Effectiveness of different approaches to mass delivery of praziquantel among school-aged children in rural communities in Nigeria

Factors affecting the uptake of preventive chemotherapy treatment for schistosomiasis in Sub-Saharan Africa: A systematic review

Background

Schistosomiasis affects nearly 220 million people worldwide, mainly in Sub-Saharan Africa (SSA). Preventive chemotherapy (PC) treatment, through regular mass-drug administration (MDA) of Praziquantel tablets remains the control measure of choice by Ministries of Health. Current guidelines recommend that 75% of school-aged children receive treatment. Many programmes, however, struggle to achieve this target. Given the risk of high reinfection rates, attaining sustained high levels of treatment coverage is essential. This study provides a comprehensive review of the barriers and facilitators operating at different levels of analysis, from the individual to the policy level, conditioning the uptake of PC for schistosomiasis in SSA.

Methodology/Principal findings

A systematic literature search was conducted in several databases for publications released between January 2002 and 2019 that examined factors conditioning the uptake of Praziquantel in the context of MDA campaigns in SSA. A total of 2,258 unique abstracts were identified, of which 65 were selected for full text review and 30 met all eligibility criteria. Joanna Briggs Institute’s Critical Appraisal and the Mixed-Methods Assessment tools were used to assess the strength of the evidence. This review was registered with PROSPERO (CRD42017058525).

A meta-synthesis approach was used. Results indicated publication bias, with the literature focusing on East African rural settings and evidence at the individual and programmatic levels. The main influencing factors identified included material wellbeing, drug properties, knowledge and attitudes towards schistosomiasis and MDAs, fears of side effects, gender values, community and health systems support, alongside programme design features, like training, sensitisation, and provision of incentives for drug-distributors. The effect of these factors on determining Praziquantel uptake were explored in detail.

Conclusions/Significance

Multiple determinants of treatment uptake were found in each level of analysis examined. Some of them interact with each other, thus affecting outcomes directly and indirectly. The promotion of context-based transdisciplinary research on the complex dynamics of treatment uptake is not only desirable, but essential, to design effective strategies to attain high levels of treatment coverage.

Schistosomiasis is a parasitic infection that affects nearly 220 million people worldwide. Long-term effects include anaemia, growth stunting, bladder cancer and infertility. Currently, the main approach to schistosomiasis control involves mass preventive chemotherapy treatment. Current guidelines recommend treating 75% of school-aged children but many programmes struggle to achieve this target. This study conducted a comprehensive review of factors conditioning the uptake of treatment in Sub-Saharan Africa across different levels of analysis: individual, interpersonal, organisational, community and policy. This examination showed, first, that the literature suffers of publication bias, with most studies based in rural East African sites and focusing in discussing individual- and policy-level factors. It indicated as well that people’s livelihoods, food security, and school-enrolment, alongside knowledge and attitudinal factors influenced treatment uptake at the individual level. Various contextual factors concerning interpersonal relations, organisations’ resources, and prevalent socio-cultural features (e.g., gender) further shaped people’s responses to MDA campaigns. Finally, it was observed that the effectiveness of programme-level decisions on sensitisation, training, and drug-delivery strategies were constantly re-shaped by mediating factors operating at lower levels of analysis. We conclude that the promotion of context-based transdisciplinary research is essential to design effective strategies to promote sustainable high levels of treatment coverage.

Approaches in scaling up schistosomiasis intervention towards transmission elimination in Africa: Leveraging from the Chinese experience and lessons

Schistosoma japonicum, differs from the African species including S. mansoni and S. haematobium, is a zoonotic parasite as it infects both human and animals including domestic ruminant animals such as cattle and animals from the wild. Considering China's success story in the elimination of schistosomiasis, the China-Africa collaboration on schistosomaisis elimination in Africa is an important cooperative health development initiative. This review examines the importance of China-Africa collaboration on schistosomiasis elimination using effective surveillance-response intervention strategy as the platform to effectively drive the elimination of schistosomiasis in Africa. Three conclusions were made after reviewing the similarity and differences in schistososmiasis control programmes between China and African continent as follows: (i) Politically, China's lessons is that leveraging on the integrated control strategies and the recognition that schistosomiasis is a public health problem which prompted the interest of government in China. It is necessary for African leaders and governments to recognize schistosomiasis as a public health challenge that must be given serious attention in terms of funding and setting up frameworks to complement control efforts. (ii) Technically, efficient monitoring and surveillance system mechanism will facilitate contextual and effective management of schistosomiasis elimination across different environment, and African programme managers should embrace the use of appropriate diagnostic tools to guide treatment strategies at different thresholds of schistosomiasis control. (iii) Strategically, effective control of snail intermediate hosts and precision mapping of snail distribution should be prioritized for successful schistosomiasis elimination in Africa.

