With competitive price and timely delivery, Jiayi Pharmaceutical sincerely hope to be your supplier and partner.
Tungiasis is an ectoparasitosis causing considerable pathology in endemic areas. Standard therapy consists of removing the embedded parasite with a sterile needle. There is no effective chemotherapy at hand. To fill this gap, a double-blinded randomized controlled trial with oral ivermectin was conducted. A total of 54 individuals (27 in the placebo group, 27 in the ivermectin group) was followed up for seven days. They presented a total of 192 lesions. Patients received either ivermectin (300 µg/kg body weight at a single dose, repeated after 24 h) or placebo. Outcome measures included the clinical stage of lesion, presence of erythema, pain, itching, signs of viability of the parasite, and total lysis of flea. The ratio of fleas with total lysis per total number of fleas was slightly higher in the ivermectin group; however, this difference was not statistically significant. There was no significant difference in any of the other outcome measures between the treatment and the placebo group. The results show that oral ivermectin is without any clinically significant efficacy against embedded sand fleas at the dose given.
DIANOSTIC, IMMUNIZATION AND THERAPEUTIC TRIALS
Therapy of tungiasis: a double-blinded randomized controlled trial with oral ivermectin
Jörg HeukelbachI,II, ; Sabine FranckIII; Hermann FeldmeierII,III
IDepartamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará, Rua Prof. Costa Mendes , 5º andar, -140 Fortaleza, CE, Brasil
IIFundação de Educação e Saúde Mandacaru, Fortaleza, CE, Brasil
IIIInstitute for Infection Medicine, Department of Microbiology, Charité University of Medicine, Berlin, Germany
ABSTRACT
Tungiasis is an ectoparasitosis causing considerable pathology in endemic areas. Standard therapy consists of removing the embedded parasite with a sterile needle. There is no effective chemotherapy at hand. To fill this gap, a double-blinded randomized controlled trial with oral ivermectin was conducted. A total of 54 individuals (27 in the placebo group, 27 in the ivermectin group) was followed up for seven days. They presented a total of 192 lesions. Patients received either ivermectin (300 µg/kg body weight at a single dose, repeated after 24 h) or placebo. Outcome measures included the clinical stage of lesion, presence of erythema, pain, itching, signs of viability of the parasite, and total lysis of flea. The ratio of fleas with total lysis per total number of fleas was slightly higher in the ivermectin group; however, this difference was not statistically significant. There was no significant difference in any of the other outcome measures between the treatment and the placebo group. The results show that oral ivermectin is without any clinically significant efficacy against embedded sand fleas at the dose given.
Key words: tungiasis - Tunga penetrans - therapy - ivermectin - randomized controlled trial - Brazil
Tungiasis, an ectoparasitosis caused by the penetration of the female sand flea Tunga penetrans into the epidermis, is endemic in South America, the Caribbean and sub-saharan Africa and a scourge for many resource-poor populations (Heukelbach et al. ). In Brazil, tungiasis occurs from the far north of the country to the state of Rio Grande do Sul in the south (Heukelbach et al. ). However, the disease is neglected by health care providers and the scientific community (Heukelbach et al. , b). By consequence, there are few valid data on the usefulness of chemotherapeutic interventions (Ade-Serrano et al. , Heukelbach et al. a).
Standard therapy of tungiasis consists of removing the embedded flea with a sterile needle and disinfection of the remaining sore (Heukelbach et al. ). Surgical extraction of the flea, though, is not an easy task, as it requires a skilled hand and good eye-sight. The procedure is painful for the patient and children often scream when their lesions are manipulated by a carer. If strict hygiene is not applied and appropriate instruments are not at hand (which is the rule in resource-poor settings and wholly impossible in children who may harbour more than a hundred fleas), attempts to remove the fleas often do more harm than good (Feldmeier et al. ). Hence, there is a clear need for a safe, simple and effective drug treatment, particularly in heavily infested individuals. One case report suggests that oral ivermectin given at a single dose of 200 µg/kg body weight clears embedded sand fleas from the skin (Saraceno et al. ). Additionally, there are several anecdotal reports of health care providers about the efficacy of oral ivermectin for the treatment of tungiasis (Heukelbach, pers. commun.). To base these observations on a scientific rationale, we conducted a double-blinded randomized placebo-controlled trial with oral ivermectin.
