FioSchisto's expert perspective on implementing WHO guidelines for schistosomiasis control and transmission elimination in Brazil.

The World Health Organization (WHO) recognizes schistosomiasis as one of the Neglected Tropical Diseases targeted for global elimination in the 2030 Agenda of the Sustainable Development Goals. In Brazil, schistosomiasis mansoni is considered a public health problem, particularly prevalent among vulnerable populations living in areas with poor environmental and sanitary conditions. In 2022, the WHO published a Guideline encompassing recommendations to assist national programs in endemic countries in achieving morbidity control, eliminating schistosomiasis as a public health problem, and advancing towards interrupting transmission. The perspectives presented here, collectively prepared by members of the Oswaldo Cruz Foundation's (Fiocruz) Schistosomiasis Translational Program (FioSchisto), along with invited experts, examine the feasibility of the WHO recommendations for the Brazilian settings, providing appropriate recommendations for public health policies applicable to the epidemiological reality of Brazil, and suggests future research to address relevant issues. In Brazil, the provision of safe water and sanitation should be the key action to achieve schistosomiasis elimination goals. The agencies involved in measures implementation should act together with the Primary Care teams for planning, executing, monitoring, and evaluating actions in priority municipalities based on their epidemiological indicators. Host snails control should prioritize judicious ecological interventions at breeding sites. The Information, Education, and Communication (IEC) strategy should be associated with water and sanitation and other control actions, actively involving school community. To identify infected carriers, FioSchisto recommends a two-stage approach of immunological and molecular tests to verify transmission interruption during the intervention and beyond. Praziquantel administration should be done under medical supervision at the Primary Care level. MDA should be considered in exceptional settings, as a measure of initial attack strategy in locations presenting high endemicity, always integrated with water and sanitation, IEC, and snail control. To assist decision-making, as well as the monitoring and evaluation of strategic actions, there is a need for an Information System. FioSchisto considers this systematization essential to make investments in strategic research to support the improvement of schistosomiasis control actions. Efforts toward schistosomiasis elimination in Brazil will succeed with a paradigm shift from the vertical prescriptive framework to a community-centered approach involving intersectoral and interdisciplinary collaboration.

Accuracy of the urine point-of-care circulating cathodic antigen assay for diagnosing Schistosomiasis mansoni infection in Brazil: A multicenter study.

BACKGROUND: The World Health Organization recommends a market-ready, urine-based point-of-care diagnostic test for circulating cathodic antigens (CCA) to determine the prevalence of S. mansoni. This study evaluated the performance of the URINE CCA (SCHISTO) ECO TESTE® (POC-ECO), which is currently available in Brazil. METHODS: Residents from eight sites with different prevalence estimates provided one urine sample for POC-ECO and one stool sample for Kato-Katz (KK) and Helmintex® (HTX) testing as an egg-detecting reference for infection status. RESULTS: None of the study sites had significantly higher POC-ECO accuracy than KK. CONCLUSIONS: POC-ECO is not currently recommended in Brazilian schistosomiasis elimination programs.

Accuracy of the urine point-of-care circulating cathodic antigen assay for diagnosing Schistosomiasis mansoni infection in Brazil: A multicenter study

ABSTRACT Background: The World Health Organization recommends a market-ready, urine-based point-of-care diagnostic test for circulating cathodic antigens (CCA) to determine the prevalence of S. mansoni. This study evaluated the performance of the URINE CCA (SCHISTO) ECO TESTE® (POC-ECO), which is currently available in Brazil. Methods: Residents from eight sites with different prevalence estimates provided one urine sample for POC-ECO and one stool sample for Kato-Katz (KK) and Helmintex® (HTX) testing as an egg-detecting reference for infection status. Results: None of the study sites had significantly higher POC-ECO accuracy than KK. Conclusions: POC-ECO is not currently recommended in Brazilian schistosomiasis elimination programs.

Reliability of point-of-care circulating cathodic antigen assay for diagnosing schistosomiasis mansoni in urine samples from an endemic area of Brazil after one year of storage at -20 degrees Celsius.

