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Imported human fascioliasis, United Kingdom.

To the Editor: We initiated enhanced surveillance for human fascioliasis after a reported increase in livestock cases in the United Kingdom. From January 1, 2008, through January 31, 2009, 11 human cases were confirmed by the reference laboratory for England and Wales, compared with 6 cases during the preceding 10 years. The Scottish reference laboratory detected no human cases during the study period.

Fascioliasis was defined as a positive Fasciola immunofluorescent antibody test with a screening titer of 1:32 and either compatible clinical or radiologic features consistent with the disease. We obtained clinical and radiologic information from the referring physician. Clinical features of both acute and chronic infection include fever, upper abdominal pain, malaise, eosinophilia, and impaired liver function; therefore, distinguishing between the 2 phases can be difficult. Fifty percent of chronic infection is subclinical (1,2). Compatible radiologic features are capsular enhancement with contrast, hypodense nodular areas, and low-density serpiginous lesions (2). Our analysis comprised 11 cases (Table). Two patients were white British, both of whom had recently traveled to sub-Saharan Africa. Cases from the preceding 10 years diagnosed in our laboratory were all in persons with histories of travel to fascioliasis-endemic areas. Therefore, these cases do not provide firm evidence of indigenous zoonotic transmission within England and Wales.

Nine patients originated from Somalia, Ethiopia, or Yemen. Few cases have previously been reported from this area (3), although Ethiopian migrants have been shown to have an egg positivity of 0.4% on routine screening (4). Patients 5 and 6 had not returned to Africa for >20 years, suggesting that they acquired their infection in Europe. Therefore, a risk factor may exist that is specific to this ethnic group within the United Kingdom.

Six cases were diagnosed at 1 hospital. All 6 patients reported current or past use of locally bought khat, a leaf chewed for its stimulant properties. It is imported fresh to the United Kingdom from Africa and is an ideal environment for the survival of Fasciola cercariae. It is used most commonly by migrants from the Horn of Africa and Yemen and has been reported in association with acute fascioliasis in the United Kingdom (5). Use of imported khat may explain the apparently higher incidence of fascioliasis in this ethnic group residing in the United Kingdom.

Despite the described parallel rise in human and veterinary fascioliasis, none of these cases provide clear evidence that recent human cases resulted from zoonotic transmission within the United Kingdom. Most cases occurred in migrants from the Horn of Africa and Yemen, some of whom may have acquired Fasciola spp. in their country of origin; other cases appear likely to have been acquired in the United Kingdom, possibly due to use of imported khat. Physicians need a heightened awareness of fascioliasis when investigating impaired liver function or abnormal abdominal imaging in migrants or travelers from high-risk areas.

Meera A. Chand, Joanna S. Herman, David G. Partridge, Kirsten Hewitt, and Peter L. Chiodini

Author affiliations: Hospital for Tropical Diseases, London, UK (M.A. Chand, J.S. Herman, P.L. Chiodini); Royal Hallamshire Hospital, Sheffield, UK (D.G. Partridge); Health Protection Agency Centre for Infections, London (K. Hewitt); and London School of Hygiene and Tropical Medicine, London (P.L. Chiodini)

DOI: 10.3201/eid1511.090511


(1.) Marcos LA, Terashima A, Gotuzzo E. Update on hepatobiliary flukes: fascioliasis, opisthorchiasis and clonorchiasis. Curr Opin Infect Dis. 2008;21:523-30.

(2.) Marcos LA, Tagle M, Terashima A, Bussalleu A, Ramirez C, Carrasco C, et al. Natural history, clinicoradiologic correlates and response to triclabendazole in acute massive fascioliasis. Am J Trop Med Hyg. 2008;78:222-7.

(3.) Control of foodborne trematode infections. Report of a WHO study group. World Health Organ Tech Rep Ser. 1995;849:1-157.

(4.) Nahmias J, Greenberg Z, Djerrasi L, Giladi L. Mass treatment of intestinal parasites among Ethiopian immigrants. Isr J Med Sci. 1991;27:278-83.

(5.) Doherty JF, Price N, Moody AH, Wright SG, Glynn MJ. Fascioliasis due to imported khat. Lancet. 1995;345:462. DOI: 10.1016/S0140-676(95)90450-6

Address for correspondence: Meera A. Chand, Hospital for Tropical Diseases, Mortimer Market, Capper Street, London WC1E 6JB, UK; email:
Table. Characteristics of human fascioliasis case-patients during
enhanced surveillance, United Kingdom, January 1, 2008-January 31,
2009 *

Case Age, Country Years since
no. y/sex of origin migration Other travel

1 45/F Yemen 7 Yemen
2 44/M Somalia 16 Ethiopia
3 34/F Ethiopia 3 S. Africa
4 44/F Somalia 7 Somalia
5 54/F Somalia 21 (to None
 4 (to UK)
6 43/M Somalia 28 (to India), None
 21 (to UK)
7 28/F UK -- Uganda
8 67/M UK -- Kenya
 2008, prior
 world travel
9 38/M Ethiopia 10 Ethiopia
10 28/M Ethiopia Unknown Unknown

11 47/F Somalia 16 (to Unknown
 6 (to UK)

 Eosinophil Abnormal
Case Risk Clinical count, liver
no. factor features x (10.sup.9]/L) function

1 Khat Abdominal 8.4 Yes
 use pain
2 Khat Fever, 3.4 Yes
 use abdominal
3 Khat Fever, 11.4 No
 use abdominal
4 Khat Abdominal 8.3 No
 use pain
5 Khat Anorexia 8.4 No
6 Khat Fever 1.0 Yes
7 -- Abdominal 1.84 Yes
8 -- Malaise, 0.04 Yes
9 -- Abdominal 18.7 Yes
 pain, fever
10 -- Fever, <0.04 Yes
 sepsis; new
 HIV diagnosis
11 Khat Abdominal 16.8 Yes
 use pain, fever

no. Hepatic imaging IFAT ([dagger])

1 Mixed-density 1:128
 liver lesion (CT)
2 Serpiginous 1:64
 lesion (MRI)
3 Heterogeneous 1:128
 lesion (USS)
4 Heterogeneous 1:128
 lesion (USS)
5 Low-density 1:32
 lesion (CT)
6 Heterogeneous 1:128
 lesion (USS)
7 Hepatomegaly 1:512
 with large mixed
 cystic and solid
 lesion (USS)
8 Multiple 1:256
9 Normal (USS, 1:128
10 Lesion in 1:64
 hepatic vein
11 Low-density 1:256
 lesion (CT)

* IFAT, immunofluorescent antibody test; CT, computed tomography; MRI,
magnetic resonance imaging; USS, ultrasound scan, MRCP, magnetic
resonance cholangiopancreatography.

([dagger]) Titer of IFAT (screening titer 32).
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Article Details
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Title Annotation:LETTERS
Author:Chand, Meera A.; Herman, Joanna S.; Partridge, David G.; Hewitt, Kirsten; Chiodini, Peter L.
Publication:Emerging Infectious Diseases
Article Type:Report
Geographic Code:4EUUK
Date:Nov 1, 2009
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