Projecting the long-term impact of school- or community-based mass-treatment interventions for control of Schistosoma infection

Assessing the effects of diagnostic sensitivity on schistosomiasis dynamics

Schistosomiasis is a parasite infection that affects millions of people around the world. It is endemic in 13 different states in Brazil and responsible for increasing morbidity in the population. One of its main characteristics is a heterogeneous distribution of worm burden in the human population, which makes the diagnosis difficult. We aimed to investigate how the sensitivity of the diagnostic method may contribute to successful control interventions against infections in a population. In order to do that, we present an ordinary differential equations model that considers three levels of worm burden in the human population, a snail population, and a miracidium reservoir. Through a steady-state analysis and its local stability, we show how this worm-burden heterogeneity can be responsible for the persistence of infection, especially due to reinfection in the highest level of worm burden. The analysis highlights sensitive diagnosis, besides treatment and sanitary improvements, as a key factor for schistosomiasis transmission control.

Impact of Different Mass Drug Administration Strategies for Gaining and Sustaining Control of Schistosoma mansoni and Schistosoma haematobium Infection in Africa

This report summarizes the design and outcomes of randomized controlled operational research trials performed by the Bill & Melinda Gates Foundation–funded Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) from 2009 to 2019. Their goal was to define the effectiveness and test the limitations of current WHO-recommended schistosomiasis control protocols by performing large-scale pragmatic trials to compare the impact of different schedules and coverage regimens of praziquantel mass drug administration (MDA). Although there were limitations to study designs and performance, analysis of their primary outcomes confirmed that all tested regimens of praziquantel MDA significantly reduced local Schistosoma infection prevalence and intensity among school-age children. Secondary analysis suggested that outcomes in locations receiving four annual rounds of MDA were better than those in communities that had treatment holiday years, in which no praziquantel MDA was given. Statistical significance of differences was obscured by a wider-than-expected variation in community-level responses to MDA, defining a persistent hot spot obstacle to MDA success. No MDA schedule led to elimination of infection, even in those communities that started at low prevalence of infection, and it is likely that programs aiming for elimination of transmission will need to add supplemental interventions (e.g., snail control, improvement in water, sanitation and hygiene, and behavior change interventions) to achieve that next stage of control. Recommendations for future implementation research, including exploration of the value of earlier program impact assessment combined with intensification of intervention in hot spot locations, are discussed.

Application of Schistosomiasis Consortium for Operational Research and Evaluation Study Findings to Refine Predictive Modeling of Schistosoma mansoni and Schistosoma haematobium Control in Sub-Saharan Africa

An essential mission of the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was to help inform global health practices related to the control and elimination of schistosomiasis. To provide more accurate, evidence-based projections of the most likely impact of different control interventions, whether implemented alone or in combination, SCORE supported mathematical modeling teams to provide simulations of community-level Schistosoma infection outcomes in the setting of real or hypothetical programs implementing multiyear mass drug administration (MDA) for parasite control. These models were calibrated using SCORE experience with Schistosoma mansoni and Schistosoma haematobium gaining and sustaining control studies, and with data from comparable programs that used community-based or school-based praziquantel MDA in other parts of sub-Saharan Africa. From 2010 to 2019, models were developed and refined, first to project the likely SCORE control outcomes, and later to more accurately reflect impact of MDA across different transmission settings, including the role of snail ecology and the impact of seasonal rainfall on snail abundance. Starting in 2014, SCORE modeling projections were also compared with the models of colleagues in the Neglected Tropical Diseases Modelling Consortium. To explore further possible improvement to program-based control, later simulations examined the cost-effectiveness of combining MDA with environmental snail control, and the utility of early impact assessment to more quickly identify persistent hot spots of transmission. This article provides a nontechnical summary of the 11 SCORE-related modeling projects and provides links to the original open-access articles describing model development and projections relevant to schistosomiasis control policy.

Improving public health control of schistosomiasis with a modified WHO strategy: a model-based comparison study

Background

Schistosomiasis is endemic in many low-income and middle-income countries. To reduce infection-associated morbidity, WHO has published guidelines for control of schistosomiasis based on targeted mass drug administration (MDA) and, in 2017, on supplemental snail control. We compared the current WHO guideline-based strategies from 2012 to an alternative, adaptive decision making framework for control in heterogeneous environments, to estimate their predicted relative effectiveness and time to achievement of defined public health goals.

