Detection of Schistosoma DNA in genital specimens and urine: A comparison between five female African study populations originating from S. haematobium and/or S. mansoni endemic areas

Female Genital Schistosomiasis (FGS) is a neglected disease affecting millions, however challenging to diagnose. This explorative descriptive study compares Schistosoma real-time PCR analysis of cervico-vaginal lavages (CVL) with corresponding urine and stool samples of 933 women from five different previously described study populations. Sampling included 310 women from an S. mansoni endemic region in Mwanza, Tanzania and 112 women from a nearby S. haematobium endemic region. Findings were compared with samples collected from S. haematobium endemic regions in South Africa from 394 women and from 117 women from Madagascar of which 79 were urine pre-selected microscopy positive cases from highly-endemic communities and 38 were urine microscopy negatives from a low-endemic community. As anticipated, urine and stool microscopy and gynecological investigations varied substantially between study populations; however, the same Schistosoma real-time PCR was performed in one reference laboratory. Schistosoma DNA was detected in 13% (120/933) of the CVL, ranging from 3% in the S. mansoni Tanzanian endemic region to 61% in the pre-selected Malagasy urine microscopy positive cases. Detectable Schistosoma DNA in CVL was associated with Schistosoma DNA in urine but not with microscopic detection of eggs in urine or by cytological examination. This study confirmed real-time PCR for the detection of Schistosoma DNA in gynecological samples to be a valuable diagnostic tool to study the distribution of FGS within schistosomiasis endemic areas.

Are poor responses to praziquantel for the treatment of Schistosoma mansoni infections in Senegal due to resistance? An overview of the evidence

This paper summarizes and concludes in-depth field investigations on suspected resistance of Schistosoma mansoni to praziquantel in northern Senegal. Praziquantel at 40 mg/kg usually cures 70-90% of S. mansoni infections. In an initial trial in an epidemic S. mansoni focus in northern Senegal, only 18% of the cases became parasitologically negative 12 weeks after treatment, although the reduction in mean egg counts was within normal ranges (86%). Among other hypotheses to explain the observed low cure rate in this focus, the possibility of drug resistance or tolerance had to be considered. Subsequent field trials with a shorter follow-up period (6-8 weeks) yielded cure rates of 31-36%. Increasing the dose to 2 x 30 mg/kg did not significantly improve cure rates, whereas treatment with oxamniquine at 20 mg/kg resulted in a normal cure rate of 79%. The efficacy of praziquantel in this focus could be related to age and pre-treatment intensity but not to other host factors, including immune profiles and water contact patterns. Treatment with praziquantel of individuals from the area residing temporarily in an urban region with no transmission, and re-treatment after 3 weeks of non-cured individuals within the area resulted in normal cure rates (78-88%). The application of an epidemiological model taking into account the relation between egg counts and actual worm numbers indicated that the low cure rates in this Senegalese focus could be explained by assuming a 90% worm reduction after treatment with praziquantel; in average endemic situations, such a drug efficacy would result in normal cure rates. Laboratory studies by others on the presence or absence of praziquantel resistance in Senegalese schistosome strains have so far been inconclusive. We conclude that there is no convincing evidence for praziquantel-resistant S. mansoni in Senegal, and that the low cure rates can be attributed to high initial worm loads and intense transmission in this area.

Natural progression of Oesophagostomum bifurcum pathology and infection in a rural community of northern Ghana

An estimated 250,000 people in northern Ghana and Togo are infected with the intestinal helminth parasite Oesophagostomum bifurcum, as detected by stool cultures. Clinical disease caused by O. bifurcum is responsible for about 50 cases per year at the region's central hospital, and presents as painful abdominal masses: inflammatory colonic nodules containing live juvenile stages of the helminth. In individuals living in villages highly endemic with O. bifurcum infection, colonic pathology visible by ultrasound is also highly prevalent. These nodules also contain O. bifurcum juvenile worms but are apparently asymptomatic. Thus, O. bifurcum infection and asymptomatic colonic pathology are highly prevalent within this area, but clinical disease is relatively uncommon. The natural evolution and regression of the colonic pathology in an endemic community in northern Ghana and its distribution within the population is described. Of the 299 individuals in the study group, 28% had colonic pathology at recruitment in the late-rainy season, which decreased with a half-life of 3-4 months during the dry season. Of those negative at recruitment, 28% developed nodules during the year, the majority appearing at the end of the subsequent rainy season. Children tended to have a higher prevalence and intensity of ultrasound-visible pathology compared to adults. Almost half (49%) of the study group had colonic nodules at least once during the year, and 2% of these individuals presented with clinical disease to the local hospital during the mid-rainy season.

