The effects of genital schistosoma haematobium on human papillomavirus and the development of cervical neoplasia after five years in a Zimbabwean population.

BACKGROUND: High-risk human papillomavirus (HPV) is responsible for cervical cancer and genital Schistosoma haematobium infection has been hypothesized to be an additional co-factor or even an independent risk factor for cervical neoplasia. The present study aimed to investigate the impact of schistosomiasis on HPV persistence and development of cell atypia in a group of rural Zimbabwean women with confirmed high-risk HPV. METHODS: A five-year follow-up was done among women previously included in a study on genital schistosomiasis. Women who had high-risk HPV at baseline were invited after 5 years for examination of cell atypia, genital schistosomiasis, and high-risk HPV. Both vaginal lavage samples (low-cost) and cervix brush samples (high-cost) were obtained for further analysis. RESULTS: Thirty-seven women were re-examined. Genital Schistosoma haematobium of a minimum of five years' duration was associated with the development high-grade squamous intraepithelial neoplasia, but not with persistent high-risk HPV. There was a high concordance between the brush and vaginal lavage (96.3% agreement, kappa 0.93); however, the number of beta-globin negative vaginal lavage samples was unacceptably high. CONCLUSIONS: Findings warrant an exploration in a larger longitudinal study where a vaginal swab should be explored.

The cost of a school based mass treatment of schistosomiasis in Ugu District, KwaZulu Natal, South Africa in 2012.

INTRODUCTION: The Neglected Tropical Diseases Roadmap of the WHO set targets for potential elimination as a "public health problem" for the period 2012-2020 in multiple countries in Africa, with the aim of global elimination of schistosomiasis as a "public health problem" by 2025. AIM: The purpose of the study was to estimate the cost from a provider's perspective of the Department of Health's Schistosomiasis Mass Drug Administration (MDA) in Ugu District, KwaZulu-Natal in 2012, with a view to project the costs for the entire KwaZulu Natal Province. METHODS: A total of 491 public schools and 16 independent schools in Ugu District, a predominantly rural district in KwaZulu-Natal with a total of 218 242 learners, were included in the schistosomiasis control programme. They were randomly selected from schools situated below an altitude of 300 meters, where schistosomiasis is endemic. A retrospective costing study was conducted using the provider's perspective to cost. Cost data were collected by reviewing existing records including financial statements, invoices, receipts, transport log books, equipment inventories, and information from personnel payroll, existing budget, and the staff diaries. RESULTS: A total of 15571 children were treated in 2012, resulting in a total cost of the MDA programme of ZAR 2 137 143 and a unit cost of ZAR 137. The three main cost components were Medication Costs (37%), Human Resources Cost (36%) and Capital items (16%). The total cost for treating all eligible pupils in KwaZulu-Natal will be ZAR 149 031 888. However, should the capital cost be excluded, then the unit cost will be ZAR 112 per patient and this will translate to a total cost of ZAR 121 836 288. CONCLUSIONS: Low coverage exacerbates the cost of the programme and makes a decision to support such a programme difficult. However, a normative costing study based on the integration of the programme within the Department of Health should be conducted.

Seasonal variations in Schistosoma haematobium egg excretion in school-age girls in rural KwaZulu-Natal Province, South Africa.

BACKGROUND: A predominant feature of Schistosoma haematobium infection is urinary egg excretion, and microscopic egg detection remains the accepted standard field diagnostic tool. Praziquantel is the drug of choice for schistosomiasis, and the World Health Organization recommends that it should be administered to all children >4 years of age living in schistosomiasis-endemic areas. The frequency of mass drug administration depends on the prevalence rate in the community. Urinary schistosome egg output has a day-to-day and hour-to-hour intrasubject variation. Therefore, it is important to assess possible seasonal variations in egg excretion to improve the planning of drug treatment. OBJECTIVES: To assess the influence of seasonality on urinary schistosome egg excretion in South Africa (SA). METHODS: We performed a prospective cohort study, exploring seasonal variations of S. haematobium egg excretion in 184 girls aged 10 - 12 years from randomly selected schools in a rural area of KwaZulu-Natal Province, SA. The area has a subtropical climate characterised by a cool dry season and a hot humid season. For children, water contact is higher in the latter season. At baseline, 108 girls were examined in the hot season, and 76 in the cold season. In the next year's cold season the untreated patients were re-investigated before treatment. RESULTS: There was a decrease in infection in the group initially tested in the hot season compared with the group tested in the cold season at both time points when adjusted for age and water contact (adjusted odds ratio 3.61 (95% confidence interval 1.14 - 11.44); p=0.03). CONCLUSIONS: This unique study shows that schistosomiasis prevalence determined by microscopy exhibits seasonal variation, with a higher prevalence in the hot rainy season. Precise community prevalence estimations are key in decisions to treat communities. There was significantly lower egg output in the cold season, and sampling in that season may therefore underestimate the prevalence of urinary schistosomiasis. The study indicates that sampling in SA should be done in the hot season.

