Use of praziquantel against schistosomiasis: a review of current status

Factors associated with hookworm and Schistosoma mansoni infections among school-aged children in Mayuge district, Uganda

BACKGROUND

Hookworm infection and schistosomiasis are two of sub-Saharan Africa's most common neglected tropical diseases. An annual mass drug administration (MDA) program against schistosomiasis and soil-transmitted helminths (STHs), including hookworm, has been implemented in Mayuge district, Uganda, since 2003 to date. However, hookworm and schistosomiasis remain prevalent in Mayuge district. Understanding the factors that predispose children to these infections in the context of MDA could inform interventions to reduce prevalence in Uganda and similar settings.

METHOD

This cross-sectional study took place in 33 randomly selected primary schools in the Mayuge district from January to February 2022. Children in primary classes 4 or 5, in the selected schools provided single stool samples and completed questionnaires. Stool specimens were examined using the Kato-Katz method to determine the prevalence of hookworm and schistosomiasis. We performed univariable and multivariable logistic regression to assess the associations of each infection with potential risk factors.

RESULT

A total of 1,617 students (mean age 12.1 years, 50.1% male) were enrolled. The prevalence of hookworm infection and schistosomiasis was 21.8% (95% confidence interval (CI): 19.8-23.9%) and 18.7% (95% CI: 16.8-20.7%), respectively. In multivariable analysis, longer water fetching time (over 30 min versus less than 30 min) and working daily in the soil were associated with increased odds of hookworm infection (adjusted odds ratio (AOR): 1.49, 95% CI: 1.13-1.96 and 1.37, 95% CI: 1.03-1.82, respectively). Higher odds of schistosomiasis were linked to proximity to water bodies within a one-hour walking distance (AOR: 1.84, 95% CI: 1.35-2.50), and not always washing hands before eating (AOR: 2.00, 95% CI: 1.50-2.67). Swimming, bathing, or washing in water bodies twice a week, compared to never, also increased schistosomiasis odds (AOR: 2.91, 95% CI: 1.66-5.13).

CONCLUSION

Consistent with the mechanisms of acquisition, hookworm infection increased with exposure to soil, and schistosomiasis increased with exposure to unclean water. Our findings highlight the importance of Water, Sanitation, and Hygiene programs and strategies aimed at reducing exposure within the framework of Neglected Tropical Disease elimination programs.

Population genetics of African Schistosoma species

Blood flukes within the genus Schistosoma (schistosomes) are responsible for the major disease, schistosomiasis, in tropical and sub-tropical areas. This disease is predominantly present on the African continent with more than 85% of the human cases. Schistosomes are also parasites of veterinary importance infecting livestock and wildlife. Schistosoma population genetic structure and diversity are important characteristics that may reflect variations in selection pressures such as those induced by host (mammalian and snail) environments, habitat change, migration and also treatment/control interventions, all of which also shape speciation and evolution of the whole Schistosoma genus. Investigations into schistosome population genetic structure, diversity and evolution has been an area of important debate and research. Supported by advances in molecular techniques with capabilities for multi-locus genetic analyses for single larvae schistosome genetic investigations have greatly progressed in the last decade. This paper aims to review the genetic studies of both animal and human infecting schistosome. Population genetic structures are reviewed at different spatial scales: local, regional or continental (i.e. phylogeography). Within species genetic diversities are discussed compared and the compounding factors discussed, including the effect of mass drug administration. Finally, the ability for intra-species hybridisation questions species integrities and poses many questions in relation to the natural epidemiology of co-endemic species. Here we review molecularly confirmed hybridisation events (in relation to human disease) and discuss the possible impact for ongoing and future control and elimination.

Synthesis, Crystallization Studies, and in vitro Characterization of Cinnamic Acid Derivatives as SmHDAC8 Inhibitors for the Treatment of Schistosomiasis

Schistosomiasis is a neglected parasitic disease that affects more than 265 million people worldwide and for which the control strategy relies on mass treatment with only one drug: praziquantel. Based on the 3-chlorobenzothiophene-2-hydroxamic acid J1075, a series of hydroxamic acids with different scaffolds were prepared as potential inhibitors of Schistosoma mansoni histone deacetylase 8 (SmHDAC8). The crystal structures of SmHDAC8 with four inhibitors provided insight into the binding mode and orientation of molecules in the binding pocket as well as the orientation of its flexible amino acid residues. The compounds were evaluated in screens for inhibitory activity against schistosome and human HDACs. The most promising compounds were further investigated for their activity toward the major human HDAC isotypes. The most potent inhibitors were additionally screened for lethality against the schistosome larval stage using a fluorescence-based assay. Two of the compounds showed significant, dose-dependent killing of the schistosome larvae and markedly impaired egg laying of adult worm pairs maintained in culture.

Schistosomiasis: Drugs used and treatment strategies

Neglected tropical diseases (NTDs) affect millions of people in different geographic regions, especially the poorest and most vulnerable. Currently NTDs are prevalent in 149 countries, seventeen of these neglected tropical parasitic diseases are classified as endemic. One of the most important of these diseases is schistosomiasis, also known as bilharzia, a disease caused by the genus Schistosoma. It presents several species, such as Schistosoma haematobium, Schistosoma japonicum and Schistosoma mansoni, the latter being responsible for parasitosis in Brazil. Contamination occurs through exposure to contaminated water in the endemic region. This parasitosis is characterized by being initially asymptomatic, but it is able to evolve into more severe clinical forms, potentially causing death. Globally, more than 200 million people are infected with one of three Schistosome species, including an estimated 40 million women of reproductive age. In Brazil, about 12 million children require preventive chemotherapy with anthelmintic. However, according to the World Health Organization (WHO), only about 15% of the at-risk children receive regular treatment. The lack of investment by the pharmaceutical industry for the development and/or improvement of new pharmaceutical forms, mainly aimed at the pediatric public, is a great challenge. Currently, the main forms of treatment used for schistosomiasis are praziquantel (PZQ) and oxaminiquine (OXA). PZQ is the drug of choice because it presents as a high-spectrum anthelmintic, used in the treatment of all known species of schistosomiasis and some species of cestodes and trematodes. OXA, however, is not active against the three Schistosome species. This work presents a literature review regarding schistosomiasis. It addresses points such as available treatments, the role of the pharmaceutical industry against neglected diseases, and perspectives for treatment.