Improving Access to Diagnostics for Schistosomiasis Case Management in Oyo State, Nigeria: Barriers and Opportunities

Schistosomiasis is one of the Neglected Tropical Diseases that affects over 200 million people worldwide, of which 29 million people in Nigeria. The principal strategy for schistosomiasis in Nigeria is a control and elimination program which comprises a school-based Mass Drug Administration (MDA) with limitations of high re-infection rates and the exclusion of high-risk populations. The World Health Organization (WHO) recommends guided case management of schistosomiasis (diagnostic tests or symptom-based detection plus treatment) at the Primary Health Care (PHC) level to ensure more comprehensive morbidity control. However, these require experienced personnel with sufficient knowledge of symptoms and functioning laboratory equipment. Little is known about where, by whom and how diagnosis is performed at health facilities within the case management of schistosomiasis in Nigeria. Furthermore, there is a paucity of information on patients’ health-seeking behaviour from the onset of disease symptoms until a cure is obtained. In this study, we describe both perspectives in Oyo state, Nigeria and address the barriers using adapted health-seeking stages and access framework. The opportunities for improving case management were identified, such as a prevalence study of high-risk groups, community education and screening, enhancing diagnostic capacity at the PHC through point-of-care diagnostics and strengthening the capability of health workers.

Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage

BACKGROUND

The control and elimination of Neglected Tropical Diseases (NTDs) is dependent on mass administration of medicines (MAM) in communities and schools by community drug distributers (CDDs) who are supported and supervised by health facility staff (FLHF) and teachers. Understanding how to motivate, retain and optimise their performance is essential to ensure communities accept medicines. This study aimed to capture and translate knowledge, problems and solutions, identified by implementers, to enhance NTD programme delivery at the community level in Nigeria.

METHODS

Qualitative data was collected through participatory stakeholder workshops organised around two themes: (i) identification of problems and (ii) finding solutions. Eighteen problem-focused workshops and 20 solution-focussed workshops were held with FLHF, CDDs and teachers in 12 purposively selected local government areas (LGA) across two states in Nigeria, Ogun and Kaduna States.

RESULT

The problems and solutions identified by frontline implementers were organised into three broad themes: technical support, social support and incentives. Areas identified for technical support included training, supervision, human resource management and workload, equipment and resources and timing of MAM implementation. Social support needs were for more equitable drug distributor selection processes, effective community sensitisation mechanisms and being associated with the health system. Incentives identified were both non-financial and financial including receiving positive community feedback and recognition and monetary remuneration. The results led to the development of the 'NTD frontline implementer's framework' which was adapted from the Community Health Worker (CHW) Generic Logic Model by Naimoli et al. (Hum Resour Health 12:56, 2014).

CONCLUSION

Maximising performance of frontline implementers is key to successful attainment of NTD goals and other health interventions. As NTDs are viewed as a 'litmus test' for universal health coverage, the lessons shared here could cut across programmes aiming to achieve equitable coverage. It is critical to strengthen the collaboration between health systems and communities so that together they can jointly provide the necessary support for frontline implementers to deliver health for all. This research presents additional evidence that involving frontline implementers in the planning and implementation of health interventions through regular feedback before, during and after implementation has the potential to strengthen health outcomes.

Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs)

BACKGROUND

Community drug distributors or neglected tropical disease (NTD) volunteers have played a crucial role in ensuring the success of mass drug administration (MDA) programs using preventive chemotherapy (PC) for lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil transmitted helminths. In recent years however, a noticeable decline in motivation of some of these volunteers has been perceived, potentially negatively impacting the success of these programs. Potential hypotheses for this change in motivation include the long duration of many MDA programs, the change in sociocultural environments as well as the changes to the programs over time. This literature review identifies factors that affect NTD volunteer performance and motivation, which may be used to influence and improve future programming.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic search was conducted to identify studies published between January 1995 and September 2016 that investigate factors pertaining to volunteer motivation and performance in NTD drug distribution programs. Searches from several databases and grey literature yielded 400 records, of which 28 articles from 10 countries met the inclusion criteria. Quality assessment of studies was performed using the Critical Appraisal Skills Programme(CASP) checklist. Data pertaining to motivation, performance, retention and satisfaction was extracted and examined for themes. Recurring themes in the literature included monetary and material incentives, intrinsic motivation, gender, cost to participate, and health systems and community support. Of these, community support and the health system were found to be particularly impactful. Very few studies were found to explicitly look at novel incentives for volunteers and very few studies have considered the out of pocket and opportunity costs that NTD volunteers bear carrying out their tasks.

CONCLUSIONS/SIGNIFICANCE

There is currently great interest in incorporating more attractive incentive schemes for NTD volunteers. However, our results show that the important challenges that volunteers face (cultural, health systems, financial and community related) may have less to do with financial incentives and may actually have a larger impact on their motivation than has previously been understood. Further integration of NTD programs into existing health systems is expected to improve the NTD volunteer working environment. Relevant community engagement related to the MDA program should also provide the supportive environment needed in the community to support NTD volunteers. Programs need to consider these issues to improve working conditions for NTD volunteers.