PATIENTS AND METHODS
Patients were recruited from three shantytowns on the outskirts of Fortaleza (capital of the state of Ceará) where the disease is endemic, namely Morro de Sandra's, Favela das Placas, and Luxou. The areas are close one to another and share similar socio-economic characteristics. Infested individuals were identified with the help of community leaders of the respective shantytowns. Tungiasis was diagnosed and staged according to the recently developed Fortaleza classification (Eisele et al. ). To be eligible for the trial, an individual had to have at least one lesion in stage II or stage III, which corresponds to a developing female flea that has penetrated fully and a mature, egg-expelling flea, respectively (Eisele et al. ). The stage and the exact localization of each lesion were documented on a graphic record sheet. Individuals < 5 years of age, < 15 kg body weight, with chronic neurological or hepatic diseases as well as pregnant/breastfeeding women were not eligible for the trial.
To prevent confounding due to re-infestation, the patients were transferred to a mountain resort some 40 km away for a period of 8 days, a time period during which stage II lesions develop into stage III lesions (Eisele et al. ). Tungiasis has never been observed in the relatively cool and humid environment of the resort.
Patients were allocated to the ivermectin or placebo group by blocked randomization (blocks of six subjects each). Patients, investigators and the auxiliary nurse were blinded with respect to the treatment given. None of the investigators involved in the design or realization of the trial had access to the code book before finalization of the trial. Coded ivermectin and placebo tablets were supplied by a pharmaceutical producer of ivermectin (Solvay Farma S.A., São Paulo, Brazil). Treatment consisted of two doses of 300 µg/kg body weight ivermectin or placebo given 24 h apart.
The patients were examined immediately before as well as once per day during six days after treatment. All clinical examinations were performed by the same investigator (SF). The lesions were examined thoroughly with a magnifying glass. The following variables were used as outcome measures and noted for each lesion: clinical stage of lesion according to the Fortaleza classification (Eisele et al. ), presence of erythema, pain, itching, total lysis of flea, and vital signs (flea's faeces, eggs, pulsation). Total lysis of the flea was defined as the clearance of an embedded flea or its carcass from the skin either by tissue repair mechanisms or by falling out. Faeces, eggs and pulsation of the embedded fleas were identified when present and considered as clear indicators for the flea's viability (Eisele et al. ). Before examination, the feet were washed with tap water. Patients were asked for the presence of itching and pain associated with embedded sand fleas and, if present, to grade their complaints into weak, moderate or severe for each of the lesions. Swallowing of ivermectin/placebo tablets was controlled. Adverse events were assessed at each follow-up examination.
To estimate the sample size, a clinically significant efficacy was defined as a difference of the ratios of fleas with total lysis per total number of fleas of 0.3 in the ivermectin group as compared to 0.6 in the placebo group at any of the follow-up examinations. Conclusively, 63 viable lesions in each treatment arm are necessary to detect a clinical difference with a power of 90 to 95% significance level. Considering possible loss to follow-up, in each group, 30 patients were randomized with a total of 192 viable tungiasis lesions.
Data were entered twice into a database using version 6.04d of the Epi Info software package (Centers for Disease Control and Prevention, Atlanta, GA) and checked for errors that could have occurred during their entry. In the analysis, morphological aspects of the lesions were compared in each treatment group rather than comparing the outcome measures in individual patients. Relative frequencies were compared between treatment groups using the chi-squared test. The Wilcoxon rank sum test was used to compare ordinal data between the two groups.
RESULTS
Descriptive characteristics of the study groups are depicted in the Table. Both treatment arms consisted of 30 patients. Six patients (three of the ivermectin group and of the placebo group, respectively) were lost to follow-up as they felt homesick and asked to leave the mountain resort after two days. These were excluded from data analysis. Parasite load of those lost to follow-up was similar to the remaining study participants. There were no drop-outs in follow-up in the remaining 54 study participants. The total number of lesions followed up was 103 in the ivermectin arm and 89 in the placebo arm. There was no statistically significant difference in age (p = 0.5) or the number of lesions per patient between the treatment groups (p = 0.8). There were more males in the placebo group; however, the difference was not statistically significant (p = 0.06).