BACKGROUND: The World Health Organization recommends reliable point-of-care (POC) diagnostic testing to eliminate schistosomiasis. Lateral flow immunoassay that detects schistosome circulating cathodic antigen (CCA) in urine to establish prevalence thresholds for intervention in endemic areas is recommended. Stored urine may be useful if surveying at-risk populations is delayed or interrupted by unforeseen circumstances, such as the current COVID-19 pandemic. This study evaluated the manufacturer's claim that Schistosoma mansoni infection can be reliably diagnosed in urine samples stored at -20°C for one year. METHODS: Two-hundred-forty-two subjects from an endemic site in Brazil provided one urine sample each for testing with URINE CCA (SCHISTO) ECO TESTE® (POC-ECO) and one stool sample each for testing with Kato-Katz (KK) and Helmintex® (HTX) as a robust reference standard for infection status. At least 2 ml of urine from each participant was stored at -20°C; after one year, 76 samples were randomly selected for POC-ECO retesting. RESULTS: The POC-ECO agreement between freshly collected and stored urine was inadequate considering trace results as positive (Cohen's kappa coefficient κ = 0.08) and negative (κ = 0.36). POC-ECO accuracy was not significantly greater than that of routine KK (54%; 95% confidence interval: 42.1%-65.5%). CONCLUSIONS: The precision and accuracy of POC-ECO have to be optimized in both freshly collected and stored urine before it can be recommended for use in control programs in Brazil.

Reliability of point-of-care circulating cathodic antigen assay for diagnosing schistosomiasis mansoni in urine samples from an endemic area of Brazil after one year of storage at -20 degrees Celsius

ABSTRACT Background The World Health Organization recommends reliable point-of-care (POC) diagnostic testing to eliminate schistosomiasis. Lateral flow immunoassay that detects schistosome circulating cathodic antigen (CCA) in urine to establish prevalence thresholds for intervention in endemic areas is recommended. Stored urine may be useful if surveying at-risk populations is delayed or interrupted by unforeseen circumstances, such as the current COVID-19 pandemic. This study evaluated the manufacturer's claim that Schistosoma mansoni infection can be reliably diagnosed in urine samples stored at -20°C for one year. Methods Two-hundred-forty-two subjects from an endemic site in Brazil provided one urine sample each for testing with URINE CCA (SCHISTO) ECO TESTE® (POC-ECO) and one stool sample each for testing with Kato-Katz (KK) and Helmintex® (HTX) as a robust reference standard for infection status. At least 2 ml of urine from each participant was stored at -20°C; after one year, 76 samples were randomly selected for POC-ECO retesting. Results: The POC-ECO agreement between freshly collected and stored urine was inadequate considering trace results as positive (Cohen's kappa coefficient κ = 0.08) and negative (κ = 0.36). POC-ECO accuracy was not significantly greater than that of routine KK (54%; 95% confidence interval: 42.1%-65.5%). Conclusions The precision and accuracy of POC-ECO have to be optimized in both freshly collected and stored urine before it can be recommended for use in control programs in Brazil.

Adherence to diagnosis followed by selective treatment of schistosomiasis mansoni and related knowledge among schoolchildren in an endemic area of Minas Gerais, Brazil, prior to and after the implementation of educational actions.

INTRODUCTION: Brazilian guidelines for schistosomiasis elimination recommend regular search of infection carriers and their timely treatment. This study evaluates the effect of educational actions (EAs) among schoolchildren on adherence to diagnosis and treatment, as well as on knowledge of the disease. METHODS: In April/2013, a questionnaire was applied to 6th-to-8th-grade pupils of eight public schools to evaluate prior knowledge of disease and self-reported risk behavior. Baseline parasitological survey (PS) was done in May/2013, followed by selective treatment and cure assessment. The schools were then randomly allocated to experimental (EG) and control (CG) groups, with and without EAs, respectively. EAs were conducted for 3 months from August/2013. Questionnaire was reapplied in November/2013, April/2014, October/2014, and October/2015 to evaluate changes in knowledge about the disease and self-reported risk behavior. Two further annual PSs (May/2014 and May/2015), each followed by treatment of positives, allowed to evaluate between-group differences and intra-group changes in adherence to diagnosis and treatment, and to follow-up prevalence and intensity of infection. RESULTS: Adherence to diagnosis did not differ significantly between EG (84.1%) and CG (81.1%) at baseline but was significantly higher in EG in subsequent PSs. Overall, adherence to treatment was higher than 90% in all three PSs; cure was 98.4%, egg-reduction was 99.8% and reinfection, 2.8%. Prevalence fell significantly in EC (from 23.5% to 6.8%) and CG (from 21.8% to 2.4%), the same occurring with intensity (from 54.2 to 4.6 epg in EG and from 38.4 to 1.3 epg in CG). Disease knowledge increased significantly in EG and CG; knowledge about disease transmission increased significantly more in the EG. Self-reported risk behavior remained above 67% and did not differ significantly between EG and CG. CONCLUSION: EAs increased adherence of schoolchildren and improved knowledge about the disease, confirming that EAs are an important tool to enhance schoolchildren participation in control campaigns.

