The public health significance and control of schistosomiasis in China--then and now

Transmission risks of schistosomiasis japonica: extraction from back-propagation artificial neural network and logistic regression model

BACKGROUND

The transmission of schistosomiasis japonica in a local setting is still poorly understood in the lake regions of the People's Republic of China (P. R. China), and its transmission patterns are closely related to human, social and economic factors.

METHODOLOGY/PRINCIPAL FINDINGS

We aimed to apply the integrated approach of artificial neural network (ANN) and logistic regression model in assessment of transmission risks of Schistosoma japonicum with epidemiological data collected from 2339 villagers from 1247 households in six villages of Jiangling County, P.R. China. By using the back-propagation (BP) of the ANN model, 16 factors out of 27 factors were screened, and the top five factors ranked by the absolute value of mean impact value (MIV) were mainly related to human behavior, i.e. integration of water contact history and infection history, family with past infection, history of water contact, infection history, and infection times. The top five factors screened by the logistic regression model were mainly related to the social economics, i.e. village level, economic conditions of family, age group, education level, and infection times. The risk of human infection with S. japonicum is higher in the population who are at age 15 or younger, or with lower education, or with the higher infection rate of the village, or with poor family, and in the population with more than one time to be infected.

CONCLUSION/SIGNIFICANCE

Both BP artificial neural network and logistic regression model established in a small scale suggested that individual behavior and socioeconomic status are the most important risk factors in the transmission of schistosomiasis japonica. It was reviewed that the young population (≤15) in higher-risk areas was the main target to be intervened for the disease transmission control.

Assessing the effect of an integrated control strategy for schistosomiasis japonica emphasizing bovines in a marshland area of Hubei Province, China: a cluster randomized trial

Introduction

More than 80% of schistosomiasis patients in China live in the lake and marshland regions. The purpose of our study is to assess the effect of a comprehensive strategy to control transmission of Schistosoma japonicum in marshland regions.

Methodology/Principal Findings

In a cluster randomized controlled trial, we implemented an integrated control strategy in twelve villages from 2009 through 2011 in Gong'an County, Hubei Province. The routine interventions included praziquantel chemotherapy and controlling snails, and were implemented in all villages. New interventions, mainly consisting of building fences to limit the grazing area for bovines, building safe pastures for grazing, improving the residents' health conditions and facilities, were only implemented in six intervention villages. Results showed that the rate of S. japonicum infection in humans, bovines, snails, cow dung and mice in the intervention group decreased from 3.41% in 2008 to 0.81% in 2011, 3.3% to none, 11 of 6,219 to none, 3.9% to none and 31.7% to 1.7%, respectively (P<0.001 for all comparisons). In contrast, there were no statistically significant reductions of S. japonicum infection in humans, bovines and snails from 2008 to 2011 in the control group (P>0.05 for all comparisons). Moreover, a generalized linear model showed that there was a higher infection risk in humans in the control group than in the intervention group (OR = 1.250, P = 0.001) and an overall significant downward trend in infection risk during the study period.

Conclusions/Significance

The integrated control strategy, designed to reduce the role of bovines and humans as sources of S. japonicum infection, was highly effective in controlling the transmission of S. japonicum in marshland regions in China.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-PRC-12002405.

More than 80% of schistosomiasis patients in China live in the lake and marshland regions. Hence, how to control transmission of Schistosoma japonicum in these regions is especially important. From 2009 through 2011, we implemented an integrated control strategy, designed to reduce the role of bovines and humans as sources of S. japonicum infection, in twelve villages Gong'an County of Hubei Province, which is located in typical marshland. After three years, the rate of S. japonicum infection in humans, bovines and snails significantly declined in the six intervention villages. In contrast, there was no significant decline in these indexes in the six control villages. Moreover, there was a higher infection risk in humans in the control group than the intervention group. Our study showed that the integrated control strategy was highly effective in controlling the transmission of S. japonicum in marshland regions of China.

Exogenous bone morphogenetic protein-7 reduces hepatic fibrosis in Schistosoma japonicum-infected mice via transforming growth factor-β/Smad signaling

AIM: To investigate the antifibrotic effects of bone morphogenetic protein-7 (BMP-7) on Schistosoma japonicum (S. japonicum)-induced hepatic fibrosis in BALB/C mice.

METHODS: Sixty BALB/C mice were randomly divided into three groups, including a control group (group A, n = 20), model group (group B, n = 20) and BMP-7 treated group (group C, n = 20). The mice in group B and group C were abdominally infected with S. japonicum cercariae to induce a schistosomal hepatic fibrosis model. The mice in group C were administered human recombinant BMP-7. Liver samples were extracted from mice sacrificed at 9 and 15 wk after modeling. Hepatic histopathological changes were assessed using Masson’s staining. Transforming growth factor-beta 1 (TGF-β1), alpha-smooth muscle actin (α-SMA), phosphorylated Smad2/3 (pSmad2/3) and Smad7 protein levels and localization were measured by Western blotting and immunohistochemistry, respectively, and their mRNA expressions were detected by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS: The schistosomal hepatic fibrosis mouse model was successfully established, as the livers of mice in group B and group C showed varying degrees of typical schistosomal hepatopathologic changes such as egg granuloma and collagen deposition. The degree of collagen deposition in group C was higher than that in group A (week 9: 22.95 ± 6.66 vs 2.02 ± 0.76; week 15: 12.84 ± 4.36 vs 1.74 ± 0.80; P < 0.05), but significantly lower than that in group B (week 9: 22.95 ± 6.66 vs 34.43 ± 6.96; week 15: 12.84 ± 4.36 vs 18.90 ± 5.07; P < 0.05) at both time points. According to immunohistochemistry data, the expressions of α-SMA, TGF-β1 and pSmad2/3 protein in group C were higher than those in group A (α-SMA: week 9: 21.24 ± 5.73 vs 0.33 ± 0.20; week 15: 12.42 ± 4.88 vs 0.34 ± 0.27; TGF-β1: week 9: 37.00 ± 13.74 vs 3.73 ± 2.14; week 15: 16.71 ± 9.80 vs 3.08 ± 2.35; pSmad2/3: week 9: 12.92 ± 4.81 vs 0.83 ± 0.48; week 15: 7.87 ± 4.09 vs 0.90 ± 0.45; P < 0.05), but significantly lower than those in group B (α-SMA: week 9: 21.24 ± 5.73 vs 34.39 ± 5.74; week 15: 12.42 ± 4.88 vs 25.90 ± 7.01; TGF-β1: week 9: 37.00 ± 13.74 vs 55.66 ± 14.88; week 15: 16.71 ± 9.80 vs 37.10 ± 12.51; pSmad2/3: week 9: 12.92 ± 4.81 vs 19.41 ± 6.87; week 15: 7.87 ± 4.09 vs 13.00 ± 4.98; P < 0.05) at both time points; the expression of Smad7 protein in group B was higher than that in group A and group C at week 9 (8.46 ± 3.95 vs 1.00 ± 0.40 and 8.46 ± 3.95 vs 0.77 ± 0.42; P < 0.05), while there were no differences in Smad7 expression between the three groups at week 15 (1.09 ± 0.38 vs 0.97 ± 0.42 vs 0.89 ± 0.39; P > 0.05). Although minor discrepancies were observed, the results of RT-PCR and Western blotting were mainly consistent with the immunohistochemical results.

CONCLUSION: Exogenous BMP-7 significantly decreased the degree of hepatic fibrosis in both the acute and chronic stages of hepato-schistosomiasis, and the regulatory mechanism may involve the TGF-β/Smad signaling pathway.

A simple noninvasive index to predict significant liver fibrosis in patients with advanced schistosomiasis japonica

BACKGROUND

Schistosoma japonicum causes marked liver fibrosis, while lethal syndromes present in advanced schistosomiasis patients. Its management depends on the degree of fibrosis present.

PATIENTS AND METHODS

Fifty-two patients were recruited to assess the diagnostic value of bio-markers in patients with advanced schistosomiasis japonica. Fibrosis was assessed in liver biopsies using METAVIR system. The correlation between conventional parameters and significant fibrosis (F2-F4) was assessed using univariate analysis and logistic regression. The method of area under receiver operating characteristic curves (AUROCs) was used as a measurement of diagnostic efficacy.