The Figure presents the proportion of lesions showing total lysis of the flea in relation to the total number of lesions in each treatment arm. The ratio was slightly higher in the ivermectin group for the days of follow-up indicating some insecticidal activity of the drug. However, the difference never gained statistical significance (p > 0.3 in all cases).
Ratio of lesions with total lysis of the ectoparasite/total number of lesions in the placebo (n = 89) and ivermectin (n = 103) group.
Both treatment groups were also compared with respect to the other outcome measures such as itching and pain but again there was no statistically significant difference between the two groups at any time point of the follow-up.
Adverse events were reported in 12 cases. In the treatment group 3 patients complained of headache, 2 of abdominal pain and 1 of sore throat. In the placebo group, 3 patients complained of headache and 3 of itching.
DISCUSSION
Ivermectin is a comparatively cheap drug, and its use has been suggested in individuals infected with intestinal helminths and ectoparasites when specific diagnoses are difficult to establish due to lack of appropriate health infrastructure (Heukelbach & Feldmeier , Heukelbach et al. ). A few open and blinded trials have shown a high efficacy of the drug for scabies (Chouela et al. , Madan et al. , Brooks & Grace , Buffet & Dupin ), head lice (Glaziou et al. ), and cutaneous larva migrans (Caumes ) with no significant adverse events. Ivermectin is contraindicated for children younger than five years of age or less than 15 kg body weight because of the ongoing uncertainty of possible neuro-toxicity of the drug and in view of the not yet fully developed blood-brain barrier in small children (Edwards ). However, preliminary data indicate that ivermectin is excellently tolerated also by children of less than five years of age (del Mar Saez-De-Ocariz et al. ). Thus, such a broad-spectrum antiparasiticidal drug is of considerable benefit in mass treatment campaigns in populations concomitantly infected with various species of intestinal helminths and ectoparasites (Heukelbach et al. ).
Using an appropriate study design, we were unable to confirm anecdotal reports on the efficacy of ivermectin in tungiasis (Saraceno et al. ). A previous trial reported some efficacy of topical ivermectin as compared to a topical placebo lotion and a control group without any treatment (Heukelbach et al. a). In this study, the relatively small effect of the drug on sand fleas was explained by the type of application: it was assumed that not sufficient quantity of the active compound would reach the embedded flea by topical application. However, as in our trial the dose given orally (2 x 300 µg/kg body weight) was considerably higher than the dose administered for intestinal helminthiases, scabies, pediculosis, and cutaneous larva migrans (usually 200 µg/kg body weight) we think that even a higher dose would not significantly improve the efficacy of ivermectin on embedded sand fleas.
The results of our study underline the importance of randomized controlled trials to conclude on the therapeutic efficacy of drugs. In northeast Brazil many dermatologists claim a good efficacy of ivermectin in tungiasis and support their notion by anecdotal observations. In fact, hitherto a single published case report suggests an effect of ivermectin (Saraceno et al. ). Similarly, other authors suggest oral thiabendazole to be effective against embedded sand fleas (Valença et al. , Cardoso ). Probably the effect observed by these authors is due to the fact that patients were severely infested and were hospitalized and thereby taken out from the endemic area, consequently preventing re-infestation. According to their developmental stage, fleas will die anyway after two to three weeks independently whether the patient is treated or not (Eisele et al. ).
The only randomized controlled trial in tungiasis with an oral drug has been realized more than 20 years ago with niridazole, an anti-schistosomal compound with severe neurological adverse events, which has been taken from the market since long (Ade-Serrano et al. ). In this study, the therapeutic efficacy of niridazole was claimed to be very good. However, the outcome measures were not well defined and the study showed other methodological problems which limit the interpretation of results.
If you are looking for more details, kindly visit Ivermectin for Fleas on Humans.