Low specificity of point-of-care circulating cathodic antigen (POCCCA) diagnostic test in a non-endemic area for schistosomiasis mansoni in Brazil.

A point-of-care test for detecting schistosome circulating cathodic antigen in urine (POCCCA) has been proposed for mapping infection and defining prevalence thresholds for mass drug administration (MDA). However, there is increasing evidence that POCCCA may yield false-positive results, which requires rigorous specificity evaluation in non-endemic areas. POCCCA was applied in an area known to be free from infection and devoid of any condition for schistosomiasis transmission as part of a multicentre study to evaluate the performance of POCCCA in Brazil's low or potentially endemic settings. Besides POCCCA detection in urine, a search for eggs in stool was performed by Kato-Katz (KK) and Helmintex (HTX) methods. One-hundred-and-seventy-four participants returned urine samples, 140 of which delivered stool samples. All these were HTX-negative for Schistosoma mansoni, and all 118 tested with KK were negative for both S. mansoni and soil-transmitted helminths. POCCCA results from freshly collected urine yielded a specificity of 62.1% (95% CI: 53.6% - 70.2%), taking trace outcomes as positive according to the manufacturer's instructions. Retesting urine from the 140 HTX-negatives after one-year storage at -20 °C with two new POCCCA batches simultaneously yielded significantly different specificities (34.3%; 95%CI: 26.5% - 42.8% and 75.0%; 95% CI: 67.0% - 81.9%). These two batches had a weak agreement (Cohen's kappa: 0.56; 95%CI: 0.44-0.68) among the 174 urine samples retested. At present, POCCCA cannot be recommended either as a cut-off point for MDA or a reliable diagnostic tool for treatment of the infection carriers (selective chemotherapy) in low endemic areas and at final stages of transmission interruption. Manufacturers should be required to optimize production standardization and to assure quality and reproducibility of the test. Extended rigorous performance evaluations by different users from different regions are needed before POCCCA is widely recommended.

Assessment of schistosomiasis in the semi-arid Northeast region of Brazil: the São Francisco River large-scale water transposition project.

UNLABELLED: INTRODUCTION Risk of schistosomiasis expansion to semi-arid northeastern Brazil under the influence of the Integration Project of the São Francisco River (IPSFR) was assessed. METHODS: Stool examinations of schoolchildren, epidemiological investigation, and survey of the local host snail Biomphalaria straminea were performed in five IPSFR municipalities. RESULTS Six of 4,770 examined schoolchildren were egg-positive for Schistosoma mansoni. Biomphalaria straminea was widespread, but not naturally infected with S. mansoni. Snails experimentally exposed to two laboratory S. mansoni strains yielded infection indices of 1-4.5%. CONCLUSIONS: There is evidence of active schistosomiasis transmission in the area; thus, intensive surveillance actions are required.

The prevalence of schistosomiasis in school-aged children as an appropriate indicator of its prevalence in the community.

