Hepatosplenic morbidity due to Schistosoma mansoni in schoolchildren on Ukerewe Island, Tanzania.

The study was conducted to assess infection intensity and morbidity due to Schistosoma mansoni in schoolchildren on Ukerewe Island in Lake Victoria, Tanzania, East Africa. Three hundred and sixty pupils who have never been treated previously were enrolled (180 males/180 females, age 6-17 years [median 10 years]) in three different schools of the island. Double stool samples were collected from each pupil and egg excretion was classified according to WHO recommendations. Ultrasound investigations were performed in accordance with the WHO Niamey-Belo-Horizonte protocol. Male (112/180, 62.2%) and female (104/180; 57.7%) pupils were infected (difference, not significant [n.s.]). In the positive 216 cases, egg excretion varied from 1 to 2,440 eggs per gramme stool (epg) [median 165 epg]. There were 69/216 (31.9%) who had a low grade, 105/216 (53.2%) had a moderate and 42/216 (14.8%) had a heavy infection. There was no significant difference between male and female sex nor with regard to age groups. There were 354/360 children who underwent sonography: 321 (90.7%) had splenomegaly, 316 (89.3%) showed a left lobe and 109 (30.9%) had a right lobe hepatomegaly. Overt signs of portal fibrosis (PF) were present in 19 children (5.4%) out of whom 11 presented with echogenic thickening of peripheral portal and 8 with thickening of central portal branches. Non-specific portal wall changes were seen in 6 children (1.7%). Association of PF to quantitative egg excretion was not seen (median in PF, 172 epg vs. median in non PF, 168 epg; difference, n.s.). Portal vein dilatation was seen in 101/354 (28.5%) cases. In Ukerewe, the prevalence of S. mansoni infection and infection intensity in children is high, yet overt hepatic morbidity is low as compared to other endemic foci. Non-specific ultrasonographic abnormalities including hepatosplenomegaly and portal vein dilatation were seen frequently but the fraction attributable to schistosomiasis is difficult to assess.

Molecular epidemiology and phylogeography of Schistosoma mansoni around Lake Victoria.

Intestinal schistosomiasis continues to be a major public health problem in sub-Saharan Africa, and is endemic in communities around Lake Victoria. Interest is growing in the molecular evolution and population genetic structure of Schistosoma mansoni and we describe a detailed analysis of the molecular epidemiology and phylogeography of S. mansoni from Lake Victoria. In total, 388 cytochrome oxidase 1 (COI) sequences were obtained from 25 sites along the Ugandan, Tanzanian and Kenyan shorelines of Lake Victoria, and 122 unique barcodes were identified; 9 corresponded to previously discovered barcodes from Lakes Victoria and Albert. A subset of the data, composed of COI sequences from miracidia from 10 individual children, was used for population genetics analyses; these results were corroborated by microsatellite analysis of 4 isolates of lab-passaged adult worms. Overall, 12 barcodes were found to be shared across all 3 countries, whereas the majority occurred singly and were locally restricted. The population genetics analyses were in agreement in revealing high diversity at the level of the human host and negligible population structuring by location. The lack of correlation between genetic distance and geographical distance in these data may be attributed to the confounding influence of high intra-individual diversity as well as human migration between communities.

Performance of circulating cathodic antigen (CCA) urine-dipsticks for rapid detection of intestinal schistosomiasis in schoolchildren from shoreline communities of Lake Victoria.

