Title: Human schistosomiasis in Egypt: historical review, assessment of the current picture and prediction of the future trends

Author: Wael M. Lotfy Parasitology Department, Medical Research Institute, Alexandria University For correspondence: Dr. Wael M. Lotfy. Email: waelotfy@alex-mri.edu.eg. Postal address: Parasitology Department, Medical Research Institute, 165 El-Horreya Avenue, Alexandria, Egypt. P.O. Box 21561.

Abstract: Schistosomiasis is a major source of morbidity affecting approximately 207 million people in 76 countries. The history of schistosomiasis in Egypt is longstanding over 5000 years. Since the discovery of the parasite by Theodor Maximillian Bilharz in early 1851, the history of the major discoveries related to the disease and the life cycle of the parasite was surprisingly linked to Egypt. The past and current pictures of the disease in Egypt are covered in the form of a review. Also the future trends are discussed in view of the effective control measures carried out by the Egyptian government. These trends are the possibility of emergence of drug resistance, the magnification of role of rodents in the transmission of the disease, and the possibility of emergence of cercarial dermatitis by nonhuman schistosomes.

Schistosomiasis is one of the most prevalent human parasitic infections. It is a major source of morbidity affecting more than 207 million people in 76 countries. It was estimated that 97% of the infected cases are on the African continent.(1) The disease is caused by trematodes of the genus Schistosoma, which exhibit dioecy and have complex life cycles comprising several morphologically distinct phenotypes in definitive human and intermediate snail hosts.(2)

The history of schistosomiasis in Egypt is longstanding for over 5000 years, with reports of Schistosoma haematobium eggs in ancient mummies.(3-7) Schistosoma mansoni does seem to be a relatively modern arrival as it has not been found in mummies. Jury is still out on when S. mansoni first appeared in Egypt.(8) There have been numerous attempts to find descriptions of the disease in the medical papyri.(9,10) The most debatable word is "aaa", which occurs in over 50 early papyri including the Ebers papyrus. In some papyri "aaa" occurs together with the initial hieroglyph suggesting a penis discharging what has been interpreted as blood.(11) The juxtaposition is the papyri of "aaa", antimony-based remedies, and possibly worms in the body suggests urinary schistomiasis, and this interpretation is widely quoted in textbooks. Unfortunately, things are not as simple as this because no passages from the papyri link "aaa" with the bladder or urine and the discharge from the penis might represent semen and not blood. It is to be mentioned here that there have been a number of other suggestions about what "aaa" might be, including hookworm disease.(12) This topic is discussed in detail by Nunn and Tapp (2000), who rejected "aaa" as a possible ancient Egyptian word for schistosomiasis.(13) However, since schistosomiasis was almost certainly common and widespread in ancient Egypt, it is strange that the Egyptians did not have a word for it unless it was so common that it was ignored.(12) Probably the first authoritative description of hematuria in the earliest medical literature is by Avicenna (c1000) in his famous book Al Kanon fi al Tib.(14) Centuries later, an epidemic among soldiers in Napoleons army in Egypt in 1798 was described by a French army surgeon, A. J. Renoult.(15) However, the cause of the disease was unknown. In early 1851, Theodor Maximillian Bilharz, a German physician working at Kasr El Ainy Hospital in Cairo, discovered the causative agent of hematuria while performing an autopsy on a young Egyptian man. He named the parasite Distomum haematobium and reported his discovery in a series of letters to his old teacher, Carl Theodor Ernst von Siebold. In 1853, extracts from these letters with von Siebold comments were published in the German Zoological Journal.(16) At the time when Bilharz wrote his letters, he did not know that he was dealing with two species of schistosomes. He regarded these lateral-spined eggs as abnormalities.(16,17) Bilharz made the connection between schistosomiasis and hematuria later.(18) The peculiar morphology of the worm (the presence of the gynaecophoric canal or the schist) made it clear that it could not be included in the genus Distomum. The parasite was described in 1856 as Bilharzia haematobium, after its discoverer, by Meckel von Hemsbach in a thesis entitled The Geology of the Human Body. This work was published but had a limited circulation.(19) In 1858, Weinland, apparently not knowing of this thesis, described the worm as Schistosoma haematobium.(20) In 1948 the International Commission on Zoological Nomenclature established the name 2