Systematic review of community-based, school-based, and combined delivery modes for reaching school-aged children in mass drug administration programs for schistosomiasis

Background

The mainstay of current schistosomiasis control programs is mass preventive chemotherapy of school-aged children with praziquantel. This treatment is delivered through school-based, community-based, or combined school- and community-based systems. Attaining very high coverage rates for children is essential in mass schistosomiasis treatment programs, as is ensuring that there are no persistently untreated subpopulations, a potential challenge for school-based programs in areas with low school enrollment. This review sought to compare the different treatment delivery methods based both on their coverage of school-aged children overall and on their coverage specifically of non-enrolled children. In addition, qualitative community or programmatic factors associated with high or low coverage rates were identified, with suggestions for overall coverage improvement.

Methodology/Principal findings

This review was registered prospectively with PROSPERO (CRD 42015017656). Five hundred forty-nine publication of potential relevance were identified through database searches, reference lists, and personal communications. Eligible studies included those published before October 2015, written in English or French, containing quantitative or qualitative data about coverage rates for MDA of school-aged children with praziquantel. Among the 22 selected studies, combined community- and school-based programs achieved the highest median coverage rates (89%), followed by community-based programs (72%). School-based programs had both the lowest median coverage of children overall (49%) and the lowest coverage of the non-enrolled subpopulation of children. Qualitatively, major factors affecting program success included fear of side effects, inadequate education about schistosomiasis, lack of incentives for drug distributors, and inequitable distribution to minority groups.

Conclusions/Significance

This review provides an evidence-based framework for the development of future schistosomiasis control programs. Based on our results, a combined community and school-based delivery system should maximize coverage for both in- and out-of-school children, especially when combined with interventions such as snacks for treated children, educational campaigns, incentives for drug distributors, and active inclusion of marginalized groups.

Trial registration

ClinicalTrials.gov CRD42015017656

Schistosomiasis is a chronic inflammatory condition, caused by parasitic flukes, that affects over 290 million people worldwide. Consequences of infection include anemia, stunted growth, liver abnormalities, and subfertility. Currently, the main approach to schistosomiasis control involves mass preventive treatment of school-aged children in endemic areas. The treatment, praziquantel, can be distributed through school-based, community-based, or combined school- and community-based systems. The first part of this systematic review compared the three delivery modes and found that combined delivery resulted in the best overall coverage of school-aged children, with community-only delivery the next-best approach. School-only delivery not only had the lowest overall coverage, but especially fell behind in targeting children not enrolled in school. As a whole, these results support the more frequent use of a combined approach to delivery in order to achieve the highest coverage rates and ensure that out-of-school children are not left persistently untreated. In the second part of this review the qualitative factors affecting program success were examined. The results indicate that overall treatment coverage can be improved via small interventions, such as snacks for participating children to reduce drug side effects, educational campaigns about schistosomiasis, incentives for drug distributors, and active inclusion of marginalized groups.

VARIABILITY OF URINE PARAMETERS IN CHILDREN INFECTED WITH SCHISTOSOMA HAEMATOBIUM IN UKAWU COMMUNITY, ONICHA LOCAL GOVERNMENT AREA, EBONYI STATE, NIGERIA

BACKGROUND

Schistosomiasis, a chronic, debilitating and neglected tropical and sub-tropical water-borne ailment, is highly endemic in Nigeria, especially among primary school children in rural communities. The study on the variability of urine parameters in children infected with Schistosomahaematobium in Ukawu community, Onicha Local Government Area of Ebonyi State, was undertaken.

MATERIALS AND METHODS

Urine samples were aseptically collected from 400 primary school children in the community and analysed using chemical reagent strips and sedimentation techniques.

RESULTS

The study revealed an overall prevalence of 27% as 108 pupils out of 400 were infected with S. haematobium in the area. Proteinuria, haematuria and leucocyturia were observed to occur in 67.0%, 79.0% and 74.9% respectively. Males had higher infections and higher occurrences of proteinuria, haematuria and leucocyturia (72.5%, 88.2% and 82.4% respectively). There was no significant difference with respect to sex (P<0.05). Children within ages 12-15 years had the highest prevalence of S. haematobium (35.5%) while those within the ages of 4-7 had the least prevalence (11.4%). The difference in the rate of infection between the different age groups was significant, statistically (P>0.05). Children within ages 12-15 had the highest occurrence of proteinuria, haematuria and leucocyturia while children within ages 4-7 had the least occurrence of the three urine parameters. All the pupils excreting above 40 egg/10ml of urine had proteinuria, haematuria and leucocyturia.

CONCLUSION

The study revealed that the community studied is endemic with Schistosoma haematobium infections and the level of the urine parameters increased with the intensity of infection. Prompt case detection and treatment, good personal hygiene, eradication of snail hosts, public enlightenment and proper waste disposal are hereby recommended.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa. Similar to other developing areas throughout the world, this region's dearth of skilled health providers renders Western-style primary care efforts to address such diseases unrealistic. Consequently, many countries rely on their corps of nurses and community health workers to engage with underserved and hard-to-reach populations in order provide interventions against these maladies. This article attempts to cull together recent literature on the impact that nurses and community health workers have had on neglected tropical diseases.