Prevalence of urinary schistosomiasis and HIV in females living in a rural community of Zimbabwe: does age matter?

A cross-sectional study was conducted on 544 women living in Mupfure rural area of Zimbabwe to determine whether infection with urinary schistosomiasis is associated with HIV infection. Schistosoma haematobium infection was examined in urine samples and HIV infection was determined in sera. The prevalence of S. haematobium infection was highest (60%) in women below 20 years of age and declined to 29% in the oldest age group (test for trends, P<0.001). Overall, women infected with urinary schistosomiasis had an HIV prevalence of 33.3%, whilst women without urinary schistosomiasis had an HIV prevalence of 25.6% (chi(2), P=0.053). Women above the age of 35 years and infected with urinary schistosomiasis had a significantly higher HIV prevalence (37.5%) than those without urinary schistosomiasis (16.8%; chi(2), P<0.001).

Control of Biomphalaria pfeifferi population and schistosomiasis transmission in Ethiopia using the soap berry endod (Phytolacca dodecandra), with special emphasis on application methods.

The endod (Phytolacca dodecandra)-based schistosomiasis mansoni control project was implemented in Ethiopia between 1994 and 1999. The aim was to develop an effective, cheap and sustainable method of controlling schistosomiasis. First, different formulations of the Ethiopian endod strain 44 (E-44) were compared for potency in the laboratory. Secondly, spray and drip-feeding methods were compared for simplicity and effectiveness in the field. Lastly, the efficacy of endod powder soap was compared with the endod spray method. In Bati stream, endod powder soap was distributed to the residents every weekend at laundry sites. In Worke stream, endod was sprayed along a 1-km stretch of the stream at 3-month intervals. No endod was applied in Harbu stream. The immediate and long-term effects of endod application on the snail population and schistosomal infection were determined. Using the spray method, 100% snail mortality could be obtained, and it was simpler and more effective than the drip-feeding method. Snail mortality ranged from 20 to 100% using endod soap. There was a progressive decline in the snail population and infection in Bati stream compared with Worke stream, mainly due to sustained use of endod soap. The advantages and disadvantages of the different endod delivery systems are discussed.

Magnetic bead antigen capture enzyme-linked immunoassay in microtitre trays for rapid detection of schistosomal circulating anodic antigen.

We have developed a new magnetic bead antigen capture enzyme-linked immunoassay for the detection of schistosomal circulating anodic antigen. The assay utilizes IgG1 monoclonal antibody coated monodisperse magnetic beads in microtitre trays fitted to a special magnet. The total test time was found to be 1-2 h, using 0.05 mg beads per well. The lower detection level was 0.7 ng AWA-TCA per ml (approximately 0.07 ng CAA per ml). Validation by sera from uninfected and Schistosoma mansoni infected Africans and Norwegians resulted in an assay specificity of 100% and sensitivity was close to 90% for cases excreting more than 100 eggs per gram faeces. At such clinically relevant levels the inter-assay CV was below 10% and photometric absorbance correlated to antigen levels was nearly linear. There was a significant correlation between the magnetic bead EIA absorbance values and the titres obtained using the previously established ELISA. The new bead assay, however, was easier and less laborious because TCA pretreatment and the titration of positive results were unnecessary.

Differences in prevalence, intensity of infection and parasite-specific antibody levels do not predict different age-infection profiles.