The reduced prevalence of tungiasis observed in an endemic community after selective mass treatment with ivermectin may be explained by seasonal variation in transmission dynamics rather than intrinsic activity of the drug on T. penetrans (Heukelbach et al. ).
Our study did not show any significant difference between oral ivermectin and a placebo at the dose chosen. This may be attributable to the relative small number of patients treated, however the study size was sufficient to detect a clinical significant difference between treatment and placebo group with a high power.
Recently, a small case series using a natural repellent on the basis of coconut and jojoba oil showed an impressive regression of clinical pathology in patients severely infested by prevention of re-infection (Schwalfenberg et al. ). It is conceivable that in endemic communities the use of an effective repellent would be a better approach to reduce tungiasis-associated morbidity than treatment after infestation has occurred.
ACKNOWLEDGEMENTS
Ivermectin and placebo were provided free of charge by Solvay Farma, São Paulo, Brazil. To Vania Andrade dos Santos and Antonia Valéria Assunção Santos. The data form part of a medical thesis by SF.
Received 2 August
Accepted 14 October
Financial support: Deutsches Komitee Ärzte für die Dritte Welt, Capes/Daad Probral academic exchange program, Solvay Farma S.A. (São Paulo, Brazil)
Ivermectin has emerged as a therapeutic option for various parasitic diseases, including strongyloidiasis, scabies, lice infestations, gnathostomiasis, and myiasis. This study comprehensively reviews the evidence-based indications for ivermectin in treating parasitic diseases, considering the unique context and challenges in Peru. Fourteen studies were selected from a systematic search of scientific evidence on ivermectin in PubMed, from to July . The optimal dosage of ivermectin for treating onchocerciasis, strongyloidiasis, and enterobiasis ranges from 150 to 200 μg/kg, while lymphatic filariasis requires a higher dose of 400 μg/kg (Brown et al., ). However, increased dosages have been associated with a higher incidence of ocular adverse events. Scientific evidence shows that ivermectin can be safely and effectively administered to children weighing less than 15 kg. Systematic reviews and meta-analyses provide strong support for the efficacy and safety of ivermectin in combating parasitic infections. Ivermectin has proven to be an effective treatment for various parasitic diseases, including intestinal parasites, ectoparasites, filariasis, and onchocerciasis. Dosages ranging from 200 μg/kg to 400 μg/kg are generally safe, with adjustments made according to the specific pathology, patient age, and weight/height. Given Peru's prevailing social and environmental conditions, the high burden of intestinal parasites and ectoparasites in the country underscores the importance of ivermectin in addressing these health challenges.
Keywords: Ivermectin, Antiparasitic agents, Scientific evidence, Helminthiasis, Peru
In pursuit of novel antiparasitic agents, a new compound called avermectin was discovered. From this compound, ivermectin, a semisynthetic molecule, was derived and initially introduced as a commercial product for animal health purposes. (González Canga et al., ). In humans, the first specialty containing ivermectin was Mectizan, which has a long history of use in the medical field (González Canga et al., ). Over the years, numerous studies have been conducted and published investigating the efficacy and safety of Mectizan in treating various parasitic diseases. These studies have helped establish Mectizan as a cornerstone in the management of parasitic infections, highlighting its role in improving public health outcomes. The extensive body of research on Mectizan has not only informed clinical practice but also contributed to our understanding of ivermectin's potential applications, paving the way for its expanded use in the treatment of other parasitic diseases.
Ivermectin is a secondary metabolite produced by the bacterium Streptomyces avermitilis, which belongs to the soil-dwelling actinomycetes group. In this context, a secondary metabolite is a compound that is not essential for the basic growth, development, or reproduction of the organism but serves other important functions, such as defending against predators or inhibiting the growth of competing organisms. Streptomyces avermitilis is a type of soil-dwelling actinomycete, which are filamentous bacteria known for their ability to produce a wide variety of biologically active compounds, including antibiotics and other pharmaceuticals.