School-aged children (6-15 years) from the endemic area of Pernambuco were evaluated both as a target group for and an indicator of schistosomiasis control in the community. Parasitological data were drawn from baseline stool surveys of whole populations that were obtained to diagnose Schistosoma mansoni infection. Nineteen representative localities were selected for assessing the prevalence of schistosomiasis among individuals in the following age groups: 0-5, 6-15, 16-25, 26-40 and 41-80 years. For each locality, the prevalence in each age group was compared to that of the overall population using contingency table analysis. To select a reference group, the operational difficulties of conducting residential surveys were considered. School-aged children may be considered to be the group of choice as the reference group for the overall population for the following reasons: (i) the prevalence of schistosomiasis in this age group had the highest correlation with the prevalence in the overall population (r = 0.967), (ii) this age group is particularly vulnerable to infection and plays an important role in parasite transmission and (iii) school-aged children are the main target of the World Health Organization in terms of helminth control. The Schistosomiasis Control Program should consider school-aged children both as a reference group for assessing the need for intervention at the community level and as a target group for integrated health care actions of the Unified Health System that are focused on high-risk groups.

The prevalence of schistosomiasis in school-aged children as an appropriate indicator of its prevalence in the community

School-aged children (6-15 years) from the endemic area of Pernambuco were evaluated both as a target group for and an indicator of schistosomiasis control in the community. Parasitological data were drawn from baseline stool surveys of whole populations that were obtained to diagnose Schistosoma mansoni infection. Nineteen representative localities were selected for assessing the prevalence of schistosomiasis among individuals in the following age groups: 0-5, 6-15, 16-25, 26-40 and 41-80 years. For each locality, the prevalence in each age group was compared to that of the overall population using contingency table analysis. To select a reference group, the operational difficulties of conducting residential surveys were considered. School-aged children may be considered to be the group of choice as the reference group for the overall population for the following reasons: (i) the prevalence of schistosomiasis in this age group had the highest correlation with the prevalence in the overall population (r = 0.967), (ii) this age group is particularly vulnerable to infection and plays an important role in parasite transmission and (iii) school-aged children are the main target of the World Health Organization in terms of helminth control. The Schistosomiasis Control Program should consider school-aged children both as a reference group for assessing the need for intervention at the community level and as a target group for integrated health care actions of the Unified Health System that are focused on high-risk groups.

Assessment of schistosomiasis, through school surveys, in the Forest Zone of Pernambuco, Brazil

This work had the objective of assessing the present epidemiological situation regarding schistosomiasis through performing Kato-Katz coproscopic tests on representative samples of schoolchildren from each of the 43 municipality of endemic area of the state of Pernambuco, Brazil. The methodology is recommended by the World Health Organization to conduct sampled surveys among children at elementary school levels, ideal target group for baseline surveys: (i) schools are accessible; (ii) the greatest prevalence of schistosomiasis is found within this group; (iii) the data gathered from this age group can be used for intervention within the community as a whole. The following infection indicators were utilized: positivity (percentage of individuals examined with eggs of Schistosoma mansoni in the feces) and severity (geometric mean number of eggs per gram of feces, epg). These indicators allowed the area in general and the municipalities in particular to be categorized into prevalence and severity classes for S. mansoni. The prevalence classes were: low (<10 percent), medium (> 10 and < 50 percent), and high (> 50 percent); the severity classes were: low (1-99 epg), moderate (100-399 epg), and severe (> 400 epg). For the geohelminthic diseases, the following indicators were used: positivity for each geohelminth (percentage of individuals examined with eggs of geohelminths), and cumulative positivity (percentage of individuals examined with eggs of at least one geohelminth). The municipalities were categorized by means of their cumulative positivity into the following geohelminth prevalence classes (WHO 2002): low (< 50 percent), medium (> 50 and < 70 percent), and high (> 70 percent). The study covered 271 schools in 179 different localities, thus giving a total of 11,234 examinations performed. The overall positivity for S. mansoni was 14.4 percent and the egg count for this parasite in the feces gave a geometric mean of 67.9 epg which suggests...

Assessment of schistosomiasis, through school surveys, in the Forest Zone of Pernambuco, Brazil.

