Road to the elimination of schistosomiasis from Asia: the journey is far from over

Mapping schistosomiasis risk in Southeast Asia: a systematic review and geospatial analysis

BACKGROUND

Schistosomiasis is a water-borne parasitic disease estimated to have infected >140 million people globally in 2019, mostly in sub-Saharan Africa. Within the goal of eliminating schistosomiasis as a public health problem by 2030 in the World Health Organization (WHO) Roadmap for neglected tropical diseases, other regions cannot be neglected. Empirical estimates of the disease burden in Southeast Asia largely remain unavailable.

METHODS

We undertook a systematic review to identify empirical survey data on schistosomiasis prevalence in Southeast Asia using the Web of Science, ScienceDirect, PubMed and the Global Atlas of Helminth Infections, from inception to 5 February 2021. We then conducted advanced Bayesian geostatistical analysis to assess the geographical distribution of infection risk at a high spatial resolution (5 × 5 km) using the prevalence, number of infected individuals and doses needed for preventive chemotherapy.

RESULTS

We identified 494 Schistosoma japonicum surveys in the Philippines and Indonesia, and 285 in Cambodia and Laos for S. mekongi. The latest estimates suggest that 225 [95% credible interval (CrI): 168-285] thousand in the endemic areas of Southeast Asian population were infected in 2018. The highest prevalence of schistosomiasis was 3.86% (95% CrI: 3.40-4.31) in Laos whereas the lowest was 0.29% in Cambodia (95% CrI: 0.22-0.36). The estimated number of praziquantel doses needed per year was 1.99 million (95% CrI: 1.92-2.03 million) for the entire population in endemic areas of Southeast Asia.

CONCLUSIONS

The burden of schistosomiasis remains far from the WHO goal and our estimates highlighted areas to target with strengthened interventions against schistosomiasis.

First bovine vaccine to prevent human schistosomiasis - a cluster randomised Phase 3 clinical trial

OBJECTIVE

Schistosomiasis is a neglected tropical parasitic disease caused by blood flukes of the genus Schistosoma. Schistosoma japonicum is zoonotic in China, the Philippines, and Indonesia, with bovines acting as major reservoirs of human infection. The primary objective of the trial was to examine the impact of a combination of human mass chemotherapy, snail control through mollusciciding, and SjCTPI bovine vaccination on the rate of human infection.

METHODS

A 5-year phase IIIa cluster randomized control trial was conducted among 18 schistosomiasis-endemic villages comprising 18,221 residents in Northern Samar, The Philippines.

RESULTS

Overall, bovine vaccination resulted in a statistically significant decrease in human infection (relative risk [RR] = 0.75; 95% confidence interval [CI] = 0.69 to 0.82) across all trial follow-ups. The best outcome of the trial was when bovine vaccination was combined with snail mollusciciding. This combination resulted in a 31% reduction (RR = 0.69; 95% CI = 0.61 to 0.78) in human infection.

CONCLUSION

This is the first trial to demonstrate the effectiveness of a bovine vaccine for schistosomiasis in reducing human schistosome infection. The trial is registered with Australian New Zealand Clinical Trials Registry (ACTRN12619001048178).

Advances in Diagnosis of Schistosomiasis: Focus on Challenges and Future Approaches

Schistosomiasis is the second most devastating parasite prevalent in the tropical region of the world, posing significant public health impacts in endemic areas. Presently, several disease mitigation measures have shown a decline in transmission of the infection rate in risk localities using mass drug administration (MDA) of school-based or community-wide treatments. Despite all the endeavors made, the decline in transmission of infection rate has not been attained in the entire medicated segment of the population. Perhaps the current challenges of control of the disease appear to be strongly associated with a lack of appropriate diagnostic tools. It's well known that the current diagnosis of schistosomiasis greatly relies on conventional methods. On the other hand, minor symptoms of schistosomiasis and low sensitivity and specificity of diagnostic methods are still unresolved diagnostic challenges to clinicians. Numerous scholars have reviewed various diagnostic methods of schistosomiasis and attempted to identify their strengths and weaknesses, currently on function. As a result of the known limitations of the existing diagnostic tools, the need to develop new and feasible diagnostic methods and diagnostic markers is unquestionable for more precise detection of the infection. Hence, advances in diagnostic methods have been considered part of the solution for the control and eventual elimination strategy of the disease in endemic areas. As of today, easy, cheap, and accurate diagnostics for schistosomiasis are difficult to get, and this limits the concerted efforts towards full control of schistosomiasis. While looking for new diagnostic methods and markers, it is important to simultaneously work on improving the existing diagnostic methods for better results. This review tries to give new insights to the status of the existing diagnostic methods of schistosomiasis from conventional to modern via summarizing the strengths and limitations of the methods. It also tries to recommend new, sensitive and feasible diagnostic methods for future approaches.

Proposed morbidity markers among Schistosoma mansoni patients

Background

Fecal calprotectin (FC) and fecal occult blood (FOB) were suggested as potential inflammatory markers for assessing intestinal schistosomiasis morbidity that are conventionally detected through invasive methods.

Aim and Objectives

The present work aimed to evaluate FC and FOB as morbidity markers of Schistosoma mansoni infection before and after praziquantel treatment.

Materials and Methods

A total of 205 stool samples (117 schoolchildren and 88 adults) were collected and examined by Kato Katz. A questionnaire enquiring about diarrhea, history of blood in stool, and abdominal pain was designed and applied.

Results

S. mansoni prevalence rates were 20.5% and 11.36% among children and adults, respectively; the majority of cases had light infection intensity. FC and FOB were studied among 25 cured S. mansoni cases (17 children and 8 adults) pre and one-month post treatment. Before treatment, six and four children of moderate and high S. mansoni infection intensity tested positive for FC and FOB, respectively, all turning negative after treatment. FC showed borderline statistical significance before and after treatment among children. However, all adults tested negative for FC and FOB.

Conclusion

FC and FOB could be possibly used as morbidity monitoring tools for S. mansoni infection in children with moderate and high infection intensity.

Comparative proteomic profiles of Schistosoma japonicum male worms derived from single-sex and bisexual infections

Schistosomiasis, which is caused by parasitic schistosomes, remains the second most prevalent parasitic disease of mammals worldwide. To successfully maintain fecundity, schistosomes have evolved a lifecycle that involves the cooperation of morphologically distinct male and female forms. Eggs produced by worm pairs are vital to the lifecycle of the parasite and are responsible for pathogenesis. Understanding the reproductive mechanism of schistosomes will help to control infection. In this study, the proteomic profiles of single-sex infected male (SM) worms and bisexual infected mated male (MM) worms of Schistosoma japonicum at 18, 21, 23, and 25 days p.i. were identified through data-independent acquisition. In total, 674 differentially expressed proteins (DEPs) were identified for the SM and MM worms at all four timepoints. Bioinformatic analysis demonstrated that most of the DEPs were involved in biosynthetic processes including locomotion, cell growth and death, cell motility, and metabolic processes such as protein metabolism and glucose metabolism. Schistosoma japonicum glycosyltransferase (SjGT) and S. japonicum nicastrin protein (SjNCSTN) were selected for quantitative real‑time PCR analysis and long-term interference with small interfering RNA (siRNA) to further explore the functions of the DEPs. Sjgt mRNA expression was mainly enriched in male worms, while Sjncstn was enriched in both sexes. siRNA against SjGT and SjNCSTN resulted in minor morphological changes in the testes of male worms and significant decreased vitality and fertility. The present study provides comprehensive proteomic profiles of S. japonicum SM and MM worms at 18, 21, 23, and 25 days p.i. and offers insights into the mechanisms underlying the growth and maturation of schistosomes.

