Multilevel modelling and malaria: a new method for an old disease.

BACKGROUND: Malaria is influenced by a web of individual and ecological factors, i.e. factors relating to people and relating to environment. For a long time analysing these factors concurrently has raised statistical problems. Multilevel modelling provides a new attractive solution, which is still uncommon in tropical medicine. METHODS: Using an actual data set of 3864 individuals from 38 villages of the Highland Madagascar, a two-level modelling process is presented. Individual malaria parasitaemia is modelled step by step according to age (individual factor), altitude, and DDT indoor house-spraying status (village factors). RESULTS: The hierarchical organization of a data set in levels, fixed and random effects, and cross-level interactions are considered. Accurate estimations of standard errors, impact of unknown or unmeasured variables quantified and accounted for through random effects, are the highlighted advantages of multilevel modelling. CONCLUSION: While not denying the importance of understanding an aetiological chain, the authors recommend an increased use of multilevel modelling, mainly to identify accurately ecological targets for public health policy.

[Long-term impact of a mass treatment by praziquantel on morbidity due to Schistosoma haematobium in two hyperendemic villages of Niger]. / Evaluation à long-terme d'un traitement de masse par praziquantel sur la morbidité due à Schistosoma haema- tobium dans deux villages hyper-endémiques du Niger.

Although it is established that the treatment by praziquantel reduces the urinary lesions due to Schistosoma haematobium, the frequency of mass treatment necessary to maintain a low morbidity level remains poorly known. The objective of this work was to study the impact over three years of a single praziquantel mass treatment on schistosomiasis morbidity in two different systems of disease transmission in Niger. The study was performed in 2 villages hyperendemic for schistosomiasis in the South-West of Niger presenting respectively 2 different systems of schistosomiasis transmission: Koutoukalé-Zéno (K Zéno), located close to an irrigated area of the Niger River Valley where the transmission is permanent, and Téguey located along a temporary pond where the transmission is seasonal. After the initial evaluation (1994), we carried out a survey 3 years later (1997) except in K. Zéno where an intermediate evaluation was performed 10 months after the initial survey (1995). Approximately 300 randomised people have been examined as follows: macroscopic examination of urine and reagent sticks for macro- and micro-haematuria, filtration and microscopic examination of urine for Schistosoma eggs, and ultrasound scan of the urinary tract for morbidity. The therapeutic coverage has reached 69.9% in K. Zéno and 78.2% in Téguey. The prevalence of infestation decreased from 74.1% to 56.4 % in K. Zéno (p < 0.001) and from 65.3% to 30.4% in Téguey (p < 0.001) at the end of the 3 years. The prevalence of heavy infestation (eggs > or = 50) went in the same time from 9.9% to 12.8% (p = 0.3) in K. Zéno and from 9.1% to 3.3% in Téguey (p = 0.01). Using ultrasound scan, the prevalence of the bladder lesions reached its previous level in both villages. However the prevalence of hydronephrosis decreased from 21.1% to 3.9% in K. éno (p < 0.001) and from 12.6% to 4.2% in Téguey (p < 0.001). Three years after the single mass treatment, the morbidity did not reach the initial level. The effectiveness of the treatment is better in the pond system where the transmission is seasonal. The lesions of the upper tract decreased more slowly than the bladder lesions, but a long time after the treatment. The re-infestation induced the re-appearance of the bladder lesions sooner than the lesions of the upper tract. The periodicity of the treatment should be variable according to the transmission system. It should occur every 2 years in irrigated areas and could be delayed (3 years) in temporary ponds. The control was beneficial in the pond system and induced a significant reduction of the severe lesions.

Blood pressure, body mass index and socio-economic status in the urban population of Antananarivo (Madagascar).

In many developing countries and especially those in the Indian Ocean, the prevalences of hypertension and obesity have increased markedly over the past decade. In a community-based study set in Antananarivo, the capital of Madagascar, multi-level modelling has now been used to look for associations between blood pressure or body mass index (BMI) and levels of occupation, education and income, among 773 adults. Many (23%) of the subjects had elevated blood pressure (i.e. over 140/90 mmHg). The prevalence of such elevated blood pressure increased with age - with an odds ratio (OR) of 2.16 and a corresponding 95% confidence interval (CI) of 1.81-2.58 for each 10-year increase - but decreased with educational level (high school: OR=0.74; CI = 0.41-1.31) and income (fourth quartile: OR= 0.66; CI = 0.35-1.27). The BMI data indicated that 18.4% of the subjects were underweight, 6.0% were overweight but not obese and 2.4% were obese. Being overweight was directly associated with level of occupation (management level: OR= 3.49; CI = 1.18-10.29) and income (fourth quartile: OR= 3.55;CI = 1.48-8.50). Despite the trends, underweight and overweight individuals and cases of elevated blood pressure were found to co-exist in all socio-economic classes.