Schistosoma and it is thus the current name of the parasite.(21) However, both bilharzia and schistosomiasis are used to denote the various diseases caused by the numerous species of the genus in man and animals. Our knowledge of the history of intestinal schistosomiasis caused by S. mansoni dates back to 1902, Sir Patrick Manson saw in London a case of intestinal bilharziasis, contracted in the West Indies, in which lateral-spined eggs only were present. He concluded there are two species of Schistosoma in humans.(22) Sambon (1907) named the new species as S. mansoni after Sir Patrick Manson.(23) The name was officially accepted in 1913.(24) Although it was known that other digeneans employed a snail intermediate host, a number of experienced parasitologists including Arthur Looss, Prospero Sonsino, and Thomas Cobbold, working at the end of the 19th century, all failed to infect snails and reveal the life cycle of schistosomes;(12) it was not until 1915 that Robert Leiper demonstrated the complete life cycle in the snail host. In February 1915, Leiper was sent to Egypt to investigate the life cycle of the schistosomes and to advise the British troops on preventive measures. He established experimentally that there were two species of Schistosoma in Egypt, a urinary form with terminal-spined eggs (S. haematobium) and an intestinal form with lateral-spined eggs (S. mansoni), and that the former is transmitted by Bulinus truncatus and the latter is transmitted by Biomphalaria alexandrina snails.(25,26) Audouin in 1826 described Physa truncate (Synonym B. truncatus)in Savigny's Description of Egypt. The snail occurs throughout the whole length of the Nile Valley in Egypt, in irrigation channels and drains and in many places in the River Nile itself. It is especially common in the region of the Nile Delta, and also occurs in the Baharia, Dakhla and Kharga oases.(27) Ehrenberg in 1831 described Planorbis alexandrina(Synonym B. alexandrina) which he collected from the brackish water of Lake Maryut near Alexandria.(28) The snail has historically been confined to the Nile Delta especially the area between Alexandria and Rosetta.(29) There are some indications that a larger geographic range existed in wetter periods, as fossilized shells of B. alexandrina were detected in a Paleolithic site in the Egyptian Western Desert(30) and in a Neolithic site in Sinai.(31) However, at late Paleolithic sites in the Nile valley in Upper Egypt (Edfu and Esna), fossilized shells of other freshwater snails, including B. truncatus, but not B. alexandrina, have been recovered,(32) which may indicate that B. alexandrina was not present in Upper Egypt in that time. In 1856, Bilharz noted that schistosomiasis is one of the most frequent helminthic infections among Egyptians. He estimated that it will be rather low when he assumes that half of the adult population of Egypt harbor the worm or traces of it.(18) According to Abdel-Azim (1935) there were not any reliable surveys conducted to detect the prevalence of schistosomiasis in Egypt

until 1915.(32) A survey was made by MacCallan during 1913-1915. He was the first to introduce microscopic examination in population studies.(33,34) From 1933 to 1935, Dr. John A. Scott carried out an extensive country-wide house-to-house schistosomiasis survey. It was the first accurate epidemiological study in Egypt's long history of schistosomiasis. Scott examined 40,000 persons from different governorates and analyzed the data from two million examinations at government treatment centers. His paper published in 1937, offers unique information on the various aspects of the epidemiology of the disease in Egypt. He reported that S. haematobium was the only species transmitted along the Nile Valley in Middle and Upper Egypt, south of Cairo, and both species of schistosomes were endemic in the Nile Delta (under perennial system for several years before that time). The perennial system had also been established for some time in most of Upper Egypt as far south as Assiut. South to Assiut, the ancient basin system was still in use except in a few, relatively small districts where sugar plantations had been established. Scott estimated that 47% of the Egyptian population which was 15.23 million persons were infected with either one or both species of Schistosomes.(35) In 1955, about 20 years after Scott survey, the Egyptian Ministry of Health performed a randomized survey utilizing the same diagnostic methods as Scott and in the same villages surveyed by him. The overall S. haematobium prevalence was 38%, with only 9% infected with S. mansoni in the Delta. Schistosoma mansoni was not locally transmitted in Upper Egypt until the time of that survey. The overall prevalence of S. haematobium south of Assiut was dramatically rose from 3 to 42% following the change from basin irrigation to perennial irrigation.(36) Khalil and Abdel-Azim in 1938 demonstrated a remarkable impact of conversion of the ancient form of basin irrigation to perennial irrigation in Aswan on the transmission of S. haematobium.(37) It is to be noted here that Aswan Low Dam was completed in 1902. More than two-thirds of Egypt had been converted to perennial irrigation by the 1930s and by the 1950s most of the arable land in the Egyptian Nile valley had been converted to perennial irrigation including much of old Nubia.(38,39) El-Zawahry in 1963 reported that S. haematobium had increased strikingly in those areas of old Nubia where perennial irrigation systems had been constructed.(40) Farooq et al., in 1966 estimated that about half of the population was already infected (14 million out of 30 million). In areas that were to be converted or reclaimed, Farooq expected the prevalence to increase from 5 to 70 % and calculated that 2.65 million new cases of schistosomiasis would result from the completion of the Aswan High Damin 1970.(41) AbdelWahab et al., in 1979 reported an inversion from Scotts survey in prevalence of S. mansoni and S. haematobium (from 3% and 73% to 74% and 2%) in a Nile Delta rural community. Most probably this is due to the changes in the irrigation system after the construction of the High 4

