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

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

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

Schistosomiasis at the Crossroad to Elimination: Review of Eclipsed Research with Emphasis on the Post-Transmission Agenda

While chronic schistosomiasis is pathologically well defined, the acute form of the disease is less well understood. It is generally agreed that early lesions, such as lung nodules and bladder polyps, are reversible, which impedes identification of the time elapsed since exposure. The intermediate stage between the acute and the chronic forms of schistosomiasis requires further investigation, as does the clinical stage due to lesions remaining after treatment. With current schistosomiasis control efforts gradually progressing to elimination, there is a need to focus on post-transmission schistosomiasis, which not only refers to remaining lesions from previous infections, but also accounts for the potential presence of surviving worms after treatment. This issue is particularly salient for migrants from endemic to non-endemic countries and should be kept in mind for returning expatriates from schistosomiasis-endemic countries. Negative stool examination or urine filtration are generally taken as indicative of cure since rectoscopy for Schistosoma mansoni infection, or cystoscopy for S. haematobium infection, are rarely performed. However, pathology of affected organs may persist indefinitely, while potentially remaining live worms could produce additional pathology. Hence, post-transmission schistosomiasis can prevail for years after elimination of the disease, and thus, warrant further attention.

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

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

Genetic diversity and structure of Oncomelania hupensis hupensis in two eco-epidemiological settings as revealed by the mitochondrial COX1 gene sequences

BACKGROUND

Oncomelania hupensis hupensis is the only intermediate host of Schistosoma japonicum, the causative agent of schistosomiasis in China and is therefore of significant medical and veterinary health importance. Although tremendous progress has been achieved, there remains an understudied area of approximately 2.06 billion m² of potential snail habitats. This area could be further increased by annual flooding. Therefore, an understanding of population genetics of snails in these areas may be useful for future monitoring and control activities.

METHODS AND RESULTS

We sampled snails from Hexian (HX), Zongyang (ZY) and Shitai (ST) in Anhui (schistosomiasis transmission control), and from Hengtang (HT), Taicang (TC), Dongsan (DS) and Xisan (XS) in Jiangsu (schistosomiasis transmission interrupted), downstream of Anhui. ST, DS and XS are classified as hilly and mountainous areas, and HX, ZY, TC and HT as lake and marshland areas. The mitochondrial cytochrome c oxidase subunit I gene were sequenced. Out of 115 snails analyzed, 29 haplotypes were identified. We observed 56 (8.72%) polymorphic sites consisting of 51 transitions, four transversions and one multiple mutational change. The overall haplotype and nucleotide diversity were 0.899 and 0.01569, respectively. Snail populations in Anhui had higher genetic diversity than in Jiangsu. 73.32% of total variation was distributed among sites and 26.68% within sites. Snails were significantly separated according to eco-epidemiological settings in both network and phylogenetic analyses.

CONCLUSION

Our results could provide important guidance towards assessing coevolutionary interactions of snails with S. japonicum, as well as for future molluscan host monitoring and control activities.

Elimination of schistosomiasis in China: Current status and future prospects

Elimination of schistosomiasis as a public health problem among all disease-endemic countries in 2030 is an ambitious goal. Recent achievements resulting from mass drug administration (MDA) with praziquantel is promising but may need to be complemented with also other means. Schistosomiasis was highly prevalent in China before the initiation of the national schistosomiasis control program in the mid-1950s, and, at that time, the country bore the world's highest burden of schistosomiasis. The concerted control efforts, upheld without interruption for more than a half century, have resulted in elimination of the disease as a public health problem in China as of 2015. Here, we describe the current status of schistosomiasis in China, analyze the potential challenges affecting schistosomiasis elimination, and propose the future research needs and priorities for the country, aiming to provide more universal insights into the structures needed for a global schistosomiasis elimination encompassing also other endemic regions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Core components, concepts and strategies for parasitic and vector-borne disease elimination with a focus on schistosomiasis: A landscape analysis

