagnosis based on the use of ELISA employing
Toxocara excretory/excretory (TES) antigens (de Savigny et al.,
1979; Maizels et al., 1984) as well as commercially produced
test kits (ELISA NOVUM, ELISA PU and Toxocara CHEK) are avail-
able and are widely used for diagnosis and in seroepidemiologi-
cal studies. Differences in the quality of antigens used and lack
of standardisation of results coupled to differences in human
populations (polypararasitism), cross-reactivity, diet and expo-
sure to other pathogens makes it challenging to compare survey
outcomes (Smith and Noordin, 2006). Positive serum samples
must be confirmed by western blotting (WB) (Fillaux and Mag-
naval, 2013). WB, based on the use of fractionated, native, TES
antigens of T. canis larvae has been shown to increase specificity,
with reactivity to bands of low molecular weight (24–32 kDa)
shown previously to be specific for T. canis (Mohamad et al.,
2009; Smith et al., 2009). Polypararasitism with gastrointestinal
helminths can reduce specificity to 650%, and an ELISA for the
detection of IgG subclasses including specific IgG2 serum anti-
bodies to glycan of TES antigens, has sensitivities of IgG, 50%;
IgG1, 60%; IgG2, 98%; IgG3, 78%; IgG4, 64% and specificities of
IgG, 73%; IgG1, 76%; IgG2, 71%; IgG3, 81%; IgG4, 71% (Watt-
hanakulpanich et al., 2008). An ELISA for the specific detection
of anti-Toxocara IgG4 serum antibodies achieves increased spec-
ificity (Noordin et al., 2005). IgE- and IgM-ELISAs may be used
post-treatment to show a decline in antibody titre but are not
highly specific or sensitive (Smith et al., 2009). The immuno-
Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
5
Fig. 1. Ultrasound of the liver showing multiple hypoechoic areas which show L3
Toxocara spp. larvae (arrowed). Repeat ultrasound images over time can reveal their
migration.
pathogenesis of toxocariasis in paratenic hosts, including hu-
mans, has been reviewed by Fan et al. (2013).
Imaging techniques can be useful in aiding diagnosis in patients
with VLM and OLM. In VLM patients multiple, ill-defined, oval he-
patic lesions measuring 1.0–1.5 cm in diameter can be detected on
computerised tomography, magnetic resonance imaging (MRI) or
as oval hypoechoic lesions upon sonographic examination
(Fig. 1). The lesions differ from metastatic nodules is as much as
they have fuzzy margins, are uniform in size and have a non-spher-
ical shape (Lim, 2008).
The diagnosis of NT is difficult but should include an examina-
tion of serum and CSF for anti-T. canis antibodies and eosinophils
in the CSF. Computerised tomography and MRI scans reveal cortical
or sub-cortical granulomata as diffuse lesions or circumscribed hy-
per-intense areas on T2-weighted images with resolution following
treatment (Ruttinger and Hadidi, 1991; Zachariah et al., 1994; Fin-
sterer and Auer, 2007). In different regions of the world, care should
be exercised in making a differential diagnosis of other parasites
that can infect the CNS including protozoans (Acanthamoeba spp.,
Naegleria spp., Entamoeba histolytica, P. falciparum, T. gondii, Trypan-
osoma spp.), trematodes (Paragonimus spp., Schistosoma spp.), ces-
todes (Echinococcus spp., T. solium, Spirometra spp.) and nematodes
(Angiostrongylus spp., Gnathostoma spp.) (Finsterer and Auer, 2012).
Similarly the diagnosis of OLM is problematic as specific anti-T.
canis serum antibody titres may be low or absent (Despommier,
2003). The detection of specific anti-T. canis antibody in vitreous
and/or aqueous humor helps to confirm a diagnosis (Yokoi et al.,
2003). A wide range of imaging techniques can assist with the
diagnosis and treatment of OLM. Optical coherence tomography,
fluorescein angiography, computerised tomography and ocular
ultrasound using transducers (>10 MHz) can be used to infer the
location of the L3s (Fig. 2) and in providing a differential diagnosis
of other ocular diseases including retinoblastoma (Cella et al.,
2004; Brennan et al., 2012; Arevalo et al., 2013).
6. Treatment in humans
The chemotherapy of toxocariasis in people varies according to
the severity and location of symptoms. Patients with VLM and
symptomatic NT or CT are administered anthelmintics such as
albendazole, thiabendazole and mebendazole, and may also be gi-
6 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx
ven anti-inflammatory corticosteroids to relieve symptoms caused
by severe allergic responses (Despommier, 2003; Magnaval and
Glickman, 2006). Cases of OLM are usually treated with corticoste-
roids and may also require delicate ophthalmologic procedures
(Despommier, 2003; Magnaval and Glickman, 2006).