METHODS

A review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses' and community health workers' responsibilities for neglected tropical disease control within their respective countries' health systems.

RESULTS

A total of 59 articles were identified that fit all inclusion criteria.

CONCLUSIONS

Successful disease control requires deep and meaningful engagement with local communities. Expanding the role of nurses and community health workers will be required if sub-Saharan African countries are to meet neglected tropical disease treatment goals and eliminate the possibility future disease transmission. Horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies-benefits that vertical programs are not able to attain.

An assessment of maternal, newborn and child health implementation studies in Nigeria: implications for evidence informed policymaking and practice

BACKGROUND

The introduction of implementation science into maternal, newborn and child health (MNCH) research has facilitated better methods to improve uptake of research findings into practices. With increase in implementation research related to MNCH world-wide, stronger scientific evidence are now available and have improved MNCH policies in many countries including Nigeria. The purpose of this study was to review MNCH implementation studies undertaken in Nigeria in order to understand the extent the evidence generated informed better policy.

METHODS

This study was a systematic review. A MEDLINE Entrez PubMed search was performed in August 2015 and implementation studies that investigated MNCH in Nigeria from 1966 to 2015 in relation to health policy were sought. Search key words included Nigeria, health policy, maternal, newborn, and child health. Only policy relevant studies that were implementation or intervention research which generated evidence to improve MNCH in Nigeria were eligible and were selected.

RESULTS

A total of 18 relevant studies that fulfilled the study inclusion criteria were identified out of 471 studies found. These studies generated high quality policy relevance evidence relating to task shifting, breastfeeding practices, maternal nutrition, childhood immunization, kangaroo mother care (KMC), prevention of maternal to child transmission of HIV, etc. These indicated significant improvements in maternal health outcomes in localities and health facilities where the studies were undertaken.

CONCLUSION

There is a dire need for more implementation research related to MNCH in low income settings because the priority for improved MNCH outcome is not so much the development of new technologies but solving implementation issues, such as how to scale up and evaluate interventions within complex health systems.

Reduced uptake of mass treatment for schistosomiasis control in absence of food: beyond a randomized trial

Background

Sustaining high uptake of praziquantel is key for long-term control of schistosomiasis. During mass treatment in 2013, we randomized 12 primary schools into two groups; one group received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. The uptake of praziquantel in the snack schools was 94 % compared to 79 % in the non-snack schools. During mass treatment in 2014, no snack was provided. We compared the uptake of praziquantel in 2014 to that in 2013 and attempt to explain the reasons for the observed differences.

Methods

Serial cross sectional surveys were conducted among a random sample of children from the 12 primary schools, 1 month after mass treatment in 2013 and 2014 to measure uptake of praziquantel, reported side effects attributable to praziquantel and prevalence and intensity of schistosomiasis infection. Differences in the demographic and descriptive variables between the 2013 and 2014 samples were compared using chi squared tests for categorical variables and student’s t-test for geometric mean intensity of S. mansoni infection.

Results

Uptake of praziquantel reduced from 93.9 to 78.0 % (p = 0.002) in the snack schools but was unchanged in the non-schools 78.7 and 70.4 % (p = 0.176). The occurence of side-effects attributable to praziquantel increased from 34.4 to 61.2 % (p = 0.001) in the snack schools but was unchanged in the non-snack schools; 46.9 and 53.2 % (p = 0.443). Although the prevalence of S. mansoni infection increased in both the snack and non-snack schools, the differences did not reach statistical significance;1.3 and 7.5 % (p = 0.051) and 14.1 and 22.0 % (p = 0.141), respectively. Similarly, the difference in the geometric mean intensity of S. mansoni infection in both the snack and non-snack schools was not statistically significant; 38.3 eggs per gram of stool (epg) and 145.7 epg (p = 0.197) and 78.4 epg and 322.5 epg (p = 0.120), respectively.

Conclusion

Our results show that in absence of food, uptake of praziquantel reduced and the side-effects of the drug increased. However, the reduced uptake did not affect the prevalence and intensity of schistosomiasis among school children. Rescinding of the provision of the snack is what probably caused the reduction in uptake of treatment in the subsequent mass treatment cycle.

Effectiveness of a pre-treatment snack on the uptake of mass treatment for schistosomiasis in Uganda: a cluster randomized trial

BACKGROUND

School-based mass treatment with praziquantel is the cornerstone for schistosomiasis control in school-aged children. However, uptake of treatment among school-age children in Uganda is low in some areas. The objective of the study was to examine the effectiveness of a pre-treatment snack on uptake of mass treatment.

