Comment
Adaptive strategies for schistosomiasis control
In this issue of The Lancet Global Health, Emily Li and
colleagues1 outline an innovative approach to adapting
the current WHO schistosomiasis guidelines for morbidity
control and elimination as a public health problem. The
authors conclude that programmes can achieve their aims
quicker if they undertake an early review of programme
progress (after 2–3 years) and use the results to adapt
their programmes. This adaptation can include increasing
the frequency of praziquantel mass drug administration
(MDA) and the possible addition of snail control.
Li and colleagues found that this strategy led to larger
decreases in prevalence over fewer rounds of MDA. Not
only was it quicker but it was also more likely than the
current guidelines to achieve morbidity control and
elimination as a public health problem, particularly in
high-risk areas. The proposal for a shorter interval from
programme initiation to evaluation and modification
than the 5–6 years currently recommended2 would
allow the incorporation of empirical data more quickly
and increase the use of data for decision making.
Having this feedback loop to inform the treatment
approach is important. Currently, there is some
hesitancy among country programmes over doing
impact assessments, as often the treatment approach
does not subsequently change.
As Li and colleagues identify, the time taken to
achieve programmatic goals is not the only factor to
be considered. The additional costs of increased MDA
and impact surveys are also important, as is a better
understanding of the transmission environment. To this
we would add the logistical and planning complexities
introduced by changing approach, especially in cases
in which this might vary between neighbouring areas.
Additional factors specific to snail control include
community acceptance, environmental impact, and an
incomplete evidence base.
MDA alone is likely to reduce infection in most places,
but infection will rebound in the absence of ongoing
treatment. These programmes typically aim for long-
term control rather than elimination of transmission;
achieving elimination as a public health problem will
require continued treatment, unlike for other neglected
tropical diseases such as lymphatic filariasis and
trachoma. Although the World Health Assembly 2012
resolution3 encourages countries to aim for transmission
www.thelancet.com/lancetgh Vol 7 October 2019 e1302
interruption, this goal is unlikely to be realistic in the See Articles page e1414
short term in sub-Saharan Africa. In a 2018 paper,4 we
argued that elimination of transmission is a long-term
aim requiring substantial socioeconomic development
and systematic water and sanitation improvements.
Aiming for morbidity control is an ambitious, probably
achievable, and worthwhile goal.
A relevant area requiring further study is the
definition of schistosomiasis-related morbidity, which
of course is crucial to define programme goals and to
measure progress. Currently, morbidity is measured
by a proxy: the proportion of people excreting a large
number of eggs in the stool or urine. However, there is
increasing recognition of morbidity in people excreting
low numbers of eggs, and even those who do not
excrete any eggs.5 Furthermore, the management of
chronic cases of morbidity is not addressed by MDA
with praziquantel. We know that current prevalence
estimates are probably substantially underestimated
because of insensitive diagnostics. The development of
the point-of-contact circulating cathodic antigen and
circulating anodic antigen tests will help provide a more
accurate estimate of the number of people infected who
are potentially requiring treatment.
As well as looking at new adaptive approaches, it is
important that we continue to focus on aspects that
can be effective immediately, such as high-quality
programme implementation to ensure repeated
rounds of high treatment coverage. In cases where this
treatment coverage is not being achieved, quantitative
and qualitative approaches should be used to
understand the location-specific challenges.
Likewise, accurately identifying the at-risk population is
important. Most programmes focus primarily on children
aged 5–14 years. Expanding treatment to adults, where
required and where praziquantel is available, might be
essential in reducing transmission and morbidity but
will require accurate estimates of individuals at risk.
The projected availability of a paediatric formulation
of praziquantel will be another useful tool, given the
increasing evidence of disease in this age-group.6,7
We know that schistosomiasis infection is highly
focal, often with substantial heterogeneity between
neighbouring communities. Being better able to
identify and respond to this focality and to persistent
 Comment
hotspots—ie, areas not responding as expected
to treatment8,9—requires new focused mapping
approaches. Work to this end is being done by WHO,
the Global Schistosomiasis Alliance, and partners.
Finally, all of these discussed elements need to
happen under the ownership of the government of
the endemic country, led by their Ministry of Health.
As Li and colleagues state, “it is crucial to design a
sustainable control programme that can maintain
government support, adequate funding, community
involvement, [and] coordination between control
programmes”. Countries need to take the lead in
designing, implementing, and evaluating their own
programmes. One approach to this management is the
use of schistosomiasis (and soil-transmitted helminth)
expert committees. The committees are created under
the auspices of the Ministry of Health with input
from domestic and international experts as required,
modelled on the successful onchocerciasis elimination
expert advisory groups.10 In this way, the capacity of
the programme staff can be built to plan and adapt
appropriately to the changing needs of the control
programme.
*Mike French, Darin Evans
RTI International, Washington, DC 20005, USA (MF); United
States Agency for International Development, Washington, DC,
USA (DE)
mfrench@rti.org
e1303 www.thelancet.com/lancetgh Vol 7 October 2019
We declare no competing interests.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY 4.0 license.
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