Acquired immunity is believed to influence the age-infection profile of Schistosoma infections. We compared antibody responses against Schistosoma mansoni adult worm antigen (AWA) and soluble egg antigen (SEA) in 164 residents of two communities with different levels of infection. IgG, IgA, IgM, IgE, and IgG subclass 1 to 4 antibodies were determined by ELISA. Seventy-five of the subjects were from Harbu, an area with a prevalence of 39% and an intensity of infection of 116 eggs per gram of stool (EPG), whereas 89 subjects were from Bati, with a prevalence of 66% and intensity of infection of 256 EPG. In both communities the prevalence and the intensity of infection were highest in the age group 10-14 years, although both were significantly higher in Bati than in Harbu. Mean levels of AWA-specific IgA, IgM, IgG, IgG1 and IgG2, and of SEA-specific IgG, IgM, IgG2 and IgG3 were significantly higher in Bati than in Harbu. However, mean levels of IgE against worm and egg antigens were significantly higher in Harbu than in Bati. Significant differences were detected in the levels of IgA, IgE, IgG, IgM, IgG1 and IgG2 against AWA, and in IgE, IgM, IgG2 and IgG3 against SEA according to the place of residence. The levels of anti-AWA IgG, IgG1 and IgG2 and anti-SEA IgG, IgG1 and IgG4 were significantly associated with the intensity of infection. Anti-AWA IgM levels were associated with age, whereas sex and age had interacting effects on the levels of AWA-specific IgG1 and SEA-specific IgG and IgM. Antibody responses exhibited different age-related patterns in the two communities. This may indicate that differences in history of exposure influence the evolution of immune responses. However, the study did not support the view that differences in antibody levels between communities subject to different levels of infection result in a systematic deviation in age-infection profile (the "peak shift").

Age- and sex-related differences in antibody responses against Schistosoma mansoni soluble egg antigen in a cohort of school children in Ethiopia.

Acquired immunity is believed to be the main factor in the age-related differences in prevalence and intensity of Schistosoma infections. We studied antibody responses against S. mansoni soluble egg antigen (SEA) by ELISA in children before treatment, 5 weeks and one year after treatment. After screening for S. mansoni infection, positive children were treated with praziquantel (40 mg per kg body weight). Infection rate was significantly higher in boys younger than 12 years than in girls in the same age group. Levels of all antibody isotypes, except IgG1 (before treatment) or IgA (one year after treatment), were higher in children older or equal to 12 years than in those younger. The difference between age groups was significant for IgE, IgM, IgG3 and IgG4 (before treatment) and IgE (one year after treatment). Similarly, all antibody isotypes, except IgE, before treatment were higher in boys than in girls. At 5 weeks after treatment, IgG, IgE and IgG1 showed an increasing tendency, whereas IgM and IgG3 tended to decrease. One year after treatment, significant decreases were observed in IgG, IgG1 and IgG4 and a significant increase in IgG2 levels. The study presents further evidence for the difference in acquired immunity between younger and older children, and between boys and girls. The study also suggests that praziquantel differentially affects antibody responses against S. mansoni SEA.

The relationships between dehydroepiandrosterone sulphate (DHEAS), the intensity of Schistosoma mansoni infection and parasite-specific antibody responses. A cross-sectional study in residents of endemic communities in north-east Ethiopia.

There are speculations that the puberty-related hormone dehydroepiandrosterone sulphate (DHEAS) might influence the intensity of infection and immune responses during Schistosoma infections. We studied the relationships between DHEAS, intensity of Schistosoma mansoni infection and humoral immune responses in 135 residents of Ethiopia. Serum levels of eight antibody isotypes against worm and egg antigens were determined by ELISA. DHEAS was measured with an immunoluminometric assay. There was a significant negative correlation between serum levels of DHEAS and intensity of S. mansoni infection. A significant increase in serum levels of DHEAS in the age group 15-19 years was accompanied by a progressive decline in the intensity of infection. Peak level of DHEAS coincided with the lowest intensity of infection in the age group 20-29 years. Multiple regression analysis showed that DHEAS alone had a significant (p<0.0001) negative effect when the effect of age was removed. Age also had a significant (p<0.0001) negative effect on the intensity of infection, after removing the effect of DHEAS. The two predictive variables accounted for 34.4% of the decline in the intensity of infection. Age accounted for 24.9%, whereas DHEAS accounted for 15.2% when the effect of each of the variables was removed. DHEAS had significant negative effects on AWA-specific IgG (p=0.02) and IgG1 (p=0.018) and SEA-specific IgG1 (p=0.009), after adjusting for the effect of age.

Onchocerciasis in the Blue Nile Valley of western Ethiopia.

In a survey among 477 inhabitants of the Blue Nile Valley of western Ethiopia 182 (38%) were positive by skin snip investigation for microfilariae of Onchocerca volvulus. Of these only 23% had typical clinical signs and symptoms of onchocerciasis. The highest prevalence rate of microfilariae (84%) was found among Nilotics in the lowlands, where 50% of the children above 10 years, and 90% of adults above 30 years of age, were infected. The mean microfilarial density per skin snip was significantly higher in the high prevalence areas (14) than in the low prevalence areas (3). Positive skin snips from both hip and shoulder were found in 24% of the population, whereas 3% had microfilariae only in the shoulder and 11% only in the hip region. The mean microfilarial density in the hips (16) was double that in the shoulders (8). Ophthalmological evaluation, including slit lamp examination, was possible in 77 of the 182 cases with positive skin snips. Severe eye damage due to onchocerciasis was not observed. However, one 35 year old female had live microfilariae in the anterior chambers of both eyes.