[Impact of health education programs on the control of urinary bilharziasis in Niger]. / Impact de la sensibilisation des populations dans la lutte contre la bilharziose urinaire au Niger.

The objective of this study was to assess the effect of health education in the control of bilharziasis, as a part of an investigation on anti-urinary bilharziasis campaign in Niger. We carried out a survey in two groups of endemic villages on the Niger, one group of villages where there are health education campaigns (target villages) and a control village (no education campaign). Five hundred and seventy-seven people were interviewed in the area. The bilharziasis project has been the main source of information on bilharziasis of people in the project zone. The awareness of measures to fight against bilharziasis has been moderate. Indeed, 46.6% of people interrogated in the project area couldn't cite any means for containing bilharziasis. In the area of intervention, 41.5% of people interrogated were unaware of the intervention of an intermediate host in the transmission of the urinary bilharziasis. The notion of reinfestation remains little known. Behaviours that favour the illness were ignored by 1/3 of people interrogated in the project area. However, there was an increase in knowledge about the illness in the program zone in comparison with the control area. Despite the increase in knowledge level, changes in behaviour in relation to the illness remained low. Risky behaviour continued in about 2/3 of people interrogated. Only 33% of persons of the project area declared having adopted at least a single good behaviour. Changes of behaviour are slow to take place. Activities of health education must be sustained throughout a long period of time for sustainable profits of control actions to occur.

Bulinus species on Madagascar: molecular evolution, genetic markers and compatibility with Schistosoma haematobium.

Of the four species of Bulinus found on Madagascar, three species: B. obtusispira, B. liratus and B. bavayi are endemic while the fourth, B. forskalii, is probably a recent introduction from the African mainland. The evolutionary relationships of these species with Bulinus species from Africa were studied by phylogenetic analysis of DNA sequence variation at two mitochondrial loci: cytochrome oxidase subunit I (COI) and large ribosomal subunit (LSU) or 16S. The observed levels of nucleotide divergence within Bulinus were substantial but may underestimate the true levels as there was evidence of 'saturation' of transitional substitutions at both loci. A putative secondary structure model for the sequenced segment of the 16S was developed. Subsequent phylogenetic analysis using transversional changes only for both loci, showed that there were contrasting levels of divergence within the four species groups. B. obtusispira was consistently placed within the B. africanus group, appearing ancestral to this group and was closest to the basal node within Bulinus. Together with B. bavayi, the two species appear to have been isolated on Madagascar for a long time, contrasting with both B. liratus and B. forskalii that appear more recent colonisers; however, estimate of exact times of divergence is problematic. A PCR-RFLP assay was developed to enable identification and discrimination of B. obtusispira and B. liratus using discriminatory variation within the COI. To enable population genetic analysis within B. obtusispira, microsatellite markers were developed using an enrichment method and 8 primer pairs are reported. Laboratory infection experiments using Madasgacan S. haematobium from the Mahabo area showed that certain populations of B. obtusispira, B. liratus and B. bavayi were compatible.

The impact of the local water-development programme on the abundance of the intermediate hosts of schistosomiasis in three villages of the Senegal River delta.

The populations of the potential intermediate hosts of Schistosoma mansoni and S. haematobium were studied for a year at transmission sites near three villages in the lower delta of the Senegal River. Biomphalaria pfeifferi, found to be widely distributed and increasingly abundant, appears to be well adapted to the new areas of irrigation (created by the dams at Diama and Manantali) thanks to its ability to withstand changes in temperature and to aestivate. This species is responsible for intense transmission of S. mansoni during the rainy season. In contrast, Bulinus globosus, the species responsible for the transmission of S. haematobium (which occurs during the dry season), had a more limited distribution. The changing distributions of these two snail species appear to be linked to changes in local ecology, themselves the result of the recent programme of water-development in the delta.

Increase of intestinal schistosomiasis after praziquantel treatment in a Schistosoma haematobium and Schistosoma mansoni mixed focus.

