The unacknowledged impact of chronic schistosomiasis

Praziquantel: its use in control of schistosomiasis in sub-Saharan Africa and current research needs

Treatment with praziquantel (PZQ) has become virtually the sole basis of schistosomiasis control in sub-Saharan Africa and elsewhere, and the drug is reviewed here in the context of the increasing rate that it is being used for this purpose. Attention is drawn to our relative lack of knowledge about the mechanisms of action of PZQ at the molecular level, the need for more work to be done on schistosome isolates that have been collected recently from endemic areas rather than those maintained in laboratory conditions for long periods, and our reliance for experimental work mainly on Schistosoma mansoni, little work having been done on S. haematobium. There is no evidence that resistance to PZQ has been induced in African schistosomes as a result of its large-scale use on that continent to date, but there is also no assurance that PZQ and/or schistosomes are in any way unique and that resistant organisms will not be selected as a result of widespread drug usage. The failure of PZQ to produce complete cures in populations given a routine treatment should therefore solicit considerable concern. With few alternatives to PZQ currently available and/or on the horizon, methods to monitor drug-susceptibility in African schistosomes need to be devised and used to help ensure that this drug remains effective for as long a time as possible.

Schistosoma haematobium total antigen induces increased proliferation, migration and invasion, and decreases apoptosis of normal epithelial cells

Schistosome worms are blood-dwelling flukes that cause chronic infection in more than 200 million people and are thought to be responsible for 500,000 deaths annually. During infection with Schistosoma haematobium, eggs are deposited in the mucosa and submucosa of the bladder and lower ureters. Squamous cell carcinoma (SCC) of the bladder is a long-term sequela of chronic infection. The mechanisms underlying the association between S. haematobium and SCC of the bladder are largely unknown, with all reports to date exclusively demonstrating epidemiological evidence linking S. haematobium infection with SCC of the bladder. We hypothesised that the parasite antigens might induce alterations in epithelial cells towards cancer. For this we used Chinese Hamster Ovary (CHO) cells and treated the cells in culture with S. haematobium total antigen (Sh). Our results showed increased proliferation, increased S-phase and decreased apoptosis, as well as down-regulation of tumour suppressor p27 and up-regulation of anti-apoptotic molecule Bcl-2 in Sh-treated cells compared with controls. We also found increased migration and invasion. To our knowledge, this is the first report demonstrating alterations of normal epithelial cells as a direct effect of S. haematobium antigens.

A new approach to characterize populations of Schistosoma mansoni from humans: development and assessment of microsatellite analysis of pooled miracidia

OBJECTIVES

To develop and assess a microsatellite technique to characterize populations of Schistosoma mansoni from humans.

METHODS

For each of five patients, we calculated the allele count and frequency at 11 loci for several pools of miracidia (50 and 100), and compared these to population values, determined by amplifying microsatellites from 186 to 200 individual miracidia per patient.

RESULTS

We were able to detect up to 94.5% of alleles in pools. Allele count and frequency strongly and significantly correlated between singles and pools; marginally significant differences (P < 0.05) were detected for one patient (pools of 50) for allele frequencies and for two patients (pools of 100) for allele counts. Kato-Katz egg counts and number of alleles per pool did not co-vary, indicating that further direct comparisons of the results from these two techniques are needed.

CONCLUSIONS

Allele counts and frequency profiles from pooling provide important information about infection intensity and complexity, beyond that obtained from traditional methods. Although we are not advocating use of pooling to replace individual genotyping studies, it can potentially be useful in certain applications as a rapid and cost effective screening method for studies of S. mansoni population genetics, or as a more informative way to quantify and characterize human worm populations.

Prevalence distribution and risk factors for Schistosoma hematobium infection among school children in Blantyre, Malawi

BACKGROUND

Schistosomiasis is a public health problem in Malawi but estimates of its prevalence vary widely. There is need for updated information on the extent of disease burden, communities at risk and factors associated with infection at the district and sub-district level to facilitate effective prioritization and monitoring while ensuring ownership and sustainability of prevention and control programs at the local level.

