Integration of prevention and control measures for female genital schistosomiasis, HIV and cervical cancer

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review

Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.

Knowledge of female genital schistosomiasis and urinary schistosomiasis among final-year midwifery students in the Volta Region of Ghana

BACKGROUND

Female genital schistosomiasis (FGS) is a gynaecological complication of urinary schistosomiasis (US) with an estimated burden of 20-120 million cases in endemic areas. A neglected sexual and reproductive health disease in sub-Saharan Africa, FGS increases susceptibility to sexually transmitted infections including cervical cancer and infertility among other morbidities. However, there appears to be limited FGS knowledge among practicing and pre-service health providers with implications for control. We assessed FGS awareness among final-year midwifery students who would soon be delivering primary maternal and reproductive health care.

METHODS

A cross-sectional study was conducted among 193 randomly selected final-year students from all three midwifery training institutions in the Volta region of Ghana in August/September, 2022. Data on participants' demographics and knowledge of the transmission, signs and symptoms, complications, treatment and prevention of both FGS and US were collected using structured questionnaires. Summary statistics were presented as frequencies, proportions and percentages.

RESULTS

Only 23.3% (44/189) of participants had heard about FGS compared to 64% (123/192) for US. Of the former, 42 (95%), 40 (91%) and 36 (81.8%) respectively identified genital itching/burning sensation, bloody vaginal discharge and pelvic pain/pain during intercourse as part of the symptoms of FGS. Less than a third (13/44) and about half (25/44) of those who indicated hearing about FGS knew it can be a risk for ectopic pregnancies and infertility respectively. Majority of these participants, 40 (91%), wrongly selected antibiotics as treatment for FGS while 9 indicated it is prevented by sleeping in insecticide-treated nets.

CONCLUSION

Awareness of FGS was limited among the study participants. The high prevalence of knowledge of some FGS symptoms related to the genitalia needs cautious interpretation. Health care training institutions must make deliberate efforts to highlight FGS in the training of midwives as the condition has diagnostic and management implications for some sexual and reproductive health conditions.

Illness experiences and mental health challenges associated with female genital schistosomiasis in Cameroon: a gender analysis

BACKGROUND

This paper highlights the role of cultural and structural gaps that shape illness experiences of women with manifestations of female genital schistosomiasis (FGS) and their impacts upon mental well-being.

METHODS

Using ethnography, case study narrative accounts of women manifesting symptoms of FGS, as well as interviews with health workers within FGS-endemic rural fishing communities in Cameroon, we present experiences of women affected by FGS, alongside information on FGS health service provision.

RESULTS

Our results show how gendered power dynamics in decision making, gendered experiences around menstrual health and structural gaps in service provision, combine and lead to poor mental well-being. Subfertility brings a heavy psychosocial toll from external blame and rejection, exacerbated by internalised stigma and the challenge of not being able to fulfil cultural and gendered social norms.

CONCLUSIONS

Gender analysis is key to developing context-embedded understanding and addressing FGS-related challenges. With context-specific experiences demonstrating FGS comorbidity with mental ill health, there is a need to prioritise mental health integration at policy level through a person-centred approach. Furthermore, to address stigma and discrimination, campaigns to raise awareness in Cameroon, and beyond, are needed.

CONTEXTE

Cet article met en évidence le rôle des lacunes culturelles et structurelles qui façonnent les expériences des femmes atteintes de schistosomiase génitale féminine (SGF) et leur impact sur le bien-être mental.

LA MÉTHODE

À l'aide de l'ethnographie, de récits d'études de cas de femmes présentant des symptômes de schistosomiase génitale féminine, et d'entretiens avec des agents de santé au sein de communautés de pêcheurs ruraux endémiques de la schistosomiase génitale féminine au Cameroun, nous présentons les expériences des femmes touchées par le SGF, ainsi que des informations sur les services de santé liés au SGF.

RÉSULTATS

Nos résultats montrent comment la dynamique du pouvoir dans la prise de décision, les expériences de la santé menstruelle et les lacunes structurelles dans la fourniture de services, interagissent et conduisent à un manque de bien-être psychologique. La sous-fécondité entraîne un lourd fardeau psychosocial du fait du blâme et de rejet externes auxquelles sont assujetties les personnes souffrant de la maladie, ce qui est exacerbé par la stigmatisation intériorisée et le défi que représente leur incapacité à respecter les normes sociales culturelles et sexospécifiques.

CONCLUSION

L'analyse de genre est essentielle pour développer une compréhension intégrée au contexte et pour relever les défis liés aux SGF. les défis liés à l'ESF. Avec des expériences spécifiques au contexte démontrant la comorbidité de la FGS avec la mauvaise santé mentale, il est nécessaire de donner la priorité à l'intégration de la santé mentale au niveau politique par le biais d'une approche centrée sur la personne. l'intégration de la santé mentale au niveau politique par une approche centrée sur la personne. En outre, pour lutter contre la stigmatisation et la stigmatisation et la discrimination, des campagnes de sensibilisation sont nécessaires au Cameroun et au-delà.

ANTECEDENTES

En este documento se pone de relieve el papel de las brechas culturales y estructurales que dan forma a las experiencias de enfermedad de las mujeres con manifestaciones de Esquistosomiasis Genital Femenina (EGF), y sus impactos en el bienestar mental.

MÉTODO

Utilizando la etnografía, estudios de caso mediante relatos narrativos de mujeres que manifiestan síntomas de EGF y entrevistas con trabajadores sanitarios de comunidades pesqueras rurales endémicas en Camerún, presentamos las experiencias de las mujeres afectadas por la EGF, junto con información sobre la prestación de servicios sanitarios para la EGF.

RESULTADOS

Nuestros resultados muestran cómo la dinámica de poder de género en la toma de decisiones, las experiencias de género en torno a la salud menstrual y las deficiencias estructurales en la prestación de servicios se combinan y conducen a un bienestar mental deficiente. La subfertilidad conlleva un alto coste psicosocial debido a la culpa y el rechazo externos, exacerbados por el estigma interiorizado y el reto de no poder cumplir las normas culturales y de género.

CONCLUSIÓN

El análisis de género es clave para desarrollar una comprensión integrada en el contexto y abordarlos retos relacionados con la EGF. Dado que las experiencias específicas de cada contexto demuestran la comorbilidad de las EGF con la enfermedad mental, es necesario priorizar la integración de la salud mental en las políticas a través de un enfoque centrado en la persona. Además, para hacer frente al estigma y la discriminación, son necesarias campañas de sensibilización en Camerún y en otros lugares.

Time to bring female genital schistosomiasis out of neglect

BACKGROUND

Female genital schistosomiasis (FGS) is a chronic gynaecological disease affecting girls and women in sub-Saharan Africa (SSA), caused by the parasite Schistosoma (S.) haematobium. FGS is associated with sexual dysfunction, reproductive tract morbidity and increased prevalence of HIV and cervical precancer lesions.

