TABLE OF CONTENTS

ABSTRACT....................................................................................................................................ii
INTRODUCTION...........................................................................................................................1
EPIDEMIOLOGY...........................................................................................................................4
DISEASE TRANSMISSION..........................................................................................................5
LIFE CYCLE...................................................................................................................................5
Snail Hosts.......................................................................................................................................6
Mammalian Hosts............................................................................................................................7
CLINICAL MANIFESTATION.....................................................................................................7
KATAYAMA SYNDROME...........................................................................................................9
CHRONIC INFECTION.................................................................................................................9
DIAGNOSIS....................................................................................................................................9
MHT, Kato-Katz, and FECT.........................................................................................................10
PCR method...................................................................................................................................10
TREATMENT...............................................................................................................................10
CONTROL....................................................................................................................................11
CONTROL MEASURES IN ADDITION TO MDA....................................................................12
Mapping Studies and Snail Control...............................................................................................12
Education and Knowledge.............................................................................................................13
CONTROL OF SCHISTOSOMIASIS: THE NEW WHO GUIDELINE ON CONTROL AND
ELIMINATION OF HUMAN SCHISTOSOMIASIS..................................................................13
VACCINE DEVELOPMENT.......................................................................................................14
CONCLUSION..............................................................................................................................15
REFERENCES..............................................................................................................................16

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 ABSTRACT

Intestinal schistosomiasis caused by the Schistosoma mansoni, S. mekongi, S. japonicum, and S.

intercalatum is a common neglected tropical disease of impoverished people in many developing
countries in tropical Africa, the Middle East, Asia, and Latin America. Substantial progress has
been made in controlling schistosomiasis in some African countries, but the disease still prevails
in most parts of sub-Saharan Africa with an estimated 800 million people at risk of infection.
Adult worms reside in the mesenteric veins and excrete eggs that migrate through the intestinal
wall and pass out with the stool. The clinical manifestations depend on the stage of the disease,
the intestinal schistosomiasis mostly affects the colon, but it can also affect the small intestine.
Current control strategies rely primarily on treatment with praziquantel, as no vaccine is
available; however, treatment alone does not prevent reinfection. School age children are the
main targets for control as they are considered to be at the highest risk of infection. Treatment of
at-risk people on a wide scale, access to good water, improved sanitation, hygiene education,
and snail control are all used to combat schistosomiasis.

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INTRODUCTION
Schistosomiasis is a parasitic disease caused by the presence of adult pairs of a trematode
helminth of a genus Schistosoma in the venous vasculature of the host. Schistosomiasis is
known to be an acute and chronic infection, affecting the immune system of the host at both
stages. The immunological interplay between the host immune system and the adult worms
and eggs might explain the impact of schistosomiasis on concomitant infectious diseases
(Angeles et al., 2020). It is also known as “bilharziasis” named after Theodor Bilharz, who
first identified the parasite in 1852 (Clerinx and Soentjens, 2017). The WHO reported that
258 million people worldwide were infected with trematodes of the genus schistosoma, and
required treatment and preventive regime (Rivadeneira and Luo, 2019).

In humans, the infection of schistosomiasis outranks all parasitic diseases except malaria,
causing great morbidity with profound economic and public health importance (Gashaw et
al., 2015). The disease exists in two forms, urogenital schistosomiasis caused by S.
haematobium; and intestinal schistosomiasis caused by four species, Schistosoma mansoni, S.
mekongi, S. japonicum, and S. intercalatum (Odoya et al., 2021). Some variances are
reported; notably S. guineensis known as variant of S. intercalatum (WHO, 2021). All these
species are unevenly distributed across various endemic regions in the world, mainly tropical
and subtropical regions (CDC, 2019). Indeed, schistosomiasis is reported from five
continents, with Asia and Africa being mostly affected. The African continent in particular
bears the highest disease burden, with 93% of the global schistosomiasis cases (Dejon-Agobe
et al., 2022), rendering schistosomiasis a major public health issue of concern. Mainly S.
haematobium and S. mansoni are present, with some cases of S. guineensis and S.
intercalatum reported particularly from Central Africa (WHO, 2021).