This compound exhibits lipophilic properties, meaning it has an affinity for lipid-rich environments. As a result, individuals with a higher body mass index (BMI) may experience lower plasma concentrations of the compound due to its increased distribution within fatty tissues. This can lead to a longer half-life (Schulz et al., ), which is the time it takes for the concentration of the substance in the body to decrease by half. Consequently, it is essential to prescribe the dose of this compound based on the patient's body weight, using a specific unit such as micrograms per kilogram (μg/kg) (Duthaler et al., ), in order to ensure its therapeutic efficacy and minimize potential side effects.
Ivermectin has demonstrated its effectiveness in combating a broad spectrum of parasitic infections. As an antiparasitic agent, it targets a diverse range of parasites, including those responsible for diseases such as onchocerciasis (river blindness), strongyloidiasis, lymphatic filariasis, and scabies. The drug works by disrupting the normal functioning of the parasite's nervous system, ultimately leading to paralysis and death. This allows the host's immune system to effectively eliminate the invaders. Ivermectin's wide-ranging efficacy against various parasites makes it a valuable tool in the treatment and control of multiple parasitic diseases, contributing to significant improvements in global public health.
In helminths (parasitic worms), ivermectin works by targeting the chloride channels that are sensitive to the neurotransmitter glutamate (Fox, ). By opening these channels, the drug disrupts the normal functioning of the parasite's central nervous system, leading to paralysis and eventual death. A notable example of ivermectin's effectiveness is its action against human onchocerciasis, a disease caused by the parasitic worm Onchocerca volvulus. Onchocerciasis, also known as river blindness, is a vector-borne disease transmitted through the bites of infected Simulium species, commonly known as black flies (Aziz et al., ). By incapacitating the adult worms and preventing the release of microfilariae (immature larvae), ivermectin aids in controlling the spread and impact of this debilitating disease.
Ivermectin is also effective against certain protozoa, which, along with helminths, are prevalent in children and pose a significant public health concern, particularly in developing countries (Vasquez-Elera et al., ). Protozoa are single-celled microorganisms that can cause various diseases in humans. Both protozoan and helminthic infections can lead to serious health issues, especially in children, who may suffer from impaired growth, cognitive development, and immune function as a result. By targeting these parasites, ivermectin plays a crucial role in addressing these health challenges and improving the overall well-being of affected populations, especially in resource-limited settings where access to healthcare may be limited.
In Latin America, it is estimated that more than 40 million children are exposed to an intestinal parasite type, which is one of the main public health problems that affect more than 30% of the world population. The prevalence and intensity of the parasite diseases are associated with a higher risk of the disease and are often very high, especially in school-age populations, which lead to problems in regard to physical and mental performance, and health (Geletaw et al., ).
In recent times, the use of ivermectin has expanded globally, primarily due to numerous information sources promoting its potential as a treatment for SARS-CoV-2, the virus responsible for COVID-19 (Castañeda-Marín et al., ). As the pandemic unfolded, researchers and healthcare professionals sought to identify existing drugs that could be repurposed to combat the virus. Ivermectin, with its known antiparasitic and anti-inflammatory properties, emerged as a candidate for further investigation. Consequently, the widespread dissemination of this information, through various channels such as scientific articles, news reports, and social media, has contributed to the increased global interest in and utilization of ivermectin as a potential treatment option for COVID-19.
In Peru, ivermectin was administered to approximately 90% of hospitalized patients suffering from SARS-CoV-2 infections (Vasquez-Elera et al., ). Amid the COVID-19 pandemic, healthcare professionals sought potential treatment options to alleviate the burden on patients and healthcare systems. Ivermectin, with its known antiparasitic properties and suggested potential against SARS-CoV-2, became a widely used treatment option in Peru. This widespread adoption can be attributed to the urgent need for effective therapies and the desire to explore available drugs that could potentially improve patient outcomes during the pandemic.
Due to the recent interest in the use of ivermectin for COVID-19 treatment and prevention, we conducted a comprehensive review of the scientific literature on the use of ivermectin as an antiparasitic agent worldwide. The objective of this study is to conduct a comprehensive literature review of the use of ivermectin in the treatment of parasitic infections, including its efficacy and safety, with a specific focus on the prevalence of parasitic infections in Peru and the potential for the use of ivermectin in mass treatment campaigns.
