Co-parasitism of intestinal protozoa and Schistosoma japonicum in a rural community in the Philippines

Beyond schistosomiasis: unraveling co-infections and altered immunity

Schistosomiasis is a neglected tropical disease caused by the helminth Schistosoma spp. and has the second highest global impact of all parasites. Schistosoma are transmitted through contact with contaminated fresh water predominantly in Africa, Asia, the Middle East, and South America. Due to the widespread prevalence of Schistosoma, co-infection with other infectious agents is common but often poorly described. Herein, we review recent literature describing the impact of Schistosoma co-infection between species and Schistosoma co-infection with blood-borne protozoa, soil-transmitted helminths, various intestinal protozoa, Mycobacterium, Salmonella, various urinary tract infection-causing agents, and viral pathogens. In each case, disease severity and, of particular interest, the immune landscape, are altered as a consequence of co-infection. Understanding the impact of schistosomiasis co-infections will be important when considering treatment strategies and vaccine development moving forward.

Optimisation of the DNA dipstick as a rapid extraction method for Schistosoma japonicum in infected mice samples and spiked human clinical samples

BACKGROUND

Schistosomiasis remains a public health issue and the need for accurate and affordable diagnostics is crucial in the elimination of the disease. While molecular diagnostics are highly effective, they are expensive, with the main costs been associated with DNA extraction. The DNA dipstick is a rapid, affordable and simple purification method that allows DNA to be extracted from diagnostic samples within 30 s. We aimed to optimise the DNA dipstick method for samples from mice and egg-spiked human samples.

METHODS

Urine, blood and faeces were collected from mice exposed to Schistosoma japonicum infection at weekly intervals from Day 0 to Day 42. Urine and faecal samples were also collected from volunteer, uninfected humans and spiked with S. japonicum eggs. All samples were subject to several optimisation procedures and DNA extracted with the DNA dipstick. Amplification of the target DNA was carried out using LAMP and visualised using agarose gel electrophoresis and flocculation.

RESULTS

The DNA dipstick successfully identified S. japonicum from infected mice and human clinical samples spiked with cracked eggs or genomic DNA from S. japonicum. Amplification was observed from week 4 post infection in infected mice. For human samples, amplification was observed in sieved faecal samples, filtered urine samples heated at 95 °C for 30 min, and sera samples heated at 95 °C for 30 min.

CONCLUSIONS

The DNA dipstick combined with LAMP has huge potential in providing cost-effective, simple and accurate detection of schistosomiasis infection in endemic regions. This will allow for rapid treatment, tracking outbreaks-such as occur after typhoons, leading to better health outcomes and contributing to control and eventual elimination of schistosomiasis.

Subtypes and phylogenetic analysis of Blastocystis sp. isolates from West Ismailia, Egypt

In Egypt, Blastocystis sp. is not yet on the diagnostic list of parasitology reports, and information about its subtypes (STs) is scarce. This study investigated its prevalence and its STs/alleles, performed phylogenetic analysis, and considered the distribution of risk factors associated with Blastocystis sp. infections in West Ismailia, Ismailia governorate. Sociodemographic data, exposure factors, and previous parasitic infection status were recorded for symptomatic and asymptomatic individuals. Microscopy, polymerase chain reaction, sequencing, and phylogenetic analysis for Blastocystis sp. isolated from fecal samples were performed. Eighty Blastocystis sp.-infected individuals (15.3%) were examined. The age of the individuals ranged between 0.60 and 85.0 (mean 17.10 ± 15.70), the male/female ratio was 33/47, and the asymptomatic/symptomatic ratio was 55/25. The findings demonstrate clear evidence of direct contact with animals, poor water quality, and previous parasitic infections. Eleven samples yielded three Blastocystis STs (ST1: allele 4, ST2: alleles 9 and 12, and ST3: allele 34), with ST3 (45.5%) representing the most common subtype. Phylogenetic analysis with a robust bootstrap revealed three distinct clades for isolates of each subtype. This study updates the epidemiological knowledge of the distribution of Blastocystis sp. STs in Egypt and expands the current understanding of the prevalence, risk factor frequencies, and genetic diversity of this protist in the studied area.

