Schistosomiasis

Prevention and Control

Background
Schistosomiasis, a parasitic disease caused by blood
flukes, is one of the neglected tropical diseases (NTDs)
continuing to affect the Region. It is endemic in parts of
Cambodia, China, the Lao People’s Democratic
Republic and the Philippines. Transmission occurs
through contact with freshwater that has been
contaminated by excreta from people already infected.
The disease can cause bloody diarrhoea and vomiting,
anaemia, stunting, developmental retardation, spleen
enlargement and even death in severe cases. The
economic and social effects of the disease are
significant.
Copyright Trustees of the Natural History Museum
Schistosomiases
Schistosomiases are acute or chronic visceral parasitic
diseases due to 5 species of trematodes (schistosomes).
The three main species infecting humans
are Schistosoma haematobium, Schistosoma
mansoni and Schistosoma japonicum. Schistosoma
mekongi and Schistosoma intercalatum have a more
limited distribution
Humans are infected while wading/bathing in fresh
water infested with schistosome larvae. Symptoms
occurring during the phases of parasite invasion
(transient localized itching as larvae penetrate the skin)
and migration (allergic manifestations and
gastrointestinal symptoms during migration of
schistosomules) are frequently overlooked. In general,
schistosomiasis is suspected when symptoms of
established infection become evident
Each species gives rise to a specific clinical form:
genito-urinary schistosomiasis due to S. haematobium,
intestinal schistosomiasis due S. mansoni, S.
japonicum, S. mekongi and S. intercalatum.
The severity of the disease depends on the parasite
load. Heavily infected patients are prone to visceral
lesions with potentially irreversible sequelae.
Children aged 5 to 15 years are particularly at risk:
prevalence and parasite load are highest in this age
group.
An antiparasitic treatment should be administered to
reduce the risk of severe lesions, even if there is a
likelihood of re-infection.
Genito-urinary schistosomiasis
 S. haematobium
Distribution: Africa, Madagascar and the Arabian peninsula
 Urinary manifestations:
 In endemic areas, urinary schistosomiasis should be suspected in
any patients who complain of macroscopic haematuria (red coloured urine
throughout, or at the end of, micturition). Haematuria is frequently associated with
polyuria/dysuria (frequent and painful micturition).
 In patients, especially children and adolescents, with urinary symptoms, visual
inspection of the urine (and dipstick test for microscopic haematuria if the urine
appears grossly normal) is indispensible.
 Presumptive treatment is recommended in the presence of macro- or microscopic
haematuria, when parasitological confirmation (parasite eggs detected in urine)
cannot be obtained.
 Genital manifestations:
In women, symptoms of genital infection (white-yellow or bloody vaginal discharge,
itching, lower abdominal pain, dyspareunia) or vaginal lesions resembling genital warts
or ulcerative lesions on the cervix; in men, haematospermia (blood in the semen).
 If left untreated: risk of recurrent urinary tract infections, fibrosis/calcification of the
bladder and ureters, bladder cancer; increased susceptibility to sexually transmitted
infections and risk of infertility.
 In endemic areas, genito-urinary schistosomiasis may be a differential diagnosis to the
genito-urinary tuberculosis, and in women, to the sexually transmitted infections
(especially in women with an history of haematuria).
 Intestinal schistosomiasis
 S. mansoni
Distribution: tropical Africa, Madagascar, the Arabian peninsula, South America (especially
Brazil)
 S. japonicum
Distribution: China, Indonesia, the Philippines
 S. mekongi
Distribution: parts of Lao PDR, Cambodia (along the Mekong River)
 S. intercalatum
Distribution: parts of DRC, Congo, Gabon, Cameroon, Chad
 Non-specific digestive symptoms (abdominal pain; diarrhoea, intermittent
or chronic, with or without blood) and hepatomegaly.
 For S. intercalatum: digestive symptoms only (rectal pain, tenesmus,
rectal prolapse, bloody diarrhoea).
 If left untreated: risk of hepatic fibrosis, portal hypertension,
cirrhosis, gastrointestinal haemorrhage (hematemesis, melanea, etc.), except
with S. intercalatum (less pathogenic than other intestinal schistosomes, no severe
hepatic lesions).
 The diagnosis is confirmed when parasite eggs are detected in stools.
 In the absence of reliable parasitological diagnosis: in areas where
intestinal schistosomiasis is common, diarrhoea (especially bloody
diarrhoea) with abdominal pain and/or hepatomegaly may
be a basis for presumptive diagnosis and treatment.
Infection & Transmission
People become infected when larval forms of the parasite
– released by freshwater snails – penetrate the skin during
contact with infested water.
Transmission occurs when people suffering from
schistosomiasis contaminate freshwater sources with their
excreta containing parasite eggs, which hatch in water.
In the body, the larvae develop into adult schistosomes.
Adult worms live in the blood vessels where the females
release eggs. Some of the eggs are passed out of the body
in the faeces or urine to continue the parasite’s lifecycle.
Others become trapped in body tissues, causing immune
reactions and progressive damage to organs.
Epidemiology
Schistosomiasis is prevalent in tropical and subtropical
areas, especially in poor communities without access
to safe drinking water and adequate sanitation. It is
estimated that at least 90% of those requiring treatment
for schistosomiasis live in Africa.
There are 2 major forms of schistosomiasis – intestinal
and urogenital – caused by 5 main species of blood
fluke.
Parasite species and geographical distribution of schistosomiasis

