Common Liver Fluke Fasciola Hepatica

Executive Summary (BLUF)

A Med-DART team is deploying to northern part of Thailand due to the
outbreak of common liver fluke in the area. It has been spreading from water
source to nearby animals and now they are expanding to human. The team
consist of local cops, teachers, local reporters, medical teams and engineers. It
will be going next month and expected to come back with in 3 months.
Everything will be organized by the ministry of Science. The purpose of this
trip is to contain and cure the Common Liver Fluke and help the locals to
prevent from events that can happen again. All the process of the plan involves
curing infected patients, stopping the life cycle of the parasite, and preventing
livestocks from being carriers.

Background information of Common Liver Fluke and life cycle

Common Liver Fluke or Fasciola Hepatica is an infective parasitic
trematode in the flat shape which can be mostly found in sheep and cattle. The
fluke can expand its length to 2-3 centimeters, and breed in one cell. In fact,
humans who like eating raw watercress and contaminated water plants gain
higher chances to get infected by the fluke which it will directly invade humans’
intestine, bile ducts, and liver causing both acute and chronic diseases such as
fasciolosis​. Fasciolosis will normally destroy appetite leading to great weight
loss together with resulting in Anaemia. The way to prevent ​fasciolosis is
vaccination which is available in several countries, and can be cured with the
anthelmintic drugs.
 Life cycle of Common Liver Fluke can be divided into two main stages
which contain dangerous impacts on several mammal species, especially in
sheep and cattle. The fluke in the adult age produces the eggs within host’s
organ, and sends those eggs into the intestines and stools. Actually, apart from
sheep, cattle, and buffalo, humans can be the host as well. After that, with more
than 10°C temperatures, the eggs will slightly grow in soggy ranch. Then, the
larvae will grow in an intermediate hosts which most of the case are various
kinds of snails. For example, in Europe, the snail specie is Galba, and in
American continents, the snail species are Lymnaea viator, L. neotropica,
Pseudosuccinea columella, and L. cubensis. Then, the growing larvae will find
the new place to live by finding vegetation and forming cysts. When animals eat
those contaminated vegetation, they will be infected by the fluke before
repeating the same cycle again.
Situation
The parasite, Common Liver Fluke, is concentrated in the dirty
freshwater that villagers consume. Villager in this area with a population size of
about 10000 people rely on mostly agriculture and fishing. They eat fish living
in the dirty water which is the main habitat for this type of parasite. At the same
time, villagers’ livestocks such as cow and sheep also drink water from the
river. In the other word, parasites live spreadly including in human body.
According to the data collected, infected patients steadily increase each
month since September last year, indicating the problem remaining unsolved
and more likely to be seen as getting worse. See the table below for the number
of the cases per month.

Month New Cases Total Cases

September 1 1

October 3 4

CURRENT November 10 14

SITUATION December 25 39

January 29 68

February 35 103

March 52 155

April 47 202
INFECTION TREND WITHOUT TREATMENT

INFECTION TREND WITH TREATMENT

 May 32 234

FUTURE June 17 251

PREDICTION July 2 253

August 0 253

Constraints
- Killing all the infected are not allowed
- No new medical are allow without permission
- All informations are classified
- People properties are off limit

Restraints
- We will bring our own equipments
- All medical supply must be available as requested
- All cost must be paid by Ministry of Health
- Be able to contain people who are suspected to be infected

Response Procedures
Symptom : In the early phase as the parasite move from intestine to the
liver, symptoms can include gastrointestinal problem such as nausea, vomiting
and abdominal pain. Some patient also have fever, rash and difficulty breathing
may occur. After the parasite is in bile ducts, chronic phrase, the symptoms are
inflammation and blockage of bile ducts, liver, gallbladder and pancreas.
Inflammation Symptoms

Bile obstruction Dark urine, jaundice (yellowish eyes

and skin), weight loss and vomiting.

Inflammation of liver Indigestion, hiccups, swollen

abdomen, weight loss

Inflammation of gallbladder Upper right abdomen pain, vomiting,

fever, malaise (feeling of discomfort
and illness)

Inflammation of pancreas Swollen abdomen, increased heart

rate, fever, vomiting, upper
abdominal pain

Treatment (sick people):

Firstly, you have to make sure that the diagnosis is correct then contact the
healthcare service. Presently, we are using a medicine called triclabendazole to
treat a common liver fluke infection. This medicine is effectively destroying the
liver fluke’s eggs. Most of the people are given a medicine approximately one
month. We also used other drugs such as a pain reliever to treat some of the
symptoms of diarrhea and pain. In some cases, the surgery is necessary when
the cholangitis is developed. Cholangitis is bile duct disease that is the
inflammation of the bile duct.

