Predictors for participation in mass-treatment and female genital schistosomiasis re-investigation, and the effect of praziquantel treatment in South African adolescents

OBJECTIVE

Female Genital Schistosomiasis (FGS) causes intravaginal lesions and symptoms that could be mistaken for sexually transmitted diseases or cancer. In adults, FGS lesions [grainy sandy patches (GSP), homogenous yellow patches (HYP), abnormal blood vessels and rubbery papules] are refractory to treatment. The effect of treatment has never been explored in young women; it is unclear if gynaecological investigation will be possible in this young age group (16-23 years). We explored the predictors for accepting anti-schistosomal treatment and/or gynaecological reinvestigation in young women, and the effects of anti-schistosomal mass-treatment (praziquantel) on the clinical manifestations of FGS at an adolescent age.

METHOD

The study was conducted between 2011 and 2013 in randomly selected, rural, high schools in Ilembe, uThungulu and Ugu Districts, KwaZulu-Natal Province, East Coast of South Africa. At baseline, gynaecological investigations were conducted in female learners in grades 8 to 12, aged 16-23 years (n = 2293). Mass-treatment was offered in the low-transmission season between May and August (a few in September, n = 48), in accordance with WHO recommendations. Reinvestigation was offered after a median of 9 months (range 5-14 months). Univariate, multivariable and logistic regression analysis were used to measure the association between variables.

RESULTS

Prevalence: Of the 2293 learners who came for baseline gynaecological investigations, 1045 (46%) had FGS lesions and/or schistosomiasis, 209/1045 (20%) had GSP; 208/1045 (20%) HYP; 772/1045 (74%) had abnormal blood vessels; and 404/1045 (39%) were urine positive. Overall participation rate for mass treatment and gynaecological investigation: Only 26% (587/2293) learners participated in the mass treatment and 17% (401/2293) participated in the follow up gynaecological reinvestigations. Loss to follow-up among those with FGS: More than 70% of learners with FGS lesions at baseline were lost to follow-up for gynaecological investigations: 156/209 (75%) GSP; 154/208 (74%) HYP; 539/722 (75%) abnormal blood vessels; 238/404 (59%) urine positive. The grade 12 pupil had left school and did not participate in the reinvestigations (n = 375; 16%). Follow-up findings: Amongst those with lesions who came for both treatment and reinvestigation, 12/19 still had GSP, 8/28 had HYP, and 54/90 had abnormal blood vessels. Only 3/55 remained positive for S. haematobium ova. Factors influencing treatment and follow-up gynaecological investigation: HIV, current water contact, water contact as a toddler and urinary schistosomiasis influenced participation in mass treatment. Grainy sandy patches, abnormal blood vessels, HYP, previous pregnancy, current water contact, water contact as a toddler and father present in the family were strongly associated with coming back for follow-up gynaecological investigation. Challenges in sample size for follow-up analysis of the effect of treatment: The low mass treatment uptake and loss to follow up among those who had baseline FGS reduced the chances of a larger sample size at follow up investigation. However, multivariable analysis showed that treatment had effect on the abnormal blood vessels (adjusted odds ratio = 2.1, 95% CI 1.1-3.9 and p = 0.018).

CONCLUSION

Compliance to treatment and gynaecological reinvestigation was very low. There is need to embark on large scale awareness and advocacy in schools and communities before implementing mass-treatment and investigation studies. Despite challenges in sample size and significant loss to follow-up, limiting the ability to fully understand the treatment's effect, multivariable analysis demonstrated a significant treatment effect on abnormal blood vessels.

The Association Between Female Genital Schistosomiasis and Other Infections of the Lower Genital Tract in Adolescent Girls and Young Women: A Cross-Sectional Study in South Africa

OBJECTIVES/PURPOSES OF THE STUDY

This study aimed to explore the relationship between female genital schistosomiasis (FGS), sexually transmitted infections, bacterial vaginosis, and yeast among young women living in Schistosoma haematobium-endemic areas.

METHODS

In a cross-sectional study of young women, sexually active, aged 16 to 22 years in rural KwaZulu-Natal, South Africa, in 32 randomly selected rural schools in schistosomiasis-endemic areas, the authors performed gynecological and laboratory investigations, diagnosed FGS and other infections, and did face-to-face interviews.