RESULTS

White blood cell counts, platelet counts and albumin (all P<0.05) were significantly lower, while prothrombin time, international normalized ratio (INR), hyaluronic acid (HA), IV collagen and ultrasound fibrosis scores (all P<0.01) were significantly elevated in F2-F4 patients compared with F0-F1 patients. HA and INR were identified as independent predictors by multivariate analysis (P=0.023 and P=0.013, respectively). Of the routine laboratory tests for the diagnosis of significant fibrosis, HA gave the best AUROC of 0.875 (95% confidence interval (CI): 0.701-0.997). We constructed a new simple index (INR×HA/100) to discriminate between F2-F4 patients and F0-F1 patients. It showed the highest AUROC of 0.921 (95% CI: 0.828-1.000), and had better diagnostic values than APRI and FIB-4.

CONCLUSION

HA and INR were reliable markers for differentiating significant liver fibrosis in patients with advanced schistosomiasis japonica. And the new simple index can easily predict significant liver fibrosis with a high degree of accuracy.

A boswellic acid-containing extract attenuates hepatic granuloma in C57BL/6 mice infected with Schistosoma japonicum

Granuloma formation has been shown to be induced and elicited by schistosome egg antigens, and it finally develops into fibrosis in intestine and the liver. Hepatic fibrosis is the main cause of increased morbidity and mortality in humans infected with schistosomes. Boswellic acid (BA)-containing extracts such as extracts of the oleogum resin from Boswellia serrata (BSE) have anti-inflammatory and immunomodulatory activity. However, little is known about the role of such extracts in schistosome egg-induced granulomatous inflammation. In order to investigate the effect of a watersoluble cyclodextrin complex preparation of BSE (BSE-CD) on Schistosoma japonicum (S. japonicum) egg-induced liver granuloma, mice infected with S. japonicum cercariae were injected with BSE-CD during egg granuloma formation. The data showed that BSE-CD significantly reduced the size of liver granuloma and levels of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST); however, BSE-CD treatment had no effect on worm load and egg burden. The data also showed that BSE-CD significantly decreased the expression of leukotriene B(4) (LTB(4)) and prostaglandin E(2) (PGE(2)), as well as the expression of matrix metallopeptidase 9 (MMP-9) in liver both on the mRNA and protein level. Thus, BSE-CD can significantly attenuate S. japonicum egg-induced hepatic granuloma, which may be partly dependent on the downregulation of some biochemical mediators.

Prevalence of Schistosoma japonicum in wild rodents in five islands of the West Dongting Lake, China

To estimate the prevalence of Schistosoma japonicum in field rodents, we conducted surveys of S. japonicum infection on 5 islands in the west Dongting Lake, China: Julinyuan, Jiangjiazui, Longwangmiao, Goutouzhou, and Niujiaojian. Thirty-five Rattus flavipectus, 43 Rattus norvegicus, 42 Rattus rattus , and 48 Microtus fortis were captured and examined from July to August 2011. Schistosoma japonicum was found in the 3 rat species but not in the vole M. fortis . No statistically significant differences in infection rates were found among the 5 locations or the 3 species of Rattus (P > 0.05). The average prevalence in the Rattus species was 14.2% (17/120), revealing that S. japonicum infection within field rodents was widespread in the Dongting Lake region. Wild rodents can be an important reservoir for S. japonicum transmission in the region and are of public health concern.

Factors impacting on progress towards elimination of transmission of schistosomiasis japonica in China

Over the past decades China has made a great stride in controlling schistosomiasis, eliminating transmission of Schistosoma japonicum in 5 provinces and remarkably reducing transmission intensities in the rest of the seven endemic provinces. Recently, an integrated control strategy, which focuses on interventions on humans and bovines, has been implemented throughout endemic areas in China. This strategy assumes that a reduction in transmission of S. japonicum from humans and bovines to the intermediate Oncomelania snail host would eventually block the transmission of this parasite, and has yielded effective results in some endemic areas. Yet the transmission of S. japonicum is relatively complicated--in addition to humans and bovines, more than 40 species of mammalians can serve as potential zoonotic reservoirs. Here, we caution that some factors--potential roles of other mammalian reservoirs and human movement in sustaining the transmission, low sensitivity/specificity of current diagnostic tools for infections, praziquantel treatment failures, changes in environmental and socio-economic factors such as flooding in key endemic areas--may pose great obstacles towards transmission interruption of the parasite. Assessing potential roles of these factors in the transmission and implications for current control strategies aiming at transmission interruption is needed.

Magnetic affinity enzyme-linked immunoassay based on recombinant 26 kDa glutathione-S-transferase for serological diagnosis of schistosomiasis japonica

Schistosomiasis remains a serious worldwide public health problem. Improving the diagnostic assay for surveillance and monitoring will contribute to hastening the possible elimination of the disease in endemic regions. Therefore, this study aims to develop magnetic affinity enzyme-linked immunoassay (MEIA) for serological diagnosis of schistosomiasis based on recombinant 26kDa glutathione-S-transferase of Schistosoma japonicum (rSj26GST). BALB/c mice infected with S. japonicum cercariae (40 per mouse) were used. After infecting for 6 weeks, the antibody was detected by MEIA. All of the infected mouse sera were effectively determined by MEIA. Compared with the enzyme-linked immunosorbent assay (ELISA), MEIA has a higher ratio of the mean positive value to the mean negative value (P/N) at the same dilution ratio (3.92 versus 2.66). MEIA was further applied for diagnosis of human schistosomiasis. Sera from 28 schistosomiasis-confirmed patients with low-intensity infection, 15 treated patients, and 20 non-endemic negative controls, were used to assess the assay. The results showed that MEIA and ELISA had similarity in positive detection rates. However, the higher P/N of MEIA was observed at the same dilution ratio. MEIA had high negative rate in detection of specific IgG in the treated patients. Moreover, there was no cross reaction with the sera of paragonimiasis patients. These results suggested that MEIA based on rSj26GST is a simple, rapid, convenient assay for the diagnosis of schistosomiasis.

The effects of health education on schistosomiasis japonica prevalence and relevant knowledge in the People's Republic of China: a systematic review and meta-analysis

Schistosomiasis japonica continues to be an important zoonotic disease in the People's Republic of China (P.R. China), despite decades of dedicated control efforts. Different interventions for its control including chemotherapy of humans and animals, mollusciciding, environmental modification, and health education have been implemented at various stages of the control efforts and in different combinations, resulting in remarkable achievements. Here, we present a systematic review and meta-analysis of the documented effectiveness of health education to reduce schistosomiasis japonica transmission in P.R. China. A total of 10 relevant publications were identified and included in the meta-analysis. The reported results indicate that the prevalence of Schistosoma japonicum infection in humans and schistosomiasis-related knowledge are significantly influenced by health education. The implementation of health education over more than 2 years was associated with an overall schistosomiasis japonica prevalence decrease of 6% (95% CI: 2%, 11%) and an overall increase of 51% (95% CI: 41%, 61%) in schistosomiasis-related knowledge after controlling for confounding factors. Among control groups, the prevalence of schistosomiasis japonica and relevant knowledge levels were not significantly influenced. The relative risk (RR) of an infection with S. japonicum following health education lasting more than 2 years was 0.43 (95% CI: 0.24, 0.78). In summary, a considerable effectiveness of health education with regard to preventing S. japonicum infections in P.R. China and increasing relevant knowledge is documented in the extant literature. This suggests that the effectiveness of health education may be considerable, particularly after its long-term implementation.

Schistosomiasis control and the health system in P.R. China

Over the last sixty years advances have been made in the control of schistosomiasis in P.R. China. There are, however, difficult challenges still to be met. This paper looks at the extent to which the health system offers a positive environment for the control of the disease. It starts by tracing three phases in schistosomiasis control: disease elimination strategy through snail control (1950s-early 1980s); morbidity control strategy based on chemotherapy (mid 1980s to 2003); integrated control strategy (2004+). Each one of these phases took place in distinct policy-making environments. The paper partly draws on these phases to set out five issues of disease control and discusses them in the context of the health system and its recent trends. These cover the policy-making process, intersectoral action for health, equity and access to health services, funding for public goods and externalities, and strengthening resource management and planning. These issues form the basis of an agenda for integrating research and capacity strengthening in the Chinese health system with a view to creating a more positive enabling environment for schistosomiasis control. In so doing it is important to emphasize the role and integrity of the public sector against its commercialization, the underlying value of equity, a systems wide perspective, and the role of advocacy.