Wharton's jelly-derived mesenchymal stem cells combined with praziquantel as a potential therapy for Schistosoma mansoni-induced liver fibrosis

Liver fibrosis is one of the most serious consequences of S. mansoni infection. The aim of the present study was to investigate the potential anti-fibrotic effect of human Wharton’s jelly-derived mesenchymal stem cells (WJMSCs) combined with praziquantel (PZQ) in S. mansoni-infected mice. S. mansoni-infected mice received early (8^th week post infection) and late (16^th week post infection) treatment with WJMSCs, alone and combined with oral PZQ. At the 10^th month post infection, livers were collected for subsequent flow cytometric, histopathological, morphometric, immunohistochemical, gene expression, and gelatin zymographic studies. After transplantation, WJMSCs differentiated into functioning liver-like cells as evidenced by their ability to express human hepatocyte-specific markers. Regression of S. mansoni-induced liver fibrosis was also observed in transplanted groups, as evidenced by histopathological, morphometric, and gelatin zymographic results besides decreased expression of three essential contributors to liver fibrosis in this particular model; alpha smooth muscle actin, collagen-I, and interleukin-13. PZQ additionally enhanced the beneficial effects observed in WJMSCs-treated groups. Our results suggest that combining WJMSCs to PZQ caused better enhancement in S. mansoni-induced liver fibrosis, compared to using each alone.

Efficacy and side effects of praziquantel in the treatment of Schistosomiasis mansoni in schoolchildren in Shesha Kekele Elementary School, Wondo Genet, Southern Ethiopia

OBJECTIVE

To evaluate the efficacy and side effects of praziquantel (PZQ) in the treatment of schistosomiasis in Ethiopia.

METHODS

In a cross-sectional study, stool specimens were collected from randomly selected 299 school children in Shesha Kekele Elementary School, Wondo Genet, Southern Ethiopia, in April 2010. Stool specimens were examined using a single Kato-Katz thick smear for Schistosoma mansoni (S. mansoni) ova. Children who were found positive for S. mansoni were treated with a single oral dose of PZQ at 40 mg/kg bw and interviewed for treatment-related symptoms 24 hours after drug administration. Four weeks post-treatment, stool specimens were collected from the same children and examined following the same procedure as in the pre-treatment. Drug efficacy was determined based on cure and egg reduction rates.

RESULTS

Pre-treatment prevalence of S. mansoni infection was 74.9% with geometric mean egg count of 268. The evaluated generic PZQ produced an overall cure rate of 73.6% (P<0.000 1, OR: 8.33, CI: 5.3-13.1) and egg reduction rate of 68.2% (P=0.03, F=0.64). The cure rate showed significant association with age (χ(2)=11, P=0.004), the highest rate being observed in the 15-22 age group. 83% of S. mansoni infected children showed various treatment-related symptoms, the most frequent being headache, nausea, and abdominal pain. These symptoms were associated with age (P<0.001) and pre-treatment intensity of infection (P<0.05).

CONCLUSIONS

The present observations revealed relatively lower cure and egg reduction rates of the PZQ evaluated as compared to previous reports for other PZQ brands in Ethiopia. Hence, in depth studies are recommended to clarify whether the present relatively lower cure rate is the actual cure rate of the praziquantel evaluated, treatment failure, or reduced susceptibility of the parasite. Treatment-related side effects observed were transient and tolerable.

Praziquantel efficacy against Schistosoma mansoni among HIV-1 infected and uninfected adults living in fishing villages along Lake Victoria, Northwest Tanzania

Background

Animal studies have demonstrated that functional immune responses, as determined by the levels of CD4⁺ cell counts and anti-schistosome antibodies responses, determine the efficacy of praziquantel. Based on this evidence, it has been hypothesised that the immunodeficiency effects of the human immunodeficiency virus (HIV)-1 infection may affect the efficacy of praziquantel in co-infected human hosts. Thus, the present study assessed the efficacy of praziquantel by comparing parasitological cure rates and the reduction in infection intensity in HIV-1 seronegative individuals infected with S. mansoni and HIV-1 seropositive individuals co-infected with S. mansoni, following treatment with a single oral dose of praziquantel.

Methods

This was a prospective longitudinal study which included, at baseline, 555 S. mansoni infected adults aged 21–55 years, who were either co-infected or not with HIV-1 and who lived in fishing villages along Lake Victoria in Northwest Tanzania. These individuals were treated with a single oral dose of praziquantel (40 mg/kg) and, at 12 weeks, single stool samples were obtained and examined for S. mansoni eggs using the Kato-Katz technique. Finger prick and venous blood samples were collected for HIV-1 screening and CD4⁺ cell quantification.

Results

The parasitological cure rate did not differ significantly from the HIV-1 serostatus (P = 0.12): among the co-infected individuals, the cure rate was 48.3% (14/29), and among the individuals infected only with S. mansoni, the cure rate was 62.6% (329/526). The egg reduction rate did not vary with the HIV-1 serostatus (P = 0.22): 77.22% for HIV-1 seronegative and 75% for HIV-1 seropositive individuals. The level of CD4⁺ cell counts (median 228 cells/μL: range 202–380 cells) did not influence the cure rate (P = 0.23) or the reduction in the intensity of the infection (P = 0.37).

Conclusion

The HIV-1 infection per se or its moderate immunodeficiency effects, demonstrated by the range of CD4⁺ cell counts observed in co-infected individuals, did not affect praziquantel efficacy, as measured by the parasitological cure rate and the reduction in intensity of infection in the present study cohort.

Electronic supplementary material

The online version of this article (doi:10.1186/2049-9957-3-47) contains supplementary material, which is available to authorized users.

Control efficacy of annual community-wide treatment against Schistosoma japonicum in China: a meta-analysis

Backgrounds

Human schistosomiasis is caused by schistosome, with annual loss of over 70 million disability adjusted life years in the world. China is endemic with Schistosoma japonicum and large-scale chemotherapy with praziquantel has become the mainstay of control in China since 1990s. However, the control effects of mass treatment in the field have been uneven. Moreover, mass treatment has come into a wide use in other countries with limited health resources. Therefore, a better understanding of the control effect of mass treatment is in an urgent need.