The recent emergence of a mixed focus of Schistosoma haematobium-Schistosoma mansoni, in the lower delta of the Senegal river, requires adapted control programmes. A mass treatment with praziquantel was organised in April 1994 by local authorities in three villages where populations had been examined. A total of 2042 subjects participated. In Savoigne S. haematobium prevailed (53% for prevalence), in Diagambaly S. haematobium (64%) and S. mansoni (76%) were both abundant, and in Boundoum S. mansoni prevailed (53%). Therapeutic coverage (80%) was assessed on a representative sample. A cohort of 968 treated subjects were followed-up 40, 100, 200 and 300 days after treatment. Six weeks after treatment, the average of egg excretion decreased by 95% for S. haematobium, ranging from 23 to one egg(s)/10 ml at Savoigne and from 14 to one egg(s)/10 ml at Diagambal. Conversely, egg excretion only decreased by 75% for S. mansoni, from 23 to six eggs/g at Boundoum and from 69 to 16 eggs/g at Diagambal, showing evidence of the low susceptibility of S. mansoni local strain to praziquantel. Ten months after treatment, reinfections with S. haematobium remained weak at Savoigne (two eggs/10 ml) while those with S. mansoni were so high at Boundoum (24 eggs/g) that they compensated the reduction of load induced by the treatment. At Diagambal, where the two parasites were present before treatment, the disappearance of the urinary schistosomiasis after treatment concurred with a dramatic increase of intestinal schistosomiasis. S. manoni egg excretion was seven times higher than before treatment (478 eggs/g). These different effects of treatment are discussed according to the ecology of transmission in the three villages.

The oral route as a potential way of transmission of Schistosoma bovis in goats.

The infectivity of Schistosoma bovis cercariae administered orally was evaluated in Sahelian goats. Compared to the percutaneous route, a single massive oral dose resulted in a worm burden and in fecal egg excretion reduced by one-half. Surprisingly, tissue egg counts were increased by more than 4-fold. Fecundity of individual female schistosomes was, therefore, markedly increased. When infective doses were administered weekly for 20 wk, both worm and egg burdens were doubled without modification of the individual worm pair fecundity. Repeated oral infections seem to have induced an acquired tolerance toward parasite antigens. These results confirm the epidemiologic relevance of the oral route in a host species inclined to become infected through drinking water rather than percutaneous exposures.

Schistosoma bovis: vaccine effects of a recombinant homologous glutathione S-transferase in sheep.

The economic importance of the trematode Schistosoma bovis in African livestock has justified the development of a specific vaccine. Administered preventively to sheep, rSb28GST--the only molecule cloned from S. bovis which has demonstrated vaccine potentialities in goats and cattle--reduced the mean worm burden in vaccinated animals and improved their health status compared with that of non-vaccinated controls. As in goats, but not in bovines, the fecundity of the settled worm pairs was not modified. Therefore, rSb28GST can be proposed as a universal tool for the prevention of clinical disorders engendered by the main schistosome species affecting domestic ruminants in the African continent.

Vaccine potential of a recombinant glutathione S-transferase cloned from Schistosoma haematobium in primates experimentally infected with an homologous challenge.

Patas monkeys were twice immunized with a Schistosoma haematobium-derived recombinant glutathione S-transferase (Sh28GST) then challenged with an homologous calibrated challenge. BCG and Freund's Complete Adjuvant (FCA) were used as adjuvants in two distinct protocols. Specific IgG and IgA antibody responses were intense and homogeneous in the animals receiving Sh28GST in the presence of FCA, whereas BCG could only induce moderate and heterogeneous antibody titres. No significant effect on worm burdens was evidenced 36 weeks post-infection in either group of Sh28GST-immunized animals compared to their matched controls receiving an irrelevant protein. Although not significant, 50% reductions in the numbers of eggs located in all tissues (FCA group) and in the urogenital system (BCG group) were noted. Moreover, the total number of excreted eggs was dramatically diminished by 60% and 77% in the BCG and FCA groups, respectively. These reductions reached 75% and 80% in the urines of vaccinated monkeys. Bladder pathology was also reduced in the animals displaying the lowest urinary egg excretions. There was no clear positive or negative correlate between antibody responses and individual levels of protection. Taken as a whole, our results show that Sh28GST was capable of significantly reducing S. haematobium worm fecundity in experimentally infected primates. Although FCA induced higher levels of protection, the efficacy of BCG as an adjuvant appeared sufficient to justify consideration of the future application of this new formulation as a vaccine against human urogenital schistosomosis.

[Preliminary evaluation of usable indicators during a control program for urinary bilharziosis in Niger]. / Evaluation préliminaire des indicateurs utilisables au cours d'un programme de lutte contre la bilharziose urinaire au Niger.