Prevalence and Associated Risk Factors of Intestinal Parasites and Enteric Bacterial Infections among Selected Region Food Handlers of Ethiopia during 2014-2022: A Systematic Review and Meta-Analysis

Food-borne disease due to intestinal parasites (IPs) and enteric bacterial infections (EBIs) remain a major public health problem. Food handlers, individuals involved in preparing and serving food, working with poor personal hygiene could pose a potential threat of spreading IPs and EBIs to the public. The aim of this study was to examine the overall prevalence and risk factors of IPs and EBIs among food handlers in four selected regions of Ethiopia. Scientific articles written in English were recovered from PubMed, ScienceDirect, Web of Science, Google Scholar, Cochrane Library, and other sources from Google Engine and University Library Databases. “Prevalence,” “Intestinal Parasites,” “Enteric Bacterial Infections,” “Associated Factors,” “Food Handlers,” and “Ethiopia” were the search terms used for this study. For critical appraisal, PRISMA 2009 was applied. Stata software version 16 was used to perform the meta-analysis. Heterogeneity and publication bias were evaluated using Cochran's Q, inverse variance (I²), and funnel plot asymmetry tests. A random-effects model was used to calculate the pooled burden of IPs and EBIs and its associated factors among food handlers, along with the parallel odds ratio (OR) and 95% confidence interval (CI). For this meta-analysis, a total of 5844 food handlers were included in the 20 eligible studies. The overall pooled prevalence of IPs and EBIs among food handlers in four selected regions of Ethiopia was 29.16% (95% CI: 22.61, 35.71), with covering (25.77%) and (3.39%) by IPs and EBIs, respectively. Ascaris lumbricoides, Entamoeba histolytica/dispar, Giardia lamblia, and hookworm were the most prevalent IPs among food handlers with a pooled prevalence of 7.58%, 6.78%, 3.67%, and 2.70%, respectively. Salmonella and Shigella spp. were the most prevalent EBIs among food handlers with a pooled prevalence of 2.78% and 0.61%, respectively. A high prevalence of IPs and EBIs among food handlers was observed in Oromia (38.56%; 95% CI: 29.98, 47.14), while a low prevalence was observed in the Tigray region (19.45%; 95% CI: 6.08, 32.82). Food handlers who had not taken food hygiene training (OR: 0.68, 95% CI: −0.34, 1.69), untrimmed finger nail (OR: 2.23, 95% CI: 1.47, 2.99), lack of periodic medical checkup (OR: 1.52, 95% CI: 0.41, 2.64), lack of handwashing habits (OR: 1.97, 95% CI: 0.53, 3.41), and eating raw vegetables and meat (OR: 2.63, 95% CI: 0.92, 4.34) were factors significantly associated with the prevalence of IPs and EBIs. The prevalence of IPs and EBIs was high in the selected Ethiopian region (Amhara, Oromia, SNNPR, and Tigray) food handlers along an increasing prevalence trend from 2014 to 2022. Therefore, this study recommends the provision of proper health education and training regarding personal hygiene, hand washing, food handling, medical checks, as well as raw vegetable and meat safety.

Prevalence of intestinal protozoan parasites among school children in africa: A systematic review and meta-analysis

Introduction

Parasitic infections, especially intestinal protozoan parasites (IPPs) remain a significant public health issue in Africa, where many conditions favour the transmission and children are the primary victims. This systematic review and meta-analysis was carried out with the objective of assessing the prevalence of IPPs among school children in Africa.

Methods

Relevant studies published between January 2000 and December 2020 were identified by systematic online search on PubMed, Web of Science, Embase and Scopus databases without language restriction. Pooled prevalence was estimated using a random-effects model. Heterogeneity of studies were assessed using Cochrane Q test and I² test, while publication bias was evaluated using Egger’s test.

Results

Of the 1,645 articles identified through our searches, 46 cross-sectional studies matched our inclusion criteria, reported data from 29,968 school children of Africa. The pooled prevalence of intestinal protozoan parasites amongst African school children was 25.8% (95% CI: 21.2%-30.3%) with E. histolytica/ dispar (13.3%; 95% CI: 10.9%-15.9%) and Giardia spp. (12%; 95% CI: 9.8%-14.3%) were the most predominant pathogenic parasites amongst the study participants. While E. coli was the most common non-pathogenic protozoa (17.1%; 95% CI: 10.9%-23.2%).

