HEALTH EDUCATION AND THE CONTROL OF UROGENITAL SCHISTOSOMIASIS: ASSESSING THE IMPACT OF THE JUMA NA KICHOCHO COMIC-STRIP MEDICAL BOOKLET IN ZANZIBAR.

Endeavours to control urogenital schistosomiasis on Unguja Island (Zanzibar) have focused on school-aged children. To assess the impact of an associated health education campaign, the supervised use of the comic-strip medical booklet Juma na Kichocho by Class V pupils attending eighteen primary schools was investigated. A validated knowledge and attitudes questionnaire was completed at baseline and repeated one year later following the regular use of the booklet during the calendar year. A scoring system (ranging from 0.0 to 5.0) measured children's understandings of schistosomiasis and malaria, with the latter being a neutral comparator against specific changes for schistosomiasis. In 2006, the average score from 751 children (328 boys and 423 girls) was 2.39 for schistosomiasis and 3.03 for malaria. One year later, the score was 2.43 for schistosomiasis and 2.70 for malaria from 779 children (351 boys and 428 girls). As might be expected, knowledge and attitudes scores for schistosomiasis increased (+0.05), but not as much as originally hoped, while the score for malaria decreased (-0.33). According to a Kolmogorov-Smirnov test, neither change was statistically significant. Analysis also revealed that 75% of school children misunderstood the importance of reinfection after treatment with praziquantel. These results are disappointing. They demonstrate that it is mistaken to assume that knowledge conveyed in child-friendly booklets will necessarily be interpreted, and acted upon, in the way intended. If long-term sustained behavioural change is to be achieved, health education materials need to engage more closely with local understandings and responses to urogenital schistosomiasis. This, in turn, needs to be part of the development of a more holistic, biosocial approach to the control of schistosomiasis.

Transmission studies of intestinal schistosomiasis in Lake Albert, Uganda and experimental compatibility of local Biomphalaria spp.

Despite ongoing preventive chemotherapy campaigns, intestinal schistosomiasis is hyper-endemic in shoreline communities living along Lake Albert, Uganda. To provide a deeper insight into the local epidemiology of Schistosoma mansoni, a variety of field-based studies were undertaken focusing upon schistosome-snail interactions and confirmation of transmission foci. Cercarial shedding patterns of field-caught Biomphalaria spp., as identified by morphology, were hourly observed over a ten day period and showed that Biomphalaria stanleyi produced significantly more cercariae than Biomphalaria sudanica. Peak production times in both species were between 12.00 and 14.00h indicating greatest infection risk from lake water exposure is during the early afternoon. Laboratory-bred snails were exposed to locally hatched miracidia and susceptibility of Biomphalaria spp. was confirmed experimentally. Biomphalaria stanleyi was a more permissive host. After ascertaining appropriate conditions for infection of laboratory mice, 28 groups of between 5 and 6 naïve mice were placed in floatation cages at four suspected shoreline transmission sites for a 30 minute period of exposure. Eight weeks later, mice (n=142) were culled and S. mansoni adult worms were retrieved from 10 animals. Taken as a whole, these observations highlight the local importance of B. stanleyi in transmission of intestinal schistosomiasis and clearly demonstrate the risk of infection on the Lake Albert shoreline. To mitigate this risk local environmental modification(s), i.e. improvement in sanitation and hygiene and control of snail populations, is needed to bolster the impact of chemotherapy-based interventions.

Evaluation and application of potential schistosome-associated morbidity markers within large-scale mass chemotherapy programmes.

A primary objective of schistosomiasis control programmes is to achieve, and hence also demonstrate, a quantifiable reduction in schistosome-associated morbidity as a consequence of chemotherapeutic intervention. Inherent within such an objective, it is necessary to define and validate direct and indirect indicators of schistosome-related morbidity. However, to define and thereby document such morbidity, and its reduction following treatment, may not be straightforward, particularly for intestinal schistosomiasis-induced morbidity, which is often not apparent in all but the most severe or chronic cases. Within all 'Schistosomiasis Control Initiative' activities, across selected sub-Saharan African countries since 2002, a range of standard and novel potential morbidity markers have been monitored and evaluated. Parasitological intensity measures, combined with haemoglobin/anaemia counts and ultrasonography, proved valuable schistosomiasis-related morbidity indicators, being both logistically practical and informative. Additional measures tested, such as albumin excretion profiles, were promising, and are subject to ongoing research, whilst some measures, such as distended stomach/umbilical circumference, anthropometrics and health questionnaires proved less reliable. These results serve to both illustrate the success of current control activities in reducing schistosome-induced morbidity, and to highlight key tools and techniques for continued application within ongoing and future mass drug administration programmes.