Evolution of the National Schistosomiasis Control Programmes in The People's Republic of China

Optimized strategy for schistosomiasis elimination: results from marginal benefit modeling

BACKGROUND

Poverty contributes to the transmission of schistosomiasis via multiple pathways, with the insufficiency of appropriate interventions being a crucial factor. The aim of this article is to provide more economical and feasible intervention measures for endemic areas with varying levels of poverty.

METHODS

We collected and analyzed the prevalence patterns along with the cost of control measures in 11 counties over the last 20 years in China. Seven machine learning models, including XGBoost, support vector machine, generalized linear model, regression tree, random forest, gradient boosting machine and neural network, were used for developing model and calculate marginal benefits.

RESULTS

The XGBoost model had the highest prediction accuracy with an R2 of 0.7308. Results showed that risk surveillance, snail control with molluscicides and treatment were the most effective interventions in controlling schistosomiasis prevalence. The best combination of interventions was interlacing seven interventions, including risk surveillance, treatment, toilet construction, health education, snail control with molluscicides, cattle slaughter and animal chemotherapy. The marginal benefit of risk surveillance is the most effective intervention among nine interventions, which was influenced by the prevalence of schistosomiasis and cost.

CONCLUSIONS

In the elimination phase of the national schistosomiasis program, emphasizing risk surveillance holds significant importance in terms of cost-saving.

Spatiotemporal distribution of schistosomiasis transmission risk in Jiangling County, Hubei Province, P.R. China

OBJECTIVE

This study aims to explore the spatiotemporal distribution of schistosomiasis in Jiangling County, and provide insights into the precise schistosomiasis control.

METHODS

The descriptive epidemiological method and Joinpoint regression model were used to analyze the changes in infection rates of humans, livestock, snails, average density of living snails and occurrence rate of frames with snails in Jiangling County from 2005 to 2021. Spatial epidemiology methods were used to detect the spatiotemporal clustering of schistosomiasis transmission risk in Jiangling county.

RESULTS

The infection rates in humans, livestock, snails, average density of living snails and occurrence rate of frames with snails in Jiangling County decreased from 2005 to 2021 with statistically significant. The average density of living snails in Jiangling County was spatially clustered in each year, and the Moran's I varied from 0.10 to 0.26. The hot spots were mainly concentrated in some villages of Xionghe Town, Baimasi Town and Shagang Town. The mean center of the distribution of average density of living snails in Jiangling County first moved from northwest to southeast, and then returned from southeast to northwest after 2014. SDE azimuth fluctuated in the range of 111.68°-124.42°. Kernal density analysis showed that the high and medium-high risk areas of Jiangling County from 2005 to 2021 were mainly concentrated in the central and eastern of Jiangling County, and the medium-low and low risk areas were mainly distributed in the periphery of Jiangling County.

CONCLUSIONS

The epidemic situation of schistosomiasis decreased significantly in Jiangling County from 2005 to 2021, but the schistosomiasis transmission risk still had spatial clustering in some areas. After transmission interruption, targeted transmission risk intervention strategies can be adopted according to different types of schistosomiasis risk areas.

Sentinel Surveillance of Schistosomiasis - China, 2021

Introduction

This report analyzes the national surveillance data for schistosomiasis in 2021 to understand the current status and provide evidence for further policy actions to promote elimination. This analysis is in line with the National Surveillance Plan of Schistosomiasis, which was revised in 2020 to adapt to the new stage of moving towards elimination.

Methods

Data from the 2021 national surveillance of schistosomiasis in humans, livestock, and snails were collected from 13 provincial-level administrative divisions (PLADs) and analyzed using descriptive epidemiological methodology. The antibody-positive rate and area of newly discovered and re-emergent snail habitats were calculated.

Results

In 2021, a total of 31,661 local residents and 101,558 transient population were screened for antibodies using indirect hemagglutination assay (IHA). Of those who tested positive, 745 local residents and 438 transient population underwent further parasitological examination, with only one stool-positive result in the transient population. Additionally, 12,966 livestock were examined using the miracidia hatching test, with no positives detected. The total area of newly discovered and re-emergent snail habitats was 957,702 m² and 4,381,617 m², respectively. No infected snails were found using the microscopic dissection method, but six pooled snail samples were reported as positive using the loop-mediated isothermal amplification method for detecting specific sequences of Schistosoma. japonicum, in Anhui and Jiangxi Provinces.

Conclusions

The prevalence of schistosomiasis among humans and livestock was found to be low, however, a potential transmission risk was identified in certain areas. To reduce the risk of transmission, a comprehensive control strategy should be continued and new techniques should be implemented in the surveillance and early warning system.

The Current Distribution of Oncomelania hupensis Snails in the People's Republic of China Based on a Nationwide Survey

Schistosomiasis is a helminth infection caused by the genus Schistosoma, which is still a threat in tropical and sub-tropical areas. In the China, schistosomiasis caused by Schistosoma japonicum is mainly endemic to the Yangtze River valley. The amphibious snail Oncomelania hupensis (O. hupensis) is the unique intermediate host of S. japonicum; hence, snail control is a crucial approach in the process of schistosomiasis transmission control and elimination. In 2016, a nationwide snail survey was conducted involving all snail habitats recorded since 1950 in all endemic counties of 12 provinces. A total of 53,254 existing snail habitats (ESHs) were identified, presenting three clusters in Sichuan Basin, Dongting Lake, and Poyang Lake. The overall habitat area was 5.24 billion m², of which 3.58 billion m² were inhabited by O. hupensis. The area inhabited by snails (AIS) in Dongting and Poyang Lakes accounted for 76.53% of the population in the country. Three typical landscape types (marshland and lakes, mountains and hills, and plain water networks) existed in endemic areas, and marshland and lakes had a predominant share (3.38 billion m²) of the AIS. Among the 12 endemic provinces, Hunan had a share of nearly 50% of AIS, whereas Guangdong had no ESH. Ditches, dryland, paddy fields, marshland, and ponds are common habitat types of the ESH. Although the AIS of the marshland type accounted for 87.22% of the population in the whole country, ditches were the most common type (35,025 or 65.77%) of habitat. Six categories of vegetation for ESHs were identified. A total of 39,139 habitats were covered with weeds, accounting for 55.26% of the coverage of the area. Multiple vegetation types of snail habitats appeared in the 11 provinces, but one or two of these were mainly dominant. Systematic sampling showed that the presence of living snails was 17.88% among the 13.5 million sampling frames. The occurrence varied significantly by landscape, environment, and vegetation type. The median density of living snails in habitats was 0.50 per frame (0.33 m × 0.33 m), and the highest density was 40.01 per frame. Furthermore, two main clusters with high snail densities and spatial correlations indicated by hotspot analysis were identified: one in Hunan and Hubei, the other in Sichuan. This national survey is the first full-scale census on the distribution of O. hupensis, which is significant, as transmission interruption and elimination are truly becoming the immediate goal of schistosomiasis control in China. The study discerns the detailed geographic distribution of O. hupensis with the hotspots of snail density in China. It is beneficial to understand the status of the snail population in order to finally formulate further national control planning.

Open-source environmental data as an alternative to snail surveys to assess schistosomiasis risk in areas approaching elimination

Background: Although the presence of intermediate snails is a necessary condition for local schistosomiasis transmission to occur, using them as surveillance targets in areas approaching elimination is challenging because the patchy and dynamic quality of snail host habitats makes collecting and testing snails labor-intensive. Meanwhile, geospatial analyses that rely on remotely sensed data are becoming popular tools for identifying environmental conditions that contribute to pathogen emergence and persistence. Methods: In this study, we assessed whether open-source environmental data can be used to predict the presence of human Schistosoma japonicum infections among households with a similar or improved degree of accuracy compared to prediction models developed using data from comprehensive snail surveys. To do this, we used infection data collected from rural communities in Southwestern China in 2016 to develop and compare the predictive performance of two Random Forest machine learning models: one built using snail survey data, and one using open-source environmental data. Results: The environmental data models outperformed the snail data models in predicting household S. japonicum infection with an estimated accuracy and Cohen’s kappa value of 0.89 and 0.49, respectively, in the environmental model, compared to an accuracy and kappa of 0.86 and 0.37 for the snail model. The Normalized Difference in Water Index (NDWI) within half to one kilometer of the home and the distance from the home to the nearest road were among the top performing predictors in our final model. Homes were more likely to have infected residents if they were further from roads, or nearer to waterways. Conclusion: Our results suggest that in low-transmission environments, investing in training geographic information systems professionals to leverage open-source environmental data could yield more accurate identification of pockets of human infection than using snail surveys. Furthermore, the variable importance measures from our models point to aspects of the local environment that may indicate increased risk of schistosomiasis. For example, households were more likely to have infected residents if they were further from roads or were surrounded by more surface water, highlighting areas to target in future surveillance and control efforts.