Conclusions

This study revealed a relatively high prevalence of IPPs in school children, especially in northern and western Africa. Thus, poverty reduction, improvement of sanitation and hygiene and attention to preventive control measures will be the key to reducing protozoan parasite transmission.

Pathogenic intestinal protozoan parasites (IPPs) remain a major public health concern. Studies have documented that, the prevalence rates of protozoan infections are quite high in developing regions, particularly Africa and children are the primary victims. Despite numerous studies have been conducted on IPPs in school children in African countries, data on the burden of these infections in African school children have not yet been synthesised. This systematic review and meta-analysis was conducted to provide continent-wide prevalence of IPPs amongst African school children. Our study found that about 25.8% of the children had one or more species of intestinal protozoan parasites in their faecal specimens. E. histolytica/ dispar and Giardia spp. were the most predominant parasites amongst the study participants. The relatively high prevalence estimate of IPPs amongst African children and the considerable variation in the disease prevalence over the years, between and within countries and regions clearly indicates the needs to improve sanitation and hygiene, paying more attention to preventive control measures as well as poverty reduction which are the key to reducing protozoan parasite transmission.

The Coexistence of Blastocystis spp. in Humans, Animals and Environmental Sources from 2010-2021 in Asia

Blastocystis spp. are controversial unicellular protists that inhabit the gastrointestinal tract of humans and a wide range of animals worldwide. This review provides an overview of the prevalence and distribution of Blastocystis spp. and their subtypes throughout Asia. Research articles reporting on the presence of Blastocystis spp. in locations within Asia, between 1 January 2010, and 10 May 2021, were obtained from Scopus, PubMed, and Google Scholar. In 427 articles, the prevalence of Blastocystis spp. in 31 countries within the last decade was revealed. Isolates were found in humans, various mammals, birds, reptiles, insects, water sources, vegetables, and ambient air. Prevalence of Blastocystis spp. varied widely across host categories. Subtypes identified throughout Asia were STs 1-14, and ST18-22 (novel subtypes). ST1, ST2, ST3, ST4 were the most frequently isolated in humans; ST5 in pigs; ST10 and ST14 in goats, sheep, and cattle; and ST6 and ST7 in chickens. ST1 and ST3 were most common in water samples. ST1, ST2, ST3, ST4, ST5 and ST6 were shared by humans, animals, and water sources. There is a growing interest in the study of Blastocystis spp. and their subtypes in Asia. Due to the isolation of Blastocystis spp. from biotic and abiotic sources in Asia, the application of the One Health (OH) approach to the study of Blastocystis spp. is proposed for improved perception of this organism.

Intestinal giardiasis in children: Five years' experience in a reference unit

BACKGROUND

Giardiasis is highly prevalent in children and is often mildly symptomatic. First-line treatment is metronidazole, but treatment failure is not uncommon. We describe a paediatric series, to identify risk factors for treatment failure and to analyse the safety and effectiveness of other treatment strategies.

METHODS

Retrospective observational study, including children diagnosed with giardiasis from 2014 to 2019. Diagnosis was based on direct visualisation by microscopy after concentration using an alcohol-based fixative, antigen detection and/or DNA detection by polymerase chain reaction in stool. Treatment failure was considered when GI was detected 4 weeks after treatment.

RESULTS

A total of 120 patients were included, 71.6% internationally adopted, median age 4.2 (2.3-7.3) years. Only 50% presented with symptoms, mainly diarrhoea (35%) and abdominal pain (14.1%); co-parasitism was frequent (45%). First-line treatment failure after a standard dose of metronidazole was 20%, lowering to 8.3% when a higher dose was administered (p < 0.001). Quinacrine was administered in 10 patients, with 100% effectiveness. Children <2 years were at higher risk of treatment failure (OR 3.49; 95% CI 1.06-11.53; p = 0.040).

CONCLUSIONS

In children with giardiasis, treatment failure is frequent, especially before 2 years of age. Quinacrine can be considered as a second-line treatment. After treatment, eradication should be confirmed.

Rapid parasite detection utilizing a DNA dipstick

Molecular diagnostics are powerful tools for disease detection but are typically confined to the laboratory environment due to the cumbersome methods required to extract nucleic acids from biological samples. Accurate diagnosis is essential for early detection of parasitic worm infections and for monitoring control programs, particularly during new transmission outbreaks to limit infection spread. We optimized the recently developed DNA dipstick technology to purify Schistosoma japonicum DNA from different life stages in <60 s. We successfully detected DNA from adult worms, eggs and infected snails. The speed and simplicity of this method enables the point-of-care detection of S. japonicum.