SOURCE OF DATA

Key peer-reviewed published literature.

AREAS OF AGREEMENT

FGS screening and diagnosis require costly equipment and specialized training, seldom available in resource-limited settings. FGS surveillance is not included in wider schistosomiasis control strategies. The interplay of FGS with other SRH infections is not fully understood. Integration of FGS within sexual and reproductive health (SRH) control programmes needs to be explored.

AREAS OF CONTROVERSY

There are no standardized methods for individual or population-based FGS screening and diagnosis, hindering accurate disease burden estimates and targeted resource allocation. Treatment recommendations rely on public health guidelines, without rigorous clinical evidence on efficacy.

GROWING POINTS

Integrating FGS screening with SRH programmes offers an opportunity to reach at-risk women with limited access to healthcare services. Home-based self-sampling coupled with handheld colposcopes operated by primary healthcare workers show promise for FGS diagnosis and surveillance at scale.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is growing interest in decentralizing strategies for FGS screening and diagnosis. The accurate predictions on the 'cost-effectiveness' of these approaches will determine their affordability and feasibility within the overburdened health systems in SSA. Clinical trials are needed to optimize FGS treatment. Longitudinal studies can expand on the epidemiological knowledge on co-morbidities and integration within other SRH interventions.

Predictors for participation in mass-treatment and female genital schistosomiasis re-investigation, and the effect of praziquantel treatment in South African adolescents

OBJECTIVE

Female Genital Schistosomiasis (FGS) causes intravaginal lesions and symptoms that could be mistaken for sexually transmitted diseases or cancer. In adults, FGS lesions [grainy sandy patches (GSP), homogenous yellow patches (HYP), abnormal blood vessels and rubbery papules] are refractory to treatment. The effect of treatment has never been explored in young women; it is unclear if gynaecological investigation will be possible in this young age group (16-23 years). We explored the predictors for accepting anti-schistosomal treatment and/or gynaecological reinvestigation in young women, and the effects of anti-schistosomal mass-treatment (praziquantel) on the clinical manifestations of FGS at an adolescent age.

METHOD

The study was conducted between 2011 and 2013 in randomly selected, rural, high schools in Ilembe, uThungulu and Ugu Districts, KwaZulu-Natal Province, East Coast of South Africa. At baseline, gynaecological investigations were conducted in female learners in grades 8 to 12, aged 16-23 years (n = 2293). Mass-treatment was offered in the low-transmission season between May and August (a few in September, n = 48), in accordance with WHO recommendations. Reinvestigation was offered after a median of 9 months (range 5-14 months). Univariate, multivariable and logistic regression analysis were used to measure the association between variables.

RESULTS

Prevalence: Of the 2293 learners who came for baseline gynaecological investigations, 1045 (46%) had FGS lesions and/or schistosomiasis, 209/1045 (20%) had GSP; 208/1045 (20%) HYP; 772/1045 (74%) had abnormal blood vessels; and 404/1045 (39%) were urine positive. Overall participation rate for mass treatment and gynaecological investigation: Only 26% (587/2293) learners participated in the mass treatment and 17% (401/2293) participated in the follow up gynaecological reinvestigations. Loss to follow-up among those with FGS: More than 70% of learners with FGS lesions at baseline were lost to follow-up for gynaecological investigations: 156/209 (75%) GSP; 154/208 (74%) HYP; 539/722 (75%) abnormal blood vessels; 238/404 (59%) urine positive. The grade 12 pupil had left school and did not participate in the reinvestigations (n = 375; 16%). Follow-up findings: Amongst those with lesions who came for both treatment and reinvestigation, 12/19 still had GSP, 8/28 had HYP, and 54/90 had abnormal blood vessels. Only 3/55 remained positive for S. haematobium ova. Factors influencing treatment and follow-up gynaecological investigation: HIV, current water contact, water contact as a toddler and urinary schistosomiasis influenced participation in mass treatment. Grainy sandy patches, abnormal blood vessels, HYP, previous pregnancy, current water contact, water contact as a toddler and father present in the family were strongly associated with coming back for follow-up gynaecological investigation. Challenges in sample size for follow-up analysis of the effect of treatment: The low mass treatment uptake and loss to follow up among those who had baseline FGS reduced the chances of a larger sample size at follow up investigation. However, multivariable analysis showed that treatment had effect on the abnormal blood vessels (adjusted odds ratio = 2.1, 95% CI 1.1-3.9 and p = 0.018).

CONCLUSION

Compliance to treatment and gynaecological reinvestigation was very low. There is need to embark on large scale awareness and advocacy in schools and communities before implementing mass-treatment and investigation studies. Despite challenges in sample size and significant loss to follow-up, limiting the ability to fully understand the treatment's effect, multivariable analysis demonstrated a significant treatment effect on abnormal blood vessels.

Female genital schistosomiasis is a neglected public health problem in Tanzania: Evidence from a scoping review

Schistosoma haematobium, the parasite that causes urogenital schistosomiasis, is widely prevalent in Tanzania. In addition to well-known effects on the urinary tract, S. haematobium also causes clinically- evident damage to the reproductive tract in approximately half of infected women, which is known as female genital schistosomiasis (FGS). FGS has major gynecologic and social consequences on women's reproductive health, yet little information is available regarding FGS in Tanzania. To cover that gap, we conducted the present scoping review to examine the epidemiology of FGS in Tanzania (both in the mainland and Zanzibar island) and to make recommendations for future work in this area. The available evidence from community-based and hospital-based retrospective studies indicates that FGS is a significant health problem in the country. Very few community-based studies have been reported from mainland Tanzania, and Zanzibar. Our review highlights the scarcity of efforts to address FGS in Tanzania and the need for additional community-based studies. The studies will help us understand the true burden of the disease nationwide, to assess the impact of praziquantel on FGS lesions, and to address social and mental health in relation to FGS. This review emphasizes integration of delivery of FGS related services in primary health care systems through the reproductive health clinics which covers sexually transmitted infections, HIV and cervical cancer screening. These actions are essential if this neglected gynecological disease is to be addressed in Tanzania.

Female genital schistosomiasis: my personal account and key recommendations to the global health community

One woman's personal account of contracting female genital schistosomiasis, a neglected tropical disease that currently affects 56 million women worldwide. This account includes recommendations to the public health community to improve outcomes for women living with or having had the illness.