ABSTRACT: For disease surveillance and mapping within large-scale control programmes, RDTs are becoming popular. For intestinal schistosomiasis, a commercially available urine-dipstick which detects schistosome circulating cathodic antigen (CCA) in host urine is being increasingly applied, however, further validation is needed. In this study, we compared the CCA urine-dipstick test against double thick Kato-Katz faecal smears from 171 schoolchildren examined along the Tanzanian and Kenyan shorelines of Lake Victoria. Diagnostic methods were in broad agreement; the mean prevalence of intestinal schistosomiasis inferred by Kato-Katz examination was 68.6% (95% confidence intervals (CIs) = 60.7-75.7%) and 71.3% (95% CIs = 63.9-78.8%) by CCA urine-dipsticks. There were, however, difficulties in precisely 'calling' the CCA test result, particularly in discrimination of 'trace' reactions as either putative infection positive or putative infection negative, which has important bearing upon estimation of mean infection prevalence; considering 'trace' as infection positive mean prevalence was 94.2% (95% CIs = 89.5-97.2%). A positive association between increasing intensity of the CCA urine-dipstick test band and faecal egg count was observed. Assigning trace reactions as putative infection negative, overall diagnostic sensitivity (SS) of the CCA urine-dipstick was 87.7% (95% CIs = 80.6-93.0%), specificity (SP) was 68.1% (95% CIs = 54.3-80.0%), positive predictive value (PPV) was 86.1% (95% CIs = 78.8-91.7%) and negative predictive value (NPV) was 71.1% (95% CIs = 57.2-82.8%). To assist in objective defining of the CCA urine-dipstick result, we propose the use of a simple colour chart and conclude that the CCA urine-dipstick is a satisfactory alternative, or supplement, to Kato-Katz examination for rapid detection of intestinal schistosomiasis.

Community's willingness to pay for a school-based chemotherapy programme to control morbidity due to schistosomiasis and soil-transmitted helminthiasis in children in rural Tanzania.

A cross-sectional questionnaire survey was conducted on a random sample of 523 households having at least one child attending primary school in 3 villages in Buchosa Division, Sengerema District, Tanzania. The aim was to determine the community's willingness to pay (WTP) for a school-based chemotherapy programme to control morbidity due to schistosomiasis and soil-transmitted helminthiasis (STH) in schoolchildren and identify socio-economic and cultural factors influencing community's WTP. Results showed that households WTP for a school-based chemotherapy programme varied from Tanzanian Shillings (TShs.) 0-20,000 (US dollars 0-25) per child per year. The community's WTP (median of households WTP) was TSh. 1,000 (US dollars 1.25). The community was also willing to pay extra TSh.100 (US dollars 0.125) per year to cover for the cost of schoolchildren whose parents were unable to pay or who could pay less than the community's WTP. Age of household head and number of schoolchildren in a household had a negative effect on the household's willingness to pay. Households with children in expensive schools had high willingness to pay for the intervention package to control worms in their children. This was also observed in households keeping animals (cattle, goats, sheep, chiken, ducks) and those who cultivated a number of cash crops.

Predicting the distribution of urinary schistosomiasis in Tanzania using satellite sensor data.

In this paper, remotely sensed (RS) satellite sensor environmental data, using logistic regression, are used to develop prediction maps of the probability of having infection prevalence exceeding 50%, and warranting mass treatment according to World Health Organization (WHO) guidelines. The model was developed using data from one area of coastal Tanzania and validated with independent data from different areas of the country. Receiver operating characteristic (ROC) analysis was used to evaluate the model's predictive performance. The model allows reasonable discrimination between high and low prevalence schools, at least within those geographical areas in which they were originally developed, and performs reasonably well in other coastal areas, but performs poorly by comparison in the Great Lakes area of Tanzania. These results may be explained by reference to an ecological zone map based on RS-derived environmental data. This map suggests that areas where the model reliably predicts a high prevalence of schistosomiasis fall within the same ecological zone, which has common intermediate-host snail species responsible for transmission. By contrast, the model's performance is poor near Lake Victoria, which is in a different ecological zone with different snail species. The ecological map can potentially define a template for those areas where existing models can be applied, and highlight areas where further data and models are required. The developed model was then used to provide estimates of the number of schoolchildren at risk of high prevalence and associated programme costs.

Evolutionary relationships and biogeography of Biomphalaria (Gastropoda: Planorbidae) with implications regarding its role as host of the human bloodfluke, Schistosoma mansoni.

