Echinococcus multilocularis is causing increasing concern in Ontario lately (amongst the few people who are aware of it, at least) as there’s evidence that it may have become established in the province. This parasite is a tapeworm harboured by canids (including both domestic dogs and wild ones like coyotes and foxes), and can cause serious disease in people. It’s an insidious problem since the incubation period in humans is many years, meaning it takes a long to realize that there’s a problem.
We don’t know the status of this parasite in the province but there’s enough evidence to be concerned and look into the issue further.
If you want to learn more about it, Dr. Andrew Peregrine’s recent seminar on the topic is a great start.
The latest Worms & Germs infosheets are all about some common and not-so-common members of a particular group of parasites: tapeworms. There are a number of different groups and species of tapeworms that can infect pets, people, and other domestic animals, and sorting through which is which can be tricky, so we created a Tapeworms infosheet to help sort out the details.
There is one group of tapeworms in pets that is a particular concern from a zoonotic disease perspective. These parasites belong to the genus Echinococcus. Normally these tapeworms circulate in the wildlife population, mostly in wild canids such as foxes and various prey species, but they can also affect domestic dogs (and sometimes cats) that scavenge or hunt the same prey. In most cases the pet does not become sick, but people who are exposed to the tapeworm eggs in the pet’s feces can develop slow-growing cysts known as hydatid cysts or alveolar hydatid cysts. Over time these cysts can become very large and difficult to treat. There is also now evidence that one Echinococcus species (E. multilocularis) may be spreading - in 2012 a dog in Ontario was found to be infected with the cystic form of E. multilocularis (which is unusual in itself), but the animal had no history of travel outside of the province, therefore it was most likely infected via local wildlife.
Because echinococcosis can be such a severe disease in people, we created an additional infosheet focused on just Echinococcus. Both infosheets can be found on the Worms & Germs Resources - Pets page.
Image: Dozens of Echinococcus granulosus tapeworms from the small intestine of a dog. Although these adult tapeworms are tiny compared to some other species, this species can cause significant problems in people through the formation of hydatid cysts. (Photo credit: Ontario Veterinary College)
If you ask people about tapeworms, they typically think about the "ick" factor of having a large worm in their gut, but they probably don't get too concerned. However, some types of tapeworm infection can be serious health problems in humans and animals. One of the worst is infection by the tapeworm species Echinococcus multilocularis. A couple of recent reports about E. multilocularis in Canada have received a lot of attention.
With Echinococcus, the problem isn't the worm living in the intestine. Adult worms live in the intestinal tract of only "definitive hosts," which are primarily foxes and coyotes in North America. The worms aren't necessarily a problem for these animals, but they can pass large numbers of tapeworm eggs in their stool. The parasite's normal life cycle continues when small animals (e.g. rodents like mice and voles) swallow a tapeworm egg. The parasite then develops into a cyst in the animal's body, and if/when the little critter is eaten by a fox or coyote, the cyst gets eaten too and the fox/coyote develops a new adult tapeworm in the intestinal tract.
When it comes to people (and some other domestic species), the problem is what happens when they ingest tapeworm eggs. Like in rodents, the eggs hatch and the immature parasites migrate through the intestinal wall, and can then spread to virtually any place in the body. They can then develop into large cysts that, over a long period of time, result in serious disease. Large cysts and/or cysts in critical areas (e.g. the brain) can be devastating. Treatment is difficult, prolonged and expensive, and death rates are high.
Dogs are a bit of an oddity in this cycle, since they can carry adult tapeworms (not surprising, since they are similar to foxes and coyotes) but they can also get these large tissue cysts. From public health and infection control standpoints, dogs shedding Echinococcus eggs are the main concern, but cysts are potentially devastating in the rare dog that develops one, just as they are in people.
Recent concerns revolve around two papers, one that described a dog from British Columbia with Echinococcus cysts (Jenkins et al. Emerging Infectious Diseases 2012) and a study that identified E. multilocularis eggs in feces from 23/91 (25%) urban coyotes in Alberta (Catalano et al. Emerging Infectious Diseases 2012).
What's the risk in Canada?
It's low. Actually it's very low, and there have been only a handful of cases diagnosed even in people in North America. But with a serious disease like this, you can't ignore it. If Echinococcus is spreading in coyotes and foxes, it creates the potential for exposure of other species (including humans). The risk gets higher as coyotes and foxes get closer and closer to people and dogs, as is happening in some areas because of urban sprawl. The more coyotes that are around and the closer they are to human populations, the greater the chance that a person or dog will inadvertently ingest a tapeworm egg from coyote feces. Dog parks may be of particular concern because of the high traffic through them and the potential for them to be a big mixing site between wildlife, pets and humans.