Transmission Risk Predicting for Schistosomiasis in Mainland China by Exploring Ensemble Ecological Niche Modeling

Schistosomiasis caused by Schistosoma japonicum is one of the major neglected tropical diseases worldwide. The snail Oncomelania hupensis is the only intermediate host of S. japonicum, which is recognized as an indicator of the schistosomias occurrence. In order to evaluate the risk of schistosomiasis in China, this work investigate the potential geographical distribution of host snail habitus by developing an ensemble ecological niche model with reference to the suitable environmental factors. The historical records of snail habitus were collected form the national schistosomiasis surveillance program from the year of 2005 to 2014. A total of 25 environmental factors in terms of the climate, geographic, and socioeconomic determinants of snail habitats were collected and geographically coded with reference to the snail data. Based on the correlations among snail habitats and the geographically associated environmental factors, an ensemble ecological niche model was developed by integrating ten standard models, aiming for improving the predictive accuracy. Three indexes are used for model performance evaluation, including receiver operating characteristic curves, kappa statistics, and true skill statistics. The model was used for mapping the risk of schistosomiasis in the middle and lower reaches of the Yangtze River. The results have shown that the predicted risk areas were classified into low risk (4.55%), medium risk (2.01%), and high risk areas (4.40%), accounting for 10.96% of the land area of China. This study demonstrated that the developed ensemble ecological niche models was an effective tool for evaluating the risk of schistosomiasis, particularly for the endemic regions, which were not covered by the national schistosomiasis control program.

Cross-watershed distribution pattern challenging the elimination of Oncomelania hupensis, the intermediate host of Schistosoma japonica, in Sichuan province, China

Background

Snail control is critical to schistosomiasis control efforts in China. However, re-emergence of Oncomelania hupensis is challenging the achievements of schistosomiasis control. The present study aimed to test whether the amphibious snails can spread across watersheds using a combination of population genetics and geographic statistics.

Methods

The digital maps and attributes of snail habitats were obtained from the national survey on O. hupensis. Snail sampling was performed in 45 counties of Sichuan Province. The cox1 gene of specimens was characterized by sequencing. Unique haplotypes were found for phylogenetic inference and mapped in a geographical information system (GIS). Barriers of gene flow were identified by Monmonier’s maximum difference algorithm. The watercourses and watersheds in the study area were determined based on a digital elevation model (DEM). Plain areas were defined by a threshold of slope. The slope of snail habitats was characterized and the nearest distance to watercourses was calculated using a GIS platform. Spatial dynamics of high-density distributions were observed by density analysis of snail habitats.

Results

A total of 422 cox1 sequences of O. hupensis specimens from 45 sampling sites were obtained and collapsed into 128 unique haplotypes or 10 clades. Higher haplotype diversity in the north of the study area was observed. Four barriers to gene flow, leading to five sub-regions, were found across the study area. Four sub-regions ran across major watersheds, while high-density distributions were confined within watersheds. The result indicated that snails were able to disperse across low-density areas. A total of 63.48% habitats or 43.29% accumulated infested areas were distributed in the plain areas where the overall slope was < 0.94°. Approximately 90% of snail habitats were closer to smaller watercourses. Historically, high-density areas were mainly located in the plains, but now more were distributed in hilly region.

Conclusions

Our study showed the cross-watershed distribution of Oncomelania snails at a large scale. Natural cross-watershed spread in plains and long-distance dispersal by humans and animals might be the main driver of the observed patterns. We recommend cross-watershed joint control strategies for snail and schistosomiasis control.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05496-0.

Schistosomiasis model with treatment, habitat modification and biological control

Schistosomiasis is a parasitic disease caused by Schistosoma worm infection. Some species of snails can serve as the intermediate hosts for the parasite. Numerous interventions have been performed to repress the snail population. One of them is the use of molluscicide. Nevertheless, it is debated that molluscicide intervention has negative impacts on the ecosystem. To investigate the impact of more environmentally friendly interventions, we develop a schistosomiasis model with treatment, habitat modification and biological control. The biological control agent examined in our model is a snail predator. Moreover, to investigate the impact of snail habitat modification, we assume that the snail population grows logistically. We show that all solutions of our model are non-negative and bounded. We also study the existence and stability conditions of equilibrium points. The basic reproduction numbers are determined using the next-generation operator. Linearization combined with the Routh-Hurwitz criterion is used to prove the local stability condition of disease-free equilibrium points. Bifurcation theory is applied to investigate the local stability condition of the endemic equilibrium points. To examine the global behavior of our model, we use asymptotically autonomous system theory and construct a Lyapunov function. We perform several numerical simulations to validate and support our deductive results. Our results show that early treatment can reduce the basic reproduction number and schistosomiasis cases. In addition, modifying snail habitat and releasing the snail predator at the snail habitat can reduce schistosomiasis prevalence. We suggest using snail predators which can hunt and kill snails effectively as a biological control agent.

Efforts to eliminate schistosomiasis in Hubei province, China: 2005-2018

BACKGROUND

The Hubei province is one of the most schistosomiasis-epidemic-prone provinces in China. A series of strategies were adopted by the government to curb the rebound schistosomiasis endemic status that has prevailed since the early 2000s. This study aimed to elucidate the trends of schistosomiasis transmission and to appraise the effectiveness of the integrated control strategy in lake and marshland areas.

METHODS

Surveillance data of schistosomiasis in the Hubei province between 2005 and 2018 were analyzed, including conventional health control measures, integrated strategies, and measures that focused on the infection source. According to the local annual plan for schistosomiasis control in endemic counties, previous measures were human and snail control and surveillance. Residents aged 6-65 years were screened by an immunological detection method called indirect hemagglutination assay (IHA) after the transmission season each year. All residents who tested positive were then asked to provide a fecal sample for examination by the miracidium hatching technique (MHT) to detect the presence of schistosomes. Moreover, systematic snail surveys were conducted as a part of the combined environmental sampling method. The latter included integrated strategies and measures that focused on the infection source. Bovine stool samples were also collected and concurrently assessed using the MHT by the agriculture department, river-hardening slope protection was constructed by the water conservancy department, and forestation promotion was conducted by the forest department. The effectiveness of the integrated control strategy was assessed using two indicators of resident and livestock infection rates and three indicators of snail epidemics across all endemic areas.

RESULTS

From 2005 to 2018, a total of 28. 46 million and 2. 05 million residents were assessed by immunological (IHA) and etiological (MHT) detection techniques, respectively. Snail surveys and molluscicide application were performed in 2. 26 hectares and 0. 37 hectares, respectively. Moreover, 2. 60 million bovines were assessed by etiological detection techniques (MHT). The river-hardening slope protection project was implemented in 503 places, and 46 thousand hectares in endemic areas underwent environmental modification. Forestation was implemented at an area of 0. 15 million hectares. Between 2005 and 2018, the epidemic indicators, including resident and livestock infection rates and the infested areas and infection rate of snails, all presented downward trends. The resident infection rate decreased from 3. 78% in 2005 to 0% in 2016, which persisted through 2018. The livestock infection rate decreased from 5. 63% in 2005 to 0% in 2013, which also persisted through 2018. From 2005 to 2018, the snail-inhabited area was slightly reduced, but the area of infected snails decreased to 0 in 2012; this persisted through 2018. All counties met the goal for schistosomiasis infection control, transmission control, and disruption of schistosomiasis activity in 2008, 2013, and 2018 separately. That means the goal has been achieved in each stage.

CONCLUSIONS

The decline of the schistosomiasis epidemic rate demonstrates that the Chinese government was successful in meeting its public health goal in Hubei province. In the next decade, precision interventions must be implemented in endemic counties with a relatively low epidemic status to achieve the goals of the Outline of the Healthy China 2030 Plan. A similar strategy can be applied in other countries to eliminate schistosomiasis globally.

Molecular evidence on the presence of Schistosoma japonicum infection in snails along the Yangtze River, 2015-2019

Background

Due to sustained control activities, the prevalence of Schistosoma japonicum infection in humans, livestock and snails has decreased significantly in P. R. China, and the target has shifted from control to elimination according to the Outline of Healthy China 2030 Plan. Applying highly sensitive methods to explore the presence of S. japonicum infection in its intermediate host will benefit to assess the endemicity or verify the transmission interruption of schistosomiasis accurately. The aim of this study was to access the presence of S. japonicum infection by a loop-mediated isothermal amplification (LAMP) method through a 5-year longitudinal study in five lake provinces along the Yangtze River.

Methods

Based on previous epidemiological data, about 260 villages with potential transmission risk of schistosomiasis were selected from endemic counties in five lake provinces along the Yangtze River annually from 2015 to 2019. Snail surveys were conducted in selected villages by systematic sampling method and/or environmental sampling method each year. All live snails collected from field were detected by microscopic dissection method, and then about one third of them were detected by LAMP method to assess the presence of S. japonicum infection with a single blind manner. The infection rate and nucleic acid positive rate of schistosomes in snails, as well as the indicators reflecting the snails’ distribution were calculated and analyzed. Fisher's exact test was used to examine any change of positive rate of schistosomes in snails over time.

Results

The 5-year survey covered 94,241 ha of environment with 33,897 ha of snail habitats detected accumulatively. Totally 145.3 ha new snail habitats and 524.4 ha re-emergent snail habitats were found during 2015–2019. The percentage of frames with snails decreased from 5.93% [45,152/761,492, 95% confidence intervals (CI): 5.88–5.98%] in 2015 to 5.25% (30,947/589,583, 95% CI: 5.19–5.31%) in 2019, while the mean density of living snails fluctuated but presented a downward trend generally from 0.20 snails/frame (155,622/761,492, 95% CI: 0.17–0.37) in 2015 to 0.13 snails/frame (76,144/589,583, 95% CI: 0.11–0.39) in 2019. A total of 555,393 live snails were collected, none of them was positive by dissection method. Totally 17 pooling snail samples were determined as positives by LAMP method among 8716 pooling samples with 174,822 of living snails, distributed in 12 villages of Hubei, Hunan, Jiangxi and Anhui provinces. The annual average positive rate was 0.41% (95% CI: 0.13–0.69%) in 2015, 0% in 2016, 0.36% (95% CI: 0.09–0.63%) in 2017, 0.05% (95% CI: 0–0.16%) in 2018, 0.05% (95% CI: 0–0.15%) in 2019, respectively, presenting a downward trend from 2015 to 2019 with statistical significance (χ² = 11.64, P < 0.05).