 Geographical distribution
 Intestinal schistosomiasis
 Schistosoma mansoni
 Africa, the Middle East, the Caribbean, Brazil, Venezuela and Suriname

 Schistosoma japonicum
 China, Indonesia, the Philippines

 Schistosoma mekongi
 Several districts of Cambodia and the Lao People’s Democratic Republic

 Schistosoma guineensis and related S. intercalatum

 Rain forest areas of central Africa

 Urogenital schistosomiasis
 Schistosoma haematobium
 Africa, the Middle East, Corsica (France)
 Schistosomiasis mostly affects poor and rural communities,
particularly agricultural and fishing populations. Women doing
domestic chores in infested water, such as washing clothes, are also
at risk and can develop female genital schistosomiasis. Inadequate
hygiene and contact with infected water make children especially
vulnerable to infection.
 Migration to urban areas and population movements are introducing
the disease to new areas. Increasing population size and the
corresponding needs for power and water often result in
development schemes, and environmental modifications facilitate
transmission.
 With the rise in eco-tourism and travel “off the beaten track”,
increasing numbers of tourists are contracting schistosomiasis. At
times, tourists present severe acute infection and unusual problems
including paralysis.
 Urogenital schistosomiasis is also considered to be a risk factor for
HIV infection, especially in women.
Symptoms
Symptoms of schistosomiasis are caused by the body’s
reaction to the worms' eggs.
Intestinal schistosomiasis can result in abdominal pain,
diarrhoea, and blood in the stool. Liver enlargement is
common in advanced cases, and is frequently
associated with an accumulation of fluid in the
peritoneal cavity and hypertension of the abdominal
blood vessels. In such cases there may also be
enlargement of the spleen.
The classic sign of urogenital schistosomiasis is
haematuria (blood in urine). Fibrosis of the bladder and
ureter, and kidney damage are sometimes diagnosed in
advanced cases. Bladder cancer is another possible
complication in the later stages. In women, urogenital
schistosomiasis may present with genital lesions,
vaginal bleeding, pain during sexual intercourse, and
nodules in the vulva. In men, urogenital schistosomiasis
can induce pathology of the seminal vesicles, prostate,
and other organs. This disease may also have other
long-term irreversible consequences, including
infertility.
The economic and health effects of schistosomiasis are
considerable and the disease disables more than it kills.
In children, schistosomiasis can cause anaemia,
stunting and a reduced ability to learn, although the
effects are usually reversible with treatment. Chronic
schistosomiasis may affect people’s ability to work
and in some cases can result in death. The number of
deaths due to schistosomiasis is difficult to estimate
because of hidden pathologies such as liver and kidney
failure, bladder cancer and ectopic pregnancies due to
female genital schistosomiasis.
The death estimates due to schistosomiasis need to be
re-assessed, as it varies between 24 072 and 200
000 globally per year. In 2000, WHO estimated the
annual death rate at 200 000 globally. This should
have decreased considerably due to the impact of a
scale-up in large-scale preventive chemotherapy
campaigns over the past decade.
Diagnosis
Schistosomiasis is diagnosed through the detection of
parasite eggs in stool or urine specimens. Antibodies
and/or antigens detected in blood or urine samples are
also indications of infection.
For urogenital schistosomiasis, a filtration technique
using nylon, paper or polycarbonate filters is the
standard diagnostic technique. Children with S.
haematobium almost always have microscopic blood
in their urine which can be detected by chemical
reagent strips.
The eggs of intestinal schistosomiasis can be detected
in faecal specimens through a technique using
methylene blue-stained cellophane soaked in glycerin
or glass slides, known as the Kato-Katz technique.
In S. mansoni transmission areas, CCA (Circulating
Cathodic Antigen) test can also be used.
For people living in non-endemic or low-transmission
areas, serological and immunological tests may be
useful in showing exposure to infection and the need
for thorough examination, treatment and follow-up.
In Cambodia and the Lao People’s Democratic
Republic, in some villages bordering the Mekong River,
the disease was highly endemic with high mortality a
few decades ago. Annual mass drug administrations
(MDAs) over 20 years have significantly reduced the
prevalence of infection in these endemic villages.
Continuing contamination of the river with excreta due
to poor sanitation in affected villages means MDAs are
not enough to achieve elimination. Also key are efforts
to prevent contamination of river water by improving
access to sanitation and eliminating open defecation
Open defecation problem
Open defecation can pollute the environment and
cause health problems. High levels of open
defecation are linked to high child mortality, poor
nutrition, poverty, and large disparities between rich
and poor. ... Therefore, eliminating open defecation is