Diagnostic performance of a urine-based ELISA assay for the screening of human schistosomiasis japonica: A comparative study

The current study developed and evaluated the performance of a urine-based enzyme-linked immunosorbent assay (ELISA) for the screening of Schistosoma japonicum infection in a human cohort (n = 412) recruited from endemic areas, Northern Samar, the Philippines. The diagnostic performance of the urine ELISA assay was further compared with the Kato-Katz (KK) technique, serum-based ELISA assays, point-of-care circulating cathodic antigen (POC-CCA) urine cassette test, and droplet digital (dd)PCR assays performed on feces, serum, urine, and saliva samples, which were designated as F_ddPCR, SR_ddPCR, U_ddPCR, and SL_ddPCR, respectively. When urine samples concentrated 16× were assessed, the SjSAP4 + Sj23-LHD-ELISA (U) showed sensitivity/specificity values of 47.2/93.8% for the detection of S. japonicum infection in KK-positive individuals (n = 108). The prevalence of S. japonicum infection in the total cohort determined by the urine ELISA assay was 48.8%, which was lower than that obtained with the F_ddPCR (74.5%, p < 0.001), SR_ddPCR (67.2%, p < 0.001), and SjSAP4 + Sj23-LHD-ELISA (S) (66.0%, p < 0.001), but higher than that determined by the Sj23-LHD-ELISA (S) (24.5%, p < 0.001), POC-CCA assay (12.4%, p < 0.001), and SL_ddPCR (25.5%, p < 0.001). Using the other diagnostic tests as a reference, the urine ELISA assay showed a sensitivity between 47.2 and 56.9%, a specificity between 50.7 and 55.2%, and an accuracy between 49.3 and 53.4%. The concentrated urine SjSAP4 + Sj23-LHD-ELISA developed in the current study was more sensitive than both the KK test and POC-CCA assay, and showed a comparable level of diagnostic accuracy to that of the U_ddPCR. However, its diagnostic performance was less robust than that of the F_ddPCR, SR_ddPCR, and SjSAP4 + Sj23-LHD-ELISA (S) assays. Although they are convenient and involve a highly acceptable non-invasive procedure for clinical sample collection, the insufficient sensitivity of the three urine-based assays (the urine ELISA assay, the U_ddPCR test, and the POC-CCA assay) will limit their value for the routine screening of schistosomiasis japonica in the post mass drug administration (MDA) era, where low-intensity infections are predominant in many endemic areas.

Diagnosis of Schistosoma infection in non-human animal hosts: A systematic review and meta-analysis

BACKGROUND

Reliable and field-applicable diagnosis of schistosome infections in non-human animals is important for surveillance, control, and verification of interruption of human schistosomiasis transmission. This study aimed to summarize uses of available diagnostic techniques through a systematic review and meta-analysis.

METHODOLOGY AND PRINCIPAL FINDINGS

We systematically searched the literature and reports comparing two or more diagnostic tests in non-human animals for schistosome infection. Out of 4,909 articles and reports screened, 19 met our inclusion criteria, four of which were considered in the meta-analysis. A total of 14 techniques (parasitologic, immunologic, and molecular) and nine types of non-human animals were involved in the studies. Notably, four studies compared parasitologic tests (miracidium hatching test (MHT), Kato-Katz (KK), the Danish Bilharziasis Laboratory technique (DBL), and formalin-ethyl acetate sedimentation-digestion (FEA-SD)) with quantitative polymerase chain reaction (qPCR), and sensitivity estimates (using qPCR as the reference) were extracted and included in the meta-analyses, showing significant heterogeneity across studies and animal hosts. The pooled estimate of sensitivity was 0.21 (95% confidence interval (CI): 0.03-0.48) with FEA-SD showing highest sensitivity (0.89, 95% CI: 0.65-1.00).

CONCLUSIONS/SIGNIFICANCE

Our findings suggest that the parasitologic technique FEA-SD and the molecular technique qPCR are the most promising techniques for schistosome diagnosis in non-human animal hosts. Future studies are needed for validation and standardization of the techniques for real-world field applications.

Comparative characterization of microRNAs of Schistosoma japonicum from SCID mice and BALB/c mice: Clues to the regulation of parasite growth and development

Schistosomiasis, caused by a parasite with a wide range of mammalian hosts, remains one of the most prevailing parasitic diseases in the world. While numerous studies have reported that the growth and reproduction of schistosomes in immunodeficient mice was significantly retarded, the underlying molecular mechanisms have yet to be revealed. In this study, we comparatively analyzed the microRNA expression of Schistosoma japonicum derived from SCID and BALB/c mice on the 35^th day post-infection by high-throughput RNA sequencing as prominent morphological abnormalities had been observed in schistosomes from SCID mice when compared with those from BALB/c mice. The results revealed that more than 72% and 61% of clean reads in the small RNA libraries of female and male schistosomes, respectively, could be mapped to the selected miRs in the miRBase or the sequences of species-specific genomes. Further analysis identified 122 miRNAs using TPM >0.01 as the threshold value, including 75 known and 47 novel miRNAs, 96 of which were commonly expressed across all the four tested schistosome libraries. Comparative analysis of the libraries of schistosomes from SCID and BALB/c mice identified 15 differentially expressed miRNAs (5 up-regulated and 10 down-regulated) among females and 16 among males (9 up-regulated and 7 down-regulated). Integrated analysis of the two sets of differentially expressed miRNAs of female and male worms identified 2 miRNAs (sja-miR-3488 and sja-miR-novel_29) that overlapped between female and male datasets. Prediction of miRNA targets and Gene Ontology (GO) term enrichment analysis of the predicted target genes revealed that these genes were involved in some important biological processes, such as nucleic acid metabolic process, macromolecule modification, and cellular aromatic compound metabolic process. The predicted target genes were further matched to the differentially expressed genes in male and female schistosomes from the above two hosts, obtaining 7 genes that may be responsible for regulating the growth, development and sex maturation of schistosomes. Taken together, this study provides the first identification of differentially expressed miRNAs in schistosomes from SCID and BALB/c mice. These miRNAs and their predicted target mRNAs are probably involved in the regulation of development, growth, and maturation of schistosomes. Therefore, this study expands our understanding of schistosome development regulation and host-parasite relationship, and also provides a valuable set of potential anti-schistosomal targets for prevention and control of schistosomiasis.

Challenges and Opportunities Presented by Current Techniques for Detecting Schistosome Infections in Intermediate Host Snails: A Scoping Review

Schistosomiasis, a neglected tropical disease (NTD), causes morbidity and mortality in over 250 million people globally. And 700 million people are at risk of contracting it. It is caused by a parasite of the genus Schistosoma. Freshwater snails of the family Planorbidae are of public health significance as they are intermediate hosts of these highly infective flukes. Accurate diagnostic techniques to detect schistosome infections in intermediate host snails (IHS) and environmental surveillance are needed to institute measures for the interruption of transmission and eventual elimination. We carried out a systematic review of the literature to assess advantages and limitations of different diagnostic techniques for detecting schistosome infections in snails. Literature from Scopus, Web of Science, and PubMed databases from 2008 to 2020 were searched using combinations of predefined search terms with Boolean operators. The studies revealed that conventional diagnostics are widely used, although they are labor-intensive, have low specificity and sensitivity levels, and cannot detect prepatent infections. Whereas more advanced techniques such as immunological, nucleic-acid amplification, and eDNA diagnostics have high sensitivity and specificity levels, they are costly, hence, not suitable for field applications and large-scale surveys. Our review highlights the importance of designing and developing innovative diagnostics that are high in specificity and sensitivity as well as affordable and technically feasible for use in field laboratories and for large-scale surveys.

Economic evaluations of human schistosomiasis interventions: a systematic review and identification of associated research needs

Background: Schistosomiasis is one of the most prevalent neglected tropical diseases (NTDs) with an estimated 229 million people requiring preventive treatment worldwide. Recommendations for preventive chemotherapy strategies have been made by the World Health Organization (WHO) whereby the frequency of treatment is determined by the settings prevalence. Despite recent progress, many countries still need to scale up treatment and important questions remain regarding optimal control strategies. This paper presents a systematic review of the economic evaluations of human schistosomiasis interventions. Methods: A systematic review of the literature was conducted on 22nd August 2019 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. The focus was economic evaluations of schistosomiasis interventions, such as cost-effectiveness and cost-benefit analyses. No date or language stipulations were applied to the searches. Results: We identified 53 relevant health economic analyses of schistosomiasis interventions. Most studies related to Schistosoma japonicum followed by S. haematobium. Several studies also included other NTDs. In Africa, most studies evaluated preventive chemotherapy, whereas in China they mostly evaluated programmes using a combination of interventions (such as chemotherapy, snail control and health education). There was wide variation in the methodology and epidemiological settings investigated. A range of effectiveness metrics were used by the different studies. Conclusions: Due to the variation across the identified studies, it was not possible to make definitive policy recommendations. Although, in general, the current WHO recommended preventive chemotherapy approach to control schistosomiasis was found to be cost-effective. This finding has important implications for policymakers, advocacy groups and potential funders. However, there are several important inconsistencies and research gaps (such as how the health benefits of interventions are quantified) that need to be addressed to identify the resources required to achieve schistosomiasis control and elimination.