Efforts to control and eliminate human schistosomiasis have accelerated over the past decade. In a number of endemic countries and settings, interruption of schistosome transmission has been achieved. In others, Schistosoma infections continue to challenge program managers at different levels, from the complexity of the transmission cycle, over limited treatment options and lack of field-friendly accurate diagnostics, to controversy around adequate intervention strategies. We conducted a landscape analysis on parasitic and vector-borne disease elimination approaches with the aim to identify evidence-based strategies, core components and key concepts for achieving and sustaining schistosomiasis control and for progressing elimination efforts towards interruption of transmission in sub-Saharan Africa. A total of 118 relevant publications were identified from Web of Science, Pubmed and the grey literature and reviewed for their content. In addition, we conducted in-depth interviews with 23 epidemiologists, program managers, policymakers, donors and field researchers. Available evidence emphasizes the need for comprehensive, multipronged and long-term strategies consisting of multiple complementary interventions that must be sustained over time by political commitment and adequate funding in order to reach interruption of transmission. Based on the findings of this landscape analysis, we propose a comprehensive set of intervention strategies for schistosomiasis control and elimination. Before deployment, the proposed interventions will require review, evaluation and validation in the frame of an expert consultation as a step towards adaptation to specific contexts, conditions and settings. Field testing to ensure local relevance and effectiveness is paramount given the diversity of socio-ecological and epidemiological contexts.

This landscape analysis explored successful concepts, approaches and interventions of past and ongoing parasitic and vector-borne disease elimination efforts and programs with regard to relevance for progress in the elimination of human schistosome infections. Schistosomiasis is a disabling, water borne parasitic disease of public health concern with an estimated 250 million people infected worldwide. The long-term morbidity of this neglected tropical disease significantly impacts growth, cognition and socioeconomic development at all ages. Despite increased global efforts to control morbidity and advance elimination, challenges in view of the complex life cycle which involves freshwater sources, intermediate snail hosts and humans, remain. This calls for targeted interventions and concerted programs. According to the evidence from the literature and as proposed by a wide range of key informants, comprehensive, multipronged and long-term strategies supported by strong political commitment and adequate funding are required in order to achieve and sustain the set goals. Based on the findings, we propose here a comprehensive set of intervention strategies for schistosomiasis control and elimination for review and evaluation to inform implementation research needs and elimination program design.

Meta-analyses of Schistosoma japonicum infections in wild rodents across China over time indicates a potential challenge to the 2030 elimination targets

China once suffered greatly from schistosomiasis japonica, a major zoonotic disease. Nearly 70 years of multidisciplinary efforts have achieved great progress in disease control, with infections in both humans and bovines significantly reduced to very low levels. However, reaching for the target of complete interruption of transmission at the country level by 2030 still faces great challenges, with areas of ongoing endemicity and/or re-emergence within previously 'eliminated' regions. The objectives of this study were, by using meta-analytical methods, to estimate the overall prevalence of Schistosoma japonicum infections in abundant commensal rodent species in mainland China after the introduction of praziquantel for schistosomiasis treatment in humans and bovines in 1980s. In doing so we thereby aimed to further assess the role of wild rodents as potential reservoirs in ongoing schistosome transmission. Published studies on infection prevalence of S. japonicum in wild rodents in mainland China since 1980 were searched across five electronic bibliographic databases and lists of article references. Eligible studies were selected based on inclusion and exclusion criteria. Risks of within and across study biases, and the variations in prevalence estimates attributable to heterogeneities were assessed. The pooled infection prevalence and its 95% confidence intervals (CIs) were calculated with the Freeman-Tukey double arcsine transformation. We identified a total of 37 relevant articles involving 61 field studies which contained eligible data on 8,795 wild rodents across mainland China. The overall pooled infection prevalence was 3.86% (95% CI: 2.16-5.93%). No significant change in the overall pooled prevalence was observed between 1980-2003 (n = 23 studies) and 2004-current (n = 38 studies). However, whilst the estimated prevalence decreased over time in the marshland and lake regions, there was an apparent increase in prevalence within hilly and mountainous regions. Among seven provinces, a significant prevalence reduction was only seen in Jiangsu where most endemic settings are classified as the marshland and lakes. These estimates changed over season, ranging from 0.58% in spring to 22.39% in winter, in association with increases in rodent density. This study systematically analyzed S. japonicum infections in wild rodents from the published literature over the last forty years after the introduction of praziquantel for schistosomiasis treatment in humans and bovines in 1980s. Although numbers of schistosomiasis cases in humans and bovines have been greatly reduced, no such comparable overall change of infection prevalence in rodents was detected. Furthermore, there appeared to be an increase in S. japonicum prevalence in rodents over time within hilly and mountainous regions. Rodents have been projected to become the dominant wildlife in human-driven environments and the main reservoir of zoonotic diseases in general within tropical zones. Our findings thus suggest that it is now necessary to include monitoring and evaluation of potential schistosome infection within rodents, particularly in hilly and mountainous regions, if we are ever to reach the new 2030 elimination goals and to maximize the impact of future public, and indeed One Health, interventions across, regional, national and international scales.