thought to be an important part of the effort to
eliminate poverty.
 A community-led initiative called CLSWASH, building on national
efforts to expand participatory water safety planning, is being
implemented jointly by Government authorities responsible for NTDs
and water, sanitation and hygiene (WASH) in Cambodia and the Lao
People’s Democratic Republic, and by the affected communities
themselves, facilitated by WHO. This initiative aims to eliminate
schistosomiasis through strengthening WASH in affected villages, in
addition to annual rounds of MDA. Reflecting the cross-cutting nature
of the initiative, it has been supported by WHO teams in the Regional
Office and in the country offices responsible for malaria, vector-borne
and parasitic diseases including NTDs, and health and the environment.
Local facilitators conducted community training in endemic villages
with a focus on the empowerment of villagers to identify and address
key local issues.
 During the training, villagers selected a village CL-SWASH team that
then went house to house with checklists, water test kits and
malnutrition screening kits to assess the situation. They mapped the
results of the survey including areas used for open defecation and
households without latrines, and discussed the findings and possible
solutions they could enact without outside assistance. Villagers
developed their own CL-SWASH plan and pledged to follow it,
including building and using latrines at their own expense. Encouraged
by the enthusiasm of villagers, the countries have developed a roll-out
plan for expanding the initiative to all endemic villages, with the goal
of eliminating schistosomiasis by 2020.
 CL-SWASH, a community-led initiative to eliminate schistosomiasis
with water, sanitation and hygiene interventions, uses team members
chosen by their communities in Cambodia to discuss open defecation
and households without latrines.
Prevention and control
The control of schistosomiasis is based on large-scale
treatment of at-risk population groups, access to safe
water, improved sanitation, hygiene education, and snail
control.
The WHO strategy for schistosomiasis control focuses
on reducing disease through periodic, targeted treatment
with praziquantel through the large-scale treatment
(preventive chemotherapy) of affected populations. It
involves regular treatment of all at-risk groups. In a few
countries, where there is low transmission, the
interruption of the transmission of the disease should be
aimed for.
Groups targeted for treatment are:
School-aged children in endemic areas.
Adults considered to be at risk in endemic areas, and
people with occupations involving contact with
infested water, such as fishermen, farmers, irrigation
workers, and women whose domestic tasks bring them
in contact with infested water.
Entire communities living in highly endemic areas.
WHO also recommends treatment of preschool aged
children. Unfortunately, there is no suitable
formulation of praziquantel to include them in current
large-scale treatment programmes.
The frequency of treatment is determined by the
prevalence of infection in school-age children. In high-
transmission areas, treatment may have to be repeated
every year for a number of years. Monitoring is
essential to determine the impact of control
interventions.
The aim is to reduce disease morbidity and
transmission: periodic treatment of at-risk populations
will cure mild symptoms and prevent infected people
from developing severe, late-stage chronic disease.
However, a major limitation to schistosomiasis control
has been the limited availability of praziquantel. Data
for 2017 show that 46.3% of people requiring
treatment were reached globally, with a proportion of
70.8% of school-aged children requiring preventive
chemotherapy for schistosomiasis being treated.
 Praziquantel is the recommended treatment against all forms
of schistosomiasis. It is effective, safe, and low-cost. Even
though re-infection may occur after treatment, the risk of
developing severe disease is diminished and even reversed
when treatment is initiated and repeated in childhood.
 Schistosomiasis control has been successfully implemented
over the past 40 years in several countries, including Brazil,
Cambodia, China, Egypt, Mauritius, Islamic Republic of
Iran, Oman, Jordan Saudi Arabia, Morocco, Tunisia, etc. In
Burkina Faso, Ghana, Niger, Rwanda, Sierra Leone, the
United Republic of Tanzania, and Yemen, it has been
possible to scale-up schistosomiasis treatment to the
national level and have an impact on the disease in a few
years. An assessment of the status of transmission is
required in several countries.
Over the past 10 years, there has been scale-up of
treatment campaigns in a number of sub-Saharan
countries, where most of those at risk live.
 WHO response
 WHO’s work on schistosomiasis is part of an integrated
approach to the control of neglected tropical diseases.
Although medically diverse, neglected tropical diseases
share features that allow them to persist in conditions of
poverty, where they cluster and frequently overlap.
 WHO coordinates the strategy of preventive chemotherapy
