Factors contributing to reinfection with schistosomiasis japonica after treatment in the lake region of China

Unprotected water sources and low latrine coverage are contributing factors to persistent hotspots for schistosomiasis in western Kenya

BACKGROUND

Evidence indicates that whereas repeated rounds of mass drug administration (MDA) programs have reduced schistosomiasis prevalence to appreciable levels in some communities referred to here as responding villages (R). However, prevalence has remained high or less than anticipated in other areas referred to here as persistent hotspot villages (PHS). Using a cross-sectional quantitative approach, this study investigated the factors associated with sustained high Schistosoma mansoni prevalence in some villages despite repeated high annual treatment coverage in western Kenya.

METHOD

Water contact sites selected based on observation of points where people consistently go to collect water, wash clothes, bathe, swim or play (young children), wash cars and harvest sand were mapped using hand-held smart phones on the Commcare platform. Quantitative cross-sectional surveys on behavioral characteristics were conducted using interviewer-based semi-structured questionnaires administered to assess water usage/contact patterns and open defecation. Questionnaires were administered to 15 households per village, 50 pupils per school and 1 head teacher per school. One stool and urine sample was collected from 50 school children aged 9-12 year old and 50 adults from both responding (R) and persistent hotspot (PHS) villages. Stool was analyzed by the Kato-Katz method for eggs of S. mansoni and soil-transmitted helminths. Urine samples were tested using the point-of-care circulating cathodic antigen (POC-CCA) test for detection of S. mansoni antigen.

RESULTS

There was higher latrine coverage in R (n = 6) relative to PHS villages (n = 6) with only 33% of schools in the PHS villages meeting the WHO threshold for boy: latrine coverage ratio versus 83.3% in R, while no villages met the girl: latrine ratio requirement. A higher proportion of individuals accessed unprotected water sources for both bathing and drinking (68.5% for children and 89% for adults) in PHS relative to R villages. In addition, frequency of accessing water sources was higher in PHS villages, with swimming being the most frequent activity. As expected based upon selection criteria, both prevalence and intensity of S. mansoni were higher in the PHS relative to R villages (prevalence: 43.7% vs 20.2%; P < 0.001; intensity: 73.8 ± 200.6 vs 22.2 ± 96.0, P < 0.0001), respectively.

CONCLUSION

Unprotected water sources and low latrine coverage are contributing factors to PHS for schistosomiasis in western Kenya. Efforts to increase provision of potable water and improvement in latrine infrastructure is recommended to augment control efforts in the PHS areas.

Host determinants of reinfection with schistosomes in humans: a systematic review and meta-analysis

Background

Schistosomiasis is still a major public health burden in the tropics and subtropics. Although there is an effective chemotherapy (Praziquantel) for this disease, reinfection occurs rapidly after mass drug administration (MDA). Because the entire population do not get reinfected at the same rate, it is possible that host factors may play a dominant role in determining resistance or susceptibility to reinfection with schistosomes. Here, we systematically reviewed and meta-analyzed studies that reported associations between reinfection with the principal human-infecting species (S. mansoni, S. japonicum and S. haematobium) and host socio-demographic, epidemiological, immunological and genetic factors.

Methodology/Principal Findings

PubMed, Scopus, Google Scholar, Cochrane Review Library and African Journals Online public databases were searched in October 2013 to retrieve studies assessing association of host factors with reinfection with schistosomes. Meta-analysis was performed to generate pooled odds ratios and standardized mean differences as overall effect estimates for dichotomous and continuous variables, respectively. Quality assessment of included studies, heterogeneity between studies and publication bias were also assessed. Out of the initial 2739 records, 109 studies were included in the analyses, of which only 32 studies with 37 data sets were eligible for quantitative data synthesis. Among several host factors identified, strong positive association was found with age and pre-treatment intensity, and only slightly for gender. These factors are major determinants of exposure and disease transmission. Significant positive association was found with anti-SWA IgG4 level, and a negative overall effect for association with IgE levels. This reconfirmed the concept that IgE/IgG4 balance is a major determinant of protective immunity against schistosomiasis. Other identified determinants were reported by a small number of studies to enable interpretation.

Conclusions

Our data contribute to the understanding of host-parasite interaction as it affects reinfection, and is a potential tool to guide planning and tailoring of community interventions to target high-risk groups.