Prevalence and transmission of the different types of schistosomiasis are typically associated
with poor environmental and sanitary conditions, thus usually affecting people living in
unfavorable socioeconomic conditions (Calasans et al., 2018). Due to environmental
degradation and climate change, leading to warmer, tropical temperatures, and shifting
rainfall patterns, there may be a change and even increase in the geographic and periodic
distribution of Schistosoma spp. infections (Calasans et al., 2018; Gomes et al., 2018). Hotez
2018, draws attention to “new global hot zones for emerging and parasitic diseases” due to
combined forces of climate change, urbanization, and poverty, possibly explaining why we

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are already seeing emergences of NTDs in wealthy G20 countries, for example, urogenital
schistosomiasis in Corsica, France (Klohe et al., 2021).

Globally, it is estimated that 779 million people at risk, and more than 207 million people
infected with schistosomiasis worldwide. Apart from its health consequences, schistosomiasis
is associated with negative social and economic impacts. It causes a loss of about 4.5 million
Disability-Adjusted Life Years (DALYs) and 150,000–280,000 deaths annually in the region
(Mnkugwe et al., 2020).

Schistosomiasis is one of the 20 diseases considered by the World Health Organization

(WHO) as neglected tropical diseases (NTDs). The disease has been reported in 78 countries,
52 of which have moderate to high transmission requiring large-scale intervention through
preventive chemotherapy (WHO, 2023). Neglected tropical diseases (NTD) primarily affect
the poorest and most vulnerable populations in the world; they are caused by infectious and
parasitic agents. Currently the NTD are affecting 41.4 billion people, causing approximately
35,000 deaths per day worldwide (Rivadeneira and Luo 2019). These “neglected” diseases
are due to under-financing and low recognition by the pharmaceutical industries (Siqueira et
al., 2017).

Like other NTDs, schistosomiasis is linked to the Sustainable Development Goals (SDGs);
and its control is associated with direct impact on achieving the goals; such goals include
reduction of poverty (SDG1), ensure healthy lives and promote well-being for all at all ages
(SDG3) and attaining quality education to children (SDG4) (Mnkugwe et al., 2020). Due to
their global burden and impact on development, in 2015 the United Nations General Summit
recognized and gave special attention to NTDs under the list of SDGs, Goal number 3.3:
“ending the epidemic of NTDs by 2030” (Brolan et al., 2017). Schistosomiasis is among the
17 NTDs earmarked for elimination globally (Tchuem Tchuente et al., 2017).

Infammation caused by schistosoma in the intestine is called intestinal schistosomiasis. The

manifestations of acute schistosomiasis intestinal infection are intestinal mucosal hyperemia,
edema and punctured hemorrhage. Microscopic examination reveals numerous neutrophils
and eosinophil deposits. Patients present with fever, abdominal pain, diarrhea, stool with
blood, etc. A few patients may present with symptoms of acute appendicitis due to non-
calcified eggs deposited in the appendix. Chronic infection manifests as intestinal wall
vascular network disorder, smooth or prominent mucous membrane yellow-white or grayish
yellow nodules, colonic polyps, and intestinal lumen stenosis. The yellow nodules are mostly

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the presentations of calcified worm egg deposition, fibrous tissue thickening and atrophy of
the overlying mucosa. Lymphocytes and plasma cells can be seen under a microscope.
Patients may have intestinal obstruction, intussusception, abdominal mass and other
symptoms. Acute and chronic inflammatory changes coexist in the intestinal mucosal tissues
of people in some epidemic areas due to repeated infection with Schistosoma, and their
clinical symptoms are varied (Qui et al., 2021).