Control of Schistosoma mansoni in the Blue Nile Valley of western Ethiopia by mass chemotherapy and focal snail control: a primary health care experience.

A simplified combination of human mass treatment with oxamniquine and focal snail control has been applied in a local Schistosoma mansoni control programme in a primary health care setting in the Dalati and Agallu Metti areas of the Ethiopian Blue Nile Valley. Teams of local health personnel and farmers did the daily work under intermittent supervision. Monthly snail surveys near the major villages disclosed a seasonal pattern with many infected snails during the dry season in upper stagnant sections of tributary rivers (1000-1200 m altitude) with favourable temperatures, and few snails in the rainy season. The highest prevalences and intensities of human infection were found in the 15-19 year age group living in the lower altitudes around 700 m. 5067 individuals (50-80% of the local population) were treated with 20-40 mg oxamniquine per kg body weight during the rainy seasons of 1985 (Dalati) and 1986 (Agallu Metti). In the Dalati area cross sectional surveys in 1985 and 1986, before and after the mass treatment, showed a reduction in prevalence from 42.4% to 11.4%, while in the Agallu Metti area a stratified random sample showed a prevalence reduction from 65.4% in 1986 to 7.8% in 1987 and a reduction in the prevalence of moderate to heavy infection (greater than 100 eggs per gram of stool) from 36.9% to 1.4%. Beginning in 1986 niclosamide was applied focally wherever infected snails were found and the monthly snail surveillance continued until 1989. As a result of this combined approach overall snail infection rates were reduced from 11.2% (Dalati) and 32% (Agallu Metti) to zero and 2% respectively. In 1989 the human prevalence was still only 8.6% in Agallu Metti. This programme has shown that it is feasible to control S. mansoni in these very remote localities through the primary health care system.

Quantitative detection of schistosomal circulating anodic antigen by a magnetic bead antigen capture enzyme-linked immunosorbent assay (MBAC-EIA) before and after mass chemotherapy.

The magnetic bead antigen capture enzyme-linked immunosorbent assay (MBAC-EIA) has been applied to detect schistosomal circulating anodic antigen (CAA) in pre- and post-treatment sera from 55 individuals in a Schistosoma mansoni control project in the Blue Nile valley of western Ethiopia. The amounts of CAA detected by this assay were positively correlated with the numbers of eggs per gram of faeces (epg). A significant reduction in CAA levels as measured by the MBAC-EIA was observed after mass chemotherapy. The sensitivity was 88-89% in clinically significant cases excreting more than 100 epg. In light infections, however, the sensitivity was lower. None of 32 uninfected Norwegian blood donors or 12 Ethiopian immigrants to Norway were positive. The specificity was thus estimated to be 100%. The test is rapid (1-2 h) and simple to perform without sophisticated equipment and could therefore, with slight modification, be used as a reliable method of diagnosis at field level in endemic areas undergoing mass chemotherapy campaigns or population surveys.

Praziquantel side effects and efficacy related to Schistosoma mansoni egg loads and morbidity in primary school children in north-east Ethiopia.

A total of 611 Schistosoma mansoni infected primary school children from three schools in north-east Ethiopia were treated with praziquantel at 40 mg/kg body weight in a single dose. Pre-treatment, 40.4% had no presenting symptoms and 30-40% had nausea, abdominal cramps and/or bloody-mucoid diarrhoea. None of the pre-treatment symptoms was related to nutritional status, intensity of S. mansoni egg excretion, or to the presence of other concomitant intestinal parasitic infections. During the first 4-6 h post-treatment observation period, 90 (14.7%) children self-presented with severe gastro-intestinal symptoms. Children who self-presented with severe symptoms had a higher mean age and mean S. mansoni egg excretion compared with children who did not self-present. The following day a total of 529 (86.6%) children, including all who self-presented during the first 4-6 h post-treatment, reported for clinical check-up and were subjected to a structured questionnaire interview on symptoms they had experienced over the time lapse following treatment. Among these, 91.5% reported one or more treatment related symptoms which were at times severe. Abdominal cramps (86.9%), diarrhoea with blood and/or mucus (49.5%), dizziness (31.2%) and vomiting (24.9%) were the most common treatment related symptoms. Skin rash with oedema were observed in four cases. Among treatment related symptoms, the combination of abdominal cramps with vomiting, bloody diarrhoea, vomiting alone and general weakness were significantly higher among the malnourished. A proportion of these symptoms increased with increasing categories of S. mansoni egg excretion before and after adjusting for nutritional status and concurrent intestinal parasitic infections. Overall, the cure rate of praziquantel, among 541 children who had stool examination 5 weeks after treatment was 83.2% and this rate decreased with increasing pre-treatment egg counts. In conclusion, most of the treatment related symptoms were mild. However, some of the objective symptoms were at times severe and may reduce drug compliance in primary health care based population chemotherapy.

