Institue of Malariology Parastology and Entomology Quy Nhon

Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. Estimates show that at least 258 million people required preventive treatment in 2014. Preventive treatment, which should be repeated over a number of years, will reduce and prevent morbidity. Schistosomiasis transmission has been reported from 78 countries. However, preventive chemotherapy for schistosomiasis, where people and communities are targeted for large scale treatment, is only required in 52 endemic countries with moderate to high transmission.

Transmission

Transmission occurs when people suffering from schistosomiasis contaminate freshwater sources with their excreta containing parasite eggs which hatch in water.

People become infected when larval forms of the parasite - released by freshwater snails - penetrate the skin during contact with infested water.

In the body, the larvae develop into adult schistosomes. Adult worms live in the blood vessels where the females release eggs. Some of the eggs are passed out of the body in the faeces or urine to continue the parasite?s life-cycle. Others become trapped in body tissues, causing immune reactions and progressive damage to organs.

Epidemiology

Schistosomiasis is prevalent in tropical and subtropical areas, especially in poor communities without access to safe drinking water and adequate sanitation. It is estimated that at least 90% of those requiring treatment for schistosomiasis live in Africa.

There are two major forms of schistosomiasis - intestinal and urogenital - caused by five main species of blood fluke (see table).

Table: Parasite species and geographical distribution of schistosomiasis

	Species	Geographical distribution
*Intestinal schistosomiasis*	Schistosoma mansoni	Africa, the Middle East, the Caribbean, Brazil, Venezuela and Suriname
	Schistosoma japonicum	China, Indonesia, the Philippines
	Schistosoma mekongi	Several districts of Cambodia and the Lao People's Democratic Republic
	Schistosoma guineensis and related S. intercalatum	Rain forest areas of central Africa
*Urogenital schistosomiasis*	Schistosoma haematobium	Africa, the Middle East, Corsica (France)

Schistosomiasis mostly affects poor and rural communities, particularly agricultural and fishing populations. Women doing domestic chores in infested water, such as washing clothes, are also at risk. Inadequate hygiene and contact with infected water make children especially vulnerable to infection.

Migration to urban areas and population movements are introducing the disease to new areas. Increasing population size and the corresponding needs for power and water often result in development schemes, and environmental modifications facilitate transmission.

With the rise in eco-tourism and travel "off the beaten track", increasing numbers of tourists are contracting schistosomiasis. At times, tourists present with severe acute infection and unusual problems including paralysis.

Urogenital schistosomiasis is also considered to be a risk factor for HIV infection, especially in women.

Symptoms

Symptoms of schistosomiasis are caused by the body's reaction to the worms' eggs.

Intestinal schistosomiasis can result in abdominal pain, diarrhoea and blood in the stool. Liver enlargement is common in advanced cases, and is frequently associated with an accumulation of fluid in the peritoneal cavity and hypertension of the abdominal blood vessels. In such cases there may also be enlargement of the spleen.

The classic sign of urogenital schistosomiasis is haematuria (blood in urine). Fibrosis of the bladder and ureter, and kidney damage are sometimes diagnosed in advanced cases. Bladder cancer is another possible complication in the later stages. In women, urogenital schistosomiasis may present with genital lesions, vaginal bleeding, pain during sexual intercourse and nodules in the vulva. In men, urogenital schistosomiasis can induce pathology of the seminal vesicles, prostate and other organs. This disease may also have other long-term irreversible consequences, including infertility.

The economic and health effects of schistosomiasis are considerable and the disease disables more than it kills. In children, schistosomiasis can cause anaemia, stunting and a reduced ability to learn, although the effects are usually reversible with treatment. Chronic schistosomiasis may affect people?s ability to work and in some cases can result in death.¹ The number of deaths due to schistosomiasis is difficult to estimate because of hidden pathologies such as liver and kidney failure and bladder cancer. Estimates therefore vary widely between 20 000 and 200 000 deaths per year.

Diagnosis

Schistosomiasis is diagnosed through the detection of parasite eggs in stool or urine specimens. Antibodies and/or antigens detected in blood or urine samples are also indications of infection.