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EPIDEMIOLOGY
Intestianl schistosomiasis is a prevalent infection in tropical and subtropical areas, especially
in communities without adequate sanitation and safe drinking water (Rivadeneira and Lou,
2019). S. mansoni is the most widely distributed in endemicity and is found in sub-Saharan
Africa, the Middle East, and Latin America. Schistosoma intercalatum is endemic in the
rainforest area of Sao Tome and Equatorial Guinea and in the Central Africa Republic.
Schistosoma mekongi and S. japonicum are found in China, the Philippines, and Cambodia
districts, while in Africa, S. mansoni and S. intercalatum are the most prevalent species of
intestinal schistosomiasis. Schistosoma intercalatum causes human rectal schistosomiasis in
Africa and has been associated with clinical non-typhoidal salmonella (NTS) septicaemia in
children. Additionally, S. mansoni infection causes bloody diarrhea (Odoya et al., 2021).
The disease mostly affects school-aged children in low-income communities, but all age
groups can be victims due to different water contact activities such as fishing and domestic
water use (Adenewo et al., 2015). Infected children have poor school attendance, poor
concentration in class and poor academic performance in school either due to illness itself or
associated morbidities such as anaemia, fatigue, poor growth and poor cognitive development
(Mnkugwe et al., 2020). For adults, the infected become less productive to their families and
communities.
In Nigeria, only two Schistosoma species cause human schistosomiasis, S. mansoni, which
causes intestinal schistosomiasis, and S. haematobium, which causes urinary schistosomiasis.
In Nigeria, schistosomiasis is a disease of considerable and growing importance, mainly
affecting rural areas and vulnerable age groups. School children are the major victims of this
disease (Alade et al., 2023).
The World Health Organization (WHO) classifies schistosomiasis as neglected tropical
diseases (NTDs) (Taylor, 2020). These NTDs in Nigeria are targeted to for their control,
elimination, and eradication by the Federal Ministry of Health and Government of Nigeria, in
collaboration with various stakeholders and partners. The National Schistosomiasis Control
Programme was initiated in 1988, and the goal of the programme is to control/eliminate
schistosomiasis in the region through MDA, delivering regular praziquantel tablets, donated
by Merck KGaA Germany since 2009, to at least 75% of school-age children in endemic
areas in the country in line with WHO recommendation.
Schistosomiasis is predominantly considered a rural disease, associated with places where
people are reliant on natural freshwater bodies for everyday activities, with a subsequent
focus of research and control activities in rural settings. Yet, over the past decades,
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occurrence and even expansion of schistosomiasis foci in peri-urban and urban settings have
increasingly been observed (Hotez 2018; Klohe et al., 2021). Rural–urban migration in low-
and middle-income countries (LMICs) and subsequent rapid and unplanned urbanization are
thought to explain these observations (Mwakitalu, 2014). Fifty-five percent (55%) of the
world population is already estimated to live in urban areas, with a projected increase to 68%
by 2050 (Klohe et al., 2021).

DISEASE TRANSMISSION
Intestinal schistosomiasis is transmitted through direct environmental contamination routes
via the excretion of schistosome eggs into a viable body of freshwater.  Indirect faecal
contamination of freshwater can occur, for example, while bathing, through infected stools
deposited on the banks of rivers and ponds being washed into these waters by heavy rains or
floods, through overflowing pit latrines, and possibly through animals such as cattle walking
through sites of defecation and transporting faecal matter to bodies of water on their hooves
(Archer et al., 2020).  S. mansoni eggs can survive up to approximately eight days in the stool
post-defecation and before reaching freshwater.
Dam and irrigation projects are potential sites for outbreaks of schistosomiasis. Movements
of populations with schistosomiasis, for example from rural to urban areas, can cause the
spread of schistosomiasis. Seasonal migrations of employees can also lead to outbreaks of
schistosomiasis infections, and refugees can also contribute to the outbreaks of this disease
(Mohamed et al., 2018). A clean water supply, sanitation, vector control, and health
education can interrupt the spread of schistosomiasis (Chala and Torben 2018). It is also
indicated that water treatment could help to reduce schistosomiasis. Five water treatment
processes are available: storage, heating, chlorination, filtration, and ultraviolet light.
Unfortunately, reliable design guidelines for water treatment to control schistosomiasis do not
exist (Braun et al., 2018). This suggests that research is still required to find an effective
water treatment technique. It is possible to use sanitation and water treatment to help control
schistosomiasis. Governments in endemic areas should control schistosomiasis at provincial,
district, and municipal levels. Non-endemic countries should also test and treat people from
endemic countries for schistosomiasis in particular.

LIFE CYCLE
Schistosomes have a complex life cycle involving both intermediate gastropod hosts and a
definitive mammalian host (Figure 1). Unlike other trematode species, Schistosoma spp. are
dioecious (separate male and female worms) which undergo sexual reproduction in the

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mammalian definitive host (Aula et al., 2021). Asexual reproduction occurs in fresh water
snails. In the snail, this begins with the development of miracidia into a sporocyst. Sporocysts
multiply and grow into cercariae. In the mammalian hosts, parasites grow to become mature,
mate, and produce eggs (Viana et al., 2018; Mouahid et al., 2018). Mammalian hosts include
humans, mice, and dogs.