Prevalence of strongyloidiasis and schistosomiasis among migrants: a systematic review and meta-analysis

BACKGROUND

Global migration from regions where strongyloidiasis and schistosomiasis are endemic to non-endemic countries has increased the potential individual and public health effect of these parasitic diseases. We aimed to estimate the prevalence of these infections among migrants to establish which groups are at highest risk and who could benefit from screening.

METHODS

We did a systematic review and meta-analysis of strongyloidiasis and schistosomiasis prevalence among migrants born in endemic countries. Original studies that included data for the prevalence of Strongyloides or Schistosoma antibodies in serum or the prevalence of larvae or eggs in stool or urine samples among migrants originating from countries endemic for these parasites and arriving or living in host countries with low endemicity-specifically the USA, Canada, Australia, New Zealand, Israel, and 23 western European countries-were eligible for inclusion. Pooled estimates of the prevalence of strongyloidiasis and schistosomiasis by stool or urine microscopy for larvae or eggs or serum antibodies were calculated with a random-effects model. Heterogeneity was explored by stratification by age, region of origin, migrant class, period of study, and type of serological antigen used.

FINDINGS

88 studies were included. Pooled strongyloidiasis seroprevalence was 12·2% (95% CI 9·0-15·9%; I² 96%) and stool-based prevalence was 1·8% (1·2-2·6%; 98%). Migrants from east Asia and the Pacific (17·3% [95% CI 4·1-37·0]), sub-Saharan Africa (14·6% [7·1-24·2]), and Latin America and the Caribbean (11·4% [7·8-15·7]) had the highest seroprevalence. Pooled schistosomiasis seroprevalence was 18·4% (95% CI 13·1-24·5; I² 97%) and stool-based prevalence was 0·9% (0·2-1·9; 99%). Sub-Saharan African migrants had the highest seroprevalence (24·1·% [95% CI 16·4-32·7]).

INTERPRETATION

Strongyloidiasis affects migrants from all global regions, whereas schistosomiasis is focused in specific regions and most common among sub-Saharan African migrants. Serological prevalence estimates were several times higher than stool estimates for both parasites. These data can be used to inform screening decisions for migrants and support the use of serological screening, which is more sensitive and easier than stool testing.

FUNDING

None.

Economic evaluations of human schistosomiasis interventions: a systematic review and identification of associated research needs

Background: Schistosomiasis is one of the most prevalent neglected tropical diseases (NTDs) with an estimated 229 million people requiring preventive treatment worldwide. Recommendations for preventive chemotherapy strategies have been made by the World Health Organization (WHO) whereby the frequency of treatment is determined by the settings prevalence. Despite recent progress, many countries still need to scale up treatment and important questions remain regarding optimal control strategies. This paper presents a systematic review of the economic evaluations of human schistosomiasis interventions. Methods: A systematic review of the literature was conducted on 22nd August 2019 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. The focus was economic evaluations of schistosomiasis interventions, such as cost-effectiveness and cost-benefit analyses. No date or language stipulations were applied to the searches. Results: We identified 53 relevant health economic analyses of schistosomiasis interventions. Most studies related to Schistosoma japonicum followed by S. haematobium. Several studies also included other NTDs. In Africa, most studies evaluated preventive chemotherapy, whereas in China they mostly evaluated programmes using a combination of interventions (such as chemotherapy, snail control and health education). There was wide variation in the methodology and epidemiological settings investigated. A range of effectiveness metrics were used by the different studies. Conclusions: Due to the variation across the identified studies, it was not possible to make definitive policy recommendations. Although, in general, the current WHO recommended preventive chemotherapy approach to control schistosomiasis was found to be cost-effective. This finding has important implications for policymakers, advocacy groups and potential funders. However, there are several important inconsistencies and research gaps (such as how the health benefits of interventions are quantified) that need to be addressed to identify the resources required to achieve schistosomiasis control and elimination.

Comparative Transcriptome Analyses of Schistosoma japonicum Derived From SCID Mice and BALB/c Mice: Clues to the Abnormality in Parasite Growth and Development

Schistosomiasis, caused by the parasitic flatworms called schistosomes, remains one of the most prevailing parasitic diseases in the world. The prodigious oviposition of female worms after maturity is the main driver of pathology due to infection, yet our understanding about the regulation of development and reproduction of schistosomes is limited. Here, we comparatively profiled the transcriptome of Schistosoma japonicum recovered from SCID and BALB/c mice, which were collected 35 days post-infection, when prominent morphological abnormalities could be observed in schistosomes from SCID mice, by performing RNA-seq analysis. Of the 11,183 identified genes, 62 differentially expressed genes (DEGs) with 39 upregulated and 23 downregulated messenger RNAs (mRNAs) were found in male worms from SCID mice (S_M) vs. male worms from BALB/c mice (B_M), and 240 DEGs with 152 upregulated and 88 downregulated mRNAs were found in female worms from SCID mice (S_F) vs. female worms from BALB/c mice (B_F). We also tested nine DEGs with a relatively higher expression abundance in the gonads of the worms (ovary, vitellaria, or testis), suggesting their potential biological significance in the development and reproduction of the parasites. Gene ontology (GO) enrichment analysis revealed that GO terms such as “microtubule-based process,” “multicellular organismal development,” and “Rho protein signal transduction” were significantly enriched in the DEGs in S_F vs. B_F, whereas GO terms such as “oxidation–reduction process,” “response to stress,” and “response to DNA damage stimulus” were significantly enriched in the DEGs in S_M vs. B_M. These results revealed that the differential expression of some important genes might contribute to the morphological abnormalities of worms in SCID mice. Furthermore, we selected one DEG, the mitochondrial prohibitin complex protein 1 (Phb1), to perform double-stranded RNA (dsRNA)-mediated RNA interference (RNAi) in vivo targeting the worms in BALB/c mice, and we found that it was essential for the growth and reproductive development of both male and female S. japonicum worms. Taken together, these results provided a wealth of information on the differential gene expression profiles of schistosomes from SCID mice when compared with those from BALB/c mice, which were potentially involved in regulating the growth and development of schistosomes. These findings contributed to an understanding of parasite biology and provided a rich resource for the exploitation of antischistosomal intervention targets.

Identification of linear epitopes in SjSP-13 of Schistosoma japonicum using a GST-peptide fusion protein microplate array

Background

The identification and characterization of epitopes facilitate the discovery and development of new therapeutics, vaccines and diagnostics for infectious diseases. In this study, we developed a glutathione S-transferase (GST)-peptide fusion protein microplate array for the identification of linear B-cell epitopes and applied this novel method to the identification of linear B-cell epitopes of SjSP-13, an immunodiagnostic biomarker of schistosomiasis japonica.

Methods

SjSP-13 was divided into 17 overlapped peptides (p1-17), and the coding sequence of each peptide was obtained by annealing two complementary oligonucleotides. SjSP-13 peptides were expressed by fusion with an N-terminal GST tag and a C-terminal 6xHis tag. The GST-peptide-His fusion protein was specifically bound to the Immobilizer Glutathione MicroWell 96-well plates without purification. SjSP-13 peptides and core epitopes that could be recognized by sera from schistosomiasis patients were identified by ELISA and confirmed by Western blot analysis. The receiver operating characteristic (ROC) analysis was performed to determine the diagnostic validity of the identified peptide.

Results

Full-length GST-peptide-His fusion proteins were successfully expressed and specifically bound to the Immobilizer Glutathione MicroWell 96-well plates. Two adjacent peptides (p7 and p8) were found to be highly immunogenic in humans. The core epitope of p7 and p8 is an 11-aa peptide (₈₀KCLDVTDNLPE₉₀) and an 8-aa peptide (₉₀EKIIQFAE₉₇), respectively. The area under the ROC curve (AUC) value of the peptide which contains the two identified epitopes is 0.947 ± 0.019. The diagnostic sensitivity and specificity of the peptide is 76.7% (95% CI: 68.8–84.5%) and 100%, respectively.