The wide geographic distribution of Schistosoma mansoni, a digenetic trematode and parasite of humans, is determined by the occurrence of its intermediate hosts, freshwater snails of the genus Biomphalaria (Preston 1910). We present phylogenetic analyses of 23 species of Biomphalaria, 16 Neotropical and seven African, including the most important schistosome hosts, using partial mitochondrial ribosomal 16S and complete nuclear ribosomal ITS1 and ITS2 nucleotide sequences. A dramatically better resolution was obtained by combining the data sets as opposed to analyzing each separately, indicating that there is additive congruent signal in each data set. Neotropical species are basal, and all African species are derived, suggesting an American origin for the genus. We confirm that a proto-Biomphalaria glabrata gave rise to all African species through a trans-Atlantic colonization of Africa. In addition, genetic distances among African species are smaller compared with those among Neotropical species, indicating a more recent origin. There are two species-rich clades, one African with B. glabrata as its base, and the other Neotropical. Within the African clade, a wide-ranging tropical savannah species, B. pfeifferi, and a Nilotic species complex, have both colonized Rift Valley lakes and produced endemic lacustrine forms. Within the Neotropical clade, two newly acquired natural hosts for S. mansoni (B. straminea and B. tenagophila) are not the closest relatives of each other, suggesting two separate acquisition events. Basal to these two species-rich clades are several Neotropical lineages with large genetic distances between them, indicating multiple lineages within the genus. Interesting patterns occur regarding schistosome susceptibility: (1) the most susceptible hosts belong to a single clade, comprising B. glabrata and the African species, (2) several susceptible Neotropical species are sister groups to apparently refractory species, and (3) some basal lineages are susceptible. These patterns suggest the existence of both inherent susceptibility and resistance, but also underscore the ability of S. mansoni to adapt to and acquire previously unsusceptible species as hosts. Biomphalaria schrammi appears to be distantly related to other Biomphalaria as well as to Helisoma, and may represent a separate or intermediate lineage.

Anaemia in schoolchildren in eight countries in Africa and Asia.

OBJECTIVE: To report on the haemoglobin concentrations and prevalence of anaemia in schoolchildren in eight countries in Africa and Asia. DESIGN: Blood samples were collected during surveys of the health of schoolchildren as a part of programmes to develop school-based health services. SETTING: Rural schools in Ghana, Indonesia, Kenya, Malawi, Mali, Mozambique, Tanzania and Vietnam. SUBJECTS: Nearly 14 000 children enrolled in basic education in three age ranges (7-11 years, 12-14 years and > or =15 years) which reflect the new UNICEF/WHO thresholds to define anaemia. RESULTS: Anaemia was found to be a severe public health problem (defined as >40% anaemic) in five African countries for children aged 7-11 years and in four of the same countries for children aged 12-14 years. Anaemia was not a public health problem in the children studied in the two Asian countries. More boys than girls were anaemic, and children who enrolled late in school were more likely to be anaemic than children who enrolled closer to the correct age. The implications of the four new thresholds defining anaemia for school-age children are examined. CONCLUSIONS: Anaemia is a significant problem in schoolchildren in sub-Saharan Africa. School-based health services which provide treatments for simple conditions that cause blood loss, such as worms, followed by multiple micronutrient supplements including iron, have the potential to provide relief from a large burden of anaemia.

Age patterns in stunting and anaemia in African schoolchildren: a cross-sectional study in Tanzania.

