Intestinal parasites including Cryptosporidium,Cyclospora, Giardia,and Microsporidia,Entamoeba histolytica,Strongyloides, Schistosomiasis,and Echinococcus: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of intestinal parasites in the pre‐ and post‐transplant period. Intestinal parasites are prevalent in the developing regions of the world. With increasing travel to and from endemic regions, changing immigration patterns, and the expansion of transplant medicine in developing countries, they are increasingly recognized as a source of morbidity and mortality in solid‐organ transplant recipients. Parasitic infections may be acquired from the donor allograft, from reactivation, or from de novo acquisition post‐transplantation. Gastrointestinal multiplex assays have been developed; some of the panels include testing for Cryptosporidium, Cyclospora, Entamoeba histolytica, and Giardia, and the performance is comparable to conventional methods. A polymerase chain reaction test, not yet widely available, has also been developed to detect Strongyloides in stool samples. New recommendations have been developed to minimize the risk of Strongyloides donor‐derived events. Deceased donors with epidemiological risk factors should be screened for Strongyloides and recipients treated if positive as soon as the results are available. New therapeutic agents and studies addressing the optimal treatment regimen for solid‐organ transplant recipients are unmet needs.     

Tissue and blood protozoa including toxoplasmosis,Chagas disease,leishmaniasis, Babesia,Acanthamoeba, Balamuthia,and Naegleria in solid organ transplant recipients— Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of tissue and blood protozoal infections in the pre‐ and post‐transplant period. Significant new developments in the field have made it necessary to divide the previous single guideline published in 2013 into two sections, with the intestinal parasites separated from this guideline devoted to tissue and blood protozoa. The current update reflects the increased focus on donor screening and risk‐based recipient monitoring for parasitic infections. Increased donor testing has led to new recommendations for recipient management of Toxoplasma gondii and Trypanosoma cruzi. Molecular diagnostics have impacted the field, with access to rapid diagnostic testing for malaria and polymerase chain reaction testing for Leishmania. Changes in Babesia treatment regimens in the immunocompromised host are outlined. The risk of donor transmission of free‐living amebae infection is reviewed. Changing immigration patterns and the expansion of transplant medicine in developing countries has contributed to the recognition of parasitic infections as an important threat to transplant outcomes. Medications such as benznidazole and miltefosine are now available to US prescribers as access to treatment of tissue and blood protozoa is increasingly prioritized.     

Genetically similar hepatitis E virus strains infect both humans and wild boars in the Barcelona area,Spain, and Sweden

Hepatitis E virus (HEV) is a hepatotropic virus, endemic in Europe where it infects humans and animals, with domestic pigs and wild boars as main reservoirs. The number of HEV‐infected cases with unknown source of infection increases in Europe. There are human HEV strains genetically similar to viruses from domestic pigs, and zoonotic transmission via consumption of uncooked pork meat has been shown. Due to continuous growth of the wild boar populations in Europe, another route may be through direct or indirect contacts with wild boars. In the Collserola Natural Park near Barcelona, Spain, the wild boars have spread into Barcelona city. In Sweden, they are entering into farmlands and villages. To investigate the prevalence of HEV and the risk for zoonotic transmissions, the presence of antibodies against HEV and HEV RNA were analysed in serum and faecal samples from 398 wild boars, 264 from Spain and 134 from Sweden and in sera from 48 Swedish patients with HEV infection without known source of infection. Anti‐HEV was more commonly found in Spanish wild boars (59% vs. 8%; p < 0.0001) while HEV RNA had similar prevalence (20% in Spanish vs. 15% in Swedish wild boars). Seven Swedish and three Spanish wild boars were infected with subtype 3f, and nine Spanish with subtype 3c/i. There were three clades in the phylogenetic tree formed by strains from wild boars and domestic pigs; another four clades were formed by strains from humans and wild boars. One strain from a Spanish wild boar was similar to strains from chronically infected humans. The high prevalence of HEV infections among wild boars and the similarity between wild boar HEV strains and those from humans and domestic pigs indicate that zoonotic transmission from wild boar may be more common than previously anticipated, which may develop into public health concern.     

