Schistosomiasis and neglected tropical diseases: towards integrated and sustainable control and a word of caution.

In May 2001, the World Health Assembly (WHA) passed a resolution which urged member states to attain, by 2010, a minimum target of regularly administering anthelminthic drugs to at least 75% and up to 100% of all school-aged children at risk of morbidity. The refined global strategy for the prevention and control of schistosomiasis and soil-transmitted helminthiasis was issued in the following year and large-scale administration of anthelminthic drugs endorsed as the central feature. This strategy has subsequently been termed 'preventive chemotherapy'. Clearly, the 2001 WHA resolution led the way for concurrently controlling multiple neglected tropical diseases. In this paper, we recall the schistosomiasis situation in Africa in mid-2003. Adhering to strategic guidelines issued by the World Health Organization, we estimate the projected annual treatment needs with praziquantel among the school-aged population and critically discuss these estimates. The important role of geospatial tools for disease risk mapping, surveillance and predictions for resource allocation is emphasised. We clarify that schistosomiasis is only one of many neglected tropical diseases and that considerable uncertainties remain regarding global burden estimates. We examine new control initiatives targeting schistosomiasis and other tropical diseases that are often neglected. The prospect and challenges of integrated control are discussed and the need for combining biomedical, educational and engineering strategies and geospatial tools for sustainable disease control are highlighted. We conclude that, for achieving integrated and sustainable control of neglected tropical diseases, a set of interventions must be tailored to a given endemic setting and fine-tuned over time in response to the changing nature and impact of control. Consequently, besides the environment, the prevailing demographic, health and social systems contexts need to be considered.

Field testing of the WHO dose pole for administration of praziquantel in the treatment of opisthorchiasis in Lao PDR.

In 2001, the WHO developed a dose pole that employs height measurements for estimation of the dose of praziquantel. In the present study, conducted in December 2005 during a mass treatment campaign for the control of opisthorchiasis in 232 individuals in Nala village, Keo Udom district, Lao PDR, performance of the dose pole in estimating dosages of praziquantel was compared with a bathroom scale; a digital scale was used as the gold standard. Results showed that the bathroom scale performed significantly better than the dose pole in delivering dosages of 40-50 mg/kg for opisthorchiasis treatment (70.7% vs. 44.8%). Furthermore, the dose pole performed significantly better for children than adults. The reason for the poor performance of the dose pole among adults is likely to be due to the high percentage (19.4%) of overweight individuals in the adult population of the village. It was concluded that the WHO dose pole is not recommended for distribution of praziquantel for the treatment of opisthorchiasis in populations where being overweight is common.

Treatment efficacy and regulatory host responses in chronic experimental Schistosoma bovis infections in goats.

The aim of this study was to elucidate the regulatory responses and the long-term effect of praziquantel treatment in chronically Schistosoma bovis-infected West African Dwarf goats. Forty-two goats were used and the design comprised a primary infection followed by treatment at week 13, challenge infection at week 36 and termination at week 52. Dependent variables included clinico-pathological data, worm numbers, faecal and tissue egg counts, and gross pathology of the liver. The results showed that primary infections remained suppressed for up to 52 weeks and, although challenge infections imposed on 36-week-old primary infections established fully, the impairment of their egg production capacity provided protection against clinico-pathological consequences measured by body weight and haemoglobin levels. The study also confirmed a high efficacy (97.7%) of praziquantel for treatment of S. bovis infection in goats and showed that anthelminthic removal of primary infections does not interfere with the ability of the goat to elicit a marked resistance to a subsequent challenge infection. Although treated goats had more fibrous scarring of livers than untreated goats, no negative effects of liver lesions were reflected in weight gains of treated goats. This study provides strong evidence for the beneficial effects of anthelminthic treatment of young domestic stock as an element of treatment and preventive programmes.

Studies on the interaction between Salmonella enterica ser. Typhimurium and intestinal helminths in pigs.