METHODS AND FINDINGS

We conducted a cross-sectional study between May and July 2006 among pupils in Blantyre district from a stratified random sample of 23 primary schools. Information on socio-demographic factors, schistosomiasis symptoms and other risk factors was obtained using questionnaires. Urine samples were examined for Schistosoma hematobium ova using filtration method. Bivariate and multiple logistic regressions with robust estimates were used to assess risk factors for S. hematobium. One thousand one hundred and fifty (1,150) pupils were enrolled with a mean age of 10.5 years and 51.5% of them were boys. One thousand one hundred and thirty-nine (1,139) pupils submitted urine and S. hematobium ova were detected in 10.4% (95%CI 5.43-15.41%). Male gender (OR 1.81; 95% CI 1.06-3.07), child's knowledge of an existing open water source (includes river, dam, springs, lake, etc.) in the area (OR 1.90; 95% CI 1.14-3.46), history of urinary schistosomiasis in the past month (OR 3.65; 95% CI 2.22-6.00), distance of less than 1 km from school to the nearest open water source (OR 5.39; 95% CI 1.67-17.42) and age 8-10 years (OR 4.55; 95% CI 1.53-13.50) compared to those 14 years or older were associated with infection. Using urine microscopy as a gold standard, the sensitivity and specificity of self-reported hematuria was 68.3% and 73.6%, respectively. However, the positive predictive value was low at 23.9% and was associated with age.

CONCLUSION

The study provides an important update on the status of infection in this part of sub-Saharan Africa and exemplifies the success of deliberate national efforts to advance active participation in schistosomiasis prevention and control activities at the sub-national or sub-district levels. In this population, children who attend schools close to open water sources are at an increased risk of infection and self-reported hematuria may still be useful in older children in this region.

Mefloquine--an aminoalcohol with promising antischistosomal properties in mice

BACKGROUND

The treatment and control of schistosomiasis, an often neglected tropical disease that exacerbates poverty, depends on a single drug, praziquantel. The large-scale use of praziquantel might select for drug-resistant parasites, hence there is a need to develop new antischistosomal compounds. Here, we report that the antimalarial drug mefloquine possesses promising antischistosomal properties in mice.

METHODOLOGY/PRINCIPAL FINDINGS

A single dose of mefloquine (200 or 400 mg/kg) administered orally to mice infected with adult Schistosoma mansoni or adult S. japonicum resulted in high or complete total and female worm burden reductions (72.3%-100%). Importantly, high worm burden reductions were also observed for young developing stages of S. mansoni and S. japonicum harbored in the mouse. Both mefloquine erythro-enantiomers resulted in high and comparable total and female worm burden reductions when given to mice with either a sub-patent or patent S. mansoni infection.

CONCLUSIONS/SIGNIFICANCE

Our findings hold promise for the development of a novel antischistosomal drug based on an aminoalcohol functionality. Further in vitro and in vivo studies have been launched to elucidate the possible mechanism of action and to study the effect of mefloquine on S. haematobium and other trematodes. It will be interesting to investigate whether mefloquine, which is widely and effectively used for the treatment of malaria, has an impact on schistosomiasis in areas where both malaria and schistosomiasis co-exist.

Parasitic helminths: a pharmacopeia of anti-inflammatory molecules

Infection with parasitic helminths takes a heavy toll on the health and well-being of humans and their domestic livestock, concomitantly resulting in major economic losses. Analyses have consistently revealed bioactive molecules in extracts of helminths or in their excretory/secretory products that modulate the immune response of the host. It is our view that parasitic helminths are an untapped source of immunomodulatory substances that, in pure form, could become new drugs (or models for drug design) to treat disease. Here, we illustrate the range of immunomodulatory molecules in selected parasitic trematodes, cestodes and nematodes, their impact on the immune cells in the host and how the host may recognize these molecules. There are many examples of the partial characterization of helminth-derived immunomodulatory molecules, but these have not yet translated into new drugs, reflecting the difficulty of isolating and fully characterizing proteins, glycoproteins and lipid-based molecules from small amounts of parasite material. However, this should not deter the investigator, since analytical techniques are now being used to accrue considerable structural information on parasite-derived molecules, even when only minute quantities of tissue are available. With the introduction of methodologies to purify and structurally-characterize molecules from small amounts of tissue and the application of high throughput immunological assays, one would predict that an assessment of parasitic helminths will yield a variety of novel drug candidates in the coming years.