Evaluation of density-dependent fecundity in human Schistosoma mansoni infections by relating egg counts to circulating antigens through Deming regression

Regression analysis of the relationship of serum circulating anodic and cathodic antigens (CAA and CCA), as a possible direct measure of worm burden, and fecal egg counts allows the study of phenomena like density-dependent fecundity in human Schistosoma mansoni infections. For a reliable analysis, variations in egg count measurements as well as in circulating antigen levels have to be taken into account, and an accurate estimation of these variations (represented by parameter lambda in the so-called Deming regression) is of great importance. From a new, extensive data set of repeated measurements of fecal egg counts and CAA and CCA concentrations we determined the respective values for parameter lambda, and (re)analysed the relationship between circulating antigens and egg counts in 3 data sets from Burundi, Senegal and Zaire by Deming regression. For comparison, ordinary linear regression was performed as well, which considerably biased the regression lines for CCA, but not for CAA. The analyses resulted in a clearly non-proportional relationship between egg counts and CAA, and, to a lesser extent, CCA. Assuming that egg counts and antigen measurements directly reflect egg production and worm burdens, respectively, our findings reinforce the indication of density-dependent fecundity in schistosomiasis mansoni, as suggested by others.

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

Recently, our group determined the relationship between serum CAA levels and fecal egg counts in two foci with very intense Schistosoma mansoni transmission: Maniema (Zaire), an area endemic for S. mansoni since several decades, and Ndombo (Senegal), where transmission has only been established since a few years. The objective was to study and compare age-related worm load and worm fecundity patterns in these two different endemic settings. Here, we will summarize the most important findings and conclusions of this study.

Levels of circulating soluble egg antigen in urine of individuals infected with Schistosoma mansoni before and after treatment with praziquantel

We used a recently developed sandwich enzyme-linked immunosorbent assay to determine the kinetics of Schistosoma mansoni circulating soluble egg antigen (CSEA) after chemotherapy and compared these with previously determined levels of circulating cathodic antigen (CCA). Urine samples were collected from 35 Egyptian patients with S. mansoni infection before, and one, 3 and 6 weeks after treatment. Thirteen patients were treated with 60 mg praziquantel/kg body weight and 22 patients with 40 mg/kg. Following chemotherapy, the kinetics of CSEA in urine appeared to be clearly different from those of the worm-derived antigen CCA, levels of which decreased markedly within one week after chemotherapy; CSEA levels decreased at a much lower rate. Six weeks after successful chemotherapy, CSEA could still be detected in urine of 7 cases while CCA had already disappeared and no viable egg was found by faecal examination. There was no significant difference between the 2 dose regimens during follow-up in the percentage remaining positive or in the CSEA level. These results suggest that the egg antigens detected are primarily derived from viable eggs in the tissues and might be used as a marker for morbidity.

Serum circulating egg antigen levels in two areas endemic for Schistosoma mansoni