RESULTS

Female genital schistosomiasis was the second most prevalent current genital infection (23%), significantly more common in those who had urinary schistosomiasis (35%), compared with those without (19%, p < .001). In the FGS-positive group, 35% had human papillomavirus compared with 24% in the FGS-negative group (p = .010). In the FGS-positive group, 37% were seropositive for herpes simplex virus infection, compared with 30% in the FGS-negative group (p = .079). There were significantly fewer chlamydia infections among women with FGS (20%, p = .018) compared with those who did not have FGS (28%).

CONCLUSIONS

Female genital schistosomiasis was the second most common genital infection after herpes simplex virus. Human papillomavirus infection was significantly associated with FGS, but Chlamydia was negatively associated with FGS. Women with FGS may have had more frequent contact with the health system for genital discharge. The results show the importance of the inclusion of FGS in the national management protocols for genital infections in areas endemic for S. haematobium and highlight a more comprehensive approach to diagnosis and genital disease management.

Female Genital Schistosomiasis Lesions Explored Using Circulating Anodic Antigen as an Indicator for Live Schistosoma Worms

Background

In areas where reinfection with schistosomiasis is rampant, it is not known if the lesions of Female Genital Schistosomaisis are a consequence of live worms, or caused by dead ova. Live schistosome worms regurgitate Circulating Anodic Antigen (CAA). We sought to explore the association between the different lesions of FGS (grainy sandy patches, homogenous yellow patches, rubbery papules and abnormal blood vessels) and the presence of live worms as indicated by S. haematobium-derived CAA in blood.

Materials and Methods

In this cross-sectional study, rural high schools were randomly selected from Ilembe, uThungulu and Ugu Districts on the East Coast of South Africa, KwaZulu-Natal Province. Serum samples for CAA analysis were collected from 246 female learners aged 16 - 23 years. Uncorrected chi-square and odds ratio with 95% confidence interval (CI) were used to evaluate the null hypothesis.

Results

CAA was positive in 82/246 (33%) of the participants. Sandy patches were found in 123 (50%) of the study population. Grainy sandy patches were significantly associated with CAA even after controlling for age (Adjusted Odds Ratio (AOR) 4.2, 95% CI 2.3 - 7.9, p &lt; 0.001). Likewise, abnormal blood vessels were associated with CAA (AOR 3.0, 95% CI 1.5-4.5, p = 0.001) whereas homogenous yellow patches were not associated with CAA (p = 0.57). Rubbery papules were not found in this study population.

Conclusion

Grainy sandy patches and abnormal blood vessels are found more commonly in women who harbour live Schistosoma haematobium worms whilst homogenous yellow patches may indicate chronic tissue damage due to dead ova.

Mapping Schistosoma haematobium for Novel Interventions against Female Genital Schistosomiasis and Associated HIV Risk in KwaZulu-Natal, South Africa

Women with female genital schistosomiasis (FGS) have been found to have genital symptoms and a three-fold higher risk of HIV infection. Despite WHO recommendations, regular antischistosomal mass drug administration (MDA) has not yet been implemented in South Africa possibly because of the lack of updated epidemiological data. To provide data for future prevention efforts against FGS and HIV, this study explored Schistosoma haematobium prevalence in girls and young women and the effects of antischistosomal MDA, respectively. Urinary schistosomiasis and genital symptoms were investigated in 70 randomly selected secondary schools in three districts within KwaZulu-Natal and 18 primary schools. All study participants were treated for schistosomiasis, and schools with the highest urinary prevalence were followed up after 1 and 4 years of MDA. At baseline, urine analysis data showed that most schools were within the moderate-risk prevalence category where biennial antischistosomal MDA is recommended, as per WHO guidelines. Young women had high prevalence of genital symptoms (36%) after correcting for sexually transmitted infections. These symptoms may be caused by infection with schistosomes. However, FGS cannot be diagnosed by urine analysis alone. In KwaZulu-Natal rural schools, this study suggests that antischistosomal MDA with praziquantel could prevent genital symptoms in more than 200,000 young women. Furthermore, it is feasible that more than 5,000 HIV infections could be prevented in adolescent girls and young women by treatment and prevention of FGS.