Conclusions

The results suggest that S. japonicum infection still persisted in nature along the Yangtze River and traditional techniques might underestimate the prevalence of schistosomiasis in its intermediate hosts. Exploring and integrating molecular techniques into national surveillance programme could improve the sensitivity of surveillance system and provide guidance on taking actions against schistosomiasis.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00995-9.

Molecular Techniques as Alternatives of Diagnostic Tools in China as Schistosomiasis Moving towards Elimination

Schistosomiasis japonica caused by the trematode flukes of Schistosoma japonicum was one of the most grievous infectious diseases in China in the mid-20th century, while its elimination has been placed on the agenda of the national strategic plan of healthy China 2030 after 70 years of continuous control campaigns. Diagnostic tools play a pivotal role in warfare against schistosomiasis but must adapt to the endemic status and objectives of activities. With the decrease of prevalence and infection intensity of schistosomiasis in human beings and livestock, optimal methodologies with high sensitivity and absolute specificity are needed for the detection of asymptomatic cases or light infections, as well as disease surveillance to verify elimination. In comparison with the parasitological methods with relatively low sensitivity and serological techniques lacking specificity, which both had been widely used in previous control stages, the molecular detection methods based on the amplification of promising genes of the schistosome genome may pick up the baton to assist the eventual aim of elimination. In this article, we reviewed the developed molecular methods for detecting S. japonicum infection and their application in schistosomiasis japonica diagnosis. Concurrently, we also analyzed the chances and challenges of molecular tools to the field application process in China.

The Dynamics of Hepatic Fibrosis Related to Schistosomiasis and Its Risk Factors in a Cohort of China

China has had a long history against schistosomiasis japonica. The most serious prognosis of chronic schistosome infection is hepatic fibrosis, which develops into advanced schistosomiasis if the process is not effectively controlled. After a more than seven decades endeavor, China has gained remarkable achievements in schistosomiasis control and achieved transmission control nationwide (infection rate of schistosomes in residents and domestic animals both less than 1%) by 2015. However, new advanced schistosomiasis cases emerge annually in China, even in areas where the transmission of schistosomiasis had been interrupted. In the present study, the residents (>5 years old) in a schistosomiasis endemic village were examined for schistosomiasis every year during 1995-2019 by the modified Kato-Katz thick smear method and/or miracidium hatching technique. Residents who were identified to have an active infection method were treated with praziquantel at a dose of 40 mg/kg body weight. Ultrasonography was carried out to assess the liver morbidity related to schistosomiasis in 1995 and 2019, respectively. The prevalence of schistosomiasis among residents presented a downward trend annually, from 17.89% (175/978) in 1995 to 0 (0/475) in 2019. Among 292 residents who received ultrasound scan both in 1995 and 2019, 141 (48.29%) presented stable liver damage, while liver fibrosis was developed severely in 86 (29.45%) and reversed in 65 (22.26%) residents. Univariate and multivariate analysis showed that anti-fibrosis treatment was the protective factor against schistosomiasis hepatic fibrosis. Males, residents aged 38 and above, fishermen, and people who did not receive anti-fibrosis treatment were groups with higher risk of liver fibrosis development. Our results revealed that although the infection rate of schistosome dropped significantly in endemic areas, liver fibrosis was still developing among some residents, even though they had received deworming treatment. Liver protection/anti-fibrosis treatment should be administered in endemic regions and regions with historically uncontrolled transmission to slow down the deterioration of hepatic fibrosis among patients in schistosomiasis endemic areas.

In vivo praziquantel efficacy of Schistosoma japonicum over time: A systematic review and meta-analysis

Praziquantel (PZQ), the only choice of chemotherapy for schistosomiasis recommended by World Health Organization (WHO), has been widely used over 40 years. The long-term, and rapid expansion of, PZQ use for disease control across a large populations continues to raise concern regarding the potential for emergence and establishment of drug resistance. Recent research has also proposed that the long survival and low sensitivity of unpaired worms, derived from either incomplete treatment cure rates or single-sex schistosome infections within final hosts, could exacerbate the risk of PZQ resistance (PZQ-R) emerging. With the aim of assessing whether PZQ efficacy amongst S. japonicum may have changed over time in China, we performed a unique systematic review and meta-analyses on datasets which evaluated the efficacy of PZQ via laboratory assays of field S. japonicum isolates on experimental mice over time. Relevant published literatures from four electronic bibliographic databases and lists of article references were searched. Two indexes, d, a measure used in meta-analyses for worm burden difference between two groups, and r, a traditional measure for worm reduction percentage after treatment but without considering sample size were calculated for each study. A total of 25 papers including 127 experimental studies with eligible data on 2230 mice were retrieved. The pooled d (D) was 3.91 (3.56-4.25) and pooled r (R) was 54.52% (52.55%-56.52%). D significantly increased over time, whereas R non-significantly decreased; both estimates were significantly associated with the total drug dose. Such findings suggested no evidence of PZQ-R emergence S. japonicum to date. However, we consider the potential role of parasite origins, PZQ dosage, and single versus mixed gender infections of the results published to date, and the avenues now needed for further research.

History of Human Schistosomiasis (bilharziasis) in China: From Discovery to Elimination

PURPOSE

For the evolution of schistosomiasis in China, a systematic review was provided about the history of the disease and its public health impacts. We aimed to depict the journey from disease discovery to elimination and the experience and lessons learned during the process.

METHODS

We systematically reviewed the Chinese history of schistosomiasis and its public health impacts and collected data on the disease by searching relevant books and articles.

RESULTS

An important milestone for the disease discovery is that Schistosoma japonicum eggs were identified in the two Chinese corpses dating back to around 2180 years ago. The earliest Chinese ancient book documented symptoms resembling schistosomiasis that could date back to about 4700 years ago. The first nationwide survey on the disease in the mid-1950s revealed that schistosomiasis was endemic in 433 counties or cities of 12 provinces and affected about 11.6 million people in China. The Chinese government has provided continuous investment in schistosoiasis control, and the national multifaceted, integrated control programs have been uninterruptedly implemented since 1955. Schistosomiasis control in China can be divided into six stages, and various schistosomiasis control strategies have been developed and adjusted. The number of schistosomiasis cases decreased from 11.6 million in 1950s to 38,000 in 2017 and the number of acute cases decreased from 13,191 in 1989 to only 1 in 2017.

CONCLUSIONS

Schistosomiasis transmission has been under control in all parts of China since 2017. An elimination of schistosomiasis can be achieved in the foreseeable future in China.

Patented technologies for schistosomiasis control and prevention filed by Chinese applicants

BACKGROUND

Many valuable and productive patented technologies have been developed to control schistosomiasis in China in the past 70 years. We conducted a research to analyse patented technologies for schistosomiasis control and prevention filed by Chinese applicants for determining the future patent layout.

METHODS

The patent databases of China National Intellectual Property Administration and Baiten were comprehensively searched, and patented technologies for schistosomiasis control and prevention, published between January 1950 and December 2020 filed by Chinese applicants were sorted on 30 December 2020. The patent types, technical fields, and patent development trends were analysed using patent indexing.

RESULTS

There are 184 valid schistosomiasis control technology patents, among them 128 invention patents. The patents related to schistosomiasis control and prevention technology have gone through the germination, growth, and maturity stages. These phases correspond with three phases in schistosomiasis control in China. The main technical aspects were fundamental research (n = 37), detection (n = 13), chemotherapy (n = 61), and armamentarium/devices (n = 73), of which the number of patents for detection for diagnosis was smaller. The top three specialised technical fields for patents subgroups, focusing on antiparasitic agents, DNA or RNA, vectors and medicines, of which schistosomicides are the major dominant subgroup.

CONCLUSIONS

We recommend that technologies to be patented for schistosomiasis control and prevention be focused on detection, preliminary studies for molecular detection methods should be significantly enhanced, and patent layout must be performed, which will, in turn, promote accuracy of early diagnosis, not only in humans but also in livestock. It is necessary to develop more anti-schistosomal drugs safely and effectively, exceptionally eco-friendly molluscicides and herbal extracts anti-schistosomes, improve treatment, develop vaccines for use in humans.

Infestation risk of the intermediate snail host of Schistosoma japonicum in the Yangtze River Basin: improved results by spatial reassessment and a random forest approach

BACKGROUND

Oncomelania hupensis is only intermediate snail host of Schistosoma japonicum, and distribution of O. hupensis is an important indicator for the surveillance of schistosomiasis. This study explored the feasibility of a random forest algorithm weighted by spatial distance for risk prediction of schistosomiasis distribution in the Yangtze River Basin in China, with the aim to produce an improved precision reference for the national schistosomiasis control programme by reducing the number of snail survey sites without losing predictive accuracy.

METHODS

The snail presence and absence records were collected from Anhui, Hunan, Hubei, Jiangxi and Jiangsu provinces in 2018. A machine learning of random forest algorithm based on a set of environmental and climatic variables was developed to predict the breeding sites of the O. hupensis intermediated snail host of S. japonicum. Different spatial sizes of a hexagonal grid system were compared to estimate the need for required snail sampling sites. The predictive accuracy related to geographic distances between snail sampling sites was estimated by calculating Kappa and the area under the curve (AUC).