There shouldn't be any panic because of this, as it still remains an extremely rare disease. But, it's not much consolation that it's a rare disease if you're the one with a big Echinococcus cyst in the brain. So, while the risk is low, we don't really know (yet) whether it's changing, and it's worth using some basic practices to reduce the risk. These include:
- The standard: Don't eat poop. Pretty straightforward but easier said than done, in many respects, since fecal contamination of the environment is pretty common. Avoiding inadvertent ingestion of feces can be done through proper handling of dog and wildlife feces and attention to handwashing.
- Controlling rodents and preventing pets from catching and eating rodents.
- Preventing dogs from eating wildlife feces.
- Routine tapeworm deworming should kill Echinococcus and if a dog is at particularly high risk, more regular testing and treatment for tapeworms may be indicated. Not many dogs fit into that category at the moment, though.
Image: Echinococcus multilocularis isolated from a fox in Hungary. Unlike the very long tapeworms of the Taenia genus, which are most commonly found in dogs and cats, Echinococcus tapeworms are quite small (the bar in the picture is 0.5 mm), but the eggs shed in the feces of animals with an intestinal infection (involving mature adult worms) are virtually identical to those of Taenia spp. (click image for source).
Travel always carries a risk of infectious diseases. More people are paying attention to their health and going to travel clinics to find out about these risks and what preventive measures they can take. They still constitute only a minority of travelers, but it’s an improvement. There aren’t travel clinics for pets, so travelers thinking about pets and infectious diseases need to rely on sources like their regular veterinarians and government websites.
Unfortunately, that doesn’t always result in good information, as shown in a study recently published in Zoonoses and Public Health (Davidson et al 2012). For the study, the authors called veterinary clinics in eight European countries (Austria, Belgium, Finland, France, Germany, Sweden, Switzerland and the UK) and asked them about taking a dog to Norway. They also called clinics in Norway and asked about bringing a dog to the country from an unspecified location in Europe. Calling was done not as a research survey but by a person pretending to be a pet owner.
The study focused on two main pathogens, Echinococcus multilocularis (a tapeworm that is present in some parts of Europe but not others, and one that is both an animal and public health concern) and rabies. Only 9% of clinics provided accurate information about these two problems. Some clinics (58%) referred people to government sites that have good information, but unfortunately 13% of clinics referred people to websites or government agencies that provided incorrect or incomplete information. When information from websites is included, people received correct advice 62% of the time. Not bad but not great.
Among the bad advice that was given (or important information that was not given):
- Failure to tell people about the requirement for tapeworm treatment after arrival.
- Incorrect tapeworm treatment information.
- No mention of rabies titre testing.
- False information that pets traveling to Norway don’t require tapeworm treatment.
This shouldn’t be taken as indicating that veterinary clinics aren’t competent. Travel medicine certainly isn’t something I was taught in vet school. Most veterinarians (understandably) don’t spend much time reading about problems that only occur in other geographic regions, since there’s enough other new information on which they must stay current. So, they may not have answers at the tip of their tongues when asked a question. Trying to get good information by random phone calls or as an aside during a veterinary appointment might not be the best approach. However, since we have a surprisingly mobile pet population, with pets traveling with owners to many different regions, it’s an important area for veterinarians to think about, from two standpoints:
1) Counseling people who are traveling: As was the focus here, it’s important for people to know about disease risks and regulatory requirements for places to which they travel. Specific preventive measures (e.g. vaccination, deworming) that are not needed at home may be indicated when traveling.
2) Diagnosing disease in returning animals: It’s easy to miss travel-associated diseases, and that can lead to bad outcomes. If veterinarians don’t ask whether a pet has traveled, they won’t realize that there might be some other diseases to consider. If they don’t know about disease concerns in other regions or (perhaps more importantly) don’t have ready access to good information about disease risks in other regions (e.g. accurate websites), they might not consider important diseases even if they ask about travel history.
This study highlights a few of the current gaps in the system, involving background knowledge, client communications and variable accuracy of electronic sources. People who are traveling with pets (or acquiring pets from abroad) should have a thorough discussion with their veterinarian (not just a casual call to the veterinary clinic, during which information may come from or through lay staff) about the situation, and they need to do their own homework. It's probably best to make sure the clinic knows that there will be travel questions in advance, so mentioning it at the time of booking the appointment might help.
As the authors of this research state “An accessible, centralized, easy to use website, that is updated by a central regulating agency and applies to all countries, would allow veterinarians to refer pet owners to one site for further information regardless of which country they are travelling from and going to.”
That's the ideal situation. Given the minimal attention that governments pay to pet animals, it's probably going to have to be an government-independent, collaborative venture. We've had some discussions about this in the past and it would be great to do, but the logistics are a bit daunting. Maybe it's time to resurrect those discussions.
Echinococcus granulosus, the cause of hydatid disease/hydatosis in people, is on the rise in the Bashkiria (Bashkortostan) region of Russia. Fifty-three cases were identified in Bashkiria in 2008, 1.7 times the number of cases reported the year before. Over 500 cases of human infection with Echinococcus are reported in Russia annually.