Integration of female genital schistosomiasis into HIV/sexual and reproductive health and rights and neglected tropical diseases programmes and services: a scoping review

Female genital schistosomiasis (FGS) affects approximately 56 million women and girls across sub-Saharan Africa and is associated with up to a threefold increased prevalence of HIV. Integrating FGS with HIV programmes as part of comprehensive sexual and reproductive health (SRH) services may be one of the most significant missed opportunities for preventing HIV incidence among girls and women. A search of studies published until October 2021 via Scopus and ProQuest was conducted using PRISMA guidelines to assess how FGS can be integrated into HIV/SRH and neglected tropical diseases (NTDs) programmes and services. Data extraction included studies that integrated interventions and described the opportunities and challenges. A total of 334 studies were identified, with 22 eligible for analysis and summarised conducting a descriptive numerical analysis and qualitative review. We adapted a framework for integrated implementation of FGS, HIV, and HPV/cervical cancer to thematically organise the results, classifying them into five themes: awareness and community engagement, diagnosis, treatment, burden assessment, and economic evaluation. Most activities pertained to awareness and community engagement (n = 9), diagnosis (n = 9) and were primarily connected to HIV/AIDS (n = 8) and school-based services and programming (n = 8). The studies mainly described the opportunities and challenges for integration, rather than presenting results from implemented integration interventions, highlighting an evidence gap on FGS integration into HIV/SRH and NTD programmes. Investments are needed to realise the potential of FGS integration to address the burden of this neglected disease and improve HIV and SRH outcomes for millions of women and girls at risk.

Persistent Vulvar Itch Unresponsive to Treatment: A Case of Vulvar Schistosomiasis Caused by Schistosoma mansoni and a Brief Review of Literature

Background

Vulvar schistosomiasis is a female genital schistosomiasis (FGS), which occurs because of the damage caused by the presence of schistosome ova within the vulva. FGS is mostly misdiagnosed as a sexually transmitted infection. There is no reported case of vulvar schistosomiasis from Schistosoma mansoni in an immunocompetent or immunocompromised person in Ghanaian medical literature; however, there is a reported case of S. haematobium in an immunocompromised person. This is the first case of vulvar schistosomiasis from S. mansoni infection in an immunocompromised person. This case report discusses the need to consider vulvar schistosomiasis in patients with itchiness of the vulva. Case Presentation. A sixty-nine-year-old married woman presents with a persistent vulvar itch that is unresponsive to treatment. A clinical diagnosis of vulvar lichen planus unresponsive to medical therapy was made. A histopathological diagnosis of vulvar schistosomiasis was, however, made. Ziehl-Neelsen stain revealed the ova of Schistosoma mansoni. Symptoms resolved on administration of oral praziquantel.

Conclusion

Vulvar schistosomiasis must be considered in clinical history-taking and investigation of signs and symptoms related to itchiness of the vulva. Ziehl-Neelsen staining is a helpful histopathology armamentarium to determine the species of schistosome ova.

Awareness and knowledge of female genital schistosomiasis in a population with high endemicity: a cross-sectional study in Madagascar

Introduction

Female genital schistosomiasis (FGS) is a neglected disease with long-term physical and psychosocial consequences, affecting approximately 50 million women worldwide and generally representing an unmet medical need on a global scale. FGS is the chronic manifestation of a persistent infection with Schistosoma haematobium. FGS services are not routinely offered in endemic settings with a small percentage of women at risk receiving adequate care. Madagascar has over 60% prevalence of FGS and no guidelines for the management of the disease. This study aimed to determine FGS knowledge among women and health care workers (HCWs) in a highly endemic area of Madagascar.

Methods

A convenience sampling strategy was used for this cross-sectional study. Descriptive statistics including proportions and 95% confidence intervals (CI) were calculated, reporting socio-demographic characteristics of the population. Knowledge sources were evaluated descriptively. Binary Poisson regression with robust standard errors was performed; crude (CPR) and adjusted prevalence ratio (APR) with 95% CIs were calculated.

Results

A total of 783 participants were included in the study. Among women, 11.3% (n = 78) were aware of FGS while among the HCWs 53.8% (n = 50) were aware of FGS. The highest level of knowledge was observed among women in an urban setting [24%, (n = 31)] and among those with a university education/vocational training [23% (n = 13)]. A lower APR of FGS knowledge was observed in peri-urban [APR 0.25 (95% CI: 0.15; 0.45)] and rural [APR 0.37 (95% CI 0.22; 0.63)] settings in comparison to the urban setting. Most HCWs reported other HCWs [40% (n = 20)] while women mainly reported their family [32% (n = 25)] as being their main source of information in the 6 months prior to the survey.

Discussion and conclusions

Our study shows limited awareness and knowledge of FGS among population groups in the highly endemic Boeny region of Madagascar. With this study we contribute to identifying an important health gap in Madagascar, which relates to a disease that can silently affect millions of women worldwide. In alignment with the targets of the NTD roadmap, addressing schistosomiasis requires a paradigm shift for its control and management including a greater focus on chronic forms of the disease.

Cytobrush and cotton swab as sampling tools for molecular diagnosis of female genital schistosomiasis in the uterine cervix

Female genital schistosomiasis (FGS) caused by Schistosoma haematobium is a neglected chronic parasitic disease. Diagnosis relies mainly on a colposcopy, which reveals non-specific lesions. This study aimed to assess the performance of two sampling methods for the molecular diagnosis of FGS in the uterine cervix. We conducted a descriptive cross-sectional study in women of reproductive age in Saint Louis, Senegal, who presented for cervical cancer screening. Cotton swab and cytobrush samples were collected from the cervix and examined by real-time PCR. The PCR results obtained using the cotton swabs were compared with those obtained using cytobrush. Of the 189 women recruited, 56 (30%) were found to be positive for S. haematobium infection via real-time PCR. Women aged 40-54 years were predominantly infected (45%) followed by those aged 25-39 years (36%). Numerically more PCR-positive specimens were identified using cytobrush sampling. Of the 89 women who underwent both cytobrush and cotton swab sampling, 27 were PCR-positive in the cytobrush sampling vs 4 in the swab sampling. The mean Ct-value was 31.0 ± 3.8 for cytobrush-based PCR vs 30.0 ± 4.4 for swab-based PCR. The results confirm that real-time PCR can detect Schistosoma haematobium DNA in the uterine cervix. The next step will be to compare PCR with the other diagnostic methods of FGS.

Female genital schistosomiasis, human papilloma virus infection, and cervical cancer in rural Madagascar: a cross sectional study

BACKGROUND

Women's health in resource-limited settings can benefit from the integrated management of high-burden diseases, such as female genital schistosomiasis (FGS) and human papilloma virus (HPV)-related cervical cancer. In schistosomiasis-endemic countries such as Madagascar, data on FGS and HPV prevalence are lacking as well as preventive measures for both conditions. This study aims to estimate the prevalence of FGS and HPV in rural Madagascar, and to examine associated risk factors to identify opportunities for improving women's health.

METHODS

After initial community outreach activities, interested women aged 18-49 years were recruited consecutively in 2021 at three primary health care centers in the district of Marovoay. FGS was detected by colposcopy. Colposcopy images were double-blind reviewed by two independent specialists. A Luminex bead-based assay was performed on cervical vaginal lavage specimens for HPV typing. Crude (CPR) and adjusted prevalence ratios (APR) of associations between selected factors and FGS and HPV positivity were estimated using univariable and multivariable binary Poisson regression with 95% confidence intervals (CIs).