Delayed reinfection of Schistosoma mansoni in the Blue Nile Valley of western Ethiopia 10 years after mass chemotherapy.

In the Blue Nile Valley of western Ethiopia a successful control programme against Schistosomiasis mansoni starting from 1985 was in 1989 interrupted by local guerrilla warfare. The control was based on human mass chemotherapy campaigns during the rainy season of 1985 and 1986 and a limited annual, focal molluscicidal activity where re-infection was demonstrated. In 1995 the area was revisited and selected schools in previously hyperinfected villages were examined for reinfection. The results were compared to re-calculated figures for the 5-19 year age group from previous pre-, per- and post-control surveys in the same localities. In 1995 prevalence rates in the 5-19 year age group had risen to 68% (Salba-Korka) and 63% (Sirba), which are very close to the 1985-1986 pre-control prevalences. Infection intensities, however, had not risen to the same degree. In Salba-Korka the 1986 pre-control geometric mean S. mansoni eggs per gram of faeces in the 5-19 year age group was 73, after mass treatment until 1989 it was close to 0, whereas in 1995 it was still only 27. In Sirba the result was similar. This might indicate a slower transmission rate after the control period than previously. The reported seasonality of transmission and the local use of the molluscicidal bark of the 'Bitza' tree might possibly have had some delaying effect.

Optimization of the Magnetic Bead Antigen Capture Enzyme Immuno Assay for the detection of circulating anodic antigens in mixed Schistosoma infections.

In the present study, simplification and adaptation of the Magnetic Bead Antigen Capture Enzyme Immuno Assay (MBAC-EIA) technique for detection of circulating anodic antigens (CAA) under field conditions was achieved. It was shown that the assay could be performed successfully within the broad temperature range of 18-37 degrees C. The slightly lower sensitivity observed at low temperatures could be adjusted for by prolonging the incubation period. Shaking the plate by hand was as good as automatic mechanical shaking, aspiration of the supernatant before the addition of conjugate was not necessary, and the use of whole blood and serum offered similar assay sensitivity. Furthermore incubation times could be considerably shortened without loss of sensitivity. A major advantage of the MBAC-EIA was that the beads, after elution of bound components, were found to be reusable. The study also showed that the sensitivity of the MBAC-EIA technique in diagnosis of schistosomiasis in a Zimbabwean community endemic for both urinary and intestinal schistosomiasis, was 94%.

Schistosomiasis in women: manifestations in the upper reproductive tract.

Female genital schistosomiasis (FGS) is a neglected disease entity which may give rise to considerable suffering among women of child-bearing age in areas where schistosomiasis (especially due to Schistosoma haematobium) is prevalent. The close relation between the vessels in genital organs and the urinary bladder enables the parasite to easily change location to virtually any organs in the female pelvic area. Symptoms concur with the anatomical location of worm pairs and their ova. Lesions of the lower female genital tract can easily be investigated by cytology, histology or direct demonstration of eggs in scrapings or biopsies whereas schistosomiasis of the upper genital tract is clinically indecipherable and less accessible for examination. In the literature there are references to FGS as a cause of infertility, complications of pregnancy, menstrual disorders, problems related to sexual intercourse, diagnostic similarities to STDs and cancer, unspecified complaints related to blood loss, chronic abdominal pain, social segregation and related psychological problems. The diagnosis of female upper genital schistosomiasis is difficult and the authors point out possible diagnostic procedures which might be helpful for further understanding of this complex entity.

Female genital schistosomiasis due to Schistosoma haematobium. Clinical and parasitological findings in women in rural Malawi.