Figure 1. Life Cycle. Source: (Aula et al., 2021).

Snail Hosts
Mammal hosts release worm eggs into the external environment through feces or urine (Shuja
et al., 2018; Geyer et al., 2018). In fresh water, these eggs form miracidia, which hatch and
infect snails (Mouahid et al., 2018; Geyer et al., 2018). S. japonicum infects snails of the
genus Oncomelania. S. mekongi infects snails of the genus Neutricula (Roquis et al., 2018).
S. mansoni infects snails of the genus Biomphalaria (Roquis et al., 2018; Gurarie et al.,
2018). After infiltration, the miracidium removes the ciliated plates, develops into a mother
sporocyst, and then produces daughter sporocysts (Mouahid et al., 2018; Gurarie et al.,
2018). Daughter sporocysts produce either cercaria (cercariogenous sporocysts) or more
daughter sporocysts (sporocystogenous sporocysts). Daughter sporocysts can also experience
a re-differentiation into new daughter sporocysts (Mouahid et al., 2018). Infected snails shed
cercariae into the water and upon locating a suitable definitive host, penetrate the skin,
transform into schistosomula and migrate through the circulatory system to the lungs, heart
and liver where they mature into adult worms (Aula et al., 2021). Snails can shed hundreds of
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cercariae daily; about 200 for S. haematobium, 15 to 160 for S. japonicum, and 250 to 600 for
S. mansoni (Braun et al., 2018).

Mammalian Hosts
Cercariae enter human skin and shed their forked tail, forming schistosomula (Gurarie et al.,
2018). The schistosomula migrate throughout the body’s tissues through blood circulation.
Schistosomula grow into schistosomes and adult worms (Chala and Torben 2018; Gurarie et
al., 2018). These adult worms each have a ZZ chromosome pair in males and a ZW
chromosome pair in females (Gurarie et al., 2018).
Adult worms in humans exist in various locations specific to each species. S. haematobium
exists in the bladder (Abe et al., 2018) and ureters, but it can also exist in the rectal venules.
S. japonicum exists more frequently in the small intestine (Nelwan, 2019). S. mansoni worms
can exist in either large or small intestine (Nelwan, 2019; Abe et al., 2018) and they are able
to transfer between those sites (Nelwan, 2019). Water containing cercariae can cause human
schistosomiasis (Braun et al., 2018).

CLINICAL MANIFESTATION
Clinical manifestations of intestinal schistosomiasis consist of acute (Katayama syndrome)
and chronic manifestations. Katayama syndrome may include symptoms such as fever and
headache. Clinical manifestations of the chronic disease are blood in the stool, constipation,
and diarrhea. These clinical manifestations occur in patients with S. japonicum and S.
mansoni schistosomiasis. It can cause bowel wall ulceration, fibrosis, hyperplasia, polyposis,
and portal hypertension (Nelwan, 2019). In addition; infection by S. japonicum in human
could cause anemia, growth disorders, and even death (Gordon et al., 2019).
Physiopathologically, 2 to 3 centimeters adult worms may cause venous obstruction where
they reside. However, the disease is more commonly caused by the daily of numerous eggs
released by the females. Schistosoma species can release hundreds to thousands eggs per day,
depending on the species. These eggs invade local tissues, release toxins and enzymes and
provoke a Th-2-mediated immune response. Inflammation and granuloma formation occur
around deposited eggs, which can lead to extensive tissue damage (fibrosis and scarring).
Most patients infected with schistosomes of all species are asymptomatic (Nelwan, 2020).
Intestinal clinical manifestations include abdominal pain, diarrhea, and blood in the stool. In
advanced cases, hepatosplenomegaly is common and is repeatedly associated with ascites and
other signs of portal hypertension. Intestinal schistosomiasis represents another form of
schistosomal affection. Among spectrum of intestinal lesions, polyps are the commonest