Concomitant infections with helminths and bacteria may affect the course and the resulting disease outcome of the individual infections. Salmonella, Oesophagostomum, Trichuris and Ascaris coexist naturally in pig herds in Denmark, and possible interactions were studied. Pigs in one experiment were trickle infected with low or moderate dose levels of Oesophagostomum spp. and challenge infected with S. Typhimurium. In another experiment, pigs were inoculated with S. Typhimurium followed by a challenge exposure to either Oesophagostomum, Trichuris or Ascaris. Enhancement of the Salmonella infection was not demonstrated in either experiment. The helminth effect on the pigs was modest and may explain the lack of influence on the Salmonella infection. A previous experiment with a larger Oesophagostomum infection level resulted in enhancement of the S. Typhimurium infection. A dose dependency of the interaction is therefore suggested. However, the relatively high worm burdens in the present study suggest that infection with these common pig helminths does generally not influence the course of concurrent S. Typhimurium infections under natural conditions.

Evaluation of PCR based coprodiagnosis of human opisthorchiasis.

In this study, a recently developed PCR test for the detection of Opisthorchis viverrini in human faecal samples was evaluated using two parasitological methods as references. During a survey of foodborne trematodes (FBT) in the Vientiane Province, Lao PDR, 85 samples were collected and evaluated for FBT eggs by the Kato Katz (KK) technique, the formalin ethyl acetate concentration technique (FECT) and a PCR analysis for the distinction between O. viverrini and other FBT. The two parasitological methods did not differ in the ability of detecting FBT eggs, and a single KK reading was characterized by a sensitivity of 85% when compared to two FECT readings. The PCR tested positive only in cases where eggs had been demonstrated by parasitological examination. However, the PCR tested negative in some samples with very high egg counts. Demonstrating a PCR sensitivity of approximately 50% in samples with faecal egg counts>1000, the previously reported PCR sensitivity based on in vitro studies was not supported. It is believed that technical problems rather than diagnostic reference related issues were responsible for the relatively low PCR performance. Further studies should aim at optimizing DNA extraction and amplification, and future PCR evaluation should include specificity control such as the scanning electron microscopy of eggs in test samples or the expulsion of adult trematodes from PCR tested individuals.

The effect of colostrum on pigs pre-natally or post-natally exposed to Schistosoma japonicum.

Pre-natal infection of Schistosoma japonicum in pigs may prove to be a useful model in shedding light on human pre-natal schistosomiasis. This study describes the effects of immune colostrum on worm burdens, tissue egg counts, liver pathology and crude worm or egg antigen-specific IgG and IgA responses, in groups of pigs pre-natally, pre-natally + post-natally or post-natally exposed to S. japonicum. Results suggest that pre-natal exposure and immune colostrum did not affect the establishment of a post-natal challenge infection. However, immune colostrum seemed to increase the levels of septal fibrosis in pre-natally exposed pigs. These findings indicate that further investigations will prove valuable, elucidating the influence of the parasitological and immunological status of the sow, on pre-natally exposed pigs, and on the ability of these pigs to develop resistance against S. japonicum later in life.

Epidemiology and morbidity of Schistosoma mansoni infection in a fishing community along Lake Albert in Uganda.

Schistosoma mansoni infection, associated morbidity and symptoms were studied in Piida fishing community at Butiaba, along Lake Albert, Uganda, from November 1996 to January 1997. The study revealed that S. mansoni is highly endemic with an overall prevalence of 72%, a mean intensity of 419.4 eggs per gram (epg) faeces (geometric mean for positives only), with 37.8% of males and 33.0% of females excreting over 1000 epg. Prevalence and intensity peaked in the 10-14 year old age group and decreased with increasing age. Females were less heavily infected than males. Differences were also shown between tribes. Diarrhoea and abdominal pain were commonly reported in Piida. However, no clear-cut correlation between intensity of S. mansoni infection and these conditions could be demonstrated, indicating that retrospective questionnaires concerning S. mansoni related-symptomatology are of limited value. Organomegaly, as assessed by ultrasonography, was frequent and hepatomegaly was associated with heavy S. mansoni infection. No correlation was demonstrated between splenomegaly and infection. This study emphasizes that schistosomiasis mansoni is a major public health problem in Piida fishing community and presumably also in many similar fishing communities. These observations call for immediate intervention and can help in planning long-term strategies for sustainable morbidity control.