METHODS AND FINDINGS

In a cluster randomized trial carried out in Jinja district, Uganda, 12 primary schools were randomized into two groups; one received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. Four weeks after mass treatment, uptake of praziquantel was assessed among a random sample of 595 children in the snack schools and 689 children in the non-snack schools as the primary outcome. The occurrence of side effects and the prevalence and mean intensity of Schistosoma mansoni infection were determined as the secondary outcomes. Uptake of praziquantel was higher in the snack schools, 93.9% (95% CI 91.7%-95.7%), compared to that in the non-snack schools, 78.7% (95% CI 75.4%-81.7%) (p = 0.002). The occurrence of side effects was lower in the snack schools, 34.4% (95% CI 31.5%-39.8%), compared to that in the non-snack schools, 46.9% (95% CI 42.2%-50.7%) (p = 0.041). Prevalence and mean intensity of S. mansoni infection was lower in the snack schools, 1.3% (95% CI 0.6%-2.6%) and 38.3 eggs per gram of stool (epg) (95% CI 21.8-67.2), compared to that in the non-snack schools, 14.1% (95% CI 11.6%-16.9%) (p = 0.001) and 78.4 epg (95% CI 60.6-101.5) (p = 0.001), respectively.

CONCLUSIONS

Our results suggest that provision of a pre-treatment snack combined with education messages achieves a higher uptake compared to the education messages alone. The use a pre-treatment snack was associated with reduced side effects as well as decreased prevalence and intensity of S. mansoni infection.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT01869465

Understanding low uptake of mass treatment for intestinal schistosomiasis among school children: a qualitative study in Jinja district, Uganda

Despite attempts to control intestinal schistosomiasis through school-based mass drug administration (MDA) with praziquantel using school teachers in Uganda, less than 30% of the school children take the treatment in some areas. The aim of the study was to understand why the uptake of praziquantel among school children is low and to suggest strategies for improved uptake. This was a cross-sectional qualitative study in which 24 focus group discussions and 15 key informant interviews were conducted 2 months after MDA. The focus group discussions were held with school children in twelve primary schools and the key informant interviews were held with school teachers, sub-county health assistants and the District Vector Control Officer. The study shows that the low uptake of praziquantel among school children is a result of a complex interplay between individual, interpersonal, institutional, community and public policy factors. The individual and interpersonal factors underpinning the low uptake include inadequate information about schistosomiasis prevention, beliefs and attitudes in the community about treatment of schistosomiasis and shared concerns among children and teachers about the side-effects of praziquantel, especially when the drug is taken on an empty stomach. The institutional, policy and community factors include inadequate preparation and facilitation of teachers and the school feeding policy, which requires parents to take responsibility for providing their children with food while at school, yet many parents cannot meet the cost of a daily meal due to the prevailing poverty in the area. It is concluded that strategies to improve uptake of praziquantel among school children need to be multi-pronged addressing not only the preparation and motivation of teachers and health education for children, but also the economic and political aspects of drug distribution, including the school feeding policy.

Diagnosis and treatment of schistosomiasis in children in the era of intensified control

In the current era of intensified and integrated control against schistosomiasis and other neglected tropical diseases, there is a need to carefully rethink and take into consideration disease-specific issues pertaining to the diagnosis, prevention, control and local elimination. Here, we present a comprehensive overview about schistosomiasis including recent trends in the number of people treated with praziquantel and the latest developments in diagnosis and control. Particular emphasis is placed on children. Identified research needs are offered for consideration; namely, expanding our knowledge about schistosomiasis in preschool-aged children, assessing and quantifying the impact of schistosomiasis on infectious and noncommunicable diseases, developing new antischistosomal drugs and child-friendly formulations, designing and implementing setting-specific control packages and developing highly sensitive, but simple diagnostic tools that are able to detect very light infections in young children and in people living in areas targeted for schistosomiasis elimination.

Uptake of preventive treatment for intestinal schistosomiasis among school children in Jinja district, Uganda: a cross sectional study

Background

In Uganda, the current national health sector strategic and investment plan underscores schistosomiasis as one of the diseases targeted for elimination by the year 2015. However, uptake of treatment among school children is unknown but suspected to be low. We estimated the uptake and predictors of preventive treatment with praziquantel.

Methods

In a cross sectional study carried out in Jinja district of Uganda, a random sample of 1,010 children in 12 primary schools was questioned about their uptake of praziquantel, knowledge and perceptions about schistosomiasis, support for taking preventive treatment and the dangers of taking praziquantel. The prevalence and mean intensity of infection with Schistosoma mansoni were determined.

Results

Self reported uptake of praziquantel at last mass treatment was 28.2% (95% confidence interval (CI): 22.9%–33.6%). Overall prevalence and mean intensity of S. mansoni infection was 35% (95% CI: 25.4%–37.9%) and 116.1 eggs per gram (epg) of stool (95% CI: 98.3–137.1) respectively. Uptake of praziquantel was more likely if a child was from a school with high prevalence of infection, had knowledge about schistosomiasis transmission and prevention, and reported teachers’ support to take praziquantel. Of the 285 children who took praziquantel, 142 (49.8%) developed side effects. Of the 725 children who did not take the drug, 522 (72.0%) reported fear of side effects as a major reason for non-uptake.