Dam which affected the freshwater ecology and snail fauna.(42) In very recent times, B. alexandrina appears to be expanding its range upstream in Egypt. In the late 1970s and 1980s, the snail was found at increasing distances upstream, as far as Aswan City and Abu Simbel at Lake Nasser, respectively.(43,44) However, Lotfy et al., in 2005 reported that B. alexandrina snails were widely distributed in the Nile Delta and along the Nile Valley as far south as Aswan City only.(45) Changes in the hydrology of the Nile basin, controlled water flow, and new irrigation networks following construction of the Low and High Dams at Aswan, have been implicated in increasing appropriate habitats for the snail.(44,46) In 1976, the Ministry of Health started the National Schistosomiasis Control Programme (NSCP), based on case detection and treatment. The objectives of the NSCP were: control of morbidity by reduction of the prevalence and intensity of infection, thereby limitation of complications; protection of young age groups and other at risk populations; protection of settlers in newly reclaimed lands; and prevention of the spread of S. mansoni to Upper Egypt. By 1989, the distribution of PZQ doses, free of charge, to all diagnosed schistosomiasis cases was implemented through different health facilities including the network of rural health units. Chemotherapy was frequently supplemented with focal snail control with chemical molluscicides (niclosamide at 1-2 ppm).(47) In 1988, under sponsorship of the Ministry of Health and the United States Agency for International Development (USAID), the Schistosomiasis Research Project (SRP) was started. This ten-year program supported the investigation of prevalence and intensity of Schistosoma infection, the prevalence and magnitude of morbidity caused by schistosomiasis, the changing pattern of distribution of S. mansoni and S. haematobium, and the determinants of infection and morbidity in a random sample of the rural inhabitants of nine governorates in the country, selected as representative of each area (Upper and Lower Egypt) and of governorates with both high and low infection rates. The program is the second national house-to-house survey for schistosomiasis in Egypt after J. A. Scotts work which was conducted 60 years previously.(48) The SRP results showed that although a significant progress was undeniably made in the control of schistosomiasis, particularly urinary schistosomiasis, one of the striking findings of this study was that in parts of Egypt, especially in the Nile Delta, the prevalence of the related schistosome, S. mansoni, remains quite high.(49) Furthermore, it is replacing S. haematobium in the Delta and has become well established in Middle Egypt(50) and has been reported in parts of Upper Egypt.(51,52) By 1997, the Ministry of Health started to distribute praziquantel (PZQ) to endemic populations without prior diagnosis. These populations included schoolchildren (4.3 million) in 11 governorates and the entire population (2.9 million)