Methods

We performed a systematic search of the literature to investigate the control efficiency of annual community-wide treatment (ACWT, treatment to an entire community without any preliminary screening) with a single dose of PZQ (40 mg kg⁻¹ bodyweight) against schistosome in humans in China. Three Chinese literature databases, including China National Knowledge Infrastructure, WanFang and Chinese Scientific Journal Databases, and the PubMed were searched. Pooled prevalence ratios (prevalence after to before treatment) were used to assess effect. Our protocol is available on PROSPERO (No. CRD42013003628).

Results

22 articles were included. Meta-analyses on data from 18 studies on one round of ACWT, 17 studies on two consecutive rounds and 6 studies on three consecutive rounds were performed. The results showed control effects of ACWT plus other measures were statistically significant, with prevalence ratios being 0.38 (0.31, 0.46) for one round, 0.28 (0.22, 0.35) for two rounds and 0.22 (0.10, 0.46) for three rounds. When ACWT was performed alone or with health education only, the values for one and two rounds were 0.389 (0.307, 0.492) and 0.348 (0.300, 0.403), respectively.

Conclusions

The control effect of ACWT alone or with other measures is significant and increases with the number of rounds. Such program is recommended in high endemic areas and the criteria yet merit further assessment.

Application of praziquantel in schistosomiasis japonica control strategies in China

Schistosomiasis remains a major public health problem with an estimated 200 million people infected in the world, and in China, schistosomiasis japonica is endemic in the south part of the country. In 1960s, before praziquantel was developed, there were about seven million patients. Praziquantel has a high efficacy against Schistosoma, few and transient side effects, simple administration and competitive cost, and is equally suited for both individual and large-scale treatment. Praziquantel has been widely used in the morbidity control, transmission control, and prevention of schistosomiasis japonica in China since 1980s. The schemes of praziquantel chemotherapy include the diagnostic selective chemotherapy, extensive chemotherapy, mass chemotherapy, stratified chemotherapy, phased chemotherapy, etc. Chemotherapy alone or combined with other control measure, such as Oncomelania snail control, health education, safety water supply, and so on, has achieved a great success, and there are only 0.33 million infected people now. This paper reviews the application of praziquantel in the schistosomiasis japonica control strategies in China so as to provide the rich experiences for reference of health workers of other countries where schistosomiasis is endemic.

Novel therapeutic and prevention approaches for schistosomiasis: review

Schistosomiasis is a debilitating disease affecting approximately 600 million people in 74 developing countries, with 800 million, mostly children at risk. To circumvent the threat of having praziquantel (PZQ) as the only drug used for treatment, several PZQ derivatives were synthesized, and drugs destined for other parasites were used with success. A plethora of plant-derived oils and extracts were found to effectively kill juvenile and adult schistosomes, yet none was progressed to pre- and clinical studies except an oleo-gum resin extracted from the stem of Commiphora molmol, myrrh, which action was challenged in several trials. We have proposed an essential fatty acid, a component of our diet and cells, the polyunsaturated fatty acid arachidonic acid (ARA) as a remedy for schistosomiasis, due to its ability to activate the parasite tegument-bound neutral sphingomyelinase, with subsequent hydrolysis of the apical lipid bilayer sphingomyelin molecules, allowing access of specific antibody molecules, and eventual worm attrition. This concept was convincingly supported using larval and adult Schistosoma mansoni and Schistosoma haematobium worms in in vitro experiments, and in vivo studies in inbred mice and outbred hamsters. Even if ARA proves to be an entirely effective and safe therapy for schistosomiasis, it will not prevent reinfection, and accordingly, the need for developing an effective vaccine remains an urgent priority. Our studies have supported the status of S. mansoni calpain, glutathione-S-transferase, aldolase, triose phosphate isomerase, glyceraldehyde 3-phosphate dehydrogenase, enolase, and 2-cys peroxiredoxin as vaccine candidates, as they are larval excreted-secreted products and, contrary to the surface membrane molecules, are entirely accessible to the host immune system effector elements. We have proposed that the use of these molecules, in conjunction with Th2 cytokines-inducing adjuvants for recruiting and activating eosinophils and basophils, will likely lead to development and implementation of a sterilizing vaccine in a near future.

New insight into praziquantel against various developmental stages of schistosomes

Praziquantel, due to high efficacy, excellent tolerability, few and transient side effects, simple administration, and competitive cost, is virtually the only drug of choice for treatment of human schistosomiasis. Treatment of schistosomiasis has shown great advances with the introduction of the drug into the therapeutic arsenal in areas that are endemic for the parasite. However, the drug presents various efficacies against different developmental stages of schistosomes, appearing an oddity intermitted mode. The present review article reviews the effects and mechanism of action of praziquantel against schistosomes briefly and suggests the research on this oddity phenomenon.

Observed reductions in Schistosoma mansoni transmission from large-scale administration of praziquantel in Uganda: a mathematical modelling study

Background

To date schistosomiasis control programmes based on chemotherapy have largely aimed at controlling morbidity in treated individuals rather than at suppressing transmission. In this study, a mathematical modelling approach was used to estimate reductions in the rate of Schistosoma mansoni reinfection following annual mass drug administration (MDA) with praziquantel in Uganda over four years (2003–2006). In doing this we aim to elucidate the benefits of MDA in reducing community transmission.

Methods

Age-structured models were fitted to a longitudinal cohort followed up across successive rounds of annual treatment for four years (Baseline: 2003, Treatment: 2004–2006; n = 1,764). Instead of modelling contamination, infection and immunity processes separately, these functions were combined in order to estimate a composite force of infection (FOI), i.e., the rate of parasite acquisition by hosts.

Results

MDA achieved substantial and statistically significant reductions in the FOI following one round of treatment in areas of low baseline infection intensity, and following two rounds in areas with high and medium intensities. In all areas, the FOI remained suppressed following a third round of treatment.

Conclusions/Significance

This study represents one of the first attempts to monitor reductions in the FOI within a large-scale MDA schistosomiasis morbidity control programme in sub-Saharan Africa. The results indicate that the Schistosomiasis Control Initiative, as a model for other MDA programmes, is likely exerting a significant ancillary impact on reducing transmission within the community, and may provide health benefits to those who do not receive treatment. The results obtained will have implications for evaluating the cost-effectiveness of schistosomiasis control programmes and the design of monitoring and evaluation approaches in general.