This work had the objective of assessing the present epidemiological situation regarding schistosomiasis through performing Kato-Katz coproscopic tests on representative samples of schoolchildren from each of the 43 municipality of endemic area of the state of Pernambuco, Brazil. The methodology is recommended by the World Health Organization to conduct sampled surveys among children at elementary school levels, ideal target group for baseline surveys: (i) schools are accessible; (ii) the greatest prevalence of schistosomiasis is found within this group; (iii) the data gathered from this age group can be used for intervention within the community as a whole. The following infection indicators were utilized: positivity (percentage of individuals examined with eggs of Schistosoma mansoni in the feces) and severity (geometric mean number of eggs per gram of feces, epg). These indicators allowed the area in general and the municipalities in particular to be categorized into prevalence and severity classes for S. mansoni. The prevalence classes were: low (<10%), medium (> 10 and < 50%), and high (> 50%); the severity classes were: low (1-99 epg), moderate (100-399 epg), and severe (> 400 epg). For the geohelminthic diseases, the following indicators were used: positivity for each geohelminth (percentage of individuals examined with eggs of geohelminths), and cumulative positivity (percentage of individuals examined with eggs of at least one geohelminth). The municipalities were categorized by means of their cumulative positivity into the following geohelminth prevalence classes (WHO 2002): low (< 50%), medium (> 50 and < 70%), and high (> 70%). The study covered 271 schools in 179 different localities, thus giving a total of 11,234 examinations performed. The overall positivity for S. mansoni was 14.4% and the egg count for this parasite in the feces gave a geometric mean of 67.9 epg which suggests a low general state of infection. These results allow this mesoregion to be categorized as presenting medium prevalence and low severity of schistosomiasis. The overall positivity rates for the geohelminths, Ascaris lumbricoides, Ancylostomidae, and Trichuris trichiura were, respectively, 30.4, 10.1, and 27.8%; the cumulative positivity was 45.4%. These results allow this mesoregion to be categorized as presenting low prevalence of geohelminthic diseases. The data show some municipalities in Pernambuco with prevalence greater than 20%, while others presented parasite loads greater than 100 epg. These indicators attest to the significant morbidity due to schistosomiasis regarding to the severity of infections established in young populations.

Impact of antihelminthic treatment on infection by Ascaris lumbricoides, Trichuris trichiura and hookworms in Covas, a rural community of Pernambuco, Brazil.

This work aims to evaluate the impact of drug treatment on infection by Ascaris lumbricoides (Al), Trichuris trichiura (Tt) and hookworms (Hook) in a rural community from the sugar-cane zone of Pernambuco, Brazil. Four parasitological surveys were carried out from March 2001 to March 2002. Individual diagnosis was based on eight slides (four by the Kato-Katz method and four by the Hoffman method) per survey. Infected subjects were assigned to two groups for treatment with either albendazole (n = 62) or mebendazole (n = 57). Prevalence of infection fell significantly (p < 0.05) one month after treatment: Al (from 47.7% to 6.6%); Tt (from 45.7% to 31.8%) and Hook (from 47.7% to 24.5%). One year after treatment, infections by Tt and Hook remained significantly below pre-control levels. A substantial decrease in single-infection cases and multiple infections was found. Egg-negative rate was significant for Al (94.0%), Hook (68.3%) but not for Tt (45.5%), and did not differ significantly between subjects treated with mebendazole or albendazole. Egg counts fell significantly in the individuals remaining positive for Tt. It is recommended that antihelminthic treatment should be selective and given at yearly intervals preferably with albendazole, due to its cost-effectiveness.

Impact of antihelminthic treatment on infection by Ascaris lumbricoides, Trichuris trichiura and hookworms in Covas, a rural community of Pernambuco, Brazil

Este trabalho avalia o impacto do tratamento antihelmíntico sobre a infecção por A. lumbricoides (Al), T. trichiura (Tt) e ancilostomídeos (Anc) na população de Covas, Pernambuco. Durante março/2001 e março/2002, quatro inquéritos parasitológicos foram realizados. Em cada um foram coletados dois exames de fezes por morador. O diagnóstico foi feito pelos métodos de Kato-Katz e Hoffmann. Em abril/01, os indivíduos positivos foram separados em dois grupos para tratamento com albendazol (n = 62) ou mebendazol (n = 57). As proporções de indivíduos positivos reduziram-se significativamente um mês pós-tratamento: Al (de 47,7 por cento para 6,6 por cento), Tt (de 45,7 por cento para 31,8 por cento) e Anc (de 47,7 por cento para 24,5 por cento); permanecendo abaixo do nível inicial um ano pós-tratamento. Os casos de monoinfecção, exceto os por Tt, e infecções múltiplas reduziram-se após o tratamento. A negativação foi significativa para Al (94,0 por cento), Anc (68,3 por cento), mas não para Tt (45,5 por cento) e foi maior para Al. A negativação não diferiu significativamente entre os tratados com mebendazol ou albendazol. A intensidade da infecção reduziu-se significativamente nos indivíduos que permaneceram positivos para Tt. Recomenda-se que o tratamento seja seletivo, administrado anualmente, de preferência com albendazole, devido ao seu custo-benefício.