Experimental Infection of Human Volunteers with the Heat-Stable Enterotoxin-Producing Enterotoxigenic Escherichia coli Strain TW11681

Infection with enterotoxigenic Escherichia coli (ETEC) producing the heat-stable enterotoxin (ST) is one of the most important causes of childhood diarrhoea in low- and middle-income countries. Here, we undertook a controlled human infection model (CHIM) study to investigate whether ST-producing ETEC strain TW11681 would be suitable for testing the protective efficacy of new ST-based vaccine candidates in vaccine challenge models. In groups of three, nine volunteers ingested 1 × 10⁶, 1 × 10⁷, or 1 × 10⁸ colony-forming units (CFU) of TW11681. Flow cytometry-based assays were used to measure CD4+ T cell responses and antibody levels targeting virulence factors expressed by the strain. We found that infection with TW11681 elicited few and mild symptoms, including mild diarrhoea in two volunteers, both of whom ingested 1 × 10⁶ CFU. Averaged across all volunteers, the CD4+ T cell responses specific for E. coli YghJ mucinase peaked 10 days after infection (3.2-fold (p = 0.016)), while the CD4+ T cell responses specific for Colonization Factor Antigen I (CFA/I) major fimbrial subunit (CfaB) peaked after 28 days (3.6-fold (p = 0.063)). The serum CfaB-specific anti-IgA and anti-IgG/IgM levels were significantly increased and peaked 3 months after infection. Both remained elevated for the duration of the 12-month follow-up. The corresponding anti-YghJ serological response was strongest after 10 days, although a significant increase was seen only for IgA levels (3.2-fold (p = 0.008)). In conclusion, due to its low diarrhoea attack risk, TW11681 is probably not suitable for testing the efficacy of new vaccines in human challenge studies at doses 1 × 10⁶ to 1 × 10⁸. However, the strain may still be useful in CHIMs for studying ETEC host-pathogen interactions.

Reproductive health problems in rural South African young women: risk behaviour and risk factors

BACKGROUND

South African young women continue to be vulnerable, with high prevalence of teenage pregnancy, HIV, sexually transmitted infections (STIs) and female genital schistosomiasis (FGS). This study seeks to examine the underlying factors that may be associated with these four adverse reproductive health outcomes.

METHODS

In a cross-sectional study of 1413 sexually active of young women, we explored these four adverse reproductive health outcomes by considering socio-demographic factors, socio-economic factors, sexual risk behaviour, substance abuse and knowledge about reproductive health by using a questionnaire. Consenting participants were asked about previous pregnancies and were tested for HIV, STIs and FGS. Multivariable regression analyses were used to explore the factors associated with these four reproductive health outcomes.

RESULTS

1. Early pregnancy: Among the young women, 44.4% had already been pregnant at least once. Associated factors were hormonal contraceptives, (adjusted odds ratio (AOR): 17.94, 95% confidence interval (CI): 12.73-25.29), and sexual debut < 16 years (AOR: 3.83, 95% CI: 2.68-5.47). Living with both parents (AOR 0.37, 95% CI: 0.25-0.57) and having a steady partner (AOR: 0.43, 95% CI: 0.24-0.76) were identified as protective factors against pregnancy. 2. HIV: HIV prevalence was 17.1%. The odds of having HIV were higher in intergenerational (AOR: 2.06, 95% CI: 1.05-4.06) and intragenerational relationships (AOR: 1.51 95% CI: 1.06-2.15), compared to age-homogenous relationships. Other associated factors were: condom use (AOR: 1.60, 95% CI: 1.16-2.20), number of times treated for an STI (AOR: 1.32, 95% CI: 1.02-1.71), and total number of partners (AOR: 1.14, 95% CI: 1.03-1.28). 3. STIs: Participants who had at least one STI (40.5%) were associated with total partner number (AOR 1.17, 95% CI: 1.06-1.30), and testing HIV positive (AOR: 1.88, 95% CI 1.41-2.50). 4. FGS: FGS prevalence (19.7%) was associated with previous anti-schistosomal treatment (AOR: 2.18, 95% CI: 1.57-3.05).

CONCLUSION

There is a high prevalence of pregnancy, HIV, STIs and FGS among sexually active young women in rural KwaZulu-Natal. Multidisciplinary approaches are urgently needed for educational and health literacy programs prior to sexual debut, and health care facilities, which should be made accessible for young women.