A monoclonal antibody-based enzyme-linked immunosorbent assay detecting Schistosoma mansoni circulating soluble egg antigen (CSEA) was applied in epidemiological studies. The serum CSEA levels were determined for 2 populations with a high prevalence (> 95%) and high intensity of infection as determined by faecal egg counts. In one population (Maniema, Zaire) transmission had been occurring for several decades, while in the other population (Ndombo, Senegal) transmission had started only recently. CSEA could be detected in 88% and 70% of the serum samples from Maniema and Ndombo, respectively. The sensitivity of the CSEA assay increased with rising egg count. The age-related CSEA profiles of the Maniema population followed a pattern similar to that of egg counts and of the adult worm antigen CAA (circulating anodic antigen). However, the recently infected Ndombo population showed a clearly different profile: while the CSEA prevalence reached a peak in children and adolescents, the mean CSEA levels did not vary significantly in the different age groups. CSEA levels were significantly lower in Ndombo than in Maniema. As egg antigens in serum are thought to be in part, or even primarily, derived from eggs in the tissues, these findings indicate a relatively smaller tissue egg load in Ndombo than in Maniema.

Circulating anodic antigen levels in two areas endemic for schistosomiasis mansoni indicate differences in worm fecundity

Serum levels of the adult schistosome circulating anodic antigen (CAA) were compared in 2 populations, both living in an area with extremely high transmission levels of Schistosoma mansoni. In one focus (Maniema, eastern Zaire) transmission has been established for several decades, while in the other focus (Ndombo, northern Senegal) transmission started only recently. While parasite egg counts in the 2 populations were virtually similar, including analogous age-related distributions, serum levels of CAA were approximately 5 times higher in the chronically exposed community. This difference in antigen level was most pronounced in adolescents and adults. As the level of CAA is assumed to be a direct reflection of worm burden, these findings suggest higher parasite fecundity in the recently exposed community. It is not very likely that these observations could be explained solely by differences in clearance mechanisms caused by a variation in experience of infection. The relationship between circulating antigen levels and egg counts was consistent for all age groups in the Maniema population, while in the Ndombo population only children showed a pattern similar to that in the chronically exposed community.

Validation of a chart to estimate true Schistosoma mansoni prevalences from simple egg counts

Schistosoma mansoni egg counts by faecal examination vary considerably and are not very sensitive, so prevalences are underestimated. The distribution of egg counts can adequately be described by a stochastic model which distinguishes variation in counts between persons and variation in repeated counts within a person. Based on this model a pocket chart has been developed which predicts the proportion of individuals harbouring at least 1 S. mansoni worm pair-the 'true prevalence'-from a simple single survey prevalence and geometric mean egg count (using common duplicate 25 mg Kato-Katz smears). The current paper describes the validation of this chart by comparing predicted true prevalences with prevalences observed after 5-7 repeated Kato-Katz faecal examinations (Burundi), by examination of a large quantity of stool using the Visser filter (Brazil) or a selective sedimentation-filtration method (Surinam). Because 5-7 repeated examinations do not suffice to measure all infections, predictions have been made of the cumulative proportion positives over 5-7 surveys-the 'approximate true prevalence'-as well. After dividing the data into age groups, 12 different subsets were considered for validation. In all 12 cases, predicted true prevalences (or approximate true prevalences for the Burundi data) agree well with those observed. The overall agreement depends only slightly on the assumed relationship between worm numbers and mean egg counts, with a good fit for a productivity between 0.8 and 4.4 eggs per gramme faeces (EPG) per worm pair (WP). This interval includes the most plausible value from the literature, i.e. 1.0 EPG/WP, which has been applied in the initial pocket chart. These findings support the validity of the chart to predict true prevalences for a wide range of productivity assumptions, and reinforces the applicability of its underlying stochastic model to describe egg count variation. However, as predictions appear to vary importantly when using only part of the data, it is also concluded that the pocket chart never compensates for limited validity of initial single survey prevalences and geometric means in consequence of small sample sizes.