Molecular Survey of Anaplasma and Ehrlichia of Red Deer and Sika Deer in Gansu,China in 2013

Anaplasma and Ehrlichia are important emerging tick‐borne pathogens in both humans and animals. Here, we conducted a molecular surveillance study in Gansu, China to assess the prevalence of Anaplasma and Ehrlichia spp. in red deer and sika deer based on polymerase chain reaction (PCR) analysis and sequencing of 16S rRNA or msp genes. PCR revealed that the prevalence of Anaplasma ovis, Anaplasma bovis and Anaplasma platys of the Qilian Mountain samples was 32%, 9% and 9%, respectively; the prevalence of Anaplasma ovis, Anaplasma bovis, Anaplasma platys was 20%, 15% and 15% among the Long Mountain samples, respectively. Of the Long Mountain samples, two (5%) of the 40 samples were positive for Ehrlichia canis, but all 44 of the Qilian Mountain samples were negative for E. canis, and no other Anaplasma or Ehrlichia spp. were found in the samples. The phylogenetic tree showed that the newly isolated Anaplasma and Ehrlichia spp. could be classified as belonging to four clades, including an A. bovis cluster, A. ovis cluster, A. platys cluster and E. canis cluster. In addition, Bartonella schoenbuchensis was firstly identified in blood samples from red deer in Gansu, China. Our results provide important data to increase the understanding of the epidemiology of anaplasmosis and ehrlichiosis of red deer and sika deer and will assist with the implementation of measures to control anaplasmosis and ehrlichiosis transmission to red deer, sika deer and other animals in Gansu, China.     

Glanders in Animals: A Review on Epidemiology,Clinical Presentation,Diagnosis and Countermeasures

Glanders or farcy, caused by Burkholderia mallei, is an infectious and zoonotic disease of solipeds. Horses, donkeys and mules are the only known natural reservoir of B. mallei. Although glanders has been eradicated from most countries, it has regained the status of a re‐emerging disease because of the numerous recent outbreaks. Pre‐symptomatic or carrier animals are the potential source of infection for the healthy equine population and play a crucial role in the spreading of the infectious agent. Glanders is characterized by ulcerating nodular lesions of the skin and mucous membrane. Generalized symptoms include fever, malaise, depression, cough, anorexia and weight loss. Burkholderia mallei can invade its host through mucous membranes, gastrointestinal tract and the integument. Its virulence mechanisms and pathogenesis are not yet completely understood. A major problem when using serological tests for diagnosing glanders is the occurrence of false‐positive and false‐negative results leading to difficulties in international trade with equids and to the spread of glanders to disease‐free regions. Moreover, poor tests critically result in poor control of disease. These tests are not only incapable of discriminating between B. mallei and B. pseudomallei antibodies, they are also unable to differentiate between malleinized and naturally infected animals. Combined use of both serological and molecular detection methods increases the detection rate of glanders. Countermeasures against glanders include early detection of disease in susceptible animals, stringent quarantine measures, testing and safe destruction of infected carcasses, adequate compensation to the animal owners, disinfection of infected premises and awareness about glanders and the zoonotic implications through veterinary extension services. An account of the clinical picture and successful experimental therapy of spontaneous equine glanders is also given.     

Leishmaniasis in cat shelters: A serological,molecular and entomological study

An epidemiological Leishmania spp. and entomological Phlebotomine sandflies survey was performed in cat shelters at leishmaniasis endemic area of Brazil. Blood and conjunctival swab (CS) samples were collected from 94 cats in two animal protection shelters. These samples were subjected to serological tests using the indirect immunofluorescence antibody test (IFAT) and indirect enzyme‐linked immunosorbent assay (ELISA) and to molecular test by polymerase chain reaction (PCR). In addition, a Phlebotomine sandflies survey was performed in the same shelters. The analyses revealed a positivity of 31.91% (30/94) through ELISA and 29.79% (28/94) through IFAT. The two serological tests showed a positive association with perfect agreement (k = 0.925). None of the cats were positive by Leishmania spp. DNA. One Lutzomyia (Lutzomyia) longipalpis male was found in one of the cat shelters. The results and the implications of our findings are discussed below.     