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(Schwartz and Fallon, 2018). Intestinal and/or hepatosplenic disease are current abnormalities
in individuals from areas with high or even low endemicity (Christinet et al., 2016).
Egg-laying worms are present in the intestinal microvasculature especially in the distribution
of the inferior mesenteric venous plexus. In the large intestine, ova are mainly distributed in
the loose sub mucosa, and to a lesser extent in the sub serosa where frequently multiple
granulomas are formed. Subsequently, the muscularis mucosa becomes involved and the
overlying mucosa is either denuded forming small superficial ulcers or undergoes
hyperplastic changes. Sandy patches develop when the sub mucosa becomes densely
thickened by fibrous tissue containing immense numbers of calcified eggs. The overlying
mucosa becomes atrophic and acquires a granular dirty yellowish appearance (Nelwan,
2020).
Polyp formation is one of the most frequently intestinal lesions seen in chronic intestinal
schistosomiasis. The underlying mechanism starts with egg deposition in the loose superficial
layers of sub-mucosa and subsequently progresses into cell mediated inflammatory response
with granuloma formation to form polyps. It frequently presents as abdominal pain, diarrhea,
tenesmus and weight loss, all of which are not specific to intestinal schistosomiais (Shuja et
al., 2018).
Table 1. Manifestations of acute and chronic intestinal schistosomiasis
Manifestation Specie Symptoms/disease
Acute Schistosoma japonicum Myalgia, respiratory symptoms,
(Katayama Syndrome) Schistosoma mansoni rash, fever, headache.
Chronic Schistosoma japonicum Blood in the stool, constipation,
Schistosoma mansoni diarrhea, bowel wall ulceration,
fibrosis, hyperplasis, polyposis,
portal hypertension.
Source: Nelwam, 2020.
The pathology associated with intestinal schistosomiasis is due to egg deposition and
granuloma formation. This eventually leads to acute then chronic schistosomal colitis and
polyp formation. Although areas in both the small and large intestine may be involved, most
severe lesions are found in the large intestine. It seems that the adult worms have a tendency
to inhabit the branches of the inferior mesenteric vein and superior hemorrhoidal vein. Hence,
more eggs are deposited in the large intestine, especially in the rectum, sigmoid, and
descending colon (Olveda et al., 2014).

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KATAYAMA SYNDROME
The clinical manifestation of Katayama syndrome with S. japonicum is outstanding. These
manifestations are more serious than that the infection with S. intercalatum, and S. mansoni.
Clinical presentations of the Katayama syndrome include fever, headache, cough, malaise,
fatigue, abdominal pain, urticarial rash, rigor, sweating, general muscular pain,
gastrointestinal disturbances, enlargement and tenderness of the liver, and eosinophilia
(Gobbi et al., 2020). Serious patients are usually very sick with high-grade fever, and if not
treated in time, the subjects may be dying. In China, the frequency of Katayama syndrome
with S. japonicum schistosomiasis is much lower that it was in 1950s and 1960s. The number
of Katayama syndrome was less than 100 annually for three consecutive years by 2011
(Nelwan, 2020).
CHRONIC INFECTION
In chronic schistosomiasis, the adult worms live in the venous mesenteric, where worms lay
hundreds to thousands of eggs daily for several years. The continuos deposition of eggs
causes a granulomatous response resulting, over time, in chronic inflammation with fibrosis
and, eventually, severe organ damage, such as periportal fibrosis with portal hypetention for
S. japonicum and S. mansoni (Gobbi et al., 2020).
Schistosomiasis is a chronic infection that is rarely recognized in its early stages. Chronic
schistosomiasis is the most prevalent form of the disease in region endemic for
schistosomiasis, due to repeated exposure and re-infection. In general, a child’s initial
infection occurs by age 2 years (Butrous, 2019).

DIAGNOSIS
Examination of excrement is a key method used to diagnose suspected schistosomiasis
infections. For examination purposes, several diagnostic techniques are available: the Kato-
Katz, miracidium hatching test (MHT), formol-ether concentration technique (FECT),
circulating cathodic antigen (CCA), point of care test (POCT), and polymerase chain reaction
(PCR)-based technique. Alemu et al., 2018 showed that the FECT is time-consuming and
requires several materials. Moreover, the sensitivity and specificity of the FECT are almost
similar to the Kato-Katz technique. The Kato-Katz technique is fast, easy to perform, and
requires minimal training. This technique has an 87.5% sensitivity rate and 100% specificity
rate.