RESULTS

Among 500 women enrolled, 302 had complete information on FGS and HPV diagnosis, and were thus eligible for analysis. Within the sample, 189 (62.6%, 95% CI: 56.9-68.1) cases of FGS were detected. A total of 129 women (42.7%, 95% CI: 37.1-48.5) tested positive for HPV. In total, 80 women (26.5%, 95% CI: 21.6-31.8]) tested positive for both conditions. No association was observed between FGS and HPV positivity, while previous pregnancy (APR = 0.65, 95% CI: 0.43-0.78) and older age (APR = 0.59, 95% CI: 0.42-0.81) are showing a negative association with HPV infection compared to no previous pregnancy and younger age groups.

CONCLUSIONS

The results of the study show that FGS and HPV are highly prevalent in rural Madagascar. The concurrent prevalence of these two conditions requires urgent adaptations of public health strategies to improve women's health, such as integrated services at primary level of care.

A 14-year follow-up of ultrasound-detected urinary tract pathology associated with urogenital schistosomiasis in women living in the Msambweni region of coastal Kenya

BACKGROUND

Complications of urogenital schistosomiasis include acute inflammatory and chronic fibrotic changes within the urogenital tract. Disease burden of this neglected tropical disease is often underestimated, as only active, urine egg-patent Schistosoma infection is formally considered. Previous studies have focussed on short-term effects of praziquantel treatment on urinary tract pathology, demonstrating that acute inflammation is reversible. However, the reversibility of chronic changes is less well studied.

METHODS

Our study compared, at two time points 14 y apart, urine egg-patent infection and urinary tract pathology in a cohort of women living in a highly endemic area having intermittent praziquantel treatment(s). In 2014 we matched 93 women to their findings in a previous study in 2000.

RESULTS

Between 2000 and 2014 the rate of egg-patent infection decreased from 34% (95% confidence interval [CI] 25 to 44) to 9% (95% CI 3 to 14). However, urinary tract pathology increased from 15% (95% CI 8 to 22) to 19% (95% CI 11 to 27), with the greatest increase seen in bladder thickening and shape abnormality.

CONCLUSIONS

Despite praziquantel treatment, fibrosis from chronic schistosomiasis outlasts the presence of active infection, continuing to cause lasting morbidity. We suggest that future efforts to eliminate persistent morbidity attributable to schistosomiasis should include intensified disease management.

Visual diagnosis of female genital schistosomiasis in Zambian women from hand-held colposcopy: agreement of expert image review and association with clinical symptoms

Background: Female genital schistosomiasis (FGS) can occur in  S. haematobium infection and is caused by egg deposition in the genital tract. Confirming a diagnosis of FGS is challenging due to the lack of a diagnostic reference standard. A 2010 expert-led consensus meeting proposed visual inspection of the cervicovaginal mucosa as an adequate reference standard for FGS diagnosis. The agreement of expert human reviewers for visual-FGS has not been previously described. Methods: In two Zambian communities, non-menstruating, non-pregnant, sexually-active women aged 18-31 years participating in the HPTN 071 (PopART) Population-Cohort were enrolled in a cross-sectional study. Self-collected genital swabs and a urine specimen were collected at a home visit; trained midwives performed cervicovaginal lavage (CVL) and hand-held colposcopy at a clinic visit.  S. haematobium eggs and circulating anodic antigen (CAA) were detected from urine. Two senior physicians served as expert reviewers and independently diagnosed visual-FGS as the presence of sandy patches, rubbery papules or abnormal blood vessels in cervicovaginal images obtained by hand-held colposcopy. PCR-FGS was defined as  Schistosoma DNA detected by real-time PCR in any genital specimen (CVL or genital swab).  Results: Of 527 women with cervicovaginal colposcopic images, 468/527 (88.8%) were deemed interpretable by Reviewer 1 and 417/527 (79.1%) by Reviewer 2. Visual-FGS was detected in 35.3% (165/468) of participants by expert review of colposcopic images by Reviewer 1 and in 63.6% (265/417) by Reviewer 2. Cohen's kappa statistic for agreement between the two reviewers was 0.16, corresponding to "slight" agreement. The reviewers made concordant diagnoses in 38.7% (204/527) participants (100 negative, 104 positive) and discordant diagnoses in 31.8% (168/527) participants. Conclusions: The unexpectedly low level of correlation between expert reviewers highlights the imperfect nature of visual diagnosis for FGS based on cervicovaginal images. This finding is a call to action for improved point-of-care diagnostics for female genital schistosomiasis.

Correlates of prior HIV testing and schistosomiasis treatment: Baseline survey findings from the "creating demand for fishermen's schistosomiasis HIV services" (FISH) cluster-randomized trial in Mangochi, Malawi

BACKGROUND

Fishing exposes fishermen to schistosomiasis-infested fresh water and concurrently through precarious livelihoods to risky sexual behaviour, rendering these two infections occupational hazards for fishermen. This study aimed to characterize the knowledge of the two conditions to obtain necessary data for a subsequent cluster randomized trial designed to investigate demand creation strategies for joint HIV-schistosomiasis service provision in fishing villages on the shores of southern Lake Malawi.

METHODS

Enumeration of all resident fishermen in 45 clusters (fishing communities) was carried out between November 2019 and February 2020. In a baseline survey, fishermen reported their knowledge, attitudes and practices in the uptake of HIV and schistosomiasis services. Knowledge of HIV status and previous receipt of praziquantel were modelled using random effects binomial regression, accounting for clustering. Prevalence of willingness to attend a beach clinic was computed.

RESULTS

A total of 6,297 fishermen were surveyed from the 45 clusters with harmonic mean number of fishermen per cluster of 112 (95% CI: 97; 134). The mean age was 31.7y (SD: 11.9) and nearly 40% (2,474/6,297) could not read or write. Overall, 1,334/6,293 (21.2%) had never tested for HIV, with 64.4% (3,191/4,956) having tested in the last 12 months, and 5.9% (373/6290) taking antiretroviral therapy (ART). In adjusted analyses, being able to read and write (adjusted risk ratio [aRR: 1.91, 95% CI: 1.59-2.29, p<0.001); previous use of praziquantel (aRR: 2.00,95% CI: 1.73-2.30, p<0.001); knowing a relative or friend who died of HIV (aRR: 1.54,95% CI: 1.33-1.79, p<0.001); and being on ART (aRR: 12.93, 95% CI: 6.25-32.93, p<0.001) were associated with increased likelihood of ever testing for HIV. Only 40% (1,733/4,465) had received praziquantel in the last 12 months. Every additional year of age was associated with 1% decreased likelihood of having taken praziquantel in the last 12 months (aRR: 0.99, 95% CI: 0.98-0.99, p<0.001). However, recent HIV testing increased the likelihood of taking praziquantel by over 2-fold (aRR 2.24, 95% CI: 1.93-2.62, p<0.001). Willingness to attend a mobile beach clinic offering integrated HIV and schistosomiasis services was extremely high at 99.0% (6,224/6,284).