Praziquantel: mechanisms of action, resistance and new derivatives for schistosomiasis

PURPOSE OF REVIEW

Praziquantel (PZQ) is the only drug being used to treat human schistosomiasis on a large scale. This review focuses on current knowledge about the mechanisms of action of PZQ, prospects for PZQ resistance, possible future alternative drugs and on exhortations that control of schistosomiasis and other so-called neglected tropical diseases becomes more integrated.

RECENT FINDINGS

Schistosome calcium ion (Ca2+) channels are the only moiety so far identified as the molecular target of PZQ, but the evidence remains indirect. In the presence of cytochalasin D worms survive high concentrations of PZQ and experiments with cytochalasin D also indicated that PZQ induced worm death and Ca2+ influx are not correlated. Despite PZQ being widely used, there is no clinically relevant evidence for resistance to date, but worryingly low-cure rates have been recorded in some studies in Africa. Artemisinins and the related 1,2,4-trioxolanes are new promising antischistosomal compounds, as are inhibitors of a schistosome-specific bifunctional enzyme, thioredoxin-glutathione reductase.

SUMMARY

Use of PZQ will increase in the foreseeable future, whether given alone or coadministered with other anthelminthics in integrated control programmes. PZQ resistance remains a threat and its prevention requires adequate monitoring of current mass drug administration programmes and development of new schistosomicides.

Metabolic profiling of a Schistosoma mansoni infection in mouse tissues using magic angle spinning-nuclear magnetic resonance spectroscopy

In order to enhance our understanding of physiological and pathological consequences of a patent Schistosoma mansoni infection in the mouse, we examined the metabolic responses of different tissue samples recovered from the host animal using a metabolic profiling strategy. Ten female NMRI mice were infected with approximately 80 S. mansoni cercariae each, and 10 uninfected age- and sex-matched animals served as controls. At day 74 post infection (p.i.), mice were killed and jejunum, ileum, colon, liver, spleen and kidney samples were removed. We employed (1)H magic angle spinning-nuclear magnetic resonance spectroscopy to generate tissue-specific metabolic profiles. The spectral data were analyzed using multivariate modelling methods including an orthogonal signal corrected-projection to latent structure analysis and hierarchical principal component analysis to assess the differences and/or similarities in metabolic responses between infected and non-infected control mice. Most tissues obtained from S. mansoni-infected mice were characterized by high levels of amino acids, such as leucine, isoleucine, lysine, glutamine and asparagine. High levels of membrane phospholipid metabolites, including glycerophosphoryl choline and phosphoryl choline were found in the ileum, colon, liver and spleen of infected mice. Additionally, low levels of energy-related metabolites, including lipids, glucose and glycogen were observed in ileum, spleen and liver samples of infected mice. Energy-related metabolites in the jejunum, liver and renal medulla were found to be positively correlated with S. mansoni worm burden upon dissection. These findings show that a patent S. mansoni infection causes clear disruption of metabolism in a range of tissues at a molecular level, which can be interpreted in relation to the previously reported signature in a biofluid (i.e. urine), giving further evidence of the global effect of the infection.

Socioeconomic studies of schistosomiasis in Brazil: a review

This review finds considerable evidence that socioeconomic status has significantly influenced the transmission, spread and treatment of schistosomiasis in Brazil. High infection rates persist among both the rural and urban poor. Rural living, poor housing and water supplies and low educational level were major factors in schistosomiasis occurrence among agricultural populations. In urban areas, prevailing living conditions in shantytowns and labor migrations from and periodic return movements to rural areas were predictive of schistosomiasis. The risk of the establishment of new transmission foci exists in both rural and urban areas, conferred by and affecting poorer people. Associations between schistosomiasis and socioeconomic parameters, persisting inequities in health services accessibility, prevailing health impacts of schistosomiasis, and the ongoing decentralization of health services point to opportunities and strategies for focused interventions aimed at promoting health-enhancing behavior and living conditions and improving access to health care. The authors call for multidisciplinary studies to better examine the complexities of the socioeconomic environment in relation to schistosomiasis and for economic programs to reduce prevailing socioeconomic inequalities.