Animal tuberculosis: Impact of disease heterogeneity in transmission,diagnosis and control

Animal tuberculosis (TB) in terrestrial mammals is mainly caused by Mycobacterium bovis. This pathogen is adapted to a wide range of host species, representing a threat to livestock, wildlife and human health. Disease heterogeneity is a hallmark of multi‐host TB and a challenge for control. Drivers of animal TB heterogeneity are very diverse and may act at the level of the causative agent, the host species, the interface between mycobacteria and the host, community of hosts, the environment and even policy behind control programmes. In this paper, we examine the drivers that seem to contribute to this phenomenon. We begin by reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological and socio‐environmental factors contribute to the establishment and maintenance of animal TB, setting the grounds for heterogeneity. We then highlight the complex interplay between individual, species‐specific and community protective factors with risk/maintenance variables that include animal movements and densities, co‐infection and super‐shedders. We finally consider how current interventions should seek to consider and explore heterogeneity in order to tackle potential limitations for diagnosis and control programmes, simultaneously increasing their efficacy.     

Molecular,serological, pathological,immunohistochemical and microbiological investigation of Brucella spp. in marine mammals of Brazil reveals new cetacean hosts

Brucella‐exposure and infection is increasingly recognized in marine mammals worldwide. To better understand the epidemiology and health impacts of Brucella spp. in marine mammals of Brazil, molecular (conventional PCR and/or real‐time PCR), serological (Rose Bengal Test [RBT], Competitive [c]ELISA, Serum Agglutination Test [SAT]), pathological, immunohistochemical (IHC) and/or microbiological investigations were conducted in samples of 129 stranded or by‐caught marine mammals (orders Cetartiodactyla [n = 124], Carnivora [n = 4] and Sirenia [n = 1]). Previous serological tests performed on available sera of 27 of the 129 animals (26 cetaceans and one manatee), indicated 10 seropositive cetaceans. Conventional PCR and/or real‐time PCR performed in cases with available organs (n = 119) and/or blood or swabs (n = 10) revealed 4/129 (3.1%) Brucella‐infected cetaceans (one of them with positive serology; the remaining three with no available sera). Pathological, IHC and/or microbiological analyses conducted in PCR/real‐time PCR and/or seropositive cases (n = 13) revealed Brucella‐type lesions, including meningitis/meningoencephalitis, pneumonia, necrotizing hepatitis, pericarditis and osteoarthritis in some of those animals, and positive IHC was found in all of them (excepting two live‐stranded animals without available organs). Brucella spp. culture attempts were unsuccessful. Our results demonstrated exposure, asymptomatic, acute and chronic Brucella sp. infection in several cetacean species in the Brazilian coast, highlighting the role of this pathogen in stranding and/or death, particularly in Clymene dolphin (Stenella clymene) and short‐finned pilot whale (Globicephala macrorhynchus) off Ceará State. Novel hosts susceptible to Brucella included the franciscana (Pontoporia blainvillei), the Guiana dolphin (Sotalia guianensis) and the spinner dolphin (Stenella longirostris). Additionally, three coinfection cases involving Brucella spp. and cetacean morbillivirus, Edwarsiella tarda and Proteus mirabilis were detected. To the best of our knowledge, this is the first long‐term and large‐scale survey of Brucella spp. in marine mammals of South America, widening the spectrum of susceptible hosts and geographical distribution range of this agent with zoonotic potential.     

Isolation and Genetic Characterization of a Tembusu Virus Strain Isolated From Mosquitoes in Shandong,China

Tembusu virus (TMUV) is a flavivirus, presumed to be a mosquito‐borne flavivirus of the Ntaya virus subgroup. To date, however, there have been no reports indicating that mosquitoes are involved in the spread of TMUV. In this study, we report the first isolation of TMUV from Culex mosquitoes. We describe the isolation and characterization of a field strain of TMUV from mosquitoes collected in Shandong Province, China. The virus isolate, named TMUV‐SDMS, grows well in mosquito cell line C6/36, in Vero and duck embryo fibroblast (DEF) cell lines, and causes significant cytopathic effects in these cell cultures. The TMUV‐SDMS genome is a single‐stranded RNA, 10 989 nt in length, consisting of a single open reading frame encoding a polyprotein of 3410 amino acids, with 5′ and 3′ untranslated regions of 142 and 617 nt, respectively. Phylogenetic analysis of the E and NS5 genes revealed that the TMUV‐SDMS is closely related to the TMUV YY5 and BYD strains which cause severe egg‐drop in ducks. The 3′NTR of TMUV‐SDMS contains two pairs of tandem repeat CS and one non‐duplicate CS, which have sequence similarities to the same repeats in the YY5 and BYD strains. Our findings indicate that mosquitoes carrying the TMUV may play an important role in the spread of this virus and in disease outbreak.     