Schistosomiasis is a parasitic disease of enormous public health importance, infecting over 200 million people worldwide, of which the large majority live in sub-Saharan Africa. Control programmes based on the mass treatment of individuals in infected areas with the drug praziquantel have been shown to be successful in reducing the parasite burden and likelihood of developing morbidity in those individuals who receive treatment. Using data from an ongoing intestinal schistosomiasis control programme in Uganda and through the application of a mathematical model, we show that an additional benefit of mass treatment is a decrease in parasite acquisition, via a reduction in the number of transmission stages in the environment. This leads to a lower rate of infection and reinfection of individuals in those areas. We show that this result is valid in areas of differing average infection intensity. The importance of this finding is that this will benefit untreated as well as treated individuals, and will allow a fuller estimation of the benefits of schistosomiasis control programmes.

Efficacy of two praziquantel treatments among primary school children in an area of high Schistosoma mansoni endemicity, Nile Delta, Egypt

Praziquantel is the cornerstone of schistosomiasis control. A number of reports from endemic areas suggest that resistance or tolerance to praziquantel might exist in Schistosoma mansoni. Several explanations were postulated. The present work was designed to test the hypothesis that a low praziquantel (pzq) cure rate in Egypt is due to survival and maturation of immature stages that escaped pzq, which is effective against mature S. mansoni worms only. The study sample included 1351 children attending El Rouse primary school located in El Rouse village, Nile Delta, Egypt. All children received 2 pzq doses (40 mg/kg) 4 weeks apart. Diagnosis of S. mansoni infection and cure assessment were based on examination of 2 Kato slides prepared from a single stool sample collected before and 4 weeks after the first and second treatments. The cure rate was 78·8% after the first treatment and increased significantly to 90·8% after the second treatment. Egg reduction rates were 71·2% and 77·2% after 1 and 2 treatments respectively. Pre-treatment intensity of infection has a great influence on cure and egg reduction rates. Our results confirmed that low praziquantel cure rate, in Egypt, might be attributed, even partially, to survival and maturation of the immature S. mansoni stages that escaped pzq that is effective against mature worms only.

Is there reduced susceptibility to praziquantel in Schistosoma japonicum? Evidence from China

Praziquantel is widely used for the treatment of human schistosomiasis. However, in recent years, there has been increasing concern about the resistance of Schistosoma species to praziquantel. The study described here was designed to evaluate the current susceptibility to praziquantel in S. japonicum in China. During the non-transmission period of schistosomiasis, a random sample of 4760 subjects from the main endemic foci of China were examined using parasitological stool examination. In total, 584 subjects were identified as being infected with S. japonicum, with a prevalence rate of 12.27%. Among them, 565 stool-egg-positive subjects were treated with praziquantel in a single oral dose of 40 mg/kg. Six weeks post-treatment, among the 505 villagers re-examined, 480 (95.05%) had no detectable S. japonicum eggs. Twenty-one subjects still excreting eggs after the first treatment were treated with praziquantel for the second time. All stool samples, including those from those participants with second treatment were re-examined 6 weeks after the second treatment, and no stool-egg-positives were found. The results indicate that the current efficacy of praziquantel against S. japonicum is still high and has not changed after more than 2 decades of repeated, expanded chemotherapy in the main endemic areas of China. It is suggested that no evidence of tolerance or resistance to praziquantel in S. japonicum was detected in China.

Praziquantel efficacy in mice infected with PZQ non-susceptible S. mansoni isolate treated with artemether: parasitological, biochemical and immunohistochemical assessment

Based on the fact that artemether (ART) affects immature schistosomes and that the effect of praziquantel (PZQ) mainly targets mature schistosomes, this work investigates the possible enhanced efficacy of PZQ in combination with ART in mice harboring a PZQ non-susceptible Schistosoma mansoni isolate. Associated schistosomal, inflammatory, hepatic histopathological changes have been investigated by examining the tissue markers expressing apoptosis using FAS (CD95), anti-apoptosis (Bcl2) and angiogenesis [vascular endothelial growth factor (VEGF)]. A batch of Swiss albino mice infected with a PZQ non-susceptible (EE10) S. mansoni isolate was divided into 12 groups. Animals of the first group were left without treatment as infected controls, while groups 2-6 received PZQ in increasing doses. The animals of group 7 received ART in double doses. Those comprising groups 8-12 received combined therapy of PZQ and ART in the same doses and at the same timings postinfection (PI) as those belonging to groups 2-6. Parasitological parameters, liver function, and histopathological and immunohistochemical studies of FAS, Bcl2 and VEGF antibodies were assessed. Combined administration of ART and PZQ reduced the ED(50) (the dose at which the worm burden was decreased by 50%) of PZQ. Typical granulomas were not seen in animals treated with ART alone and combined with PZQ, with least expression of FAS and VEGF and increased expression of Bcl2. The minimal histopathological changes recorded in mice treated with both ART and PZQ could be related to a synergistic/additive effect of ART, markedly reducing the intensity of infection. Improved liver function tests support the less severe histopathological changes under the influence of this treatment protocol. This study encourages human trials especially in areas where malaria is not endemic, and differing combination doses should be investigated in view of the antagonistic effect noticed with some dose regimens.

Efficacy of artesunate with sulfalene plus pyrimethamine versus praziquantel for treatment of Schistosoma mansoni in Kenyan children: an open-label randomised controlled trial

BACKGROUND

Schistosomiasis is an important parasitic disease in Kenya. Decreasing susceptibility of schistosomes to praziquantel, the major drug used to reduce disease morbidity, has made assessment of new antischistosomal drugs a priority. We aimed to assess the safety and efficacy of an artesunate-based combination drug in the treatment of schistosomiasis.

METHODS

In this open-label randomised trial in Rarieda district of western Kenya, we enrolled school children (aged 6-15 years) who had Schistosoma mansoni infection according to duplicate Kato-Katz thick smears from a stool sample. Computer-generated block randomisation was used to assign children (1:1) to receive artesunate (100 mg) with sulfalene (also known as sulfamethoxypyrazine; 250 mg) plus pyrimethamine (12.5 mg) as one dose every 24 h for 3 days or one dose of praziquantel (40 mg/kg per day). The primary efficacy endpoint was the number of participants cured 28 days after treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01054651.

