Decision No. 1450/2004/QĐ-BYT on Issuing Guidelines for Diagnosis and Treatment of Clonorchiasis, Paragonimiasis, Cysticercosis, and Sparganosis

DECISION OF THE MINISTER OF HEALTH

On issuing Guidelines for Diagnosis and Treatment of Small Intestinal Fluke Disease, Lung Fluke Disease, Tapeworm Disease, and Pork Tapeworm Larva Disease

tapeworm disease and cysticercosis

 __________________

THE MINISTER OF HEALTH

Pursuant to Decree No. 49/2003/NĐ-CP dated May 15, 2003 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

Considering the proposal of the Director of the Central Institute of Malariology, Parasitology and Entomology at Circular No. 278/VSR dated April 19, 2004;

At the proposal of the Director of the Department of Treatment, Ministry of Health,

DECISION:

Article 1. Issuing along with this Decision are the "Guidelines for Diagnosis and Treatment of Small Intestinal Fluke Disease, Lung Fluke Disease, Tapeworm Disease, and Pork Tapeworm Larva Disease."

Article 2. These Guidelines shall be applied in all state, semi-state, and private healthcare facilities.

Article 3. This Decision takes effect 15 days after its publication in the Official Gazette. All previous regulations that conflict with this Decision are hereby abolished.

Article 4. The Heads of the Office, Directors of the Departments of Treatment, Preventive Medicine and HIV/AIDS Control, Directors of Institutes and Hospitals under the Ministry of Health, Provincial Health Directors, and Heads of Health Departments in centrally governed cities and provinces are responsible for implementing this Decision.

GUIDELINES FOR DIAGNOSIS AND TREATMENT
SMALL INTESTINAL FLUKE DISEASE, LUNG FLUKE DISEASE,
TAPEWORM DISEASE AND PORCINE TAPEWORM LARVA DISEASE
(issued together with Decision No. 1450/2004/QĐ-BYT
dated April 25, 2004 of the Minister of Health)

1. Small Intestinal Fluke Disease
1.1. Cause of the disease

Small intestinal fluke disease (Clonorchiasis, Opisthorchiasis) in Vietnam is caused by the Clonorchis sinensis or Opisthorchis viverrini fluke species parasitizing in the bile ducts.

1.2. Distribution
Small intestinal fluke disease has been identified in at least 18 provinces and cities: Nam Dinh, Ninh Binh, Ha Nam, Thai Binh, Hai Phong, Quang Ninh, Bac Giang, Ha Tay, Hoa Binh, Ha Giang, Thanh Hoa, Nghe An, Thua Thien Hue, Quang Nam, Binh Dinh, Phu Yen, Dak Lak, Gia Lai, with some places having infection rates up to 37%, such as Nam Dinh and Phu Yen.

1.3. Life cycle of small intestinal flukes
1. Adult flukes in the bile duct lay eggs which pass through the bile into the intestines and then out with feces. The eggs fall into water.

2. Eggs are ingested by snails where they hatch into spined larvae that develop into tail larvae.

3. Tail larvae leave the snail and swim freely in water.

4. Tail larvae invade freshwater fish, shed their tails and develop into cysticercoids parasitizing within the flesh of the fish.

5. When humans or animals consume raw or undercooked fish containing cysticercoids, these larvae enter the stomach, move to the duodenum, ascend via the bile ducts to the liver, and mature into adult flukes causing disease in the bile ducts.

6. It takes approximately 26 days from consuming cysticercoids in fish until the development of adult flukes.

1.4. Diagnosis

1.4.1. History:

Consuming raw fish dishes, eating undercooked or raw fish, or living in areas with the custom of eating raw fish dishes.

1.4.2. Clinical manifestations:

Pain and discomfort in the liver area.

Indigestion, poor appetite.

Often accompanied by digestive disorders (loose stools or pale color, stools not formed...).

Occasionally jaundice or yellowish skin discoloration.

May have signs of hepatomegaly or cirrhosis depending on the severity and duration of the disease.

1.4.3. Laboratory tests:

Examination of stool for fluke eggs in stool or duodenal fluid is the definitive diagnostic criterion.

Ultrasound of the liver may show increased brightness of the liver, dilatation of the bile ducts, thickening of the bile duct walls and gallbladder walls.

1.5. Treatment

Praziquantel: 75 mg/kg, taken over one day, divided into three doses, spaced 4-6 hours apart.

Contraindications for Praziquantel

Pregnant women in the first trimester.

Liver failure due to other causes.

Acute illness or heart, liver, kidney failure, or mental illness,...

Allergy to Praziquantel.