Prevalence,Isolation and Molecular Characterization of Bartonella Species in Republic of Korea

To determine the prevalence of Bartonella species and identify which species of Bartonella naturally infects the striped field mouse (Apodemus agrarius) in the Republic of Korea (ROK), spleens from 200 mice were assayed by nested polymerase chain reaction (nPCR) targeting the RNA polymerase subunit beta (rpoB) gene and the 16S‐23S internal transcribed spacer (ITS) region for members of the genus Bartonella. Utilizing PCR techniques, the prevalence of Bartonella spp. ranged from 31.5% (63/200) to 62.0% (124/200) for the rpoB and ITS gene fragments, respectively. The most prevalent species, Bartonella grahamii, was assigned to 17 genotypes and closely related to the zoonotic pathogens, B. taylorii, B. tribocorum, B. phoceensis and B. henselae, which also were detected. Two Bartonella isolates (KRBG28 and KRBG32) were recovered from blood of A. agrarius captured in Gyeonggi Province, ROK. Comparison of the 16S rRNA, hemin‐binding protein E (hbpE), glutamate dehydrogenase 1 (gdh1), invasion‐associated protein B (ialB), cell division protein (ftsZ), citrate synthase (gltA), 60 kDa heat shock protein (groEL), rpoB gene fragments and the ITS region sequences from the isolates with GenBank was confirmed as B. grahamii. Phylogenetic analysis based on the alignment of concatenated sequences (4933 bp) of KRBG28 and KRBG32 clustered with B. grahamii, forming an independent clade between Asian and American/European B. grahamii genogroups.     

Effect of brain‐derived neurotrophic factor on sperm function,oxidative stress and membrane integrity in human

Oxidative stress has negative impacts on the clinical outcomes of assisted reproduction techniques. The brain‐derived neurotrophic factor (BDNF) promotes the viability of nerve cells and is known to decrease oxidative stress and apoptosis in different cells. The aim of this study was to evaluate the effect of BDNF treatment on human sperm functions that are known to be essential for fertilisation. Our findings showed that treatment of human spermatozoa with 0.133 nM BDNF significantly increased the percentages of both total (P = 0.001) and progressive (P < 0.01) motile sperm cells compared to those observed in the nontreated (control) group. We also showed that the mean fluorescence intensity of DCFH‐DA, as an indicator of intracellular reactive oxygen species, was significantly lower (P < 0.05) in spermatozoa treated with BDNF compared to the control group. Treatment of spermatozoa with BDNF significantly decreased the percentages of both dead (P = 0.001) and apoptotic‐like sperm cells (P < 0.05) compared to the control group. On the other hand, BDNF treatment significantly increased the percentage of viable sperm cells compared to the control (P = 0.001). In conclusion, BDNF has protective effects against oxidative stress in spermatozoa and could improve sperm functions that are essential for sperm–egg fusion and subsequent fertilisation.     

Molecular Demonstration of Trypanosoma evansi and Trypanosoma lewisi DNA in Wild Rodents from Cambodia,Lao PDR and Thailand