in consultation with collaborating centres and partners from
academic and research institutions, the private sector,
nongovernmental organizations, international development
agencies, and other United Nations organizations. WHO
develops technical guidelines and tools for use by national
control programmes.
Working with partners and the private sector, WHO
has advocated for increased access to praziquantel and
resources for implementation. A significant amount of
praziquantel, to treat more than 100 million children of
the school age per year, has been pledged by the
private sector and development partners.
In the Philippines
SCHISTOSOMIASIS CONTROL PROGRAM
Vision
Schistosomiasis Free Philippines
Mission
Synchronized and harmonized public and private
stakeholders’ efforts in the elimination of
schistosomiasis in the Philippines
 Objectives
 Interruption of transmission of Schistosomiasis Infection by 2025.
1. All high endemic barangays will reach the target of criteria for
Morbidity/Infection Control (<5% prevalence of heavy intensity
infection for 5 years).
2. All moderate endemic barangays will reach the target of criteria
of Transmission Control (Elimination as a Public Health Problem
with <1% prevalence of heavy intensity infection for 5 years).
3. All low endemic barangays will reach the target criteria of
Transmission Interruption (no local infection in man and animals,
no infection in snail for 5 years).
 Program Components
 Schistosomiasis is an acute and chronic disease caused by parasitic
worms called trematodes or blood flukes. It is endemic in the
Philippines affecting 1,599 barangays (villages), in 189 municipalities
(towns) and 15 cities, in 28 endemic provinces, in 12 regions. The total
population at risk is approximately 12 million with 2.5 million
individuals directly exposed to the disease. It is transmitted through
contact with fresh water infested with the cercarial schistosome of the
parasite that penetrates human skin. Given the magnitude of the problem
of schistosomiasis in the country, the Department of Health (DOH)
strengthened the Schistosomiasis Control and Elimination Program by
adopting a multi- pronged multi-stakeholders’ approach and fueling
additional funding.
1. Preventive Chemotherapy
2. Intensified Case Management
3. Water, Sanitation and Hygiene (WASH)
4. Veterinary Public Health and the Promotion of Animal Health under
One Health Approach.
5. Effective Intermediate Host Control and Surveillance
Partner Institutions
Research Triangle Institute (RTI) International, Save
the Children, Plan International, WHO, DA, DepEd,
DILG, NIA, Academe, LGUs
Policies and Laws
-Schistosomiasis Clinical Practice Guidelines
-DM 2016-0212
-AO 2009-0013
-AO 2007-0015
Strategies, Action Points and Timeline
1. Preventive Chemotherapy through Mass Drug
Administration
2. Intensified Case Management
3. Promotion of Animal Health and Veterinary Public
Health under One Health Approach
4. Effective Intermediate Host Control and
Surveillance
5. Water, Sanitation and Hygiene (WASH)
 Program Accomplishments/Status
 1. Formulation and development of the strategic plan to cut
transmission of schistosomiasis infection in the Philippines, 2018-
2025
2. Demonstration project for the control of animal schistosomiasis
and promotion of animal health in Northern Samar
3. Updating of endemic maps on snail transmission sites in the
Philippines
4. Establishment of the Laboratory Network for NTDs addresses
by preventive chemotherapy
5. Capability building of LGU partners on the Coverage
Supervision Tool (CST) to monitor and improved MDA coverage
6. Policy Development on surveillance and response of the snail
vector of schistosomiasis
7. Policy development on updated mass drug administration under
the preventive chemotherapy strategy for schistosomiasis endemic
barangays in the Philippines
Statistics
The National Prevalence is 4.68% (Focal Survey,
2017) with 435 (27%) Barangays having prevalence of
>5%, 357 (22%) Barangays with prevalence of > 1%
but < 5% and 379 (24%) with Prevalence of < 1%.
A comprehensive control strategy for helminth
infection should include: • ensuring wide availability
of anthelminthics for schistosomiasis and soil-
transmitted helminth infections in all health services in
endemic areas; • ensuring good case management of
symptomatic cases (e.g. IMCI); • regular treatment of
all children at risk, including adolescent girls, through
school- and community-based initiatives
treating pregnant women at risk, through antenatal care
and other women’s health programmes; • ensuring a
safe water supply and adequate sanitation facilities in
all schools; • ensuring provision of potable water and
sanitation facilities at household/community level; •
promoting good hygiene and sanitation practices
among schoolchildren and caregivers (hand-washing,
use of latrines, use of footwear) through community
capacity development activities and in school
curricula.
PREVENTIVE CHEMOTHERAPY AND ITS ROLE IN THE
CONTROL OF HELMINTHIASIS
 Aim and rationale
 The aim of preventive chemotherapy is to avert the widespread morbidity that
invariably accompanies helminth and other infections – and sometimes leads to
death.