Magnetic affinity enzyme-linked immunoassay for diagnosis of Schistosomiasis japonicum in persons with low-intensity infection

Most schistosome-endemic areas in China are characterized by low-intensity infections that are independent of prevalence. To establish an effective diagnostic method, we developed a magnetic affinity enzyme-linked immunoassay based on soluble egg antigens (SEA-MEIA) for diagnosing schistosomiasis in persons with low-intensity infection with Schistosoma japonicum by comparing it with a conventional enzyme-linked immunosorbent assay (ELISA). Our results showed that the SEA-MEIA had a higher sensitivity and greater precision in the diagnosis of low-intensity S. japonicum infections than the ELISA. In addition, when we used Pearson's correlation in associating SEA-MEIA with ELISA, a significant correlation existed between the two assays (r = 0.845, P < 0.001). Our data indicated that SEA-MEIA, with a higher sensitivity and greater ease of performance, would be valuable for diagnosis of schistosomiasis japonicum in persons with low-intensity infections.

Ambient air pollution, climate change, and population health in China

As the largest developing country, China has been changing rapidly over the last three decades and its economic expansion is largely driven by the use of fossil fuels, which leads to a dramatic increase in emissions of both ambient air pollutants and greenhouse gases (GHGs). China is now facing the worst air pollution problem in the world, and is also the largest emitter of carbon dioxide. A number of epidemiological studies on air pollution and population health have been conducted in China, using time-series, case-crossover, cross-sectional, cohort, panel or intervention designs. The increased health risks observed among Chinese population are somewhat lower in magnitude, per amount of pollution, than the risks found in developed countries. However, the importance of these increased health risks is greater than that in North America or Europe, because the levels of air pollution in China are very high in general and Chinese population accounts for more than one fourth of the world's totals. Meanwhile, evidence is mounting that climate change has already affected human health directly and indirectly in China, including mortality from extreme weather events; changes in air and water quality; and changes in the ecology of infectious diseases. If China acts to reduce the combustion of fossil fuels and the resultant air pollution, it will reap not only the health benefits associated with improvement of air quality but also the reduced GHG emissions. Consideration of the health impact of air pollution and climate change can help the Chinese government move forward towards sustainable development with appropriate urgency.

Systematic review of pentachlorophenol occurrence in the environment and in humans in China: not a negligible health risk due to the re-emergence of schistosomiasis

Pentachlorophenol (PCP) has been widely used for killing snails in areas of China where schistosomiasis is epidemic. With the re-emergence of schistosomiasis, the warranted production and consumption of PCP has inevitably resulted in persistent environmental contamination by it and its impurities, polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs). This study aimed to evaluate the contamination status and human burden of PCP and its impurities (PCDD/Fs) in China, considering the previous epidemic and re-emergence of schistosomiasis. We searched studies relevant to PCP occurrence in the environment and in humans in China. Data on snail elimination areas were included to estimate PCP consumption. Relevant publications were analyzed to distinguish PCDD/Fs contamination from PCP usage. PCP contamination was detected ubiquitously in various environmental media and in human samples; environmental levels were generally low, with the exception of some hot spots. In schistosomiasis-epidemic areas, there were significantly higher PCP levels in the environment and in humans than in control areas. Spatial disparities indicated the consistency between serious schistosomiasis epidemic areas and hot spots of PCP contamination. The data suggest an increased trend in PCP contamination of the environment. Specific PCDD/Fs contamination from PCP usage existed even at low environmental levels. The occurrence of PCP in the environment and in humans positively correlated with the epidemic of schistosomiasis. Thyroid-disrupting effects and cancer risk caused by PCP and PCDD/Fs even at low environmental levels in China's schistosomiasis-epidemic areas are of concern.

The sensitivity of Schistosoma japonicum to praziquantel: a field evaluation in areas with low endemicity of China

The purpose of the current study was to investigate the susceptibility of Schistosoma japonicum to praziquantel in low endemic foci of China. During the non-transmission period of schistosomiasis, a total of 43 of 1,242 subjects were identified as being infected with the parasite using parasitological stool examinations in two low-endemicity areas of China, with a prevalence rate of 3.46%. All stool-egg-positive subjects were treated with praziquantel in a single oral dose of 40 mg/kg or 30 mg/kg for two successive days. Six weeks post-treatment, no S. japonicum eggs were detected in the 43 treated villagers. The results indicate that the current efficacy of praziquantel against S. japonicum seems satisfactory and has not changed over the past three decades in the low endemic areas of China. It is also suggested that no evidence of tolerance or resistance to praziquantel in S. japonicum is detected in areas with low endemicity in China.

The second transcribed spacer rDNA sequence: an effective genetic marker for inter-species phylogenetic analysis of trematodes in the order Strigeata

In the present study, the second nuclear internal transcribed spacer (ITS-2) rDNA of Schistosoma japonicum isolates in mainland China was amplified, sequenced, and assessed for inferring the intra- and inter-species phylogenetic relationships of trematodes in the order Strigeata. The fragment containing ITS-2 rDNA was obtained from 24 S. japonicum isolates from eight epidemic provinces in mainland China. The length polymorphisms were observed among these ITS-2 rDNA sequences, ranging from 343 to 346 bp, and the intra- and inter-population variations in ITS-2 sequence were 0.0-2.1% among S. japonicum isolates in China. Phylogenetic analyses using the maximum parsimony and maximum likelihood methods revealed that the ITS-2 rDNA sequence is not a suitable marker for studying inter- and intra-population variation in S. japonicum. However, phylogenetic analysis of trematodes in the order Strigeata indicated that the ITS-2 rDNA sequence provides an effective molecular marker for studying inter-species phylogenetic relationships among trematodes in this order.

Study of the activity of 3-benzyl-5-(4-chloro-arylazo)-4-thioxo-imidazolidin-2-one against Schistosomiasis mansoni in mice

Previous studies conducted with the imidazolidinic derivative 3-benzyl-5-(4-chloro-arylazo)-4-thioxo-imidazolidin-2-one (LPSF-PT05) show outstanding activity against adult Schistosoma mansoni worms in vitro. In the first phase of this study, S. mansoni-infected mice were treated, orally, with 100 mg/Kg of the LPSF-PT05 in three formulations: Tween 80 and saline solution, oil/water (70 : 30) emulsion, and solid dispersion with polyethylene glycol (PEG). In the second phase, three other doses of the LPSF-PT05 in PEG were tested: 3, 10, 30 mg/kg. These treatment regimens significantly reduced the number of recovered worms due to increases in the solubility of the compound in this formulation; the greatest reduction (70.5%) was observed at the dose of 100 mg/kg. There was no changes in the pattern of mature egg compared to immature eggs; however there was a significant increase in the number of dead eggs. Histopathological analysis of liver tissue showed changes in morphological aspects of the hepatic parenchyma with decrease exudative-productive hepatic granuloma stages, although we found no significant differences in IFN-γ, IL-4, IL-10, or NO production in response to the specific antigen SEA. The results show the derivative LPSF-PT05 to be a potential candidate in the etiological treatment of schistosomiasis with a possible dampening effect of the granulomatous process.

Long-term impact of the World Bank Loan Project for schistosomiasis control: a comparison of the spatial distribution of schistosomiasis risk in China

BACKGROUND

The World Bank Loan Project (WBLP) for controlling schistosomiasis in China was implemented during 1992-2001. Its short-term impact has been assessed from non-spatial perspective, but its long-term impact remains unclear and a spatial evaluation has not previously been conducted. Here we compared the spatial distribution of schistosomiasis risk using national datasets in the lake and marshland regions from 1999-2001 and 2007-2008 to evaluate the long-term impact of WBLP strategy on China's schistosomiasis burden.

METHODOLOGY/PRINCIPAL FINDINGS

A hierarchical Poisson regression model was developed in a Bayesian framework with spatially correlated and uncorrelated heterogeneities at the county-level, modeled using a conditional autoregressive prior structure and a spatially unstructured Gaussian distribution, respectively. There were two important findings from this study. The WBLP strategy was found to have a good short-term impact on schistosomiasis control, but its long-term impact was not ideal. It has successfully reduced the morbidity of schistosomiasis to a low level, but can not contribute further to China's schistosomiasis control because of the current low endemic level. A second finding is that the WBLP strategy could not effectively compress the spatial distribution of schistosomiasis risk. To achieve further reductions in schistosomiasis-affected areas, and for sustainable control, focusing on the intermediate host snail should become the next step to interrupt schistosomiasis transmission within the two most affected regions surrounding the Dongting and Poyang Lakes. Furthermore, in the lower reaches of the Yangtze River, the WBLP's morbidity control strategy may need to continue for some time until snails in the upriver provinces have been well controlled.