In this study, we investigated the molecular evidence of Trypanosoma evansi in wild rodents from Cambodia, Lao PDR and Thailand. Between November 2007 and June 2009, 1664 rodents were trapped at eight sites representative of various ecological habitats. Of those animals, 94 were tested by direct microscopic blood examination, 633 using the Card Agglutination Test for Trypanosomes (CATT/T. evansi) and 145 by Polymerase Chain Reaction (PCR) with two sets of primers: TRYP1 (amplifying ITS1 of ribosomal DNA of all trypanosomes) and TBR (amplifying satellite genomic DNA of Trypanozoon parasites). Using TRYP1, based on the size of the PCR products, 15 samples from the three countries were positive for Trypanosoma lewisi (two were confirmed by sequencing), and three were positive for Trypanozoon (one was confirmed by sequencing and three by TBR primers); the specificity of the primers failed as rodent DNA was amplified in some cases. Using TBR, six samples were positive for Trypanozoon (one was confirmed by sequencing); as T. evansi is the only species of the Trypanozoon sub‐genus possibly present in Asian rodents, these results confirmed its presence in rodents from Thailand (Rattus tanezumi) and Cambodia (R. tanezumi, Niviventer fulvescens & Maxomys surifer). Further investigations are necessary to establish the situation in Lao PDR. None of the 16 samples most strongly positive to the CATT proved to be positive for Trypanozoon by PCR. The merits of the CATT for such studies were not confirmed. Studying the urban and rural circulation of these parasites in rodents will enable an evaluation of human exposure and infection risk, as human infections by T. evansi were recently described in India and by T. lewisi in India and Thailand. As sequencing PCR products is expensive, the development of new molecular and serological tools for rodents would be very useful.     

Non‐tuberculous Mycobacteria in Wild Boar (Sus scrofa) from Southern Spain: Epidemiological,Clinical and Diagnostic Concerns

Non‐tuberculous mycobacteria (NTM) are widely distributed in the environment, particularly in wet soil, marshland, rivers or streams, but also are causative agents of a wide variety of infections in animals and humans. Little information is available regarding the NTM prevalence in wildlife and their effects or significance in the bovine tuberculosis (bTB) epidemiology and diagnosis. This research shows the most frequently NTM isolated in lymph nodes of wild boar (Sus scrofa) from southern Spain, relating the NTM presence with the individual characteristics, the management of animals and the possible misdiagnosis of Mycobacterium bovis in concurrent infections. A total of 219 NTM isolates were obtained from 1249 wild boar mandibular lymph nodes sampled between 2007 and 2011. All but 75 isolates were identified by the PCR‐restriction analysis‐hsp65, and a partial sequencing of the 16S rDNA was carried out to identify the rest of the isolates. Results showed that Mycobacterium chelonae was the most frequently isolated NTM specie (133 isolates, 60.7%), followed by Mycobacterium avium (24 isolates, 11%). No relation was found regarding sex, body condition and management, but M. chelonae was more frequently detected in adults, whereas M. avium was more prevalent in subadults. The high NTM prevalence observed in the studied wild boar populations could make difficult the bTB diagnostic.     

Moku virus detection in honey bees,Belgium, 2018

We report the detection of Moku virus in honey bees (Apis mellifera) collected in 2017 from hives with a history of attacks by invasive Asian hornets (Vespa velutina nigrithorax) in Belgium. End 2016, Moku virus was reported in Asian hornets from the same area. In addition, the Moku virus was already present in historical samples of bees collected in 2013, that is, 2 years after the official first detection of Asian hornets in the same area of Belgium. This study suggests a spread of Moku virus to honey bees with possible consequences.     

Seroprevalence of selected flaviviruses in free‐living and captive capuchin monkeys in the state of Pernambuco,Brazil

Mosquito‐borne diseases such as dengue, yellow fever and, more recently, Chikungunya virus (CHIKV ) and Zika virus (ZIKV ) have a great impact in the public health. In addition, the presence of such viruses might have an impact on wild animal conservation as well as their possible role as animal reservoir. Here, we performed a serological survey searching for antibodies against a panel of flaviviruses [ZIKV , Dengue virus (DENV ), Yellow Fever virus (YFV ), West Nile virus (WNV ), Saint Louis Encephalitis virus (SLEV ), Ilheus virus (ILHV ) and Rocio virus (ROCV )] using plaque reduction neutralization test (PRNT ₉₀) in both free‐ranging and captive capuchin monkeys (Sapajus flavius and Sapajus libidinosus ). Captive and free‐living monkeys were sampled between June 2015 and January 2016 in the state of Pernambuco, including in the border with State of Paraíba, the epicentre of the ZIKV epidemics in Brazil. We have found neutralizing antibodies for ZIKV , DENV ‐1, DENV ‐2, DENV ‐3, DENV ‐4, YFV , ILHV and SLEV in both S . flavius and S . libidinosus samples. No positives samples were found for ROCV and WNV . Our results suggest that these flaviviruses might be circulating in capuchin monkey in the studied region. The possible presence of these viruses represents a risk for public health, as well as for animal conservation, especially for S . flavius which is a critically endangered species, facing high risk of extinction.     