HTLV-I and Strongyloides in Australia: The worm lurking beneath

Strongyloidiasis and HTLV-I (human T-lymphotropic virus-1) are important infections that are endemic in many countries around the world with an estimated 370 million infected with Strongyloides stercoralis alone, and 5-10 million with HTVL-I. Co-infections with these pathogens are associated with significant morbidity and can be fatal. HTLV-I infects T-cells thus causing dysregulation of the immune system which has been linked to dissemination and hyperinfection of S. stercoralis leading to bacterial sepsis which can result in death. Both of these pathogens are endemic in Australia primarily in remote communities in Queensland, the Northern Territory, and Western Australia. Other cases in Australia have occurred in immigrants and refugees, returned travellers, and Australian Defence Force personnel. HTLV-I infection is lifelong with no known cure. Strongyloidiasis is a long-term chronic disease that can remain latent for decades, as shown by infections diagnosed in prisoners of war from World War II and the Vietnam War testing positive decades after they returned from these conflicts. This review aims to shed light on concomitant infections of HTLV-I with S. stercoralis primarily in Australia but in the global context as well.

Prevalence and Associated Risk Factors of Human Intestinal Protozoan Parasitic Infections in Ethiopia: A Systematic Review and Meta-Analysis

Background

Human intestinal protozoan parasitic infections (HIPPIs) are a series of public health problems in developing countries like Ethiopia. The overall prevalence of HIPPIs in Ethiopia is not known. Therefore, this systematic review and meta-analysis study is aimed at determining the overall prevalence of HIPPIs in Ethiopia.

Methods

Articles written in English were searched from online public databases. Searching terms used were "prevalence," "intestinal protozoan parasite," "associated factors," and "Ethiopia." We used Stata version 14 for meta-analysis and Cochran's Q test statistics and the I ² test for heterogeneity.

Result

A total of 286 articles were reviewed, but only 45 of them fulfilled the inclusion criteria. The pooled prevalence of HIPPIs in Ethiopia was 25.01% (95% CI: 20.08%-29.95%) where Entamoeba histolytica/dispar is the most prevalent (14.09%, 95% CI: 11.03%-17.14%) followed by Giardia lamblia (10.03%, 95% CI: 7.69%-12.38%) and Cryptosporidium spp. (5.93%, 95% CI: 2.95%-8.91%). This meta-analysis showed that family size (OR: 3.7, 95% CI: 1.45-5.85), source of drinking water (OR: 3.33, 95% CI: 1.30-5.36), open field defecation (OR: 2.91, 95% CI: 1.60-4.21), handwashing habit (OR: 2.82, 95% CI: 2.01-3.63), playing with soil (OR: 2.15, 95% CI: 1.01-3.29), the habit of eating raw vegetables (OR: 1.77, 95% CI: 1.03-2.51), and fingernail trimming (OR: 1.70, 95% CI: 0.89-2.25) were strongly associated with the HIPPIs in Ethiopia. High heterogeneity on the prevalence of HIPPIs was observed among studies within and among regions (I ² > 99% and P ≤ 0.01).

Conclusion

The prevalence of HIPPIs was significantly high among the Ethiopian population. Family size, source of drinking water, open field defecation, handwashing habit, the habit of eating raw vegetables, and fingernail trimming habits were significantly associated with HIPPIs.

Molecular identification of Ancylostoma ceylanicum in the Philippines

Hookworms are some of the most widespread of the soil-transmitted helminths (STH) with an estimated 438.9 million people infected. Until relatively recently Ancylostoma ceylanicum was regarded as a rare cause of hookworm infection in humans, with little public health relevance. However, recent advances in molecular diagnostics have revealed a much higher prevalence of this zoonotic hookworm than previously thought, particularly in Asia. This study examined the prevalence of STH and A. ceylanicum in the municipalities of Palapag and Laoang in the Philippines utilizing real-time polymerase chain reaction (PCR) on stool samples previously collected as part of a cross-sectional survey of schistosomiasis japonica. Prevalence of hookworm in humans was high with 52.8% (n = 228/432) individuals positive for any hookworm, 34.5% (n = 149/432) infected with Necator americanus, and 29.6% (n = 128/432) with Ancylostoma spp; of these, 34 were PCR-positive for A. ceylanicum. Considering dogs, 12 (n = 33) were PCR-positive for A. ceylanicum. This is the first study to utilize molecular diagnostics to identify A. ceylanicum in the Philippines with both humans and dogs infected. Control and elimination of this zoonotic hookworm will require a multifaceted approach including chemotherapy of humans, identification of animal reservoirs, improvements in health infrastructure, and health education to help prevent infection.