A total of 51 women with urinary schistosomiasis haematobium were examined in order to identify diagnostic indicators for female genital schistosomiasis (FGS). Patients were selected at random from the outpatient department of the Mangochi District Hospital, Malawi. The medical histories were recorded according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination including colposcopy and photographic documentation of lesions. Microscopy of genital biopsies revealed that 33 of the 51 women had S. haematobium ova in cervix, vagina and/or vulva in addition to the presence of ova in urine. The most sensitive diagnostic procedure was beside microscopic examination of a wet cervix biopsy crushed between two glass slides, which revealed 25 of the 33 genital infections. There was a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. Women with FGS had significantly more tumours in the vulva than women with schistosomiasis limited to the urinary tract. Most of the observed genital pathology could easily be identified by the naked eye, but colposcopic examination yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches. Few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova in genital tissue. Husbands of infertile women with FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis. This, together with the finding that the majority of the divorced women had FGS, indicates that the manifestation of this disease may have implications for the marital and sexual life of the affected women.

Urine reagent strips for diagnosis of schistosomiasis haematobium in women of fertile age.

Hematuria, proteinuria and leukocyturia were semiquantitatively assessed by reagent strips in single morning urine of women of fertile age visiting the outpatient department of the Mangochi district hospital, Malawi. This was part of a diagnostic approach to female genital schistosomiasis (FGS). In 51 women ova of Schistosoma haematobium were detected in urine by a filtration technique. In 33 of these women ova were also present in genital tissue as demonstrated by microscopic examination of biopsies. In 209 women no ova were found in the single urine filtered. There were significantly higher scores for hematuria, proteinuria and leukocyturia as well as of the combined reagent strip index (RSI) in egg-excreting than in egg-negative women. The sensitivity of a single hematuria, proteinuria and leukocyturia reading was 98, 84 and 73%, respectively. However, the respective specificity was only 24, 22 and 23%. The best prediction of urinary schistosomiasis was achieved by a +2 score for hematuria, of which the sensitivity was 94% and the specificity was 61%. The high false-positive rates can probably be explained by contamination of urine by vaginal secretion. Moreover, cases of schistosomiasis have probably been overlooked because only a single morning urine sample was examined. The total absence of hematuria, proteinuria and leukocyturia, however, may be used to rule out heavy infections in community surveys. There was no difference in reagent strip scores between women with genital and urinary schistosomiasis as compared with those with urinary tract lesions alone. Thus urine analysis reagent strip readings do not help to discriminate between S. haematobium infected women with and without FGS.

Diagnosis of female genital schistosomiasis by indirect disease markers: determination of eosinophil cationic protein, neopterin and IgA in vaginal fluid and swab eluates.

Based on assumptions about the pathophysiology of egg-related lesions in the lower reproductive tract, putative indirect disease markers were investigated in vaginal fluids from 54 Malawi adolescent girls and women infected with S. haematobium. These women received a careful gynecological examination during which biopsies were taken from the cervix, and, if present, also from suspicious lesions in the vagina and the vulva. If the biopsies, either in wet crushed preparations or in histological sections, contained eggs the patients were considered to have female genital schistosomiasis (FGS; n = 33). The remainder (n = 21) were classified as having urinary schistosomiasis only. Eosinophil cationic protein (ECP), a cytotoxic granule protein of eosinophils, neopterin, a second messenger molecule generated during the activation of macrophages, and IgA as an indicator of local B-cell activation were quantitatively determined in vaginal fluid. To clarify the origin of ECP, this protein was also looked for in histological sections by an immunohistochemical method. In order to explore whether such disease markers can be detected after absorption to a tampon-like material, ECP and IgA were also assessed after elution from a non-porous, polypropylene fibre web impregnated with vaginal fluid. The concentration of ECP in vaginal fluid and the degree of immunohistochemical staining in histological sections were significantly higher in patients with FGS than in women with urinary schistosomiasis only. The amount of ECP detected in histological sections correlated to the number of eggs/mm2 of compressed genital tissue (rho = 0.36, P = 0.02), and the concentration of ECP in vaginal fluid correlated to the concentration of neopterin as well as to that of IgA (rho = 0.52, P = 0.004 and rho = 0.37, P = 0.02, respectively). Median neopterin concentration in vaginal fluid was also higher in the FGS group, but the difference was not statistically significant. ECP could also be detected in eluates from impregnated fibre webs, but the concentration was approximately one power of 10 less than in the original vaginal fluid. These results demonstrate that indicators of immunological mechanisms related to the egg-granuloma might be useful as indirect disease markers for women with FGS if assessed in vaginal washings or swab eluates.