Treatment (non-sick people):

To prevent the disease to undergo further outbreak, appropriate
prevention should be announced clearly by the local reporter to those who has
not been infected yet. Villagers should make sure that they clean and cook
thoroughly before consuming food made from freshwater fish or watercress,
which is the most effective way to prevent the liver fluke infection. For the
people who travel to the area with poor sanitation should avoid drinking water
that might be contaminated with parasites or fluke. Furthermore, people also
shouldn’t drink water directly from the stream that located near domestication
area especially for cattle and sheep livestock. Lastly, people should boil all
untreated water before drinking the water. It is very important to prevent
themselves from the common liver fluke because there is no vaccine available to
treat liver fluke infection​s.

Medical Team
The medical team is responsible for the treatment to identify the people who
infected by the fluke.​ ​The local hospital are good but they cannot deal with
many patients at one time. As a result we should create the medical camp in
many areas in order to detect the infected patient quickly. If we can identify the
fluke inside the sick people as soon as possible, it will be easier to cure in the
early phase of this infection. In addition, we should expand the hospital in local
area in order to cure many people at once. We need to ensuring that the parasite
inside the patients is completely killed so that it will not spread and begin their
new life cycle again. Lastly, we need to provide the accession of the medical
treatment easily since the chronic symptoms of Common Liver Fluke Fasciola
Heptica is fatal to the health of patients.

Teacher Team
Teacher is responsible for broadcasting education to villagers regarding the
symptom and prevention of the parasite. Teacher will collaborate with medical
team to inform the villager the accurate information. Also, the reporter will
assist teacher to distribute the current situation to villagers and make a right
decision under the certain scenario. For agricultural-based village, the farmer
should be well-educated, especially farmings and livestocks because plant and
animal are one of the main carriers of this type of parasite toward human.

Corps and Military Team

The military team and cops are responsible for controlling and keeping
discipline of outlaws. Infected patients will be sent to do the further diagnosis
and proper treatment. The team is also assigned to form a checkpoint around the
market and restaurant area in order to make sure that foods are free from the
parasite. Corps and military team need to make sure that the agriculture farm
will not outbreak the laws such as run off the feces with the fluke in the river. In
addition, they are responsible for prevent people from access to the water plant
and river that are contaminated with the fluke.

Prevention
There is no vaccine to protect people against Fasciola infection. As a
result, the Med-DART plan need to control the setting to prevent the parasite
from growing.
 From this diagram, it is about the Fasciola cycle which we can create the
prevention step by interrupting its life cycle.
Step 1 & 2 (see life cycle diagram). Stop embryonated eggs before
reaching into river : We can stop by creating fences around to territorial control
the livestocks and build latrine to manage their feces not to contaminate the
river so that the parasite egg will not be embryonated. As a result, it will not run
off to the river. In addition build the river path way to the farm instead of
building the farm near the river. We need to keep the feces away from the river
and not push it into the river for our convenience.
Step 5 & 6 (see life cycle diagram). Free Swimming cercariae encyst on
water plants & Metacercariae on water plant ingested by human, sheep or cattle
: Not eating raw watercress and other water plants from grazing areas. Avoid
contaminated food and water from poor sanitation areas. Make sure vegetable
and food are clean and portable before consuming. In case of using water from
the river, villagers need to filter and boil it first.
Step 7 (see life cycle diagram). In human body : kill the Fasciola
Hepatica by eating the medicine ‘triclabendazole’ and build the efficient
sanitation to manage human feces which might contaminated with the fluke.

Future Prevention
Health officials educate people to identify the symptoms of this infection
so that they can go to hospital and take the appropriate treatment. Also, people
should be informed how to prevent themselves from getting infected with
parasite. Enforce the law seriously to contain any feces from runoff the river and
pick up the contaminated watercress. Build the foundation to accumulate the
fund in order to improve quality of agriculture farms, system of sanitation and
local hospital (to receive more patient). In addition, we will also create an
organization that will observe the agriculture farm in terms of quality of the
water that will run off to the river so the river will not be contaminated with the
feces.

Finance Management

FIXED VARIABLE

- Fence - Treatment (1000 Bth/Psn)

- Latrine - Equipment
- Toilet - Doctors and staffs
- Cops - Medical apparatus
- Teachers - Shelter cost
- Reporter
 - Transportation

Conclusion
With a medical plan created by MED-DART team, it is predicted that the
number of the current infected patients (253 people) will be completely cured
within three months, or else, the outbreak of the parasite will dramatically rise
the number of the patients. In addition, the plan involves stopping the life cycle
of the parasite and being carried by the livestocks. The parasite will be no
longer interfere villager’s lives due to the efficient quality of MED-DART team
prevention. All in all, the cost of this team is approximately 253,000 baht which
is worthy to invest since it is a long-term plan.

Med-DART team :
Chinorod Tavichai
Suparuek Saetoen
Pitcha Boonachathong
Vachanon Lttikraichareon
Lasika Taweewattanakitborvon