Effectiveness of health education in improving knowledge, practice and belief related to clonorchiasis in children

Clonorchiasis is caused by the ingestion of raw freshwater fish containing Clonorchis sinensis larvae. Health education is crucial in sustainable control of clonorchiasis but extremely challenging when dealing with adults. To investigate if education in children would be a beneficial long-term approach, a cluster-controlled trial was implemented in two primary schools between 2017 and 2019 in Binyang county, Guangxi, China. A baseline survey was conducted in both schools, and then comprehensive education activities were implemented in the interventional one. Six and 12 months later, all pupils were subjected to a survey to assess the potential change of knowledge, practice and belief related to clonorchiasis. Finally, 247 pupils in interventional school and 151 ones in control were eligible for analysis. In the interventional school, the percentage of pupils with knowledge on transmission route, early symptoms, complications and carcinogenicity increased from 15.0% to 78.5% (p < 0.001), from 6.5% to 36.8% (p < 0.001), from 4.0% to 93.9% (p < 0.001) and from 4.5% to 49.4% (p < 0.001) after 12 months. In this school, 16 pupils (6.5%) had eaten raw freshwater fish during the year immediately before the baseline survey, a number that decreased to 3 (1.2%) (p = 0.002) 12 months later. The percentage of students had the belief on the ability not to eat raw freshwater fish in the future was 70.9% at the baseline and 97.2% 12 months later (p < 0.001). Although knowledge related to clonorchiasis also increased in the control school, the absolute percentage of changes was lower; in particular, practice and belief had not changed.

Elimination of schistosomiasis requires multifactorial diagnostics: evidence from high- and low-prevalence areas in the Nile Delta, Egypt

Background

Schistosomiasis is one of the neglected tropical diseases (NTDs) selected for worldwide elimination in the near future. Egypt has made strong progress against its two endemic species of Schistosoma mansoni and S. haematobium. The former is prevalent in the Nile Delta with the latter dominating in the Nile south of Cairo. Innovative efforts are needed to reach the goal as further reduction of the prevalence has stalled due to ongoing transmission. In this study we aimed to explore the difference between low and high prevalence villages with regard to knowledge attitude and practice about schistosomiasis, utilization of health services, infection and transmission indices.

Methods

A hybrid cross-sectional longitudinal study was conducted with three annual follow-ups conducted during 1994–1996. We used a representative systematic random sampling technique investigating 993 individuals from the high prevalence village and 614 from the low prevalence village. Data were analyzed using SPSS, comparing proportions with the Chi square test and means with the Student t test, and ANOVA.

Results

Compliance of faecal sampling and chemotherapy was above 70% in both villages over the whole study period. Selective praziquantel treatment resulted in a significant reduction of prevalence and intensity of infection in both villages, dropping from 35.8% prevalence to 20.6%, in the low-prevalence village, and from 69.5 to 45.9% in the high-prevalence one. Intensity of infection at the base line was 30 eggs per gram (EPG) of stool in the low-prevalence village versus 105 EPG in the high-prevalence village. However, after the second round, reinfection rebounded by 22% in the high-prevalence village, while a slight improvement of the infection indices was demonstrated in the low-prevalence one. The level of knowledge was modest in both villages: people knew about self-protection and treatment, but not much about the role of human excreta for schistosomiasis transmission. While all participants maintained that using the water from the canals was inevitable, inhabitants in the high-prevalence village showed significantly lower scores reflecting higher water contact compared to the low-prevalence one. Many of them (67%) did not utilize the health centre at all compared to 26% of the people in the low-prevalence village. Interestingly, private clinics were seen as the primary source of health care by both villages, but more frequently so in the high-prevalence village (used by 87.2% of the inhabitants) compared to the low-prevalence one (59.8%).

Conclusions

Even if chemotherapy works well as reflected by the observed downregulation of intensity of infection in both villages, reinfection continued due to difficulties to avoid water contact. Efforts must be made to make people understand the role of human excreta for transmission. There is also a need to make people better trust the medical services available.

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

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

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

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

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.