RESULTS

Between October and December, 2009, 212 children were enrolled and assigned to receive artesunate with sulfalene plus pyrimethamine (n=106) or praziquantel (n=106). 69 patients (65%) were cured in the praziquantel treatment group compared with 15 (14%) in the artesunate with sulfalene plus pyrimethamine treatment group (p<0.0001). Adverse events were less common in patients taking artesunate with sulfalene plus pyrimethamine than in those taking praziquantel (22% [n=23] vs 49% [n=52], p<0.0001), and no drug-related serious adverse events occurred.

INTERPRETATION

The standard treatment with praziquantel is more effective than artesunate with sulfalene plus pyrimethamine in the treatment of children with S mansoni infection in western Kenya. Whether artemisinin-based combination therapy has a role in the treatment of schistosomiasis is unclear.

Susceptibility to praziquantel of male and female cercariae of praziquantel-resistant and susceptible isolates of Schistosoma mansoni

Praziquantel (PZQ) is now widely used for the treatment of human schistosomiasis. However, in recent years, there has been a growing concern about the resistance of Schistosoma to PZQ. The mechanisms of PZQ action against Schistosoma and resistance of Schistosoma to PZQ are poorly understood. Here, we report differential susceptibilities to PZQ between male and female cercariae in the PZQ-susceptible and PZQ-resistant isolates of Schistosoma mansoni, using tail loss as a measurement of PZQ action. The miracidia were collected by hatching eggs collected from faeces of infected mice. Single-sex cercaria lines were made by infecting a single Biomphalaria glabrata snail with a single miracidium. The sex of each single-sex cercaria line was identified by a direct W1-specific polymerase chain reaction (PCR) technique. Single-sex cercariae of two isolates were exposed to four different concentrations of PZQ, respectively. The tail shedding of cercariae was observed under a dissecting microscope for five time points up to 100 min after adding PZQ. The results showed that male cercariae have higher tail-shedding rates than that of female cercariae when PZQ-susceptible isolates of S. mansoni are exposed to the same concentration of PZQ. But this phenomenon was not observed in the PZQ-resistant isolates. This sexual differential resistance phenomenon of S. mansoni suggests that resistance to PZQ is induced by decreasing the PZQ susceptibility of male worms. The experiment described here may also be useful for developing tests to detect PZQ resistance in the field.

Treatment of intestinal schistosomiasis in Ugandan preschool children: best diagnosis, treatment efficacy and side-effects, and an extended praziquantel dosing pole

The Ugandan national control programme for schistosomiasis has no clear policy for inclusion of preschool-children ( Collapse

Key Words

• schistosomiasis
• national control programme
• preschoolaged children (psac)
• deworming
• guidelines

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MESH Headings Collapse

Grants

• Wellcome Trust

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Affiliation(s)

José Carlos Sousa-Figueiredo WHO Collaborating Centre Schistosomiasis, Wolfson Wellcome Biomedical Laboratories, Department of Zoology, Natural History Museum, London, SW7 5BD, United Kingdom Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, United Kingdom
Joyce Pleasant Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, United Kingdom
Matthew Day Faculty of Medicine, University of Dundee, Nethergate, Dundee, DD1 4HH, United Kingdom
Martha Betson WHO Collaborating Centre Schistosomiasis, Wolfson Wellcome Biomedical Laboratories, Department of Zoology, Natural History Museum, London, SW7 5BD, United Kingdom
David Rollinson WHO Collaborating Centre Schistosomiasis, Wolfson Wellcome Biomedical Laboratories, Department of Zoology, Natural History Museum, London, SW7 5BD, United Kingdom
Antonio Montresor Department of Control of Neglected Tropical Diseases, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
Francis Kazibwe Vector Control Division, Ministry of Health, P.O. Box 1661, Kampala, Uganda
Narcis B. Kabatereine Vector Control Division, Ministry of Health, P.O. Box 1661, Kampala, Uganda
J. Russell Stothard WHO Collaborating Centre Schistosomiasis, Wolfson Wellcome Biomedical Laboratories, Department of Zoology, Natural History Museum, London, SW7 5BD, United Kingdom

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The influence of transmission season on parasitological cure rates and intensity of infection after praziquantel treatment of Schistosoma haematobium-infected schoolchildren in Mozambique

Schistosoma haematobium is refractory to praziquantel (PZQ) during the prepatent period of infection. A hypothesis based on this observation is that in areas where S. haematobium transmission is seasonal, the outcome of chemotherapy depends on the timing of the treatment relative to the annual transmission pattern. To examine this hypothesis, a study was carried out in southern Mozambique. Following demonstration of seasonal transmission, PZQ was administered separately to two cohorts of S. haematobium-infected schoolchildren in (1) the high and (2) the low transmission seasons and followed up after two months when levels of infection and intensities were measured. The prevalence of infection decreased from 54.2% and 51.7% in cohorts 1 and 2 to 30.3% and 1.8%, respectively. The geometric mean intensity of infection decreased from 23.3 eggs/10 ml of urine at baseline to 15.6 eggs/10 ml of urine in cohort 1 (treated during high transmission season), and from 23.5 eggs/10 ml urine to 7.3 eggs/10 ml of urine in cohort 2 (treated during low transmission season). The observed cure rates in cohorts 1 and 2 were 69.7% and 98.2%, respectively. Differences in infection between the cohorts in terms of cure rate and level of infection two months post-treatment were statistically significant and indicate that in areas with a seasonal transmission pattern, the effect of PZQ can be enhanced if treatment takes place during the low transmission season. We conclude that appropriately timed PZQ administration will increase the impact of schistosomiasis control programmes.

Treatment of praziquantel wastewater using the integrated process of coagulation and gas membrane absorption

Praziquantel is an anti-schistosoma drug, its wastewater contains numerous cyanide and other colloid pollutant. A novel integrated treatment process was proposed in this study, i.e., using coagulation to eliminate colloid pollutant and using gas membrane absorption (GMA) to remove cyanide. The optimization of coagulation condition, determination of cyanide removal rate, elimination of membrane fouling, and overall evaluation of the integrated process for the treatment of praziquantel wastewater were investigated in this study. Good results were achieved: turbidity reduced from 700 NTU to 10-40 NTU, 92% COD was removed, cyanide concentration dropped from 3500 mg/L to below 0.5 mg/L, recovery rate of cyanide reached to 98%, and operation cost could be entirely compensated from the gain of recovered cyanide. The results demonstrate that the novel integrated process offers a number of advantages over alkaline chlorination method in the treatment of praziquantel wastewater: cyanide can be reused rather than destroyed, no secondary pollutants are produced, the operation cost is low and the equipment etching is avoided.