One of the major challenges of schistosomiasis control is that disease prevalence reverts to baseline levels after mass drug administration due to high rate of reinfection. Host factors play a major role in determining resistance or susceptibility to reinfection with schistosomiasis and other diseases. We systematically searched and analyzed studies that identified potential host determinants of reinfection with schistosomes. Among demographic variables, age but not gender was strongly associated with reinfection with schistosomes. Pretreatment infection intensity was also identified as a major determinant of reinfection. Positive association with IgG4 levels and negative association with IgE levels reconfirmed the notion that IgE/IgG4 balance is the major factor controlling protective immunity against schistosomiasis. Other factors were reported by few studies to allow correct inferences. These results contribute to our understanding of host-parasite relationship as it affects reinfection, and will be useful for planning and targeting the limited resources for intervention on high-risk groups.

Effect of mefloquine administered orally at single, multiple, or combined with artemether, artesunate, or praziquantel in treatment of mice infected with Schistosoma japonicum

The purpose of the study is to explore the efficacy of mefloquine administered orally at single, multiple doses, or in combination with artesuante, artemether, or praziquantel in mouse--Schistosoma japonicum model. A total of 205 mice were divided into 4 batches and each batch of mice was infected percutaneously with 40 S. japonicum cercariae for 35 days. The infected mice were treated orally with mefloquine at single doses, multiple daily doses, or combined with artesunate, artemether, or praziquantel, while infected but untreated mice served as control. All treated animals were killed 4 weeks post-treatment for assessment of effect. When infected mice were treated orally with mefloquine at single or multiple daily doses under the same total dose levels, the tendency to decrease the efficacy was seen. Particularly, when a lower single dose of 100 mg/kg was divided equally into five daily doses of 20 mg/kg, the efficacy decreased statistically significant (P<0.05), i.e., the total worm and female worm reductions of 67.9% and 73.4% decreased to 31.3% and 30.3%, respectively. In infected mice treated with mefloquine or artesuante at a single dose of 100 mg/kg, a moderate effect against schistosomes was observed. No further significant reduction of total and female worm burdens was seen, when the two drugs combined together at the same dose level. On the other hand, administration of mefloquine combined with artesunate at single dose of 50 mg/kg, which exhibited no effect against schistosomes, resulted in significant reduction of total and female worm burdens in comparison with the groups treated with mefloquine and artesunate alone at the same dose level. Similar results were observed in treatment of infected mice with mefloquine in combination with artemether at the smaller dose of 50 mg/kg. The total worm burden was significantly lower than that of control and the female worm burden was also significant lower than that of groups treated with mefloquine and artemether alone. Interestingly, in administration of mefloquine 100 mg/kg combined with artemether 100 mg/kg to the infected mice, all female worms were killed and the total worm burden was also statistically significant lower than that of groups treated with either drug alone. Finally, when infected mice were treated with mefloquine combined with prazqiuatel at single dose of 50 mg/kg, no apparent improvement in efficacy was seen. Administration of mefloquine 100 mg/kg combined with praziquantel 100 mg/kg, only the difference of female worm burdens between praziquantel group and combined treatment group was statistically significant. The results indicate that under the same dose level of mefloquine, the efficacy of single dose is superior to that of multiple daily doses; mefloquine combined with artesunate or artemether at an invalid or moderate effective dose may show synergistic effect, especially the effect against female worms; no prominent synergistic effect is observed, when the similar dose level of mefloquine in combination with praziquantel.

Analysis of complex patterns of human exposure and immunity to Schistosomiasis mansoni: the influence of age, sex, ethnicity and IgE

Background

Numerous factors may influence Schistosoma infection intensity and prevalence within endemic communities, including exposure-related factors such as local environment and behaviour, and factors relating to susceptibility to infection such as immunology and genetics. While animal studies performed in the laboratory can be tightly controlled, human populations are highly heterogeneous, varying according to demographic characteristics, genetic background and exposure to infection. The heterogeneous nature of human water contact behaviour in particular makes it difficult to distinguish between a lack of cercarial exposure and reduced susceptibility to infection as the cause for low levels of infection in the field.