The performance of several indirect screening tests was evaluated during the start-up phase of a urinary schistosomiasis control program in Niger. Urine tests were carried out on a total of 354 children attending 3 primary schools on five consecutive days. Tests included filtration of 10 ml of urine, search for microscopic hematuria using reagent strips, and gross examination of urine. In addition a questionnaire was administered on the first day to identify signs of dysuria and hematuria. Repeat testing had a strong effect on the epidemiological profile of urinary schistosomiasis in the 3 schools. Although day-to-day counts varied greatly, egg excretion could be considered as high in all infected subjects. The screening sensitivity of urine filtration was low when the level of endemicity was moderate (up to 55 p. 100). Microscopic hematuria was common. However the sensitivity of this method was overestimated in comparison with urine filtration alone and use of reagent strips can be inconvenient. Using carefully defined diagnostic criteria, gross examination of urine was as effective as urine filtration and easier to perform. The value of the questionnaire for evaluation of morbidity was low despite relatively good performance of the diagnostic techniques. The children's responses concerning hematuria were not objective and questions concerning dysuria were poorly understood and time-consuming. In the next phase of study, these findings will be validated by ultrasound imaging.

[Epidemiologic study of the main human intestinal nematodes in the middle west of Madagascar]. / Etude épidémiologique des principales nématodoses intestinales humaines dans le Moyen-ouest de Madagascar.

An epidemiological study of human intestinal helminthiasis was conducted during July and August 1995, in the middle west of Madagascar, with 4571 adults and children ranging from six months to 90 years, in 61 communities between Betafo and Miandrivazo. Faecal examination utilising the MIF concentration method revealed that ascariasis was the dominant nematodosis in the middle west with high prevalences in the high-altitude communities. Ascaris lumbricoides prevalences increase among children and women. Interesting more than 50% of the pattern, ascariasis is a public health problem and its association with infant malnutrition is statistically significant. Hookworm infection prevalence is higher in low-altitude communities, it increases among adults. The Trichuris trichiura prevalences were lower than the prevalences of ascariasis and hookworm infection in all of the communities. Important variations of the prevalences of intestinal helminthiasis are observed essentially in relation with climatic conditions.

The WHO collaborating centre for research and control of schistosomiasis at Niamey, Niger

The Centre de Recherche sur les Meningites et les Schistosomes (CERMES) is a research institute depending on the Organisation de Coordination et de Cooperation pour la lutte contre les Grandes Endemies - a West African Organisation for Public Health - devoted to the studies on schistosomiasis and meningitis. The staff includes 32 persons with 11 scientists and one financial officer. The activities of the CERMES involving schistosomiasis concern three research units: (a) ecology of human and animal schistosomiasis transmission: the CERMES defined the different patterns of schistosomiasis transmission in Niger (involving African dry savana); in this field, we have shown, (i) the existence of important variability in conditions of transmission of S. haematobium and, (ii) natural hybridization between parasite species of the ruminants (s. bovis and S. curassoni) and genetic interaction between human and animal parasites; (b) definition of morbidity indicators usable for rapid assessment methods, for appraisal of the severity of the disease and for the evaluation of the efficiency of control methods; we have established the correlation between ultrasonographic data and some cheap and sample field indicators; (c) immune response and protective immunity by recombinant glutathion S-transferase (Sm28, Sb28 and Sh28) in homologous and heterologous animal including goats, sheep and non human primates (Erythocebus patas). In Niger, we participate in all control programs against schistosomiasis to define control strategies, to supervise operations and to participate in their evaluation with external experts. International collaborations constitute a frame including four laboratories in Africa and six labotatories in developed countries (Europe and USA).

Comparison of human and murine isolates of Schistosoma mansoni from Richard-Toll, Senegal, by isoelectric focusing.

Studies on human and murine isolates of Schistosoma mansoni, from Richard-Toll, Senegal, were carried out by isoelectric focusing in polyacrylamide gels. Seven enzyme systems; lactate dehydrogenase (LDH), malate dehydrogenase (MDH), glucose-6-phosphate dehydrogenase (G6PD), acid phosphatase (AcP), hexokinase (HK), glucose phosphate isomerase (GPI), and phosphoglucomutase (PGM), were used to compare the two isolates. All systems tested, apart from LDH, were found to be polymorphic for both isolates. Interestingly, one phenotype is more frequent than the remainder. The results show that there is no significant genetic variation between the S. mansoni isolates from man and the rodents, Arvicanthis niloticus and Mastomys huberti.

