We aimed to map the probability of Schistosoma haematobium infection being >50%, a threshold for ... more We aimed to map the probability of Schistosoma haematobium infection being >50%, a threshold for annual mass praziquantel distribution. Parasitologic surveys were conducted in Burkina Faso, Mali, and Niger, 2004-2006, and predictions were made by using Bayesian geostatistical models. Clusters with >50% probability of having >50% prevalence were delineated in each country.
The development of new diagnostics is an important tool in the fight against disease. Latent Clas... more The development of new diagnostics is an important tool in the fight against disease. Latent Class Analysis (LCA) is used to estimate the sensitivity and specificity of tests in the absence of a gold standard. The main field diagnostic for Schistosoma mansoni infection, Kato-Katz (KK), is not very sensitive at low infection intensities. A point-of-care circulating cathodic antigen (CCA) test has been shown to be more sensitive than KK. However, CCA can return an ambiguous 'trace' result between 'positive' and 'negative', and much debate has focused on interpretation of traces results. We show how LCA can be extended to include ambiguous trace results and analyse S. mansoni studies from both Côte d'Ivoire (CdI) and Uganda. We compare the diagnostic performance of KK and CCA and the observed results by each test to the estimated infection prevalence in the population. Prevalence by KK was higher in CdI (13.4%) than in Uganda (6.1%), but prevalence by CCA wa...
The cornerstone of current schistosomiasis control programmes is delivery of praziquantel to at-r... more The cornerstone of current schistosomiasis control programmes is delivery of praziquantel to at-risk populations. Such preventive chemotherapy requires accurate information on the geographic distribution of infection, yet the performance of alternative survey designs for estimating prevalence and converting this into treatment decisions has not been thoroughly evaluated. We used baseline schistosomiasis mapping surveys from three countries (Malawi, Côte d'Ivoire and Liberia) to generate spatially realistic gold standard datasets, against which we tested alternative two-stage cluster survey designs. We assessed how sampling different numbers of schools per district (2-20) and children per school (10-50) influences the accuracy of prevalence estimates and treatment class assignment, and we compared survey cost-efficiency using data from Malawi. Due to the focal nature of schistosomiasis, up to 53% simulated surveys involving 2-5 schools per district failed to detect schistosomiasi...
Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MD... more Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MDA). Community-directed MDA relies on volunteer community medicine distributors (CMDs) and their achievement of high coverage and compliance. Yet, it is unknown if village social networks influence effective MDA implementation by CMDs. In Mayuge District, Uganda, census-style surveys were conducted for 16,357 individuals from 3,491 households in 17 villages. Praziquantel, albendazole, and ivermectin were administered for one month in community-directed MDA to treat Schistosoma mansoni, hookworm, and lymphatic filariasis. Self-reported treatment outcomes, socioeconomic characteristics, friendship networks, and health advice networks were collected. We investigated systematically missed coverage and noncompliance. Coverage was defined as an eligible person being offered at least one drug by CMDs; compliance included ingesting at least one of the offered drugs. These outcomes were analyzed a...
Background: Soil-transmitted helminth (STH) infections are amongst the most prevalent infections ... more Background: Soil-transmitted helminth (STH) infections are amongst the most prevalent infections in the world. Mass drug administration (MDA) programmes have become the most commonly used national interventions for endemic countries to achieve elimination. This paper aims to describe the effect of an 8-year MDA programme on the prevalence, intensity of infection and co-infection of STH in Burundi from 2007 to 2014 and critically appraise the trajectory towards STH elimination in the country. Results: Annual STH parasitological surveys (specifically, a "pilot study" from 2007 to 2011, an "extension study" from 2008 to 2011, and a "national reassessment" in 2014; n = 27,658 children), showed a significant drop in prevalence of infection with any STH ("pooled STH") between baseline and 2011 in both studies, falling from 32 to 16 % in the pilot study, and from 35 to 16 % in the extension study. Most STH infections were of low intensity according to WHO classification. The national reassessment in 2014 showed that prevalence of pooled STH remained significantly below the prevalence in 2007 in both studies but there was no further decrease in STH prevalence from 2011 levels during this time. Spatial dependence analysis showed that prevalence of Trichuris trichiura and Ascaris lumbricoides had a tendency to cluster over the years, whilst only trends in spatial dependence were evident for hookworm infections. Spatial dependence fluctuated over the course of the programme for Ascaris lumbricoides and Trichuris trichiura. However, spatial trends in spatial dependence were evident in 2010 for Ascaris lumbricoides. Analysis of spatial clustering of intensity of infection and heavy infections revealed that the intensity changed over time for all parasites. Heavy intensity was only evident in Ascaris lumbricoides for 2008 and did not appear in proceeding years and other parasites. Conclusions: These results demonstrate that sustained annual MDA significantly reduced the prevalence of STH infection in school-age children but was unable to achieve elimination. Additionally, significant decline in prevalence was accompanied by a drop in spatial clustering of infection indicators across all sites from 2008. The lack of consistency in the results of the spatial dependence analysis highlights that MDA programmes can interrupt the normal transmission dynamics of STH parasites.