In Peru, parasitic infections are a significant public health concern, particularly in rural and economically disadvantaged areas (Chosidow et al., ). The prevalence of these infections can vary considerably depending on factors such as region, age, socioeconomic status, and access to clean water and sanitation facilities.
In Peru, the distribution of parasitic diseases has been documented in populations treated between and (Vidal-Anzardo et al., ). Nationally, the prevalence of overall parasitic diseases and helminth infections was 4.9% and 3.3%, respectively. Furthermore, 5.3% of children aged 12 to 17 years were found to have a parasitic infection. The most affected regions included the northeastern areas with tropical climates and the high Andean regions (Vidal-Anzardo et al., ) (Fig. 1). These regions are known for their low socioeconomic status in Peru (León Mendoza, ). Additionally, the prevalence of parasitic diseases varied across age groups: 9.5% among children aged 0 to 11 years, 5.3% among adolescents aged 12 to 17 years, 2.2% among young adults aged 18 to 29 years, and lower frequencies among other age groups.
Spatial distribution of parasitic diseases in Peru (Vidal-Anzardo et al., ). In the map, blue represents the overall prevalence of parasitic diseases, while red indicates the prevalence of helminth infections. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
At the regional level, the departments with the highest parasite burden in Peru were Loreto (32.4%), San Martín (12.0%), and Ucayali (9.5%). The remaining regions exhibited a prevalence ranging from 4.3% to 6.3%. As for helminth infections, the results showed a similar pattern, with an annual prevalence of 3.3%: Loreto (12.8%), San Martín (8.9%), Pasco (8.0%), and Ucayali (7.6%) (Fig. 1) (Vidal-Anzardo et al., ).
In the Amazon region of Peru, for example, intestinal parasites are highly prevalent due to factors like inadequate sanitation, contaminated water sources, and limited access to healthcare. Ascaris lumbricoides, Trichuris trichiura, and hookworms are among the most common helminths in these areas, while protozoan parasites like Giardia lamblia and Entamoeba histolytica are also frequently observed. The prevalence of these infections is generally higher in children, as they are more susceptible to acquiring parasites through play and contact with contaminated soil or water.
In the highlands and coastal regions, other parasites such as Fasciola hepatica (liver fluke) and Echinococcus granulosus (causing cystic echinococcosis) may be more prevalent due to specific environmental conditions, such as the presence of intermediate hosts or livestock farming practices. The transmission of these parasites can be influenced by factors like close contact with infected animals and consumption of contaminated water or undercooked food.
In Peru, the prevalence of specific parasite species varies across different regions, environments, and age groups. Several factors, including climate, sanitation, and access to clean water, contribute to the distribution and prevalence of these parasites. Some of the most common parasitic infections in Peru include:
1.
Ascaris lumbricoides: This is a type of roundworm and is one of the most prevalent parasitic infections in Peru, particularly in rural areas (Choi & Kim, ). It is commonly found in children, who are more prone to ingesting the eggs through contaminated soil or food.
2.
Trichuris trichiura: Also known as whipworm, this parasite is frequently observed in rural and impoverished areas with poor sanitation. Like Ascaris, children are often more susceptible to this infection due to their exposure to contaminated environments.
3.
Hookworms: Necator americanus and Ancylostoma duodenale are two species of hookworms commonly found in Peru, especially in regions with warm, moist soil. These parasites can penetrate the skin, typically affecting people who walk barefoot or come into contact with contaminated soil.
4.
Giardia lamblia: This protozoan parasite is prevalent in areas with inadequate water treatment and sanitation facilities. It can affect all age groups but is more common in children due to their increased likelihood of ingesting contaminated water or food.
5.
Entamoeba histolytica: Another protozoan parasite, it is responsible for causing amoebic dysentery and liver abscesses. It is more prevalent in areas with poor sanitation and contaminated water sources, affecting both children and adults.
6.
