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Immigrant and Refugee Health

Parasitic Infections

Central American Refugee Health Profile

Chagas Disease

Approximately 10% of Chagas disease cases in the Americas are found in Central America36. El Salvador, Guatemala, and Honduras are uniformly affected, with approximately 200,000 cases per country37. Chagas disease is caused by the parasite Trypanosoma cruzi and is most commonly transmitted through contact with the feces of an infected triatomine insect (“kissing bug”). Transmission can also occur when humans are bitten by infected triatomines (CDC Chagas Disease). Reports of congenital and post-transplant infections, as well as infection after consumption of contaminated food and drink, although rare, have also been documented.

Chagas disease has an acute and chronic phase. Acute infection may be asymptomatic or may be characterized by nonspecific symptoms such as malaise, fever, and anorexia. Swelling may be observed around the site where the parasite entered the body. If left untreated, acute infection is lifelong and can lead to severe complications in 20-30% of patients. Severe complications may include heart rhythm abnormalities that can lead to sudden death, dilated heart, and dilated esophagus or colon. Chronic Chagas disease is considered to be the most common cause of nonischemic heart disease in Central America and may cause cardiomyopathy years after initial infection36. However, the majority of people will be asymptomatic and unaware of infection, and few parasites are found in the blood. At this time, routine screening is not recommended for Central American children38.

Giardiasis

Giardiasis is a common infection in all refugee populations. Routine screening of asymptomatic individuals is not recommended, as there is no evidence that screening and treatment are beneficial in these cases. However, giardia infection can be associated with mild symptoms such as abdominal discomfort, loose stool, flatulence, and eructation. In addition, it has been associated with failure to thrive in children. As young children may not verbalize symptoms or express overt signs of the disease, it is reasonable to screen children, particularly those under 5 years old. When screening is performed, stool antigen testing is the preferred method, as it is more sensitive and convenient than stool ova and parasite examination.

Malaria

Although malaria is endemic to El Salvador, Guatemala, and Honduras, the prevalence is not high enough to justify routine screening or presumptive treatment. The malaria species predominantly found in these countries is Plasmodium vivax, also known as relapsing malaria. This form of malaria may become dormant in the liver and reactivate months and even years after exposure, causing clinical disease. As such, clinicians should consider malaria in the differential diagnosis with a patient with symptoms associated with malaria, such as fever, even if exposure to malaria was not recent. For further and updated information, see the domestic screening guidelines for malaria in refugees.

Soil-transmitted Helminths (STH)

People living in extreme poverty, including indigenous populations in El Salvador, Guatemala, and Honduras, are at high risk for neglected tropical diseases, including STH (mainly ascariasis, trichuriasis, and hookworm)39. Guatemala is known to have the highest rate of STH infections in Central America40. Children from El Salvador, Guatemala, and Honduras require periodic deworming campaigns due to significant STH endemicity, with 300,000 children treated in El Salvador and 1.1 million children treated in Guatemala and Honduras annually41. However, STH surveillance data in Central America is limited42.

Children from El Salvador, Guatemala, and Honduras do not receive presumptive STH treatment before departure. Upon arrival in the United States, these children should be presumptively treated with albendazole, or tested and then treated. It is necessary to check three ova and parasite stool samples collected 12-24 hours apart in order to identify STH infection and treat appropriately.

Strongyloides stercoralis

Available data on Strongyloides prevalence in Central America are limited. Similarly, no data are available on the prevalence of Strongyloides infections in U.S. immigrants and refugees from Central America43. It is prudent to presumptively treat or screen for Strongyloides according to current CDC guidelines.

Taeniasis

Taeniasis in humans, caused by Taenia solium (pork tapeworm) and Taenia saginata (beef tapeworm), is endemic in Central America; however, surveillance data is limited44. Infections are spread by ingestion of undercooked beef or pork, or ingestion of cysts directly via oral-fecal contamination. Most infections are asymptomatic; however, some patients may have nausea, anorexia, or epigastric pain. Taenia solium is the cause of cysticercosis and neurocysticercosis45. In a 2011 house-to-house survey in rural Honduras, neurocysticercosis was the leading cause of seizures, accounting for 13% of cases46.

Hymenelopis nana tapeworm infection is endemic in Guatemala and is presumed to be present in other Central American countries47. Although infection is often asymptomatic, it may cause abdominal pain, diarrhea, anorexia, and anal pruritus. Hymenelopis nana is spread is via oral-fecal contamination, and infection is most common in children48.

Tapeworm infection is diagnosed using stool ova and parasite testing. Testing three stool samples collected 12-24 hours apart increases sensitivity. Tapeworm is treated with praziquantel, with the type of tapeworm dictating the dosage and duration of treatment 49. However, if seizures or neurologic deficits of unknown cause are present, neurocysticercosis must be ruled out using neuroimaging before treatment with praziquantel.

All Central American children should have a complete blood count (CBC) with differential to evaluate for eosinophilia (absolute eosinophil count ≥400). The differential diagnosis for an increased eosinophil count is broad and should include parasitic infections for this population. It should be noted that not all parasitic infections cause eosinophilia. Please refer to CDC guidelines for presumptive treatment options or further evaluation, as clinically indicated.

Neurocysticercosis infection can cause seizures and neurologic deficits. Treatment of a person with neurocysticercosis with albendazole and praziquantel can cause adverse effects such as provoking or worsening seizures. Therefore, any child with a known history of neurologic deficit or seizures should not receive albendazole or praziquantel until neurocysticercosis infection has been ruled out or should be done in consultation with an infectious disease expert.

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