Neurocysticercosis caused by tapeworms is easily spread between humans and pigs. This poses a real and imminent danger to zoonotic diseases; indifferent sanitation infrastructure leaves nowhere for workers to turn to help

Mukhen Murah is a tea plantation worker in his early 20s. One day he lost consciousness while working in the Basmatia tea plantation in Assam, India. Since 2014, Mulla has been seizures repeatedly-over time, he feels when he will collapse.

“In order to avoid rolling, I would lie on my back and eventually fall asleep. My friends who worked nearby would come to pick me up,” said Mulla. 

At first, he started taking medicine prepared by traditional healers. Then, a computed tomography (CT) scan at the Assam Medical College and Hospital (AMCH) quickly found a worm in his brain. 

Mugla suffers from neurocysticercosis (NCC), a preventable disease that has caused severe damage in pig communities in Assam. This disease that can cause epilepsy in adults is caused by humans eating the meat of pigs infected with tapeworms or indirectly contacting pig meat. 

The eggs of tapeworms invade human muscles and form cysts. Sometimes these cysts can enter people’s brains, causing seizures, headaches, balance difficulties, and excessive fluid around the brain

These frequent collapses caused Mulla to lose his job: six or seven months ago, when the tea plantation manager noticed him, he was fired as a tea picker. Today, at Mulla’s location, his wife picks tea leaves with his mother and brother. 

Assam is the world's largest tea-producing area, with more than 800 estates, producing half of India's tea. It is estimated that 1 million plantation workers pick tea at these estates at a price of 205 rupees a day. 

A 2019 study by the non-profit organization Oxfam showed that tea workers in Assam are among the most marginalized workers in the state, with unsafe working conditions. They lack basic conveniences, have low incomes, and are at high risk of human rights violations.   

In order to supplement the meager income, many plantation workers-both permanent and temporary-raise pigs. It requires very little investment and labor.

A study published in the journal Nature earlier this year stated that patients with active epilepsy in Assam tea gardens have a higher prevalence of NCC (42.2%).

These findings are consistent with earlier studies that NCC is one of the main causes of epileptic seizures in developing countries, especially in areas without proper sanitation, where pig raising is common. 

Murah's brother Bikul Murah said that he had raised four pigs for eight months near a field by the Tengakhat River. His income per pig is at least 3,000 rupees-which greatly increases his daily salary of 170 rupees. 

Pork is the main protein in northeastern India. It accounts for approximately 68.75% of India's pork consumption. Nagaland topped the list, followed by Assam and Meghalaya.

A plantation worker told this reporter that, like Mugla, at least half of the 100 families living in the area had raised pigs in the past to supplement their meagre daily wages. 

“In Assam, pigs are mostly raised in dirty backyards and fed garbage. Only 1-2% of farmers are keen on hygiene,” said Digita Saikia, a commercial pig farmer and member of the Northeast Progressive Pig Farmers Association.

He claimed that commercial pig farmers bought pig feed from there and followed a deworming schedule.

Families with NCC have a history of raising pigs in the backyard and open defecation (due to lack of proper toilets). In this case, the chance of contracting this little-known zoonotic disease is even higher.

The life cycle of the pork tapeworm (Taenia solium) infects it from pigs to humans and vice versa.

Tapeworm eggs are spread through food, water, or surfaces contaminated with feces. Humans swallow eggs when eating contaminated food or putting contaminated fingers in their mouths. 

"When people eat infected undercooked pork, they get tapeworms (the larval stage of tapeworms) and develop into adults in the intestines (taeniasis). When they reach the brain, the infection turns into NCC and causes seizures. ," Dr. Kanwar Naran, director of the Indian Council of Medical Research (ICMR), told our reporter.

"The eggs produced by adult tapeworms are excreted in human feces. During open defecation, the eggs get stuck in the nails and eventually enter the human body. These hands can contaminate the food other people eat," he added.

“A person who has never eaten pork may be infected in this way,” explains Narain, the author of Nature Research, who attributed most cases of adult-onset active epilepsy in Assam tea gardens to NCC.

Humans are the only ultimate host for the parasite to complete its life cycle. This spillover from pigs to humans (and vice versa) makes NCC a zoonotic disease. 

The Centers for Disease Control and Prevention (CDC) clearly stated that although people with NCC cannot transmit the disease to others, “taeniasis (taenia Other people’s good hygiene practices (such as washing hands after going to the toilet) may cause cysticercosis if people swallow eggs."

Dr. Dhruba Jyoti Kurmi, a neurosurgeon at AMCH, pointed out that it is important to go beyond the stereotype that NCC spreads only in pork-eating communities. He said that in fact, the most recent case of NCC came from an urban area in Assam, where people ate raw salad.

"NCC has been popular in Assam for a long time. The only difference is that it was only discovered recently," said Dr. Bhagat Lal Dutta, an epidemiologist at One Health in Assam.

He added that in most hospitals in Assam, NCC is considered a common disease, not other zoonotic or vector-borne diseases-for example, there is a separate register for Japanese encephalitis. Doctors often confuse NCC with brain tuberculosis. 