Circulating antigen levels in serum of cattle naturally infected with Schistosoma mattheei

Levels of 2 Schistosoma circulating antigens, the circulating anodic antigen (CAA) and the circulating cathodic antigen (CCA), were determined in serum samples collected, on a monthly basis over a period of 1.5 years, from 32 farm animals of different ages and from 12 tracer calves exposed to Schistosoma mattheei infection on a Zambian farm. Faecal egg counts were monitored in all animals and worm burdens in tracers determined after perfusion. Antigen determination tests in serum, with sensitivities between 95 and 100% in heifers and adult cows, proved to be excellent tools for the diagnosis of cattle schistosomiasis. Also in young calves, some infections could be demonstrated earlier by CCA determination than by faecal egg examination. A poor correlation was seen between the data for faecal egg counts and for CAA and CCA levels. It therefore appears that circulating antigen measurements in serum are of limited value as indicators of the pathogenesis of infection in cattle. Although all tracer calves were found infected at perfusion, large variations were recorded in antigen levels. An unexpected finding was the observation in farm animals of a clear seasonal pattern in CAA levels, with significant increase between August and October during the second half of the dry season, when animals are subjected to heavy physical and nutritional stress. It therefore appears that, although circulating antigen determination may provide an indication of the worm burden in ageing infections, possible variations of antigen clearance rate with the physiological condition of the host may complicate the interpretation of the results.

Analysis of worm burden variation in human Schistosoma mansoni infections by determination of serum levels of circulating anodic antigen and circulating cathodic antigen

Serum circulating anodic antigen (CAA) and circulating cathodic antigen (CCA) concentrations, as a possible direct measure of worm burden, were compared with fecal egg counts in a heavily Schistosoma mansoni-infected population from Zaire to allow differentiation between worm loads and worm fecundity in relation to age and intensity of infection. Of the 517 subjects, 95% excreted eggs and 97% demonstrated circulating antigens. Fecal egg counts showed an age-related pattern characteristic for an area in which schistosomiasis is endemic with intense transmission levels. Regression analysis showed that antigen concentrations were strongly associated with egg counts. For CAA, but not for CCA, this relation was found to be nonlinear, which would be consistent with density-dependent fecundity or crowding. The trend was uniform for all age groups, which for this particular population indicated a genuine reduction of worm loads rather than reduced worm fecundity with age of the host.

Epidemiologic application of circulating antigen detection in a recent Schistosoma mansoni focus in northern Senegal

Quantitative enzyme-linked immunosorbent assays (ELISAs) for the detection of circulating anodic antigen (CAA) and circulating cathodic antigen (CCA) in serum and urine were applied as an epidemiologic tool in a recent, intense focus of Schistosoma mansoni in Senegal. Both CAA and CCA in serum and CCA in urine were found in 94%, 83%, and 95%, respectively, of the population, of which 91% were positive on stool examination. Circulating antigens were also detectable in sera and urines of most egg-negative individuals. The sensitivities of the urine CCA and serum CAA ELISA were substantially higher than that of a single egg count, and increased with egg output. The CAA and CCA levels correlated well with egg counts and with each other. The age-related evolution of antigen levels followed a similar pattern as egg counts, providing supplementary evidence for a genuine reduction of worm burdens in adults in spite of the supposed absence of acquired immunity in this recently exposed community. The antigen:egg ratios decreased in adults, suggesting lower worm fecundity in children. This would be compatible with a density-dependent reduction of fecundity, but not with anti-fecundity immunity in adults that perhaps has not yet developed in this new focus.

Serum levels of circulating anodic antigen and circulating cathodic antigen detected in mice infected with Schistosoma japonicum or S. mansoni

Serum concentrations of circulating anodic antigen (CAA) and circulating cathodic antigen (CCA) were studied in mice infected with either Schistosoma japonicum or S. mansoni cercariae. Sera from uninfected mice were negative for both antigens. CAA was detectable in the S. japonicum-infected mice as early as at 2 weeks post-infection (p.i.), and levels were higher in these animals than in the S. mansoni-infected group during the full study period. At the moment of perfusion, 10 weeks p.i., a median of 9 and 29 worms, respectively, were recovered from the S. japonicum- and S. mansoni-infected mice, and the median CAA levels were 326 and 27 ng/ml, respectively. In contrast, CCA levels were much lower in the S. japonicum-infected group (27 ng/ml) as compared with the S. mansoni-infected mice (282 ng/ml). These results suggest an important difference between S. japonicum and S. mansoni infections in CAA and CCA production and/or clearance and indicate a significant role for CAA in the diagnosis of human schistosomiasis japonicum.