7. Public health importance
Toxocariasis is not a notifiable disease but is of major impor-
tance as a public health problem. Epidemiological studies demon-
strate that T. canis is one of the most prevalent and ubiquitous
zoonotic parasite species occurring from the sub-Arctic to the tro-
pics (Rubinsky-Elefant et al., 2011; Pinelli et al., 2011; Messier
et al., 2012; Fan et al., 2013; Jenkins et al., 2013). Serological sur-
veys, conducted mostly in children, suggest that prevalences in
industrialised countries vary between 0.7% in New Zealand, 1.6%
in Japan, 2.4% in Denmark, 7.5% in Australia, 14% in the USA and
15% in Poland (Jarosz et al., 2010; Fan et al., 2013). In contrast,
higher seroprevalences have been reported in less industrialised,
tropical countries including in Africa: 30% in Nigeria, 45% in Swazi-
land and 93% in La Reunion (Africa), 81% in Nepal, 63.2% in Indone-
sia and 58% in Malaysia (Asia) and 36% in Brazil and 37% in Peru
(South America) (Smith and Noordin, 2006; Liao et al., 2010; Rol-
dan et al., 2010; Schoenardie et al., 2013).
A recent web-based survey involving eye specialists throughout
the USA was used to collect epidemiological, demographic and
clinical information on patients with OLM (CDC, 2011). The survey
found 68 patients with OLM diagnosed between September 2009
and September 2010. The median patient age was 8.5 years (range:
1–60 years), and 25 patients (57%) were from the south. The most
common symptom was vision loss, reported by 25 (83%) patients;
of these, 17 (68%) had suffered permanent vision loss. The results
of this first national web-based survey demonstrated the useful-
ness of using such an approach to obtain national data which
might be applicable in other countries.
The high seroprevalence (13.9%) of Toxocara infection reported
by Won et al. (2008) and the estimated 1.3–2.8 million people in-
fected in the USA (Hotez, 2008) indicate that, even in the richest
country in the world, toxocariasis poses an important burden on
society and at the individual level. This zoonosis together with
those caused by other helminths such as strongyloidiasis, ascaria-
sis and cysticercosis are regarded as the neglected diseases dispro-
portionately affecting impoverished human populations. Their
existence continues to entrap people in generational poverty and
Fig. 2. Ultrasound of the eye showing a Toxocara spp. L3 in the choroid. Visual
impairment depends on the location of the larvae and the host’s reaction to its
presence.
Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
should be addressed (Hotez, 2008; Hotez et al., 2013). The benefits
of control have been calculated (Torgerson and Budke, 2006) and
suggest that there would be significant human health and animal
production (T. vitulorum) gains if implemented.
8. Control
The wide range of domestic and wild definitive and paratenic
host species and modes of transmission of Toxocara spp. means
that the control of T. canis is complicated. To date no specific na-
tional control programs against this zoonosis have ever been
attempted.
8.1. Control in pet dogs and cats
Of the four main reservoirs of parasite infection, viz, intestinal
infections in definitive hosts, eggs in the environment, larvae in
paratenic hosts and somatic larvae in the host (Schnieder et al.,
2011), the easiest populations in which to control Toxocara spp.
infection are the pet dogs and cats. There are excellent treatment
options for dogs and cats. Compliance with treatment regimens
will reduce environmental contamination from this potential
source. The role of education, as with all other Toxocara spp. related
control activities, is pivotal to the reduction of human infection
and for compliance with reducing infection for others. Veterinari-
ans play an important role in educating pet owners and the general
public on zoonoses. The multi-billion dollar small animal health
companies which historically played a major role in education pro-
grams should be encouraged to revitalise this role. Such companies
together with others involved in the pet industry such as some of
the pharmaceutical companies, trusts and foundations could also
play a more active role in the control of Toxocara spp. in the pet
population. Australia in particular has seen a reduction in the prev-
alence and importance of T. canis infections in dogs and cats
throughout the country (Palmer et al., 2008, 2010).
Reduction in the number of pet dogs contaminating the envi-
ronment, particularly in cities where recreational areas are shared
by many people and pets, has been achieved to some extent in
North America, Europe and Australia. This reduction was enforced
through the introduction, over 30 years ago, of the ‘‘scoop laws’’
(Beck, 1979). The regulations required dog owners to collect faeces
deposited by their dog when in public areas. This has allowed peo-
ple and dogs to share the public areas in cities in ways that benefit
them both. Studies of interventions on dog fouling are lacking and
would be useful to fill gaps in our approaches to this method of
control (Atenstaedt and Jones, 2011). Restricting dogs from play-
grounds, squares and gardens would also be useful. Such methods
have not always proved effective, with some surveys failing to find
lower egg densities inside such restricted areas than outside them
(Kirchheimer and Jacobs, 2008).
8.2. Control of ingestion of eggs and larvae
Good hygiene and the proper cooking of food can prevent the
accidental ingestion of eggs from the environment and larvae from
paratenic hosts. Unfortunately such hygiene measures are almost
impossible to implement, especially with children and with few
options to destroy Toxocara spp. eggs in the environment, this
route of infection persists. The increasing global proclivity for eat-
ing meat, liver and vegetables raw, undercooked, smoked, pickled
or dried facilitates transmission of a number of parasitic zoonoses
(Macpherson, 2005). Changes in human behaviour to reduce para-
site transmission are difficult due in part to the long prepatent
periods and lack of correlation between disease and infection.
