Cross-Sectional Assessment of the Association of Eosinophilia with Intestinal Parasitic Infection in US-Bound Refugees in Thailand: Prevalent, Age Dependent, but of Limited Clinical Utility

The most common causes of eosinophilia globally are helminth parasites. Refugees from high endemic areas are at increased risk of infection compared with the general U.S. population. It is widely accepted that eosinophilia is a good marker for helminth infection in this population, yet its absence has little predictive value for excluding infection. During an enhanced premigration health program, the CDC offered voluntary testing and management of intestinal parasites, among other conditions, to U.S.-bound refugees in Thailand. Stool specimens were tested for Ascaris lumbricoides, Strongyloides stercoralis, Trichuris trichiura, hookworms, Giardia lamblia, Cryptosporidium spp., and Entamoeba histolytica using quantitative polymerase chain reaction. Complete blood counts were performed to identify eosinophilia. Predictive values of eosinophilia for parasitic infections were calculated within nematode groups. Between July 9, 2012 and November 29, 2013, 2,004 participants were enrolled. About 73% were infected with at least one parasite. The overall median eosinophil count was 483 cells/mu L (interquartile range [IQR] = 235-876 cells/mu L). Compared with participants who did not test positive for any infection, higher eosinophil counts were observed in those infected with A. lumbricoides (RR = 1.3, 95% CI=1.1-1.4), S. stercoralis (RR=1.8, 95% CI=1.4-2.4), Necator americanus (RR=1.2, 95% CI=1.1-1.4), and Ancylostoma ceylanicum (RR=1.8, 95% CI=1.5-2.2). Eosinophil counts were higher in younger participants (2-4 years versus 651 years: RR=4.2, 95% CI=2.5-6.9), and lower in female participants (RR=0.9, 95% CI=0.8-0.9). Sensitivities ranged from 51% to 73%, specificities from 48% to 65%, and predictive values from 4% to 98%. The predictive value of eosinophilia is poor for the most common parasitic infections, and it should not be used alone for screening refugees.