CONCLUSION

It is difficult to further reduce morbidity due to schistosomiasis using a chemotherapy-based control strategy in the lake and marshland regions of China because of the current low endemic levels of infection. The future control strategy for schistosomiasis should instead focus on a snail-based integrated control strategy to maintain the program achievements and sustainably reduce the burden of schistosomiasis in China.

Five-year longitudinal assessment of the downstream impact on schistosomiasis transmission following closure of the Three Gorges Dam

BACKGROUND

Schistosoma japonicum is a major public health concern in the Peoples' Republic of China (PRC), with about 800,000 people infected and another 50 million living in areas at risk of infection. Based on ecological, environmental, population genetic and molecular factors, schistosomiasis transmission in PRC can be categorised into four discrete ecosystems or transmission modes. It is predicted that, long-term, the Three Gorges Dam (TGD) will impact upon the transmission of schistosomiasis in the PRC, with varying degree across the four transmission modes.

METHODOLOGY/PRINCIPAL FINDINGS

We undertook longitudinal surveillance from 2002 to 2006 in sentinel villages of the three transmission modes below the TGD across four provinces (Hunan, Jiangxi, Hubei and Anhui) to determine whether there was any immediate impact of the TGD on schistosomiasis transmission. Eight sentinel villages were selected to represent both province and transmission mode. The primary end point measured was human incidence. Here we present the results of this five-year longitudinal cohort study. Results showed that the incidence of human S. japonicum infection declined considerably within individual villages and overall mode over the course of the study. This is also reflected in the yearly odds ratios (adjusted) for infection risk that showed significant (P<0.01) downward trends in all modes over the follow-up period.

CONCLUSIONS/SIGNIFICANCE

The decrease in human S. japonicum incidence observed across all transmission modes in this study can probably be attributed to the annual human and bovine PZQ chemotherapy. If an increase in schistosome transmission had occurred as a result of the TGD, it would be of negligible size compared to the treatment induced decline seen here. It appears therefore that there has been virtually no immediate impact of the TGD on schistosomiasis transmission downstream of the dam.

The South-to-North Water Diversion Project: effect of the water diversion pattern on transmission of Oncomelania hupensis, the intermediate host of Schistosoma japonicum in China

BACKGROUND

The South-to-North Water Diversion Project (SNWDP) is the largest national water conservancy project in China. However, the Eastern Route Project (ERP) of SNWDP will refer to the habitats of Oncomelania hupensis, the intermediate host of Schistosoma japonicum. The present study was aimed at investigating the effects of some factors relating to the water diversion pattern on the spread north of O. hupensis and transmission of S. japonicum.

METHODS

Marked snails were attached to the floating debris, and then placed on the water surface, the passage of snails through water pumps was observed. Some marked living adult snails were placed under water in the 5 spots, 15, 30, 60, 90 and 120 days later, their survival and transfer under water were investigated. 2, 4, 8, 16, 32, 64 and 128 juvenile snails, with a male: female ratio of about 1, were caged, 1 year later, their reproductions were calculated.

RESULTS

The snails attached on the floating debris at 100-, 50- and 20-cm-distance from the inlet pipe of the big pump (with a diameter of 80 cm), could be absorbed into the pumps, with passing rates of 2.45%, 3.93% and 43.46%, respectively, compared with 72.07% and 91.00% for the snails at 20 cm and 10 cm-distance from the inlet pipe of the small pump (with a diameter of 20 cm). A total of 36,600 marked living snails were put into 5 ponds and ditches, with the water depths of 1-1.6 m, 15-120 days later, no marked ones were found along the ponds and ditches or in the straw packages. The juvenile snails did not reproduce until their density reached up to 8 snails (ratio of male: female of 1)/0.16 m2.

CONCLUSIONS

During the construction of ERP of SNWDP, the risk of northward spread of schistosomiasis japonica will be decreased or eliminated as long as long-term reliable interventions for snail control are implemented.

A specific PCR assay for the identification and differentiation of Schistosoma japonicum geographical isolates in mainland China based on analysis of mitochondrial genome sequences

In the present study, near-complete mt genome sequences for eight representative Schistosoma japonicum samples from seven endemic provinces in mainland China were analyzed. Sequence differences among the eight mt genomes of S. japonicum samples were 0.20-2.51%. Variation in protein-coding genes was greater than that in rRNA genes. The mt DNA sequences of S. japonicum samples from south-western (SW) China were 2 bp [position 11727-11728 within tRNA-Cys, microsatellite (AG) indel] longer than those of the parasites from the lower Yangtze/Zhejiang areas. Representative DNA sequencing confirmed that such (AG) indel could be exploited for identification and differentiation of S. japonicum populations in SW China's Yunnan and Sichuan province which have two (AG) repeats from those in all remaining endemic provinces along the Yangtze River below the Three Gorges regions or close to the east coast of China (e.g., Zhejiang) which have only one (AG) repeat. Phylogenetic analyses based on the concatenated amino acids of 12 protein-coding genes also showed that samples from SW China (Sichuan and Yunnan provinces), above the Three Gorges Dam, formed a distinct cluster. Based on this indel polymorphism, a pair of specific primers was designed and used to develop a specific-PCR polyacrylamide gel detection assay. There was an obvious length difference in the amplified PCR products between S. japonicum samples from the two endemic types. The specific-PCR assay allowed the specific identification of S. japonicum, with no amplicons being amplified from other closely related trematodes, and the minimum amount of DNA detectable was 0.05 ng. This approach is inexpensive, easy to perform and the whole detection process can be completed within 4h. Examination of 81 S. japonicum samples from SW China's Yunnan and Sichuan provinces, and 264 samples from the lower Yangtze provinces (Hubei, Jiangsu, Jiangxi, Anhui and Hunan) and from Zhejiang validated the value of the specific PCR assay and proved its reliability. These findings indicate that the specific PCR assay would provide a useful tool for the epidemiological surveillance and for tracing the source of S. japonicum infection in humans and animals in China.

Association of MICA gene polymorphisms with liver fibrosis in schistosomiasis patients in the Dongting Lake region

Major histocompatibility complex class I chain-related A (MICA) is a highly polymorphic gene located within the MHC class I region of the human genome. Expressed as a cell surface glycoprotein, MICA modulates immune surveillance by binding to its cognate receptor on natural killer cells, NKG2D, and its genetic polymorphisms have been recently associated with susceptibility to some infectious diseases. We determined whether MICA polymorphisms were associated with the high rate of Schistosoma parasitic worm infection or severity of disease outcome in the Dongting Lake region of Hunan Province, China. Polymerase chain reaction-sequence specific priming (PCR-SSP) and sequencing-based typing (SBT) were applied for high-resolution allele typing of schistosomiasis cases (N = 103, age range = 36.2-80.5 years, 64 males and 39 females) and healthy controls (N = 141, age range = 28.6-73.3 years, 73 males and 68 females). Fourteen MICA alleles and five short-tandem repeat (STR) alleles were identified among the two populations. Three (MICA*012:01/02, MICA*017 and MICA*027) showed a higher frequency in healthy controls than in schistosomiasis patients, but the difference was not significantly correlated with susceptibility to S. japonicum infection (Pc > 0.05). In contrast, higher MICA*A5 allele frequency was significantly correlated with advanced liver fibrosis (Pc < 0.05). Furthermore, the distribution profile of MICA alleles in this Hunan Han population was significantly different from those published for Korean, Thai, American-Caucasian, and Afro-American populations (P < 0.01), but similar to other Han populations within China (P > 0.05). This study provides the initial evidence that MICA genetic polymorphisms may underlie the severity of liver fibrosis occurring in schistosomiasis patients from the Dongting Lake region.

Diversification of Schistosoma japonicum in Mainland China revealed by mitochondrial DNA

Background

Schistosoma japonicum still causes severe parasitic disease in mainland China, but mainly in areas along the Yangtze River. However, the genetic diversity in populations of S. japonicum has not been well understood across its geographical distribution, and such data may provide insights into the epidemiology and possible control strategies for schistosomiasis.

Methodology/Principal Findings

In this study infected Oncomelania snails were collected from areas in the middle and lower (ML) reaches of the Yangtze River, including Hubei, Hunan, Anhui, Jiangxi and Jiangsu provinces, and in the upper reaches of the river, including Sichuan and Yunnan provinces in southwest (SW) China. The adult parasites obtained from experimentally infected mice using isolated cercariae were sequenced individually for several fragments of mitochondrial regions, including Cytb-ND4L-ND4, 16S-12S and ND1. Populations in the ML reaches exhibited a relatively high level of diversity in nucleotides and haplotypes, whereas a low level was observed for populations in the SW, using either each single fragment or the combined sequence of the three fragments. Pairwise analyses of F-statistics (Fst) revealed a significant genetic difference between populations in the ML reaches and those in the SW, with limited gene flow and no shared haplotypes in between. It is rather obvious that genetic diversity in the populations of S. japonicum was significantly correlated with the geographical distance, and the geographical separation/isolation was considered to be the major factor accounting for the observed difference between populations in the ML reaches and those in the SW in China.

