Multidisciplinary studies of schistosomiasis and HIV on the shoreline of Lake Malawi: A longitudinal cohort study of male genital schistosomiasis (MGS) among fishermen in Mangochi District.

Male genital schistosomiasis (MGS) is a specific chronic manifestation of schistosomiasis associated with schistosome eggs and related pathologies in the genital system of men inhabiting or visiting endemic areas. Despite description of the first recognised MGS patient by Madden in 1911, the epidemiology, diagnostic testing and case management of MGS are not well described owing to limited research and diminishing focus over several decades. Furthermore, as the human immunodeficiency virus (HIV) epidemic expands across sub-Saharan Africa (SSA), there is renewed interest in MGS owing to plausible but as of yet under-explored interactions with HIV. To shed new light on MGS, a longitudinal cohort study was conducted among fishermen along the southern shoreline of Lake Malawi, an endemic area in SSA to investigate the prevalence of MGS, its associated knowledge, attitudes and practices (KAP), and determine the potential increase of viral shedding in semen of HIV-positive men with MGS. A systematic review conducted prior to the onset of the research fieldwork describing the MGS epidemiology, clinico-pathological manifestations, diagnostic techniques and treatment outlined and informed the current approach to the body of research presented here. Fishermen aged 18+ years were recruited into the study after providing informed written consent and individual questionnaires were administered to assess their KAP associated with MGS. Thereafter, participants submitted urine, semen, and blood for point-of-care (POC) field parasitological tests, and later laboratory-based molecular polymerase chain reaction (PCR), and HIV VL analyses. In addition, transabdominal and scrotal ultrasonography to assess the pathological effects of MGS on their genital organs were performed. Praziquantel therapy was provided to all participants, together with the follow-up diagnoses and treatment dates after 1, 3, 6 and 12-months’ intervals. 376 fishermen (320 HIV-negative and 56 HIV-positive on Antiretroviral therapy (ART)) aged between 18 and 70 years (median: 30.0 years), were recruited into the study, and had questionnaires interviews. At baseline, prevalence of UGS (S. haematobium eggs in urine) was 17.1% (n = 210, median: 2.3 per 10 ml, range: 0.1 – 186.0), 3.8% had a positive point-of-care circulating cathodic antigen (POC-CCA) indicative of intestinal S. mansoni infection, while MGS prevalence was 10.4% by semen microscopy (n = 114, median: 5.0, range: 0.1 – 30.0) and 26.5% by real-time PCR (n = 65, Ct value range: 18.8 – 36.6). More participants (66.7%) with schistosome eggs in semen were observed to not have any eggs in their urine. 6.9% of participants (n = 130) were observed to have pathological lesions in their genital organs on ultrasonography. For 15 HIV-MGS cases and 16 HIV-only controls who submitted paired blood and semen samples during the longitudinal study, more cases than controls had detectable and quantifiable VL, which regressed with PZQ. Similarly, the results of the diagnostic tests improved, with negative schistosome egg, real-time PCR in semen and pathological resolution on follow-up. In conclusion, MGS has been observed, via parasitological, molecular and radiological examinations, to be common in local male inhabitants (fishermen) of endemic areas along the south shoreline of Lake Malawi in the SSA region and shown to respond to standard PZQ treatment. Improving availability and accessibility for all people in these areas to PZQ, diagnostic tools for MGS, and combined HIV and schistosomiasis control interventions are advocated to reduce morbidity and improve the lives and reproductive health of men, their partners and communities in endemic areas

Prevalence and distribution of Schistosoma haematobium infection among school children living in southwestern shores of Lake Malawi