Conclusions

₉₀EKIIQFAE₉₇ and ₈₀KCLDVTDNLPE₉₀ are the two linear epitopes of SjSP-13 recognized by patient sera, and could be potential serological markers for schistosomiasis japonica.

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.

Knowledge, attitudes and practices related to schistosomiasis transmission and control in Leyte, Philippines

Schistosomiasis is a chronic but preventable disease that affects 260 million people worldwide. In the Philippines, 860,000 people are afflicted with Schistosoma japonicum annually, and another 6.7 million live in endemic areas. The disease’s complex epidemiology as well as the influence of poverty in endemic areas demand an integrated, multi-sectoral approach to disease control. Results from behavioral or sociocultural studies on schistosomiasis could improve the content and impact of schistosomiasis control in rural villages in the Philippines. We investigated knowledge, attitudes and practices related to schistosomiasis transmission and control in an endemic village in Leyte Province, Philippines. We administered a questionnaire to 219 participants covering 1) knowledge and attitudes related to schistosomiasis, its symptoms, and its transmission; 2) attitudes and practices in relation to schistosomiasis prevention; 3) willingness to comply with public health control programs; and 4) whether the respondent had previously contracted schistosomiasis. Responses revealed fairly high measures of schistosomiasis knowledge (mean 17.0 out of 23 questions, range 6–23), but also inconsistent disease prevention behavior. A high proportion of participants (72.6%, n = 159) reported previous disease. Participant belief in the preventability of schistosomiasis was revealed to be a key attitude, as carabao owners who believed in prevention were over five times more likely to be willing to vaccinate their carabaos (OR = 5.24, 95% CI 1.20–27.68, P = 0.04). Additionally, participants who did not believe in prevention were about twice as likely to report previous disease (OR = 2.31, 95% CI 1.02–5.63, P = 0.05). Our results suggest that future public health interventions should address barriers to disease-preventing behavior, as well as maintaining community belief in disease prevention. Comprehensive disease control programs should be supplemented by sociocultural and behavioral context in order to improve their impact in endemic communities.

Schistosomiasis is a chronic tropical disease caused by parasitic worms of the genus Schistosoma. In the Philippines, Schistosoma japonicum afflicts over 800,000 people annually, and another 6.7 million live in endemic areas. The current national control program based on human mass treatment has been unable to eliminate schistosomiasis on its own. This is in part due to the poverty of endemic areas as well as the parasite’s complex life cycle, which includes transmission by freshwater snails and livestock. A more comprehensive disease control strategy would include periodic treatment and vaccination of the widely used domestic water buffalo or carabao. Sociocultural and behavioral research would also inform and improve the impact of future control programs. To this end, we investigated knowledge, attitudes, and practices related to schistosomiasis in an endemic village in Leyte, Philippines. We found high levels of disease knowledge and awareness, but also inconsistencies in disease prevention habits. Belief in whether schistosomiasis could be prevented was important in this community, associated with previous disease experience as well as receptivity to new strategies like livestock vaccination. This kind of social context is vital to future public health campaigns, and highlights the importance of cross-disciplinary work to achieve successful disease control.

Comparative analysis of microRNA expression profiles of adult Schistosoma japonicum isolated from water buffalo and yellow cattle

BACKGROUND

Yellow cattle and water buffalo are important natural reservoir hosts and the main transmission sources of Schistosoma japonicum in endemic areas of China. The worms from the two hosts have marked differences in general worm morphology and ultrastructure, gene transcription and protein expression profiles.

RESULTS

To investigate microRNAs (miRNAs) involved in the regulation of schistosome development and survival, we compared miRNA expression profiles of adult schistosomes derived from yellow cattle and water buffalo by using high-throughput sequencing with Illumina Hiseq Xten. Schistosoma japonicum from water buffalo and yellow cattle yielded 63.78 million and 63.21 million reads, respectively, of which nearly 50% and 49% could be mapped to selected miRNAs in miRbase. A total of 206 miRNAs were identified, namely 79 previously annotated miRNAs of S. japonicum and 127 miRNAs that matched with the S. japonicum genome and were highly similar to the annotated miRNAs from other organisms. Among the 79 miRNAs, five (sja-miR-124-3p, sja-miR-219-5p, sja-miR-2e-3p, sja-miR-7-3p and sja-miR-3490) were significantly upregulated in the schistosomes from water buffalo compared with those from yellow cattle. A total of 268 potential target genes were predicted for these five differentially expressed miRNAs. Eleven differentially expressed targets were confirmed by qRT-PCR among 15 tested targets, one of which was further validated through dual-luciferase reporter assay. Among the 127 'possible' S. japonicum miRNAs, ten were significantly differentially expressed in the schistosomes from these two hosts.

CONCLUSIONS

These results highlight the important roles of miRNAs in regulating the development and survival of schistosomes in water buffalo and yellow cattle and facilitate understanding of the miRNA regulatory mechanisms in schistosomes derived from different susceptible hosts.

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.

Mmu-miR-92a-2-5p targets TLR2 to relieve Schistosoma japonicum-induced liver fibrosis

According to conservative estimates, >230 million people are infected with schistosomiasis,which becomes one of the most common parasitic diseases. This study focuses on investigating in vivo and in vitro effects of mmu-miR-92a-2-5p in Schistosoma japonicum-induced liver fibrosis by targeting TLR2. Through bioinformatic analysis, the overexpression of TLR2 and the down-regulation of mmu-miR-92a-2-5p were revealed in the progression of S. japonicum-induced liver fibrosis. BALB/C mice were taken advantage to construct normal control and schistosomiasis liver fibrosis (SLF) model. The mice in model groups were transfected recombinant lentivirus (Lenti-mmu-miR-92a-2-5p or Lenti-NC) to alter the expression of mmu-miR-92a-2-5p in vivo. HE and Masson staining were employed to observe the pathological changes and collagenous fibrosis. QRT-PCR showed that mmu-miR-92a-2-5p was decreased while TLR2 was elevated in the infected groups. However, lenti-mmu-miR-92a-2-5p group could inhibit liver fibrosis. Then the effect of mmu-miR-92a-2-5p on S. japonicum-induced liver fibrosis including cell apoptosis rates, proliferation and proteins related to liver fibrosis was examined in NIH-3T3 mouse embryonic fibroblasts. Moreover, the association between mmu-miR-92a-2-5p and TLR2 was detected by dual-luciferase reporter gene assay and the expression of cytokines IL-4, IFN-γ and TNF-α in SLF model was detected by ELISA. Further, the knockout of TLR2 in C57BL/6J mice was used to confirm the association between mmu-miR-92a-2-5p and TLR2. Thus, these findings demonstrated that mmu-miR-92a-2-5p inhibited S. japonicum-induced liver fibrosis by targeting TLR2 in vitro and in vivo.

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.

DNA Diagnostics for Schistosomiasis Control

Despite extensive efforts over the last few decades, the global disease burden of schistosomiasis still remains unacceptably high. This could partly be attributed to the lack of accurate diagnostic tools for detecting human and animal schistosome infections in endemic areas. In low transmission and low prevalence areas where schistosomiasis elimination is targeted, case detection requires a test that is highly sensitive. Diagnostic tests with low sensitivity will miss individuals with low infection intensity and these will continue to contribute to transmission, thereby interfering with the efficacy of the control measures operating. Of the many diagnostic approaches undertaken to date, the detection of schistosome DNA using DNA amplification techniques including polymerase chain reaction (PCR) provide valuable adjuncts to more conventional microscopic and serological methods, due their accuracy, high sensitivity, and the capacity to detect early pre-patent infections. Furthermore, DNA-based methods represent important screening tools, particularly in those endemic areas with ongoing control where infection prevalence and intensity have been reduced to very low levels. Here we review the role of DNA diagnostics in the path towards the control and elimination of schistosomiasis.

Mass drug administration and the sustainable control of schistosomiasis: an evaluation of treatment compliance in the rural Philippines

Background

Preventive chemotherapy is the current global control strategy for schistosomiasis. The WHO target coverage rate is at least 75% for school-aged children. In the Philippines, the reported national coverage rate (43.5%) is far below the WHO target. This study examined the factors associated with non-compliance to mass drug administration.