Immunodiagnosis of schistosomiasis mansoni in a low endemic area in Surinam by determination of the circulating antigens CAA and CCA

We evaluated the applicability of circulating antigen detection in serum and urine for the diagnosis of Schistosoma infections in a low endemic area. In total 389 individuals from Saramacca (Surinam) participated in the survey. Stool samples were examined using the Kato method, while circulating anodic antigen (CAA) and circulating cathodic antigen (CCA) were determined by highly specific monoclonal antibody-based ELISA's. Also schistosome specific IgM antibodies were measured by the indirect immunofluorescence assay, but the diagnostic performance of this test was found to be poor in this population. S. mansoni eggs were found in 29% of the examined cases, while CAA and CCA could be demonstrated in 23% and 17% of the serum samples and in 3% and 28% of the urine samples, respectively. Forty three percent of the study population was positive in at least one of these diagnostic assays, indicating that each individual test misses a substantial part of the subjects with an active infection. In most positive cases, intensities of infection were very low. As 204 individuals participated in all screening assays, diagnostic performance of each test was evaluated in this sub-population. The highest sensitivities were achieved with the urine-CCA assay and the parasitological examination, detecting 59 and 58 out of the 107 cases with an active infection, respectively. The serum-CAA assay detected 47 positive cases. Our results demonstrate that determination of circulating antigens, especially CCA in urine and CAA in serum, provides information additional to the parasitological examination, for the assessment of prevalence and intensity of Schistosoma infection in low endemic areas.

Evaluation of an ELISA for combined measurement of CAA and CCA in schistosomiasis mansoni

An enzyme-linked immunosorbent assay was developed for combined measurement of schistosome circulating anodic antigen (CAA) and circulating cathodic antigen (CCA). Monoclonal antibodies against CAA and CCA were used as coating and as fluorescein-labeled detecting antibodies in a FITC-anti-FITC system. The lower detection limit of the assay was 1.1 ng antigen (AWA-TCA)/ml. Serum samples of Schistosoma mansoni infected individuals from Zaire (n = 60) and Burundi (n = 60) were tested in this assay and in single-antigen ELISAs. Sensitivities of assaying for CAA, CCA, combined CAA + CCA, and of parallel testing for CAA and for CCA were calculated from titres and antigen concentrations. With serum samples from the heavily infected individuals (Zaire), all assays had a sensitivity of 97% or higher. In contrast, with serum samples from individuals from Burundi (low to moderate infections) it was shown that combined testing resulted in a slightly lower sensitivity than testing for individual antigens. By parallel testing for CAA and CCA, the sensitivity could be increased considerably (to 95%), however.

Improved diagnostic performance of the circulating antigen assay in human schistosomiasis by parallel testing for circulating anodic and cathodic antigens in serum and urine

Serum and urine levels of two Schistosoma circulating antigens, the circulating anodic antigen (CAA) and the circulating cathodic antigen (CCA), were determined by monoclonal antibody-based enzyme-linked immunosorbent assays in 56 Egyptian patients infected with S. mansoni and in 12 patients infected with both S. mansoni and S. haematobium. Both CAA and CCA could be specifically demonstrated in 82% and 88% of the serum samples and in 88% and 87% of the urine samples, respectively. While complete specificity was maintained, sensitivity was increased to a range of 91-98% by parallel use of the two circulating antigen assays, i.e., an individual with a positive titer for at least one of the assays was considered to be infected. A combination of CAA and CCA determinations in urine samples only resulted in a sensitivity of 94%. However, the highest sensitivity was achieved when the serum-CCA assay was combined with the urine-CCA assay (98%) or with the urine-CAA assay (97%). Sensitivity could not be increased further by combining more than two tests. A significant correlation was demonstrated between the level of circulating antigen and the number of parasite eggs in feces in each of the four assays. In addition, the levels of CAA and CCA in serum and urine were significantly correlated with each other. Our results indicate that diagnosis of schistosome infections by detection of circulating antigens can be significantly improved by parallel testing for multiple antigens.