Fasciola hepatica: Commonly known as liver fluke, this parasite is more prevalent in highland and coastal regions where livestock farming is practiced (Espinoza et al., ). The transmission occurs through the consumption of contaminated water or undercooked food, affecting people of all age groups.
7.
Echinococcus granulosus: This tapeworm is responsible for causing cystic echinococcosis, a zoonotic disease primarily affecting livestock and humans in close contact with infected animals (Moro et al., ). It is more prevalent in rural areas where people engage in livestock farming or animal husbandry practices.
In addition to the primary parasitic infections prevalent in Peru, other common parasites and parasitic interactions have been identified, with their prevalence varying based on specific regions within the country. For instance, the prevalence of Strongyloides stercoralis ranges from 0.8% to 19.5% depending on the region (Silva-Díaz et al., ). Infections such as cutaneous and visceral larva migrans have been found, with a prevalence of 7.3% in Lima and 32.4% in Morrope. Myiasis cases have been reported sporadically (1 per 100,000 people) in Lambayeque, located in northern Peru (Failoc-Rojas et al., ). Furthermore, a study investigating the distribution of parasitic diseases among children under 11 years old in Cajamarca found that Giardia lamblia was the most prevalent, affecting 27.2% of the population, followed by Ascaris lumbricoides at 19.5%. Co-infections of both types of parasites occurred in 3.3% of cases (Ipanaque-Chozo et al., ).
Safety of ivermectin has been assessed in several scientific studies and it has been found that the effective dose of ivermectin for treating onchocerciasis, strongyloidiasis, and enterobiasis is between 150 and 200 μg/kg (Juarez et al., ). For other diseases such as lymphatic filariasis the used dose is 400 μg/kg.
Higher doses than 400 μg/kg are still effective, but increase the number of cases of ocular adverse events, especially in onchocerciasis patients (Aziz et al., ). It is stated that ivermectin generates low levels of toxicity because its effect does not reach the central nervous system, and toxicity depends on immune and inflammatory responses against parasites, such as fever, pruritus, skin rashes, and malaise (Chandler, ).
In children under two years of age with less than 15 kg, not using ivermectin was suggested; however, there exists solid scientific evidence that the use of ivermectin can be safe and effective in children with less than 15 kg. In this regard, a systematic review analyzed the efficacy and safety of ivermectin in children under 15 kg, in which it was found that ivermectin was used in children that weighed less than 15 kg. The medical indication for this age group was to use this antiparasitic agent for treating infections due to strongyloidiasis, scabies, lice infestations, gnathostomiasis, myiasis, and for helminths reduction transmitted through soil, for which this drug was useful for the control of the above mentioned diseases (Jittamala et al., ). In the mentioned study, 18 possible adverse events were recorded; the most frequent were four (4/) due to diarrhea (0,4%).
Ivermectin shows promise as a treatment option for pregnant women as studies have shown that it can effectively reduce rates of anemia and parasitic infections in this population. Additionally, it has had good perinatal outcomes in neonates. However, it has not been approved globally yet, and clinical trials are still being conducted (Nicolas et al., ).
Ivermectin is an effective antiparasitic agent that acts against many intestinal parasites (strongyloidiasis, ascariasis, trichuriasis, ancylostomiasis, among others), ectoparasites (scabies, larva migrans, myiasis, etc.), as well as filariasis and onchocerciasis. Ivermectin has a good safety profile. The dose of 200 μg/kg to 400 μg/kg is safe, depending on the treated pathology, age, and weight/height of the patient. Peru is still, because of its social and environmental conditions, a country with a high load of intestinal parasites and ectoparasites, reported by several research studies. The use of ivermectin to treat parasitic diseases and against ectoparasites is feasible, and it can be indicated for welfare activities in children with a suspected or diagnosed parasitic disease. Welfare initiatives involving mass ivermectin administration should be carried out with careful consideration of the drug's safety for individuals aged two years and older. However, it is recommendable that studies develop measurements of the impact of these activities in different regions.
No funding was received.
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Thanks to the Health Technology Assessment and Research Institute of ESSALUD.
For more Is Praziquantel Harmful to Older Catsinformation, please contact us. We will provide professional answers.