Methods

A cross-sectional survey was conducted in 2015 among 2189 adults in the province of Northern Samar, the Philippines using a structured face-to-face survey questionnaire.

Results

The overall rate of non-compliance to mass drug administration (MDA) in the last treatment round was 27%. Females (aOR = 1.67, P = 0.033) were more likely to be non-compliant. Respondents who believed that schistosomiasis was acquired by open defecation and poor sanitation (aOR = 1.41, P = 0.015), and by drinking unclean water (aOR = 2.09, P = 0.001) were more likely to refuse treatment. Uncertainties on whether schistosomiasis can be treated (aOR = 2.39, P = 0.033), their fear of adverse reactions to praziquantel (aOR = 1.94, P = 0.021), misconceptions about alternative forms of treatment (aOR = 1.45, P = 0.037), and that praziquantel is used for purposes other than deworming (aOR = 2.15, P = 0.021) were all associated with a higher odd of non-compliance. In contrary, being a farmer (aOR = 0.62, P =0.038), participation in past MDA (aOR = 0.30, P < 0.001), informed about impending MDA (aOR = 0.08, P < 0.001), and having heard of schistosomiasis (aOR = 0.22, P = 0.045) were all significantly associated with reduced non-compliance.

Conclusions

To improve drug compliance for schistosomiasis there is an urgent need for intensive health education campaigns before conducting MDA that would not only provide disease specific information, but also deal with prevailing misconceptions about transmission, prevention, treatment, and drug side-effects.

Mass drug administration and the global control of schistosomiasis: successes, limitations and clinical outcomes

PURPOSE OF REVIEW

Preventive chemotherapy is advocated for the global control and elimination of schistosomiasis. Despite the well known short-term benefits of treating patients for schistosomiasis, the impact of mass drug administration (MDA) campaigns to control the disease in the long term remains unresolved.

RECENT FINDINGS

Many studies have advocated the success of MDA programs in order to attract donor funds for elimination efforts but such successes are often short-lived given the drug does not alter the life cycle of the organism or prevent reinfection. Within a matter of months to years after halting treatment, the prevalence, intensity of infection and morbidity of disease return to baseline levels. Other mitigating factors contribute to the failings of MDA campaigns namely: poverty, poor drug coverage, poor drug compliance, and, in the case of Asiatic schistosomiasis, zoonotic transmission. Genetic and innate and acquired immunologic mechanisms complicate the epidemiologic picture of schistosomiasis globally, and may contribute indirectly to MDA shortcomings. The possibility of drug resistance is an ever present concern because of the sole reliance on one drug, praziquantel.

SUMMARY

Preventive chemotherapy is advocated for the global control and elimination of schistosomiasis. The short-term benefits of MDA campaigns are well documented but the long-term benefits are questionable.

Evaluation of Schistosoma japonicum thioredoxin peroxidase-1 as a potential circulating antigen target for the diagnosis of Asian schistosomiasis

Asian schistosomiasis caused by Schistosoma japonicum is a serious zoonotic disease endemic in China, the Philippines and parts of Indonesia. Mass drug administration in endemic areas resulted to decline in disease severity and intensity. The low intensity of infection limits the use of current parasitological methods for schistosomiasis diagnosis. Detection of parasite circulating antigens might provide more informative result as it may indicate the true status of infection. In this study, S. japonicum thioredoxin peroxidase-1 (SjTPx-1) a 22 kDa secreted antioxidant enzyme expressed throughout the life stages of the parasite was evaluated for its potential use as a biomarker for schistosomiasis japonica infection. Rabbit polyclonal antibody and mouse monoclonal antibodies (mAbs) were raised against the recombinant SjTPx-1 (rSjTPx-1). The antibodies produced against the recombinant antigen was confirmed to detect the native SjTPx-1 in crude adult worm lysate. Likewise, the specific binding of mAbs to parasite TPx-1 and not to mammalian peroxiredoxin-1 orthologues was also confirmed. The double antibody sandwich ELISA developed in this study was able to detect at least 1 ng/ml of rSjTPx-1. In addition, this method was able to detect the antigen from all serum samples of experimentally infected rabbit and mice. The diagnostic potential of SjTPx-1 in human clinical samples was also evaluated, in which 4 out of 10 stool-confirmed serum samples had detectable levels of the antigen. The results suggest that SjTPx-1 can be a potential biomarker for Asian zoonotic schistosomiasis.

Village-based spatio-temporal cluster analysis of the schistosomiasis risk in the Poyang Lake Region, China

Background

The Poyang Lake Region, one of the major epidemic sites of schistosomiasis in China, remains a severe challenge. To improve our understanding of the current endemic status of schistosomiasis and to better control the transmission of the disease in the Poyang Lake Region, it is important to analyse the clustering pattern of schistosomiasis and detect the hotspots of transmission risk.

Results

Based on annual surveillance data, at the village level in this region from 2009 to 2014, spatial and temporal cluster analyses were conducted to assess the pattern of schistosomiasis infection risk among humans through purely spatial (Local Moran’s I, Kulldorff and Flexible scan statistic) and space-time scan statistics (Kulldorff). A dramatic decline was found in the infection rate during the study period, which was shown to be maintained at a low level. The number of spatial clusters declined over time and were concentrated in counties around Poyang Lake, including Yugan, Yongxiu, Nanchang, Xingzi, Xinjian, De’an as well as Pengze, situated along the Yangtze River and the most serious area found in this study. Space-time analysis revealed that the clustering time frame appeared between 2009 and 2011 and the most likely cluster with the widest range was particularly concentrated in Pengze County.

Conclusions

This study detected areas at high risk for schistosomiasis both in space and time at the village level from 2009 to 2014 in Poyang Lake Region. The high-risk areas are now more concentrated and mainly distributed at the river inflows Poyang Lake and along Yangtze River in Pengze County. It was assumed that the water projects including reservoirs and a recently breached dyke in this area were partly to blame. This study points out that attempts to reduce the negative effects of water projects in China should focus on the Poyang Lake Region.

Early detection of circulating DNA of Schistosoma japonicum in sentinel mice models

Currently in China, the schistosomiasis control program has shifted its focus from transmission control to the elimination of the disease. Effective forecast and surveillance systems of schistiosomiasis are of great importance for issuing timely and early warnings on risk of infection, and therefore implementing preventive measures to avoid infection. There is great demand in more sensitive and specific methods to improve the surveillance system for early detection of S. japonicum infection in sentinel mice. In this study, we reported a sensitive nested-PCR assay targeting a 303-bp fragment from highly repetitive retrotransposon SjCHGCS19 to detect the S. japonicum DNA in sera of experimental mice. Meanwhile, detection efficacy of the nested-PCR was compared with two conventional methods for field monitoring schistosomiasis such as ELISA and IHA. The nested-PCR assay could detect the specific DNA at 3-day post-infection in sera of mice with 5 cercariae infection, while for ELISA and IHA, both show negative results even after 2 weeks post-infection in mice with 20 cercariae infection. Our results demonstrated the DNA-based assay was more sensitive to make early diagnosis of S. japonicum infection in sentinel mice models, which will improve the early-warning ability of schistosomiasis surveillance system.

Antischistosomiasis Liver Fibrosis Effects of Chlorogenic Acid through IL-13/miR-21/Smad7 Signaling Interactions In Vivo and In Vitro

This study investigated the antischistosomiasis liver fibrosis effects of chlorogenic acid (CGA) on interleukin 13 (IL-13)/microRNA-21 (miR-21)/Smad7 signaling interactions in the hepatic stellate LX2 cell line and schistosome-infected mice. The transfection was based on the ability of the GV273-miR-21-enhanced green fluorescent protein (EGFP) and GV369-miR-21-EGFP lentiviral system to up- or downregulate the miR-21 gene in LX2 cells. The mRNA expression of miR-21, Smad7, and connective tissue growth factor (CTGF) and the protein expression of Smad7, CTGF, Smad1, phosphor-Smad1 (p-Smad1), Smad2, p-Smad2, Smad2/3, p-Smad2/3, transforming growth factor β (TGF-β) receptor I, and α-smooth muscle actin (α-SMA) was assayed. Pathological manifestation of hepatic tissue was assessed for the degree of liver fibrosis in animals. The results showed that CGA could inhibit the mRNA expression of miR-21, promote Smad7, and inhibit CTGF mRNA expression. Meanwhile, CGA could significantly lower the protein levels of CTGF, p-Smad1, p-Smad2, p-Smad2/3, TGF-β receptor I, and α-SMA and elevate the Smad7 protein level. In vivo, with treatment with CGA, the signaling molecules of IL-13/miR-21/Smad7 interactions were markedly regulated. CGA could also reduce the degree of liver fibrosis in pathological manifestations. In conclusion, CGA could inhibit schistosomiasis-induced hepatic fibrosis through IL-13/miR-21/Smad7 signaling interactions in LX2 cells and schistosome-infected mice and might serve as an antifibrosis agent for treating schistosomiasis liver fibrosis.