The association of anaemia with intestinal schistosomiasis and hookworm infections are poorly exp... more The association of anaemia with intestinal schistosomiasis and hookworm infections are poorly explored in populations that are not limited to children or pregnant women. We sampled 1,832 individuals aged 5-90 years from 30 communities in Mayuge District, Uganda. Demographic, village, and parasitological data were collected. Infection risk factors were compared in ordinal logistic regressions. Anaemia and infection intensities were analyzed in multilevel models, and population attributable fractions were estimated. Household and village-level predictors of Schistosoma mansoni and hookworm were opposite in direction or significant for single infections. S. mansoni was found primarily in children, whereas hookworm was prevalent amongst the elderly. Anaemia was more prevalent in individuals with S. mansoni and increased by 2.86 fold (p-value<0.001) with heavy S. mansoni infection intensity. Individuals with heavy hookworm were 1.65 times (p-value = 0.008) more likely to have anaemia ...
Background: Over 200,000 people, most of them infected with Schistosoma mansoni inhabit 150 islan... more Background: Over 200,000 people, most of them infected with Schistosoma mansoni inhabit 150 islands in Lake Victoria in Uganda. Although a programme to control the disease has been ongoing since 2003, its implementation in islands is inadequate due to high transport costs on water. In 2011 and 2012, the Global Network for Neglected Tropical Diseases (GNNTD) through Schistosomiasis Control Initiative (SCI) provided financial support to ease treatment delivery on the islands and over the period, therapeutic coverage has been increasing. We conducted a study with an objective to assess community awareness of existence of the disease, its signs, symptoms, causes and transmission as well as attitude, practice and health seeking behavior. Methods: This was a cross sectional descriptive study which used pre-tested interviewer administered questionnaire among purposively selected individuals in schools, health facilities and communities. Frequency distribution tables, graphs and cross tabulations were the main forms of data presentation.
Background: In 2004 Niger established a large scale schistosomiasis and soil-transmitted helminth... more Background: In 2004 Niger established a large scale schistosomiasis and soil-transmitted helminths control programme targeting children aged 5-14 years and adults. In two years 4.3 million treatments were delivered in 40 districts using school based and community distribution. Method and Findings: Four districts were surveyed in 2006 to estimate the economic cost per district, per treatment and per schistosomiasis infection averted. The study compares the costs of treatment at start up and in a subsequent year, identifies the allocation of costs by activity, input and organisation, and assesses the cost of treatment. The cost of delivery provided by teachers is compared to cost of delivery by community distributers (CDD). The total economic cost of the programme including programmatic, national and local government costs and international support in four study districts, over two years, was US$ 456,718; an economic cost/treatment of $0.58. The full economic delivery cost of school based treatment in 2005/06 was $0.76, and for community distribution was $0.46. Including only the programme costs the figures are $0.47 and $0.41 respectively. Differences at sub-district are more marked. This is partly explained by the fact that a CDD treats 5.8 people for every one treated in school. The range in cost effectiveness for both direct and direct and indirect treatments is quantified and the need to develop and refine such estimates is emphasised. Conclusions: The relative cost effectiveness of school and community delivery differs by country according to the composition of the population treated, the numbers targeted and treated at school and in the community, the cost and frequency of training teachers and CDDs. Options analysis of technical and implementation alternatives including a financial analysis should form part of the programme design process.
SUMMARYA primary objective of schistosomiasis control programmes is to achieve, and hence also de... more SUMMARYA primary objective of schistosomiasis control programmes is to achieve, and hence also demonstrate, a quantifiable reduction in schistosome-associated morbidity as a consequence of chemotherapeutic intervention. Inherent within such an objective, it is necessary to define and validate direct and indirect indicators of schistosome-related morbidity. However, to define and thereby document such morbidity, and its reduction following treatment, may not be straightforward, particularly for intestinal schistosomiasis-induced morbidity, which is often not apparent in all but the most severe or chronic cases. Within all ‘Schistosomiasis Control Initiative’ activities, across selected sub-Saharan African countries since 2002, a range of standard and novel potential morbidity markers have been monitored and evaluated. Parasitological intensity measures, combined with haemoglobin/anaemia counts and ultrasonography, proved valuable schistosomiasis-related morbidity indicators, being bo...