From country control programmes to translational research

From the time it was conceptualized in 1998 to the present, RNAS⁺ has largely concentrated on research that will generate results to facilitate control, prevention and elimination of its target diseases. Diagnostics has remained an active field of research in order to develop tools that are appropriate for each stage from the first efforts until attempts to block transmission. For example, with regard to schistosomiasis, chemotherapy has excellent impact on morbidity, while better diagnostics and vaccine research have been promoted to complement the other components of the control programme. The need for surveillance in areas where the prevalence has been brought down to very low levels necessitated development of spatio-temporal tools and ecological models based on geographical information systems (GIS) to produce risk and distribution maps for monitoring and evaluation of programme success. New knowledge and experiences in management of the diseases contribute to the formulation of new schemes in management and treatment. Ways of drawing attention to the disease, such as determining disability weights for use in computation of burden of disease, updating epidemiological profile and unravelling new aspects of the disease provide bases for modifying the operation of control programmes as we move forward. Programme evaluation based on reports of actual implementation of activities brought to the fore problems related to the distribution of chemotherapy as well as social, cultural and behavioural aspects of endemic communities. Importantly, this highlighted the necessity of adapting control activities to specific situations of the endemic areas. New models evolving from reviews of this kind and success stories, such us the elimination of lymphatic filariasis (LF) in PR China and Cambodia are presented.

From inspiration to translation: Closing the gap between research and control of helminth zoonoses in Southeast Asia

Poverty magnifies limitations resulting from traditional biases and environmental risks in endemic areas. Any approach towards disease control needs to recognise that socially embedded vulnerabilities can be as powerful as externally imposed infections. Important for RNAS was networking across borders, not just on schistosomiasis but on the whole spectrum of endemic helminthiases, and this bore fruit in the form of the expansion of RNAS into the 'Regional Network on Asian Schistosomiasis and other Helminth Zoonoses (RNAS⁺)', which focuses on technical standardization, supporting the growth of research capacity and the further development of networking. Administration is lean and largely virtual with the focus on connecting members via the Internet, providing databases and administrative back-up. The strategy emphasizes ways and means to alleviate the spectre of disease and poverty from the endemic areas through boosting research on target diseases and supporting collaboration between basic and operational research on the one hand and control/elimination activities on the other. RNAS⁺ also benefits from continuing input from outside research institutions in areas outside Southeast Asia. This paper is aiming to identify the priority actions to close the gap between researcher and policy makers.

Schistosomiasis Elimination: Beginning of the End or a Continued March on a Trodden Path

In spite of spectacular progress towards the goal of elimination of schistosomiasis, particularly in China but also in other areas, research gaps and outstanding issues remain. Although expectations of achieving elimination of this disease have never been greater, all constraints have not been swept aside. Indeed, there are some formidable obstacles, such as insufficient amounts of drugs to treat everybody and still limited use of high-sensitive diagnostic techniques, both for the definitive and the intermediate hosts, which indicate that prevalence is considerably underrated in well-controlled areas. Elimination will be difficult to achieve without a broad approach, including a stronger focus on transmission, better diagnostics and the establishment of a reliable survey system activating a rapid response when called for. Importantly, awareness of the crucial importance of transmission has been revived resulting in renewed interest in snail control together with more emphasis on health education and sanitation. The papers collected in this special issue entitled ‘Prospects for Schistosomiasis Elimination’ reflect these issues and we are particularly pleased to note that some also discuss the crucial question when to declare a country free of schistosomiasis and present techniques that together create an approach that can show unequivocally when interruption of transmission has been achieved.

Artemether and Praziquantel: Origin, Mode of Action, Impact, and Suggested Application for Effective Control of Human Schistosomiasis

The stumbling block for the continued, single-drug use of praziquantel (PZQ) against schistosomiasis is less justified by the risk of drug resistance than by the fact that this drug is inactive against juvenile parasites, which will mature and start egg production after chemotherapy. Artemisinin derivatives, currently used against malaria in the form of artemisinin-based combination therapy (ACT), provide an opportunity as these drugs are not only active against malaria plasmodia, but surprisingly also against juvenile schistosomes. An artemisinin/PZQ combination would be complementary, and potentially additive, as it would kill two schistosome life cycle stages and thus confer a transmission-blocking modality to current chemotherapy. We focus here on single versus combined regimens in endemic settings. Although the risk of artemisinin resistance, already emerging with respect to malaria therapy in Southeast Asia, prevents use in countries where ACT is needed for malaria care, an artemisinin-enforced praziquantel treatment (APT) should be acceptable in regions of North Africa (including Egypt), the Middle East, China, and Brazil that are not endemic for malaria. Thanks to recent progress with respect to high-resolution diagnostics, based on circulating schistosome antigens in humans and molecular approaches for snail surveys, it should be possible to keep areas scheduled for schistosomiasis elimination under surveillance, bringing rapid response to bear on problems arising. The next steps would be to investigate where and for how long APT should be applied to make a lasting impact. A large-scale field trial in an area with modest transmission should tell how apt this approach is.