Intraspecific diversity of Schistosoma haematobium in west Africa: chronobiology of cercarial emergence.

Cercarial emergence patterns were used to analyse the intraspecific variability within and between nine populations of Schistosoma haematobium collected along a transect line from the north to the South of the Ivory Coast (Africa) and using Bulinus truncatus or Bulinus globosus as intermediate snail hosts. Statistical comparison demonstrated the existence of a chronobiological polymorphism and the existence of three homogeneous groups of S. haematobium isolates with mean shedding times of the cercariae decreasing from the North to the South. The chronobiological variability observed was not correlated with the species of Bulinus (B. truncatus vs. B. globosus) implicated in the parasite transmission but with the climatic and vegetal features of the transmission area. S. haematobium from shaded sites of the forest zone (South) showed cercarial emergence patterns significantly earliest than that of S. haematobium from open sites of the savanna zone (North). Differences in sensitivity to light intensity could characterize the existence of eco-geographical races of S. haematobium one of the forest, the other from the savanna.

Changes in human schistosomiasis levels after the construction of two large hydroelectric dams in central Côte d'Ivoire.

The construction of large dams has been shown to increase the prevalence and intensity of human schistosomiasis. However, until now no study had been carried out to assess the impact of such a project in Côte d'Ivoire. For Kossou and Taabo, two large dams which became operational in the 1970s, baseline data are available on schistosomiasis prevalence in the surrounding area before dam construction, so that the changes in schistosomiasis levels can be assessed. We re-evaluated the prevalence of Schistosoma haematobium and S. mansoni in November 1992, by analysing 548 urine and 255 stool samples, respectively, from schoolchildren from five villages around each lake. A marked increase in the overall prevalence of S. haematobium was observed, from 14% to 53% around Lake Kossou and from 0 to 73% around Lake Taabo. Baseline data for S. mansoni are only available for Lake Taabo, where a prevalence of 3% was found in 1979 and where the prevalence in 1992 was still low at 2%. The construction of these two large dams therefore led to little change in S. mansoni prevalence but to a significant increase in that of S. haematobium.

The WHO Collaborating Centre for Research and Control of Schistosomiasis at Niamey, Niger.

The Centre de Recherche sur les Méningites et les Schistosomes (CERMES) is a research institute depending on the Organisation de Coordination et de Coopération pour la lutte contre les Grandes Endémies--a West African Organization for Public Health--devoted to the studies on schistosomiasis and meningitis. The staff includes 32 persons with 11 scientists and one financial officer. The activities of the CERMES involving schistosomiasis concern three research units: (a) ecology of human and animal schistosomiasis transmission; the CERMES defined the different patterns of schistosomiasis transmission in Niger (involving African dry savana); in this field, we have shown, (i) the existence of important variability in conditions of transmission of S. haematobium and, (ii) natural hybridization between parasitic species of the ruminants (S. bovis and S. curassoni) and genetic interaction between human and animal parasites; (b) definition of morbidity indicators usable for rapid assessment methods, for appraisal of the severity of the disease and for the evaluation of the efficiency of control methods; we have established the correlation between ultrasonographic data and some cheap and simple field indicators; (c) immune response and protective immunity induced by recombinant glutathion S-transferase (Sm28, Sb28 and Sh28) in homologous and heterologous animal models including goats, sheep and non human primates (Erythrocebus patas). In Niger, we participate in all control programs against schistosomiasis to define control strategies, to supervise operations and to participate in their evaluation with external experts. International collaborations constitute a frame including four laboratories in Africa and six laboratories in developed countries (Europe and USA).

PIP: The Centre de Recherche sur les Meningites et les Schistosomoses (CERMES), a research center in Niamey, Niger, affiliated with a West African public health organization, conducts studies in the areas of parasitology, epidemiology, and immunology. Significant variability in factors related to transmission of Schistosoma haematobium have been noted. Experimental research on the Schistosoma-bulinid compatibility and field surveys of the geographic distribution and role of snails in transmission have been essential to the design of parasite control interventions in West Africa. A CERMES-sponsored project, supported by the European Community, is examining urinary schistosomiasis control in the Niger river valley and the impact of treatment on ultrasonically visualized urologic lesions. The Experimental Vaccine Unit seeks to improve the route of administration and choice of adjuvant and to propose a vaccine protocol for field testing. Recombinant proteins have been found to alter the development of the parasite either by inducing a reduction in the parasite burden or an inhibition of the fecundity of the parasite.