Methods

In this model-based comparison study, we adapted an established transmission model for Schistosoma infection that couples local human and snail populations and includes aspects of snail ecology and parasite biology. We calibrated the model using data from high-risk, moderate-risk, and lower-risk rural villages in Kenya, and then simulated control via MDA. We compared 2012 WHO guidelines with a modified adaptive strategy that tested a lower-prevalence threshold for MDA and shorter intervals between implementation, evaluation, and modification. We also explored the addition of snail control to this modified strategy. The primary outcomes were the proportion of simulations that achieved the WHO targets in children aged 5–14 years of less than 5% (2020 morbidity control goal) and less than 1% (2025 elimination as a public health problem goal) heavy infection and the mean duration of treatment required to achieve these goals.

Findings

In high-risk communities (80% baseline prevalence), current WHO strategies for MDA were not predicted to achieve morbidity control (<5% prevalence of heavy infections) in 80% of simulations over a 10-year period, whereas the modified adaptive strategy was predicted to achieve this goal in over 50% of simulations within 5 years. In low-risk and moderate-risk communities, current WHO guidelines from 2012 were predicted to achieve morbidity control in most simulations (96% in low-risk and 41% for moderate-risk), although the proposed adaptive strategy reached this goal in a shorter period (mean reduction of 5 years). The model predicted that the addition of snail control to the proposed adaptive strategy would achieve morbidity control in all high-risk communities, and 54% of communities could reach the goal for elimination as a public health problem (<1% heavy infection) within 7 years.

Interpretation

The modified adaptive decision making framework is predicted to be more effective than the current WHO guidelines in reaching 2025 public health goals, especially for high-prevalence regions. Modifications in current guidelines could reduce the time and resources needed for countries who are currently working on achieving public health goals against schistosomiasis.

Funding

University of Georgia Research Foundation, The Bill & Melinda Gates Foundation, and the Medical Scientist Training Program at Stanford University School of Medicine.

Challenges in Protocol Development and Interpretation of the Schistosomiasis Consortium for Operational Research and Evaluation Intervention Studies

In 2010, the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) began the design of randomized controlled trials to compare different strategies for praziquantel mass drug administration, whether for gaining or sustaining control of schistosomiasis or for approaching local elimination of Schistosoma transmission. The goal of this operational research was to expand the evidence base for policy-making for regional and national control of schistosomiasis in sub-Saharan Africa. Over the 10-year period of its research programs, as SCORE operational research projects were implemented, their scope and scale posed important challenges in terms of research performance and the final interpretation of their results. The SCORE projects yielded valuable data on program-level effectiveness and strengths and weaknesses in performance, but in most of the trials, a greater-than-expected variation in community-level responses to assigned schedules of mass drug administration meant that identification of a dominant control strategy was not possible. This article critically reviews the impact of SCORE’s cluster randomized study design on performance and interpretation of large-scale operational research such as ours.

Biomphalaria glabrata immunity: Post-genome advances

The freshwater snail, Biomphalaria glabrata, is an important intermediate host in the life cycle for the human parasite Schistosoma mansoni, the causative agent of schistosomiasis. Current treatment and prevention strategies have not led to a significant decrease in disease transmission. However, the genome of B. glabrata was recently sequenced to provide additional resources to further our understanding of snail biology. This review presents an overview of recently published, post-genome studies related to the topic of snail immunity. Many of these reports expand on findings originated from the genome characterization. These novel studies include a complementary gene linkage map, analysis of the genome of the B. glabrata embryonic (Bge) cell line, as well as transcriptomic and proteomic studies looking at snail-parasite interactions and innate immune memory responses towards schistosomes. Also included are biochemical investigations on snail pheromones, neuropeptides, and attractants, as well as studies investigating the frontiers of molluscan epigenetics and cell signaling were also included. Findings support the current hypotheses on snail-parasite strain compatibility, and that snail host resistance to schistosome infection is dependent not only on genetics and expression, but on the ability to form multimeric molecular complexes in a timely and tissue-specific manner. The relevance of cell immunity is reinforced, while the importance of humoral factors, especially for secondary infections, is supported. Overall, these studies reflect an improved understanding on the diversity, specificity, and complexity of molluscan immune systems.