Methods and Principal Findings

In this study we investigate risk factors for Schistosoma mansoni infection in a rural Ugandan fishing community receiving treatment as part of a multi-disciplinary longitudinal reinfection study. More specifically, we examine the influence that age, sex and ethnic background have on susceptibility to reinfection after anti-helminth drug treatment, but use individual estimates of cercarial exposure and multivariable methods in an attempt to remove noise created by environmental and behavioural heterogeneities. We then investigate whether schistosome-specific IgE immune responses could account for any remaining variations in susceptibility to reinfection. Our findings suggest that observed ethnic- and sex-related variations in S. mansoni reinfection were due to variations in cercarial exposure, as opposed to biological differences in susceptibility to infection. Age-related differences in reinfection were not explained by exposure, however, and appeared linked to the balance of IgE and IgG₄ to the tegumental antigen SmTAL1 (formerly Sm22.6), which itself was significantly related to resistance to reinfection.

Conclusions

This study highlights the benefit of taking a multidisciplinary approach in complex field settings; it allows the ecology of a population to be understood and thus more robust conclusions to be made.

Human schistosomiasis is a chronic parasitic disease affecting around 200 million people worldwide. Infection occurs when cercariae penetrate the skin during water contact. Although there is effective treatment for schistosomiasis, individuals remain susceptible to reinfection after treatment; some individuals, however, appear more susceptible to reinfection than others. The highly heterogeneous nature of human water contact behaviour makes it difficult to identify whether low levels of reinfection are caused by immunity or a simple lack of cercarial exposure; this complicates the characterisation of risk factors for infection and immune correlates of protection. Here, we take a multidisciplinary approach using individual estimates of cercarial exposure and multivariable analysis to allow for environmental and behavioural heterogeneities. We examine the influence of demographic factors and antibody responses on susceptibility to reinfection. While observed ethnic- and sex-related variations in Schistosoma mansoni reinfection could be explained by differences in exposure, age-related differences appeared linked to the balance of specific IgE and IgG4 antibodies, themselves related to resistance to reinfection. Our study highlights the benefits of a multidisciplinary approach in complex field settings: it improves our understanding of a population's ecology and therefore the biology of disease.

Schistosomiasis in the People's Republic of China: the era of the Three Gorges Dam

The potential impact of the Three Gorges Dam (TGD) on schistosomiasis transmission in China has invoked considerable global concern. The TGD will result in changes in the water level and silt deposition downstream, favoring the reproduction of Oncomelania snails. Combined with blockages of the Yangtze River's tributaries, these changes will increase the schistosomiasis transmission season within the marshlands along the middle and lower reaches of the Yangtze River. The changing schistosome transmission dynamics necessitate a comprehensive strategy to control schistosomiasis. This review discusses aspects of the epidemiology and transmission of Schistosoma japonicum in China and considers the pathology, clinical outcomes, diagnosis, treatment, immunobiology, and genetics of schistosomiasis japonica together with an overview of current progress in vaccine development, all of which will have an impact on future control efforts. The use of synchronous praziquantel (PZQ) chemotherapy for humans and domestic animals is only temporarily effective, as schistosome reinfection occurs rapidly. Drug delivery requires a substantial infrastructure to regularly cover all parts of an area of endemicity. This makes chemotherapy expensive and, as compliance is often low, a less than satisfactory control option. There is increasing disquiet about the possibility that PZQ-resistant schistosomes will develop. Consequently, as mathematical modeling predicts, vaccine strategies represent an essential component in the future control of schistosomiasis in China. With the inclusion of focal mollusciciding, improvements in sanitation, and health education into the control scenario, China's target of reducing the level of schistosome infection to less than 1% by 2015 may be achievable.

The in vitro effect of mefloquine and praziquantel against juvenile and adult Schistosoma japonicum