Conclusions

S. japonicum in mainland China exhibits a high degree of genetic diversity, with a similar pattern of genetic diversity as observed in the intermediate host snails in the same region in China.

Despite the existing threat of schistosomiasis in some rural areas along the Yangtze River, the genetic diversity of Schistosoma japonicum has not been investigated across its wide geographical distribution in China, and such information may provide insight into the disease epidemiology and the development of its control measures. In this study, the adult parasites, obtained through infecting mice with cercariae from snails of the genus Oncomelania collected from a wide range of localities in currently endemic areas of schistosomiasis in the middle and lower (ML) reaches of the Yangtze River, and in Sichuan and Yunnan provinces in the upper reaches of the river in southwest (SW) China, were sequenced individually for mitochondrial genes. In general, a relatively high degree of genetic variation was observed in populations in the ML reaches in terms of nucleotide and haplotype diversity, but a low level was observed in populations in the SW. The significant difference in genetic diversity as revealed by F-statistics, and the existence of no shared haplotypes, were observed between populations in the ML reaches and those in the SW, indicating the effect of geographical separation/isolation upon the schistosomes and probably the parasite-snail system in China.

Effect of an integrated control strategy for schistosomiasis japonica in the lower reaches of the Yangtze River, China: an evaluation from 2005 to 2008

Background

Schistosomiasis japonica remains a major public health concern in China. There are many interventions implemented to control the transmission of the disease. The purpose of the present study was to investigate the effects of an integrated control strategy for schistosomiasis control.

Methods

An integrated control strategy for schistosomiasis japonica with emphasis on removing cattle from snail-infested grasslands, providing farmers with mechanized farm equipment, improving sanitation by supplying tap water and building lavatories and latrines and providing boats with fecal-matter containers was implemented in 107 villages of the lower reaches of the Yangtze River, Jiangsu Province, China, during a 32-month period from May 2005 to 2008, and the effectiveness was investigated.

Results

Following the effects of the comprehensive control, the snail habitat, infected snail habitat, snail infection rate, and S. japonicum prevalence in both humans and livestock all appeared a declining trend year by year, with reductions of 47.88%, 94.29%, 92.55%, 96.94%, and 100% compared with those before the comprehensive control. In addition, all of the 17 counties achieved the infection control in 2007, and 7 reached the criteria of transmission control in 2008. The confirmed snail habitats reduced from 107 to 20, and the acute infections have also been controlled for 2 successive years since 2007.

Conclusions

The integrated control strategy for schistosomiasis japonica is effective to control the transmission of S. japonicum.

Tools to support policy decisions related to treatment strategies and surveillance of Schistosomiasis japonica towards elimination

Background

Appropriate diagnostics to monitor disease trends and assess the effectiveness and impact of interventions are essential for guiding treatment strategies at different thresholds of schistosomiasis transmission and for certifying elimination. Field validation of these assays is urgently needed before they can be adopted to support policy decisions of the national programme for control and elimination of schistosomiasis in P.R. China. We compared the efficacy and utility of different immunoassays in guiding control strategies and monitoring the endemic status of S. japonicum infections towards elimination.

Methodology/Principal Findings

A cross-sectional survey was conducted in seven villages with different transmission intensities settings to assess the performance and utility of three immunoassays, e.g., an indirect hemagglutination assay (IHA_JX), an enzyme linked immunosorbent assay (ELISA_SZ), and a dot immunogold filtration assay (DIGFA_SH). 6,248 individuals aged 6–65 years old who gave consent and supplied their stool and blood samples were included for data analysis. Results showed that ELISA_SZ performed significantly higher sensitivity (95.45%, 95%CI: 92.94–97.97%) than IHA_JX (87.59%, 95%CI: 83.51–91.49%) and DIGFA_SH (79.55%, 95%CI: 74.68–84.41%), especially in subgroups with very low infection intensity. The specificity of ELISA_SZ, IHA_JX, DIGFA_SH in 6–9 year olds with occasional exposure was nearly 90%. DIGFA_SH performed the highest screening efficacy for patients among three assays with overall positive predicative value of 13.07% (95%CI: 11.42–14.72%). We found a positive correlation of antibody positive rate of IHA_JX with results of stool examination in age strata (r = 0.70, P<0.001). Seropositivity of IHA_JX in children aged 6–9 years old showed an excellent correlation with prevalence of schistosome infection in the seven communities (r = 0.77, P<0.05).

Conclusions/Significance

Studies suggest that ELISA_SZ could be used to guide selective chemotherapy in moderate or low endemic regions. IHA_JX could be used to as a surveillance tool and for certifying elimination of schistosomiasis through monitoring children as a sentinel population.

Immunodiagnostic assays are widely applied in the field to control schistosomiasis in P.R. China as the prevalence and infection intensity of schistosome infections decrease. Field evaluations are urgently needed before they can be adopted to support policy decisions of the national programme for the control and elimination of schistosomiasis in P.R. China. We carried out a large scale cross-sectional survey in field settings with different transmission situations to validate immunodiagnostic tools that can be used to formulate new schistosomiasis elimination strategy in P.R. China. Regarding stool examination as gold reference, the validity and screening efficacy of each immunodiagnostic kit were calculated and compared with each other. The association of the prevalence of schistosomiasis and antibody positive rates determined by immunoassays were analyzed using Pearson's correlation coefficient values. The study indicates that which test to use with the elimination strategy is dependent on the purpose of testing, the endemic status of community and the resources available. And more sensitive methods need to be explored and used to target infected individuals for treatment or to eliminate schistosomiasis.

Osteopontin expression is associated with hepatopathologic changes in Schistosoma japonicum infected mice

AIM: To investigate osteopontin expression and its association with hepatopathologic changes in BALB/C mice infected with Schistosoma japonicum.

METHODS: The schistosomal hepatopathologic mouse model was established by abdominal infection with schistosomal cercaria. Liver samples were obtained from mice sacrificed at 6, 8, 10, 14, and 18 wk after infection. Liver histopathological changes were observed with hematoxylin-eosin and Masson trichrome staining. The expression of osteopontin was determined with immunohistochemistry, reverse transcription-polymerase chain reaction, and Western blotting. The expression of α-smooth muscle actin (α-SMA) and transforming growth factor-β1 (TGF-β1) were determined by immunohistochemistry. Correlations of osteopontin expression with other variables (α-SMA, TGF-β1, hepatopathologic features including granuloma formation and degree of liver fibrosis) were analyzed.

RESULTS: Typical schistosomal hepatopathologic changes were induced in the animals. Dynamic changes in the expression of osteopontin were observed at week 6. The expression increased, peaked at week 10 (P < 0.01), and then gradually decreased. Positive correlations between osteopontin expression and α-SMA (r = 0.720, P < 0.01), TGF-β1 (r = 0.905, P < 0.01), granuloma formation (r = 0.875, P < 0.01), and degree of liver fibrosis (r = 0.858, P < 0.01) were also observed.

CONCLUSION: Osteopontin may play an important role in schistosomal hepatopathology and may promote granuloma formation and liver fibrosis through an unexplored mechanism.

Communicable disease control in China: From Mao to now

China's progress on communicable disease control (CDC) in the 30 years after establishment of the People's Republic in 1949 is widely regarded as remarkable. Life expectancy soared by around 30 years, infant mortality plummeted and smallpox, sexually transmitted diseases and many other infections were either eliminated or decreased massively in incidence, largely as a result of CDC. By the mid-1970s, China was already undergoing the epidemiologic transition, years ahead of other nations of similar economic status. These early successes can be attributed to population mobilization, mass campaigns and a focus on sanitation, hygiene, clean water and clean delivery, and occurred despite political instability and slow economic progress. The 10-year Cultural Revolution from 1966 brought many hardships, but also clinical care and continuing public health programs to the masses through community-funded medical schemes and the establishment of community-based health workers. These people-focused approaches broke down with China's market reforms from 1980. Village doctors turned to private practice as community funding ceased, and the attention paid to rural public health declined. CDC relied on vertical programs, some of them successful (such as elimination of lymphatic filariasis and child immunisation), but others (such as control of schistosomiasis and tuberculosis) demonstrating only intermittent progress due to failed strategies or reliance on support by the poorest governments and health workers, who could not or would not collaborate. In addition, China's laissez-faire approach to public health placed it at great risk, as evidenced by the outbreak in 2003 of the Severe Acute Respiratory Syndrome. Since then, major changes to disease reporting, the priority given to CDC including through major new domestic resources and reform of China's health system offer encouragement for CDC. While decentralized funding and varying quality diagnosis, reporting and treatment of infectious diseases remain major challenges, national priority on CDC in China is high.