The human-snail transmission environment shapes long term schistosomiasis control outcomes: Implications for improving the accuracy of predictive modeling

INTRODUCTION

Schistosomiasis is a chronic parasitic trematode disease that affects over 240 million people worldwide. The Schistosoma lifecycle is complex, involving transmission via specific intermediate-host freshwater snails. Predictive mathematical models of Schistosoma transmission have often chosen to simplify or ignore the details of environmental human-snail interaction in their analyses. Schistosome transmission models now aim to provide better precision for policy planning of elimination of transmission. This heightens the importance of including the environmental complexity of vector-pathogen interaction in order to make more accurate projections.

METHODOLOGY AND PRINCIPAL FINDINGS

We propose a nonlinear snail force of infection (FOI) that takes into account an intermediate larval stage (miracidium) and snail biology. We focused, in particular, on the effects of snail force of infection (FOI) on the impact of mass drug administration (MDA) in human communities. The proposed (modified) model was compared to a conventional model in terms of their predictions. A longitudinal dataset generated in Kenya field studies was used for model calibration and validation. For each sample community, we calibrated modified and conventional model systems, then used them to model outcomes for a range of MDA regimens. In most cases, the modified model predicted more vigorous post-MDA rebound, with faster relapse to baseline levels of infection. The effect was pronounced in higher risk communities. When compared to observed data, only the modified system was able to successfully predict persistent rebound of Schistosoma infection.

CONCLUSION AND SIGNIFICANCE

The observed impact of varying location-specific snail inputs sheds light on the diverse MDA response patterns noted in operational research on schistosomiasis control, such as the recent SCORE project. Efficiency of human-to-snail transmission is likely to be much higher than predicted by standard models, which, in practice, will make local elimination by implementation of MDA alone highly unlikely, even over a multi-decade period.

Assessing the benefits of five years of different approaches to treatment of urogenital schistosomiasis: A SCORE project in Northern Mozambique

Background

In Mozambique, schistosomiasis is highly endemic across the whole country. The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) coordinates a five-year study that has been implemented in various African countries, including Mozambique. The overall goal of SCORE was to better understand how to best apply preventive chemotherapy with praziquantel (PZQ) for schistosomiasis control by evaluating the impact of alternative treatment approaches.

Methods

This was a cluster-randomised trial that compared the impact of different treatment strategies in study areas with prevalence among school children of ≥21% S. haematobium infection by urine dipstick. Each village was randomly allocated to one of six possible combinations of community-wide treatment (CWT), school-based treatment (SBT), and/or drug holidays over a period of four years, followed by final data collection in the fifth year. The most intense intervention arm involved four years of CWT, while the least intensive arm involved two years of SBT followed by two consecutive years of PZQ holiday. Each study arm included 25 villages randomly assigned to one of the six treatment arms. The primary outcome of interest was change in prevalence and intensity of S. haematobium among 100 children aged 9-to-12-years that were sampled each year in every village. In addition to children aged 9-to-12 years, 100 children aged 5–8 years in their first-year of school and 50 adults (aged 20–55 years) were tested in the first and final fifth year of the study. Prevalence and intensity of S. haematobium infection was evaluated by two filtrations, each of 10mL, from a single urine specimen.

Principal findings

In total, data was collected from 81,167 individuals across 149 villages in ten districts of Cabo Delgado province, Northern Mozambique. Overall PZQ treatment resulted in a significant reduction in the prevalence of S. haematobium infection from Year 1 to Year 5, where the average prevalence went from 60.5% to 38.8%, across all age groups and treatment arms. The proportion of those heavily infected also reduced from 17.6% to 11.9% over five years. There was a significantly higher likelihood of males being infected than females at baseline, but no significant difference between the sexes in their response to treatment. The only significant response based on a study arm was seen in both the 9-to-12-year-old and first-year cross sections, where two consecutive treatment holidays resulted in a significantly higher final prevalence of S. haematobium than no treatment holidays. When the arms were grouped together, four rounds of treatment (regardless of whether it was CWT or SBT), however, did result in a significantly greater reduction in S. haematobium prevalence than two rounds of treatment (i.e. with two intermittent or consecutive holiday years) over a five-year period.