The original article (translated from Russian) states that the people at risk are those in contact with cattle and other domestic animals. Echinococcus actually causes the same type of disease in cattle and livestock as it does in people – it forms slow-growing cysts in the lungs, liver or other tissues. When the cysts are small they usually don’t cause a problem, but eventually (sometimes even years later) they can grow to a size that interferes with normal organ and body functions. However, people do NOT become infected by contact with cattle, sheep or other intermediate hosts. The infection can only be spread to humans (and livestock) by the definitive host - dogs, including domestic dogs and wild canids. In dogs, the parasite lives in the intestine in the form of a tiny adult tapeworm, and the tapeworm eggs are shed in the dog’s stool. When the eggs are swallowed by an intermediate host, the immature form of the parasite penetrates the intestinal wall and migrates through the body tissues to the site where it ultimately forms a hydatid cyst. If the animal dies or is killed, and the cyst is eaten by a dog, then the cycle begins again.
The most probably reason for the increased number of human infections in this case is an increase in the number of dogs in the same area, particularly those used for herding sheep. This may be equivalent to the dog-reindeer cycle present in Siberia. Echinococcus infection in dogs can be treated with common deworming agents that kill other tapeworms, but it is likely that dogs in these areas are not dewormed as often as they should be to prevent this disease.
The article reiterates some sound recommendations for decreasing the risk of Echinococcus infection. These may sound familiar, because many of them also help decrease the risk of transmission of infectious diseases in general:
- Wash your hands after contact with animals.
- Wash your hands after working in orchards where cattle have wandered (not the most widely applicable recommendation for people living in North America, but is along the same lines as our recommendation to wash your hands after working outside, particularly with soil).
- Do not consume unwashed greens or vegetables (all fruits and vegetables should be thoroughly washed with potable water before being processed or eaten).
- Do not drink water from untreated sources.
More information about Echinococcus and other tapeworms is available in the Worms & Germs Archives.
Photo: Central Asian Shepherd Dog (Sredneaziatskaya Ovcharka), click here for source (Wikipedia).
Echinococcus granulosus is a tapeworm of dogs that causes a condition known as hydatid disease or hydatidosis in humans. The parasite is found in many parts of the world, and is very common in some regions of southern South America, the Mediterranean, the Middle East, southwestern Asia, northern Africa and Australia. To the best of our knowledge, E. granulosus does not occur in southern Ontario, but it is present in other parts of Canada including the western provinces and northern Ontario. A related, but much nastier, tapeworm called Echinococcus multilocularis is much less commonly found in North America.
A previous Worms & Germs post described what is known as the sylvatic cycle of Echinococcus granulosus, which is thought to be a common route of infection for dogs in Canada. In the sylvatic cycle, dogs become infected with Echinococcus by eating the internal organs (usually lungs and liver) of wild game such as moose and caribou. The dogs then pass tapeworm eggs in their stool, which can cause infection in other wild animals (thus continuing the cycle) or in people who accidentally swallow the eggs. In humans, Echinococcus forms slow-growing cysts (called hydatid cysts) in different organs of the body which can be very difficult to remove or treat in some cases.
Echinococcus also has a pastoral or domestic cycle. In this cycle, dogs acquire the parasite by eating the internal organs of infected sheep, and sometimes other livestock such as cattle and swine. This cycle is potentially very important in areas where there is a lot of sheep farming. In some areas of Latin America, 20-95% of sheep at slaughter may have evidence of hydatid cysts in their organs.
It is much more difficult to tell when a dog is infected with Echinococcus compared to other tapeworms such as Taenia or Dipylidium. An adult Echinococcus is tiny - only a few milimetres long (see picture right), very unlike the long, stringy white tapeworms that most people picture. Dogs can carry hundreds, even thousands of these tiny tapeworms without showing any signs of illness at all. The eggs can sometimes be difficult to detect on fecal examinations, and when they are seen they cannot be differentiated from Taenia eggs. Nonetheless, this is still the best way to detect infection, so fecal examinations should be performed regularly.
- In areas where Echinococcus is known to exist, it's important to have your veterinarian perform fecal examinations on your dog's stool more frequently than the usual once-a-year, because of the serious zoonotic potential of this parasite.
- Always wash your hands well after handling dog stools.
- Do not let your dog eat uncooked meat, or the organs from farm animals or wild game.
For more information on Echinococcus, see Worms & Germs post entitled Echinococcus and hydatid disease - not your average tapeworm. There is also information available on the Michigan State Department of Natural Resources site.