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MHT, Kato-Katz, and FECT
Many strategies are available to detect schistosomiasis. These include MHT, Kato-Katz, and
FECT. MHT involves analyzing the concentration of eggs in stool samples. Samples come in
nylon tissue bags and are suspended in distilled water in flasks. The presence of miracidia
hatching from ova could be a sign of infection. Flask examination occurs at 4, 6, 8, and 24
hours. Kato-Katz stool sample examinations need 3 slides and use a light microscope (He et
al., 2018). The investigator takes about 42 mg stool sample and places it in a 200 μm Kato-
Katz screen mesh. The stool is transferred into a 6 millimeters hole of a template on the
microscopic slide. A glycerol-soaked cellophane strip covers the stool. The investigator then
examines the stool for schistosome eggs. After that, eggs per gram of stool can be counted
(Nelwan, 2019).
For FECT, stool sample examinations use a centrifuge tool. The preparation contains about
500 mg stool sample. It is combined with 10 mL normal saline. Then, 2.5 mL 10%
formaldehyde and 1mL diethyl ether are added to this preparation. This preparation is placed
in gauze within a funnel. The centrifugation was at 1000g force for 3 minutes. Then, the
investigator covers the supernatant with a glass cover to inspect it (Alemu et al., 2018).
Active infections can be detected from worm-derived circulating anodic antigens (CAAs) and
circulating cathodic antigens (CCAs) in serum and urine using enzyme-linked
immunosorbent assay (ELISA) or monoclonal- antibody-based lateral flow tests (Aula et al.,
2021). These detection methods have the ability to detect infection before the worms begin
producing eggs (Marchese et al., 2018). However, they do not discriminate between past,
active or re-infections, especially in endemic areas where patients can remain seropositive
several years after treatment (Aula et al., 2021).
PCR method
For low-intensity levels, PCR can be beneficial. PCR has sufficient sensitivity and specificity
for detection of schistosome eggs in mammalians (He et al., 2018). Polymerase chain
reaction (PCR) and quantitative PCR (qPCR)-based molecular methods are now increasingly
being employed for diagnosis in high-resource settings globally but they are expensive, take
time, require a significant laboratory infrastructure and training which hampers their current
use in low socio-economic endemic field settings (Aula et al., 2021).
TREATMENT
Schistosomiasis eradication attempts commonly concentrate on controlling the infection
through preventive chemotherapy. Praziquantel is cost-effective for treating schistosomiasis.
The World Health Organization recommends a single dose of 40 mg/kg for all species and
10
ages (Zwang and Olliaro, 2014). Praziquantel’s mechanism of action is on the tegumentary
and muscular tissue, causing contractions in the parasite that are followed by its death and
also it inhibits the egg production in female parasites (Rivadeneira and Lou, 2019).
However, this recommendation has a limitation: praziquantel does not kill immature worms
present in the body at the time of treatment (Munisi et al., 2017). Thus, treatment needs to be
repeated after 2 to 4 weeks to increase effectiveness (Nelwan, 2019). This disease continues
to be among the most alarming diseases in humans (Mohamed et al., 2018).
Probably the cornerstone of treatment of the intestinal schistosomiasis is the use of anti-
inflammatory such as corticosteroids. It is hypothesized that if indeed adult worms already
present early after infection, then praziquantel, in association with steroids, could be started at
an earlier stage than generally recommended. Praziquantel would avoid novel oviosition,
while steroids would attenuate the inflammatory reaction caused by already-laid eggs (Gobbi
et al., 2020).
Jatsa et al., 2018 showed that Sidapilosa Retz aqueous (SpAE) extract could treat S. mansoni.
SpAE reduced granuloma numbers in the liver by 52% and the small intestine by 52.79%.
SpAE also reduced granuloma volumes in the liver by 48.76%. The thickness of the small
intestine’s muscular layer was reduced by 10.52%. Thus, SpAE might be used for the
development of medication against S. mansoni infection. Jatsa et al., 2018 also reported other
groups had successfully reduced granuloma number and/or size on blood-worms. Those
authors used zingeber officinole rhizome berberine and selenium nanoparticles (Jatsa et al.,
2018).

