Parasitic Infections

The majority of Syrian refugees are receiving albendazole and ivermectin prior to departure to the United States.  Routine post-arrival stool ova (eggs) and parasite testing is likely not cost-effective and is not routinely recommended for Syrian refugees.  Domestic screening physicians and providers should refer to CDC’s Domestic Intestinal Parasite Guidelines.

Giardiasis

Giardiasis has been detected in Syrian refugees and can be associated with subtle symptoms such as abdominal complaints, loose stool, flatulence, and eructation. Giardiasis has been associated with failure to thrive in children. A lower threshold to screen or test children younger than 5 years of age who may not verbalize symptoms or express overt signs of infection is reasonable. When screening is performed, stool antigen testing is more sensitive and convenient than stool ova and parasite examination. U.S. clinicians should note that overseas presumptive parasite treatments are not effective in treating Giardiasis.

Leishmaniasis

Leishmaniasis is caused by infection with Leishmania parasites, which are spread by the bite of phlebotomine sand flies. Leishmaniasis is endemic to Syria. There are several different forms of leishmaniasis in people. The most common forms are cutaneous leishmaniasis, which causes skin sores, and visceral leishmaniasis, which affects several internal organs (usually spleen, liver, and bone marrow). Cutaneous leishmaniasis is the most common form of the disease observed in Syrian refugees. L. tropica and L. major have been reported in Syrian refugees in Lebanon ⁴⁵. In 2013, 1,033 new cases of leishmaniasis were reported in Lebanon, with approximately 97% of cases occurring in Syrian refugees ⁴⁶. Cutaneous leishmaniasis has also been reported in refugees in Turkey ^{47, 48}, as well as in Syrian refugees screened at a GeoSentinel site in Berlin, Germany ³⁸.

Currently, there is no additional screening recommended to detect leishmaniasis. However, clinicians should be aware of the disorder and consider it in the differential diagnosis of any Syrian with chronic skin sores or other symptoms that might indicate infection (e.g., chronic cutaneous lesions). Information on the diagnosis and management of leishmaniasis may be accessed at the CDC Division of Parasitic Diseases website.

Echinococcosis

Echinococcosis is a parasitic disease caused by infection with the larval stage of Echinococcus granulosus, a tapeworm found in dogs (definitive host), sheep, cattle, goats, and pigs (intermediate hosts). Echinococcosis is classified as either cystic or alveolar. Cystic echinococcosis (CE), or hydatid disease, is the primary form of echinococcosis found in Syrian refugees. Most people with CE infections are asymptomatic. However, in some cases, CE causes harmful, slow-growing cysts in the liver, lungs, and other organs. These cysts often grow for years and go unnoticed and neglected. Clinical presentation is highly variable. Most often, clinical presentation is due to mass effect—as the cyst grows, it impinges on local tissues causing discomfort and/or abnormal test results (e.g., increased liver function tests). Infection may also be incidentally noted when diagnostic procedures are done for other reasons (e.g., chest X-ray). Cyst rupture may result in anaphylactic reactions, including death, when the contents of the cyst are released. This can occur spontaneously following trauma, or, most importantly, when clinical evaluation/intervention is being attempted.

Currently, no additional screening is recommended for asymptomatic refugees. However, when a cystic lesion is noted, echinococcosis diagnosis should be considered. Expert advice should be obtained prior to performing any invasive diagnostic or intervention procedures. Further information is available from the CDC Division of Parasitic Diseases website.

References

38. Mockenhaupt, F.P., et al., Profile of illness in Syrian refugees: A GeoSentinel analysis, 2013 to 2015. Euro Surveill, 2016. 21(10).
45. Saroufim M, et al., Ongoing epidemic of cutaneous leishmaniasis among Syrian refugees, Lebanon. Emerg Infect Dis, 2014. 20(10): p. 1712-5.
46. Alawieh, A., et al., Revisiting leishmaniasis in the time of war: the Syrian conflict and the Lebanese outbreak. Int J Infect Dis. , 2014. Dec;29:115-9.
47. Inci R, et al., Effect of the Syrian Civil War on Prevalence of Cutaneous Leishmaniasis in Southeastern Anatolia, Turkey. Med Sci Monit, 2015. 20(21): p. 2100-4.
48. Koçarslan S, et al.,Clinical and histopathological characteristics of cutaneous Leishmaniasis in Sanliurfa City of Turkey including Syrian refugees. Indian J Pathol Microbiol., 2013 56(3): p. 211-5