OBJECTIVE: To describe the nutritional status of schoolchildren from a rural area of Tanzania, with a particular emphasis on older adolescents to determine the timing of the growth spurt and differences by sex. DESIGN: A cross-sectional survey using a randomly selected sample. SUBJECTS: Six thousand eight hundred and one children aged 7-18 y randomly selected from those enrolled in standards 2-5 in 59 primary schools in Magu District, Tanzania. RESULTS: Overall, 52.5% of children were stunted and 43.0% were underweight, with significantly more boys stunted and underweight than girls. Z-scores of height-for-age for both boys and girls decreased progressively between 7 and 12 y. After 12 y the height-for-age z-scores of girls show a marked upturn, whilst z-scores for boys continue to decrease throughout the school-aged years until 16 y when a slight upturn is observed. Anaemia (Hb<120 g/L) was present in 62.6% of children, with the prevalence decreasing with age. Anaemia improved throughout the school years for boys, but did not for girls. Age, sex and hookworm infection were significant predictors of anaemia. CONCLUSION: Stunting and anaemia are exceptionally common conditions in African schoolchildren. The findings highlight important differences between boys and girls, which are suggestive of compensatory growth at 12 y for girls and at 16 y for boys, although it remains unclear whether boys will catch up in height at older ages. SPONSORSHIP: Funding was provided by the Wellcome Trust. European Journal of Clinical Nutrition (2000) 54, 36-40

The performance of school-based questionnaires of reported blood in urine in diagnosing Schistosoma haematobium infection: patterns by age and sex.

This study investigates the performance of school-based questionnaires of reported blood in urine as an indicator of the prevalence of Schistosoma haematobium infection in schools and the presence of infection in individuals. In most schools (87%), the prevalence of reported blood in urine underestimates the prevalence of S. haematobium infection. Predictive value analysis suggests that a threshold of 30% reported blood in urine would identify most of the high prevalence schools (i.e. those with 50% or more children infected with S. haematobium). Although the prevalence of S. haematobium infection was greater in males than females, girls reported a lower prevalence of blood in urine than boys even at comparable levels of infection. Reported blood in urine in females was more specific (identifying 10% more uninfected girls than the sign in boys), but was far less sensitive (identifying less than 20% of infected girls than boys). The sensitivity of reported blood in urine was also related to age, being significantly lower in girls over 14 years of age. The proportion of infected children who reported blood in urine was also lower in schools where the prevalence of reported blood in urine is less than 30%. The results suggest that the selective treatment of children based on reported blood in urine in low prevalence schools would miss a high proportion of infected children, particularly girls. It remains unclear whether other rapid assessment techniques, such as the use of reagent strips, would offer greater cost-effectiveness.

Patterns of concurrent hookworm infection and schistosomiasis in schoolchildren in Tanzania.

A cross-sectional study of 6897 schoolchildren in 59 out of the 155 primary schools in Magu District on the shores of Lake Victoria, Tanzania, was undertaken in 1997 to determine the prevalence of single- and multiple-species helminth infection. Schistosoma haematobium, hookworm (primarily Necator americanus) and S. mansoni were the most common helminth species infecting schoolchildren in the district. The prevalences of Ascaris lumbricoides and Trichuris trichiura were negligible (< 1%). Anaemia and stunting were highly prevalent and widespread. Hookworm and S. mansoni occurred more frequently in multiple infections with other helminths than as single-species infections, but triple-species infection was rare. Analysis of the frequency distribution of infection amongst schools showed that prevalences of S. haematobium and hookworm tended to be normally distributed, with medians 75% and 45%, respectively, while the distribution of S. mansoni was markedly skewed such that only 17% schools had a prevalence greater than 20%. An inverse association between S. mansoni and S. haematobium was observed. Geographical information system (GIS) analysis indicated that S. mansoni infection was highly prevalent only along the shore of Lake Victoria, whilst S. haematobium was homogeneously prevalent everywhere except the lakeshore. This pattern appears to reflect the distribution of schistosome species-specific snail intermediate hosts. The results imply that joint treatment for hookworm infection and schistosomiasis would be beneficial throughout the district.

Control of Schistosoma haematobium morbidity on Pemba Island: validity and efficiency of indirect screening tests.