See the editorial commentary by King, on pages 653-5.) Background. In sub-Saharan Africa, 112 mil... more See the editorial commentary by King, on pages 653-5.) Background. In sub-Saharan Africa, 112 million people are infected with Schistosoma haematobium, with the most intense infections in children 5-15 years old. Methods. We describe a longitudinal epidemiological study that evaluates the relationship between S. haematobium infection and associated morbidity in children before and after the large-scale administration of praziquantel for schistosomiasis and albendazole for soil-transmitted helminths. Results. At baseline, higher intensities of S. haematobium infection were observed in children with anemia and/or severe microhematuria, but there was no apparent association between the risk of undernutrition and intensity of S. haematobium infection. Significant reductions in the prevalence and intensity of S. haematobium infection 1 year after treatment were, however, observed. Children who benefited the most from anthelmintic treatment in terms of increased hemoglobin concentrations were those who had anemia at baseline and those with highly positive microhematuria scores at baseline. Conclusions. This study suggests that even a single round of mass chemotherapy can have a substantial impact on S. haematobium infection and its associated morbidity in children.
Background: Over 1 billion of the world's poorest inhabitants are afflicted by neglected tropical... more Background: Over 1 billion of the world's poorest inhabitants are afflicted by neglected tropical diseases (NTDs). Integrated control programmes aimed at tackling these debilitating NTDs have been recently initiated, mainly using preventative chemotherapy. Monitoring and evaluation (M&E) of these integrated programs presents particular challenges over and above those required for single disease vertical programmes. We used baseline data from the National NTD Control Programme in Burkina Faso in order to assess the feasibility of an integrated survey design, as well as to elucidate the contribution of environmental variables to the risk of either Schistosoma haematobium, trachoma, or both among school-aged children. Methods: S. haematobium infection was diagnosed by detecting eggs in urine. A trachoma case was defined by the presence of Trachomatous inflammation-Follicular (TF) and/or Trachomatous inflammation-Intense (TI) in either eye. Baseline data collected from 3,324 children aged 7-11 years in 21 sentinel sites across 11 regions of Burkina Faso were analyzed using simple and multivariable hierarchical binomial logistic regression models fitted by Markov Chain Monte Carlo estimation methods. Probabilities of the risk of belonging to each infection/disease category were estimated as a function of age, gender (individual level), and environmental variables (at sentinel site level, interpolated from national meteorological stations). Results: Overall prevalence at the sentinel sites was 11.79% (95% CI: 10.70-12.89) for S. haematobium; 13.30% (12.14-14.45) for trachoma and 0.84% (0.53-1.15) for co-infections. The only significant predictor of S. haematobium infection was altitude. There were significant negative associations between the prevalence of active trachoma signs and minimum temperature, and air pressure. Conditional upon these predictors, these data are consistent with the two pathogens being independent.
Background It is widely advocated that integrated strategies for the control of neglected tropica... more Background It is widely advocated that integrated strategies for the control of neglected tropical diseases (NTDs) are cost-effective in comparison to vertical disease-specific programmes. A prerequisite for implementation of control interventions is the availability of baseline data of prevalence, including the population at risk and disease overlap. Despite extensive literature on the distribution of schistosomiasis on the mainland in Uganda, there has been a knowledge gap for the prevalence of co-infections with malaria, particularly for island communities in Lake Victoria. In this study, nine lakeshore and island districts were surveyed for the prevalence of NTDs and malaria, as well as educational and health infrastructure. Results A total of 203 communities were surveyed, including over 5000 school-age children. Varying levels of existing health infrastructure were observed between districts, with only Jinja District regularly treating people for NTDs. Community medicine distr...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 25, 2015
Repeated mass drug administration (MDA) with preventive chemotherapies (PCs) is the mainstay of ... more Repeated mass drug administration (MDA) with preventive chemotherapies (PCs) is the mainstay of morbidity control for schistosomiasis and soil-transmitted helminths. Yet, the World Health Organization (WHO) recently reported that less than one third of individuals who required PCs received treatment. Coverage of community-directed treatment with praziquantel and albendazole was analyzed in 17 villages of Mayuge District, Uganda. National drug registers, household questionnaires, and parasitological surveys were collected to track 935 individuals before and after MDA. Multilevel logistic regressions, including household and village effects, were specified with a comprehensive set of socioeconomic and parasitological variables. The factors predicting who does not receive praziquantel and albendazole from community medicine distributors were identified. Drug receipt was correlated amongst members within a household and non-recipients of praziquantel or albendazole were profiled by h...