Serum Exosomal miRNAs for Grading Hepatic Fibrosis Due to Schistosomiasis

Chronic infection with Schistosoma japonicum or Schistosoma mansoni results in hepatic fibrosis of the human host. The staging of fibrosis is crucial for prognosis and to determine the need for treatment of patients with schistosomiasis. This study aimed to determine whether there is a correlation between the levels of serum exosomal micro-ribonucleic acids (miRNAs) (exomiRs) and fibrosis progression in schistosomiasis. Reference gene (RG) validation was initially carried out for the analysis of serum exomiRs expression in staging liver fibrosis caused by schistosome infection. The expression levels of liver fibrosis-associated exomiRs in serum were determined in a murine schistosomiasis model and in a cohort of Filipino schistosomiasis japonica patients (n = 104) with different liver fibrosis grades. Of twelve RG candidates validated, miR-103a-3p and miR-425-5p were determined to be the most stable genes in the murine schistosomiasis model and subjects from the schistosomiasis-endemic area, respectively. The temporal expression profiles of nine fibrosis-associated serum exomiRs, as well as their correlations with the liver pathologies, were determined in C57BL/6 mice during S. japonicum infection. The serum levels of three exomiRs (miR-92a-3p, miR-146a-5p and miR-532-5p) were able to distinguish subjects with fibrosis grades I-III from those with no fibrosis, but only the serum level of exosomal miR-146a-5p showed potential for distinguishing patients with mild (grades 0–I) versus severe fibrosis (grades II–III). The current data imply that serum exomiRs can be a supplementary tool for grading liver fibrosis in hepatosplenic schistosomiasis with moderate accuracy.

Prior Toxoplasma Gondii Infection Ameliorates Liver Fibrosis Induced by Schistosoma Japonicum through Inhibiting Th2 Response and Improving Balance of Intestinal Flora in Mice

Schistosomiasis is an immunopathogenic disease in which a T helper (Th) cell type 2-like response plays vital roles. Hepatic fibrosis is its main pathologic manifestations, which is the leading cause of hepatic cirrhosis. Co-infections of Schistosoma japonicum (Sj) with other pathogens are frequently encountered but are easily ignored in clinical studies, and effective therapeutic interventions are lacking. In this study, we explored the effect of Toxoplasma gondii (Tg) prior infection on Th1/Th2 response, community shifts in gut microbiome (GM), and the pathogenesis of schistosomiasis in murine hosts. Mice were prior infected with Tg before Sj infection. The effects of co-infection on Th1/Th2 response and hepatic fibrosis were analyzed. Furthermore, we investigated this issue by sequencing 16S rRNA from fecal specimens to define the GM profiles during co-infection. Tg prior infection markedly reduced the granuloma size and collagen deposit in livers against Sj infection. Prior infection promoted a shift toward Th1 immune response instead of Th2. Furthermore, Tg infection promoted the expansion of preponderant flora and Clostridiaceae was identified as a feature marker in the GM of the co-infection group. Redundancy analysis (RDA)/canonical correspondence analysis (CCA) results showed that liver fibrosis, Th1/Th2 cytokines were significantly correlated (P < 0.05) with the GM compositions. Tg infection inhibits hepatic fibrosis by downregulating Th2 immune response against Sj infection, and further promotes the GM shifts through "gut-liver axis" in the murine hosts. Our study may provide insights into potential anti-fibrosis strategies in co-infection individuals.