Conclusions

Although PC was successful in reducing the burden of active infection, even among those heavily infected, annual CWT did not have a significantly greater impact on disease prevalence or intensity than less intense treatment arms. This may be due to extremely high starting prevalence and intensity in the study area, with frequent exposure to reinfection, or related to challenges in achieving high treatment coverage More frequent treatment had a greater impact on prevalence and intensity of infection when arms were grouped by number of treatments, however, cost efficiency was greater in arms only receiving two treatments. Finally, a significant reduction in prevalence of S. haematobium was seen in adults even in the SBT arms implying the rate of transmission in the community had been decreased, even where only school children have been treated, which has significant logistical and cost-saving implications for a national control programme in justifying CWT.

Urogenital schistosomiasis is highly endemic in Mozambique. This study was part of a multi-country trial, including Mozambique, designed to understand the impact of different schistosomiasis treatment strategies involving community-wide treatment (CWT), school-based (SBT), and treatment holidays over a five-year period. Results from Mozambique showed that although preventive chemotherapy was successful in reducing the prevalence of Schistosoma haematobium over five-years, the most intense treatment approach, annual CWT, did not have a significantly greater impact than less intense treatment strategies, such as bi-annual SBT. Infection rates were higher among males, but there was no difference in response to treatment by gender. Four rounds of treatment (regardless of whether it was given in the community or school) did result in a significantly greater reduction of S. haematobium prevalence than two rounds of treatment over a five-year period. There was, however, a resurgent increase in prevalence and intensity of S. haematobium infection shown after two consecutive treatment-holiday years, implying a bounce back in infection after a two year pause in treatment. Interestingly and unexpectedly, there was a significant reduction in prevalence of schistosomiasis in adults even in communities that had received SBT implying the force of transmission in the community had been decreased, even where only school children had been treated. These findings provide an evidence-base with significant logistical and cost-saving implications for programmatic decisions on how best to gain control of Schistosoma haematobium.

Cross-sectional interview study of fertility, pregnancy, and urogenital schistosomiasis in coastal Kenya: Documented treatment in childhood is associated with reduced odds of subfertility among adult women

Background

Previous research has documented an increased risk of subfertility in areas of sub-Saharan Africa, as well as an ecological association between urogenital schistosomiasis prevalence and decreased fertility. This pilot project examined reproductive patterns and the potential effects of childhood urogenital Schistosoma haematobium infection and individual treatment experience on adult subfertility among women who were long-term residents in an S. haematobium-endemic region of coastal Kenya.

Methodology/Principal findings

We analyzed findings from 162 in-depth interviews with women of childbearing age in a rural, coastal community, linking them, if possible, to their individual treatment records from previous multi-year longitudinal studies of parasitic infections. Reproductive histories indicated a much local higher local rate of subfertility (44%) than worldwide averages (8–12%). Although, due to the very high regional prevalence of schistosomiasis, a clear relationship could not be demonstrated between a history of S. haematobium infection and adult subfertility, among a convenience sub-sample of 61 women who had received documented treatment during previous interventional trials, a significant association was found between age at first anti-schistosomal treatment and later fertility in adulthood, with those women treated before age 21 significantly less likely to have subfertility (P = 0.001).

Conclusions/Significance

The high subfertility rate documented in this pilot study suggests the importance of programs to prevent and treat pelvic infections in their early stages to preclude reproductive tract damage. The available documented treatment data also suggest that early anti-schistosomal treatment may prevent the fertility-damaging effects of urogenital schistosomiasis, and lend support for programs that provide universal treatment of children in S. haematobium-endemic regions.

Infertility is an unwelcome complication of many infectious diseases. In sub-Saharan Africa, where women experience the highest rates of subfertility in the world, the helminthic parasite Schistosoma haematobium, is also highly prevalent. Chronic and repeated infections with S. haematobium cause inflammation of the pelvic organs and kidneys, a condition known as urogenital schistosomiasis. Past studies have statistically linked past and present S. haematobium infection to the risk of infection-associated female genital lesions and with risk for subfertility in adulthood. The present study used in-depth interviews to document reproductive health histories of 162 women, aged 15 to 62, residing in an S. haematobium-endemic area of coastal Kenya, in order to examine the association of their earlier anti-schistosomal treatment with their fertility patterns. A self-reported history of past treatment was not associated with lower odds of infertility. However, among 61 with verified treatments given during previous local campaigns, it was found that women who were treated before age 21 experienced significantly fewer period of subfertility during their adult life. The findings suggest that anti-schistosomal treatment during childhood may prevent the fertility-damaging effects of urogenital schistosomiasis. They also lend support for programs that provide universal treatment of children in S. haematobium-endemic regions.

