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      Study and implementation of urogenital schistosomiasis elimination in Zanzibar (Unguja and Pemba islands) using an integrated multidisciplinary approach

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          Abstract

          Background

          Schistosomiasis is a parasitic infection that continues to be a major public health problem in many developing countries being responsible for an estimated burden of at least 1.4 million disability-adjusted life years (DALYs) in Africa alone. Importantly, morbidity due to schistosomiasis has been greatly reduced in some parts of the world, including Zanzibar. The Zanzibar government is now committed to eliminate urogenital schistosomiasis. Over the next 3–5 years, the whole at-risk population will be administered praziquantel (40 mg/kg) biannually. Additionally, snail control and behaviour change interventions will be implemented in selected communities and the outcomes and impact measured in a randomized intervention trial.

          Methods/Design

          In this 5-year research study, on both Unguja and Pemba islands, urogenital schistosomiasis will be assessed in 45 communities with urine filtration and reagent strips in 4,500 schoolchildren aged 9–12 years annually, and in 4,500 first-year schoolchildren and 2,250 adults in years 1 and 5. Additionally, from first-year schoolchildren, a finger-prick blood sample will be collected and examined for Schistosoma haematobium infection biomarkers. Changes in prevalence and infection intensity will be assessed annually. Among the 45 communities, 15 were randomized for biannual snail control with niclosamide, in concordance with preventive chemotherapy campaigns. The reduction of Bulinus globosus snail populations and S. haematobium-infected snails will be investigated. In 15 other communities, interventions triggering behaviour change have been designed and will be implemented in collaboration with the community. A change in knowledge, attitudes and practices will be assessed annually through focus group discussions and in-depth interviews with schoolchildren, teachers, parents and community leaders. In all 45 communities, changes in the health system, water and sanitation infrastructure will be annually tracked by standardized questionnaire-interviews with community leaders. Additional issues potentially impacting on study outcomes and all incurring costs will be recordedand monitored longitudinally.

          Discussion

          Elimination of schistosomiasis has become a priority on the agenda of the Zanzibar government and the international community. Our study will contribute to identifying what, in addition to preventive chemotherapy, needs to be done to prevent, control, and ultimately eliminate schistosomiasis, and to draw lessons for current and future schistosomiasis elimination programmes in Africa and elsewhere.

          Trial registration

          ISRCTN48837681

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          Most cited references 61

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          Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk.

          An estimated 779 million people are at risk of schistosomiasis, of whom 106 million (13.6%) live in irrigation schemes or in close proximity to large dam reservoirs. We identified 58 studies that examined the relation between water resources development projects and schistosomiasis, primarily in African settings. We present a systematic literature review and meta-analysis with the following objectives: (1) to update at-risk populations of schistosomiasis and number of people infected in endemic countries, and (2) to quantify the risk of water resources development and management on schistosomiasis. Using 35 datasets from 24 African studies, our meta-analysis showed pooled random risk ratios of 2.4 and 2.6 for urinary and intestinal schistosomiasis, respectively, among people living adjacent to dam reservoirs. The risk ratio estimate for studies evaluating the effect of irrigation on urinary schistosomiasis was in the range 0.02-7.3 (summary estimate 1.1) and that on intestinal schistosomiasis in the range 0.49-23.0 (summary estimate 4.7). Geographic stratification showed important spatial differences, idiosyncratic to the type of water resources development. We conclude that the development and management of water resources is an important risk factor for schistosomiasis, and hence strategies to mitigate negative effects should become integral parts in the planning, implementation, and operation of future water projects.
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            Human schistosomiasis.

            Schistosomiasis or bilharzia is a tropical disease caused by worms of the genus Schistosoma. The transmission cycle requires contamination of surface water by excreta, specific freshwater snails as intermediate hosts, and human water contact. The main disease-causing species are S haematobium, S mansoni, and S japonicum. According to WHO, 200 million people are infected worldwide, leading to the loss of 1.53 million disability-adjusted life years, although these figures need revision. Schistosomiasis is characterised by focal epidemiology and overdispersed population distribution, with higher infection rates in children than in adults. Complex immune mechanisms lead to the slow acquisition of immune resistance, though innate factors also play a part. Acute schistosomiasis, a feverish syndrome, is mostly seen in travellers after primary infection. Chronic schistosomal disease affects mainly individuals with long-standing infections in poor rural areas. Immunopathological reactions against schistosome eggs trapped in the tissues lead to inflammatory and obstructive disease in the urinary system (S haematobium) or intestinal disease, hepatosplenic inflammation, and liver fibrosis (S mansoni, S japonicum). The diagnostic standard is microscopic demonstration of eggs in the excreta. Praziquantel is the drug treatment of choice. Vaccines are not yet available. Great advances have been made in the control of the disease through population-based chemotherapy but these required political commitment and strong health systems.
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              Parasites and poverty: the case of schistosomiasis.

               Charles King (2010)
              Simultaneous and sequential transmission of multiple parasites, and their resultant overlapping chronic infections, are facts of life in many underdeveloped rural areas. These represent significant but often poorly measured health and economic burdens for affected populations. For example, the chronic inflammatory process associated with long-term schistosomiasis contributes to anaemia and undernutrition, which, in turn, can lead to growth stunting, poor school performance, poor work productivity, and continued poverty. To date, most national and international programs aimed at parasite control have not considered the varied economic and ecological factors underlying multi-parasite transmission, but some are beginning to provide a coordinated approach to control. In addition, interest is emerging in new studies for the re-evaluation and recalibration of the health burden of helminthic parasite infection. Their results should highlight the strong potential of integrated parasite control in efforts for poverty reduction. Copyright 2009 Elsevier B.V. All rights reserved.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2012
                30 October 2012
                : 12
                : 930
                Affiliations
                [1 ]Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, P.O. Box,, CH–4002, Basel, Switzerland
                [2 ]University of Basel, P.O. Box,, CH–4003, Basel, Switzerland
                [3 ]Wolfson Wellcome Biomedical Laboratories, Department of Life Sciences, Natural History Museum, Cromwell Road, London, SW7 5BD, UK
                [4 ]Helminth Control Laboratory Unguja, Ministry of Health, P.O. Box 236, Zanzibar, United Republic of Tanzania
                [5 ]Public Health Laboratory - Ivo de Carneri, Ministry of Health, P.O. Box 122, Chake-Chake, Pemba, United Republic of Tanzania
                [6 ]Ivo de Carneri Foundation, Viale Monza 44, 20127, Milan, Italy
                [7 ]Schistosomiasis Control Initiative, Department of Infectious Disease Epidemiology, Faculty of Medicine, VB1 Norfolk Place, St. Mary's Campus, London, UK
                [8 ]Department of Control of Neglected Tropical Diseases, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland
                [9 ]Department of Microbiology and Center for Tropical and Emerging Global Diseases, University of Georgia, 330B Coverdell Building, Athens, GA, 30602, USA
                [10 ]National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C-14, Atlanta, GA, 30333, USA
                Article
                1471-2458-12-930
                10.1186/1471-2458-12-930
                3533998
                23110494
                Copyright ©2012 Knopp et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Study Protocol

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