Precautions when taking medication

Do not breastfeed for 72 hours after taking the medication.

Be cautious with malnourished children, elderly, or those with vestibular disorders...

Take the medication after eating; abstain from alcohol, beer, and stimulants.

The minimum interval between two doses of medication is 4 hours.

Rest in place, do not drive or travel, do not work for at least 24 hours.

Adverse effects of the drug and management
Symptoms: dizziness, headache, drowsiness, nausea, discomfort in the lower abdomen, itching, and possibly mild fever.

Management: Allow the patient to rest in bed, treat symptoms appropriately based on their manifestation and monitor closely.

1.6. Cure criteria

Negative stool examination results after treatment for 3-4 weeks (three consecutive tests over three days).

1.7. Prevention

Do not eat raw or undercooked fish such as: raw fish dishes, fried fish, or fish cooked insufficiently in any form.

Do not use human feces to fertilize fish ponds, do not defecate in water sources.

2. Lung Fluke Disease

2.1. Cause of the disease

Lung fluke disease (Paragonimiasis) in Vietnam is caused by the Paragonimus heterotremus fluke species parasitizing in the lungs or pleura.

2.2. Distribution
Lung fluke disease is confirmed to be circulating in at least eight northern provinces: Lai Chau, Son La, Hoa Binh, Lao Cai, Yen Bai, Ha Giang, Lang Son, Nghe An. In some places, the infection rate reaches 15%, such as in Son La.

2.3. Life cycle of lung flukes

1. Lung flukes lay eggs, which pass through sputum via the throat or through feces when swallowing sputum, and the eggs fall into water.

2.3. In water, the eggs develop and hatch into spined larvae.

4. Spined larvae penetrate snails to develop into tail larvae.

5. Tail larvae leave the snail and swim freely in water, invading freshwater crabs or crayfish, shedding their tails and developing into cysticercoids within the flesh and organs of the crabs or crayfish.

6. When humans or animals consume raw or undercooked crabs or crayfish containing cysticercoids, such as grilled crabs, crab paste, or raw crab juice, the larvae enter the stomach and intestines, penetrate the intestinal wall into the abdominal cavity, and migrate in pairs through the diaphragm and pleura into the bronchi to establish themselves there.

7. It takes about 5-6 weeks from consuming cysticercoids until the development of adult flukes.

2.4. Diagnosis

2.4.1. History:

Consumed raw crabs (Potamicus) such as grilled crabs... or lived in areas with crabs.

2.4.2. Clinical manifestations:

Hemoptysis (usually mixed with sputum, bright red, dark red, or rust-colored, sometimes large amounts of fresh blood at once).

Episodes of hemoptysis throughout the year, sometimes lasting for many years.

Usually without fever, no signs of infection (except secondary infections), body condition is generally stable (unlike tuberculosis and other lung diseases).

Three signs of reduction at the base of the lungs (if the flukes are in the pleura, it can cause pleural effusion).

2.4.3. Testing:

Testing for lung fluke eggs in sputum, feces, or pleural fluid is the definitive diagnostic criterion.

Chest X-ray may show faint spots, patches, small cavities, mainly in the lower regions (if the fluke is in the lungs) or pleural effusion (if the fluke is in the pleura).

Blood test: Eosinophils usually increase significantly.

2.5. Treatment
Praziquantel: 75 mg/kg/day, divided into three doses every 4-6 hours for 2 days.

During treatment for lung fluke, patients may cough up large amounts of blood at once; they need absolute rest and hemostatic and antitussive medications.

Cases of dizziness, headache... only require lying down to rest and drinking lemon water or fruit juice.

Note: The contraindications, precautions when using praziquantel, and management of adverse effects of praziquantel as described in the treatment section for small liver fluke.

2.6. Cure Standard

Negative results in stool and sputum tests after 3-4 weeks of treatment (three consecutive tests over three days).

2.7. Prevention

Do not eat raw stone crab or uncooked crab in any form such as grilled crab, crab paste, or raw crab soup.

3. Adult Tapeworm Disease

3.1. Causes

Adult tapeworm disease (Taeniasis) is caused by adult tapeworms including Taenia saginata, Taenia solium, and Taenia asiatica parasitizing in the human intestine.

3.2. Distribution
Adult tapeworm disease is scattered in many places nationwide, with infection rates ranging from 0.5% to 12%.

3.3. Life Cycle of Tapeworm

1. Adult tapeworms live parasitically in the human intestine. They are hermaphroditic and release eggs and proglottids into the environment.