Systematic review of community-based, school-based, and combined delivery modes for reaching school-aged children in mass drug administration programs for schistosomiasis

Background

The mainstay of current schistosomiasis control programs is mass preventive chemotherapy of school-aged children with praziquantel. This treatment is delivered through school-based, community-based, or combined school- and community-based systems. Attaining very high coverage rates for children is essential in mass schistosomiasis treatment programs, as is ensuring that there are no persistently untreated subpopulations, a potential challenge for school-based programs in areas with low school enrollment. This review sought to compare the different treatment delivery methods based both on their coverage of school-aged children overall and on their coverage specifically of non-enrolled children. In addition, qualitative community or programmatic factors associated with high or low coverage rates were identified, with suggestions for overall coverage improvement.

Methodology/Principal findings

This review was registered prospectively with PROSPERO (CRD 42015017656). Five hundred forty-nine publication of potential relevance were identified through database searches, reference lists, and personal communications. Eligible studies included those published before October 2015, written in English or French, containing quantitative or qualitative data about coverage rates for MDA of school-aged children with praziquantel. Among the 22 selected studies, combined community- and school-based programs achieved the highest median coverage rates (89%), followed by community-based programs (72%). School-based programs had both the lowest median coverage of children overall (49%) and the lowest coverage of the non-enrolled subpopulation of children. Qualitatively, major factors affecting program success included fear of side effects, inadequate education about schistosomiasis, lack of incentives for drug distributors, and inequitable distribution to minority groups.

Conclusions/Significance

This review provides an evidence-based framework for the development of future schistosomiasis control programs. Based on our results, a combined community and school-based delivery system should maximize coverage for both in- and out-of-school children, especially when combined with interventions such as snacks for treated children, educational campaigns, incentives for drug distributors, and active inclusion of marginalized groups.

Trial registration

ClinicalTrials.gov CRD42015017656

Schistosomiasis is a chronic inflammatory condition, caused by parasitic flukes, that affects over 290 million people worldwide. Consequences of infection include anemia, stunted growth, liver abnormalities, and subfertility. Currently, the main approach to schistosomiasis control involves mass preventive treatment of school-aged children in endemic areas. The treatment, praziquantel, can be distributed through school-based, community-based, or combined school- and community-based systems. The first part of this systematic review compared the three delivery modes and found that combined delivery resulted in the best overall coverage of school-aged children, with community-only delivery the next-best approach. School-only delivery not only had the lowest overall coverage, but especially fell behind in targeting children not enrolled in school. As a whole, these results support the more frequent use of a combined approach to delivery in order to achieve the highest coverage rates and ensure that out-of-school children are not left persistently untreated. In the second part of this review the qualitative factors affecting program success were examined. The results indicate that overall treatment coverage can be improved via small interventions, such as snacks for participating children to reduce drug side effects, educational campaigns about schistosomiasis, incentives for drug distributors, and active inclusion of marginalized groups.

Evaluating the variation in the projected benefit of community-wide mass treatment for schistosomiasis: Implications for future economic evaluations

Background

The majority of schistosomiasis control programmes focus on targeting school-aged children. Expanding the use of community-wide mass treatment to reach more adults is under consideration. However, it should be noted that this would require a further increase in programmatic resources, international aid, and commitment for the provision of praziquantel. Consequently, it is important to understand (i) where a change of strategy would have the greatest benefit, and (ii) how generalisable the conclusions of field trials and analytical studies based on mathematical models investigating the impact of community-wide mass treatment, are to a broad range of settings.

Methods

In this paper, we employ a previously described deterministic fully age-structured schistosomiasis transmission model and evaluate the benefit of community-wide mass treatment both in terms of controlling morbidity and eliminating transmission for Schistosoma mansoni, across a wide range of epidemiological settings and programmatic scenarios. This included variation in the baseline relative worm pre-control burden in adults, the overall level of transmission in defined settings, choice of effectiveness metric (basing morbidity calculations on prevalence or intensity), the level of school enrolment and treatment compliance.