Determinants of health-seeking behaviour for schistosomiasis-related symptoms in the context of integrating schistosomiasis control within the regular health services in Ghana

Morbidity control of schistosomiasis through integration within existing health care delivery systems is considered a potentially sustainable and cost-effective approach. We conducted a questionnaire-based field study in a Ghanaian village endemic for both urinary and intestinal schistosomiasis to determine whether infected individuals self-reported to health centres or clinics and to identify factors that influenced their decision to seek health care. A total of 317 subjects were interviewed about having signs and symptoms suggestive of schistosomiasis: blood in urine, painful urination, blood in stool/bloody diarrhoea, abdominal pain, diarrhoea, swollen abdomen and fatigue within 1 month of the day of the interview. Fever (for malaria) was included as a disease of high debility for comparison. Around 70% with blood in urine or painful urination did not seek health care, whilst diarrhoea, blood in stool, abdominal pain and fever usually led to action (mainly self-medication, with allopathic drugs being used four to five times more often than herbal treatment). On average 20% of schistosomiasis-related signs and symptoms were reported to health facilities either as the first option or second and third alternative by some of those that self-medicated. A few of those who visited a clinic or health centre as first option still self-medicated afterwards. Children under 10 years and adults were more likely to seek health care than teenagers. Also, females were more likely to visit a health facility than males of the same age groups. Socio-economic status and duration of symptoms did not appear to affect health-seeking behaviour. 'Do not have the money' (43%) and 'Not serious enough' (41%) were the commonest reasons for not visiting a clinic, reported more frequently by lower and higher socio-economic classes, respectively, for both urinary or intestinal schistosomiasis. The regular health service shows some potential in passive control of schistosomiasis as some, but far too few, people visit a health facility as first or second option.

Quantitative evaluation of integrated schistosomiasis control: the example of passive case finding in Ghana

Passive case finding based on adequate diagnosis and treatment of symptomatic individuals with praziquantel by the health care facilities is a minimum requirement for integrated schistosomiasis control. Two field studies were conducted in Ghana to obtain quantifications about the steps in this process: (1) a study of health-seeking behaviour through interview of individuals with reported schistosomiasis-related symptoms; (2) a study of the performance of the Ghanaian health system with regard to schistosomiasis case management by presenting clinical scenarios to health workers and collecting information about availability of praziquantel. It appeared that cases of blood in urine (the most typical symptom of Schistosoma haematobium) and blood in stool (the most typical symptom of S. mansoni) have a very small probability of receiving praziquantel (4.4% and 1.4%, respectively) from health facilities. Programmes aimed at making the drug available at all levels of the health care delivery system and encouraging health-seeking behaviour through health education are not likely to increase these probabilities beyond 30%. This is because many cases with blood in urine do not consider it serious enough to seek health care, and blood in stool usually requires (imperfect) diagnostic testing and referral. We therefore conclude that additional control activities, especially for high-risk groups, will remain necessary.

Efficacy and side effects of praziquantel against Schistosoma mansoni in a community of western Côte d'Ivoire

Praziquantel is efficacious against the adult stages of all human schistosome parasites, and has become the drug of choice for morbidity control of schistosomiasis. There is concern that resistance to praziquantel might develop or already exists, and could be further facilitated through new control initiatives relying on large-scale administration of praziquantel. Therefore, monitoring praziquantel efficacy in different epidemiological settings is required. We assessed the efficacy and side effects of praziquantel against Schistosoma mansoni in a rural community of western Côte d'Ivoire. Three consecutive stool specimens from 545 children and adults were examined by the Kato-Katz technique, revealing an overall prevalence of 40.9%. S. mansoni-infected individuals were treated with a single oral dose of praziquantel at 40 mg/kg. The most frequent side effects were abdominal pain, dizziness and diarrhoea. The overall cure rate, assessed 6 weeks post-treatment, was 60.9%. Moderate or heavy infections were only cleared in half or one-third of the individuals, respectively. The total egg count reduction was 61.4%. Infection intensity pre-treatment was significantly associated with age, cure rate, reported diarrhoea and dizziness. Our findings call for additional studies that rigorously evaluate the efficacy of praziquantel against different schistosome species in entire communities, using similarly sensitive diagnostic approaches as employed here.

Efficacy of artesunate and praziquantel in Schistosoma haematobium infected schoolchildren

Praziquantel is the current mainstay for morbidity control of schistosomiasis. Artemisinin and its derivatives, widely used for the treatment of malaria, also display antischistosomal properties. The present study is an effort to assess the therapeutic efficacy of artesunate, an artemisinin derivative, in Schistosoma haematobium infections in a human population. The efficacy of artesunate and praziquantel were comparatively studied in primary schoolchildren from two villages, Lampsar (n=180) and Makhana (n=108), located along the Lampsar river in the delta of the Senegal River Basin in Northern Senegal (West Africa). In each village, half of the infected children were treated with a single oral dose of 40 mg/kg praziquantel and half with artesunate following the recommended malaria monotherapy regimen. For both drugs, cure and egg count reduction rates were, without apparent explanation, higher in Makhana than in Lampsar. In both villages, high and nearly comparable egg count reduction rates were obtained with both drugs at each follow-up after treatment (5, 12 and 24 weeks) in the heavy infected group of children (>50 eggs/10 ml of urine). No major adverse effects were observed. The results demonstrate that artesunate is effective against S. haematobium, but the results obtained with praziquantel were consistently better.

Interpreting low praziquantel cure rates of Schistosoma mansoni infections in Senegal

Praziquantel is currently the drug of choice for the treatment of schistosomiasis. Selective treatment of Schistosoma mansoni infections in various endemic countries usually present cure rates of >70% when using the standard dose of 40 mg kg(-1) body weight of praziquantel. However, unusually low cure rates (18-38%) have been reported from Senegal, raising fears for emergence of resistance (or tolerance) to praziquantel. One major problem is the precise quantitative interpretation of cure rates, which allows an unequivocal distinction between drug failure and normal drug performance. This article reviews studies on praziquantel treatment of population by standardizing the data through an innovative meta-analysis and provides empirical evidence concerning the extent to which the reported low cure rates from Senegal are atypical.