Reducing inflow occlusion,occlusion duration and blood loss during hepatic resections

Background

To assess the changes in blood loss during hepatic resection with improved haemostatic devices such as a bipolar sealing device and a topical haemostatic agent.

Methods

This retrospective clinical study of prospectively collected data will assess hepatic resections performed by a single surgeon between 2005 and 2013, with the introduction of the two haemostatic techniques in 2009.

Results

A total of 371 hepatic resections (214 from 2005 to 2008 and 157 from 2009 to 2013) were included in this study. Compared with the conventional hepatic resection (2005–2008), the use of haemostatic techniques (2009–2013) significantly reduced the need for inflow occlusion (OR: 0.37, 95% CI: 0.24–0.57, P < 0.001), overall occlusion time (20.8 min versus 25.9 min, P = 0.04) and transfusion requirement (4.6% versus 12%, OR: 0.35, 95% CI: 0.14–0.90, P = 0.02). Mean overall blood loss was reduced post‐2009; however, the decrease was not statistically different (401.3 mL versus 470.8 mL, P = 0.27). Subgroup analysis revealed that blood loss was more than halved post‐2009 compared with pre‐2009 for patients who received pre‐operative chemotherapy (324.6 mL versus 738.5 mL, P = 0.005).

Conclusion

The use of a bipolar sealing device and a topical haemostatic agent reduces the need for inflow occlusion, overall occlusion time and transfusions in all patients compared with conventional hepatic resections.     

Seroepidemiology of ovine toxoplasmosis and neosporosis in breeding rams from Rio Grande do Sul,Brazil

This study determined the prevalence of ovine toxoplasmosis and neosporosis and the risk factors associated with the development of these diseases in breeding rams from the State of Rio Grande do Sul (RS), Southern Brazil. Serum samples (n = 1,800) from breeding rams maintained on 705 sheep farms from seven mesoregions were evaluated serologically to detect anti‐IgG Toxoplasma gondii by indirect ELISA and anti‐IgG Neospora caninum by the indirect immunofluorescence assay (IFA). The prevalence of T. gondii was 33.05% (595/1,800); seropositivity to N. caninum was 18.44% (332/1,800). Additionally, there was simultaneous seropositivity (8.94%;161/1,800) to N. caninum and T. gondii. The variables size of the property (<500 ha) (Prevalence Ratio, PR = 1.36); breeding system (semi‐intensive/intensive) (PR = 1.23); and natural mounting without control (PR = 1.50) were considered as risk factors for the occurrence of T. gondii. Size of the property (<500 ha) (PR = 1.58) and natural mounting without control (PR = 2.32) were risk factors associated with the prevalence of N. caninum in rams. Additionally, separation of ewes prior to parturition was considered as a protective factor for the occurrence of T. gondii (PR = 0.82) and N. caninum (PR = 0.74). These results demonstrated that these two parasitic disease agents are endemic in rams throughout all regions of RS.     

The Emergence of Theileria parva in Jonglei State,South Sudan: Confirmation Using Molecular and Serological Diagnostic Tools

A cross‐sectional survey was carried out in four counties of Jonglei State, South Sudan, between May and June 2012 to determine the distribution and northern limit of Theileria parva, the causative agent of East Coast fever in cattle, and its tick vector Rhipicephalus appendiculatus, as a prerequisite to the deployment of relevant control strategies. A total of 1636 ticks, 386 serum samples and 399 blood samples were collected from indigenous, apparently healthy, cattle of different age groups. Tick species were identified morphologically, and the identity of R. appendiculatus was confirmed by DNA barcoding. Overall, the T. parva infection rate in R. appendiculatus was 25% as shown by nested PCR. ELISA was used to assess antibodies to T. parva, and the overall seroprevalence was 22.8%. PCR of the blood samples showed 55 (13.8%) were positive for T. parva. This is the first molecular confirmation of T. parva DNA in areas north of Juba, where it was previously known and established. The northern limit of T. parva was determined as N⁰06.17.792, about 242 Km north from Juba. Implication of this limit on the epidemiology and control of ECF is discussed.