Results

Community-wide mass treatment was found to be more effective for controlling the transmission of schistosome parasites than using a school-based programme only targeting school-aged children. However, in the context of morbidity control, the potential benefit of switching to community-wide mass treatment was highly variable across the different scenarios analysed. In contrast, for areas where the goal is to eliminate transmission, the projected benefit of community-wide mass treatment was more consistent.

Conclusion

Whether community-wide mass treatment is appropriate will depend on the local epidemiological setting (i.e. the relative pre-control burden in adults and transmission intensity), and whether the goal is morbidity control or eliminating transmission. This has important implications regarding the generalisability of cost-effectiveness analyses of schistosomiasis interventions. Our results indicate that areas with poor school-enrolment/coverage could benefit more from community-wide treatment of praziquantel and should potentially be prioritised for any change in strategy. This work highlights the importance of not over-generalising conclusions and policy in this area, but of basing decisions on high quality epidemiological data and quantitative analyses of the impact of interventions in a range of settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-017-2141-5) contains supplementary material, which is available to authorized users.

One hundred years of neglect in paediatric schistosomiasis

Early in the history of schistosomiasis research, children under 5 years of age were known to be infected. Although this problem was recognized over 100 years ago, insufficient action has been taken to address this issue. Under current policy, such infected children only receive their first antiparasitic treatment (praziquantel - PZQ) upon entry into primary school as current mass drug administration programmes typically target school-aged children. For many infected children, they will wait up to 6 years before receiving their first medication and significant schistosomiasis-related morbidity may have already established. This inequity would not be accepted for other diseases. To unveil some of the reasons behind this neglect, it is paramount to understand the intricate historical relationship between schistosomiasis and British Imperial medicine, to underline its lasting influence on today's public health priorities. This review presents a perspective on the historical neglect of paediatric schistosomiasis, focusing on important gaps that persist from the early days after discovery of this parasite. Looking to end this inequity, we address several issues that need to be overcome to move forward towards the lasting success of schistosomiasis control and elimination efforts.

Refined stratified-worm-burden models that incorporate specific biological features of human and snail hosts provide better estimates of Schistosoma diagnosis, transmission, and control

BACKGROUND

Schistosoma parasites sustain a complex transmission process that cycles between a definitive human host, two free-swimming larval stages, and an intermediate snail host. Multiple factors modify their transmission and affect their control, including heterogeneity in host populations and environment, the aggregated distribution of human worm burdens, and features of parasite reproduction and host snail biology. Because these factors serve to enhance local transmission, their inclusion is important in attempting accurate quantitative prediction of the outcomes of schistosomiasis control programs. However, their inclusion raises many mathematical and computational challenges. To address these, we have recently developed a tractable stratified worm burden (SWB) model that occupies an intermediate place between simpler deterministic mean worm burden models and the very computationally-intensive, autonomous agent models.

METHODS

To refine the accuracy of model predictions, we modified an earlier version of the SWB by incorporating factors representing essential in-host biology (parasite mating, aggregation, density-dependent fecundity, and random egg-release) into demographically structured host communities. We also revised the snail component of the transmission model to reflect a saturable form of human-to-snail transmission. The new model allowed us to realistically simulate overdispersed egg-test results observed in individual-level field data. We further developed a Bayesian-type calibration methodology that accounted for model and data uncertainties.

RESULTS

The new model methodology was applied to multi-year, individual-level field data on S. haematobium infections in coastal Kenya. We successfully derived age-specific estimates of worm burden distributions and worm fecundity and crowding functions for children and adults. Estimates from the new SWB model were compared with those from the older, simpler SWB with some substantial differences noted. We validated our new SWB estimates in prediction of drug treatment-based control outcomes for a typical Kenyan community.

CONCLUSIONS

The new version of the SWB model provides a better tool to predict the outcomes of ongoing schistosomiasis control programs. It reflects parasite features that augment and perpetuate transmission, while it also readily incorporates differences in diagnostic testing and human sub-population differences in treatment coverage. Once extended to other Schistosoma species and transmission environments, it will provide a useful and efficient tool for planning control and elimination strategies.

Gaining and sustaining schistosomiasis control: study protocol and baseline data prior to different treatment strategies in five African countries

BACKGROUND

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was established in 2008 to answer strategic questions about schistosomiasis control. For programme managers, a high-priority question is: what are the most cost-effective strategies for delivering preventive chemotherapy (PCT) with praziquantel (PZQ)? This paper describes the process SCORE used to transform this question into a harmonized research protocol, the study design for answering this question, the village eligibility assessments and data resulting from the first year of the study.