Conclusions

Uptake of praziquantel in this population is very low. Fear of side effects of praziquantel, lack of knowledge about schistosomiasis transmission and prevention and lack of teacher support are some of the major factors associated with low uptake.

Mannose-binding lectin and susceptibility to schistosomiasis

BACKGROUND

Human ficolin 2 (encoded by FCN2) and mannose-binding lectin (encoded by MBL2) bind to specific pathogen-associated molecular patterns, activate the complement lectin cascade in a similar manner, and are associated with several infectious diseases. Our recently published study established certain FCN2 promoter variants and ficolin-2 serum levels as protective factors against schistosomiasis.

METHODS

We used the Nigerian cohort from our recently published study, which included 163 Schistosoma haematobium-infected individuals and 183 matched healthy subjects, and investigated whether MBL deficiency and MBL2 polymorphisms are associated with schistosomiasis.

RESULTS

MBL serum levels were significantly higher in controls and were associated with protection (P < .0001). The -550H minor allele was significantly associated with protection (P = .03), and the heterozygous genotypes -550HL were observed to confer protection (P = .03). The MBL2*HYPA haplotype was significantly associated with protection (P = .03), with significantly higher serum MBL levels in controls (P = .00073). The heterozygous 6-bp deletion in the promoter was observed to be a susceptibility factor in schistosomiasis (P = .03).

CONCLUSIONS

In agreement with findings from our recently published study, the findings reported here support the observation that MBL is also associated with protection in schistosomiasis.

Projecting the long-term impact of school- or community-based mass-treatment interventions for control of Schistosoma infection

Background

Schistosomiasis remains a significant health burden in many areas of the world. Morbidity control, focused on limiting infection intensity through periodic delivery of anti-schistosomal medicines, is the thrust of current World Health Organization guidelines (2006) for reduction of Schistosoma-related disease. A new appreciation of the lifetime impact of repeated Schistosoma infection has directed attention toward strategies for greater suppression of parasite infection per se, with the goal of transmission interruption. Variations in drug schedules involving increased population coverage and/or treatment frequency are now undergoing field trials. However, their relative effectiveness in long-term infection suppression is presently unknown.

Methodology/Principal Findings

Our study used available field data to calibrate advanced network models of village-level Schistosoma transmission to project outcomes of six different community- or school age-based programs, as compared to the impact of current 2006 W.H.O. recommended control strategies. We then scored the number of years each of 10 typical villages would remain below 10% infection prevalence (a practicable level associated with minimal prevalence of disease). All strategies that included four annual treatments effectively reduced community prevalence to less than 10%, while programs having yearly gaps (‘holidays’) failed to reach this objective in half of the communities. Effective post-program suppression of infection prevalence persisted in half of the 10 villages for 7–10 years, whereas in five high-risk villages, program effects on prevalence lasted zero to four years only.

Conclusions/Significance

At typical levels of treatment adherence (60 to 70%), current WHO recommendations will likely not achieve effective suppression of Schistosoma prevalence unless implemented for ≥6 years. Following more aggressive 4 year annual intervention, some communities may be able to continue without further intervention for 8–10 years, while in higher-risk communities, annual treatment may prove necessary until eco-social factors fostering transmission are removed. Effective ongoing surveillance and locally targeted annual intervention must then become their mainstays of control.

Debate persists about how best to prevent disease caused by Schistosoma parasites. Current guidelines focus on suppressing morbidity by limiting average intensity of infection during childhood. However, this may not be sufficient to cure infection or prevent reinfection, leaving risk for sub-clinical morbidities such as growth stunting and anemia. More intensive programs involving broader coverage and/or more frequent treatments could potentially cure most infections and even prevent their return. Because such programs' effectiveness is not currently known, we used computer simulation (grounded by past treatment program results) to project short- and long-term impact in communities where Schistosoma are common. We estimated that 4 annual treatments (delivered community-wide or only to school-age children and high-risk adults) could effectively reduce local prevalence below 10%. Programs with gap years were less effective, particularly in high-risk communities. If a program was successful, infection stayed <10% for 7–10 years in low risk communities. However, rapid resurgence (within 1–5 years) was projected for high risk villages. We conclude that, given the networked transmission of Schistosoma, annual treatment programs of sufficient duration can have secondary benefits, i.e., long-term suppression in some areas. However, high risk areas will need continuing surveillance and frequent retreatment to truly minimize their risk for disease.

Ficolin-2 levels and FCN2 genetic polymorphisms as a susceptibility factor in schistosomiasis

BACKGROUND

Human ficolin-2 (L-ficolins) encoded by the FCN2 gene are pattern-recognition proteins involved in innate immunity and are associated with several infectious diseases.

METHODS

A Nigerian cohort of 168 Schistosoma haematobium-infected individuals and 192 healthy controls were examined for functional single-nucleotide polymorphisms in the promoter region (-986G>A, -602G>A, -4A>G) and in exon 8 (+6424G>T) using real-time polymerase chain reaction.