CONCLUSION

In a setting with an underlying high prevalence of both HIV and schistosomiasis, we found low knowledge of HIV status and low utilization of free schistosomiasis treatment. Among fishermen who accessed HIV services, there was a very high likelihood of taking praziquantel suggesting that integrated service delivery may lead to good coverage.

TRIAL REGISTRATION

This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020.

Human Schistosomiasis Vaccines as Next Generation Control Tools

Human schistosomiasis remains one of the most important yet neglected tropical diseases, with the latest estimates from the Global Burden of Disease Study indicating that over 140 million people are infected with schistosomes [...]

Profiling the knowledge of female medical/para-medical students, and expertise of health care professionals on female genital schistosomiasis in Anambra, South Eastern Nigeria

BACKGROUND

Female genital schistosomiasis (FGS) is a largely neglected tropical disease (NTD), with little or no attention in the primary health care unit. Towards building momentum to address this challenge, we investigated the perception of medical and para-medical students about FGS, as well as the expertise of health care professionals in Anambra State, Nigeria.

METHODOLOGY

We conducted a cross-sectional survey among 587 female medical and para-medical university students (MPMS), and 65 health care professionals (HCPs) saddled with the responsibility of delivering care for schistosomiasis-affected persons. Pretested questionnaires were administered to document the awareness and knowledge about the disease. In addition, the expertise of HCPs vis-à-vis suspicion of FGS and management of FGS patients during routine health care service were documented. Data were subjected to descriptive, chi-square tests and regression analysis in R software.

RESULTS

Over half of the students recruited; 54.2% for schistosomiasis and 58.1% for FGS, were not aware of the disease. Knowledge about schistosomiasis was associated with student's year of study, with those in 2nd (OR: 1.66, 95% CI: 1.0, 2.7), 4th (OR: 1.97, 95% CI: 1.2, 3.2), and 6th (OR: 5.05, 95% CI: 1.2, 34.2) year having higher likelihoods of been more informed about schistosomiasis. For HCPs, we observed a contrastingly high knowledge about schistosomiasis (96.9%), but low knowledge about FGS (61.9%). Knowledge for both schistosomiasis and FGS was not associated with year of practice and expertise (95% OR included 1, p > 0.05). A considerable proportion (>40%) of the HCPs never suspected schistosomiasis during routine clinical diagnosis of patients who presented probable FGS symptoms (p < 0.05). Similarly, only 20% were certain about the use of praziquantel for treating FGS, and about 35% were uncertain of the eligibility criteria and dosage regimens. Commodities for managing FGS were also largely unavailable in about 39% of the health facilities where the HCPs operate.

CONCLUSION

Awareness and knowledge about FGS among MPMS and HCPs were poor in Anambra, Nigeria. It is therefore important to invest in innovative methods of building capacity of MPMS and HCPs, with complementary provision of necessary diagnostics to perform colposcopy, as well as competence to diagnose pathognomonic lesions using diagnostic atlas or Artificial Intelligence (AI).

Developing a Novel Method for the Analysis of Spinal Cord-Penile Neurotransmission Mechanisms

Sexual dysfunction can be caused by impaired neurotransmission from the peripheral to the central nervous system. Therefore, it is important to evaluate the input of sensory information from the peripheral genital area and investigate the control mechanisms in the spinal cord to clarify the pathological basis of sensory abnormalities in the genital area. However, an in vivo evaluation system for the spinal cord-penile neurotransmission mechanism has not yet been developed. Here, urethane-anesthetized rats were used to evaluate neuronal firing induced by innocuous or nociceptive stimulation of the penis using extracellular recording or patch-clamp techniques in the lumbosacral spinal dorsal horn and electrophysiological evaluation in the peripheral pelvic nerves. As a result, innocuous and nociceptive stimuli-evoked neuronal firing was successfully recorded in the deep and superficial spinal dorsal horns, respectively. The innocuous stimuli-evoked nerve firing was also recorded in the pelvic nerve. These firings were suppressed by lidocaine. To the best of our knowledge, this is the first report of a successful quantitative evaluation of penile stimuli-evoked neuronal firing. This method is not only useful for analyzing the pathological basis of spinal cord-penile neurotransmission in sexual dysfunction but also provides a useful evaluation system in the search for new treatments.

Visual diagnosis of female genital schistosomiasis in Zambian women from hand-held colposcopy: agreement of expert image review

Female genital schistosomiasis (FGS) can occur in S. haematobium infection and is caused by parasite egg deposition in the genital tract. Confirming a diagnosis of FGS is challenging due to the lack of a diagnostic reference standard. A 2010 expert-led consensus meeting proposed visual inspection of the cervicovaginal mucosa as an adequate reference standard for FGS diagnosis. The agreement of expert human reviewers for visual-FGS has not been previously described. Methods: In two Zambian communities, non-menstruating, non-pregnant, sexually-active women aged 18-31 years participating in the HPTN 071 (PopART) Population-Cohort were enrolled in a cross-sectional study. Self-collected genital swabs and a urine specimen were collected at a home visit; trained midwives performed CVL and hand-held colposcopy at a clinic visit. S. haematobium eggs and circulating anodic antigen (CAA) were detected from urine. Two expert reviewers independently diagnosed visual-FGS as the presence of sandy patches, rubbery papules or abnormal blood vessels in digital cervicovaginal images obtained by hand-held colposcopy. PCR-FGS was defined as Schistosoma DNA detected by real-time PCR in any genital specimen (CVL or genital swab). Results: Of 527 women with cervicovaginal colposcopic images, 468/527 (88.8%) were deemed interpretable by Reviewer 1 and 417/527 (79.1%) by Reviewer 2. Visual-FGS was detected in 35.3% (165/468) of participants by expert review of colposcopic images by Reviewer 1 and in 63.6% (265/417) by Reviewer 2. Cohen's kappa statistic for agreement between the two expert reviewers was 0.16, corresponding to "slight" agreement. The reviewers made concordant diagnoses in 38.7% (204/527) participants (100 negative, 104 positive) and discordant diagnoses in 31.8% (168/527) participants. Conclusions: The unexpectedly low level of correlation between expert reviewers highlights the imperfect nature of visual diagnosis for FGS based on cervicovaginal images obtained with a hand-held colposcope. This finding is a call to action for improved point-of-care diagnostics for female genital schistosomiasis.