There have been a few exceptions to this, including the remarkable
reduction in vertical transmission of T. gondii infection in T. gondii
 C.N.L. Macpherson / International Journal for Parasitology xxx (2013) xxx–xxx
IgG seronegative women. The women were counseled on the risks
of T. gondii during pregnancy and its prevention (Breugelmans
et al., 2004). Since toxocariasis is predominantly an infection of
young children, education, especially targeted at new parents,
would be an important part of a control program.
8.3. Control in wild and domestic animals
A wide range of wild animal definitive hosts for Toxocara spp.
exists. In addition, large populations of untreated owned, stray of
feral dogs and cats in most developing and also many developed
countries provide a continuous reservoir of infection, environmen-
tal egg contamination and potential sources of infection to humans
and other paratenic hosts.
The role of wild definitive hosts in human infection is uncertain
although it has been demonstrated that they could be an important
source of environmental contamination in the UK (Morgan et al.,
2013). It is interesting to note that despite the wide variety of wild-
life involved in rabies, the vast majority (>99%) of human rabies
cases throughout the world are transmitted by dogs (Knobel
et al., 2005). Thus our close environmental association with dogs
may be more important for the majority of human infections either
directly or indirectly, especially in areas around the world where
the majority of dogs are never treated for Toxocara spp. (Macpher-
son, 2013).
National control programs to control or reduce stray and feral
dog populations are mainly restricted to a few developed coun-
tries. National control programs have been developed in some
areas of the world against two important parasitic zoonoses, Leish-
mania donovani and Echinococcus spp., and rabies. As all of these
programs involve the control of dog populations their implementa-
tion would also assist, to some extent, with the control of Toxocara
spp. Dog population control in these programs focuses mostly on
the use of reproduction control in dogs (Lembo et al., 2013). The
rationale is to reduce the dog population turnover and the number
of ownerless dogs. Reproduction control in owned and stray dogs is
facilitated by sterilisation followed by postoperative care and re-
lease at point of capture, Animal Birth Control (ABC) also known
as catch, neuter and release. Since the 1960s, ABC programs have
been advocated as a method to control urban street dog popula-
tions and in Jodhpur, a large city in western India, an ABC program
that reached over 60% of the free-roaming dog population was
found to both reduce and stabilise dog populations (Totton et al.,
2010). Given that T. canis is most fecund and prevalent in pups,
ABC programs would also reduce the environmental contamina-
tion with T. canis eggs.
The very successful control of rabies in Europe’s fox population
has seen the expansion of the fox population which increasingly
encroaches on urban settlements and can contaminate the envi-
ronment with T. canis eggs (Deplazes et al., 2011). Control of T. ca-
nis in wildlife will be extremely difficult and will perhaps have to
await the development of an effective vaccine and method of intro-
ducing such a vaccine into the fox population. Development and
use of effective ovicidal agents, including biological agents such
as fungi (Braga et al., 2010), would also be extremely useful.
9. Conclusions
Toxocariasis remains a challenging and common zoonotic para-
sitic infection affecting millions of people and their pets around the
world. Seroprevalence studies suggest that exposure to the para-
site is extremely common, especially in children living in the war-
mer regions of the world. The variety of syndromes (VLM, OLM, NT
and CT) require diagnostic tests (serological, molecular and/or
imaging) which are often too expensive or not available to the esti-
mated two billion people who live on less than US$ 2.00 per day
Please cite this article in press as: Macpherson, C.N.L. The epidemiology and public health importance of toxocariasis: A zoonosis of global importance. Int.
J. Parasitol. (2013), http://dx.doi.org/10.1016/j.ijpara.2013.07.004
7
and who are most at risk of infection. The geographic distribution
of T. canis is expanding as a consequence of human and animal
movements, together with the effects of global warming which
has seen, for example, the northern migration of red foxes (Jenkins
et al., 2013). The rapid growth of the human and dog populations
and their increasing densities in urban areas means that, without
specific control initiatives, the importance of toxocariasis is likely
to grow. There is a need for a greater understanding of the molec-
ular biology, biochemistry, genetics, epidemiology and ecology of
Toxocara spp. (Jex et al., 2008; Gasser, 2013). Future research activ-
ities that focus on the development of molecular tools for specific
identification and genetic analysis should lead to new and im-
proved strategies for the treatment, diagnosis and control of toxo-
cariasis, and the role of other ascaridoids in the epidemiology of
Toxocara spp. These molecular technologies should help to reveal
the true extent and therefore the public health importance of
T. canis; information which would provide the evidence and
justification for the introduction of national control initiatives.
Development of a vaccine and/or effective ovicidal agent, which
have long been goals of the scientific community, would greatly
improve the chances of controlling this most challenging zoonotic
infection.
Acknowledgements
The author thanks Kareem Coomansingh for his help in the
preparation of the manuscript. Images were kindly provided by
Dr Carmen Cretu.
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