METHODS

Beginning in 2009, SCORE held a series of meetings to specify empirical questions and design studies related to different schedules of PCT for schistosomiasis control in communities with high (gaining control studies) and moderate (sustaining control studies) prevalence of Schistosoma infection among school-aged children. Seven studies are currently being implemented in five African countries. During the first year, villages were screened for eligibility, and data were collected on prevalence and intensity of infection prior to randomisation and the implementation of different schemes of PZQ intervention strategies.

RESULTS

These studies of different treatment schedules with PZQ will provide the most comprehensive data thus far on the optimal frequency and continuity of PCT for schistosomiasis infection and morbidity control.

CONCLUSIONS

We expect that the study outcomes will provide data for decision-making for country programme managers and a rich resource of information to the schistosomiasis research community.

TRIAL REGISTRATION

The trials are registered at International Standard Randomised Controlled Trial registry (identifiers: ISRCTN99401114 , ISRCTN14849830 , ISRCTN16755535 , ISRCTN14117624 , ISRCTN95819193 and ISRCTN32045736 ).

The Accuracy of Praziquantel Dose Poles for Mass Treatment of Schistosomiasis in School Girls in KwaZulu-Natal, South Africa

Background

More than 260 million people live with schistosomiasis and regular mass-treatment should be implemented to prevent morbidity. Praziquantel, dosed at 40 milligrams per kilogram bodyweight, is the drug of choice. During the last decades the WHO Tablet Pole–which estimates tablet need by height as representing weight–has been used as a practical and cheap tool in mass treatment. In South Africa this method could be inaccurate given the prevalence of overweight and obesity. In this study in female pupils in KwaZulu-Natal, South Africa, we explored the accuracy of the WHO Tablet Pole and the recently developed Modified Dose Pole for adults with two additional intervals and correction for body mass index (BMI).

Methodology

In randomly selected primary and secondary schools of schistosomiasis-endemic areas, height and weight of female pupils were measured. The WHO Tablet Pole and Modified Dose Pole were used to indicate the amount of praziquantel according to height and the dose in milligrams per kilogram bodyweight was calculated. The BMI correction was performed by adding 600 milligrams (1 tablet) to the indicated dose if a person was overweight/obese.

Principal Findings

3157 female students were investigated and 35% were found to be overweight/obese. Using the WHO Tablet Pole, 73% would have received an adequate dose (range 30–60 mg/kg). When correcting for BMI, this would have been 94%. Using the Modified Dose Pole with BMI correction, 97% would have been adequately treated.

Conclusions

This study shows that the WHO Tablet Pole will be inaccurate in estimating the dose of praziquantel in South African girls due to high prevalence of overweight/obesity. Under-dosing of individuals who appear overweight/obese could be largely prevented by adding an extra praziquantel tablet to the recommended dose. Further research must be done to explore if subjective weight estimates are reliable.

Schistosomiasis is an acute and chronic parasitic disease caused by Schistosoma worms, contributing to morbidity and mortality in 261 million people, mainly in poor, rural communities. In an effort to control schistosomiasis, the World Health Organization advocates for regular mass treatment to at-risk populations, administering free praziquantel (40mg/kg). The WHO Tablet Pole, which estimates the number of tablets for each individual by height, is recommended for the dosing of praziquantel. A Modified Dose Pole with two additional height intervals has been developed for adults. In addition, the developers of the Modified Dose Pole suggest to add an extra tablet to the indicated dose if the person appears to be overweight/obese (“correction for body mass index (BMI)”). This study explored the accuracy of these dose pole programmes in 3157 school-girls in schistosomiasis-endemic KwaZulu-Natal, South Africa. Overweight or obesity was found in 35% of the study population. With the WHO Tablet Pole, only 73% would have received an acceptable dose (30-60mg/kg), whereas when correcting for overweight/obesity almost all the girls would have been adequately treated. We suggest adding one tablet to the dose recommended by the WHO Tablet Pole if a person appears to be overweight/obese to prevent under-dosing of these individuals.