RESULTS

The FCN2 -986A and -4G alleles were significantly associated with the occurrence of schistosomiasis (P = .0004 for -986G>A; P = .0001 for -4A>G). The heterozygous genotypes (P = .0006 for -986G>A; P = .0002 for -4A>G) were observed to be a risk factor for susceptibility to schistosomiasis, whereas the homozygous genotypes of major alleles (P = .0002 for -986G>A; P = .0001 for -4A>G) were observed to shield against schistosomiasis. The haplotype AGGG (P = .0002) was observed to be a risk factor for susceptibility to schistosomiasis compared with controls, and the haplotype GGAG (P = .04) was observed to confer protection compared with patients. Ficolin-2 serum level was significantly higher in controls (P < .005) and in controls with GGAG haplotypes (P < .0001).

CONCLUSIONS

Our findings demonstrate that FCN2 promoter variants (-986G>A and -4A>G) influence ficolin-2 serum levels and susceptibility to schistosomiasis.

Community-driven interventions can revolutionise control of neglected tropical diseases

Whether global health interventions target diseases (vertical), systems (horizontal) or both (diagonal), they must address the challenge of delivering services in very remote areas of poor countries with inadequate infrastructure. The primacy of this challenge has been underscored by persistent service-delivery difficulties despite several large financial commitments - the latest, US $363 million in the January 2012 London Declaration. Community-driven approaches, pioneered in river blindness control, show that engaging communities can maximise access and performance. This experience should inform a paradigm shift in disease control whereby communities are empowered to extend health service access themselves.

Utility of repeated praziquantel dosing in the treatment of schistosomiasis in high-risk communities in Africa: a systematic review

Background

Controversy persists about the optimal approach to drug-based control of schistosomiasis in high-risk communities. In a systematic review of published studies, we examined evidence for incremental benefits from repeated praziquantel dosing, given 2 to 8 weeks after an initial dose, in Schistosoma-endemic areas of Africa.

Methodology/Principal Findings

We performed systematic searches of electronic databases PubMed and EMBASE for relevant data using search terms ‘schistosomiasis’, ‘dosing’ and ‘praziquantel’ and hand searches of personal collections and bibliographies of recovered articles. In 10 reports meeting study criteria, improvements in parasitological treatment outcomes after two doses of praziquantel were greater for S. mansoni infection than for S. haematobium infection. Observed cure rates (positive to negative conversion in egg detection assays) were, for S. mansoni, 69–91% cure after two doses vs. 42–79% after one dose and, for S. haematobium, 46–99% cure after two doses vs. 37–93% after a single dose. Treatment benefits in terms of reduction in intensity (mean egg count) were also different for the two species—for S. mansoni, the 2-dose regimen yielded an weighted average 89% reduction in standardized egg counts compared to a 83% reduction after one dose; for S. haematobium, two doses gave a 93% reduction compared to a 94% reduction with a single dose. Cost-effectiveness analysis was performed based on Markov life path modeling.

Conclusions/Significance

Although schedules for repeated treatment with praziquantel require greater inputs in terms of direct costs and community participation, there are incremental benefits to this approach at an estimated cost of $153 (S. mansoni)–$211 (S. haematobium) per additional lifetime QALY gained by double treatment in school-based programs. More rapid reduction of infection-related disease may improve program adherence, and if, as an externality of the program, transmission can be reduced through more effective coverage, significant additional benefits are expected to accrue in the targeted communities.

Infection by Schistosoma worms causes serious disease among people who live in areas of Africa, South America, and Asia where these parasites are regularly transmitted. Although yearly treatment with the drug praziquantel is fairly effective in reducing or eliminating active infection, it does not cure everyone, and reinfection remains a continuing problem in high-risk communities. Studies have suggested that a repeat dose of praziquantel, given 2 to 8 weeks after the first dose, can improve cure rates and reduce remaining intensity of infections in population-based programs. Our systematic review of published research found that, on average, in Africa, such repeated dosing appears to offer particular advantages in the treatment of S. mansoni, the cause of intestinal schistosomiasis, but there was less consistent improvement after double-dosing for S. haematobium, the cause of urogenital schistosomiasis. Based on this evidence, we used a calibrated life-path model to predict the costs and benefits of a single-dose vs. a double-dose strategy in a typical high-risk community. Our projections suggest cost-effective incremental benefits from double dosing in terms of i) limiting a person's total years spent infected and ii) limiting the number of years they spend with heavy infection, with consequent improvements in quality of life.

Social science perspectives on schistosomiasis control in Africa: past trends and future directions

New ways of integrating and scaling up control of neglected tropical diseases (including schistosomiasis) are presently underway. In this context consideration of social science perspectives is essential. In this article, we review social science publications of relevance to sustained control of schistosomiasis in Africa including diagnosis and screening, treatment, supply of clean water and improved sanitation, as well as health communication. Studies of community involvement and links between schistosomiasis control programmes and broader health care systems are also explored. Directions for future social science of relevance to sustainable schistosomiasis control are outlined, including ways of ensuring equitable access to health services as well as involvement of endemic communities and local health care systems based on equal partnership.