CONTROL
In areas where schistosomiasis transmission is identified, preventive chemotherapy through
repeated mass drug administration (MDA) of the donated anthelmintic drug praziquantel (40
mg/kg body weight) is the principal strategy for disease control (Archer et al., 2020).
Because the highest burden of infection is typically seen in children and young adolescents,
MDA is customarily carried out in schools, but aims to limit overall transmission within a
community through a reduced human reservoir of infection while also reducing overall
disease morbidity (Lo et al., 2017). Though praziquantel’s mechanism of action is not
currently fully understood, significant reductions in disease prevalence and morbidity have
been seen globally since MDA programmes began in 2001 (Park and Marchant, 2020).
Reinfection of schistosomiasis following treatment is, however, commonplace owing to
communities’ reliance on freshwater, and so MDA must be repeated annually or biannually,

11
depending on disease prevalence, to achieve a sustained impact. Severe adverse effects are
seen only very rarely when distributing praziquantel, making it well suited for mass
distribution. Praziquantel, however, typically does not achieve 100% infection clearance
primarily because dosing is usually based only on height and so does not account for
differences in body mass. As a result, treatment success varies between individuals meaning
many are still able to continue maintaining transmission (Archer et al., 2020). In addition,
and while local school systems provide a viable means of mass-distributing praziquantel,
important human reservoirs of infection, including pre-school-aged children and adults,
typically remain untreated (Bustinduy et al., 2016). The need for repeated annual or biannual
distribution of MDA in this way has also raised regular concerns about the development of
praziquantel resistance in schistosomes; particularly as there is currently no known e_cacious
alternative treatment to replace praziquantel if Schistosoma populations were to become more
drug-tolerant or resistant (Bergquist et al., 2017).

CONTROL MEASURES IN ADDITION TO MDA

Mapping Studies and Snail Control

Mapping and geospatial analysis of schistosomiasis is important to monitor transmission
trends and prevalence, leading to better understanding of the disease burden and risk factors
for infection, which will in turn result in more targeted control efforts and improved
surveillance procedures (Kabore et al., 2017). Communities that have performed mapping
have been able to effectively scale up treatment and monitor applied control strategies (Boko
et al., 2016).
Environmental factors including vegetation, temperature, elevation and precipitation are
useful predictors of snail habitats which may be more reliable in assessing the distribution of
schistosomiasis compared with prevalence survey data (Aula et al., 2021).
Snail control plays a vital role in the interruption of schistosomiasis transmission. Snail
control using chemical molluscicides was introduced and used extensively in the 1950s-
1970s in Africa, Asia and South America, until the inception of oral chemotherapeutics for
humans led to its decline. The most commonly used molluscicide is niclosamide, which is
effective against all stages of the snail life cycle. It has been shown to be effective in control
and elimination programs for schistosomiasis in several African countries including Morocco
(Aula et al., 2021). The downside of niclosamide is that it can be toxic to the environment
and other animals, expensive, labour intensive and does not prevent repopulation of snails
after treatment (Rocha-Filho et al., 2015).

12
Education and Knowledge
As with most NTDs, poverty, lack of adequate infrastructure and a low level of education are
important factors affecting the prevalence of schistosomiasis in Africa. The WHO has
highlighted education as part of its strategic plan for schistosomiasis control in Africa along
with MDA and WASH activities (Aula et al., 2021). The lack of knowledge about
schistosomiasis and how it is transmitted in endemic regions is a major risk factor and can
prevent successful implementation of control programs, including MDA, in some areas.
An interactive board game, Schisto and Ladders™, which included information on the mode
of schistosome transmission, behavioural risks associated with transmission, symptoms of
infection and information on what to do to seek treatment, prevention of reinfection and
control strategies for schistosomiasis was developed and tested in schools in an endemic area
(near Abeokuta), in Nigeria (Ejike et al., 2017).

CONTROL OF SCHISTOSOMIASIS: THE NEW WHO GUIDELINE ON CONTROL

AND ELIMINATION OF HUMAN SCHISTOSOMIASIS
Schistosomiasis is a multifaceted disease with a complicated lifecycle, which requires a
comprehensive control strategy. Over the past two decades, control efforts have led to a
58.3% decrease in the global burden of schistosomiasis (Kokaliaris et al., 2022). The new
neglected tropical diseases (NTD) roadmap and guidelines on the control and elimination of
schistosomiasis (WHO, 2022) set out to accelerate the progress made and are important
milestones in the control of this disease. The new guidelines detail an integrated control
strategy involving six evidence-based recommendations for endemic countries to facilitate
the elimination of morbidity and interruption of transmission (WHO, 2022). The
recommendations detail combining large scale preventive chemotherapy programs, WASH,
education, snail control and environmental modification to eliminate schistosomiasis as a
public health problem (defined as interventions has been simplified and reduced to reflect the
decline in the global burden of schistosomiasis (WHO, 2022). In endemic communities with
a schistosomiasis prevalence > 10%, annual preventive chemotherapy with PZQ is
recommended. Whereas in communities with an infection prevalence < 10% a test and treat
approach is recommended. In high prevalence settings and ‘persistent hotspots’ biannual PZQ
preventive chemotherapy is recommended to reduce the prevalence and intensity of infection,
and specifically to prevent high intensity infections and the associated morbidity. The
expanded eligibility for PZQ preventive chemotherapy programs requires a larger global
supply of PZQ than that currently donated (around 300 million tablets are donated annually).