 Early and regular administration of the anthelminthic drugs recommended by

WHO reduces the occurrence, extent, severity and long-term consequences of
morbidity, and in certain epidemiological conditions contributes to sustained
reduction in transmission. In practice, preventive chemotherapy requires the
delivery of good-quality drugs, either alone or in combination, to as many
people in need as possible at regular intervals throughout their lives: high
priority should be given to achieving full coverage of targeted risk groups.
 The role of social mobilization
 Large-scale preventive chemotherapy targets all eligible individuals in
communities identified as endemic for the target disease. Every individual is
considered to be at risk of the disease and its sequelae. Because helminth
diseases do not rapidly cause death and are more insidious in nature than many
diseases of acute onset, they are rarely given priority by health providers.

 The objective of preventive chemotherapy interventions is to ensure that all

eligible individuals in at-risk communities swallow the recommended drugs.
This behavioural change is dependent on the motivation of the at-risk
individual to accept treatment as well as on the health-care provider or
community volunteer adequately informing and motivating the community.
 Initially, preventive chemotherapy will be directed against the
following four common forms of helminthiasis, which are:
 Lymphatic filariasis (LF) – caused by infection with the nematodes
Wuchereria bancrofti, Brugia malayi and B. timori.
 Onchocerciasis (ONCHO) – caused by infection with the nematode
Onchocerca volvulus.
 Schistosomiasis (SCH) –
 SCHi (intestinal schistosomiasis) caused by infection with the
trematodes Schistosoma mansoni, S. mekongi, S. japonicum and S.
intercalatum, and SCHu (urinary schistosomiasis) caused by infection
with S. haematobium. Soil-transmitted helminthiasis
 (STH) – caused by infection with the nematodes Ascaris lumbricoides
(roundworm), Ancylostoma duodenale and Necator americanus
(hookworm), and Trichuris trichiura (whipworm).
Intervention
 Diseases targeted schistosomiasis and soil-transmitted helminthiasis Drug(s)
praziquantel and albendazole or mebendazole, administered
together .Frequency of implementation Once or twice a year for ALB or MBD.
The frequency of PZQ varies according to the risk of SCH: PZQ treatment
should take place once a year in high-risk communities, once every 2 years in
moderate-risk communities, and twice during the period of primary schooling
age in low-risk communities.
 Eligible population for PZQ • School-age children. • Adults considered to be at
risk, from special groups (pregnant and lactating women; groups with
occupations involving contact with infested water, such as fishermen, farmers,
irrigation workers, or women in their domestic tasks) to entire communities
living in endemic areas.
 Ineligible population for PZQ There is no documented information on the
safety of PZQ for children under 4 years of age (or under 94 cm in height).
These children should therefore be excluded from mass treatment but can be
treated on an individual basis by medical personnel.
 . Eligible population for ALB or MBD Preschool and school-age
children; women of childbearing age (including pregnant women in the
2nd and 3rd trimesters and lactating women); adults at high risk in
certain occupations (e.g. tea-pickers and miners).
 Ineligible population for ALB or MBD Children in the 1st year of life;
pregnant women in the 1st trimester of pregnancy. Note 1: If a second
annual T1 campaign is to be carried out, it should take place 6 months
after the first. In communities at very high risk, a third annual
campaign distributing ALB or MBD (T3) may be added. In this case
the appropriate frequency of the three annual campaigns would be
every 4 months. Note 2: Levamisole or pyrantel may also be used
instead of ALB or MBD.
 SCHISTOSOMIASIS IN THE PHILIPPINES: CHALLENGES AND SOME
SUCCESSES IN CONTROL Lydia Leonardo, Yuichi Chigusa, et al ;College
of Public Health, University of the Philippines Manila; Dokkyo Medical
University, Mibu, Tochigi; Nagasaki University, Nagasaki; Obihiro University