Lower photo credit: Ontario Veterinary College
A previous Worms & Germs post talked about the (very low) zoonotic risk of the tapeworm most commonly found in dogs and cats, Dipylidium caninum. Dogs can also carry other species of tapeworm, such as Taenia pisiformis, which cannot be naturally transmitted to people. But dogs can also carry tapeworms from the genus Echinococcus, the most common of which is E. granulosus. Echinococcus multilocularis is much less common in North America, and can also be carried by cats.
In Canada, dogs tend to be exposed to E. granulosus when they eat certain animals, particularly wild herbivores like moose and caribou. In other parts of the world, eating sheep organs is the most common way dogs are exposed. The immature form of the worm is found in the animal’s lungs, liver and other tissues. After being eaten by the dog, the worm matures in the intestine, and tapeworm eggs can soon be found in the dog’s stool. Tapeworm segments, as seen with Dipylidium infection, are usually not seen in the stool with Echinococcus. Under a microscope, it is possible to tell Dipylidium eggs from Echinococcus eggs, but it is not possible to tell Echinococcus eggs from Taenia eggs.
If a moose, caribou, sheep or another suitable “intermediate host” swallows the eggs from the dog stool, the parasite migrates through the animal’s body and forms cysts in various tissues which contain the immature form of the worm. If the animal dies or is killed, and a dog (or a wolf or coyote or related species) eats the cysts, the cycle begins again.
Unfortunately, humans can also be an “intermediate host” for these tapeworms. If a person ingests Echinococcus eggs from dog stool, the parasite can form cysts (called hydatid cysts) in many tissues and organs, including the liver, lungs, brain and heart. If the cysts are small and there are only a few, they may not cause any problems for years, and the person may never know they’re there. But as the cysts grow, they can get very large and start to interfere with the function of organs, or their size alone may be a problem, depending on where they are located. Treatment can be difficult – drugs are frequently not effective, and large problematic cysts may need to be surgically removed, if the surgery can be done safely. If a cyst bursts it can cause anaphylactic shock, which is very dangerous.
In Canada, Echinococcus infection and hydatid disease are most common in the western provinces. Nonetheless, everyone can take a few simple steps to help prevent exposure of people to Echinococcus:
- Always wash your hands after handling dog stool, even if you use a plastic bag or a scoop to pick it up.
- Your dog should have a fecal examination for intestinal parasites at least once per year, or more frequently if your dog is at increased risk of exposure to Echinococcus. If tapeworm eggs are identified, your veterinarian can prescribe medication to treat the infection.
- Monthly heartworm preventatives that are effective against other intestinal worms are not effective against tapeworms!
- Do not let your dog eat uncooked meat, especially the organs of sheep or wild game such as moose and caribou.
More information on Echinococcus and hydatid disease is available on the CDC’s Echinococcosis webpage.
People typically realize their pet has tapeworms when they see small tapeworm segments in the animal's stool. These whitish, rice-sized pieces (called proglottids, see the picture on the right) are parts of the adult tapeworm, which break off and are passed in the stool.
Tapeworms are not usually harmful to dogs and cats, particularly if only one or a few worms are present. In some situations, weight loss can occur. Affected animals may 'scoot' (drag their rear end across the ground) because of irritation from tapeworm segments that are passed in the stool.
Diagnosis of a tapeworm infestation is easiest through identification of tapeworm segments in stool. Identification of tapeworm eggs in stool samples through routine testing used for other intestinal parasites is less useful, as the bare eggs are infrequently shed in stool. Therefore, a negative fecal egg examination does not rule out tapeworms.
Dipylidium infections are extremely rare in people. Children are at greatest risk. Disease in people, if present, is usually mild and easily treated. However, finding tapeworms in a person's stool can be distressing to the individual (and their family). Dipylidium cannot be transmitted directly from animals to people. People and pets get infected by ingesting a flea that is infected with tapeworm larvae. Therefore, flea control is the most important aspect of tapeworm prevention. People that find tapeworm segments in their stool should contact their physician to determine whether they are actually tapeworms (people often mistake other things for tapeworm segments) and to determine whether any treatment is needed.
There are specific dewormers that can be prescribed by your veterinarian to eliminate tapeworms in pets. It is also important to take measures to control fleas and prevent dogs and cats from catching and eating animals that might be carrying fleas.
INFORMATION SHEETS specifically for KIDS, for VETERINARIANS, for PHYSICIANS and for PUBLIC HEALTH PERSONNEL are also available on the Worms & Germs RESOURCES page!
Click on the highlighted topics below for information sheets. Topics that are not highlighted are in development and coming soon. Sheets for other animal species and diseases are also under development and will be added when they are available.
- Your veterinarian and physician are your ultimate resource for information about the health of your pets or your family.
- Information provided here is accurate to the best of our knowledge, but infectious diseases can be unpredictable and these sheets are for general information purposes only.
- There can be great variation in disease risks in different geographic areas. The information provided was developed for Ontario, Canada, but most of the information is relevant for other regions as well.