SUMMARYSchistosomiasis remains one of the most prevalent parasitic diseases in developing countri... more SUMMARYSchistosomiasis remains one of the most prevalent parasitic diseases in developing countries. After malaria, schistosomiasis is the most important tropical disease in terms of human morbidity with significant economic and public health consequences. Although schistosomiasis has recently attracted increased focus and funding for control, it has been estimated that less than 20% of the funding needed to control the disease in Africa is currently available. In this article the following issues are discussed: the rationale, development and objectives of the Schistosomiasis Control Initiative (SCI)-supported programmes; the management approaches followed to achieve implementation by each country; mapping, monitoring and evaluation activities with quantifiable impact of control programmes; monitoring for any potential drug resistance; and finally exit strategies within each country. The results have demonstrated that morbidity due to schistosomiasis has been reduced by the control ...
During routine parasitological surveillance and monitoring activities within a National Control P... more During routine parasitological surveillance and monitoring activities within a National Control Programme for control of human schistosomiasis in Uganda, it was noted that cattle grazing in a water meadow immediately adjacent to Tonya primary school, where the prevalence of intestinal schistosomiasis in children was in excess of 90%, were unusually emaciated. To test the hypothesis that there may have been an anthropozoonotic focus of Schistosoma mansoni within the local herd, a young female heifer, clearly emaciated and c. 8 months old, was slaughtered from which schistosome worms were later recovered by dissection. As female worms inspected by microscopy were not gravid, morphological identification proved inconclusive but analysis of cytochome oxidase subunit I (COI) and small subunit (SSU) ribosomal DNA sequences from these worms identified them as Schistosoma bovis Sonsino, 1876. This is the first substantiated report of S. bovis from Lake Albert, western Uganda. Further epidem...
Background: To date schistosomiasis control programmes based on chemotherapy have largely aimed a... more Background: To date schistosomiasis control programmes based on chemotherapy have largely aimed at controlling morbidity in treated individuals rather than at suppressing transmission. In this study, a mathematical modelling approach was used to estimate reductions in the rate of Schistosoma mansoni reinfection following annual mass drug administration (MDA) with praziquantel in Uganda over four years (2003-2006). In doing this we aim to elucidate the benefits of MDA in reducing community transmission. Methods: Age-structured models were fitted to a longitudinal cohort followed up across successive rounds of annual treatment for four years (Baseline: 2003, Treatment: 2004-2006; n = 1,764). Instead of modelling contamination, infection and immunity processes separately, these functions were combined in order to estimate a composite force of infection (FOI), i.e., the rate of parasite acquisition by hosts. Results: MDA achieved substantial and statistically significant reductions in the FOI following one round of treatment in areas of low baseline infection intensity, and following two rounds in areas with high and medium intensities. In all areas, the FOI remained suppressed following a third round of treatment. Conclusions/Significance: This study represents one of the first attempts to monitor reductions in the FOI within a largescale MDA schistosomiasis morbidity control programme in sub-Saharan Africa. The results indicate that the Schistosomiasis Control Initiative, as a model for other MDA programmes, is likely exerting a significant ancillary impact on reducing transmission within the community, and may provide health benefits to those who do not receive treatment. The results obtained will have implications for evaluating the cost-effectiveness of schistosomiasis control programmes and the design of monitoring and evaluation approaches in general.
Schistosomiasis is a chronic and poverty-promoting disease that affects over 200 million people a... more Schistosomiasis is a chronic and poverty-promoting disease that affects over 200 million people and inflicts a considerable public health burden across large parts of the developing world. Yet, schistosomiasis remains one of the so-called ‘neglected tropical diseases’ because it affects poor populations mostly in rural areas. The distribution of schistosomiasis is focal, since transmission is governed by human water contact activities in freshwater bodies supporting intermediate host snails, and lack of access to clean water and adequate sanitation. Schistosomiasis should not be a major cause of morbidity because there is an effective treatment, and transmission could be broken by improved water supply and sanitation facilities. Indeed, schistosomiasis has been eliminated as a result of socioeconomic development and integrated control approaches from several countries, including Japan and Tunisia. However, in many parts of Africa, schistosomiasis has increased during the 20th century as a result of water resource development projects combined with population immigration without adequate provision of sanitation. In the new millennium there is renewed hope of schistosomiasis control as awareness and political will have increased, and large-scale morbidity control programs are underway, facilitated by praziquantel, a safe, efficacious, and inexpensive drug, and advocacy from the World Health Organization.