Evaluating diagnostic indicators of urogenital Schistosoma haematobium infection in young women: A cross sectional study in rural South Africa

BACKGROUND

Urine microscopy is the standard diagnostic method for urogenital S. haematobium infection. However, this may lead to under-diagnosis of urogenital schistosomiasis, as the disease may present itself with genital symptoms in the absence of ova in the urine. Currently there is no single reliable and affordable diagnostic method to diagnose the full spectrum of urogenital S. haematobium infection. In this study we explore the classic indicators in the diagnosis of urogenital S. haematobium infection, with focus on young women.

METHODS

In a cross-sectional study of 1237 sexually active young women in rural South Africa, we assessed four diagnostic indicators of urogenital S. haematobium infection: microscopy of urine, polymerase chain reaction (PCR) of cervicovaginal lavage (CVL), urogenital symptoms, and sandy patches detected clinically in combination with computerised image analysis of photocolposcopic images. We estimated the accuracy of these diagnostic indicators through the following analyses: 1) cross tabulation (assumed empirical gold standard) of the tests against the combined findings of sandy patches and/or computerized image analysis and 2) a latent class model of the four indicators without assuming any gold standard.

RESULTS

The empirical approach showed that urine microscopy had a sensitivity of 34.7% and specificity of 75.2% while the latent class analysis approach (LCA) suggested a sensitivity of 81.0% and specificity of 85.6%. The empirical approach and LCA showed that Schistosoma PCR in CVL had low sensitivity (14.1% and 52.4%, respectively) and high specificity (93.0% and 98.0, respectively). Using LCA, the presence of sandy patches showed a sensitivity of 81.6 and specificity of 42.4%. The empirical approach and LCA showed that urogenital symptoms had a high sensitivity (89.4% and 100.0%, respectively), whereas specificity was low (10.6% and 12.3%, respectively).

CONCLUSION

All the diagnostic indicators used in the study had limited accuracy. Using urine microscopy or Schistosoma PCR in CVL would only confirm a fraction of the sandy patches found by colposcopic examination.

High-risk human papillomavirus types in HIV-infected and HIV-uninfected young women in KwaZulu-Natal, South Africa: implications for vaccination

BACKGROUND

High-risk human papillomavirus (hr-HPV) infections and low-grade squamous intraepithelial lesions occur frequently in young women. The available vaccines cover up to seven hr-HPV genotypes (HPV16, HPV18, HPV31, HPV33, HPV45, HPV52 and HPV58) and two low-risk HPV types (HPV6 and HPV11). The objective of this study was to describe the hr-HPV genotypes present among HIV-uninfected and HIV-infected young women in rural high schools.

METHODS

Cervicovaginal lavages were obtained from sexually active young women recruited from high schools in KwaZulu-Natal (n = 1223). HPV testing was done by the polymerase chain reaction using GP5+/GP6 + primers and enzyme immunoassay. HIV testing was done using rapid test kits.

RESULTS

Of the 1223 cervicovaginal lavages, 301 (25%) were positive for hr-HPV. The HPV prevalence was higher in HIV infected (32.20%, 95% CI: 0.27-0.38) than in HIV-uninfected women (22.50%, 95% CI: 0.21-0.26), (p = .001). Similarly, multiple infections were slightly more common in HIV infected (59.32%) than in HIV-uninfected women (53.51%), (p = .37). The nine predominant genotypes in descending order were HPV types 16 (n = 99, 22.10%), 51 (n = 58, 12.91%), 18 (n = 56, 12.50%), 35 (n = 50, 11.10%), 33 (n = 47, 10.82%), 56 (n = 42, 9.31%), 45 (n = 34, 7.60%), 52 (n = 32, 7.14%) and 59 (n = 31, 6.91%). HPV 35, 51, 56 and 59 (40.62%), which are not covered by any vaccine, were among the most prevalent in the schools of KwaZulu-Natal.

CONCLUSION

Four of the most predominant high-risk HPV types in this region are not covered by the new nine-valent HPV vaccine.