living in 535 villages with estimated prevalence of schistosomiasis (intestinal and/or urinary) higher than 20%. The prevalence rate level at which mass chemotherapy was offered to a village has decreased over time, being 10% in 1999, 5% in 2000 and 3.5% in 2002. Consequently, the overall prevalence of both S. haematobium and S. mansoni declined steadily year by year. By the end of 2006, S. haematobium has virtually disappeared from the Nile Delta, however, still present in Upper Egypt with a prevalence rate of 1.2%. The overall prevalence rate of S. mansoni in the Nile Delta declined to 1.5% (Figure 1). All endemic villages (744 villages) have prevalence rates 1%-3%, however 68 villages (mainly in Behira and Sohag governorates) remained with slightly higher prevalence (range 3%-5%). No morbidity associated with schistosomiasis has been seen in recent years in Egypt. The NSCP has succeeded to significantly decrease the prevalence and intensity of schistosomiasis (intestinal and/or urinary) to a low level such that the disease is no longer a major public health problem.(47) The situation with respect to Biomphalaria in Egypt has become complicated in recent years by the introduction of Biomphalaria glabrata.(53-57) This large snail is the most widespread and important intermediate host of S. mansoni in the Neotropics. In 1996, snails identified as B. glabrata by conchological and morphologic criteria were found along many kilometers of irrigation canals and drains in Giza, in Qalyoubia Governorate in the south of the Nile Delta, and in Kafr El-Sheikh Governorate in the north-central Nile Delta.(54) In 1999, snails considered to be hybrids between B. glabrata and the indigenous B. alexandrina were reported to be widespread throughout the Nile Delta.(55,56) Experimentally, both B. glabrata and hybrids were found to be susceptible to Egyptian strains of S. mansoni but showed lower susceptibilities than B. alexandrina. However, the duration of cercarial shedding was longer and the numbers of cercariae shed per snail were higher in B. glabrata and hybrid snails than in B. alexandrina.(56) This may indicate that the introduced B. glabrata and the hybrid snails are more hazardous than B. alexandrina in the transmission of S. mansoni. In addition to complicating the epidemiology of schistosomiasis in Egypt, B. glabrata can also be viewed as an invasive exotic that threatens the integrity of the African aquatic biota.(58) Recent advances in molecular technology have made possible large scale surveys at the DNA sequence level. By using known nuclear and mitochondrial sequences for Biomphalaria spp. and newly developed polymerase chain reaction (PCR) based assays by Lotfy et al., (2004),(59) a molecular survey was carried out from regions between Alexandria and Ismailia in the north of the Nile Delta, to as far south as Abu Simbel at Lake Nasser. The aim of the study was to identify the species of Biomphalaria present in Egypt, to assess the current distribution of B. alexandrina, B. glabrata, and their possible hybrids, and

to examine further the nature and extent of hybridization if hybrids were found. Also, sequence data were used to assess the extent of genetic variation in B. alexandrina. They found no evidence for B. glabrata, but B. alexandrina does remain common, and no evidence for hybridization with B. glabrata was found.(45) They mentioned that after the presence of B. glabrata in the Nile Delta was reported,(53-57) the Snail Control Section in the Ministry of Health was alerted and reacted strongly by applying molluscicides in putative B. glabrata habitats.(45) Molecular approaches have become an increasingly important way to study the epidemiology of schistosomiasis, enabling more rigorous examination of schistosome population structure and genetic subdivision and response to control efforts. Microsatellite markers have been used with increasing frequency in population genetics studies of schistosomes. Among the applications of microsatellite markers, and other molecular markers, is the identification of Schistosoma genotypes among individual infected snails. The distribution of S. mansoni genotypes among snails can have significant consequences for the transmission dynamics of the parasite and on the distribution of genetic diversity of schistosomes among the definitive host population.(60) To confirm the current epidemiological picture of intestinal schistomiasis in Egypt, Lotfy et al. (in press),(61) studied the distribution of Schistosoma genotypes among a snail population. A survey of B. alexandrina from an endemic focus in Damietta (Nile Delta, Egypt), an area subjected to persistent schistosomiasis control efforts, provided only 17 snails infected with S. mansoni, each shown by microsatellite analysis to have a single genotype infection. By contrast, recent studies of uncontrolled S. mansoni transmission foci in Kenya revealed that 4.3% Biomphalaria pfeifferi and 20-25% Biomphalaria sudanica snails had multiple genotype infections.(62,63) Compared with the 3 Kenyan populations, the Egyptian population of S. mansoni also showed a lesser degree of genetic variability and was genetically differentiated from them. Although the focal persistence of snail infections indicates transmission has not been eliminated in Damietta, mono-genotypic snail infections, along with an overall low degree of genetic variability, could serve as adjuncts to human infection or prevalence rates to monitor the impact of schistosomiasis control programs in Egypt and elsewhere.(61) Praziquantel is now considered as the drug of choice for treatment of schistosomiasis and a major advance in the treatment of most trematode and cestode infections.(64,65) This pharmaceutical product is the first anthelminthic drug to fulfill the World Health Organizations requirements for population-based chemotherapy of a broad range of parasitic infections.(66) PZQ was first released by Bayer A.G. in 1979, after the mandatory toxicological tests and clinical trials had been completed.(67) In 1987, formulation of PZQ in Egypt under a licensing 7

