By Watcharit Polsen, Patsakorn Rodphol, Witchayut Ngarmpornchai

# Advance Biology B,
Mr. Andrew James Flipzack.

Platyhelminthes Medical Response Plan

Abstract:
This medical response plan is created to explain the situation of the current
parasite outbreak on the northern Thailand, the plan we created to contain the infection
and treat the infected ones, as well as the plan to prevent future infestation of the
parasites themselves throughout the area and the whole country. The parasites is the
intestinal flukes “Metagonimus Yokogawai” that lives in its marine-creature host before
transfer into human.We have a plan to send our medical teams to assist with the local
doctors for curing the patients from the parasitic infection, search and detect the
parasites, and to give the villagers information about ways to protect them for these
parasites. We also make a plan for local policemen to make posts on the road to detect
the movement of the populace, and patrolling the forest preventing more villagers from
getting infected by the parasites. By doing as the plan according so, we expect that the
case of infection will decrease until no reports of infection from the parasites will be
turned in about a year and two more months.

Background:
Our research team had discovered that the main cause of this outbreak on the
northern part of Thailand was from “Metagonimus Yokogawai,” the intestinal fluke that
infects through marine creatures like fish and snails before passed onto terrestrial
animals later on. The life-cycle of these flukes start from infecting a suitable snail host,
grow within it before penetrate through its intestine and getting out of its host. The flukes
will then seek out their new host to keep growing. Their secondary host is usually fishes
in the area. Consumption of these fishes uncooked can give you high percentage of
getting infected by these flukes including fish-eating birds as well. The flukes will laid
their eggs within its host intestine and moved out along the feces of the host. its
life-cycle repeated again when eggs had found their new suitable snail hosts. The
image below illustrated its life cycle

If they infecting human, we can have these following symptoms;

● Peripheral ​eosinophilia​.
● Diarrhea.
● Nausea.
● Abdominal pain.
● Lethargy.
● Fatigue.
● Anorexia​.
● Malaise.
 ● Seizures (in extreme cases).
● Neurological defects (in extreme cases).
● Cardiac problems (in extreme cases)
These parasites can be detected by using a medical method called “MIF method” or
“​Merthiolate, Iodine, Formalin” method which is commonly used by many health
institutions. The parasites can also be cured by Praziquantel. But their life cycles,
location within the human host, and their symptoms on human is still unpredictable even
with MIF detection method.

Situation:
There is an outbreak of a Platyhelminthes parasite in northern Thailand. At
present, there are 202 known cases that have resulted in 34 deaths. Local medical
personnel believe that the actual number of people infected may be much higher. The
area where the infections are occurring is primarily rural. There are a series of
interconnected towns with a total population of 10,000 people. ​There is no mass
transit between these areas.​ However, individuals typically will move and operate in
all towns. There is no system for sanitation. Law enforcement in the area is good. Local
hospitals are good but small and cannot accommodate large numbers of people.

The forest surrounding the towns is home to a variety of mammal, reptile, and mollusk
species. These include rats, dogs, mice, bats, snakes, skinks, snails, etc. There are
numerous freshwater rivers and streams running through the area that local people rely
on heavily for water. ​Freshwater fish and mollusks are common. Most people in all
towns utilize animals from the forest and rivers for food.

Agriculture is a vital industry in the area. Nearly 1/3 of local people actively raise farm
animals as a source of income. ​Common animals include cows, pigs, and sheep.
Meat from these animals are transported to all major cities.
The first case was reported in September. Below are the number of new and total
infection cases by month.

Month New Cases Total Cases

September 1 1

October 3 4

November 10 14

December 25 39

January 29 68

February 35 103

March 52 155

April 47 202
If we intervene now, we predict that you can slow the rate of infections by an average of
15 cases per month until 0 new cases. However, if we wait 3 months, we predict that we
can slow the rate of infections by 10 cases per month. It will cost us 1,000 baht per
person to cure their infection and return them to health.

Constraints:
We can engage this plan as immediate as possible. But the locals are our main
priority and their need is also a concern to us all. Since the locals rely heavily on the
water which we suspected to be infected with flukes and the animals around the area
that might also have a chance to get infected from them as well including animals that
the locals raised, we had created the list of regulations that we are unable to proceed by
the locals which including that:

- We can’t kill livestock using chemical

- We can’t use the chemical substance to kill the animal in the forest
 - We can’t drain the water in rivers and streams near the locals
- We can’t prevent the locals from stop doing their agricultures
- We can’t put the chemical substance into the rivers

Restraints:
We also negotiated with the locals that we had acknowledged their concern of
living and we made an agreement to them that we won’t initiate any activity that go
beyond the regulations they made for us. The agreement we made with them are
including that:

- We won’t kill the infected people

- We won’t eat local food
- We won’t use or drink the water from nearby rivers and streams
- We won’t stop the locals from doing their jobs
- We won’t dry out the water near the locals
- We won’t pay any unnecessarily rentings

Response Procedures:

The plan must be initiated as immediate as the first day of May to ensure that we
can reduce significant cases of locals getting infected by these flukes more than waiting
for a few months and reduce less cases than do so immediately. We also had created a
plan for all of our assistances from both the locals and our own as well.