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Providing a targeted treatment approach to communities through precision mapping, and
more accurate diagnostics, could allow for more effective use of donated PZQ (WHO, 2022).
The expanded preventive chemotherapy programs aim to accelerate the path to
schistosomiasis elimination, however; they also pose an increased risk of the selection of
PZQ drug resistance within populations. Increased surveillance to monitor changes in drug
efficacy via treatment monitoring and evaluation surveys (post treatment follow up surveys)
have been recommended to ensure early detection of the emergence of PZQ resistance
(WHO, 2022).

VACCINE DEVELOPMENT
A schistosomiasis vaccine could create a long-term decrease in illness spectrum and
transmission (Ricciardi et al., 2018). It could protect up to 600 to 700 million people (Tallima
et al., 2015). To date, schistosomiasis vaccines are unavailable (Nelwan, 2019). However,
experiments in animals are underway. Tallima et al., 2015 found that a cysteine peptidase-
based vaccination could shield against S. haematobium schistosomiasis. A mixture of
Schistosoma mansoni Chaptesin B1 (SmCB1) and Fasciola hepatica L1 reduced worms by
70%. The mixture also reduced eggs by 60% (Tallima et al., 2015). You et al., 2018a
discovered that the S. japonicum acetylcholinesterace (SjAChE) inhibited parasite growth and
development. The authors used ribonucleic acid interference to kill parasites in vitro. You et
al., 2018a also found that immunization of mice with the recombinant SjAChE reduced male
worm numbers (33%) as well as liver tumor density (41%), and decreased numbers of enteric
eggs (73%). In addition, You et al 2018b suggested a vaccination with rSjLD1 and 2. The
authors stated that rSjLD1 and 2 would be safe for immunizing bovines and humans (You et
al., 2018)b. The rSjLD1 vaccine reduced the number of female worms (30%–44%), fecal eggs
(61%–68%), liver eggs (44%–56%), intestinal eggs (46%-48%), and mature intestinal eggs
(58%- 63%) (You et al., 2018)b. These studies confirm the potential of SjAChE and rSjLD1
as vaccine/drug candidates.
Moreover, to control S. mansoni schistosomiasis, Ricciardi et al., 2018 discovered
Schistosoma mansoni Chaptesin B (SmCB) as a vaccine candidate. The authors performed in
vitro killing assays in schistosomula stage parasites targets for lung-derived leukocytes and
serum obtained from mice vaccinated with SmCB adjuvant with either Montanide ISA 720
VG (SEPPIC Inc., Fairfield, NJ, USA) or cytosine-guanine in the linear sequence (CpG or
CG oligodeoxynucleotides) (CpG) and from mice not vaccinated. The SmCB + Montanide
720 VG (SEPPIC Inc., Fairfield, NJ, USA) resulted in the highest death rate (63%). The

14
SmCB + CpG vaccinated animals experienced a significant death rate (53%). Also, the Sm-
cathepsin alone had a substantial success rate (41%) (Ricciardi et al., 2018). It seems that
SmCB can help to reduce schistosomiasis for S. haematobium and S. mansoni.

CONCLUSION
Intestianl schistosomiasis is a prevalent infection in tropical and subtropical areas, especially
in communities without adequate sanitation and safe drinking water. Schistosomiasis is one
of the neglected tropical diseases currently affecting mostly the poor population and causing
thousands of deaths annually worldwide and continues to be a major public health issue in
Africa with Nigeria among endemic countries. Its clinical manifestations depend on the acute
or chronic phase, but if left untreated irreversible complications occur. Currently,
praziquantel is the only drug treatment available for schistosomiasis. Several drug candidates
have been studied, including linalool and SpAE. Control of schistosomiasis in endemic areas
include water sanitation, minimizing contact with fresh water, community health-education,
eradication of snail species and domestic animals care and treatment.

15
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