Disability weight of Clonorchis sinensis infection: captured from community study and model simulation

BACKGROUND

Clonorchiasis is among the most neglected tropical diseases. It is caused by ingesting raw or undercooked fish or shrimp containing the larval of Clonorchis sinensis and mainly endemic in Southeast Asia including China, Korea and Vietnam. The global estimations for population at risk and infected are 601 million and 35 million, respectively. However, it is still not listed among the Global Burden of Disease (GBD) and no disability weight is available for it. Disability weight reflects the average degree of loss of life value due to certain chronic disease condition and ranges between 0 (complete health) and 1 (death). It is crucial parameter for calculating the morbidity part of any disease burden in terms of disability-adjusted life years (DALYs).

METHODOLOGY/PRINCIPAL FINDINGS

According to the probability and disability weight of single sequelae caused by C. sinensis infection, the overall disability weight could be captured through Monte Carlo simulation. The probability of single sequelae was gained from one community investigation, while the corresponding disability weight was searched from the literatures in evidence-based approach. The overall disability weights of the male and female were 0.101 and 0.050, respectively. The overall disability weights of the age group of 5-14, 15-29, 30-44, 45-59 and 60+ were 0.022, 0.052, 0.072, 0.094 and 0.118, respectively. There was some evidence showing that the disability weight and geometric mean of eggs per gram of feces (GMEPG) fitted a logarithmic equation.

CONCLUSION/SIGNIFICANCE

The overall disability weights of C. sinensis infection are differential in different sex and age groups. The disability weight captured here may be referred for estimating the disease burden of C. sinensis infection.

A strategy for emergency treatment of Schistosoma japonicum-infested water

BACKGROUND

Schistosomiasis japonica, caused by contact with Schistosoma japonicum cercaria-infested water when washing, bathing or production, remains a major public-health concern in China. The purpose of the present study was to investigate the effect of a suspension concentrate of niclosamide (SCN) on killing cercaria of S. japonicum that float on the water surface, and its toxicity to fish, so as to establish an emergency-treatment intervention for rapidly killing cercaria and eliminating water infectivity.

RESULTS

At 30 min after spraying 100 mg/L SCN, with niclosamide dosages of 0.01, 0.02, 0.03, 0.04 g/m², the water infectivity reduced significantly and no infectivity was found at 60 min after spraying SCN. The surface of static water was sprayed with 100 mg/L SCN, the peak concentration was found at 0 min, and the solution diffused to site with a water depth of 10 cm after 10 min. 30 min later, SCN diffused to the whole water body, and distributed evenly. After spraying 100 mg/L SCN onto the surface of the water with a volume of(3.14 × 202 × 50)cm³, with niclosamide dosages of 0.02 g/m², 96 h later, no death of zebra fish was observed.

CONCLUSIONS

By spraying 100 mg/L SCN, with a niclosamide dosage of 0.02 g/m² onto the surface of S. japonicum-infested water, infectivity of the water can be eliminated after 30-60 min, and there is no evident toxicity to fish. This cercaria-killing method, as an emergency-treatment intervention for infested water, can be applied in those forecasting and early warning systems for schistosomiasis.

Stirred, not shaken: genetic structure of the intermediate snail host Oncomelania hupensis robertsoni in an historically endemic schistosomiasis area

BACKGROUND

Oncomelania hupensis robertsoni is the sole intermediate host for Schistosoma japonicum in western China. Given the close co-evolutionary relationships between snail host and parasite, there is interest in understanding the distribution of distinct snail phylogroups as well as regional population structures. Therefore, this study focuses on these aspects in a re-emergent schistosomiasis area known to harbour representatives of two phylogroups - the Deyang-Mianyang area in Sichuan Province, China. Based on a combination of mitochondrial and nuclear DNA, the following questions were addressed: 1) the phylogeography of the two O. h. robertsoni phylogroups, 2) regional and local population structure in space and time, and 3) patterns of local dispersal under different isolation-by-distance scenarios.

RESULTS

The phylogenetic analyses confirmed the existence of two distinct phylogroups within O. h. robertsoni. In the study area, phylogroups appear to be separated by a mountain range. Local specimens belonging to the respective phylogroups form monophyletic clades, indicating a high degree of lineage endemicity. Molecular clock estimations reveal that local lineages are at least 0.69-1.58 million years (My) old and phylogeographical analyses demonstrate that local, watershed and regional effects contribute to population structure. For example, Analyses of Molecular Variances (AMOVAs) show that medium-scale watersheds are well reflected in population structures and Mantel tests indicate isolation-by-distance effects along waterways.

CONCLUSIONS

The analyses revealed a deep, complex and hierarchical structure in O. h. robertsoni, likely reflecting a long and diverse evolutionary history. The findings have implications for understanding disease transmission. From a co-evolutionary standpoint, the divergence of the two phylogroups raises species level questions in O. h. robertsoni and also argues for future studies relative to the distinctness of the respective parasites. The endemicity of snail lineages at the regional level supports the concept of endemic schistosomiasis areas and calls for future geospatial analyses for a better understanding of respective boundaries. Finally, local snail dispersal mainly occurs along waterways and can be best described by using cost distance, thus potentially enabling a more precise modelling of snail, and therefore, parasite dispersal.

Toward sustainable and comprehensive control of schistosomiasis in China: lessons from Sichuan

Triggered by a fascinating publication in the New England Journal of Medicine detailing China's new multi-pronged strategy to control and eventually interrupt the transmission of Schistosoma japonicum, this PLoS Neglected Tropical Diseases Debate critically examines the generalizability and financial costs of the studies presented from the marshlands of the lake region. Edmund Seto from the University of California and colleagues emphasize that the epidemiology and control of schistosomiasis varies according to the social-ecological context. They conjecture that the successful intervention packages piloted in the lake region is not fully fit for the hilly and mountainous environments in Sichuan and Yunnan provinces, and hence call for more flexible, setting-specific, and less expensive control strategies. In response, Xiao-Nong Zhou from the National Institute of Parasitic Diseases at the Chinese Center of Disease Control and Prevention and colleagues explain the steps from designing pilot studies to the articulation and implementation of a new national control strategy through a careful process of scaling-up and adaptations. Finally, the two opponents converge. The need for integrated, intersectoral, and setting-specific control measures is stressed, supported by rigorous surveillance and continuous research. Experiences and lessons from China are important for shaping the schistosomiasis elimination agenda.

A diagnostic challenge for Schistosomiasis japonica in China: consequences on praziquantel-based morbidity control

Worldwide schistosomiasis continues to be a serious public health problem. Over the past five decades, China has made remarkable progress in reducing Schistosoma japonicum infections in humans to a relatively low level. Endemic regions are currently circumscribed in certain core areas where re-infection and repeated chemotherapy are frequent. At present, selective chemotherapy with praziquantel is one of the main strategies in China's National Schistosomiasis Control Program, and thus diagnosis of infected individuals is a key step for such control. In this paper we review the current status of our knowledge about diagnostic tools for schistosomiasis japonica. A simple, affordable, sensitive, and specific assay for field diagnosis of schistosomiasis japonica is not yet available, and this poses great barriers towards full control of schistosomiasis. Hence, a search for a diagnostic approach, which delivers these characteristics, is essential and should be given high priority.

Monitoring specific antibody responses against the hydrophilic domain of the 23 kDa membrane protein of Schistosoma japonicum for early detection of infection in sentinel mice

Background

Schistosomiasis remains an important public health problem throughout tropical and subtropical countries. Humans are infected through contact with water contaminated with schistosome cercariae. Therefore, issuing early warnings on the risk of infection is an important preventive measure against schistosomiasis. Sentinel mice are used to monitor water body infestations, and identifying appropriate antibody responses to schistosome antigens for early detection of infection would help to improve the efficiency of this system. In this study we explored the potential of detecting antibodies to the hydrophilic domain (HD) of the 23-kDa membrane protein (Sj23HD) and soluble egg antigen (SEA) of Schistosome japonicum for early detection of schistosome infection in sentinel mice.