Improving the Response of Health Systems to Female Genital Schistosomiasis in Endemic Countries through a Gender-Sensitive Human Rights-Based Framework

The right to health was enshrined in the constitution of the World Health Organization in 1946 and in the Universal Declaration of Human Rights in 1948, which also guaranteed women's fundamental freedoms and dignity. The Declaration of Human Rights was signed by almost every country in the world. Nonetheless, gender inequalities in health and health systems continue to persist, especially in lower and middle income countries that are disproportionately affected by a litany of neglected diseases. In this paper, we focus on one of the most neglected human rights, development, and reproductive health issues globally, female genital schistosomiasis (FGS), which imposes enormous unacknowledged suffering on an estimated 56 million women and girls in Sub-Saharan Africa. Despite increasing calls for attention to FGS, no country has fully incorporated it into its health system. An appropriate response will require a comprehensive approach, guided by human rights mandates and the redress of FGS-related gender inequalities. In this paper, we propose the application of existing human rights and its clients, women, and girls affected by FGS as rights holders. Within the different components or building blocks of the health system, we propose elements of an appropriate health system response using the four components identified within the FGS Accelerated Scale Together (FAST) Package-awareness raising, prevention of infection, training of health personnel, and diagnosis and treatment. The framework is aspirational, its recommended elements and actions are not exhaustive, and countries will need to adapt it to their own situations and resource availability. However, it can be a useful guide to help health systems define how to begin to incorporate FGS into their programming in a way that responds to their human rights obligations in a gender- and culturally sensitive manner.

Establishing and Integrating a Female Genital Schistosomiasis Control Programme into the Existing Health Care System

Female genital schistosomiasis (FGS) is a complication of Schistosoma haematobium infection, and imposes a health burden whose magnitude is not fully explored. It is estimated that up to 56 million women in sub-Saharan Africa have FGS, and almost 20 million more cases will occur in the next decade unless infected girls are treated. Schistosomiasis is reported throughout the year in South Africa in areas known to be endemic, but there is no control programme. We analyze five actions for both a better understanding of the burden of FGS and reducing its prevalence in Africa, namely: (1) schistosomiasis prevention by establishing a formal control programme and increasing access to treatment, (2) introducing FGS screening, (3) providing knowledge to health care workers and communities, (4) vector control, and (5) water, sanitation, and hygiene. Schistosomiasis is focal in South Africa, with most localities moderately affected (prevalence between 10% and 50%), and some pockets that are high risk (more than 50% prevalence). However, in order to progress towards elimination, the five actions are yet to be implemented in addition to the current (and only) control strategy of case-by-case treatment. The main challenge that South Africa faces is a lack of access to WHO-accredited donated medication for mass drug administration. The establishment of a formal and funded programme would address these issues and begin the implementation of the recommended actions.

Identification of Inhibitors of the Schistosoma mansoni VKR2 Kinase Domain

Schistosomiasis is a neglected tropical disease caused by parasitic flatworms. Current treatment relies on just one partially effective drug, praziquantel (PZQ). Schistosoma mansoni Venus Kinase Receptors 1 and 2 (SmVKR1 and SmVKR2) are important for parasite growth and egg production, and are potential targets for combating schistosomiasis. VKRs consist of an extracellular Venus Flytrap Module (VFTM) linked via a transmembrane helix to a kinase domain. Here, we initiated a drug discovery effort to inhibit the activity of the SmVKR2 kinase domain (SmVKR2_KD) by screening the GSK published kinase inhibitor set 2 (PKIS2). We identified several inhibitors, of which four were able to inhibit its enzymatic activity and induced phenotypic changes in ex vivo S. mansoni. Our crystal structure of the SmVKR2_KD displays an active-like state that sheds light on the activation process of VKRs. Our data provide a basis for the further exploration of SmVKR2 as a possible drug target.

Healthcare Workers’ Low Knowledge of Female Genital Schistosomiasis and Proposed Interventions to Prevent, Control, and Manage the Disease in Zanzibar

Objectives: This study was conducted to explore healthcare workers’ knowledge of female genital schistosomiasis (FGS) and describe proposed interventions to raise awareness about FGS and strengthen healthcare facilities’ capacity to manage FGS cases.

Methods: We conducted four cross-sectional focus group discussions and 16 key informant interviews with purposively selected healthcare workers in Zanzibar. Discussions and interviews were digitally recorded, transcribed, and analyzed using NVivo software.

Results: Most participants had limited or no knowledge of FGS and lacked skills for managing it. They confused FGS with urogenital schistosomiasis and thought it was sexually transmitted. A few participants knew about FGS and associated it with Human Immunodeficiency Virus (HIV), ectopic pregnancy, cervical cancer, and infertility. To prevent and control FGS, participants proposed interventions targeting communities (including community-based health education) and the healthcare system (including training healthcare workers on FGS).

Conclusion: Healthcare workers lacked knowledge of and skills for managing FGS. Besides, healthcare facilities had no diagnostic capacity to manage FGS. Along with on-going interventions to break S. haematobium transmission and eventually eliminate urogenital schistosomiasis in Zanzibar, we recommend training healthcare workers on FGS and equip healthcare facilities with medical equipment and supplies for managing FGS.

Absence of lower genital tract lesions among women of reproductive age infected with Schistosoma mansoni: A cross-sectional study using a colposcope in Western Kenya

Background

Female genital schistosomiasis (FGS) constitutes four different lesions known to be caused by Schistosoma haematobium ova deposited in the genital tract. Schistosoma mansoni ova may also be found in the genital tract. However, it is not known if S. mansoni causes lower genital tract lesions characteristic of FGS.

Methodology

This study was conducted in 8 villages along the shores of Lake Victoria, western Kenya. Stool and urine samples, collected from women of reproductive age on three consecutive days, were analysed for S. mansoni and S. haematobium infection. S. mansoni positive and S. haematobium negative willing participants, aged 18–50 years were invited to answer a questionnaire (demographics, symptoms), undergo a gynaecological examination and cytology specimen collection by an FGS expert.

Principal findings

Gynaecologic investigations were conducted in 147 S. mansoni-positive women who had a mean infection intensity of 253.3 epg (95% CI: 194.8–311.9 epg). Nearly 90% of them used Lake Victoria as their main water source. None were found to have cervicovaginal grainy sandy patches or rubbery papules. Homogenous yellow patches were found in 12/147 (8.2%) women. Women with homogenous yellow patches were significantly older (47 years) than the rest (34 years, p = 0.001). No association was found between intensity of S. mansoni infection and homogenous yellow patches (p = 0.70) or abnormal blood vessels (p = 0.14). S. mansoni infection intensity was not associated with genital itch, bloody or malodorous vaginal discharge.

Conclusion

S. mansoni infection was neither associated with lower genital tract lesions nor symptoms typically found in women with FGS.

Female Genital Schistosomiasis Lesions Explored Using Circulating Anodic Antigen as an Indicator for Live Schistosoma Worms

Background

In areas where reinfection with schistosomiasis is rampant, it is not known if the lesions of Female Genital Schistosomaisis are a consequence of live worms, or caused by dead ova. Live schistosome worms regurgitate Circulating Anodic Antigen (CAA). We sought to explore the association between the different lesions of FGS (grainy sandy patches, homogenous yellow patches, rubbery papules and abnormal blood vessels) and the presence of live worms as indicated by S. haematobium-derived CAA in blood.