We aimed to map the probability of Schistosoma haematobium infection being >50%, a threshold for ... more We aimed to map the probability of Schistosoma haematobium infection being >50%, a threshold for annual mass praziquantel distribution. Parasitologic surveys were conducted in Burkina Faso, Mali, and Niger, 2004-2006, and predictions were made by using Bayesian geostatistical models. Clusters with >50% probability of having >50% prevalence were delineated in each country.
The development of new diagnostics is an important tool in the fight against disease. Latent Clas... more The development of new diagnostics is an important tool in the fight against disease. Latent Class Analysis (LCA) is used to estimate the sensitivity and specificity of tests in the absence of a gold standard. The main field diagnostic for Schistosoma mansoni infection, Kato-Katz (KK), is not very sensitive at low infection intensities. A point-of-care circulating cathodic antigen (CCA) test has been shown to be more sensitive than KK. However, CCA can return an ambiguous 'trace' result between 'positive' and 'negative', and much debate has focused on interpretation of traces results. We show how LCA can be extended to include ambiguous trace results and analyse S. mansoni studies from both Côte d'Ivoire (CdI) and Uganda. We compare the diagnostic performance of KK and CCA and the observed results by each test to the estimated infection prevalence in the population. Prevalence by KK was higher in CdI (13.4%) than in Uganda (6.1%), but prevalence by CCA wa...
The cornerstone of current schistosomiasis control programmes is delivery of praziquantel to at-r... more The cornerstone of current schistosomiasis control programmes is delivery of praziquantel to at-risk populations. Such preventive chemotherapy requires accurate information on the geographic distribution of infection, yet the performance of alternative survey designs for estimating prevalence and converting this into treatment decisions has not been thoroughly evaluated. We used baseline schistosomiasis mapping surveys from three countries (Malawi, Côte d'Ivoire and Liberia) to generate spatially realistic gold standard datasets, against which we tested alternative two-stage cluster survey designs. We assessed how sampling different numbers of schools per district (2-20) and children per school (10-50) influences the accuracy of prevalence estimates and treatment class assignment, and we compared survey cost-efficiency using data from Malawi. Due to the focal nature of schistosomiasis, up to 53% simulated surveys involving 2-5 schools per district failed to detect schistosomiasi...
Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MD... more Over 1.9 billion individuals require preventive chemotherapy through mass drug administration (MDA). Community-directed MDA relies on volunteer community medicine distributors (CMDs) and their achievement of high coverage and compliance. Yet, it is unknown if village social networks influence effective MDA implementation by CMDs. In Mayuge District, Uganda, census-style surveys were conducted for 16,357 individuals from 3,491 households in 17 villages. Praziquantel, albendazole, and ivermectin were administered for one month in community-directed MDA to treat Schistosoma mansoni, hookworm, and lymphatic filariasis. Self-reported treatment outcomes, socioeconomic characteristics, friendship networks, and health advice networks were collected. We investigated systematically missed coverage and noncompliance. Coverage was defined as an eligible person being offered at least one drug by CMDs; compliance included ingesting at least one of the offered drugs. These outcomes were analyzed a...
Background: Soil-transmitted helminth (STH) infections are amongst the most prevalent infections ... more Background: Soil-transmitted helminth (STH) infections are amongst the most prevalent infections in the world. Mass drug administration (MDA) programmes have become the most commonly used national interventions for endemic countries to achieve elimination. This paper aims to describe the effect of an 8-year MDA programme on the prevalence, intensity of infection and co-infection of STH in Burundi from 2007 to 2014 and critically appraise the trajectory towards STH elimination in the country. Results: Annual STH parasitological surveys (specifically, a "pilot study" from 2007 to 2011, an "extension study" from 2008 to 2011, and a "national reassessment" in 2014; n = 27,658 children), showed a significant drop in prevalence of infection with any STH ("pooled STH") between baseline and 2011 in both studies, falling from 32 to 16 % in the pilot study, and from 35 to 16 % in the extension study. Most STH infections were of low intensity according to WHO classification. The national reassessment in 2014 showed that prevalence of pooled STH remained significantly below the prevalence in 2007 in both studies but there was no further decrease in STH prevalence from 2011 levels during this time. Spatial dependence analysis showed that prevalence of Trichuris trichiura and Ascaris lumbricoides had a tendency to cluster over the years, whilst only trends in spatial dependence were evident for hookworm infections. Spatial dependence fluctuated over the course of the programme for Ascaris lumbricoides and Trichuris trichiura. However, spatial trends in spatial dependence were evident in 2010 for Ascaris lumbricoides. Analysis of spatial clustering of intensity of infection and heavy infections revealed that the intensity changed over time for all parasites. Heavy intensity was only evident in Ascaris lumbricoides for 2008 and did not appear in proceeding years and other parasites. Conclusions: These results demonstrate that sustained annual MDA significantly reduced the prevalence of STH infection in school-age children but was unable to achieve elimination. Additionally, significant decline in prevalence was accompanied by a drop in spatial clustering of infection indicators across all sites from 2008. The lack of consistency in the results of the spatial dependence analysis highlights that MDA programmes can interrupt the normal transmission dynamics of STH parasites.