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

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

Susceptibility of Schistosoma japonicum to praziquantel in China

To look for possible evidence of the development of resistance in Schistosoma japonicum to praziquantel, we conducted a field study in China. During the non-transmission period of schistosomiasis a random sample of 2860 individuals from six villages in three provinces of China were examined using a parasitological stool examination. Of the 372 stool-positive subjects, 363 subjects were treated with a single oral dose of 40 mg/kg of praziquantel. Six to Seven weeks after treatment, of 334 subjects examined using the same stool examination, stool-negative results were found in 319 patients which represents a 95.5% parasitologic cure rate. Fifteen subjects still excreting eggs were treated a second time with the same dose of praziquantel. All stool samples, including those from participants re-treated with praziquantel, were re-examined 12 weeks after the first treatment and no stool-positive subjects were found. The results indicate that there was no evidence for reduced susceptibility of S. japonicum to praziquantel despite its extensive use in the main endemic areas of China for more than 10 years. The in vitro responses to praziquantel of cercariae, miracidia and eggs of S. japonicum compared with S. mansoni demonstrate that the cercariae, miracidia and eggs of S. japonicum are more sensitive to praziquantel than those of S. mansoni. More sensitive worms would be less likely to develop resistance and this could explain why no evidence for resistance was found in S. japonicum in China.

Efficacy of praziquantel against Schistosoma mansoni with particular consideration for intensity of infection

Chemotherapy with praziquantel is the cornerstone of schistosomiasis control. In view of recent concern about tolerance or resistance to praziquantel, monitoring its efficacy in different epidemiological settings is required. We report a study among 253 schoolchildren in an area highly endemic for Schistosoma mansoni in western Côte d'Ivoire. After examining four consecutive stool specimens from each child, the first praziquantel treatment at 60 mg/kg divided into two doses was administered. Four weeks later, stool specimens were again screened over 4 consecutive days and revealed a cure rate of 71.6% and an egg reduction rate of 79.9%. There was a significant association between cure rate and intensity of infection prior to treatment with highest cure rates observed in light infections (P < 0.01). Praziquantel, at a single dose of 40 mg/kg, was again administered 35 days after the first treatment. The overall cure and egg reduction rates increased considerably. The association between cure rate and intensity of infection prior to the second treatment was significant but less pronounced. Twenty-two children remained S. mansoni positive after the two chemotherapy campaigns, and interestingly, many of these were only identified after repeated stool examinations. We argue that pre-patent infections may account for some of these 'treatment failures'. However, further studies in other endemic settings are needed, with parasitological diagnoses having a high sensitivity.

Drug resistance in human helminths: current situation and lessons from livestock

In this review the available reports on drug resistance in human helminths, particularly hookworms and schistosomes, are critically analyzed. The experiences with helminths of livestock are then reviewed, in particular the factors contributing to the development of anthelmintic resistance, the mechanisms and genetics of resistance to various anthelmintic classes, and the methods available for detection. These experiences appear to be worryingly similar and relevant to the potential development of drug resistance in human helminths. Recommendations to reduce its risks are suggested.

Oral artemether for prevention of Schistosoma mansoni infection: randomised controlled trial

BACKGROUND

Chemotherapy with praziquantel is the current strategy of choice to control schistosomiasis. However, in view of concern about praziquantel tolerance or resistance, new drugs are needed. Artemether, a derivative of the antimalarial drug artemisinin, kills immature schistosomes of Schistosoma japonicum, and reduces the incidence of infection in field trials. Laboratory studies have also showed activity by this drug against S. mansoni. We report a randomised double-blind placebo-controlled clinical trial of artemether to prevent S. mansoni infection.

METHODS

The trial was done in an area of western Côte d'Ivoire endemic for S. mansoni. 354 schoolchildren were enrolled. Stool specimens were screened over four consecutive days, followed by two mass treatments with praziquantel 4 weeks apart. All S. mansoni negative children were randomly assigned to placebo (n=151) or artemether 6 mg/kg (n=138) orally six times once every 3 weeks. Adverse events were assessed 24 h after treatment. Perceived illness episodes were recorded once a week by interviewing the children with a standardised questionnaire. 3 weeks after the final medication S. mansoni infections were assessed by screening stool samples. Blood samples were examined for Plasmodium falciparum before the first and after the last artemether treatment.

FINDINGS

Oral artemether showed no adverse reactions. The group that received artemether had a significantly lower incidence of S. mansoni infection (31/128 versus 68/140, relative risk: 0.50 [95% CI 0.35-0.71], p=0.00006). The geometric mean egg output among positive children in the artemether group was significantly lower than in placebo recipients (19 vs 32 eggs/g stool, p=0.017). There was also a significant reduction in the prevalence of P. falciparum.

INTERPRETATION

Oral artemether is safe and shows a prophylatic effect against S. mansoni. The use of artemether may be recommended in appropriated situations as an additional tool for more effective schistosomiasis control measures. However the application needs to be carefully assessed especially in view of the concern that it could select for resistant plasmodia.

Drug resistance in human helminths: current situation and lessons from livestock

In this review the available reports on drug resistance in human helminths, particularly hookworms and schistosomes, are critically analyzed. The experiences with helminths of livestock are then reviewed, in particular the factors contributing to the development of anthelmintic resistance, the mechanisms and genetics of resistance to various anthelmintic classes, and the methods available for detection. These experiences appear to be worryingly similar and relevant to the potential development of drug resistance in human helminths. Recommendations to reduce its risks are suggested.