Medical Team​:
The local doctors are quite responsive but their places and numbers are
quite low which can’t afford to cure flooding waves of patients at once. We should
create additional medical tents nearby the hospitals to ensure enough places for
treating the locals. For the treatment, we will provide both our medical team and
local doctor with Praziquantel to treat sick people with dosages of 75 mg/kg/d in
3 doses for 1 day. We will also have them use the MIF (Merthiolate, Iodine,
Formalin) method to detect and identify the infected people and those who are
not infected by the flukes. If in any case of emergency, we will provide an
immediate emergency team to pick up the patients whether they were unaffected
or not for both the emergency treatment and MIF detection. Thus, we should
have some of our medical personnels to create a stationary booth for providing
the villagers information and ways to prevent further infection from these flukes
and how to notify the hospital if the flukes return. Checking the livestocks of the
local is also recommended but they must not interfere much with the locals living
status.

Military Team:
The military and police will responsible for organize the area by divide the
area into section. For example, we will separate the infected people from non
infected people to prevent the spread and increase of the infection cases. It is
vital that we should seperate all the infected people from non-infected ones my
any necessary mean. They should also form a guard post on the street to check
the immigrants on their cargo and their destination. If they are from the
surrounding area with infection, they must be sent for the MIF immediately. If the
person is caught loading shipments of marine animals from the infected rivers
and streams, they must notify the medical team and contain the shipment ASAP.
from Furthermore, the forest, rivers and streams are highly likely to be in
fluke-infested state. They should make a patrol on these area regularly to prevent
anyone from getting infected. Police and soldiers should consider to not drink
from the river and beware of the wild as well for they can also get infected too.
We will ask them to wear tight clothes, body protection, and brought their own
water and food as they go on patrol.
 We also have a list of possible Financial aids that we predict this contamination
will cost. And the costs are organized into 2 main types :

Fixed cost:
- Shelter cost
- Food and water
- Electricity
- Transportation
- Treatment per person
Variable cost:
- Medicine
- Build the sanitation system
- Medical apparatus
- Chemicals for MIF method
- Personnel’s wage

All team will perform their duty for the local’s safety and healthiness until the last
reported case of infection was cured. However, they must stay on their task for
approximately 15 days to make confirmation that the flukes had been contained. After
everything had been secured, we will remove some of our blockade on both the road
and the forest to allow the locals to feel more comfortable on their living. Yet, some
guard posts, patrolling duty, and treatment process will still remain for preventing future
infestation.

Prevention Steps:

To ensure that future infestation of the Platyhelminthes parasite on these area

does not happen once more, we had also made a plan for our team and the local
departments as well.
 1) We will called on local doctors to make a yearly medical check-up on the locals
as well as to give them a yearly information booth for the villagers to ensure they
can receive an update on the flukes treatments and current infestation status.

2) We will give them on how to live their lives as healthy and safe from the sickness
like “Cook thoroughly, Report immediately, and Live healthy.” We will ask the
professors and health specialists from health care services to give out the
information aside the local doctors.

3) We should give make the media advertisement to share these information to both
the local and other people in both surrounding area and those in other regions to
ensure they acknowledged about the incident and report if the flukes spread to
their areas.

4) We will send the local police and medical team to create a sanitation program on
the rivers and streams nearby the former infected area to prevent the flukes from
infecting the animals and villagers that consume the water from these waterways.
Locals are also welcomed to join the program and help the police and medical
team’s out.

Executive Summary:
We have a plan to send our medical teams to assist with the local doctors for
curing the patients from the parasitic infection by using Praziquantel for 3 dosages for a
day. They will also help the locals on providing the information booth explaining the
protection method from the parasites and detect the parasite in the locals and their
livestocks. Each patients will cost 1,000 baht to cure them to full health potential and the
medical apparatus will be 750 baht for each months. The policemen and militaries can
help on check the transit between the local’s and people from outside the infected area.
They will be allowed to contained any shipments of fresh marine products for preventing
chances of parasitic invasions of the parasites to increase. Thus, we will like to have
them patrol the forest surround the parasite-infected area to make sure no locals are
getting infected from the natural waterways or wild animals we suspected to be infested
with the parasite flukes. We estimate the shelter and food per month will be 1,500 baht
until the infection stopped and the locals are completely cured.

Conclusion:
In conclusion, by following this plans; 1) having our medical teams assist with the
local doctors for curing the infected populace and detect the parasites in the livestock
and environments of the area, 2) have the police and soldiers set up the guard posts on
the road and sweep patrol the forest in the surrounding area and we initiated this plan in
the month of May, we can make a prediction that we will have a maximum case of
infection around 300 cases, last infected person will be cured around a year and 2 more
months after the we initiated the plan and the people in the northern Thailand and other
regions of Thailand will receive the knowledge for future protection of these parasites.
The cost of this containment campaign will be a total of 618,500 bath.

Reference:
http://www.mcdinternational.org/trainings/malaria/english/DPDx5/HTML/ImageLibrary/M
-R/Metagonimiasis/body_Metagonimiasis_il1
https://www.cdc.gov/dpdx/metagonimiasis/index.html
http://www.aavp.org/wiki/trematodes-2/trematodes-small-intestine/heterophyidae/metag
oniminae/metagonimus-yokogawai/
https://www.medigoo.com/articles/metagonimus-yokogawai-infection/
http://eol.org/pages/480181/overview
http://www.vetbook.org/wiki/fish/index.php?title=Metagonimus_yokogawai
https://www.cdc.gov/dpdx/metagonimiasis/index.html