Assessment of dual schistosome infection prevalence from urine in an endemic community of Ghana by molecular diagnostic approach

Schistosomiasis is an important Neglected Tropical Disease caused by blood parasites called schistosomes. In sub-Saharan Africa, two major human schistosomes, namely Schistosoma mansoni and S. haematobium, often occur sympatrically and is responsible for almost 90% of the affected 290 million people worldwide. We have utilized a highly sensitive and specific assay by amplifying species-specific cell-free repeat DNA fragments by polymerase chain reaction to detect either single or dual schistosome infection from a single urine sample from a broad age group. In this study, we have tested filtered urine samples collected from 163 individuals aged 3–63 years, mostly children (median age 10), to evaluate the prevalence of single and dual infections for S. mansoni and S. haematobium in Tomefa community in the Greater Accra region of Ghana. 40–50 mL of urine was filtered through a 12.5 cm Whatman # 3 filter paper in the field. The filter papers were dried, packed individually in sealable plastic bags with a desiccant, and shipped to Marquette University, where DNA was isolated and PCR amplification was carried out with species-specific primers. Disease prevalence was found to be 46.6% for S. mansoni and 48.5% for S. haematobium. Most importantly, 23.3% of participants had dual infections. All of the samples were detected without any cross amplification. The data was evaluated for four age groups and infection rate was highest for the age group of 3–12 years, with more S. haematobium infections than S. mansoni infections. We found a high prevalence of both S. haematobium and S. mansoni infection and a significant proportion of dual infection for the Tomefa community, which in most cases would be missed by traditional parasitological examination of urine or stool. Our highly sensitive and specific approach for detecting underlying multiple schistosome infections is an effective means to detect low intensity infections and would enhance the effectiveness of surveillance and Mass Drug Administration control programs of schistosomiasis.

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WHO recommended gold-standard tests misses low-level schistosomiasis infection.

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Cell-free repeat DNA detection can identify significant number of such infection.

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Both schistosome species can be detected effectively from a single urine sample.

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Infection rate is higher for younger age group.

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Dual infection rate is higher in Tomefa community of Ghana.

Parasite-derived circulating microRNAs as biomarkers for the detection of human Schistosoma japonicum infection

Novel tools for early diagnosis and monitoring of schistosomiasis are urgently needed. This study aimed to validate parasite-derived miRNAs as potential novel biomarkers for the detection of human Schistosoma japonicum infection. A total of 21 miRNAs were initially validated by real-time-polymerase chain reaction (RT-PCR) using serum samples of S. japonicum-infected BALB/c mice. Of these, 6 miRNAs were further validated with a human cohort of individuals from a schistosomiasis-endemic area of the Philippines. RT-PCR analysis showed that two parasite-derived miRNAs (sja-miR-2b-5p and sja-miR-2c-5p) could detect infected individuals with low infection intensity with moderate sensitivity/specificity values of 66%/68% and 55%/80%, respectively. Analysis of the combined data for the two parasite miRNAs revealed a specificity of 77.4% and a sensitivity of 60.0% with an area under the curve (AUC) value of 0.6906 (P = 0.0069); however, a duplex RT-PCR targeting both sja-miR-2b-5p and sja-miR-2c-5p did not result in an increased diagnostic performance compared with the singleplex assays. Furthermore, the serum level of sja-miR-2c-5p correlated significantly with faecal egg counts, whereas the other five miRNAs did not. Targeting S. japonicum-derived miRNAs in serum resulted in a moderate diagnostic performance when applied to a low schistosome infection intensity setting.

Collaborative RNAS+ research: Priorities and outcomes

Over the past 20 years, RNAS⁺ has been generating research results from highly collaborative projects meant to promote and advance understanding in various aspects of schistosomiasis. Epidemiological studies in endemic countries like the Philippines, the People's Republic of China (PR China), the Lao People's Democratic Republic (Lao PDR) and Cambodia clarified the role of reservoir hosts in transmission and the use of spatio-temporal methods such as remote sensing and geographical information systems (GIS) in surveillance of schistosomiasis. Morbidity studies proposed factors that might influence development of fibrosis, anaemia and malnutrition in schistosomiasis. Immune responses in schistosomiasis continue to be an interesting focus in research to explain possible development of resistance with age. Results of evaluation of candidate vaccine molecules are also presented. New diagnostics are continually being developed in response to the call for more sensitive and field applicable techniques that will be used for surveillance in areas nearing elimination of the disease. Several studies presented here show the insufficiency of mass drug administration (MDA) with praziquantel in eliminating the disease. Emphasis is given to an integrated control approach that can be accomplished through intensive and extensive intersectoral collaboration.