The association of anaemia with intestinal schistosomiasis and hookworm infections are poorly exp... more The association of anaemia with intestinal schistosomiasis and hookworm infections are poorly explored in populations that are not limited to children or pregnant women. We sampled 1,832 individuals aged 5-90 years from 30 communities in Mayuge District, Uganda. Demographic, village, and parasitological data were collected. Infection risk factors were compared in ordinal logistic regressions. Anaemia and infection intensities were analyzed in multilevel models, and population attributable fractions were estimated. Household and village-level predictors of Schistosoma mansoni and hookworm were opposite in direction or significant for single infections. S. mansoni was found primarily in children, whereas hookworm was prevalent amongst the elderly. Anaemia was more prevalent in individuals with S. mansoni and increased by 2.86 fold (p-value<0.001) with heavy S. mansoni infection intensity. Individuals with heavy hookworm were 1.65 times (p-value = 0.008) more likely to have anaemia ...
Background: Over 200,000 people, most of them infected with Schistosoma mansoni inhabit 150 islan... more Background: Over 200,000 people, most of them infected with Schistosoma mansoni inhabit 150 islands in Lake Victoria in Uganda. Although a programme to control the disease has been ongoing since 2003, its implementation in islands is inadequate due to high transport costs on water. In 2011 and 2012, the Global Network for Neglected Tropical Diseases (GNNTD) through Schistosomiasis Control Initiative (SCI) provided financial support to ease treatment delivery on the islands and over the period, therapeutic coverage has been increasing. We conducted a study with an objective to assess community awareness of existence of the disease, its signs, symptoms, causes and transmission as well as attitude, practice and health seeking behavior. Methods: This was a cross sectional descriptive study which used pre-tested interviewer administered questionnaire among purposively selected individuals in schools, health facilities and communities. Frequency distribution tables, graphs and cross tabulations were the main forms of data presentation.
Background: In 2004 Niger established a large scale schistosomiasis and soil-transmitted helminth... more Background: In 2004 Niger established a large scale schistosomiasis and soil-transmitted helminths control programme targeting children aged 5-14 years and adults. In two years 4.3 million treatments were delivered in 40 districts using school based and community distribution. Method and Findings: Four districts were surveyed in 2006 to estimate the economic cost per district, per treatment and per schistosomiasis infection averted. The study compares the costs of treatment at start up and in a subsequent year, identifies the allocation of costs by activity, input and organisation, and assesses the cost of treatment. The cost of delivery provided by teachers is compared to cost of delivery by community distributers (CDD). The total economic cost of the programme including programmatic, national and local government costs and international support in four study districts, over two years, was US$ 456,718; an economic cost/treatment of $0.58. The full economic delivery cost of school based treatment in 2005/06 was $0.76, and for community distribution was $0.46. Including only the programme costs the figures are $0.47 and $0.41 respectively. Differences at sub-district are more marked. This is partly explained by the fact that a CDD treats 5.8 people for every one treated in school. The range in cost effectiveness for both direct and direct and indirect treatments is quantified and the need to develop and refine such estimates is emphasised. Conclusions: The relative cost effectiveness of school and community delivery differs by country according to the composition of the population treated, the numbers targeted and treated at school and in the community, the cost and frequency of training teachers and CDDs. Options analysis of technical and implementation alternatives including a financial analysis should form part of the programme design process.
SUMMARYA primary objective of schistosomiasis control programmes is to achieve, and hence also de... more SUMMARYA primary objective of schistosomiasis control programmes is to achieve, and hence also demonstrate, a quantifiable reduction in schistosome-associated morbidity as a consequence of chemotherapeutic intervention. Inherent within such an objective, it is necessary to define and validate direct and indirect indicators of schistosome-related morbidity. However, to define and thereby document such morbidity, and its reduction following treatment, may not be straightforward, particularly for intestinal schistosomiasis-induced morbidity, which is often not apparent in all but the most severe or chronic cases. Within all ‘Schistosomiasis Control Initiative’ activities, across selected sub-Saharan African countries since 2002, a range of standard and novel potential morbidity markers have been monitored and evaluated. Parasitological intensity measures, combined with haemoglobin/anaemia counts and ultrasonography, proved valuable schistosomiasis-related morbidity indicators, being bo...