Increase of intestinal schistosomiasis after praziquantel treatment in a Schistosoma haematobium and Schistosoma mansoni mixed focus

The recent emergence of a mixed focus of Schistosoma haematobium-Schistosoma mansoni, in the lower delta of the Senegal river, requires adapted control programmes. A mass treatment with praziquantel was organised in April 1994 by local authorities in three villages where populations had been examined. A total of 2042 subjects participated. In Savoigne S. haematobium prevailed (53% for prevalence), in Diagambaly S. haematobium (64%) and S. mansoni (76%) were both abundant, and in Boundoum S. mansoni prevailed (53%). Therapeutic coverage (80%) was assessed on a representative sample. A cohort of 968 treated subjects were followed-up 40, 100, 200 and 300 days after treatment. Six weeks after treatment, the average of egg excretion decreased by 95% for S. haematobium, ranging from 23 to one egg(s)/10 ml at Savoigne and from 14 to one egg(s)/10 ml at Diagambal. Conversely, egg excretion only decreased by 75% for S. mansoni, from 23 to six eggs/g at Boundoum and from 69 to 16 eggs/g at Diagambal, showing evidence of the low susceptibility of S. mansoni local strain to praziquantel. Ten months after treatment, reinfections with S. haematobium remained weak at Savoigne (two eggs/10 ml) while those with S. mansoni were so high at Boundoum (24 eggs/g) that they compensated the reduction of load induced by the treatment. At Diagambal, where the two parasites were present before treatment, the disappearance of the urinary schistosomiasis after treatment concurred with a dramatic increase of intestinal schistosomiasis. S. manoni egg excretion was seven times higher than before treatment (478 eggs/g). These different effects of treatment are discussed according to the ecology of transmission in the three villages.

Parameters associated with Schistosoma haematobium infection before and after chemotherapy in school children from two villages in the coast province of Kenya

We evaluated the impact of praziquantel therapy (40 mg/kg body weight) on indicators of infection with Schistosoma haematobium by following a cohort of infected children from schools located 12 km apart in the Coast province of Kenya, at 0, 2, 4, 6, 12 and 18 months after treatment. Within this period, measurements of infection parameters pertaining to egg counts and haematuria (micro-, macro- and history) were evaluated at all time points. The initial prevalence of 100% dropped significantly 8 weeks after treatment with a similar trend in the intensity of infection. Microhaematuria followed the same trend as observed for egg counts while macrohaematuria remained low after treatment. Reinfection following successful therapy differed significantly between schools; in one school the children were reinfected immediately while those in the other remained uninfected despite similar starting prevalences, intensities of infection and cure rates. Transmission between the two areas looked homogeneous before treatment but when both groups were treated, contrasting transmission patterns became evident. In a regression model we evaluated factors that might be associated with reinfection, and after allowing for pretreatment infection level, age and sex, area (school) remained a highly significant predictor.

Schistosome resistance to praziquantel

Praziquantel (PZQ) is the drug of choice for the treatment of human schistosomiasis. In 1994, it was first demonstrated that by sustained drug pressure on a Schistosoma mansoni strain in laboratory conditions resistance to PZQ can develop. Studies in Senegal and Egypt, both schistosomiasis endemic areas, have found that there are schistosome strain(s) that are tolerant to PZQ. In this article evidence from laboratory and field studies regarding the existence of PZQ resistance or tolerant schistosome strain(s) will be examined.

Urinary excretion of the collagen cross-link pyridinoline increases during liver fibrogenesis

BACKGROUND/AIMS

Pyridinoline, a specific cross-link of mature collagen, increases in liver during fibrogenesis and its hepatic level is related to the degree of reversibility of the fibrotic process. Since pyridinoline is excreted in urine, we have investigated the relationship between its urinary level and liver fibrogenesis in a model of mild and reversible liver fibrosis, murine schistosomiasis.

METHODS

Pyridinoline was measured by HPLC in urine and in liver of Schistosoma mansoni-infected mice during the acute and the chronic phases of the infection. Collagen deposition was measured colorimetrically. Both the isolated granulomas and the surrounding liver parenchyma were analyzed.

RESULTS

In infected mice, pyridinoline increased mainly in the isolated granulomas, corresponding to the fibrotic lesions, and slightly in the surrounding parenchyma. The urinary excretion of pyridinoline increased during liver fibrogenesis and was correlated to the duration of infection (r=0.81) and to the collagen content of granulomas (r=0.81). The treatment of infected mice by praziquantel, an antiparasitic drug, did not lead to significant changes in liver collagen cross-linking by pyridinoline either in granulomas or in parenchyma. The major effect of the drug was targeted at the collagen content of parenchyma, which decreased by 50%, 18 weeks after treatment. The urinary level of pyridinoline of treated mice was negatively correlated to the length of the treatment follow-up (r=-0.76).

CONCLUSIONS

The measurement of the urinary excretion of pyridinoline could be helpful to monitor the remodeling of liver extracellular matrix occurring in fibrogenesis and the effect of chemotherapy.

Schistosoma mansoni: maturation rate and drug susceptibility of different geographic isolates

The fecundities and drug susceptibilities of Schistosoma mansoni isolates from Senegal, Puerto Rico, and Kenya have been examined in mice. The Senegal parasite, obtained from the field in 1993, was shown to have a longer prepatent period (eggs first recovered in the faeces on Day 46 after infection) than those of two isolates, from Puerto Rico and Kenya, that had been maintained for a long period in the laboratory (faecal eggs recovered on Days 38 and 36 after infection, respectively). A Kenyan isolate, also collected from the field in 1994, was shown to mature more slowly than the laboratory-maintained Kenyan isolate. Tissue egg counts confirmed that early in infection the fecundity of the recently collected isolates from Senegal and Kenya was significantly lower than that of the long-term laboratory-maintained Kenyan isolate. Praziquantel and oxamniquine treatment of 8-week-old infections caused a significant (P < 0.001) reduction in worm burden in all isolates tested. However, the reduction in worm burden after praziquantel treatment of infections of the Senegal isolate (50% reduction) was significantly lower than the > 90% reductions in worm burdens after praziquantel treatment of mice infected with either of the Kenyan isolates (P < 0.001). The study confirms that despite being tolerant to praziquantel, the Senegal isolate is fully susceptible to oxamniquine. The praziquantel tolerance of the Senegal parasite is not solely attributed to the state of maturation of the parasite at the time of drug administration.

Acute Schistosomiasis in Travelers Returning From Mali

Acute schistosomiasis or "Katayama syndrome" occurs in previously uninfected persons 3-6 weeks after exposure to cercaria-infested water.1,2 Many outbreaks among tourists have been reported.3-11 Such outbreaks occur because tourists are bathing or swimming in waters thought by tourist organizations to be bilharzial free. Imported schistosomiasis acquired in the Dogon country in Mali, West Africa, was first demonstrated in 1989 in three Spanish travelers;3 in 1991, an outbreak was described among Dutch travelers.7 In 1993, we investigated a similar outbreak among European and American travelers returning from the same area.