Risk of human helminthiases: geospatial distribution and targeted control

OBJECTIVES

We conducted a cross-sectional survey in 2012 among 22 rural barangays in Northern Samar, the Philippines in order to determine the prevalence of single and multiple species helminth infections, their geospatial distribution and underlying risk factors.

METHODS

A total of 10,434 individuals who had completed both a medical questionnaire and a stool examination were included in the analysis. Barangay specific prevalence rates were displayed in ArcMap.

RESULTS

The prevalence of Trichuris trichiura infection was found to be the highest at 62.4%, followed by Ascaris lumbricoides, hookworm and S. japonicum with the prevalence rates of 40.2%, 31.32%, and 27.1%, respectively. 52.7% of people were infected with at least two parasites and 4.8% with all four parasites. Males aged 10-19 years were the most vulnerable to coinfection infection. Students, fishermen, farmers and housewives were the most vulnerable occupations for co-infection of A. lumbricoides and T. trichiura. Considerable heterogeneity in the spatial distribution was observed for the different parasite species. There was a considerably higher risk of A. lumbricoides and T. trichiura co-infection in villages with no schistosomiasis infection (P<0.0001) regardless of MDA treatment.

CONCLUSIONS

A better understanding of the geospatial distribution of multi-parasitism will guide future integrated strategies leading to elimination.

Diagnosing schistosomiasis-induced liver morbidity: implications for global control

BACKGROUND

Subclinical morbidity due to schistosomiasis was evaluated in 565 patients, and the enhanced liver fibrosis (ELF) test was assessed for the first time as a potential screening tool for disease.

METHODS

The prevalence and intensity of infection were determined by Kato-Katz thick smear stool examination at baseline and 2 years after curative treatment. The degree of hepatic fibrosis was assessed by ultrasound. Non-invasive serum biomarkers of hepatic fibrosis were also evaluated.

RESULTS

The baseline human prevalence and infection intensity were found to be moderately high at 34% and 123 eggs per gram, respectively. However, hepatic parenchymal fibrosis occurred in 50% of subjects, with grade II fibrosis in 19% and grade III in 6%. The ELF score and higher serum levels of tissue inhibitor of metalloproteinase 1 (TIMP-1) and hyaluronic acid (HA) correlated with the grade of liver fibrosis.

CONCLUSIONS

The findings of this study demonstrated that praziquantel treatment had a short-term impact on both the prevalence and intensity of infection, but less of an impact on established morbidity. Higher TIMP-1 and HA serum levels, and an ELF cut-off score of 8 were found to be correlated with the grade of liver fibrosis; these values may, therefore, assist physicians in identifying individuals at greater risk of disease.

Risk factors for human helminthiases in rural Philippines

BACKGROUND

A cross-sectional survey was performed in 2012 among 18 rural barangays in Northern Samar, the Philippines in order to determine the prevalence of single and multiple species helminth infections and the underlying risk factors of acquiring one or more parasites.

METHODS

A total of 6976 participants who completed a medical questionnaire and provided a stool sample for examination were included in the final analysis.

RESULTS

The overall prevalence rates of Schistosoma japonicum, Ascaris lumbricoides, Trichuris trichiura, and hookworm were found to be moderate to high at 28.9%, 36.5%, 61.8%, and 28.4%, respectively. However, the prevalence of harbouring any of the helminths was found to be higher at 75.6%. Significant variation was evident among the predicted barangay-specific random effects for infection with S. japonicum (barangay variance of 0.66, 95% confidence interval 0.31-1.40) and for any helminth infection (barangay variance of 0.63, 95% confidence interval 0.30-1.29). The predictive models showed, with greater than 80% sensitivity and specificity, that low socio-economic status, low levels of education, poor sanitation, proximity to water sources, occupation (i.e., farming and fishing), and male sex were all reliable indicators of infection status.

CONCLUSIONS

This study will aid in the targeting of limited resources for national treatment and WASH (water, sanitation, and hygiene) efforts in low- and middle-income countries.

Schistosomiasis vaccines: where do we stand?

Schistosomiasis, caused mainly by S. mansoni, S. haematobium and S. japonicum, continues to be a serious tropical disease and public health problem resulting in an unacceptably high level of morbidity in countries where it is endemic. Praziquantel, the only drug currently available for treatment, is unable to kill developing schistosomes, it does not prevent re-infection and its continued extensive use may result in the future emergence of drug-resistant parasites. This scenario provides impetus for the development and deployment of anti-schistosome vaccines to be used as part of an integrated approach for the prevention, control and eventual elimination of schistosomiasis. This review considers the present status of candidate vaccines for schistosomiasis, and provides some insight on future vaccine discovery and design.

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

Schistosomiasis japonica is caused by the parasitic trematode Schistosoma japonicum. It is endemic in The People's Republic of China and has significant impact on human health and socioeconomic development in certain regions. Over the last six decades, the national control programmes evolved in remarkable ways and brought schistosomiasis japonica largely under control. We describe the history and evolution of schistosomiasis control in The People's Republic of China, with an emphasis on shifts in control strategies that evolved with new insights into the biology of the parasite and its intermediate hosts, and the epidemiology of the disease in the country. We also highlight the achievements in controlling the disease in different socioecological settings, and identify persisting challenges to fully eliminate schistosomiasis japonica from the country. To reach the goal of schistosomiasis elimination, further integration of interventions, multisector collaboration, sensitive and effective surveillance are needed to strengthen.

China-Africa and China-Asia Collaboration on Schistosomiasis Control: A SWOT Analysis

Schistosomiasis, a disease caused by a trematode, parasitic worm, is a worldwide public health problem. In spite of great progress with regard to morbidity control, even elimination of this infection in recent decades, there are still challenges to overcome in sub-Saharan Africa and endemic areas in Southeast Asia. Regarded as one of the most successful countries with respect to schistosomiasis control, The People's Republic of China has accumulated considerable experience and learnt important lessons in various local settings that could benefit schistosomiasis control in other endemic countries. Based on an analysis of conceived strengths, weaknesses, opportunities and threats (SWOT) of potential collaborative activities with regard to schistosomiasis in Africa and Asia, this article addresses the importance of collaborative efforts and explores the priorities that would be expected to facilitate the transfer of Chinese experience to low- and middle-income countries in Africa and Asia.

Advances in the Diagnosis of Human Schistosomiasis

Schistosomiasis is a major neglected tropical disease that afflicts more than 240 million people, including many children and young adults, in the tropics and subtropics. The disease is characterized by chronic infections with significant residual morbidity and is of considerable public health importance, with substantial socioeconomic impacts on impoverished communities. Morbidity reduction and eventual elimination through integrated intervention measures are the focuses of current schistosomiasis control programs. Precise diagnosis of schistosome infections, in both mammalian and snail intermediate hosts, will play a pivotal role in achieving these goals. Nevertheless, despite extensive efforts over several decades, the search for sensitive and specific diagnostics for schistosomiasis is ongoing. Here we review the area, paying attention to earlier approaches but emphasizing recent developments in the search for new diagnostics for schistosomiasis with practical applications in the research laboratory, the clinic, and the field. Careful and rigorous validation of these assays and their cost-effectiveness will be needed, however, prior to their adoption in support of policy decisions for national public health programs aimed at the control and elimination of schistosomiasis.