agreement from Shin Poong was started. Before 1987, PZQ was being produced in Egypt under license from Bayer, but sold at a very high price. Shin Poongs licensee competition with Bayers licensee in Egypt contributed to major reductions in the private market price for PZQ.(68) From 1988 onward, Egypt's Ministry of Health began providing PZQ free of charge in its national schistosomiasis control program. It is well documented that during the SRP, over a 10 year period, the Egyptian Ministry of Health dispensed almost 30 million doses of PZQ.(69) Heavy use of PZQ continues to this day as it remains the drug of choice for treatment of schistosomiasis,(70) therefore, if PZQ-resistance were to emerge, Egypt would be a likely place. Ismail et al. (1994a, 1994b, 1996), reported that during a survey in some villages of the Nile Delta some cases remained infected in spite of the PZQ three treatment regimens.(71-73) Several factors may be responsible for such result. Some of the infections resisted chemotherapy because of host factors, while others are attributable to the worms themselves. Pharmacokinetic parameters were the same in patients treated successfully after a single dose versus those not treated successfully following two or three doses, thus eliminating the possibility that poor cure rates among infected villagers was due to a decrease in PZQ bioavailability.(73) The in vitro action of the drug on schistosomes was related to its in vivo action confirming that these isolates were PZQ-resistant strains.(74-76) Recently, some of these PZQ-resistant isolates maintained in the laboratory for years reverted to a PZQ-sensitive phenotype when they were passaged in mice in the absence of PZQ pressure.(77) Moreover, after one decade of the first report of PZQ resistance in the Nile Delta,(73,74) the same villages were investigated for the current sensitivity of S. mansoni infection to PZQ. There has not been an increase of drug failure, despite ten years of therapeutic pressure in these villages where there had been resistant infections and worms with decreased response to PZQ.(78) Lotfy et al., (2009), by comparing field isolates of S. mansoni cercariae from Alexandria with those of a laboratory strain never exposed to PZQ before, concluded that PZQ resistance may not constitute a real problem in the studied field isolates.(79) A second issue that may emerge in the future is the role of the animal host in transmission of the disease. Kuntz and Malakatis (1955) reported that the Nile rat, Arvicanthis niloticus, is a satisfactory host for S. mansoni in Egypt.(80) Experimentally, it gave satisfactory yields of welldeveloped schistosomes which deposit numerous eggs in the wall of the lower intestine as well as in other organs of the body. It is frequently found near or even in the water of irrigation systems in areas where schistosome infection is common in snails and in man.(80,81) There are several reports of natural infection of A. niloticus with S. mansoni.(82-84) In the past the role of the

Nile rat in transmission of S. mansoni was minimal because of the high prevalence and intensity of infection among humans. However, after the great success of the NSCP in Egypt the role of the Nile rat must be revised and highlighted. A third issue that may emerge in the future is cercarial dermatitis. It is a cosmopolitan waterborne disease which has been recently regarded as an emerging infection of increasing concern.(85) Early reports associated the disease with infection by cercariae of bird schistosomes.(86) More recent reports indicated that larval stages of other genera and species of the family Schistosomatidae are also able to produce cercarial dermatitis. Dermatitis-producing cercariae have been reported also in brackish and salt water.(87) However, to date, the most frequently reported causative agents of the infection are cercariae of bird schistosomes from freshwater bodies.(88) Usually cercarial dermatitis often goes unrecognized in endemic areas.(89) In the past, human infection with Schistosoma japonicum was endemic in Japan.(90,91) Control programs have successfully eradicated the parasite from Japan.(92) On the other hand, the bird schistosome Gigantobilharzia sturniae has emerged as a serious cause of dermatitis in the paddy fields of the country.(93) Species known to cause cercarial dermatitis were reported from Egypt.(94,95) After control of human schistosomes in Egypt, probably cercarial dermatitis will become of more public health concern for people in contact with freshwater bodies.

Figure 1. Overall prevalence of schistosomiasis in Egypt during the period 1935-2006 (Source: the National Schistosomiasis Control Program, quoted from WHO, 2007)

10

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