Materials and Methods

In this cross-sectional study, rural high schools were randomly selected from Ilembe, uThungulu and Ugu Districts on the East Coast of South Africa, KwaZulu-Natal Province. Serum samples for CAA analysis were collected from 246 female learners aged 16 - 23 years. Uncorrected chi-square and odds ratio with 95% confidence interval (CI) were used to evaluate the null hypothesis.

Results

CAA was positive in 82/246 (33%) of the participants. Sandy patches were found in 123 (50%) of the study population. Grainy sandy patches were significantly associated with CAA even after controlling for age (Adjusted Odds Ratio (AOR) 4.2, 95% CI 2.3 - 7.9, p &lt; 0.001). Likewise, abnormal blood vessels were associated with CAA (AOR 3.0, 95% CI 1.5-4.5, p = 0.001) whereas homogenous yellow patches were not associated with CAA (p = 0.57). Rubbery papules were not found in this study population.

Conclusion

Grainy sandy patches and abnormal blood vessels are found more commonly in women who harbour live Schistosoma haematobium worms whilst homogenous yellow patches may indicate chronic tissue damage due to dead ova.

An update on female and male genital schistosomiasis and a call to integrate efforts to escalate diagnosis, treatment and awareness in endemic and non-endemic settings: The time is now

The last decades have brought important insight and updates in the diagnosis, management and immunopathology of female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS). Despite sharing a common parasitic aetiological agent, FGS and MGS have typically been studied separately. Infection with Schistosoma haematobium manifests with gender-specific clinical manifestations and consequences of infection, albeit having a similar pathogenesis within the human genital tract. Schistosoma haematobium is a known urinary bladder carcinogen, but its potential causative role in other types of neoplasia, such as cervical cancer, is not fully understood. Furthermore, the impact of praziquantel treatment on clinical outcomes remains largely underexplored, as is the interplay of FGS/MGS with relevant reproductive tract infections such as HIV and Human Papillomavirus. In non-endemic settings, travel and immigrant health clinics need better guidance to correctly identify and treat FGS and MGS. Our review outlines the latest advances and remaining knowledge gaps in FGS and MGS research. We aim to pave a way forward to formulate more effective control measures and discuss elimination targets. With a growing community awareness in health practitioners, scientists and epidemiologists, alongside the sufferers from these diseases, we aspire to witness a new generation of young women and men free from the downstream disabling manifestations of disease.

Addressing a silent and neglected scourge in sexual and reproductive health in Sub-Saharan Africa by development of training competencies to improve prevention, diagnosis, and treatment of female genital schistosomiasis (FGS) for health workers

Background

Schistosomiasis is an acute and chronic disease caused by parasitic worms, that can take two main forms: intestinal or urogenital. If left untreated, the urogenital form can lead to female genital schistosomiasis (FGS) in women and girls; frequently resulting in severe reproductive health complications which are often misdiagnosed as sexually-transmitted infections (STIs) or can be confused with cervical cancer. Despite its impact on women’s reproductive health, FGS is typically overlooked in medical training and remains poorly recognized with low awareness both in affected communities and in health professionals. FGS has been described as the one of the most neglected sexual and reproductive health issues in sub-Saharan Africa (Swai in BMC Infect Dis 6:134, 2006; Kukula in PLoS Negl Trop Dis 13:e0007207; Joint United Nations Programme on HIV/AIDS (UNAIDS) 2019). Increased knowledge and awareness of FGS is required to end this neglect, improve women’s reproductive health, and decrease the burden of this preventable and treatable neglected tropical disease.

Methods

We conducted interactive virtual workshops, in collaboration with the World Health Organization (WHO), engaging 64 participants with medical and public health backgrounds from around the world to establish standardized skills (or competencies) for prevention, diagnosis, and treatment of FGS at all levels of the health system. The competencies were drafted in small groups, peer-reviewed, and finalized by participants.

Results

This participatory process led to identification of 27 skills needed for FGS prevention, diagnosis, and management for two categories of health workers; those working in a clinical setting, and those working in a community setting. Among them, ten relate to the diagnosis of FGS including three that involve a pelvic exam and seven that do not. Six constitute the appropriate behaviors required to treat FGS in a clinical setting. Eleven address the community setting, with six relating to the identification of women at risk and five relating to prevention.

Conclusion

Defining the skills necessary for FGS management is a critical step to prepare for proper diagnosis and treatment of women and girls in sub-Saharan Africa by trained health professionals. The suggested competencies can now serve as the foundation to create educative tools and curricula to better train health care workers on the prevention, diagnosis, and management of FGS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01252-2.

Schistosomiasis belongs to the group of neglected tropical diseases (NTDs) found in tropical and subtropical countries, disproportionately affecting poor populations with limited access to safe water and adequate sanitation. Female genital schistosomiasis (FGS) is a chronic disease caused by parasitic worms, schistososomes, transmitted by contact with infested fresh water. When left untreated, FGS can lead to severe reproductive health complications, such as sub-or infertility and ectopic pregnancy. FGS is a leading neglected issue in sexual and reproductive health in sub-Saharan Africa; however, health professionals are not familiar with it, leading to misdiagnosis and improper treatment. A critical challenge in addressing the burden of FGS is the knowledge gap about the disease in communities and health professionals in endemic areas and the world at large. As part of an FGS Accelerated Scale Together (FAST) package, and in an attempt to address the knowledge gap in health professionals, we organized an interactive workshop bringing together a group of 64 participants working in sexual and reproductive health generally, and/or FGS specifically. Together, we developed a comprehensive set of required skills for health workers training on FGS. The workshop participants drafted 27 skills (or competencies) to diagnose, treat, and prevent FGS. Establishing what health workers must know is a crucial first step towards the integration of FGS into women’s health care. The competencies are now available and can be used as a framework in the development of training for health professionals, opening the doors to better reproductive health for women.

"Female genital schistosomiasis is a sexually transmitted disease": Gaps in healthcare workers' knowledge about female genital schistosomiasis in Tanzania

Female Genital Schistosomiasis is a gynecological disease that is a complication of parasitic Schistosoma haematobium infection and affects at least 40 million girls and women, mostly in sub-Saharan Africa. Little is known about how healthcare workers in endemic areas perceive and manage (diagnose and treat) Female Genital Schistosomiasis. We conducted cross-sectional focus group discussions and key informant interviews among healthcare workers in northwestern Tanzania. Healthcare workers, particularly those working in areas where S. haematobium is highly endemic, were purposively sampled to participate in the study. Discussions and interviews were digitally recorded, transcribed, and analyzed using NVivo version 12. Most healthcare workers lacked knowledge and skills to manage Female Genital Schistosomiasis. They also had multiple misconceptions about its aetiology, modes of transmission, symptoms, and management. Healthcare workers did not consider Female Genital Schistosomiasis in differential diagnoses of women presenting with gynecologic symptoms except sometimes in patients who did not respond to the initial therapy for sexually transmitted infections. Healthcare facilities had limited capacity to manage Female Genital Schistosomiasis. Our findings show critical gaps in both the knowledge of healthcare workers to manage Female Genital Schistosomiasis and in the capacity of healthcare facilities to manage it. To fill these gaps, two urgent needs must be fulfilled: first, training healthcare workers (particularly those working in schistosomiasis-endemic settings) on Female Genital Schistosomiasis, and second, stocking healthcare facilities with necessary medical equipment and supplies for managing this disease.

