Age-related worm load and worm fecundity patterns in human populations, as indicated by schistosome circulating antigens

Context-Specific Procedures for the Diagnosis of Human Schistosomiasis – A Mini Review

Schistosomiasis is a parasitic disease caused by trematode blood flukes of the genus Schistosoma, affecting over 250 million people mainly in the tropics. Clinically, the disease can present itself with acute symptoms, a stage which is relatively more common in naive travellers originating from non-endemic regions. It can also develop into chronic disease, with the outcome depending on the Schistosoma species involved, the duration and intensity of infection and several host-related factors. A range of diagnostic tests is available to determine Schistosoma infection, including microscopy, antibody detection, antigen detection using the Point-Of-Care Circulating Cathodic Antigen (POC-CCA) test and the Up-Converting Particle Lateral Flow Circulating Anodic Antigen (UCP-LF CAA) test, as well as Nucleic Acid Amplification Tests (NAATs) such as real-time PCR. In this mini review, we discuss these different diagnostic procedures and explore their most appropriate use in context-specific settings. With regard to endemic settings, diagnostic approaches are described based on their suitability for individual diagnosis, monitoring control programs, determining elimination as a public health problem and eventual interruption of transmission. For non-endemic settings, we summarize the most suitable diagnostic approaches for imported cases, either acute or chronic. Additionally, diagnostic options for disease-specific clinical presentations such as genital schistosomiasis and neuro-schistosomiasis are included. Finally, the specific role of diagnostic tests within research settings is described, including a controlled human schistosomiasis infection model and several clinical studies. In conclusion, context-specific settings have different requirements for a diagnostic test, stressing the importance of a well-considered decision of the most suitable diagnostic procedure.

Concomitant Immunity and Worm Senescence May Drive Schistosomiasis Epidemiological Patterns: An Eco-Evolutionary Perspective

In areas where human schistosomiasis is endemic, infection prevalence and egg output are known to rise rapidly through childhood, reach a peak at 8-15 years of age, and decline thereafter. A similar peak ("overshoot") followed by return to equilibrium infection levels sometimes occurs a year or less after mass drug administration. These patterns are usually assumed to be due to acquired immunity, which is induced by exposure, directed by the host's immune system, and develops slowly over the lifetime of the host. Other explanations that have been advanced previously include differential exposure of hosts, differential mortality of hosts, and progressive pathology. Here we review these explanations and offer a novel (but not mutually exclusive) explanation, namely that adult worms protect the host against larval stages for their own benefit ("concomitant immunity") and that worm fecundity declines with worm age ("reproductive senescence"). This explanation approaches schistosomiasis from an eco-evolutionary perspective, as concomitant immunity maximizes the fitness of adult worms by reducing intraspecific competition within the host. If correct, our hypothesis could have profound implications for treatment and control of human schistosomiasis. Specifically, if immunity is worm-directed, then treatment of long-standing infections comprised of old senescent worms could enable infection with new, highly fecund worms. Furthermore, our hypothesis suggests revisiting research on therapeutics that mimic the concomitant immunity-modulating activity of adult worms, while minimizing pathological consequences of their eggs. We emphasize the value of an eco-evolutionary perspective on host-parasite interactions.