RESULTS

The highest accuracy (AUC = 0.889 and Kappa = 0.618) was achieved at the 5 km distance weight. The five factors with the strongest correlation to O. hupensis infestation probability were: (1) distance to lake (48.9%), (2) distance to river (36.6%), (3) isothermality (29.5%), (4) mean daily difference in temperature (28.1%), and (5) altitude (26.0%). The risk map showed that areas characterized by snail infestation were mainly located along the Yangtze River, with the highest probability in the dividing, slow-flowing river arms in the middle and lower reaches of the Yangtze River in Anhui, followed by areas near the shores of China's two main lakes, the Dongting Lake in Hunan and Hubei and the Poyang Lake in Jiangxi.

CONCLUSIONS

Applying the machine learning of random forest algorithm made it feasible to precisely predict snail infestation probability, an approach that could improve the sensitivity of the Chinese schistosome surveillance system. Redesign of the snail surveillance system by spatial bias correction of O. hupensis infestation in the Yangtze River Basin to reduce the number of sites required to investigate from 2369 to 1747.

Population genomic analyses of schistosome parasites highlight critical challenges facing endgame elimination efforts

Schistosomiasis persists in Asian regions despite aggressive elimination measures. To identify factors enabling continued parasite transmission, we performed reduced representation genome sequencing on Schistosoma japonicum miracidia collected across multiple years from transmission hotspots in Sichuan, China. We discovered strong geographic structure, suggesting that local, rather than imported, reservoirs are key sources of persistent infections in the region. At the village level, parasites collected after referral for praziquantel treatment are closely related to local pre-treatment populations. Schistosomes within villages are also highly related, suggesting that only a few parasites from a limited number of hosts drive re-infection. The close familial relationships among miracidia from different human hosts also implicate short transmission routes among humans. At the individual host level, genetic evidence indicates that multiple humans retained infections following referral for treatment. Our findings suggest that end-game schistosomiasis control measures should focus on completely extirpating local parasite reservoirs and confirming successful treatment of infected human hosts.

Spatio-temporal variations of emerging sites infested with schistosome-transmitting Oncomelania hupensis in Hunan Province, China, 1949-2016

BACKGROUND

Constant emerging sites infested with Oncomelania hupensis (O. hupensis) impede the goal realization of eliminating schistosomiasis. The study assessed the spatial and temporal distributions of new Oncomelania snail habitats in Hunan Province from 1949 to 2016.

METHODS

We used the data from annual snail surveys throughout Hunan Province for the period from 1949 to 2016. Global Moran's I, Anselin local Moran's I statistics (LISA) and a retrospective space-time permutation model were applied to determine the spatial and temporal distributions of emerging snail-infested sites.

RESULTS

There were newly discovered snail-infested sites almost every year in 1949-2016, except for the years of 1993, 2009 and 2012. The number of emerging sites varied significantly in the five time periods (1949-1954, 1955-1976, 1977-1986, 1986-2003 and 2004-2016) (H = 25.35, p < 0.05). The emerging sites lasted 37.52 years in marshlands, 30.04 years in hills and 24.63 at inner embankments on average, with the values of Global Moran's I being 0.52, 0.49 and 0.44, respectively. High-value spatial clusters (HH) were mainly concentrated along the Lishui River and in Xiangyin County. There were four marshland clusters, two hill clusters and three inner embankment clusters after 1976.

CONCLUSIONS

Lower reaches of the Lishui River and the Dongting Lake estuary were the high-risk regions for new Oncomelania snail habitats with long durations. Snail surveillance should be strengthened at stubborn snail-infested sites at the inner embankments. Grazing prohibition in snail-infested grasslands should be a focus in marshlands. The management of bovines in Xiangyin County is of great importance.

Patterns of relatedness and genetic diversity inferred from whole genome sequencing of archival blood fluke miracidia (Schistosoma japonicum)

Genomic approaches hold great promise for resolving unanswered questions about transmission patterns and responses to control efforts for schistosomiasis and other neglected tropical diseases. However, the cost of generating genomic data and the challenges associated with obtaining sufficient DNA from individual schistosome larvae (miracidia) from mammalian hosts have limited the application of genomic data for studying schistosomes and other complex macroparasites. Here, we demonstrate the feasibility of utilizing whole genome amplification and sequencing (WGS) to analyze individual archival miracidia. As an example, we sequenced whole genomes of 22 miracidia from 11 human hosts representing two villages in rural Sichuan, China, and used these data to evaluate patterns of relatedness and genetic diversity. We also down-sampled our dataset to test how lower coverage sequencing could increase the cost effectiveness of WGS while maintaining power to accurately infer relatedness. Collectively, our results illustrate that population-level WGS datasets are attainable for individual miracidia and represent a powerful tool for ultimately providing insight into overall genetic diversity, parasite relatedness, and transmission patterns for better design and evaluation of disease control efforts.

Loss of natural resistance to schistosome in T cell deficient rat

Schistosomiasis is among the major neglected tropical diseases and effective prevention by boosting the immune system is still not available. T cells are key cellular components governing adaptive immune response to various infections. While common laboratory mice, such as C57BL/6, are highly susceptible to schistosomiasis, the SD rats are extremely resistant. However, whether adaptive immunity is necessary for such natural resistance to schistosomiasis in rats remains to be determined. Therefore, it is necessary to establish genetic model deficient in T cells and adaptive immunity on the resistant SD background, and to characterize liver pathology during schistosomiasis. In this study we compared experimental schistosomiasis in highly susceptible C57BL/6 (B6) mice and in resistant SD rats, using cercariae of Schistosoma japonicum. We observed a marked T cell expansion in the spleen of infected B6 mice, but not resistant SD rats. Interestingly, CD3e^−/− B6 mice in which T cells are completely absent, the infectious burden of adult worms was significantly higher than that in WT mice, suggesting an anti-parasitic role for T cells in B6 mice during schistosome infection. In further experiments, we established Lck deficient SD rats by using CRISPR/Cas9 in which T cell development was completely abolished. Strikingly, we found that such Lck deficiency in SD rats severely impaired their natural resistance to schistosome infection, and fostered parasite growth. Together with an additional genetic model deficient in T cells, the CD3e^−/− SD rats, we confirmed the absence of T cell resulted in loss of natural resistance to schistosome infection, but also mitigated liver immunopathology. Our further experiments showed that regulatory T cell differentiation in infected SD rats was significantly decreased during schistosomiasis, in contrast to significant increase of regulatory T cells in infected B6 mice. These data suggest that T cell mediated immune tolerance facilitates persistent infection in mice but not in SD rats. The demonstration of an important role for T cells in natural resistance of SD rats to schistosomiasis provides experimental evidences supporting the rationale to boost T cell responses in humans to prevent and treat schistosomiasis.

Schistosomiasis is among the major neglected tropical diseases and affects mainly the developing countries. Although the role of the immune system in driving immunopathology in schistosomiasis has been extensively studied, how adaptive immunity contributes to disease resistance during schistosome infection is still not completely understood. Most livestock species as well as humans are susceptible to schistosomiasis, while some mammals are extremely resistant. The common laboratory C57BL/6 mice are highly susceptible to schistosomiasis; however, the SD rats are extremely resistant. In this study, we first used T cell deficient CD3e^−/− C57BL/6 mice and experimental Schistosoma japonicum infection and further established novel T cell deficient models in SD rats to assess anti-parasite roles of T cells. Strikingly, we found that the natural resistance of SD rat to schistosomiasis was abolished in the absence of T cells, despite the fact that the liver pathology was mitigated following infection. Therefore, our study presented experimental support for the rationale to boost T cell function for clearance of schistosome parasites.

Helminthiases in the People's Republic of China: Status and prospects

Helminth infections, many of them listed as neglected tropical diseases by the World Health Organization, remain a public health issue in many parts of the world. The People's Republic of China (P.R. China) stands out due to impressive progress in the control and local elimination of helminth infections. An important contextual factor is P.R. China's sustained social and economic development that allowed implementation of health-related poverty alleviation, improving water, sanitation and hygiene, enhancing information, education and communication, coupled with major engineering and infrastructure development and intersectoral collaboration. Nonetheless, food-borne trematodiases, soil-transmitted helminthiases, echinococcosis, cysticercosis/taeniasis and schistosomiasis still exert a considerable burden in P.R. China, even though the numbers of infected people have decreased substantially since the new millennium. This special issue of Acta Tropica provides a comprehensive update of the current knowledge of the main helminth infections in P.R. China, summarises progress in research and discusses future prospects for gaining and sustaining control towards the final goal of breaking transmission and hence, eliminating helminthiases. It consists of 34 articles with a wide coverage that can be grouped into six domains: (i) epidemiological assessment and disease burden estimates; (ii) diagnostics and antigen characterisation; (iii) drug and vaccine development; (iv) host-parasite interactions and snail genetics; (v) surveillance and public health response; and (vi) capacity building and international cooperation. The control and elimination of helminthiases not only furthers the health and wellbeing of the Chinese people, but also provides innovative approaches, tools and strategies, which can be adopted and applied in other countries and regions of the world where helminthiases still prevail.