For urogenital schistosomiasis, a filtration technique using nylon, paper or polycarbonate filters is the standard diagnostic technique. Children with S. haematobium almost always have microscopic blood in their urine and this can be detected by chemical reagent strips.

The eggs of intestinal schistosomiasis can be detected in faecal specimens through a technique using methylene blue-stained cellophane soaked in glycerine or glass slides, known as the Kato-Katz technique.

For people living in non-endemic or low-transmission areas, serological and immunological tests may be useful in showing exposure to infection and the need for thorough examination, treatment and follow-up.

Prevention and control

The control of schistosomiasis is based on large-scale treatment of at-risk population groups, access to safe water, improved sanitation, hygiene education and snail control.

The WHO strategy for schistosomiasis control focuses on reducing disease through periodic, targeted treatment with praziquantel through the large-scale treatment (preventive chemotherapy) of affected populations. It involves regular treatment of all at-risk groups. In a few countries, where there is low transmission, the elimination of the disease should be aimed for.

� adults considered to be at risk in endemic areas, and people with occupations involving contact with infested water, such as fishermen, farmers, irrigation workers, and women whose domestic tasks bring them in contact with infested water,

The frequency of treatment is determined by the prevalence of infection in school-age children. In high-transmission areas, treatment may have to be repeated every year for a number of years. Monitoring is essential to determine the impact of control interventions.

The aim is to reduce disease: periodic treatment of at-risk populations will cure mild symptoms and prevent infected people from developing severe, late-stage chronic disease. However, a major limitation to schistosomiasis control has been the limited availability of praziquantel. Data for 2014 show that 20.7% of people requiring treatment were reached.

Praziquantel is the recommended treatment against all forms of schistosomiasis. It is effective, safe and low-cost. Even though re-infection may occur after treatment, the risk of developing severe disease is diminished and even reversed when treatment is initiated and repeated in childhood.

Schistosomiasis control has been successfully implemented over the past 40 years in several countries, including Brazil, Cambodia, China, Egypt, Mauritius, Islamic Republic of Iran and Saudi Arabia. There is evidence that schistosomiasis transmission was interrupted in Morocco. In Burkina Faso, Niger, Sierra Leone and Yemen, it has been possible to scale up schistosomiasis treatment to the national level and have an impact on the disease in a few years. An assessment of the status of transmission is being made in several countries.

Over the past 10 years, there has been scale-up of treatment campaigns in a number of sub-Saharan countries, where most of those at risk live.

WHO response

WHO's work on schistosomiasis is part of an integrated approach to the control of neglected tropical diseases. Although medically diverse, neglected tropical diseases share features that allow them to persist in conditions of poverty, where they cluster and frequently overlap.

WHO coordinates the strategy of preventive chemotherapy in consultation with collaborating centres and partners from academic and research institutions, the private sector, nongovernmental organizations, international development agencies and other United Nations organizations. WHO develops technical guidelines and tools for use by national control programmes.

Working with partners and the private sector, WHO has advocated for increased access to praziquantel and resources for implementation. A significant amount of praziquantel, to treat more than 100 million children of the school age per year, has been pledged by the private sector and development partners.

Key facts

� Schistosomiasis is an acute and chronic disease caused by parasitic worms.

� People are infected during routine agricultural, domestic, occupational and recreational activities which expose them to infested water.

� Lack of hygiene and certain play habits of school-aged children such as swimming or fishing in infested water make them especially vulnerable to infection.

� Schistosomiasis control focuses on reducing disease through periodic, large-scale population treatment with praziquantel; a more comprehensive approach including potable water, adequate sanitation and snail control would also reduce transmission.

� Estimates show that at least 258 million people required preventive treatment for schistosomiasis in 2014.

� More than 61.6 million people were reported to have been treated for schistosomiasis in 2014.

¹ Quantification of clinical morbidity associated with schistosome infection in sub-Saharan Africa. 2003 May;86(2-3):125-39. (http://www.ncbi.nlm.nih.gov/pubmed/12745133van der Werf MJ1