Complexities of assessing the disease burden attributable to leishmaniasis

Among parasitic diseases, morbidity and mortality caused by leishmaniasis are surpassed only by malaria and lymphatic filariasis. However, estimation of the leishmaniasis disease burden is challenging, due to clinical and epidemiological diversity, marked geographic clustering, and lack of reliable data on incidence, duration, and impact of the various disease syndromes. Non-health effects such as impoverishment, disfigurement, and stigma add to the burden, and introduce further complexities. Leishmaniasis occurs globally, but has disproportionate impact in the Horn of Africa, South Asia and Brazil (for visceral leishmaniasis), and Latin America, Central Asia, and southwestern Asia (for cutaneous leishmaniasis). Disease characteristics and challenges for control are reviewed for each of these foci. We recommend review of reliable secondary data sources and collection of baseline active survey data to improve current disease burden estimates, plus the improvement or establishment of effective surveillance systems to monitor the impact of control efforts.

Schistosomiasis transmission at high altitude crater lakes in western Uganda

BACKGROUND

Contrary to previous reports which indicated no transmission of schistosomiasis at altitude >1,400 m above sea level in Uganda, in this study it has been established that schistosomiasis transmission can take place at an altitude range of 1487-1682 m above sea level in western Uganda.

METHODS

An epidemiological survey of intestinal schistosomiasis was carried out in school children staying around 13 high altitude crater lakes in Western Uganda. Stool samples were collected and then processed with the Kato-Katz technique using 42 mg templates. Thereafter schistosome eggs were counted under a microscope and eggs per gram (epg) of stool calculated. A semi-structured questionnaire was used to obtain demographic data and information on risk factors.

RESULTS

36.7% of the pupils studied used crater lakes as the main source of domestic water and the crater lakes studied were at altitude ranging from 1487-1682 m above sea level. 84.6% of the crater lakes studied were infective with over 50% of the users infected. The overall prevalence of Schistosoma mansoni infection was 27.8% (103/370) with stool egg load ranging from 24-6048 per gram of stool. 84.3%( 312) had light infections (<100 eggs/gm of stool), 10.8%( 40) had moderate infections (100-400 eggs/gm of stool) and 4.9% (18) had heavy infections (>400 egg/gm of stool). Prevalence was highest in the age group 12-14 years (49.5%) and geometric mean intensity was highest in the age group 9-11 years (238 epg). The prevalence and geometric mean intensity of infection among girls was lower (26%; 290 epg) compared to that of boys (29.6%; 463 epg) (t = 4.383, p < 0.05). Though 61%(225) of the pupils interviewed were aware of the existence of the disease, 78% (290)didn't know the mode of transmission and only 8% (30) of those found infected were aware of their infection status. In a multivariate logistic regression model, altitude and water source (crater lakes) were significantly associated with infection.

CONCLUSION AND RECOMMENDATIONS

The altitudinal threshold for S. mansoni transmission in Uganda has changed and use of crater water at an altitude higher than 1,400 m above sea level poses a risk of acquiring S. mansoni infection in western Uganda. However, further research is required to establish whether the observed altitudinal threshold change is as a result of climate change or other factors. It is also necessary to establish the impact this could have on the epidemiology of schistosomiasis and other vector-borne diseases in Uganda. In addition, sensitisation and mass treatment of the affected community is urgently required.

Helminth infections: the great neglected tropical diseases

Helminths are parasitic worms. They are the most common infectious agents of humans in developing countries and produce a global burden of disease that exceeds better-known conditions, including malaria and tuberculosis. As we discuss here, new insights into fundamental helminth biology are accumulating through newly completed genome projects and the nascent application of transgenesis and RNA interference technologies. At the same time, our understanding of the dynamics of the transmission of helminths and the mechanisms of the Th2-type immune responses that are induced by infection with these parasitic worms has increased markedly. Ultimately, these advances in molecular and medical helminth biology should one day translate into a new and robust pipeline of drugs, diagnostics, and vaccines for targeting parasitic worms that infect humans.