2. Cattle, pigs ingest eggs and proglottids dispersed in the environment or in human feces containing tapeworms.

3. Eggs enter the stomach and intestines of cattle or pigs, hatch into larvae; larvae penetrate the intestinal wall into the bloodstream and migrate to muscle tissues where they form cysts called "rice grains."

4. Humans who consume raw meat containing "rice grains" will have the larvae develop into adult tapeworms in their intestines.

5. When newly hatched, tapeworms only have heads and neck segments. As they grow, they develop new segments from the neck region and gradually elongate.

3.4. Diagnosis

3.4.1. History:

Consumed raw pork, liver, beef, or other undercooked meats. Some patients report seeing proglottids in their feces.

3.4.2. Clinical Manifestations:

Abdominal pain is commonly observed;

Proglottids can be seen moving out of the anus with feces (Taenia saginata or T. asiatica) or mixed in feces without movement (Taenia solium).

3.4.3. Laboratory Tests:

Stool examination for proglottids and tapeworm eggs is the definitive diagnosis.

3.5. Treatment
Praziquantel: Single dose of 15-20 mg/kg taken one hour after eating, or:

Niclosamide: Single dose of 2g; two hours after taking the medication, take 30g of magnesium sulfate with plenty of water (2-3 liters).

3.6. Cure Standard

After 2-3 months, no more proglottids are found in feces and stool tests are negative for tapeworm eggs or proglottids.

3.7. Prevention

Do not eat raw pork, liver, beef, or other undercooked meats.

Note: The contraindications, precautions when using praziquantel, and management of adverse effects of praziquantel as described in the treatment section for small liver fluke.

4. Pork Cysticercosis

4.1. Causes

Pork cysticercosis (Cysticercosis) is caused by pork tapeworm larvae parasitizing in muscles, brain, or eyes of humans.

People become infected by consuming pork tapeworm eggs, which hatch in the stomach and intestines, penetrate the intestinal wall into the bloodstream, and migrate to muscles, brain, or eyes. Individuals infected with adult pork tapeworms may have proglottids regurgitated into the stomach due to reverse peristalsis, leading to massive egg ingestion and numerous cysts.

4.2. Distribution
Pork cysticercosis is scattered in at least 49 provinces nationwide, with infection rates around 5-7%.

4.3. Diagnosis

4.3.1. History:

Consumed raw vegetables or previously had adult pork tapeworm infection.

4.3.2. Clinical Manifestations:

Symptoms depend on the location of the cysts.

Subcutaneous nodules similar to soybeans or peanuts that move easily, are non-itching, non-painful, located in muscle areas, not along lymph nodes.

May experience seizures, paralysis of limbs, hemiplegia, slurred speech, memory disorders, or severe headaches depending on the location of larvae in the brain.

May have increased intraocular pressure, decreased vision, or blindness if cysts are present in the eye.

4.3.3. Laboratory Tests:

Definitive diagnosis when one of the following criteria is met:

Biopsy of subcutaneous nodules/cysts, microscopic examination reveals hooklets of the scolex.

Brain CT scan shows cysts as fluid-filled lesions with eccentric white spots, size 3-5mm, larger cysts may be calcified. MRI has higher accuracy but should be considered case-by-case.

Fundus examination reveals cysts in the eye.

Positive ELISA reaction with monoclonal antibodies.

4.4. Treatment
Administered in hospitals from district level upwards. Two regimens may be used:

Praziquantel 15mg/kg/dose twice daily for 10 days, repeated 2-3 cycles, each cycle separated by 10-20 days.

or:

Albendazole 7.5mg/kg/dose twice daily for 30 days, repeated 2-3 cycles, each cycle separated by 10-20 days. Prior to this regimen, eliminate adult tapeworms with a single dose of praziquantel 15-20 mg/kg.

Contraindications for drug use:

Pregnant women.

Acute illness or heart, liver, kidney failure, or mental illness,...

Allergic to the drugs.

Precautions during drug administration:

Take the medication after meals, avoid alcohol, coffee, and stimulants.

Do not breastfeed within 72 hours after taking the medication (if using praziquantel).

Minimum interval between two doses is 4 hours.

If cysts are in the eye, be cautious when using praziquantel to prevent complications.

Rest in place, do not drive or travel long distances, avoid strenuous work during treatment.

Adverse reactions and management
Manifestations vary in severity based on the patient's condition and tolerance. Common symptoms include dizziness, headache, drowsiness, nausea, itching, and fever or convulsions.

Management: Allow the patient to rest in bed, treat symptoms appropriately, and monitor closely.

4.5. Cure Standard

Typically, after 3-6 months of treatment, clinical symptoms disappear and subcutaneous and intracranial cysts cease activity.

4.6. Prevention

Do not eat raw vegetables.

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