Mefloquine, an antimalarial drug, has been found to be effective against various stages of schistosomes in vivo. The purpose of the study is to explore the in vitro effect of mefloquine against adult and juvenile Schistosoma japonicum and to compare its efficacy with praziquantel. Three-hour-old schistosomula were prepared by penetrating the mouse skin with schistosome cercariae, while schistosomes 7-, 14-, and 35-day-old were collected from mice infected with S. japonicum cercariae for 7, 14, and 35 days by perfusion. Schistosomes were placed to each of 24 wells of a Falcon plate and maintained in Hanks' balanced salt solution-20% calf serum. Besides observation on the direct in vitro effect of mefloquine and praziquantel, adult worms exposed to mefloquine and praziquantel for 1 and 4 h were transferred to the medium without the drugs and incubated continuously for another 72 h. The reversible effect of mefloquine and praziquantel was assessed by the recovery of the worm motor activity and parasite survival. The minimal effective concentration of mefloquine against adult schistosomes in vitro was 10 microg/mL, which revealed that the worm motor activity was first stimulated, then decreased significantly, followed by bleb formation, focal swelling and elongation of the worm body, cessation of gut peristalsis, and death of 56.3% (18/32) worms within 24-72 h. Similar appearance was seen in the adult worms exposed to higher mefloquine concentration of 20 and 30 microg/mL, but all worms died within 4-24 h. The adult schistosomes exposed to praziquantel 1-30 microg/mL showed fast spasmodic contraction of the worm body, followed by bleb formation along the tegument, feeble movement of oral sucker, and death of a part of males and females 72 h after incubation. When male and female schistosomes exposed to mefloquine 10 and 20 microg/mL for 1 and 4 h were transferred to the medium without the drug, no apparent recovery of worm motor activity and survival was seen. In case of worms exposed to praziquantel at the same concentration for 1 and 4 h before replacement of drug-free medium, a well recovery of worm motor activity, looseness of worm body, and reduction or disappearance of blebs along the tegument were observed. Mefloquine also exhibited in vitro effect against 3-h-old and 7- and 14-day-old schistosomula which was similar to that seen in adult worms, but all or parts of worms showed decrease in motor activity or even death (3-h-old and 7-day-old schistosomula) at a lower mefloquine concentration of 5 microg/mL. In 14 day-old schistosomula exposed to praziquantel 1-30 microg/mL, spasmodic contraction and significant decrease in motor activity of the worm body with movement of oral and ventral suckers were observed, but no death of worm was seen during a 3-day incubation period. The results indicate that in vitro mefloquine exhibits a direct killing effect against adult and juvenile S. japonicum which is different from that of praziquantel. Meanwhile, the juvenile schistosomes are more susceptible to mefloquine than the adult ones. Furthermore, the in vitro effect of mefloquine against adult schistosomes is irreversible, while that of praziquantel is reversible.

Spatial distribution of human Schistosoma japonicum infections in the Dongting Lake Region, China

Background

The aim of this study was to spatially model the effect of demographic, reservoir hosts and environmental factors on human Schistosoma japonicum infection prevalence in the Dongting Lake area of Hunan Province, China and to determine the potential of each indicator in targeting schistosomiasis control.

Methodology/Principal Findings

Cross-sectional serological, coprological and demographic data were obtained from the 2004 nationwide periodic epidemiologic survey for Hunan Province. Environmental data were downloaded from the USGS EROS data centre. Bayesian geostatistical models were employed for spatial analysis of the infection prevalence among study participants. A total of 47,139 participants from 47 administrative villages were selected. Age, sex and occupation of residents and the presence of infected buffaloes and environmental factors, i.e. NDVI, distance to the lake and endemic type of setting, were significantly associated with S. japonicum infection prevalence. After taking into account spatial correlation, however, only demographic factors (age, sex and occupation) and the presence of infected buffaloes remained significant indicators.

Conclusions/Significance

Long established demographic factors, as well presence of host reservoirs rather than environmental factors are driving human transmission. Findings of this work can be used for epidemiologic surveillance and for the future planning of interventions in the Dongting Lake area of Hunan Province.

Effect of single-dose oral mefloquine on the morphology of adult Schistosoma japonicum in mice

It has been recently documented that the antimalarial drug mefloquine shows in vivo activity against schistosomes. In the present study, we assessed the effect of mefloquine on the morphology of adult Schistosoma japonicum worms. Mice were infected with S. japonicum cercariae for 35 days and then treated with a single 400-mg/kg oral dose of mefloquine. Groups of mice were killed between 24 h and 14 days post-treatment and worms were recovered from the liver and mesenteric veins, fixed in 70% alcohol, stained with acid carmine, and examined under a light microscope. Worms obtained from nontreated mice served as controls. S. japonicum recovered from mice 24 h post-treatment had severely dilated guts and the entire worm body was swollen. Meanwhile, reproductive glands, including the testis, ovary, and vitelline gland, showed signs of degeneration. Damage further progressed, particularly among vitelline glands, which resulted in disturbance of ova formation and cessation of oviposition 3 days post-treatment. Three to 7 days after mefloquine administration, adherence of host leukocytes on the damaged tegument was observed. Our results confirm that mefloquine possesses antischistosomal properties, exhibiting a rapid onset of action and causing extensive morphologic damage to adult S. japonicum.