Modelling control of Schistosoma haematobium infection: predictions of the long-term impact of mass drug administration in Africa

Background

Effective control of schistosomiasis remains a challenging problem for endemic areas of the world. Given knowledge of the biology of transmission and past experience with mass drug administration (MDA) programs, it is important to critically evaluate the likelihood that MDA programs will achieve substantial reductions in Schistosoma prevalence. In implementing the World Health Organization Roadmap for Neglected Tropical Diseases it would useful for policymaking to model projections of the status of Schistosoma control in MDA-treated areas in the next 5–10 years.

Methods

Calibrated mathematical models were used to project the effects of different frequency and coverage of MDA for schistosomiasis haematobia control in present-day endemic communities, taking into account uncertainties of parasite biology and input data. The modeling approach in this analysis was the Stratified Worm Burden model developed in our earlier works, calibrated using data from longitudinal S. haematobium control trials in Kenya.

Results

Model-based simulations of MDA control in typical low-risk and higher-risk communities indicated that infection prevalence can be substantially reduced within 10 years only when there is a high degree of community participation (>70 %) with at least annual MDA. Significant risk for re-emergence of infection remains if MDA is suspended.

Conclusions

In a stable (stationary) ecosystem, Schistosoma reproduction and transmission are sufficiently robust that the process of human infection continues, even under pressure from aggressive MDA. MDA alone is unlikely to interrupt transmission, and once mass treatment is suspended, the prevalence of human infection is likely to rebound to pre-control levels over a period of 25–30 years. MDA success in achieving very low levels of infection prevalence is highly dependent on treatment coverage and frequency within the local human population, and requires that both adults and children be included in drug delivery coverage. Ultimately, supplemental snail control and significant improvements in sanitation will be required to achieve full control of schistosomiasis by elimination of ongoing Schistosoma transmission.

Electronic supplementary material

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Health metrics for helminth infections

Health metrics based on health-adjusted life years have become standard units for comparing the disease burden and treatment benefits of individual health conditions. The Disability-Adjusted Life Year (DALY) and the Quality-Adjusted Life Year (QALY) are the most frequently used in cost-effect analyses in national and global health policy discussions for allocation of health care resources. While sometimes useful, both the DALY and QALY metrics have limitations in their ability to capture the full health impact of helminth infections and other 'neglected tropical diseases' (NTDs). Gaps in current knowledge of disease burden are identified, and interim approaches to disease burden assessment are discussed.

Population biology of Schistosoma mating, aggregation, and transmission breakpoints: more reliable model analysis for the end-game in communities at risk

Mathematical modeling is widely used for predictive analysis of control options for infectious agents. Challenging problems arise for modeling host-parasite systems having complex life-cycles and transmission environments. Macroparasites, like Schistosoma, inhabit highly fragmented habitats that shape their reproductive success and distribution. Overdispersion and mating success are important factors to consider in modeling control options for such systems. Simpler models based on mean worm burden (MWB) formulations do not take these into account and overestimate transmission. Proposed MWB revisions have employed prescribed distributions and mating factor corrections to derive modified MWB models that have qualitatively different equilibria, including ‘breakpoints’ below which the parasite goes to extinction, suggesting the possibility of elimination via long-term mass-treatment control. Despite common use, no one has attempted to validate the scope and hypotheses underlying such MWB approaches. We conducted a systematic analysis of both the classical MWB and more recent “stratified worm burden” (SWB) modeling that accounts for mating and reproductive hurdles (Allee effect). Our analysis reveals some similarities, including breakpoints, between MWB and SWB, but also significant differences between the two types of model. We show the classic MWB has inherent inconsistencies, and propose SWB as a reliable alternative for projection of long-term control outcomes.

Neglected tools for neglected diseases: mathematical models in economic evaluations

Despite many current interventions against neglected tropical diseases (NTDs) being highly cost-effective, new strategies are needed to reach the WHO's control and elimination goals. Here we argue for the importance of incorporating economic evaluations of new strategies in decisions regarding resource allocation. Such evaluation should ideally be conducted using dynamic transmission models that capture inherent nonlinearities in transmission and the indirect benefits ('herd effects') of interventions. A systematic review of mathematical models that have been used for economic analysis of interventions against the ten NTDs covered by the London Declaration reveals that only 16 out of 49 studies used dynamic transmission models, highlighting a fundamental--but addressable--gap in the evaluation of interventions against NTDs.

Predicted impact of mass drug administration on the development of protective immunity against Schistosoma haematobium

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A cellular automaton model of Schistosoma japonicum infection

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