Like Mugla, many tea garden workers in the area reported losing their jobs due to recurrent seizures.

Naresh Kurmi had eight such episodes in 2021. "During his attack, his brain went blank and couldn't recognize his child. He thought he was going to die," said his wife, who also worked in the garden. Fearing retaliation, she chose not to reveal her name. 

Naresh was taken to the pharmacy at the tea plantation and then to AMCH.

"There is no medicine in the pharmacy to treat my seizures. They requested a CT scan in a government hospital. When I asked the officials of the tea plantation about some of the scan fees, they explicitly denied it," Naresh said.

In this emergency situation, tea workers are eligible to seek advance payment (deducted from future wages). But Naresh's request was not approved, and he still has not been treated. 

As the seizure failed to subside, Naresh was fired from his temporary job handling heavy machinery, and he could earn 120 rupees a day. He is currently engaged in low-paying repair work (such as repairing faulty lines).

Mulla has been seizure-free for a year, but has never been able to get back to work. According to Narain, the cystic larva (taenia) in his brain may have been calcified (and therefore died). In that case, Mulan won't have seizures again. 

The pharmacy in Basmatia Gardens registered 6 cases of epilepsy. However, Montucario, a plantation worker who mobilized colleagues during the election, claimed that the actual number may be five times that. 

He added that the workers wanted to keep the true figures secret to avoid retaliation. 

In fact, two deaths in recent years—one of which was a confirmed case of NCC—has not been reported.

Biroj Majhi talks about his cousin Kamru

Kamru Majhi, a temporary plantation worker, died last year at the age of 37. In 2006, when he fell for the first time and was injured on the road, AMCH doctors found a parasite in his brain, his cousin Biroj Majhi told Down to Earth. "This family spent a hundred thousand dollars, but to no avail," he claimed.

Kamru was asked to leave his job in 2016 because he was a temporary worker at 48 rupees a day.

If there are multiple lesions, these cysts in the brain can be fatal. "If the cyst is heavier and involves important organs such as the brain, it is likely to cause death," Narain said.

Many villagers in the area said that they prefer traditional herbal medicines to prescription synthetic drugs because they are more affordable and within reach.

"I have fewer seizures when using jungli dorob, which is a viscous drink traditionally made from herbs," said Mulla. 

Biroj Majhi recalled consulting a witch doctor seven kilometers away for his cousin Kamru, who claimed that he could remove worms from patients. "He would recite some verses. They said he could guide the worm to crawl out of the victim's ear," he said. 

Taking into account the daily wages of 205 rupees for tea workers, the cost of NCC treatment may be very high. The minimum requirement to detect the disease during a seizure is a CT scan, which costs 1,000 rupees even in a government hospital. The comparison shows that another 1,500 to 2,000 rupees are needed to highlight the body area to be examined. 

“People below the poverty line can receive CT scans for free, and tea workers should ideally be covered. However, the penetration rate of health welfare programs such as Pradhan Mantri Jan Arogya Yojana and Atal Amrit Abhiyan is low. Proof of income has also become very difficult to produce. Trouble. So they end up having to bear excessive costs," said Kurmi of AMCH.

Patients should be given anthelmintics, anti-epileptics, steroids and other drugs, and surgery should be performed at the same time. But One Health expert Dutta said that a more comprehensive One Health approach is needed.  

The One Health approach combines animal health and the surrounding environment to solve human health problems. As part of this, public health practitioners need to prevent tapeworms from entering the human brain first by using cost-effective and simple tools to detect Taenia solium carriers-such as human stool inspections and inspection of trembling tongues. Dutta added that in Pigs in the feeding area.

Improving pig farming practices, such as the use of anthelmintics, can go a long way. 

But perhaps the most important thing is to improve sanitation measures and health education through on-site interventions in communities at risk. "The elimination of open defecation and hand washing are necessary to prevent this disease," Narain said.

The myth of "Swach Bharat Mission" 

Few NCC patients in this area have a fully functional toilet at home. The government claims that since the plan was launched by Indian Prime Minister Narendra Modi in 2014, India has built more than 100 million toilets to achieve the goal of “no open defecation”. 

Murah's family was passed to a semi-built toilet under the government's flagship Swachh Bharat Mission. As the toilet is still unavailable, the family continues to defecate in the open.

Most of the tea workers interviewed by the reporter are accustomed to doing the same thing by the nearby river. Pigs roam freely in the same field. The eggs of Taenia solium released through feces in these farms pollute the environment, putting pigs and humans at risk-if people use toilets, this situation can be avoided. 

Both the World Health Organization and the Centers for Disease Control and Prevention stated that as environmental sanitation and sanitation conditions improve, the risk of tapeworm disease and NCC will be greatly reduced. 

Until conditions for vulnerable tea workers in Assam are improved, an apparently treatable disease will still threaten their livelihoods and lives. 

The reporting of this story was supported by the Internews Earth News Network Asia-Pacific Zoonoses Project and One Health

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