Large water management projects and schistosomiasis control, Dongting Lake region, China

Construction of the Three Gorges Dam across the Yangtze River will substantially change the ecology of the Dongting Lake in southern China. In addition, the Chinese Central and Hunan Provinces' governmental authorities have instigated a Return Land to Lake Program that will extend the Dongting Lake surface area from the current 2,681 km2 to 4,350 km2. The previous construction of embankments and the large silt deposits made by the Yangtze River and other connecting rivers have contributed to frequent disastrous flooding. As a consequence of the 2 water projects, > 2 million persons and their domestic animals are being resettled. This article provides an overview of the historical background of these 2 large water management projects, the associated population movement, and their impact on future transmission and control of schistosomiasis in the Dongting Lake area. The dam will likely substantially extend the range of the snail habitats and increase schistosome transmission and schistosomiasis cases.

Large water management projects and schistosomiasis control, Dongting Lake region, China

Construction of the Three Gorges Dam across the Yangtze River will substantially change the ecology of the Dongting Lake in southern China. In addition, the Chinese Central and Hunan Provinces' governmental authorities have instigated a Return Land to Lake Program that will extend the Dongting Lake surface area from the current 2,681 km2 to 4,350 km2. The previous construction of embankments and the large silt deposits made by the Yangtze River and other connecting rivers have contributed to frequent disastrous flooding. As a consequence of the 2 water projects, > 2 million persons and their domestic animals are being resettled. This article provides an overview of the historical background of these 2 large water management projects, the associated population movement, and their impact on future transmission and control of schistosomiasis in the Dongting Lake area. The dam will likely substantially extend the range of the snail habitats and increase schistosome transmission and schistosomiasis cases.

Familial aggregation of human infection with Schistosoma japonicum in the Poyang Lake region, China

Despite the success of extensive control measures that have been implemented in China for over 50 years, the number of individuals infected with Schistosoma japonicum remains high in the existing endemic areas. A variance components analysis was undertaken to estimate the heritable and environmental components that contribute to S. japonicum infection in the Poyang Lake region of Jiangxi Province, PR China. The total target population was 3148 from four separate administrative villages. Two thousand seven hundred and five of these comprised 400 families ranging in size from 3 to 188. After adjustments were made for gender, water contact and past history of having had schistosomiasis, the heritable component was estimated to account for as much as 58% of the phenotype variation under the polygenic model. Household was not shown to be an important environmental factor. Incorporating village effects indicated that the results were valid for the total population. We conclude that genetic heritability in this region is high and plays an important role in determining risk of infection with S. japonicum.

Schistosomiasis control in the People's Republic of China

Schistosomes, snail-transmitted trematodes (blood flukes), cause a major parasitic disease that ranks second only to malaria in terms of human suffering in the tropics. Schistosoma japonicum has occupied its ecological niche in China for thousands of years; through natural selection it has evolved survival mechanisms that make it difficult (if not impossible) to eradicate. As discussed here by Allen Ross, Li Yuesheng, Adrian Sleigh and Don McManus, vaccination, in combination with current control strategies, may significantly reduce the morbidity of this disease and ultimately improve the quality of life for those living adjacent to endemic zones. This article provides a special focus in Hunan province and examines the potential impact of the Three Gorges Super Dam Project on schistosomiasis control.

Comparison of self-reported and observed water contact in an S. mansoni endemic village in Brazil

Estimates of exposure are critical for immuno-epidemiologic and intervention studies in human schistosomiasis. Direct observation of human water contact patterns is both costly and time consuming. To address these issues, we determined whether individuals residing in a Schistosoma mansoni endemic village in Brazil could accurately self-report their water contact patterns. We compared the results of a water contact questionnaire to the present gold standard, direct observation of water contact in 86 volunteers, aged 8--29. We administered a survey to estimate volunteers' frequency and type of water contact and directly measured each volunteers' water contact patterns during 5 weeks of detailed water contact observations. We found a poor correlation between self reported frequency of contact and directly observed exposure (rho=0.119, P=NS). The questionnaire data was supplemented by information about average body surface area of exposure and duration of contact for specific activities derived from observations of this cohort. This 'supplemented questionnaire' data was significantly correlated with their exposure index (rho=0.227, P=0.05). It provides a starting point from which questionnaires may develop to provide a more cost-effective and less labor intensive method of assessing water contact exposure at the level of the individual.

