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      Young Adults in Endemic Areas: An Untreated Group in Need of School-Based Preventive Chemotherapy for Schistosomiasis Control and Elimination

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          Abstract

          Parasitologic surveys of young adults in college and university settings are not commonly done, even in areas known to be endemic for schistosomiasis and soil-transmitted helminths. We have done a survey of 291 students and staff at the Kisumu National Polytechnic in Kisumu, Kenya, using the stool microscopy Kato-Katz (KK) method and the urine point-of-care circulating cathodic antigen (POC-CCA) test. Based on three stools/two KK slides each, in the 208 participants for whom three consecutive stools were obtained, Schistosoma mansoni prevalence was 17.8%. When all 291 individuals were analyzed based on the first stool, as done by the national neglected tropical disease (NTD) program, and one urine POC-CCA assay ( n = 276), the prevalence was 13.7% by KK and 23.2% by POC-CCA. Based on three stools, 2.5% of 208 participants had heavy S. mansoni infections (≥400 eggs/gram feces), with heavy S. mansoni infections making up 13.5% of the S. mansoni cases. The prevalence of the soil-transmitted helminths (STH: Ascaris lumbricoides, Trichuris trichiura and hookworm) by three stools was 1.4%, 3.1%, and 4.1%, respectively, and by the first stool was 1.4%, 2.4% and 1.4%, respectively. This prevalence and intensity of infection with S. mansoni in a college setting warrants mass drug administration with praziquantel. This population of young adults is ‘in school’ and is both approachable and worthy of inclusion in national schistosomiasis control and elimination programs.

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          Schistosomiasis and neglected tropical diseases: towards integrated and sustainable control and a word of caution.

          In May 2001, the World Health Assembly (WHA) passed a resolution which urged member states to attain, by 2010, a minimum target of regularly administering anthelminthic drugs to at least 75% and up to 100% of all school-aged children at risk of morbidity. The refined global strategy for the prevention and control of schistosomiasis and soil-transmitted helminthiasis was issued in the following year and large-scale administration of anthelminthic drugs endorsed as the central feature. This strategy has subsequently been termed 'preventive chemotherapy'. Clearly, the 2001 WHA resolution led the way for concurrently controlling multiple neglected tropical diseases. In this paper, we recall the schistosomiasis situation in Africa in mid-2003. Adhering to strategic guidelines issued by the World Health Organization, we estimate the projected annual treatment needs with praziquantel among the school-aged population and critically discuss these estimates. The important role of geospatial tools for disease risk mapping, surveillance and predictions for resource allocation is emphasised. We clarify that schistosomiasis is only one of many neglected tropical diseases and that considerable uncertainties remain regarding global burden estimates. We examine new control initiatives targeting schistosomiasis and other tropical diseases that are often neglected. The prospect and challenges of integrated control are discussed and the need for combining biomedical, educational and engineering strategies and geospatial tools for sustainable disease control are highlighted. We conclude that, for achieving integrated and sustainable control of neglected tropical diseases, a set of interventions must be tailored to a given endemic setting and fine-tuned over time in response to the changing nature and impact of control. Consequently, besides the environment, the prevailing demographic, health and social systems contexts need to be considered.
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            Schistosomiasis is more prevalent than previously thought: what does it mean for public health goals, policies, strategies, guidelines and intervention programs?

            Mapping and diagnosis of infections by the three major schistosome species (Schistosoma haematobium, S. mansoni and S. japonicum) has been done with assays that are known to be specific but increasingly insensitive as prevalence declines or in areas with already low prevalence of infection. This becomes a true challenge to achieving the goal of elimination of schistosomiasis because the multiplicative portion of the life-cycle of schistosomes, in the snail vector, favors continued transmission as long as even a few people maintain low numbers of worms that pass eggs in their excreta. New mapping tools based on detection of worm antigens (circulating cathodic antigen – CCA; circulating anodic antigen – CAA) in urine of those infected are highly sensitive and the CAA assay is reported to be highly specific. Using these tools in areas of low prevalence of all three of these species of schistosomes has demonstrated that more people harbor adult worms than are regularly excreting eggs at a level detectable by the usual stool assay (Kato-Katz) or by urine filtration. In very low prevalence areas this is sometimes 6- to10-fold more. Faced with what appears to be a sizable population of “egg-negative/worm-positive schistosomiasis” especially in areas of very low prevalence, national NTD programs are confounded about what guidelines and strategies they should enact if they are to proceed toward a goal of elimination. There is a critical need for continued evaluation of the assays involved and to understand the contribution of this “egg-negative/worm-positive schistosomiasis” condition to both individual morbidity and community transmission. There is also a critical need for new guidelines based on the use of these more sensitive assays for those national NTD programs that wish to move forward to strategies designed for elimination. Electronic supplementary material The online version of this article (doi:10.1186/s40249-017-0275-5) contains supplementary material, which is available to authorized users.
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              Comparison of Schistosoma mansoni Prevalence and Intensity of Infection, as Determined by the Circulating Cathodic Antigen Urine Assay or by the Kato-Katz Fecal Assay: A Systematic Review