See the editorial commentary by King, on pages 653-5.) Background. In sub-Saharan Africa, 112 mil... more See the editorial commentary by King, on pages 653-5.) Background. In sub-Saharan Africa, 112 million people are infected with Schistosoma haematobium, with the most intense infections in children 5-15 years old. Methods. We describe a longitudinal epidemiological study that evaluates the relationship between S. haematobium infection and associated morbidity in children before and after the large-scale administration of praziquantel for schistosomiasis and albendazole for soil-transmitted helminths. Results. At baseline, higher intensities of S. haematobium infection were observed in children with anemia and/or severe microhematuria, but there was no apparent association between the risk of undernutrition and intensity of S. haematobium infection. Significant reductions in the prevalence and intensity of S. haematobium infection 1 year after treatment were, however, observed. Children who benefited the most from anthelmintic treatment in terms of increased hemoglobin concentrations were those who had anemia at baseline and those with highly positive microhematuria scores at baseline. Conclusions. This study suggests that even a single round of mass chemotherapy can have a substantial impact on S. haematobium infection and its associated morbidity in children.
Background: Over 1 billion of the world's poorest inhabitants are afflicted by neglected tropical... more Background: Over 1 billion of the world's poorest inhabitants are afflicted by neglected tropical diseases (NTDs). Integrated control programmes aimed at tackling these debilitating NTDs have been recently initiated, mainly using preventative chemotherapy. Monitoring and evaluation (M&E) of these integrated programs presents particular challenges over and above those required for single disease vertical programmes. We used baseline data from the National NTD Control Programme in Burkina Faso in order to assess the feasibility of an integrated survey design, as well as to elucidate the contribution of environmental variables to the risk of either Schistosoma haematobium, trachoma, or both among school-aged children. Methods: S. haematobium infection was diagnosed by detecting eggs in urine. A trachoma case was defined by the presence of Trachomatous inflammation-Follicular (TF) and/or Trachomatous inflammation-Intense (TI) in either eye. Baseline data collected from 3,324 children aged 7-11 years in 21 sentinel sites across 11 regions of Burkina Faso were analyzed using simple and multivariable hierarchical binomial logistic regression models fitted by Markov Chain Monte Carlo estimation methods. Probabilities of the risk of belonging to each infection/disease category were estimated as a function of age, gender (individual level), and environmental variables (at sentinel site level, interpolated from national meteorological stations). Results: Overall prevalence at the sentinel sites was 11.79% (95% CI: 10.70-12.89) for S. haematobium; 13.30% (12.14-14.45) for trachoma and 0.84% (0.53-1.15) for co-infections. The only significant predictor of S. haematobium infection was altitude. There were significant negative associations between the prevalence of active trachoma signs and minimum temperature, and air pressure. Conditional upon these predictors, these data are consistent with the two pathogens being independent.
Background It is widely advocated that integrated strategies for the control of neglected tropica... more Background It is widely advocated that integrated strategies for the control of neglected tropical diseases (NTDs) are cost-effective in comparison to vertical disease-specific programmes. A prerequisite for implementation of control interventions is the availability of baseline data of prevalence, including the population at risk and disease overlap. Despite extensive literature on the distribution of schistosomiasis on the mainland in Uganda, there has been a knowledge gap for the prevalence of co-infections with malaria, particularly for island communities in Lake Victoria. In this study, nine lakeshore and island districts were surveyed for the prevalence of NTDs and malaria, as well as educational and health infrastructure. Results A total of 203 communities were surveyed, including over 5000 school-age children. Varying levels of existing health infrastructure were observed between districts, with only Jinja District regularly treating people for NTDs. Community medicine distr...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 25, 2015
Repeated mass drug administration (MDA) with preventive chemotherapies (PCs) is the mainstay of ... more Repeated mass drug administration (MDA) with preventive chemotherapies (PCs) is the mainstay of morbidity control for schistosomiasis and soil-transmitted helminths. Yet, the World Health Organization (WHO) recently reported that less than one third of individuals who required PCs received treatment. Coverage of community-directed treatment with praziquantel and albendazole was analyzed in 17 villages of Mayuge District, Uganda. National drug registers, household questionnaires, and parasitological surveys were collected to track 935 individuals before and after MDA. Multilevel logistic regressions, including household and village effects, were specified with a comprehensive set of socioeconomic and parasitological variables. The factors predicting who does not receive praziquantel and albendazole from community medicine distributors were identified. Drug receipt was correlated amongst members within a household and non-recipients of praziquantel or albendazole were profiled by h...