Schistosoma japonicum infection in the pig as a model for human schistosomiasis japonica

Valuable information on human schistosomiasis japonica has been provided using primates and experimental rodent hosts. However, major drawbacks such as high costs and ethical concerns for the primate models and large biological deviations for the rodent models have led to the search for more appropriate models. Recent data on the pig indicate that this natural host for Schistosoma japonicum might be a realistic alternative. As only very few research groups have investigated the S. japonicum/pig model, the present review mainly deals with the experimental methods and the major host/parasite findings obtained from the authors own research group. With emphasis on a critical evaluation of the work, the results are compared to the scarce information existing on human schistosomiasis japonica. Like in humans, S. japonicum establishes mainly in the large intestinal veins, with high faecal egg counts during the acute phase of infection, which varies greatly within and between days. Concomitant resistance is another shared feature, but studies in pigs have indicated that the phenomenon is more complex than generally thought. Clinical signs as eosinophilia and diarrhoea with mucus and blood in the acute phase of infection and hepatomegaly, increased portal diameter, periportal fibrosis and ascites in chronic infections are common findings in both humans and pigs. Low protein diet aggravates the disease in pigs by increasing the establishment rates, the faecal egg excretion and the morbidity. A 100% cure rate is achieved when treating S. japonicum infected pigs with praziquantel at 40 mg/kg, and 4 weeks post treatment pigs remain resistant to reinfection. Lastly, human congenital S. japonicum infection has been confirmed in pigs but the implications of such infections for the pathogenesis of schistosomiasis japonica remain to be investigated.

Pathology and course of natural Schistosoma japonicum infection in pigs: results of a field study in Hubei province, China

In order to obtain information on the natural course of porcine infection with Schistosoma japonicum, pigs were exposed to the cercariae of this parasite in a highly endemic region of China. Five, 5-month-old pigs previously infected with S. japonicum (group A) and 10, schistosome-naïve piglets (group B) were allowed on a pasture infested with Oncomelania snails for one transmission period (approximately 5.5 months). All the piglets rapidly acquired infection, and both groups remained infected throughout the study period. Group B showed fever, diarrhoea and anorexia in the early egg-excretion phase, and marked growth reduction. In both groups, post-mortem examination revealed live schistosomes and lesions associated with dead worms in the intestinal and mesenteric vasculature, and egg-related pathology in the large intestine and liver. Major findings were exudative lesions connected with egg excretion in the intestine, and granulomatous obstruction of portal veins in the liver. Signs of granuloma modulation were found in the liver, but not in the intestine. In conclusion, the study showed that field exposure of pigs to S. japonicum for one transmission period resulted in clinical disease and growth retardation in the youngest pigs, and significant pathology in both groups. Self cure, prominent in experimental porcine infections produced with single, high-dose inocula, was not induced in either group.

Measuring exposure to Schistosoma japonicum in China. III. Activity diaries, snail and human infection, transmission ecology and options for control

We used activity diaries and snail detection to relate water contact and Schistosoma japonicum infection among a cohort of 178 residents on two islands in the Dongting Lake, China. Water exposure to each of 12 mapped water zones around the islands was calculated (m(2) min/day) for each subject. Infected Oncomelania hupensis hupensis snails in this area are focal and were found in only five of the 12 zones, with the highest rate being 5.7%. Thirty-one subjects (17%) were re-infected with a mean intensity of 63.2 epg. Mean water contact was 7.9 m(2) min/day; 98% of water exposure was due to economic activity and only 2% due to swimming or bathing, washing and other necessities of daily life. Males had more exposure and infection than females (P<0.05). Infected subjects had more exposure (10.2 m(2) min/day) than those not infected (7.44 m(2) min/day) (P<0.05). Compared with uninfected subjects, those infected had 2.9 times more exposure in infected-snail zones (P<0.01). Also, human infection intensity (epg) correlated well with exposure to infected snail zones (r=0.552, P<0.01). People <20 years old had the highest re-infection (21.4%) and intensity (3.77 epg). Median exposure for 20-49-year-olds (9.00 m(2) min/day) was nearly double that of those aged <20 or >50 years old (5.5 m(2) min/day). We conclude that map-referenced water contact and snail evaluation boosts accuracy of activity-diary measurements in large transmission foci for the Asian schistosome. Protecting against faecal contamination of snail inhabited sites, and against occupational exposure for island residents, should be a priority of future research. Potential strategies for migrating buffaloes and families living on visiting fishing boats are explored.