Replacing oxamniquine by praziquantel against Schistosoma mansoni infection in a rural community from the sugar-cane zone of Northeast Brazil: an epidemiological follow-up

A group of 52 villagers was followed-up for three years regarding Schistosoma mansoni infection. All villagers were periodically surveyed by the Kato-Katz method. In March 1997 and March 1998 the positives were treated with oxamniquine (15-20 mg/kg), and in March 1999, with praziquantel (60 mg/kg). All infection indices decreased substantially between March 1999 and March 2000: prevalence of infection (from 32.7 percent to 21.2 percent), prevalence of moderate/heavy infection (from 7.7 percent to 1.9 percent), intensity of infection (from 23.1 epg to 7.4 epg) and reinfection (from 35.7 percent to 14.3 percent). Negativation increased from 53.8 to 82.4. An optimistic prognostic is assumed in the short term for the introduction of praziquantel in the study area

Infection by Schistosoma mansoni Sambon 1907 in the first four months of life of Biomphalaria straminea (Dunker, 1848) in Brazil

Compatibility between Schistosoma mansoni and Biomphalaria straminea when exposed to the parasite on the first four months of age was assessed for five parasitological aspects: indices of infection and mortality, duration of precercarial and cercarial periods, and rate of cercarial emission. Infections were made on molluscs from laboratory colonies, at the following ages: 8, 13, 18, 21, 53, 83 and 114 days. Two B. straminea colonies were used (Camorim, PE and Picos, PI), and one B. glabrata colony (Ressaca, MG) was used as control. The main results are as follows: (I) infection was significantly associated with mollusc age, being proportionally higher in sexually immature than in mature molluscs for the three colonies; (II) for B. straminea from Camorim, mortality did not differ significantly between infected and non-infected snails; for B. straminea from Picos significantly more deaths occurred among infected than among non-infected snails, while the opposite was observed for B. glabrata from Ressaca; (III) for the three colonies, the precercarial period was significantly shorter for immature molluscs than for mature ones; (IV) the duration of the cercarial period was extremely variable for the three colonies; (V) sexual maturity did not influence cercarial emission for the three colonies

Ecoepidemiologia da esquistossomose urbana na ilha de Itamaracá, Estado de Pernanbuco / Ecoepidemiology of urban schistosomiasis in Itamaracá Island, Pernambuco, Brazil

Introduçäo: Em 1988, 22 casos autóctones de esquistossomose foram registrados na Praia do Forte Orange, ilha de Itamaracá, Pernambuco. Todos os casos ocorreram em indivíduos de classe média/alta que veraneavam na ilha. Foi realizado estudo com o objetivo de identificar e caracterizar criadouros/focos de vetores da esquistossomose na localidade, correlacionanado os determinantes biológicos da doença com o contexto ambiental da sua ocorrência. Métodos: Foram levantados dados secundários para resgatar as características ambientais da área antes da ocupaçäo humana. O inquérito malacológico teve a duraçäo de um ano com mapeamento da área, coleta mensal e exame dos moluscos. Resultados/Conclusöes: em 1 Km de extensäo da praia, foram identificados 20 criadouros e demarcadas 28 estaçöes de coleta. Os resultados mostram a variaçäo mensal da densidade populacional de moluscos e das taxas de infecçäo, correlacionados com sazonalidade e tipos de criadouros. Destaca-se a importância desse novo perfil epidemiológico da esquistossomose em Pernambuco, relacionando o modo de ocupaçäo daquele espaço com o estabelecimento de sítios de transmissäo ativa da esquistossomose