Co-infection with Schistosoma haematobium and soil-transmitted helminths in rural South Africa

Abstract Schistosomiasis and soil-transmitted helminthiasis are among the most prevalent neglected tropical diseases and may lead to severe consequences. We assessed the extent of co-infection between Schistosoma haematobium and the soil-transmitted helminths (STHs) Ascaris lumbricoides and Trichuris trichiura in schoolgirls in the rural areas of KwaZulu-Natal, South Africa. We also explored if S. haematobium can serve as a predictor for soil-transmitted helminths in this area. From 15 selected schools, 726 primary schoolgirls aged 10–12 years provided both urine and stool samples. The samples were examined for the presence of eggs using the urine sedimentation technique for S. haematobium and the Kato Katz technique for STHs. Pearson’s chi-square test was used to calculate the association and Spearman’s rank correlation was used for the correlation analysis. There was a highly significant correlation between S. haematobium and STHs at a school level (Spearman’s correlation coefficient =0.93; p bigger than 0.001). The prevalences were found to be 36.9% and 38.8% for S. haematobium and STHs, respectively. A significant association was found between S. haematobium and STHs (odds ratio =2.05; confidence interval =1.58–2.93; p bigger than 0.001). Indirect indicators of urogenital schistosomiasis (e.g. water contact and haematuria) were significantly associated with A. lumbricoides and T. trichiura infection. We have demonstrated a highly significant correlation and overall association between urogenital schistosomiasis and A. lumbricoides and T. trichiura. We cautiously suggest that all S. haematobium endemic areas should be treated for STH infections.

Association of Urogenital Symptoms with History of Water Contact in Young Women in Areas Endemic for S. haematobium. A Cross-Sectional Study in Rural South Africa

Female genital schistosomiasis is a neglected tropical disease caused by Schistosoma haematobium. Infected females may suffer from symptoms mimicking sexually transmitted infections. We explored if self-reported history of unsafe water contact could be used as a simple predictor of genital schistosomiasis. In a cross-sectional study in rural South Africa, 883 sexually active women aged 16–22 years were included. Questions were asked about urogenital symptoms and water contact history. Urine samples were tested for S. haematobium ova. A score based on self-reported water contact was calculated and the association with symptoms was explored while adjusting for other genital infections using multivariable logistic regression analyses. S. haematobium ova were detected in the urine of 30.5% of subjects. Having ova in the urine was associated with the water contact score (p < 0.001). Symptoms that were associated with water contact included burning sensation in the genitals (p = 0.005), spot bleeding (p = 0.012), abnormal discharge smell (p = 0.018), bloody discharge (p = 0.020), genital ulcer (p = 0.038), red urine (p < 0.001), stress incontinence (p = 0.001) and lower abdominal pain (p = 0.028). In S. haematobium endemic areas, self-reported water contact was strongly associated with urogenital symptoms. In low-resource settings, a simple history including risk of water contact behaviour can serve as an indicator of urogenital schistosomiasis.

Cervical cytology as a diagnostic tool for female genital schistosomiasis: Correlation to cervical atypia and Schistosoma polymerase chain reaction

Background:

Female genital schistosomiasis (FGS) is a tissue reaction to lodged ova of Schistosoma haematobium in the genital mucosa. Lesions can make the mucosa friable and prone to bleeding and discharge. Women with FGS may have an increased risk of HIV acquisition, and FGS may act as a cofactor in the development of cervical cancer.

Objectives:

To explore cytology as a method for diagnosing FGS and to discuss the diagnostic challenges in low-resource rural areas. The correlation between FGS and squamous cell atypia (SCA) is also explored and discussed. Cytology results are compared to Schistosoma polymerase chain reaction (PCR) in vaginal lavage and urine and in urine microscopy.

Materials and Methods:

In a clinical study, 394 women aged between 16 and 23 years from rural high schools in KwaZulu-Natal, South Africa, underwent structured interviews and the following laboratory tests: Cytology Papanicolaou (Pap) smears for S. haematobium ova and cervical SCA, real-time PCR for Schistosoma-specific DNA in vaginal lavage and urine samples, and urine microscopy for the presence of S. haematobium ova.

Results:

In Pap smears, S. haematobium ova were detected in 8/394 (2.0%). SCA was found in 107/394 (27.1%), seven of these had high-grade squamous intraepithelial lesion (HSIL). Schistosoma specific DNA was detected in 38/394 (9.6%) of vaginal lavages and in 91/394 (23.0%) of urines. Ova were found microscopically in 78/394 (19.7%) of urines.