The expression of molecule CD28 and CD38 on CD4⁺/CD8⁺ T lymphocytes in thymus and spleen elicited by Schistosoma japonicum infection in mice model

Schistosomiasis caused by human schistosomes such as Schistosoma japonicum (S. japonicum) is considered as an immune-related disease. It was demonstrated that specific cytokine antibodies' response elicited by S. japonicum infection was gradually downregulated with the progress of the disease, resulting in a Th1/Th2 polarization and suppression of immune response. CD28 (cluster of differentiation 28) is one of the proteins expressed on T cells that provide co-stimulatory signals required for T cell activation and survival, and CD38 is an activating marker of T lymphocyte with high expression in many acute or chronic infections. The immune signature of CD28null T cells in the peripheral circulation associates with chronic inflammation in many diseases, such as HIV and CMV infection. In the thymus, CD28 expression on developing thymocytes appears to play a role for their selection, and it synergizes with CD38 to induce apoptosis of DP (double-positive) thymocytes. Few reports about CD28 and CD38 have been published in schistosomiasis. Here, we investigated the dynamic patterns of the expression of molecules CD28 and CD38 on CD4(+)/CD8(+) T lymphocytes of the thymus and spleen in mice model with S. japonicum infection. Our data indicated that at an early period of infection, the frequency of CD8(+)CD28(-) T cell in the spleen decreased significantly, but higher at chronic infection than that in control. However, it demonstrated an increasing trend in the thymus with the progression of infection. The frequency of CD4(+)CD28(-) T cells increased from acute infection in the thymus, while from chronic infection in the spleen. The expression of CD38 on CD8(+) T cells began to increase at 4 weeks post infection both in the thymus and spleen; its elevated expression on CD4(+) T cells emerged at 6 weeks post infection in the thymus and at 10 weeks post infection in the spleen. Praziquantel (PZQ) treatment could partially restore the frequency of CD28(+) T cell of CD4(+) T cells and CD38(+) T cell of CD8(+)/CD4(+) T cells in the spleen and CD38(+) T cell in the thymus. We hypothesized that the reactivation of S. japonicum infection may trigger expansion of CD28(-) T cells and hence mediate systemic inflammation. We speculated that CD8(+)CD28(-) T cell might be involved in immune modulation and CD8(+)CD28(-) T cell may be a crucial part in pathogenesis, which can provide further knowledge of the sophisticated mechanism of immuno-downregulation in schistosomiasis and potential treatment target.

Schistosomiasis in a migrating population in the lake region of China and its potential impact on control operation

Coverage of migrating people in schistosomiasis control program is a growing concern in China. Schistosomiasis caused by Schistosoma japonicum is still one of the major infectious diseases of public health importance in China though tremendous efforts have been made to control the transmission over the past decades. Along with the rapid social-economic development, migrant population has been remarkably increasing across the country. The infected migrants may introduce a new souse of infection to endemic areas or the areas where the transmission had been controlled or interrupted but the intermediate host Oncomelania snail is still present. Preliminary studies for surveillance on schistosomiasis prevalence in migrants were reported, but there is little basic information provided. We carried out an investigation on the prevalence in immigrants, emigrants and permanent residents in three villages of Hunan province located in the main endemic area of lake region, and analyzed the potential impact of migration on control practice. In the study villages, the migrant population accounts for 53.6% of the total. Schistosoma infection was detected by modified Kato-Katz method and miracidium hatching test. Questionnaire survey was conducted comprising knowledge of disease and its transmission, water contact, personal protective measures, and whether examined and treated after water contact. The survey indicated that the migrants and permanent residents had similar life style, and the majority of them experienced water contact in agricultural work or routine life activities. However, the infection rate in immigrants was significantly higher than that in permanent residents. It was also found that the migrants had significantly less knowledge about the disease than the permanent residents, and took no personal protective measures. This is due to that the control program could not cover the migrants when they were absent at the time the program being implemented. The present study suggested that the surveillance and intervention for migrants, immigrants in particular, should be included and strengthened in schistosomiasis control program and a feasible scheme be developed.

Schistosomiasis transmission and control in China

In the last 60 years, great progress has been made in controlling and preventing schistosomiasis in China. However, due to the ecosystem changes caused by the construction of the Three Gorges Dams and the South-north Water Conversion Project, the effects of climate change, the scarcity of a highly sensitive surveillance and response system, schistosomiasis is still considered as a major public health problem and is listed among the top infectious diseases in the country prioritized for control and elimination. Based on the epidemiological pattern of schistosomiasis and ecological characteristics of the vector snail, endemic areas of schistosomiasis in China were categorized into three types: (i) plain region with waterway networks, (ii) mountainous and hilly regions, and (iii) marshland and lake regions. China aims to reach the criteria of transmission control threshold of less than 1% in the lake and marshland provinces and reach transmission interruption threshold in hilly provinces of Sichuan and Yunnan by the end of 2015. The purpose of this article is to use the deterministic model proposed in our earlier study in (Chen et al., 2010) to simulate the schistosomiasis infection data from other lake and marshland provinces, including Hunan, Jiangxi and Anhui. Our simulations demonstrate that the model can reasonably mimic the schistosomiasis infection data from these lake and marshland provinces. Thus, similar control and prevention measures can be designed and proposed for these provinces. We will also try to use the model to simulate the schistosomiasis infection data from Sichuan and Yunnan provinces in the mountainous and hilly regions where cattle farming is not as popular and important as in the lake and marshland provinces and find out that different control and prevention strategies are required.

High prevalence of Schistosoma japonicum and Fasciola gigantica in bovines from Northern Samar, the Philippines

The cause of zoonotic schistosomiasis in the Philippines is Schistosoma japonicum, which infects up to 46 mammalian hosts, including humans and bovines. In China, water buffaloes have been identified as major reservoir hosts for schistosomiasis japonica, contributing up to 75% of human transmission. In the Philippines, water buffaloes (carabao; Bubalus bubalis carabanesis) have, historically, been considered unimportant reservoirs. We therefore revisited the possible role of bovines in schistosome transmission in the Philippines, using the recently described formalin-ethyl acetate sedimentation (FEA-SD) technique and a qPCR assay to examine fecal samples from 153 bovines (both carabao and cattle) from six barangays in Northern Samar. A high prevalence of S. japonicum was found using qPCR and FEA-SD in both cattle (87.50% and 77.08%, respectively) and carabao (80.00% and 55.24%, respectively). The average daily egg output for each bovine was calculated at 195,000. High prevalence and infection intensity of F. gigantica was also found in the bovines by qPCR and FEA-SD (95.33% and 96.00%, respectively). The identification of bovines as major reservoir hosts for S. japonicum transmission suggests that bovine treatment and/or vaccination, as one becomes available, should be included in any future control program that aims to reduce the disease burden due to schistosomiasis in the Philippines.

Real-time PCR demonstrates high prevalence of Schistosoma japonicum in the Philippines: implications for surveillance and control

Background

The Philippines has a population of approximately 103 million people, of which 6.7 million live in schistosomiasis-endemic areas with 1.8 million people being at risk of infection with Schistosoma japonicum. Although the country-wide prevalence of schistosomiasis japonica in the Philippines is relatively low, the prevalence of schistosomiasis can be high, approaching 65% in some endemic areas. Of the currently available microscopy-based diagnostic techniques for detecting schistosome infections in the Philippines and elsewhere, most exhibit varying diagnostic performances, with the Kato-Katz (KK) method having particularly poor sensitivity for detecting low intensity infections. This suggests that the actual prevalence of schistosomiasis japonica may be much higher than previous reports have indicated.

Methodology/Principal Findings

Six barangay (villages) were selected to determine the prevalence of S. japonicum in humans in the municipality of Palapag, Northern Samar. Fecal samples were collected from 560 humans and examined by the KK method and a validated real-time PCR (qPCR) assay. A high S. japonicum prevalence (90.2%) was revealed using qPCR whereas the KK method indicated a lower prevalence (22.9%). The geometric mean eggs per gram (GMEPG) determined by the qPCR was 36.5 and 11.5 by the KK. These results, particularly those obtained by the qPCR, indicate that the prevalence of schistosomiasis in this region of the Philippines is much higher than historically reported.

Conclusions/Significance

Despite being more expensive, qPCR can complement the KK procedure, particularly for surveillance and monitoring of areas where extensive schistosomiasis control has led to low prevalence and intensity infections and where schistosomiasis elimination is on the horizon, as for example in southern China.