Epidemiology of Schistosoma japonicum in China: morbidity and strategies for control in the Dongting Lake region

Dongting Lake, covering a very large surface water area of 2691km(2), is located in Hunan Province in the southern part of the People's Republic of China. It is the second-largest freshwater lake in China and plays an important role in regulating the amount of water in the Yangtze River, China's longest river. The annual water level of the lake changes by as much as 15m, rising in summer and falling in winter. Asian schistosomiasis has been endemic in the Dongting Lake region for centuries and it has had a devastating effect on the public health of the local people. After a difficult struggle for more than four decades, a concerted programme, supported by the World Bank Loan and instigated in 1992, has resulted in remarkable progress in the control of the disease in many endemic areas of the region. However, the great challenge remains to consolidate and maintain the achievements made to date. The Schistosoma japonicum intermediate host (Oncomelania hupensis hupensis) snail habitats are huge, estimated at 1768km(2) in 1996; these are increasing at a rate of 34.7km(2) annually due to high silt deposition from the Yangtze River itself and from the connecting rivers in Hunan province, and construction of embankments in the Dongting Lake region. It is anticipated that the construction of the Three Gorges Super Dam, the largest engineering project ever undertaken, will substantially extend the range of the snail habitats and increase the number of new schistosomiasis cases. In many areas, human re-infections with S. japonicum after drug (praziquantel) treatment remain unacceptably high (up to 20% of those treated are re-infected annually) due to occupational (mainly fishing) water contact. This paper reviews the history and the current status of schistosomiasis control in the lake region, it explores the epidemiological factors which influence the prevalence of the infection and the disease it causes, and it provides insight into future approaches to control which might finally eradicate the infection.

Cloning and molecular characterization of calpain, a calcium-activated neutral proteinase, from different strains of Schistosoma japonicum

cDNA coding for calpain of Schistosoma japonicum were cloned and sequenced, and serological basis of host responses to calpain were analyzed. cDNA of calpain from S. japonicum of two different isolates, Yamanashi strain (Sj-J) and Hunan strain (Sj-C), were 2, 468 bp and 2, 465 bp in length, including the same number (2, 274) of open reading frame. Nucleotide sequence and amino acid sequence between the two calpains are 99.1% and 98.8% identity, respectively. Sj-J and Sj-C calpains were considered to be translated as a preproenzyme, and a 746-amino acid mature enzyme contains eight motifs without a signal peptide at the N-terminal based on the deduced amino acid sequences. mRNA for calpain were detectable in different developmental stages, however, sera obtained from mice immunized with recombinant calpain showed enhanced binding to cercarial antigen. Human sera from S. japonicum-infected individuals recognized the large subunit of schistosomal calpain, and light-infected sera showed stronger reactivities to the recombinant calpain than moderate/high infection cases. When we tested synthetic peptides, there were four common human B cell epitopes in schistosomal calpain, all of which are shared with S. mansoni. Together with these results, calpain of S. japonicum seems to be not only a vaccine candidate, but also a target antigen for immunodiagnosis of human schistosomiasis.

Measuring exposure to S. japonicum in China. I. Activity diaries to assess water contact and comparison to other measures

We introduce a new method, activity diaries, in order to evaluate human water contact among fishing communities in an area moderately endemic for Schistosoma japonicum in the Dongting Lake region of Southern China. Two hundred and forty-nine subjects (76% male) were followed prospectively over a 9-month-period in order to verify exposure and reinfection. Exposure was determined crudely with questionnaires, direct 12-h water observations, and more precisely with activity diaries and an adjusted exposure model which took into account the time of day, the duration of contact and the percent body surface area in contact with water. Cohort subjects filled in activity diaries for an average of 85 days as compared with 2 days for the direct water observations. The typical unadjusted mean daily water contact (duration) based on the activity diaries was 53 min with 62% of this time spent in fishing. In contrast, the direct water observations revealed an average daily duration of 149 min with 53% of the time spent in fishing. Human water contact patterns (min/day) by site, activity and body part exposed were examined with the activity diaries. Individuals in the 36-49-year-old age range had the highest degree of water contact. Most of this daily contact occurred by males on the hands (mean+/-S.D.; 83.53+/-67.80 min/day) while fishing (mean+/-S.D.; 87.84+/-8.88 min/day) on the lake (mean+/-S.D.; 85.98+/-69.90 min/day). There was a strong positive log correlation (r=0.95) between the crude and adjusted (based on our derived exposure model) diary outcomes for the entire study sample, however, at higher exposure levels this relationship was differentially weaker (r=0.70). Results from this study suggest that current methods used in evaluating schistosomiasis exposure in China may overestimate and bias measures of the risk of infection. Activity diaries adjusted for the time of day, duration and the percent body surface area exposed are cost-effective and practical instruments to accurately quantify human exposure in the vast lake regions of Southern China where most of the endemic schistosomiasis japonica occurs.