Current Status of Schistosomiasis Control and Prospects for Elimination in the Dongting Lake Region of the People's Republic of China

Schistosomiasis japonica is an ancient parasitic disease that has severely impacted human health causing a substantial disease burden not only to the Chinese people but also residents of other countries such as the Philippines, Indonesia and, before the 1970s, Japan. Since the founding of the new People's Republic of China (P. R. China), effective control strategies have been implemented with the result that the prevalence of schistosomiasis japonica has decreased markedly in the past 70 years. Historically, the Dongting Lake region in Hunan province is recognised as one of the most highly endemic for schistosomiasis in the P.R. China. The area is characterized by vast marshlands outside the lake embankments and, until recently, the presence of large numbers of domestic animals such as bovines, goats and sheep that can act as reservoir hosts for Schistosoma japonicum. Considerable social, economic and environmental changes have expanded the Oncomelania hupensis hupensis intermediate snail host areas in the Dongting lake region increasing the potential for both the emergence of new hot spots for schistosomiasis transmission, and for its re-emergence in areas where infection is currently under control. In this paper, we review the history, the current endemic status of schistosomiasis and the control strategies in operation in the Dongting Lake region. We also explore epidemiological factors contributing to S. japonicum transmission and highlight key research findings from studies undertaken on schistosomiasis mainly in Hunan but also other endemic Chinese provinces over the past 10 years. We also consider the implications of these research findings on current and future approaches that can lead to the sustainable integrated control and final elimination of schistosomiasis from the P. R. China and other countries in the region where this unyielding disease persists.

Surveillance on schistosomiasis in five provincial-level administrative divisions of the People's Republic of China in the post-elimination era

Background

The People’s Republic of China (P. R. China) has made significant progress on schistosomiasis control. Among the 12 provincial-level administrative divisions (PLADs) with schistosomiasis endemic in P. R. China, Guangdong, Shanghai, Fujian, Guangxi and Zhejiang PLADs (following as five PLADs) had successively eliminated schistosomiasis during 1985–1995. However, consolidation of the schistosomiasis elimination in these five PLADs remains challenging. In the current study, we sought to understand the epidemic situation in these post-elimination areas and their surveillance capabilities on schistosomiasis.

Methods

Annual data reflecting the interventions and surveillance on human beings, cattle and snails based on county level from 2005 to 2016 were collected through the national schistosomiasis reporting system and the data were analyzed to understand the epidemic status of schistosomiasis in the five PLADs. A standardized score sheet was designed to assess the surveillance capacity for schistosomiasis of selected disease control agencies in five PLADs and ten counties. Assessment on surveillance capacity including schistosomiasis diagnostic skills, identification of snails’ living and infection status and knowledge about schistosomiasis and its control were made. Descriptive analysis was used to analyze the epidemic status and evaluation results on surveillance capacities.

Results

The assessments showed that no local cases in humans and cattle or infected snail were found in these five PLADs since 2005. However, from 2005 to 2016, a total of 221 imported cases were detected in Zhejiang, Shanghai and Fujian, and 11.98 hm² of new snail habitats were found in Zhejiang, Shanghai and Guangxi. In addition, snail infestation reoccurred in 247.55 hm² of former snail habitats since 2011. For the surveillance capacity assessment, the accuracy rate of IHA and MHT were 100 and 89.3%, respectively. All participants could judge the living status of snails accurately and 98.1% on the infection status of snails. The accuracy rate of the questionnaire survey was 98.0%.

Conclusions

Elimination of schistosomiasis was consolidated successfully in five PLADs of P. R. China due to effective and strong post-elimination surveillance. Comprehensive consolidation strategies should be focused on the elimination of residual snails and the prevention of imported infection sources to consolidate the achievements of schistosomiasis control.

Metabolic profiles of Oncomelania hupensis after molluscicidal treatment: Carbohydrate metabolism targeted and energy deficiency

Oncomelania hupensis is the intermediate host of Schistosoma japonicum, one of the Schistosoma species that can cause human schistosomiasis. Molluscicidal treatment remains the primary means to control snail. Niclosamide is the only molluscicide recommended by the World Health Organization, and it has been used throughout schistosomiasis-endemic areas in China for almost 30 years. In our previous studies on transcriptomics, morphology, and enzymology of snails after molluscicidal treatment, two effective molluscicides were used, 50% wettable powder of niclosamide ethanolamine salt (WPN) and a new molluscicide derived from niclosamide, the salt of quinoid-2', 5-dichloro-4'-nitro-salicylanilide (LDS, simplified for Liu Dai Shui Yang An). Genes involved in cell structure mintenance, inhibition of neurohumoral transmission, and energy metabolism showed significant differential expression after molluscicide treatments. Damages in the structure of liver and muscle cells were accompanied by inhibited activities of enzymes related to carbohydrate metabolism and energy supply. This study was designed to clarify the dynamic metabolic process by metabonomics, together with the previous transcriptomic and enzymological profiles, to identify potential metabolite markers and metabolism pathways that related to the toxic mechanism of the molluscicide. In total, 56 metabolites were identified for O. hupensis, and 75% of these metabolites consisted of amino acids and derivatives, organic acids, and nucleic acid components. The concentration of glucose, maltose, succinate, choline, and alanine changed significantly after molluscicide treatments. These changes in metabolites mainly occurred in the process of carbohydrate metabolism, energy metabolism, and amino acid metabolism, primarily related to glycolysis/gluconeogenesis, oxidative phosphorylation, and transamination by KEGG pathway identification. Most of the identified pathways were also related to those differentially expressed unigenes and observed enzymes from our previous studies. Inhibited aerobic respiration and oxidative phosphorylation, and energy deficiency were implied further to be the leading causes of the final death of snails after molluscicide treatments. The hypothesised mathematical model in this study identified the rational hysteresis to explain the inconsistency of responses of unigenes, enzymes, and metabolites to molluscicide treatments. This study contributes to the comprehensive understanding of the molluscicidal mechanism in the metabolic process and this could assist in improving existing molluscicide formulations or development of new molluscicides.

The effect of ecological environmental changes and mollusciciding on snail intermediate host of Schistosoma in Qianjiang city of China from 1985 to 2015

Background

Schistosomiasis remains prevalent in Africa, Asia and South America with an estimated burden of 1.9 million disability-adjusted life years in 2016. Targeting snails as a key to success for schistosomiasis control has been widely approved, but the long-term quantitative effects of interventions on snail control that would inform and improve future control programmes are unclear. Over the last six decades, schistosomiasis in China had been brought largely under control, and snail control as supplementary methods or part of integrated multisectoral approaches in different historical periods has played an essential role.

Methods

Ecological environment factors, prevalence and control data on Oncomelania hupensis between 1985 and 2015 at 5-year intervals in Qianjiang city, China, were collected. A multilevel growth model approach was used to examine the long-term effects of ecological environmental changes and mollusciciding on snail-infested area (SIA) and living snail density (LSD) during the 30 years.

Results

The variation of SIA was 68.4% in spatial distribution, while the variation of LSD was 68.4% in temporal distribution. Continuous mollusciciding could result in significant LSD reduction, but may not lead to significant SIA reduction. The normalized difference vegetation index (NDVI), patch size coefficient of variation (PSCoV) and mean patch size (MPS) reduction, slightly due to eco-environmental changes decreased SIA, while mean perimeter-area ratio (MPAR) and dry farm-land proportion (DFLP) reduction might increase SIA. Only NDVI and MPAR reduction led to a lower LSD.

Conclusions

Mollusciciding was more effective in reducing snail density, but it is not easy to eliminate snails completely. Environmental modifications could completely change the snail breeding environment and reduce its infestation area. Due to difficulty of scaling-up the current environmental modifications in waterway network regions, more effective snail control methods are needed. The experience in China could thereby provide guidance for other schistosomiasis endemic areas with a high snail prevalence.

Surveillance-based evidence: elimination of schistosomiasis as a public health problem in the Peoples' Republic of China

BACKGROUND

A steady progress on schistosomiasis control in the Peoples' Republic of China (P.R. China) was achieved and broadened into the twelve-year medium and long term national plan (MLNP) which marled the implementation of an integrated control strategy across all endemic areas in P.R. China in 2004. To understand the endemic trends of schistosomiasis to assess the effectiveness of an integrated strategy, we conducted an analysis of schistosomiasis surveillance data spanned from 2005 to 2015.

METHODS

The schistosomiasis sentinel surveillance data from sentinel sites were collected and analyzed from 2005 to 2015. In these sentinel sites, residents aged 6 years or above were screened annually by indirect hemagglutination assay (IHA), while only antibody positives were followed by stool examination either Kato-katz method (KK) and/or hatching technique (HT). Domestic animals raised in sentinel sites were examined by HT for confirming the infection of schistosomes. Snail investigation was conducted each year through systematic sampling method combined with environmental sampling method. The snails collected from field were tested by microscopic dissection method. The infection rates of schistosomes in residents, domestic animals and snails, as well as the indicators reflecting the snails' distribution were calculated and analyzed. ANOVA analysis was used to examine the changes of the number of eggs per gram feces in population and Chi-square test was used to examine any change in proportions among groups.