Conclusion:

Schistosoma PCR on lavage was a better way to diagnose FGS compared to cytology. There was a significant association between S. haematobium ova in Pap smears and the other diagnostic methods. In low-resource Schistosoma-endemic areas, it is important that cytology screeners are aware of diagnostic challenges in the identification of schistosomiasis in addition to the cytological diagnosis of SCA. Importantly, in this study, three of eight urines were negative but showed Schistosoma ova in their Pap smear, and one of them was also negative for Schistosoma DNA in urine. In this study, SCA was not significantly associated with schistosomiasis. HSIL detected in this young population might need future consideration.

Characteristics of Blood Vessels in Female Genital Schistosomiasis: Paving the Way for Objective Diagnostics at the Point of Care

BACKGROUND

The mucosal changes associated with female genital schistosomiasis (FGS) encompass abnormal blood vessels. These have been described as circular, reticular, branched, convoluted and having uneven calibre. However, these characteristics are subjective descriptions and it has not been explored which of them are specific to FGS.

METHODS

In colposcopic images of young women from a schistosomiasis endemic area, we performed computerised morphologic analyses of the cervical vasculature appearing on the mucosal surface. Study participants where the cervix was classified as normal served as negative controls, women with clinically diagnosed FGS and presence of typical abnormal blood vessels visible on the cervical surface served as positive cases. We also included women with cervical inflammatory conditions for reasons other than schistosomiasis. By automating morphological analyses, we explored circular configurations, vascular density, fractal dimensions and fractal lacunarity as parameters of interest.

RESULTS

We found that the blood vessels typical of FGS are characterised by the presence of circular configurations (p < 0.001), increased vascular density (p = 0.015) and increased local connected fractal dimensions (p = 0.071). Using these features, we were able to correctly classify 78% of the FGS-positive cases with an accuracy of 80%.

CONCLUSIONS

The blood vessels typical of FGS have circular configurations, increased vascular density and increased local connected fractal dimensions. These specific morphological features could be used diagnostically. Combined with colourimetric analyses, this represents a step towards making a diagnostic tool for FGS based on computerised image analysis.

The first step toward diagnosing female genital schistosomiasis by computer image analysis

Schistosoma haematobium causes female genital schistosomiasis (FGS), which is a poverty-related disease in sub-Saharan Africa. Furthermore, it is co-endemic with human immunodeficiency virus (HIV), and biopsies from genital lesions may expose the individual to increased risk of HIV infection. However, microscopy of urine and hematuria are nonspecific and insensitive predictors of FGS and gynecological investigation requires extensive training. Safe and affordable diagnostic methods are needed. We explore a novel method of diagnosing FGS using computer color analysis of colposcopic images. In a cross-sectional study on young women in an endemic area, we found strong associations between the output from the computer color analysis and both clinical diagnosis (odds ratio [OR] = 5.97, P < 0.001) and urine microscopy for schistosomiasis (OR = 3.52, P = 0.004). Finally, using latent class statistics, we estimate that the computer color analysis yields a sensitivity of 80.5% and a specificity of 66.2% for the diagnosis of FGS.

Schistosoma haematobium infection and CD4+ T-cell levels: a cross-sectional study of young South African women

Schistosoma (S.) haematobium causes urogenital schistosomiasis and has been hypothesized to adversely impact HIV transmission and progression. On the other hand it has been hypothesized that HIV could influence the manifestations of schistosomiasis. In this cross-sectional study, we explored the association between urogenital S. haematobium infection and CD4 cell counts in 792 female high-school students from randomly selected schools in rural KwaZulu-Natal, South Africa. We also investigated the association between low CD4 cell counts in HIV positive women and the number of excreted schistosome eggs in urine. Sixteen percent were HIV positive and 31% had signs of urogenital schistosomiasis (as determined by genital sandy patches and / or abnormal blood vessels on ectocervix / vagina by colposcopy or presence of eggs in urine). After stratifying for HIV status, participants with and without urogenital schistosomiasis had similar CD4 cell counts. Furthermore, there was no significant difference in prevalence of urogenital schistosomiasis in HIV positive women with low and high CD4 cell counts. There was no significant difference in the number of eggs excreted in urine when comparing HIV positive and HIV negative women. Our findings indicate that urogenital schistosomiasis do not influence the number of circulating CD4 cells.

Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa

OBJECTIVES

It has been hypothesised that ectopy may be associated with increased susceptibility to sexually transmitted infections (STIs). In this cross-sectional study, we wanted to explore the association between STIs (including HIV) and cervical ectopy.

METHODS

We included 700 sexually active young women attending randomly selected high schools in a rural district in KwaZulu-Natal, South Africa. The district is endemic of HIV and has a high prevalence of STIs. We did computer-assisted measurements of the ectocervical area covered by columnar epithelium (ectopy) in colposcopic images and STI analyses on cervicovaginal lavage and serum samples. All participating women answered a questionnaire about sexual behaviour and use of contraceptives.

RESULTS

The mean age was 19.1 years. Ectopy was found in 27.2%, HIV in 27.8%, chlamydia in 25.3% and gonorrhoea in 15.6%. We found that age, parity, chlamydia and gonorrhoea, years since menarche, years since sexual debut and number of sexual partners were associated with ectopy. In multivariate analysis with chlamydia infection as the dependent variable, women with ectopy had increased odds of having chlamydia infection (adjusted OR 1.78, p=0.033). In women under 19 years of age, we found twofold higher odds of being HIV-positive for those with ectopy (OR 2.19, p=0.014).

CONCLUSIONS

In conclusion, cervical ectopy is associated with Chlamydia trachomatis infection and HIV in the youngest women.

Colourimetric image analysis as a diagnostic tool in female genital schistosomiasis

Female genital schistosomiasis (FGS) is a highly prevalent waterborne disease in some of the poorest areas of sub-Saharan Africa. Reliable and affordable diagnostics are unavailable. We explored colourimetric image analysis to identify the characteristic, yellow lesions caused by FGS. We found that the method may yield a sensitivity of 83% and a specificity of 73% in colposcopic images. The accuracy was also explored in images of simulated inferior quality, to assess the possibility of implementing such a method in simple, electronic devices. This represents the first step towards developing a safe and affordable aid in clinical diagnosis, allowing for a point-of-care approach.

The colposcopic atlas of schistosomiasis in the lower female genital tract based on studies in Malawi, Zimbabwe, Madagascar and South Africa

BACKGROUND

Schistosoma (S.) haematobium is a neglected tropical disease which may affect any part of the genital tract in women. Female genital schistosomiasis (FGS) may cause abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies and increased susceptibility to HIV. Symptoms may mimic those typical of sexually transmitted infections (STIs) and women with genital schistosomiasis may be incorrectly diagnosed. An expert consensus meeting suggested that the following findings by visual inspection should serve as proxy indicators for the diagnosis of schistosomiasis of the lower genital tract in women from S. haematobium endemic areas: sandy patches appearing as (1) single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas, or (3) rubbery papules. In this atlas we aim to provide an overview of the genital mucosal manifestations of schistosomiasis in women.

METHODOLOGY/PRINCIPAL FINDINGS

Photocolposcopic images were captured from women, between 1994 and 2012 in four different study sites endemic for S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. Images and specimens were sampled from sexually active women between 15 and 49 years of age. Colposcopic images of other diseases are included for differential diagnostic purposes.

SIGNIFICANCE

This is the first atlas to present the clinical manifestations of schistosomiasis in the lower female genital tract. It will be freely available for online use, downloadable as a presentation and for print. It could be used for training purposes, further research, and in clinical practice.

Effect of female genital schistosomiasis and anti-schistosomal treatment on monocytes, CD4+ T-cells and CCR5 expression in the female genital tract

Background

Schistosoma haematobium is a waterborne parasite that may cause female genital schistosomiasis (FGS), characterized by genital mucosal lesions. There is clinical and epidemiological evidence for a relationship between FGS and HIV. We investigated the impact of FGS on HIV target cell density and expression of the HIV co-receptor CCR5 in blood and cervical cytobrush samples. Furthermore we evaluated the effect of anti-schistosomal treatment on these cell populations.

Design

The study followed a case-control design with post treatment follow-up, nested in an on-going field study on FGS.

Methods

Blood and cervical cytobrush samples were collected from FGS negative and positive women for flow cytometry analyses. Urine samples were investigated for schistosome ova by microscopy and polymerase chain reaction (PCR).