of Agriculture and Veterinary Medicine, Obihiro, Hokkaido, Japan; Institute of
Biology, University of the Philippines Diliman; College of Medicine,
University of the Philippines Manila;The University of Tokyo, Japan; Chinese
General Hospital, Manila, Philippines
 Abstract. Schistosomiasis is a snail-borne neglected tropical disease affecting 78
countries and territories in Africa, Asia, South America and the Middle East.Three
species are highly pathogenic to man namely Schistosoma japonicum, S. mansoni and
S. haematobium. In the Philippines, the endemic species is S. japonicum to which 2.5
million Filipinos are directly exposed. This paper describes schistosomiasis in the
Philippines, the status of the disease, the efforts in controlling it, the numerous problems
in the implementation of the control program and good practices developed in endemic
areas that have contributed to even limited success and possible prospects in control of
the disease. It traces the history of the control program from the time that the disease
was discovered in 1906 and cites various administrative orders that provided for the
implementation of the different components of the program. Much of the information
contained in this paper were collated from the program implementation review of the
control program in 2012, consultative meetings conducted in 2013 with health officials
involved in the program, reports delivered in the 15th meeting of the RNAS+ in July
2015, personal communications with program implementers in endemic areas visited in
researches of the principal author, and her research team. The principal author was
involved in all these activities and wrote the final reports. Keywords: schistosomiasis,
disease status, control program, Philippines
Results & Recommendations:
 More sensitive diagnostic techniques should be used in monitoring
infection in humans, animals and snails. Surveillance involving larger
samples should be used in order to detect infection in humans and animals
and appropriate treatment be administered. Snail sites that harbor infected
snails should be identified and monitored, and fenced off to avoid exposure
of humans and animals to the contaminated water. Documentation should
be regular for five years to show the indicators of elimination. Other
measures should be in place such as provision and utilization of toilets and
safe water supply as well as health education and promotion that would
ensure behavior change (UP CPH Foundation, 2012).
 And as the eminent Dr Edito G Garcia, a foremost expert on
schistosomiasis who has long since passed said, what worked in Leyte
before still worked at present but these interventions should be improved
and intensified while awaiting new methods of control (Leonardo et al,
2002)
Innovative approach
A multi-component integrated approach towards the
control of S. japonicum in the Philippines is critical for
long-term sustainable control and eventual elimination.
Key to such an approach is ensuring high PZQ
coverage in endemic populations and the targeting of
bovines (carabaos) through either their removal and
replacement with mechanized tractors (for farming) in
endemic areas or vaccination.
Toward the 2020 goal of soil-transmitted helminthiasis control and
elimination
 Sören L. Becker ,
 Harvy Joy Liwanag ,
 Jedidiah S. Snyder ,
 Oladele Akogun,
 Vicente Belizario. Jr,
 Matthew C. Freeman,
 Theresa W. Gyorkos,
 Rubina Imtiaz,
 Jennifer Keiser,
 Alejandro Krolewiecki,
 Bruno Levecke,
 Charles Mwandawiro,
 Rachel L. Pullan,
 David G. Addiss ,
 Jürg Utzinger
References
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 SCHISTOSOMIASIS IN THE PHILIPPINES: CHALLENGES AND
SOME SUCCESSES IN CONTROL ;Lydia Leonardo, et al; Southeast
Asian J Trop Med Public HealthVol 47 No. 4 July 2016; pp 661-666
 Eliminating schistosomiasis via MDAs and improved water, sanitation
and hygiene
 Prevention and control of schistosomiasis and soil-transmitted
helminthiasis; WHO & UNICEF Joint Statement 2004
 Prevention & Control of Schistosomiasis & Soil-transmitted
Helminthiasis; Report of a WHO Expert Committee, Geneva 2001
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