Schistosomiasis is caused by infection with trematode blood flukes of the genus Schistosoma. Schistosoma japonicum is the causative agent of schistosomiasis in the Philippines, China and parts of Indonesia. In the Philippines, 6.7 million people live in endemic areas and 1.8 million are at risk of infection whereas concerted control efforts over the past 50 years in China have reduced the number of infected individuals considerably. Currently used microscopic techniques for diagnosis, notably the Kato-Katz (KK) technique, lack sensitivity in areas with low intensity schistosome infections. We have used a molecular diagnostic approach (qPCR), to assess the prevalence of S. japonicum in humans from six barangays in Northern Samar, the Philippines. The qPCR performed considerably better than the KK as a diagnostic procedure and could be an important tool in the future for surveillance and monitoring of areas where extensive schistosomiasis control has led to low prevalence and intensity infections and where schistosomiasis elimination is possible.

Progress in research, control and elimination of helminth infections in Asia

Global health has substantially improved over the past 20 years. In low- and middle-income countries, in particular, great strives have been made in the control of communicable diseases, including helminth infections. Nevertheless, the most marginalised communities still suffer from infectious diseases that are intimately connected with poverty and lack of access to essential commodities and services, such as clean water, improved sanitation and sufficient food. A two-pronged approach is thus necessary: (i) intensifying control in remaining high-endemicity areas and pockets of high transmission; and (ii) moving from morbidity control to interruption of disease transmission in low-endemicity areas with the goal of local elimination. The latter will require new tools and strategies, going hand-in-hand with strong partnerships and new strategic alliances. In this special issue of Acta Tropica, 35 articles are featured that, together, provide an up-to-date overview of the latest progress made in research, control and elimination of helminth infections in East and Southeast Asia. The first 12 articles expound tools and approaches for improved detection, surveillance and monitoring of helminth infections. Control and elimination approaches for the most important helminth infections are revisited in the next 20 articles. The three remaining articles are cross-cutting pieces examining the interface of agriculture, environment and helminth infections and providing a rationale for integrated, multi-sectorial control approaches that are necessary for sustaining helminthiasis control and progressively moving towards elimination. An interesting aspect revealed through an in-depth analysis of the provenance of the 35 contributions is that the People's Republic of China emerges as a key player in global health, which is documented through its prominent role in research and control of helminth infection and networking throughout Asia. Policy implications are discussed and will hopefully shape the future agenda for the control and elimination of helminth infections the world over.

Schistosomiasis mass drug administration in the Philippines: lessons learnt and the global implications

Schistosomiasis was first reported in the Philippines in 1906. A variety of treatments have been deployed to cure infection and to control the disease in the long-term. We discuss the journey to combat the disease in the Philippines and the lessons learnt which have implications for schistosomiasis control globally.

Can mass drug administration lead to the sustainable control of schistosomiasis?

BACKGROUND

In the Philippines, the current national control strategy for schistosomiasis is annual mass drug administration (MDA) with 40 mg/kg of praziquantel in all schistosomiasis-endemic villages with a prevalence ≥10%.

METHODS

A cross-sectional survey of schistosomiasis was conducted in 2012 on 18 221 individuals residing in 22 schistosomiasis-endemic villages in the province of Northern Samar. The prevalence of schistosomiasis, intensity of Schistosoma infection, and morbidity of disease were assessed.

RESULTS

Despite an active schistosomiasis-control program in Northern Samar for >30 years, which included a MDA campaign in the last 5 years, the mean prevalence of schistosomiasis among 10 435 evaluated subjects was 27.1% (95% confidence interval [CI], 26.3%-28.0%), and the geometric mean intensity of infection among 2832 evaluated subjects was 17.2 eggs per gram of feces (95% CI, 16.4-18.1). Ultrasonography revealed high levels of schistosomiasis-induced morbidity in the schistosomiasis-endemic communities. Left lobe liver enlargement (≥70 mm) was evident in 89.3% of subjects. Twenty-five percent of the study population had grade II/III liver parenchyma fibrosis, and 13.3% had splenomegaly (≥100 mm).

CONCLUSIONS

MDA on its own was insufficient to control the prevalence of schistosomiasis, intensity of Schistosoma infection, or morbidity of the disease. Alternative control measures will be needed to complement the existing national MDA program.

Involvement of IL-13 and tissue transglutaminase in liver granuloma and fibrosis after schistosoma japonicum infection

Schistosomiasis, one of the most devastating parasitic diseases, is caused by Schistosoma japonicum (Sj) infection resulting in serious liver fibrosis. Interleukin- (IL-) 13, which is produced by T_H2  cells, is a critical profibrotic cytokine found in various organs, including the liver. Tissue transglutaminase (tTG), a group of multifunctional enzymes, serves a central function in the pathogenesis of chronic liver diseases. However, the relationship between IL-13, tTG, and liver fibrosis during Schistosoma infection has not been established. This study investigated the involvement of IL-13 and tTG in liver fibrogenesis during Sj infection in mice. Five weeks after Sj infection, granuloma and fibrosis development in the liver coincided with an increase in IL-13 and tTG in the liver and the upregulation of serum IL-13 in infected mice. Administration of cystamine, an inhibitor of tTG, abrogated the increase in both tTG and IL-13 in infected mice and ameliorated liver fibrogenesis and granuloma development. This result establishes a novel link among IL-13, tTG, and liver granuloma and fibrosis under Sj infection. Based on their important functions in liver fibrosis induced by Sj infection, IL-13 and tTG could be promising potential drug targets against schistosomiasis.

Clinical management of advanced schistosomiasis: a case of portal vein thrombosis-induced splenomegaly requiring surgery

We report for the first time in the Philippines a case of portal vein thrombosis in a 12 year old Filipino boy with advanced schistosomiasis. The boy was referred to the Research Institute for Tropical Medicine (RITM), Manila, due to a rapidly enlarging spleen post-praziquantel treatment. At RITM, liver function tests were within normal limits but complete blood examinations showed pancytopenia and abnormal coagulation times. Serum markers for hepatitis A, B and C were negative. Abdominal MRI revealed schistosome-induced periportal fibrosis. The main portal vein appeared thrombosed with characteristic cavernous transformation of the right portal vein. Varices were seen in the oesophagus, gastrohepatic ligament, and splenic hilum. The spleen was markedly enlarged, with parenchymal foci representing Gamna-Gandy bodies. The patient underwent splenectomy. Histopathologic findings in the liver showed moderate pipestem fibrosis and schistosome egg granulomas. The patient was discharged from the hospital in excellent clinical condition.

Preliminary crystallographic studies of a Schistosoma mansoni antigen (Sm21.7) dynein light-chain (DLC) domain

Schistosomiasis is an inflammatory chronic disease that represents a major health problem in tropical and subtropical countries. The drug of choice for treatment, praziquantel, is effective in killing adult worms but fails to kill immature forms and prevent reinfection. One prominent antigen candidate for an anti-schistosomiasis vaccine is the protein Sm21.7 (184 amino-acid residues) from Schistosoma mansoni, a tegumental protein capable of reducing the worm burden in a murine immunization model. In the present work, the Sm21.7 gene was cloned and expressed in Escherichia coli and the full-length protein was purified to homogeneity. Crystals of recombinant Sm21.7 suitable for X-ray diffraction were obtained using PEG monomethyl ether 2000 as a precipitant. X-ray diffraction images of a native crystal (at 2.05 Å resolution) and a quick-cryosoaked NaI derivative (at 1.95 Å resolution) were collected on the W01B-MX2 beamline at the Laboratório Nacional de Luz Síncrotron (LNLS, Brazilian Synchrotron Light Laboratory/MCT). Both crystals belonged to the hexagonal space group P6122, with similar unit-cell parameters a=b=108.5, c=55.8 Å. SIRAS-derived phases were used to generate the first electron-density map, from which a partial three-dimensional model of Sm21.7 (from Gln89 to Asn184) was automatically constructed. Anaysis of dissolved crystals by SDS-PAGE confirmed that the protein was cleaved in the crystallization drop and only the Sm21.7 C-terminal domain was crystallized. The structure of the Sm21.7 C-terminal domain will help in the localization of the epitopes responsible for its protective immune responses, constituting important progress in the development of an anti-schistosomiasis vaccine.