Four indirect screening methods for the detection of Schistosoma haematobium morbidity are compared (history of haematuria, visual haematuria, and microhaematuria at the 1+ and 2+ positivity limit by reagent strips) in terms of their diagnostic performance under conditions of progressive decrease in prevalence of infection, intensity and risk of morbidity as a result of repeated schistosomiasis control programmes on Pemba Island, United Republic of Tanzania. The results show that the sensitivity of a history of haematuria was higher (71%) in children but lower in adults (40%), similar to the findings for visual haematuria in children (60%) and adults (40%) at baseline. However, visual haematuria had a higher specificity, positive predictive value, and efficiency than a history of haematuria in both children and adults. Microhaematuria at the 1+ positivity limit (by reagent strips) had the highest sensitivity of all the methods investigated, but the lowest specificity, positive predictive value, and efficiency. Quantitatively, the indirect methods tended to increase in specificity, negative predictive value, and efficiency during the course of the intervention programme. In contrast, positive predictive value tended to decrease, while the sensitivity remained fairly stable. Overall, these findings suggest that a history of haematuria and/or visual haematuria are appropriate methods for preliminary screening of communities to identify those at risk of morbidity. Thereafter, microhaematuria (1+ positivity limit) may be the more appropriate method for targeting intervention at the individual level.

The relationship between prevalence of Schistosoma haematobium infection and different morbidity indicators during the course of a control programme on Pemba Island.

A long-term schistosomiasis control programme was initiated on Pemba Island, Tanzania in 1986 with the aim of eliminating morbidity due to Schistosoma haematobium infection. The programme used haematuria as a community indicator of morbidity for surveillance and for identifying individuals for selective population chemotherapy. Analysis of the first 3 evaluation studies showed that the prevalence of microhaematuria was linearly related to the prevalence of infection, and that visually detectable haematuria was a marker of the intensity of infection and risk of morbidity in a community. These relationships remained consistent during repeated community-based chemotherapy, suggesting that measures of haematuria may be useful tools for surveillance.

A new approach to morbidity risk assessment in hookworm endemic communities.

The relationship between paired hookworm prevalence and mean intensity of infection data from geographically defined communities was examined. The results show that, in spite of major socio-economic and environmental differences between communities, the relationship is consistent and non-linear. A generalized value of k (the exponent of the negative binomial distribution) for hookworms was estimated to be 0.34, which is consonant with previous estimates from cross-sectional data. Maximum likelihood analysis indicates that the severity of hookworm aggregation in humans has an inverse relationship to mean worm burden which is less marked than for Ascaris lumbricoides. A simple model, based on published estimates of hookworm burdens associated with hookworm anaemia, was used to predict prevalence of morbidity from prevalence of infection data for Tanzania, Kenya and Zambia. Predictions correspond to the observation that hookworm anaemia is highly focal, and largely coastal, in distribution. These analyses suggest that locality-targeting of chemotherapy is particularly appropriate for the control of hookworm morbidity.

The molluscicidal activity of seed pods of Swartzia madagascariensis on Marisa cornuarietis.

The molluscicidal potency of ground seed pods of Swartzia madagascariensis was tested in the laboratory against Marisa cornuarietis, a well known competitor and/or predator of pulmonate intermediate hosts of schistosomiasis. Results showed that a minimum concentration of 1.6g ground pods/1 was required to cause 100% mortality in M. cornuarietis. This concentration was by far over and above what is required (ie, 100 mg ground pods/1) to kill 10% of the pulmonate hosts of schistosomiasis. It seems that the application of S. madagascariensis at a concentration inimical to pulmonates (ie, 100 mg ground ponds/1 or slightly higher) in habitats where M. cornuarietis is introduced may not adversely affected to competitor snail population. Hence, the prospect of using S. madagascariensis in conjunction with M. cornuarietis against pulmonate snail hosts is conceived and tentatively recommended.

An improved kit for culturing clean nematode, larvae from faeces.