              The relationship between results from Kato-Katz (KK) fecal microscopy and urine-based point-of-care circulating cathodic antigen (POC-CCA) assays for Schistosoma mansoni infection remains a critical issue. This systematic literature review of 25 published papers compares prevalence of S. mansoni infection by KK with that by the POC-CCA assay. Nineteen published studies met our inclusion criteria for data extraction and analysis. Above a prevalence of 50% by KK, KK and POC-CCA results yielded essentially the same prevalence. Below 50% prevalence by KK, the prevalence by the POC-CCA assay was between 1.5- and 6-fold higher and increased as prevalence by KK decreased. Five of nine publications met inclusion criteria for extractable data on intensity of S. mansoni infection by KK assay and visual band density using the POC-CCA assay. A clear positive relationship exists between intensity by the KK and POC-CCA assays. This systematic review indicates that below 50% prevalence, the POC-CCA assay is much more sensitive than the KK assay. However, the existing data are inadequate to precisely define the relationship between POC-CCA and KK at lower levels of KK prevalence. More studies directly comparing the two assays in low-prevalence areas are essential to inform decision-making by national schistosomiasis control programs.
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                Author and article information

                Journal
                Trop Med Infect Dis
                Trop Med Infect Dis
                tropicalmed
                Tropical Medicine and Infectious Disease
                MDPI
                2414-6366
                05 September 2018
                September 2018
                : 3
                : 3
                : 100
                Affiliations
                [1 ]Centre for Global Health Research, Kenya Medical Research Institute, Kisumu 40100, Kenya; cheriyotharrison9@ 123456gmail.com (H.K.K.); awinoemmy01@ 123456gmail.com (E.K.); amosomondi2@ 123456gmail.com (A.O.); emakuto@ 123456gmail.com (E.M.N.); ondigo2002@ 123456gmail.com (B.N.O.); diana@ 123456cohesu.org (D.M.S.K.)
                [2 ]School of Public Health, Department of Biomedical Sciences, Maseno University, Kisumu 40100 Kenya
                [3 ]Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA 30602, USA; dianariner@ 123456yahoo.com (D.K.R); nupur.kittur@ 123456gmail.com (N.K.)
                [4 ]Institute of Tropical Medicine and Infectious Diseases, Jomo Kenyatta University of Agriculture and Technology, Nairobi 56100, Kenya
                [5 ]Albany Medical College, Albany, NY 12208, USA; landryj1@ 123456amc.edu
                [6 ]Department of Pathology, Kenyatta University, Nairobi 00609, Kenya
                [7 ]Department of Biochemistry and Molecular Biology, Egerton University, Nakuru 20115, Kenya
                [8 ]Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA; was4@ 123456cdc.gov
                [9 ]Department of Microbiology, University of Georgia, Athens, GA 30602, USA
                Author notes
                [* ]Correspondence: dcolley@ 123456uga.edu ; Tel.: +1-706-542-4112
                Author information
                https://orcid.org/0000-0003-0584-5961
                Article
                tropicalmed-03-00100
                10.3390/tropicalmed3030100
                6160920
                e06d5356-b43c-473c-8099-60b277b6d2a8
                © 2018 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 24 July 2018
                : 31 August 2018
                Categories
                Article

                schistosomiasis,kato-katz,poc-cca,young adults,soil-transmitted helminths

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