Is mass treatment the appropriate schistosomiasis elimination strategy?

OBJECTIVE

In the year 2000, the Philippines' Department of Health adopted mass chemotherapy using praziquantel to eliminate schistosomiasis. Mass treatment was offered to an eligible population of 30 187 residents of 50 villages in Western Samar, the Philippines, in 2004 as part of an ongoing epidemiological study, Schistosomiasis Transmission and Ecology in the Philippines (STEP), aimed at measuring the effect of irrigation on infection with schistosomiasis. This paper describes the mass-treatment activities and factors associated with participation.

METHODS

Advocacy, information dissemination and social mobilization activities were conducted before mass chemotherapy. Village leaders were primarily responsible for community mobilization. Mass treatment was offered in village meeting halls and schools. Participation proportions were estimated based on the 2002-2003 census. Community involvement was measured using a participation index. A Bayesian hierarchical logistic regression model was fitted to estimate the association between sociodemographic factors and residents coming to the treatment site.

FINDINGS

A village-level average of 53.1% of residents (range: 21.1-85.3) came to the treatment site, leading to a mass-treatment coverage with an average of 48.3% (range: 15.8-80.7). At the individual level, participation proportions were higher among males, preschool and school-age children, non-STEP participants and among those who provided a stool sample. At the village-level, better community involvement was associated with increased participation whereas a larger census was associated with decreased participation.

CONCLUSION

The conduct of mass treatment in the 50 villages resulted in far lower participation than expected. This raises concern for the ongoing mass-treatment initiatives now taking place in developing countries.

Sociocultural aspects of mass delivery of praziquantel in schistosomiasis control: the Abeokuta experience

BACKGROUND

Schistosomiasis is a public health problem in Nigeria. Although there is an ongoing national program for its control, disease control programs in other countries have shown the need to understand the sociocultural aspects of disease transmission, prevention, and treatment in endemic communities before control efforts are undertaken.

OBJECTIVE

To describe sociocultural factors that influence the distribution process of praziquantel for the mass treatment of schistosomiasis infection.

METHODS

Data for the study were collected through focus group discussions held separately with adult males and females, male and female adolescents (13-19 years), and male and female children (5-12 years). In-depth interviews were similarly held with the drug distributors of praziquantel for mass treatment and with community/opinion leaders of six hyperendemic communities in Ogun State, Southwest Nigeria on mass treatment using praziquantel. These focus group discussions and in-depth interviews were held both before and following the drug distribution. The data were analyzed using the textual analysis program, Textbase Beta.

RESULTS

Following a 3-week period of mass treatment in six communities, we observed an increased awareness of rivers/streams as a source of schistosomiasis. In addition, the communities reported overwhelming support for the mass treatment after receiving treatment. The reasons for this acceptance appear to include the perceived efficacy of praziquantel against the disease and its availability free of charge. The drug's distributors adhered to the originally specified systems-based protocol for mass treatment in only two of the six communities. The systems-based protocol adhered to strict distribution through primary health centers and schools. The four other communities used a community-based approach for mass treatment with praziquantel and attained greater coverage of treatment as a result.

CONCLUSION

Obtaining community support and involvement before the implementation of mass treatment of schistosomiasis with praziquantel contributes to an effective treatment strategy for this disease. A detailed assessment of a community's health needs, before the initiation of the control efforts against endemic infections, should be undertaken.

A combined school- and community-based campaign targeting all school-age children of Burkina Faso against schistosomiasis and soil-transmitted helminthiasis: performance, financial costs and implications for sustainability

A combined school- and community-based campaign targeting the entire school-age population of Burkina Faso with drugs against schistosomiasis (praziquantel) and soil-transmitted helminthiasis (albendazole) was implemented in 2004-2005. In total, 3,322,564 children from 5 to 15 years of age were treated, equivalent to a 90.8% coverage of the total school-age population of the country. The total costs of the campaign were estimated to be US 1,067,284 dollars, of which 69.4% was spent on the drugs. Delivery costs per child treated were US 0.098 dollar, in the same range as school-based only interventions implemented in other countries; total costs per child treated (including drugs) were US 0.32 dollar. We conclude that a combined school- and community-based strategy is effective in attaining a high coverage among school-age children in countries where school enrolment is low and where primary schools cannot serve as the exclusive drug distribution points. The challenge for Burkina Faso will now be to ensure the sustainability of these disease control activities.

Implementation of national schistosomiasis control programmes in West Africa

Burkina Faso, Mali and Niger are countries endemic for schistosomiasis, with a high predominance of Schistosoma haematobium. With the support of the Bill and Melinda Gates Foundation through the Schistosomiasis Control Initiative, national control programmes were launched in these countries in 2004. Here, we describe the progress of implementation for each programme and the challenges for maintaining sustainability for schistosomiasis control in these countries.