RESULTS

A total of 148 902 residents from sentinel sites attended this study and 631 676 blood samples were examined by IHA test during the 11 covered years. The annual average antibody positive rates presented a significant decrease trends, from 17.48% (95% CI: 17.20-17.75%) in 2005 to 5.93% (95% CI: 5.71-6.15%) (χ2 = 8890.47, P < 0.001) in 2015. During 2005-2015, the average infection rate of schistosomes in residents declined from 2.07% (95% CI: 1.96-2.17%) to 0.13% (95% CI: 0.09-0.16%), accompanied by significant decrease of infection intensity in population. In 2015, the stool positives were only found in farmers, fishermen and boatmen with infection rate of 0.16% (95% CI: 0.11-0.20%), 0.17% (95% CI: 0-0.50%) respectively. The infection rate of schistosomes in domestic animals dropped from 9.42% (538/5711, 95% CI: 8.66-10.18%) to 0.08% (2/2360, 95% CI: 0-0.20%) from 2005 to 2015. Infections were found in eight species of domestic animals at the beginning of surveillance while only two cattle were infected in 2015. Totally 98 ha of new snail habitats were found, while 94.90% (93/98) distributed in lake and marshland regions. The percentage of frames with snails decreased from 16.96% (56 884/33 5391, 95% CI: 16.83-17.09%) in 2005 to 4.28% (18 121/423 755, 95% CI: 4.22-4.34%) in 2014, with a slightly increase in 2015. Meanwhile, the infection rate of schistosomes in snails was decreased from 0.26% (663/256 531, 95% CI: 0.24-0.28%) to zero during 2005-2015.

CONCLUSIONS

The infection rate of schistosomes declined significantly, providing evidence that the goal of the MLNP was achieved. Elimination of schistosomiasis as a public health problem defined as WHO was also reached in P.R. China nationwide. Surveillance-response system should be improved and strengthened to realize the final goal of schistosomiasis elimination.

Differential Change in the Prevalence of the Ascaris, Trichuris and Clonorchis infection Among Past East Asian Populations

As we learn more about parasites in ancient civilizations, data becomes available that can be used to see how infection may change over time. The aim of this study is to assess how common certain intestinal parasites were in China and Korea in the past 2000 years, and make comparisons with prevalence data from the 20th century. This allows us to go on to investigate how and why changes in parasite prevalence may have occurred at different times. Here we show that Chinese liver fluke (Clonorchis sinensis) dropped markedly in prevalence in both Korea and China earlier than did roundworm (Ascaris lumbricoides) and whipworm (Trichuris trichiura). We use historical evidence to determine why this was the case, exploring the role of developing sanitation infrastructure, changing use of human feces as crop fertilizer, development of chemical fertilizers, snail control programs, changing dietary preferences, and governmental public health campaigns during the 20th century.

Comparative analysis of time-based and quadrat sampling in seasonal population dynamics of intermediate hosts of human schistosomes

BACKGROUND

Despite their importance for designing and evaluating schistosomiasis control trials, little attention in the literature has been dedicated to sampling protocols for the parasite's snail intermediate hosts since their first development. We propose a comparative analysis of time-based and quadrat sampling protocols to quantify the seasonal variations in the abundance of these aquatic snail species of medical importance.

METHODOLOGY/PRINCIPAL FINDINGS

Snail populations were monitored during 42 consecutive months in three types of habitats (ephemeral pond, ephemeral river and permanent stream) in two sites covering different climatic zones in Burkina Faso. We employed both a widely used time-based protocol of 30min of systematic collection at a weekly interval, and a quadrat protocol of 8 replicates per sample at a monthly interval. The correspondence between the two protocols was evaluated using an ensemble of statistical models including linear and saturating-type functional forms as well as allowing for count zero-inflation. The quadrat protocol yielded on average a relative standard error of 40%, for a mean snail density of 16.7 snails/m2 and index of dispersion of 1.51. Both protocols yielded similar seasonal patterns in snail abundance, confirming the asynchrony between permanent and ephemeral habitats with respect to the country's seasonal rainfall patterns. Formal model comparison of the link between time vs. quadrat counts showed strong support of saturation for the latter and measurement zero-inflation, providing important evidence for the presence of density feedbacks in the snail's population dynamics, as well as for spatial clustering.

CONCLUSIONS/SIGNIFICANCE

In addition to the agreement with the time-based method, quadrat sampling provided insight into snail population dynamics and comparable density estimates across sites. The re-evaluation of these "traditional" sampling protocols, as well as the correspondence between their outputs, is of practical importance for the design and evaluation of schistosomiasis control trials.

Spatiotemporal pattern analysis of schistosomiasis based on village level in the transmission control stage in lake and marshland areas in China

Hubei Province is one of the endemic regions with severe schistosomiasis in China. To eliminate schistosomiasis in lake and marshland regions, this study detected hotspots of schistosomiasis cases both spatially and spatiotemporally on the basis of spatial autocorrelation; clustering and outlier, purely spatial and spatiotemporal cluster analyses at the village level from 2013 to 2017 in Hubei Province. The number of cases confirmed positive by an immunodiagnostic test and etiological diagnosis and advanced schistosomiasis cases dramatically declined during the study period. Significant global spatial autocorrelation of schistosomiasis patients was found at the village level in the whole province in 5 years. Clustering and outlier analysis showed that most HH villages were mainly concentrated along the Yangtze River, especially in Jianghan Plain. Spatial and spatiotemporal cluster analyses showed that significant clusters of the schistosomiasis cases were detected at the village level. In general, space and spatiotemporal clustering of schistosomiasis cases at the village level demonstrated a downward trend from 2013 from 2017 in Hubei Province. High-risk regions included Jianghan Plain along the middle reach of Yangtze River and Yangxin County in the lower reaches of the Yangtze River in Hubei Province. To eliminate schistosomiasis, precise control and management of schistosomiasis cases should be strictly implemented. Moreover, comprehensive prevention and control measures should be continuously strengthened in these regions.

Neglected tropical diseases in the People's Republic of China: progress towards elimination

Since the founding of the People's Republic of China in 1949, considerable progress has been made in the control and elimination of the country's initial set of 11 neglected tropical diseases. Indeed, elimination as a public health problem has been declared for lymphatic filariasis in 2007 and for trachoma in 2015. The remaining numbers of people affected by soil-transmitted helminth infection, clonorchiasis, taeniasis, and echinococcosis in 2015 were 29.1 million, 6.0 million, 366 200, and 166 100, respectively. In 2017, after more than 60 years of uninterrupted, multifaceted schistosomiasis control, has seen the number of cases dwindling from more than 10 million to 37 600. Meanwhile, about 6000 dengue cases are reported, while the incidence of leishmaniasis, leprosy, and rabies are down at 600 or fewer per year. Sustained social and economic development, going hand-in-hand with improvement of water, sanitation, and hygiene provide the foundation for continued progress, while rigorous surveillance and specific public health responses will consolidate achievements and shape the elimination agenda. Targets for poverty elimination and strategic plans and intervention packages post-2020 are important opportunities for further control and elimination, when remaining challenges call for sustainable efforts.

The epidemiological status of schistosomiasis in P. R. China after the World Bank Loan Project, 2002-2017

World Bank Loan Project (WBLP) for schistosomiasis control conducted from 1992 to 2001, resulted in significant reduction of schistosomiasis morbidity and mortality in People's Republic of China (P.R. China), with implementation of morbidity control. Thereafter, an integrated control strategy, which targeted blocking disease transmission from reservoir hosts to the environment, was initiated in order to conquer schistosomiasis rebound after WBLP completion. Data obtained from the national schistosomiasis control reporting systems was collected and analyzed. The number of confirmed cases and infected cattle decreased significantly from 2002 to 2017, while no infected snails were found by dissection for four consecutive years. However, lake and marshland regions and some parts areas of Yunnan Province require attention for rigorous schistosomiasis control efforts. There is need to strengthen precise interventions and sensitive surveillance to achieve schistosomiasis elimination in P.R. China.

Comparison of Kato Katz, antibody-based ELISA and droplet digital PCR diagnosis of schistosomiasis japonica: Lessons learnt from a setting of low infection intensity

Background

Zoonotic schistosomiasis in Asia, caused by Schistosoma japonicum, remains a major public health concern in China and the Philippines. The developing epidemiological and socio-economic picture of the disease in endemic areas necessitates the development of affordable and highly accurate field diagnostics as an important component in evaluating ongoing integrated control and elimination efforts.

Methods

Three diagnostic methods, namely Kato-Katz (KK) stool microscopy, ELISA and droplet digital (dd) PCR assays, were compared by detecting infection in a total of 412 participants from an area moderately endemic for schistosomiasis in the Philippines.

Results

This comprehensive comparison further defined the diagnostic performance and features for each assay. Compared with the ddPCR assay analysing DNA from faeces (F_ddPCR), which exhibited the highest sensitivity, the SjSAP4 + Sj23-LHD-ELISA had the best accuracy (67.2%) among all five ELISA assays assessed. Schistosomiasis prevalence determined by the SjSAP4 + Sj23-LHD-ELISA and ddPCRs was similar and was at least 2.5 times higher than obtained with the KK method. However, the agreement between these assays was low. In terms of cost and logistical convenience, the SjSAP4 + Sj23-LHD-ELISA represents a cost-effective assay with considerable diagnostic merits. In contrast, although the ddPCR assays exhibited a high level of diagnostic performance, the high cost and the need for specialized equipment presents a major obstacle in their application in screening campaigns.

Conclusion

The SjSAP4 + Sj23-LHD-ELISA represents a cost-effective tool for the diagnosis of schistosomiasis that could prove an important component in the monitoring of integrated control measures as elimination draws closer, whereas the ddPCR assays, in addition to their high sensitivity and specificity, are capable of quantifying infection intensity. However, the high cost of ddPCR hinders its wider application in screening programs, although it could be a valuable reference in the development and improvement of other diagnostic assays.