SUMMARYSchistosomiasis remains one of the most prevalent parasitic diseases in developing countri... more SUMMARYSchistosomiasis remains one of the most prevalent parasitic diseases in developing countries. After malaria, schistosomiasis is the most important tropical disease in terms of human morbidity with significant economic and public health consequences. Although schistosomiasis has recently attracted increased focus and funding for control, it has been estimated that less than 20% of the funding needed to control the disease in Africa is currently available. In this article the following issues are discussed: the rationale, development and objectives of the Schistosomiasis Control Initiative (SCI)-supported programmes; the management approaches followed to achieve implementation by each country; mapping, monitoring and evaluation activities with quantifiable impact of control programmes; monitoring for any potential drug resistance; and finally exit strategies within each country. The results have demonstrated that morbidity due to schistosomiasis has been reduced by the control ...
During routine parasitological surveillance and monitoring activities within a National Control P... more During routine parasitological surveillance and monitoring activities within a National Control Programme for control of human schistosomiasis in Uganda, it was noted that cattle grazing in a water meadow immediately adjacent to Tonya primary school, where the prevalence of intestinal schistosomiasis in children was in excess of 90%, were unusually emaciated. To test the hypothesis that there may have been an anthropozoonotic focus of Schistosoma mansoni within the local herd, a young female heifer, clearly emaciated and c. 8 months old, was slaughtered from which schistosome worms were later recovered by dissection. As female worms inspected by microscopy were not gravid, morphological identification proved inconclusive but analysis of cytochome oxidase subunit I (COI) and small subunit (SSU) ribosomal DNA sequences from these worms identified them as Schistosoma bovis Sonsino, 1876. This is the first substantiated report of S. bovis from Lake Albert, western Uganda. Further epidem...
Background: To date schistosomiasis control programmes based on chemotherapy have largely aimed a... more Background: To date schistosomiasis control programmes based on chemotherapy have largely aimed at controlling morbidity in treated individuals rather than at suppressing transmission. In this study, a mathematical modelling approach was used to estimate reductions in the rate of Schistosoma mansoni reinfection following annual mass drug administration (MDA) with praziquantel in Uganda over four years (2003-2006). In doing this we aim to elucidate the benefits of MDA in reducing community transmission. Methods: Age-structured models were fitted to a longitudinal cohort followed up across successive rounds of annual treatment for four years (Baseline: 2003, Treatment: 2004-2006; n = 1,764). Instead of modelling contamination, infection and immunity processes separately, these functions were combined in order to estimate a composite force of infection (FOI), i.e., the rate of parasite acquisition by hosts. Results: MDA achieved substantial and statistically significant reductions in the FOI following one round of treatment in areas of low baseline infection intensity, and following two rounds in areas with high and medium intensities. In all areas, the FOI remained suppressed following a third round of treatment. Conclusions/Significance: This study represents one of the first attempts to monitor reductions in the FOI within a largescale MDA schistosomiasis morbidity control programme in sub-Saharan Africa. The results indicate that the Schistosomiasis Control Initiative, as a model for other MDA programmes, is likely exerting a significant ancillary impact on reducing transmission within the community, and may provide health benefits to those who do not receive treatment. The results obtained will have implications for evaluating the cost-effectiveness of schistosomiasis control programmes and the design of monitoring and evaluation approaches in general.
Schistosomiasis is a chronic and poverty-promoting disease that affects over 200 million people a... more Schistosomiasis is a chronic and poverty-promoting disease that affects over 200 million people and inflicts a considerable public health burden across large parts of the developing world. Yet, schistosomiasis remains one of the so-called ‘neglected tropical diseases’ because it affects poor populations mostly in rural areas. The distribution of schistosomiasis is focal, since transmission is governed by human water contact activities in freshwater bodies supporting intermediate host snails, and lack of access to clean water and adequate sanitation. Schistosomiasis should not be a major cause of morbidity because there is an effective treatment, and transmission could be broken by improved water supply and sanitation facilities. Indeed, schistosomiasis has been eliminated as a result of socioeconomic development and integrated control approaches from several countries, including Japan and Tunisia. However, in many parts of Africa, schistosomiasis has increased during the 20th century as a result of water resource development projects combined with population immigration without adequate provision of sanitation. In the new millennium there is renewed hope of schistosomiasis control as awareness and political will have increased, and large-scale morbidity control programs are underway, facilitated by praziquantel, a safe, efficacious, and inexpensive drug, and advocacy from the World Health Organization.
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Papers by Alan Fenwick