An evaluation of Schistosoma japonicum infections in three villages in the Dongting lake region of China. I. Prevalence, intensity and morbidity before the implementation of adequate control strategies

We examined three Chinese villages (one farming village and two fishing villages) in an area highly endemic for schistosomiasis japonica in order to study the prevalence, intensity of infection and the associated morbidities before the implementation of adequate control strategies. Socio-economic status, medical histories including the frequency and type of water contact, physical examinations, parasitological examinations and questionnaires relevant to the knowledge of schistosomiasis were performed on a random sample of 1542 individuals (45% female; 55% male). The prevalence of Schistosoma japonicum was 9.4% in the farming village and 16.5 and 26.2% in the fishing villages. Eighty-three percent of the infected population had light infections (8-100 eggs per gram stool (epg)) and only 6% had heavy infections (> 400 epg). Both the prevalence and intensity of infection varied significantly (P < 0.01) with the frequency of water contact. All the morbidity indicators (weakness, inability to work, diarrhoea, hepatomegaly and splenomegaly) were significantly higher (P < 0.01) among those infected with S. japonicum. Knowledge of schistosomiasis, in general, was unsatisfactory in all three villages; 12.4% of the population was infected when their knowledge of schistosomiasis was good, whereas 26.6% of the population was infected when their knowledge was poor. Further, it appears that schistosomiasis control based on selective chemotherapy (praziquantel) of randomly selected stool-positive individuals was ineffective in significantly reducing the prevalence of S. japonicum and its associated clinical manifestations in the villages under study.

An examination of current control strategies for Asian schistosomiasis in the Dongting lake region of China. II. A five year follow-up survey on Qingshan island

In 1995-1996 we conducted an epidemiological survey in two communities (1656 individuals) on Qingshan island, Hunan province P.R. China, in order to determine the efficacy of current control strategies since their upgrading in 1991. In 1996, the overall prevalence for Schistosoma japonicum, Ascaris lumbricoides, Ancylostoma duodenale, and Trichuris trichiura had decreased moderately since 1991. The age-specific prevalence for S. japonicum for each of the representative age groups decreased slightly, but there was a significant reduction in these prevalences for the 5-9 (P < 0.01), 55-59 (P < 0.05) and the over 60 (P < 0.01) age groups. The 1996 intensities of infection for schistosomiasis were higher for all the age categories except for those aged 0-4 and 25-29 years of age. When the study population was further classified according to the percent uninfected, lightly infected (8-100 eggs/g (epg)), moderately infected (101-400 epg) and heavily infected (> 400 epg) for S. japonicum, there were fewer (5.6%) people infected in 1996 but the proportions of moderately (21.3 vs. 15.5%) and heavily (7.6 vs. 2.3%) infected individuals were higher than those observed in 1991. The reported cases of weakness and hepatomegaly (MSL > or = 3) were significantly lower (P < 0.01) in 1996 for both uninfected and infected (all intensities) individuals. General episodes of diarrhoea were also significantly lower in 1996 for those lightly (P < 0.05) and heavily (P < 0.01) infected. Likewise, the occurrence of splenomegaly (Hackett's > or = 2) was significantly lower among uninfected (P < 0.01) and heavily infected (P < 0.05) patients. In summary, although significant progress has been made in controlling schistosomiasis and other helminth infections in this highly endemic focus for schistosomiasis, there is still room for improvement. Chemotherapy for bovines and humans, mollusciding for Oncomelania control and health education should be initiated and upgraded if the health and well being of these island communities is to further improve.