Schistosomiasis japonica remains prevalent in China and in the Philippines. The current changes in the epidemiological and socio-economic picture in the endemic areas makes it imperative that affordable and more sensitive field diagnostics are developed as an important component to evaluate ongoing integrated control and elimination efforts. Three diagnostic approaches, namely Kato-Katz stool microscopy, ELISA and droplet digital PCR assays, were compared by detecting infection in a cohort from schistosome-endemic areas in the Philippines. This comprehensive comparison further defined the diagnostic performance and features for each assay. Prevalence of schistosomiasis determined by the SjSAP4 + Sj23-LHD-ELISA and ddPCRs was at least 2.5 times higher than that by the KK method. The prevalence determined by the SjSAP4 + Sj23-LHD-ELISA and ddPCRs was similar, but low agreements between these assays were evident. The ddPCR assays showed considerable diagnostic performance but the high associated costs and the need for specialized equipment present major obstacles in their application in screening campaigns although they can serve as reference standards for evaluating other diagnostic assays. The SjSAP4 + Sj23-LHD-ELISA represents a cost-effective tool for the diagnosis of schistosomiasis japonica and this assay could prove an important monitoring tool to evaluate the impact of integrated control measures over time.

Asian Schistosomiasis: Current Status and Prospects for Control Leading to Elimination

Schistosomiasis is an infectious disease caused by helminth parasites of the genus Schistosoma. Worldwide, an estimated 250 million people are infected with these parasites with the majority of cases occurring in sub-Saharan Africa. Within Asia, three species of Schistosoma cause disease. Schistosoma japonicum is the most prevalent, followed by S. mekongi and S. malayensis. All three species are zoonotic, which causes concern for their control, as successful elimination not only requires management of the human definitive host, but also the animal reservoir hosts. With regard to Asian schistosomiasis, most of the published research has focused on S. japonicum with comparatively little attention paid to S. mekongi and even less focus on S. malayensis. In this review, we examine the three Asian schistosomes and their current status in their endemic countries: Cambodia, Lao People's Democratic Republic, Myanmar, and Thailand (S. mekongi); Malaysia (S. malayensis); and Indonesia, People's Republic of China, and the Philippines (S. japonicum). Prospects for control that could potentially lead to elimination are highlighted as these can inform researchers and disease control managers in other schistosomiasis-endemic areas, particularly in Africa and the Americas.

Role of ecological approaches to eliminating schistosomiasis in Eryuan County evaluated by system modelling

BACKGROUND

Schistosomiasis was severely prevalent in Yunnan Province, and it is difficult to achieve its elimination by convention approaches due to complexity of the nature. We explored the comprehensive model to eliminate schistosomiasis in Eryuan County, Yunnan Province, the People's Republic of China, through integration with the ecological protection programme in Erhai Lake, in order to promote an efficient elimination strategy. We expected that this model is able to be tailored to other local settings, which help achieve the goal of precisely eliminating the disease in Yunnan Province.

METHODS

Eryuan County of Yunnan Province was chosen as the study area, where the data on environmental protection activities in Erhai Lake and on the schistosomiasis control programme were collected through different departments of Erhai County government since 2015. System modelling was performed using system dynamics software to establish a simulation model in order to evaluate the effectiveness of intervention activities.

RESULTS

Ecological approaches to control schistosomiasis in Eryuan County consist of three major components: (i) implementing precise interventions to stop schistosomiasis transmission by means of controlling the source of infection, blocking the biological transmission chains and cutting off the route of disease transmission; (ii) employing ecological approaches to improve the co-effectiveness of environmental protection and schistosomiasis prevention in the study area; and (iii) strengthening the professional skills of personnel involving in the schistosomiasis control programme. Simulation results showed that this strategy could speed up the progress of schistosomiasis control programme moving from the control stage to the elimination stage.

CONCLUSIONS

Ecological approaches implemented in schistosomiasis endemic areas of the Eryuan region are able to improve the co-effectiveness of environmental protection and schistosomiasis control, providing a new avenue for eliminating schistosomiasis thanks to the application of precise interventions.

Effectiveness of the new integrated strategy to control the transmission of Schistosoma japonicum in China: a systematic review and meta-analysis

Since 2004, the national schistosomiasis control strategy in China has shifted from the morbidity control strategy (conventional strategy) to an integrated strategy (new strategy). We investigated the effectiveness of the new strategy and compared it against the conventional strategy. We retrieved from electronic databases the literature regarding the new strategy published from 2000 to 2017. The effect of the new or conventional strategy on infection by Schistosoma japonicum of humans and snails (Oncomelania hupensis) was evaluated with pooled log relative risk (logRR). A total of only eight eligible publications were included in the final meta-analysis. The results showed that implementation of the new strategy reduced the infection risk by 3–4 times relative to the conventional strategy. More specifically, the conventional strategy caused a reduction in both human (logRR = 0.56, 95% CI: 0.12–0.99) and snail infections (logRR = 0.34, 95% CI: −0.69–1.37), while the new strategy also significantly reduced both human (logRR = 1.89, 95% CI: 1.33–2.46) and snail infections (logRR = 1.61, 95% CI: 1.06–2.15). In contrast to the conventional strategy, the new strategy appeared more effective to control both human (logRR difference = 1.32, 95% CI: 0.78–1.86) and snail infections (logRR difference = 1.53, 95% CI: 0.76–2.31). Our data demonstrate that the new integrated strategy is highly effective to control the transmission of S. japonicum in China, and this strategy is recommended for schistosomiasis elimination in other affected regions across the world, with adaptation to local conditions.

A Spatiotemporal Analysis of Schistosomiasis in Hunan Province, China

Based on annual parasitological data recently collected at county and village levels, this article presents a multiscale spatiotemporal analysis of transmission risk of schistosomiasis japonica in Hunan Province during 2001 to 2015 in a geographic information system environment. The study shows that the incidence and prevalence rate of human Schistosoma japonicum infection in Hunan Province decreased after 2001. A spatial autocorrelation analysis reveals the existence of spatial clusters of human Schistosoma japonicum infection and a growing tendency of spatial clustering over time. The identification of high-risk areas (hot spots) helps find areas of priority for future implementation of control strategies. The research demonstrates the importance of spatial scale in public health studies.

"Farewell to the God of Plague": The Importance of Political Commitment Towards the Elimination of Schistosomiasis

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Effects of Polymorphisms in the SjSP-13 Gene of Schistosoma japonicum on Its Diagnostic Efficacy and Immunogenicity

Schistosomiasis japonica is one of the most prevalent parasitic diseases in China. The scarcity of effective diagnostic tools is a major factor that contributes to the high prevalence of schistosomiasis japonica. SjSP-13 is a promising serological diagnostic biomarker of the disease. However, it is unclear whether polymorphisms in SjSP-13 affect its diagnostic efficacy and immunogenicity. Here, we found the SjSP-13 gene was highly polymorphic, and all the alleles of the gene were clustered into two clades, clade A and B. SjSP-13.6 and SjSP-13.25, the representative alleles of clade A and B, were produced in Escherichia coli. The diagnostic value of SjSP-13.6 (AUC = 0.983 ± 0.006), was found to be similar to the SjSP-13.25 (AUC = 0.973 ± 0.009) by receiver operating characteristic (ROC) analysis. SjSP-13.6 and SjSP-13.25 have the same specificity (96.7%), while the sensitivity of SjSP-13.6 (90.4%) is slightly but not significantly higher than SjSP-13.25 (85.2%). The combination use of the two alleles (SjSP-13.6/25) didn’t increase the diagnostic performance of SjSP-13 as the AUC value of SjSP-13.6/25 is 0.977 ± 0.009, lower than individual SjSP-13.6 (AUC = 0.983 ± 0.006). In addition, we found the immunogenicity of clade A alleles is significantly higher than clade B in Schistosoma japonicum naturally infected animals and patients, as the mean antibody levels of SjSP-13.6 was significantly higher than SjSP-13.25. We conclude that polymorphisms of the SjSP-13 gene should not affect its diagnostic efficacy, and it is not necessary to combine the alleles of the two clades for diagnosis of schistosomiasis.

Schistosomiasis Japonica Control in Domestic Animals: Progress and Experiences in China

Schistosomiasis japonica, caused by Schistosoma japonicum, is an endemic, zoonotic parasitic disease. Domestic animals, particularly bovines, are thought to play an important role in transmission of the disease. Historically, China was the country mostly severely impacted by schistosomiasis japonica, but now prevalence and morbidity have been greatly reduced. Since the mid-1950s when China launched the National Schistosomiasis Control Program, the control of schistosomiasis in domestic animals has been carried out almost synchronously with that of human schistosomiasis, and this concept has been proven to be effective. Generally, the campaign of schistosomiasis japonica control in domestic animals in China went through four phases over the past six decades, namely, the large-scale epidemiological investigation phase, the case screening and small-scale chemotherapy phase, the mass chemotherapy phase, and the infection source control phase. These distinct phases were responsive to changing disease epidemiology, socioeconomic development, and technological advances, resulting in successful attainment of disease control goals.

Elimination of schistosomiasis: the tools required

Background

Historically, the target in the schistosomiasis control has shifted from infection to morbidity, then back to infection, but now as a public health problem, before moving on to transmission control. Currently, all endemic countries are encouraged to increase control efforts and move towards elimination as required by the World Health Organization (WHO) roadmap for the global control of the neglected tropical diseases (NTDs) and the WHA65.21 resolution issued by the World Health Assembly. However, schistosomiasis prevalence is still alarmingly high and the global number of disability-adjusted life years (DALYs) due to this infection has in fact increased due to inclusion of some ‘subtle’ clinical symptoms not previously counted.