Results

Development of IgM and IgG antibody levels against Sj23HD and SEA in S. japonicum infected mice was evaluated over the course of 42 days post-infection by enzyme-linked immunosorbent assay (ELISA) and immunoblotting. The Sj23HD and SEA specific IgM and IgG levels in mice all increased gradually over the course of infection, but IgM and IgG antibodies against Sj23HD presented earlier than those against SEA. Furthermore, the rates of positive antibody responses against Sj23HD were higher than those against SEA in the early stage of schistosome infection, suggesting that the likelihood of detecting early infection using anti-Sj23HD responses would be higher than that with anti-SEA responses. The use of immunoblotting could further improve the early detection of schistosome infection due to its greater sensitivity and specificity compared to ELISA. Additionally, the levels of Sj23HD and SEA specific antibodies positively correlated with the load of cercariae challenge and the duration of schistosome infection.

Conclusions

This study demonstrated that antibody responses to the Sj23HD antigen could be monitored for early detection of schistosome infection in mice, especially by immunoblotting which demonstrated greater sensitivity and specificity than ELISA for detection Sj23HD antibodies.

The challenge of effective surveillance in moving from low transmission to elimination of schistosomiasis in China

Until recently, intensified efforts in China to suppress the transmission of Schistosoma japonicum relied principally on routine praziquantel treatment, extensive use of molluscicides and health education programs. These efforts, now supplemented by a broader range of control measures, have been quite successful in reducing the prevalence and intensity of human infection to very low levels. However, re-emergent transmission has occurred in formerly endemic areas of several provinces, signalling the need for more locally effective, integrated control strategies. We argue that these low but persistent levels of transmission also require important changes in both the tactics and strategy of disease surveillance to move forward towards elimination. Here we present recent data exemplifying the low transmission environment which suggests that we are reaching limits of detection of current diagnostic techniques used for human infection surveillance in these communities. However, both epidemiological data and theoretical results indicate that (i) transmission in the human population can persist at very low infection intensities even in the presence of routine control activities; (ii) the parasite can be reintroduced into parasite-free environments by very modest external inputs; and (iii) transmission at these low infection intensities exhibits very slow inter-year dynamics. These observations motivate the need for new, sensitive tools to identify low-level infections in mammalian or snail hosts, or the presence of S. japonicum in environmental media. Environmental monitoring offers an alternative, and perhaps more efficient, approach to large-scale surveillance of human infections in low transmission regions.

Effectiveness of a comprehensive schistosomiasis japonica control program in Jiangsu province, China, from 2005 to 2008

The effectiveness of a comprehensive schistosomiasis japonica control program implemented in 8 villages along the Yangtze river in Jiangsu province from 2005 to 2008 was studied. Control measures included snail control, chemotherapy of humans and livestock, health education, and transmission cycle interruption using sanitation in dwellings and at anchorage sites for fishermen and sailors. The Schistosoma japonicum prevalence among residents and livestock, the total area of snail habitats, the Oncomelania hupensis snail density, and the percentage of infected snails served as indicators for the effectiveness of the control efforts. After 4 years of program implementation, the seroprevalence in humans had decreased from 9.03% to 3.24% (P < 0.001) and the parasitological prevalence among males had decreased from 0.42% to 0.12% (P = 0.004). Among females, it remained stable at a low level. The S. japonicum prevalence in livestock had decreased from 2.94% to 0% (P < 0.001). Additionally, the area where infected snails could be found had shrunk from 89.99 hectares (ha) to 16.00 ha, the snail density had decreased from 0.56 to 0.32 per 0.1m(2), and the percentage of infected snails had dropped from 0.38% to 0.12% (all P < 0.001). The results demonstrate that an integrated schistosomiasis japonica control strategy focusing on the main transmission cycles and reservoirs and combines chemotherapy, infrastructure interventions and health education combined with robust surveillance is feasible and allows to effectively control S. japonicum.

Schistosomiasis research in the dongting lake region and its impact on local and national treatment and control in China

Schistosomiasis is a chronic and debilitating parasitic disease that has often been neglected because it is a disease of poverty, affecting poor rural communities in the developing world. This is not the case in the People's Republic of China (PRC), where the disease, caused by Schistosoma japonicum, has long captured the attention of the Chinese authorities who have, over the past 50–60 years, undertaken remarkably successful control programs that have substantially reduced the schistosomiasis disease burden. The Dongting Lake region in Hunan province is one of the major schistosome-endemic areas in the PRC due to its vast marshland habitats for the Oncomelania snail intermediate hosts of S. japonicum. Along with social, demographic, and other environmental factors, the recent completion and closure of the Three Gorges dam will most likely increase the range of these snail habitats, with the potential for re-emergence of schistosomiasis and increased transmission in Hunan and other schistosome-endemic provinces being a particular concern. In this paper, we review the history and the current status of schistosomiasis control in the Dongting Lake region. We explore the epidemiological factors contributing to S. japonicum transmission there, and summarise some of the key research findings from studies undertaken on schistosomiasis in Hunan province over the past 10 years. The impact of this research on current and future approaches for sustainable integrated control of schistosomiasis in this and other endemic areas in the PRC is emphasised.

Risk factors for helminth infections in a rural and a peri-urban setting of the Dongting Lake area, People's Republic of China

Schistosomiasis japonica and soil-transmitted helminthiasis are endemic parasitic diseases in the People's Republic of China (PR China). As very few studies have reported on the distribution and interaction of multiple species helminth infections, we carried out a comparative study of households in a rural village and a peri-urban setting in the Dongting Lake area of Hunan province in November and December 2006 to determine the extent of single and multiple species infections, the underlying risk factors for infection, and the relationships with clinical manifestations and self-reported morbidity. In each household, stool samples were collected and subjected to the Kato-Katz method for identifying Schistosoma japonicum, Ascaris lumbricoides, hookworm and Trichuris trichiura infections. Clinical examinations were performed and questionnaire surveys conducted at both household and individual subject levels. Complete parasitological, clinical and questionnaire data were obtained for 1,298 inhabitants of the two settings. The overall prevalences of single infections of S. japonicum, A. lumbricoides, hookworm and T. trichiura were 6.5%, 5.5%, 3.0% and 0.8%, respectively; the majority of the infections were of light intensity. We found significant negative associations between wealth and infections with S. japonicum and A. lumbricoides. Clinical manifestations of splenomegaly, hepatomegaly and anaemia were prevalent (9.0%, 3.7% and 10.9%, respectively), the latter two being significantly (P<0.05) associated with schistosomiasis. Self-reported symptoms were more common among females but there was considerable under-reporting in both sexes when relying only on spontaneous recall. Our findings may guide the design and targeting of a more equitable, comprehensive and integrated parasitic disease control programme in Hunan province and in other areas of PR China.

Development of a rapid dipstick with latex immunochromatographic assay (DLIA) for diagnosis of schistosomiasis japonica

BACKGROUND

Schistosomiasis japonica (schistosomiasis) is a zoonosis that can seriously affect human health. At present, the immunodiagnostic assays for schistosomiasis detection are time-consuming and require well-trained personnel and special instruments, which can limit their use in the field. Thus, there is a pressing need for a simple and rapid immunoassay to screen patients on a large scale. In this study, we developed a novel rapid dipstick with latex immunochromatographic assay (DLIA) to detect anti-Schisaosoma japonicum antibodies in human serum.

RESULTS

Using latex microspheres as a color probe, DLIA was established to test standard positive and negative sera, in comparison with the classical enzyme-linked immunosorbent assay (ELISA). The sensitivity and specificity of DLIA were 95.10% (97/102) and 94.91% (261/275), respectively. The cross-reaction rates with clonorchiosis, intestinal nematodes, Angiostrongylus cantonensis and paragonimiasis were 0, 0, 0 and 42.11% respectively. All the results showed no significant difference to the ELISA. In field tests, 333 human serum samples from an endemic area were tested with DLIA, and compared with ELISA and Kato-Katz method. There was no significant difference between DLIA and ELISA on positive and negative rates of detection; however, significant differences existed between DLIA and Kato-Katz method, and between ELISA and Kato-Katz method. The kappa value between DLIA and ELISA was 0.90.

CONCLUSIONS

This is the first study in which DLIA was used to detect anti-Schistosoma japonicum antibody. The results show that DLIA is a simple, rapid, convenient, sensitive and specific assay for the diagnosis of schistosomiasis and is therefore very suitable for large-scale field applications and clinical detection.