The effect of a low level primary Schistosoma japonicum infection on establishment of a challenge infection in pigs.

The aim of the study was to investigate the effect of a low-level primary infection of Schistosoma japonicum on a challenge infection in pigs. Groups of pigs were given either light or heavy primary infections and heavy challenge infections 14 weeks later. One group of pigs served as a challenge control group. Challenge infection superimposed on the heavily infected pigs did not result in increased worm burden, faecal and tissue egg counts or IgG levels. In contrast, the challenge infection established fully when superimposed on the light primary infections. However, neither faecal egg counts nor the IgG levels increased, and the amount of liver pathology, as judged by septal fibrosis, did not increase either, as compared to the challenge control group. These results suggest that pigs are not able to mount an effective anti-worm response to reinfection when the primary infection is low. However, some modulation of the infection takes place, possibly as a result of an anti-embryonation effect. Collagen content in the liver was found to be relatively insensitive as a marker for liver pathology, as judged using portal and septal fibrosis as a criteria.

Efficacy and side effects of praziquantel treatment in a highly endemic Schistosoma mansoni focus at Lake Albert, Uganda.

The aim of the study was to assess the efficacy and side effects following single and repeated (6 weeks apart) praziquantel treatment (40 mg/kg) in a Schistosoma mansoni-endemic focus with long-standing transmission at Lake Albert in Uganda between December 1996 and January 1997. The results were based on 482 individuals, randomly representing all age and both gender groups. The cure rate following the first and second treatments was 41.9% and 69.1%, respectively. The cure rate was higher in adults than in children, irrespective of intensity of infection. In addition, the cure rate declined markedly with increasing intensity of infection. The reduction in intensity of infection was marked, being 97.7% and 99.6% after the first and second treatments, respectively. A pre- and post-treatment symptom questionnaire revealed a broad range of side effects, including abdominal pain and diarrhoea. However, no serious or long-lasting complications affecting compliance were observed. The marked reductions in faecal egg excretion and the acceptable level of side effects point to a single praziquantel treatment (40mg/kg) as the strategy of choice in such a highly endemic S. mansoni focus.

Congenital infection with Schistosoma japonicum but not with Schistosoma bovis in sheep.

The present study investigated whether Schistosoma japonicum or Schistosoma bois could establish prenatally in lambs. Three ewes were exposed to S. japonicum by intramuscular injection of cercariae, and 3 ewes were exposed to S. bovis cercariae using the leg-emerging technique approximately 2 mo before delivery, and 1 age-matched pregnant ewe served as an uninfected control. The study lasted 18-20 wk after infection, which was 8-9 wk after delivery. All 6 exposed ewes became infected with either S. bovis or S. japonicum. Eight lambs were borne by the 7 ewes, of which 1 (S. bovis exposed) was dead and 1 (S. japonicum exposed) died at delivery. Of the 3 S. japonicum-exposed lambs, 2 were found infected. Four lambs born of S. bovis-exposed ewes were negative. Despite having no worms, these 4 S. bovis-exposed lambs as well as the 1 negative S. japonicum-exposed lamb had, in contrast to the nonexposed control lamb, few, but distinct, liver granulomas dominated by eosinophils and giant cells with large central necrotic areas but with no remnants of eggs or worms. Hence, congenital infection was demonstrated in S. japonicum-infected lambs, but not in S. bovis-infected ones.