Main body

There is a need to restart and improve efforts to reach the elimination goal. To that end, the first conference of the Global Schistosomiasis Alliance (GSA) Research Working Group was held in mid-June 2016 in Shanghai, People’s Republic of China. It reviewed current progress in schistosomiasis control and elimination, identified pressing operational research gaps that need to be addressed and discussed new tools and strategies required to make elimination a reality. The articles emanating from the lectures and discussions during this meeting, together with some additional invited papers, have been collected as a special issue of the ‘Infectious Diseases of Poverty’ entitled ‘Schistosomiasis Research: Providing the Tools Needed for Elimination’, consisting of 26 papers in all. This paper refers to these papers and discusses critical questions arising at the conference related to elimination of schistosomiasis.

Conclusion

The currently most burning questions are the following: Can schistosomiasis be eliminated? Does it require better, more highly sensitive diagnostics? What is the role of preventive chemotherapy at the elimination stage? Is praziquantel sufficient or do we need new drugs? Contemplating these questions, it is felt that the heterogeneity of the endemic areas in the world requires WHO policies to be upgraded instituting new, differentiated guidelines.

Electronic supplementary material

The online version of this article (doi: 10.1186/s40249-017-0370-7) contains supplementary material, which is available to authorized users.

An Integrated Control Strategy Takes Clonorchis sinensis Under Control in an Endemic Area in South China

Clonorchis sinensis is an important foodborne zoonosis worldwide and prevalent in China for more than 2000 years. According to the experience of controlling Schistosoma japonica, China started to establish the integrated control strategy for C. sinensis in endemic areas. Lou village, the largest village in Shenzhen city in South China was taken as a pilot site. This longitudinal study assessed the infection status of C. sinensis among people and intermediate hosts from 2006 to 2014 in Lou village. After a continuous intervention with the integrated control strategy, the prevalence of C. sinensis decreased significantly to 2.01% in 2014. The infection intensity also reduced significantly with eggs per gram varying from 45.6 ± 3.4 in 2010 to 21.7 ± 1.6 in 2012. There is also a statistically significant decrease of the prevalence of C. sinensis metacercariae in fish hosts from 16.51% in 2008 before the intervention to 5.33% in 2014. All the old-styled toilets were replaced by sanitary ones with a harmless processing design in 2014. No viable parasite eggs were detected in stool samples from the reconstructed toilets. Health education played an important role in changing the eating habits among the local residents, with a significant decrease in the prevalence of eating raw fish from 91.99% in 2008 to 59.87% in 2014. The evaluation suggested that the integrated strategy we have performed in Lou village is effective in controlling the C. sinensis infection and maintaining the infection rate at a lower level, which can be promoted in other endemic areas.

Study roadmap for high-throughput development of easy to use and affordable biomarkers as diagnostics for tropical diseases: a focus on malaria and schistosomiasis

BACKGROUND

Interventions are currently being used against 'infectious diseases of poverty', which remain highly debilitating and deadly in most endemic countries, especially malaria, schistosomiasis, echinococcosis and African sleeping sickness. However, major limitations of current 'traditional' methods for diagnosis are neither simple nor convenient for population surveillance, and showed low sensitivity and specificity. Access to novel technologies for the development of adequate and reliable tools are expressly needed. A collaborative project between African Network for Drugs and Diagnostics Innovation and partner institutions in Africa and China aims to screen suitable serological biomarkers for diagnostic pipelines against these 'diseases of the poor'.

METHODS

Parasite-specific exposed versus unexposed individuals were screened and sera or urine/stools were collected through case-control studies in China and African countries. Target genes/open reading frames were selected, then will be cloned and cell-free expressed, quantified and immuno-detected. Target antigens/epitopes will be probed and screened with sera from exposed or unexposed individuals using a high-throughput antigen screening platform as the study progresses. The specificity and sensitivity of highly immunoreactive biomarkers will be evaluated as well, using enzyme-linked immunosorbent assays or dipsticks.

DISCUSSION

This roadmap explicitly unfolds the integrated operating procedures with focus on malaria and schistosomiasis, for the identification of suitable biomarkers that will aid the prioritization of diagnostics for population use. However, there is need to further validate any new diagnostic through comparison with standard methods in field deployable tests for each region. Our expectations for the future are to seek regulatory approval and promote the use of diagnostics in endemic areas.

A Parallel Comparison of Antigen Candidates for Development of an Optimized Serological Diagnosis of Schistosomiasis Japonica in the Philippines

Schistosoma japonicum is stubbornly persistent in China and the Philippines. Fast and accurate diagnostic tools are required to monitor effective control measures against schistosomiasis japonica. Promising antigen candidates for the serological diagnosis of schistosomiasis japonica have generally been identified from the Chinese strain of S. japonicum. However, the Chinese (SjC) and Philippine (SjP) strains of S. japonicum express a number of clear phenotypic differences, including aspects of host immune responses. This feature thereby emphasized the requirement to determine whether antigens identified as having diagnostic value for SjC infection are also suitable for the diagnosis of SjP infection. In the current study, 10 antigens were selected for comparison of diagnostic performance of the SjP infection using ELISA. On testing of sera from 180 subjects in the Philippines, SjSAP4 exhibited the best diagnostic performance with 94.03% sensitivity and 98.33% specificity using an optimized serum dilution. In another large scale testing with 412 serum samples, a combination (SjSAP4 + Sj23-LHD (large hydrophilic domain)) provided the best diagnostic outcome with 87.04% sensitivity and 96.67% specificity. This combination could be used in future for serological diagnosis of schistosomiasis in the Philippines, thereby representing an important component for monitoring integrated control measures.

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Sj23-LHD was the most promising antigen candidate for early diagnosis of schistosomiasis japonica in a murine model.

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SjSAP4 + Sj23-LHD had the highest diagnostic value when probed with sera from a human cohort with low infection intensity.

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We have developed a novel diagnostic tool that can aid in the integrated control of schistosomiasis in the Philippines.

Schistosomiasis japonica remains a major public health concern in China and the Philippines. Development of accurate and affordable diagnostic tools is a necessity for the control and elimination of schistosomiasis. The differences in the mammalian host immunological responses to Chinese (SjC) and Philippine (SjP) strains of S. japonicum necessitated validation of proven SjC serological markers for application in the diagnosis of SjP infections. Ten antigens were selected for comparison, in ELISA, for their potential of the diagnosis of SjP infection. The results provide the basis for developing an affordable and easy-to-operate tool for the diagnosis of schistosomiasis in the Philippines.

Low Transmission to Elimination: Rural Development as a Key Determinant of the End-Game Dynamics of Schistosoma japonicum in China

Rural development has been a critical component of China’s economic miracle since the start of economic reform in the early 1980s, both benefiting from and contributing to the nation’s rapid economic growth. This development has yielded substantial improvements of public health relevance, including contributing to major reductions in schistosomiasis prevalence. The history of schistosomiasis elimination in Japan suggests that development played a dominant causal role in that nation. We argue that it is highly probable that a similar story is playing out in at least some large regions of China. In particular, we summarize evidence from Sichuan Province which supports the case that economic development has led to improvements in rural irrigation and water supply which, together with changes in crop selection and agricultural mechanization, have all contributed to sustainable reductions in the prevalence of Schistosoma japonicum. The two major factors that have experienced major reductions are the area of snail habitat and the degree of human exposure, both through a variety of mechanisms which differ by region and economic circumstance. However, hotspots of transmission remain. Overall, however, economic development in traditionally endemic areas has provided the resources to carry out projects that have had major beneficial impacts on disease transmission that are likely to be sustainable.

Interruption of schistosomiasis transmission in mountainous and hilly regions with an integrated strategy: a longitudinal case study in Sichuan, China

Background

Schistosomiasis remains a major public health concern in China. Since 2004, an integrated strategy was developed to control the transmission of Schistosoma japonicum in China. However, the long-term effectiveness of this integrated strategy for the interruption of schistosomiasis transmission remains unknown in the mountainous and hilly regions of China until now. This longitudinal study aims to evaluate the effectiveness of the integrated strategy on transmission interruption of schistosomiasis in Sichuan Province from 2005 through 2014.

Methods

The data regarding replacement of bovines with machines, improved sanitation, access to clean water, construction of public toilets and household latrines, snail control, chemotherapy, and health education were captured from the annual report of the schistosomiasis control programmes in Sichuan Province from 2005 to 2014, and S. japonicum infection in humans, bovines and snails were estimated to evaluate the effectiveness of the integrated strategy.

Results

During the 10-year period from 2005 through 2014, a total of 536 568 machines were used to replace bovines, and 3 284 333 household lavatories and 15 523 public latrines were built. Tap water was supplied to 19 116 344 residents living in the endemic villages. A total of 230 098 hm² snail habitats were given molluscicide treatment, and 357 233 hm² snail habitats received environmental improvements. There were 7 268 138 humans and 840 845 bovines given praziquantel chemotherapy. During the 10-year study period, information, education and communication (IEC) materials were provided to village officers, teachers and schoolchildren. The 10-year implementation of the integrated strategy resulted in a great reduction in S. japonicum infection in humans, bovines and snails. Since 2007, no acute infection was detected, and no schistosomiasis cases or infected bovines were identified since 2012. In addition, the snail habitats reduced by 62.39% in 2014 as compared to that in 2005, and no S. japonicum infection was identified in snails since 2007. By 2014, 88.9% of the endemic counties achieved the transmission interruption of schistosomiasis and transmission control of schistosmiasis was achieved in the whole province in 2008.

Conclusion

The government-directed and multi-department integrated strategy is effective for interrupting the transmission of schistosomiasis in the mountainous and hilly regions of China.