The parasitology of female genital schistosomiasis

Female genital schistosomiasis (FGS) is the gynaecological presentation of Schistosoma haematobium infection, resulting from egg deposition in the female genital tract. Despite the fact that this condition has been reported in the early days of the discovery of S. haematobium in Egypt, its existence has been grossly neglected, causing many women in schistosomiasis-endemic areas to go through a preventable, debilitating, and stigmatizing presentation of FGS. To prevent this, increasing awareness of FGS is necessary for all, especially healthcare providers, to improve the diagnosis, management, and treatment. As proposed by the FAST package project, several healthcare professionals with different specializations are expected to be involved in the management of FGS. It is therefore important that basic updated knowledge on the parasitology of the disease be acquired by healthcare professionals. This review provides basic information necessary to improve the knowledge of FGS among healthcare professionals in areas endemic to schistosomiasis. Armed with these basic details, healthcare professionals can improve their confidence in the management and treatment of FGS, contributing significantly to the control and prevention of FGS in endemic areas.

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A review of female genital schistosomiasis.

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Data on the life-cycle of Schistosoma haematobium, and pathogenesis and clinical features of female genital schistosomiasis.

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Summary of diagnostic methods and treatment, control and prevention of female genital schistosomiasis.

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Increasing awareness among healthcare workers is key to the management, control, and prevention of the disease.

"We know about schistosomiasis but we know nothing about FGS": A qualitative assessment of knowledge gaps about female genital schistosomiasis among communities living in Schistosoma haematobium endemic districts of Zanzibar and Northwestern Tanzania

BACKGROUND

Schistosoma haematobium causes urogenital schistosomiasis and is widely distributed in Tanzania. In girls and women, the parasite can cause Female Genital Schistosomiasis (FGS), a gynecological manifestation of schistosomiasis that is highly neglected and overlooked by public health professionals and policy makers. This study explored community members' knowledge, attitudes and perceptions (KAP) on and health seeking behavior for FGS.

METHODS/PRINCIPAL FINDINGS

Using qualitative research methods-including 40 Focus Group Discussions (FGDs) and 37 Key Informant Interviews (KIIs)-we collected data from 414 participants (Males n = 204 [49.3%] and Females n = 210 [50.7%]). The study engaged 153 participants from Zanzibar and 261 participants from northwestern Tanzania and was conducted in twelve (12) purposively selected districts (7 districts in Zanzibar and 5 districts in northwestern Tanzania). Most participants were aware of urogenital schistosomiasis. Children were reported as the most affected group and blood in urine was noted as a common symptom especially in boys. Adults were also noted as a risk group due to their involvement in activities like paddy farming that expose them to infection. Most participants lacked knowledge of FGS and acknowledged having no knowledge that urogenital schistosomiasis can affect the female reproductive system. A number of misconceptions on the symptoms of FGS and how it is transmitted were noted. Adolescent girls and women presenting with FGS related symptoms were reported to be stigmatized, perceived as having a sexually transmitted infection (STI), and sometimes labeled as "prostitutes". Health seeking behavior for FGS included a combination of traditional medicine, self-treatment and modern medicine.

CONCLUSION/SIGNIFICANCE

Community members living in two very different areas of Tanzania exhibited major, similar gaps in knowledge about FGS. Our data illustrate a critical need for the national control program to integrate public health education about FGS during the implementation of school- and community-based mass drug administration (MDA) programs and the improvement of water, sanitation and hygiene (WASH) facilities.

The use of non-pharmaceutical interventions for the prevention and control of schistosomiasis in sub-Saharan Africa: A systematic review

Schistosomiasis remains a major cause of global parasitic morbidity. Current control strategies focus on pharmaceutical approaches using Mass Drug Administration (MDA) to distribute praziquantel in endemic areas of sub-Saharan Africa. Our paper systematically reviewed the literature on non-pharmaceutical interventions for enhanced schistosomiasis control. We conducted a systematic review of peer-reviewed English language literature using PubMed, Embase and Web of Science. Our search terms were limited to the year 2000 to March 2019 to reflect the period of the Millennium and Sustainable Development Goals. We initially identified 1733 publications, which were reduced to 1324 after screening by title and abstract. After the inclusion and exclusion criteria, a total of 1312 studies were excluded. Following this, we had a total of 12 articles, which we later screened by full text. Out of the twelve articles, seven were excluded for being systematic reviews or examining clinical and nutritional aspects of schistosomiasis control. We finally remained with five studies that met our inclusion criteria. Our paper indicates a gap in non-pharmaceutical based interventions for schistosomiasis control. We propose that future research addresses this gap by engaging communities in participatory approaches such as environmental sanitation, Water, Sanitation and Hygiene (WASH), health education and economic empowerment.

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities

BACKGROUND

Female Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey.

METHOD

A cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews.

RESULT

Amongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6-28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8-70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch.

CONCLUSION

With our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women's health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level.

Association of schistosomiasis and HIV infections: A systematic review and meta-analysis

Background:

Female genital schistosomiasis (FGS) affects up to 56 million women in sub-Saharan Africa and may increase risk of HIV infection.

Methods:

To assess the association of schistosomiasis with HIV infection, peer-reviewed literature published until 31 December 2018 was examined and a pooled estimate for the odds ratio was generated using Bayesian random effects models.

Results:

Of the 364 abstracts that were identified, 26 were included in the summary. Eight reported odds ratios of the association between schistosomiasis and HIV; one reported a transmission hazard ratio of 1.8 (95% CI, 1.2–2.6) among women and 1.4 (95% CI, 1.0–1.9) among men; 11 described the prevalence of schistosomiasis among HIV-positive people (range, 1.5–36.6%); and six reported the prevalence of HIV among people with schistosomiasis (range, 5.8–57.3%). Six studies were selected for quantitative analysis. The pooled estimate for the odds ratio of HIV among people with schistosomiasis was 2.3 (95% CI, 1.2–4.3).

Conclusions:

A significant association of schistosomiasis with HIV was found. However, a specific summary estimate for FGS could not be generated. A research agenda was provided to determine the effect of FGS on HIV infection. The WHO’s policy on mass drug administration for schistosomiasis may prevent HIV.