Establishment of a cerebral schistosomiasis experimental model in rabbits

OBJECTIVE

The present study aimed to establish a cerebral schistosomiasis model in rabbits, to provide a valuable tool for morphological analysis, clinical manifestation observation, as well as investigations into immunological reactions and pathogenesis of focal inflammatory reaction in neuroschistosomiasis (NS).

METHODS

Sixty New Zealand rabbits were randomly assigned into operation, sham-operation and normal groups. Rabbits in the operation group received direct injection of dead schistosome eggs into the brain, while their counterparts in the sham-operation group received saline injection. Rabbits in the normal group received no treatment. Base on the clinical manifestations, rabbits were sacrificed on days 3, 5, 7, 10, 20, and 30 post injection, and brain samples were sectioned and stained with hematoxylin-eosin. Sections were observed under the microscope.

RESULTS

The rabbits in the operation group exhibited various neurological symptoms, including anorexy, partial and general seizures, and paralysis. The morphological analysis showed several schistosome eggs in the nervous tissue on day 3 post operation, with very mild inflammation. On days 7-10 post operation, several schistosome eggs were localized in proximity to red blood cells with many neutrophilic granulocytes and eosinophilic granulocytes around them. The schistosome eggs developed into the productive granuloma stage on days 14-20 post operation. On day 30, the schistosome eggs were found to be in the healing-by-fibrosis stage, and the granuloma area was replaced by fibrillary glia through astrocytosis. The sham-operation group and the normal group showed negative results.

CONCLUSION

This method might be used to establish the cerebral schistosomiasis experimental model. Several factors need to be considered in establishing this model, such as the antigenic property of eggs, the time of scarification, and the clinical manifestations.

Compensatory density feedback of Oncomelania hupensis populations in two different environmental settings in China

Background

The most recent strategy for schistosomiasis control in the People's Republic of China aims to reduce the likelihood of environmental contamination of schistosome eggs. Despite considerable progress, it is believed that achievements would be further consolidated with additional intermediate host snail control measures. We provide an empirical framework for discerning the relative contribution of intrinsic effects (density feedback) from other extrinsic drivers of snail population dynamics.

Methods

We set up experiments in two study locations to collect reproduction data of Oncomelania hupensis, the intermediate host snail of Schistosoma japonicum. We applied a set of four population dynamic models that have been widely used to study phenomenological time-series data to examine the properties of demographic density feedback patterns from abundance data. We also contrasted the obtained results with the component feedback of density on survival rate to determine whether adult survival was the principal driver of the demographic feedback observed.

Results

Demographic density feedback models (Ricker- and Gompertz-logistic) accounted for > 99% of Akaike's information criterion model weight, with the Gompertz ranking highest in all O. hupensis population groups. We found some evidence for stronger compensatory feedback in the O. hupensis population from Sichuan compared to a Jiangsu population. Survival rates revealed strong component feedback, but the log-linear relationships (i.e. Gompertz) had less support in the demographic feedback analysis.

Conclusions

Our findings indicate that integrated schistosomiasis control measures must continue to reduce parasite abundance further because intermediate host snail populations tend to grow exponentially at low densities, especially O. hupensis populations in mountainous regions. We conclude that density feedback in adult survival is the principal component contribution to the demographic phenomenon observed in the population fitness (r)-abundance relationship.

A review of parasitic zoonoses in a changing Southeast Asia

Parasitic zoonoses are common and widely distributed in the Southeast Asian region. However, the interactions between parasites, hosts and vectors are influenced by environmental, socio-cultural and livestock production changes that impact on the distribution, prevalence and severity of disease. In this review we provide an update on new knowledge in the context of ongoing changes for the food-borne pig associated zoonoses Taenia solium and Trichinella spp., the food-borne trematodes Opisthorchis viverrini and Clonorchis sinensis, the water-borne trematodes Schistosoma spp., the vector-borne zoonotic protozoa Plasmodium knowlesi and Leishmania spp. and the soil-borne zoonotic hookworm Ancylostoma ceylanicum. These various changes need to be considered when assessing or developing regional control programs or devising new research initiatives in a changing SE Asia.

Neuroschistosomiasis

Schistosomiasis (bilharzia) is a neglected tropical disease caused by digenetic trematode platyhelminths of the genus Schistosoma. Neuroschistosomiasis is one of the most severe clinical outcomes associated with schistosome infection. Neurological complications early during the course of infection are thought to occur through in situ egg deposition following aberrant migration of adult worms to the brain or spinal cord. The presence of eggs in the CNS induces a cell-mediated Th2-driven periovular granulomatous reaction. The mass effect of thousands of eggs and the large granulomas concentrated within the brain or spinal cord explain the signs and symptoms of increased intracranial pressure, myelopathy, radiculopathy and subsequent clinical sequelae. Myelopathy (acute transverse myelitis and subacute myeloradiculopathy) of the lumbosacral region is the most common neurological manifestation of S. mansoni or S. haematobium infection, whereas acute encephalitis of the cortex, subcortical white matter, basal ganglia or internal capsule is typical of S. japonicum infection. Cerebral complications include encephalopathy with headache, visual impairment, delirium, seizures, motor deficits and ataxia, whereas spinal symptoms include lumbar pain, lower limb radicular pain, muscle weakness, sensory loss and bladder dysfunction. The finding of eggs in the stool or a positive serology, provides supportive but not direct evidence of neuroschistosomiasis. A definitive diagnosis can only be made with histopathological study showing Schistosoma eggs and granulomas. Schistosomicidal drugs (notably praziquantel), steroids and surgery are currently used for the treatment of neuroschistosomiasis. During the 'acute phase' of the disease, neuroschistosomiasis is treated with corticosteroids which are augmented with a course of praziquantel once female worm ovipositioning commences. Surgery should be reserved for special cases such as in those with evidence of medullary compression and in those who deteriorate despite clinical management.

IRAP: An efficient retrotransposon-based electrophoretic technique for studying genetic variability among geographical isolates of Schistosoma japonicum

In the present study, a inter-retrotransposon-amplified polymorphism (IRAP) technique, based on retrotransposons, was used to examine genetic variability among Schistosoma japonicum isolates from different provinces in mainland China. Of the 15 primers screened, 5 produced highly reproducible IRAP patterns. Using these primers, 54 discernible DNA fragments were generated with 40 (74.07%) being polymorphic, indicating considerable genetic variation among the examined S. japonicum isolates. The primer LTR-11 was found to be able to differentiate male and female parasites, producing one constant specific band for female S. japonicum isolates. The percentages of polymorphic bands (PPB) among all parasites, among isolates from mountainous provinces and among those from the lake/marshland areas were 74.07, 48.15, and 66.67%, respectively. UPGMA analysis revealed that the IRAP profiles could group S. japonicum isolates in mainland China into two clades (mountainous and lake/marshland types), and samples from the same geographical origins clustered together. These results demonstrated that the IRAP technique is suitable for studying genetic diversity and population structures, and also provides an effective technique for studying sex differentiation of S. japonicum.

Performance of a dipstick dye immunoassay for rapid screening of Schistosoma japonicum infection in areas of low endemicity

BACKGROUND

The dipstick dye immunoassay (DDIA), recently commercially available in the People's Republic of China (P.R. China), is a rapid and simple test to detect human antibodies against Schistosoma Japonicum. Its performance and utility for screening schistosome infection in low endemic areas is little known. We therefore carried out a cross-sectional survey in seven villages with low endemicity of schistosomiasis in P.R. China and assessed the performance and utility of DDIA for diagnosis of schistosomiasis. Stool samples were collected and examined by the Kato-Katz method and the miracidium hatching technique. Serum samples, separated from whole blood of participants, were tested by DDIA.

RESULTS

6285 individuals aged 6-65 years old participated in this study, with a prevalence of schistosomiasis of 4.20%. Using stool examination as a gold reference standard, DDIA performed with a high overall sensitivity of 91.29% (95% CI: 87.89-94.69%) and also a high negative predictive value, with a mean value of 99.29% (95% CI: 98.99-99.58%). The specificity of DDIA was only moderate (53.08%, 95% CI: 51.82-54.34%). Multivariate analysis indicated that age, occupation and history of schistosome infection were significantly associated with the false positive results of DDIA.

CONCLUSIONS

DDIA is a sensitive, rapid, simple and portable diagnostic assay and can be used as a primary approach for screening schistosome infection in areas of low endemicity. However, more sensitive and specific confirmatory assays need to be developed and combined with DDIA for targeting chemotherapy accurately.