Results

FGS was associated with a higher frequency of CD14⁺ cells (monocytes) in blood (11.5% in FGS+ vs. 2.2% in FGS-, p = 0.042). Frequencies of CD4⁺ cells expressing CCR5 were higher in blood samples from FGS+ than from FGS- women (4.7% vs. 1.5%, p = 0.018). The CD14⁺ cell population decreased significantly in both compartments after anti-schistosomal treatment (p = 0.043). Although the frequency of CD4+ cells did not change after treatment, frequencies of CCR5 expression by CD4+ cells decreased significantly in both compartments (from 3.4% to 0.5% in blood, p = 0.036; and from 42.4% to 5.6% in genital samples, p = 0.025).

Conclusions

The results support the hypothesis that FGS may increase the risk of HIV acquisition, not only through damage of the mucosal epithelial barrier, but also by affecting HIV target cell populations, and that anti-schistosomal treatment can modify this.

Real-time polymerase chain reaction for detection of Schistosoma DNA in small-volume urine samples reflects focal distribution of urogenital Schistosomiasis in primary school girls in KwaZulu Natal, South Africa

Schistosoma haematobium eggs and Schistosoma DNA levels were measured in urine samples from 708 girls recruited from 18 randomly sampled primary schools in South Africa. Microscopic analysis of two 10-mL urine subsamples collected on three consecutive days confirmed high day-to-day variation; 103 (14.5%) girls had positive results at all six examinations, and at least one positive sample was seen in 225 (31.8%) girls. Schistosoma-specific DNA, which was measured in a 200-μL urine subsample by using real-time polymerase chain reaction, was detected in 180 (25.4%) cases, and levels of DNA corresponded significantly with average urine egg excretion. In concordance with microscopic results, polymerase chain reaction results were significantly associated with history of gynecologic symptoms and confirmed highly focal distribution of urogenital schistosomiasis. Parasite-specific DNA detection has a sensitivity comparable to single urine microscopy and could be used as a standardized high-throughput procedure to assess distribution of urogenital schistosomiasis in relatively large study populations by using small sample volumes.

S. haematobium as a common cause of genital morbidity in girls: a cross-sectional study of children in South Africa

Background

Schistosoma (S.) haematobium infection is a common cause of genital morbidity in adult women. Ova in the genital mucosal lining may cause lesions, bleeding, pain, discharge, and the damaged surfaces may pose a risk for HIV. In a heterogeneous schistosomiasis endemic area in South Africa, we sought to investigate if young girls had genital symptoms and if this was associated with urinary S. haematobium.

Methodology

In a cross-sectional study of 18 randomly chosen primary schools, we included 1057 schoolgirls between the age of 10 and 12 years. We interviewed assenting girls, whose parents had consented to their participation and examined three urines from each of them for schistosome ova.

Principal findings

One third of the girls reported to have a history of genital symptoms. Prior schistosomal infection was reported by 22% (226/1020), this was associated with current genital symptoms (p<0.001). In regression analysis the genital symptoms were significantly associated both with urinary schistosomiasis (p<0.001) and water contact (p<0.001).

Conclusions

Even before sexually active age, a relatively large proportion of the participating girls had similar genital symptoms to those reported for adult genital schistosomiasis previously. Anti-schistosomal treatment should be considered at a young age in order to prevent chronic genital damage and secondary infections such as HIV, sexually transmitted diseases and other super-infections.

Urogenital schistosomiasis (Bilharzia) is a common cause of gynecological disease in adult women. Reports to date indicate that genital lesions in adults become chronic and that the damages make women susceptible to HIV. This is the first study on urogenital schistosomiasis in pre-pubertal girls. We interviewed girls aged 10 to 12 years of age for urinary and gynecological symptoms. The research assistants did not know the schistosomiasis infection status in the school or the individuals. We collected three urines that were examined for schistosome eggs. We found that a significantly increased number of girls with urinary schistosomiasis have stinking, bloody discharge, ulcers, tumors and a burning sensation in their genitals. This indicates that gynecological damages due to schistosomiasis start before sexual activity, and before menstruation. By preventing urogenital schistosomiasis in girls we may have an innovative opportunity to reduce teenage HIV transmission and gynecological disease. This study presents a new aspect of a neglected disease affecting more than 100 million females, long overdue for mass intervention.