A kit for rapid recovery of clean hookworm and Strongyloides stercoralis larvae from faeces was devised. It consists of a 2.0dl perspex cup shaped container 35 x 30 x 24mm in size. A horse shoe stirrup aluminium sheet 54mm long and 20mm wide is inserted into the container so that the free ends stand at the bottom of the apparatus. The back of the stirrup carries a plastic disc 30mm in diameter through which two adjacent crescent shaped openings are cut. A strip of filter paper 40 x 20mm in size passes through the crescent openings astride the stirrup and its loose ends are bound together by means of a stapler. When the kit is assembled, the disk fits firmly in the middle of the container dividing it into lower and upper chambers. The staples free ends of the filter paper hang immersed into water in the lower chamber of the apparatus. A faecal sample is smeared on the upper part of the filter paper. Nematode larvae, if present, crawl from the faeces down the damp filter paper into the water at the bottom of the container.

Transmission of urinary schistosomiasis in Sukumaland, Tanzania. 1. Snail infection rates and incidence of infection in school children.

Seasonal density fluctuations of Bulinus nasutus populations with accompanying Schistosoma haematobium infection rates in relation to rainfall and habitat water volumes were studied at Ukiriguru, Mwanza, Tanzania. Alongside the snail investigations, 50 school children initially negative for urinary schistosomiasis were examined regularly to determine seasonal incidence rates for the infection. Of the 17,646 B. nasutus collected in 2 years, 156 (0.88%) were found shedding cercariae. Snail populations fluctuated seasonally as influenced by rainfall through its effects on habitat water volume. Monthly snail infection rates ranged from 0.09% to 3.19% and were highest in February and March, at the time of the short dry period. Monthly incidence of S. haematobium in school children ranged between 2.6% and 12.5%, being highest in April and May. There was a significant linear association between monthly snail infection rates and S. haematobium incidence rates in school children (r2s = 0.65 in 1982/83; r2s = 0.87 in 1983/84) suggesting that the maximum transmission period for urinary schistosomiasis in the area occurs during the short dry period, sometime in February/March so that most of the infections in the community would be detected in April/May.

The host-parasite relationship between the Saudi Arabian Schistosoma mansoni and its intermediate and definitive hosts. 3. Effects of duration of exposure and cercarial concentration on the infection of mice by S. mansoni cercariae.

The percentage infection rate, worm burden and worm recovery rate in mice increased with an increase in the duration of exposure to cercariae. However, mice exposed to cercariae for 4 min had the same worm burden and worm recovery rates as those exposed for 16 min. Mice exposed to 80 and 160 cercariae each exhibited the highest percentage infection rates. The worm burden was highest in mice exposed to 160 cercariae each, while the worm recovery rate was highest in those exposed to 80 cercariae per mouse.

The host-parasite relationship between the Saudi Arabian Schistosoma mansoni and its intermediate and definitive hosts. 1. S. mansoni and its local snail host Biomphalaria arabica.

The infectivity of miracidia of the Saudi Arabian isolate of S. mansoni in Bi. arabica was found to be influenced by such factors as miracidial dose, water temperature and salinity. The pre-patent period of S. mansoni in Bi. arabica was 30 to 33 days. Miracidial dose had no effect on the mortality of snails during the pre-patent period. The infection rate increased as the miracidial dose was increased. However, cercarial production was highest in snails exposed to 1 miracidium each and decreased as the miracidial dose was increased. Water temperature during exposure had an influence on the mortality, infection rate and cercarial production in Bi. arabica exposed to S. mansoni miracidia. The infection rate was highest in snails exposed at 28 degrees and 34 degrees C. No infection of Bi. arabica occurred at the temperature of 10 degrees C. The number of cercariae per snail per day was highest in snails exposed to miracidia at 34 degrees C. It was demonstrated that salinity had an influence on the infection of Bi. arabica with miracidia of S. mansoni. The infection rate in snails decreased as the salinity increased up to 4,500 mg/l, above which no infection occurred. The daily pattern of cercarial emergence was rhythmic, whereby 94.7% of the total daily production was released within 6 h from infected Bi. arabica, with a peak between 11 a.m. and 1 p.m.