BACKGROUND: The prevalence of Schistosoma haematobium infection has been shown to be about 23.7% among children living in the lakeshore areas of Malawi, with reinfection rates of about 30% to 40%. This study aimed to determine the current prevalence and distribution of S. haematobium infection in school children along the southwestern shores of Lake Malawi and examine the control interventions present in the area. METHODS: This prospective cross-sectional study was conducted in primary schools. School children were enrolled, demographic data were collected, and urine samples were submitted for analysis on macrohaematuria, microhaematuria, and S. haematobium eggs. A questionnaire was administered to 3 health facilities on diagnosis and treatment of schistosomiasis, as well as the control interventions against it. RESULTS: Four hundred children (174 males and 226 females) were enrolled from 7 primary schools. Mean participant age was 9.57 years (range 7 to 12 years). Fifty children (12.5%) had S. haematobium eggs detected in their urine, with the mean egg count being 15/10 mL. The highest infection intensity category (≥ 50 eggs/10mL) was seen in 10 children (2.5%). Prevalence varied significantly between the schools, with rates ranging from 0% to 20%. Schools with higher prevalence rates were located farther away from the nearest public hospital that provides treatment free of charge. Prevalence correlated with previous history of mass chemotherapy in schools. Mass chemotherapy, health education, and improved water supply and sanitation were some of the interventions that contributed to lower prevalence rates in some areas. CONCLUSIONS: Schistosomiasis prevalence around southwestern Lake Malawi was lower than previously reported, owing to control interventions focusing on health education, improved water supply, sanitation, and mass chemotherapy. Consistent and uniform interventions can reduce prevalence further and sustain control. As prevalence falls, diagnostics can identify high transmission areas, monitor disease trends, and guide evidence-based control strategies

Commentary: The proposed legislation on termination of pregnancy does not protect women or children in Malawi and is not fit for the intended purpose: Christian Medical and Dental Fellowshipi position

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First Molecular Identification of Bulinus africanus in Lake Malawi Implicated in Transmitting Schistosoma Parasites

The freshwater snail genus Bulinus plays a vital role in transmitting parasites of the Schistosoma haematobium group. A hybrid schistosome between S. haematobium and S. mattheei has been recently detected using DNA-based identification methods in school children along the Lake Malawi shoreline in Mangochi District. This finding raised the need for contemporary revaluation of local interactions between schistosomes and snails, with a particular focus on snail species within the Bulinus africanus group. In 2017 and 2018, malacological surveys sampled several freshwater sites in Mangochi District. Collected snails (n = 250) were characterised using cytochrome oxidase subunit 1 gene (cox1), with DNA barcoding of the ‘Folmer’ region and a rapid PCR-RFLP typing assay with double digestion with HaeIII and SacI restriction enzymes. DNA cox1 sequence analysis, with phylogenetic tree construction, suggested the presence of at least three B. africanus group taxa in Lake Malawi, B. globosus, alongside first reports of B. africanus and B. angolensis, which can be differentiated by PCR-RFLP methods. In addition, a total of 30 of the 106 B. africanus group snails (28.30%) were positive to the Schistosoma-specific screen using real-time PCR methods. This study provides new insight into the recent changes in the epidemiology of urogenital schistosomiasis as likely driven by a new diversity of B. africanus group snails within the Lake

Modelling the age-prevalence relationship in schistosomiasis : A secondary data analysis of school-aged-children in Mangochi District, Lake Malawi.

Schistosomiasis is an aquatic snail borne parasitic disease, with intestinal schistosomiasis (IS) and urogenital schistosomiasis (UGS) caused by Schistosoma mansoni and S. haematobium infections, respectively. School-aged-children (SAC) are a known vulnerable group and can also suffer from co-infections. Along the shoreline of Lake Malawi a newly emerging outbreak of IS is occurring with increasing UGS co-infection rates. Age-prevalence (co)infection profiles are not fully understood. To shed light on these (co)infection trends by Schistosoma species and by age of child, we conducted a secondary data analysis of primary epidemiological data collected from SAC in Mangochi District, Lake Malawi, as published previously. Available diagnostic data by child, were converted into binary response infection profiles for 520 children, aged 6–15, across 12 sampled schools. Generalised additive models were then fitted to mono- and dual-infections. These were used to identify consistent population trends, finding the prevalence of IS significantly increased [p = 8.45e-4] up to 11 years of age then decreasing thereafter. A similar age-prevalence association was observed for co-infection [p = 7.81e-3]. By contrast, no clear age-infection pattern for UGS was found [p = 0.114]. Peak prevalence of Schistosoma infection typically occurs around adolescence; however, in this newly established IS outbreak with rising prevalence of UGS co-infections, the peak appears to occur earlier, around the age of 11 years. As the outbreak of IS fulminates, further temporal analysis of the age-relationship with Schistosoma infection is justified. This should refer to age-prevalence models which could better reveal newly emerging transmission trends and Schistosoma species dynamics. Dynamical modelling of infections, alongside malacological niche mapping, should be considered to guide future primary data collection and intervention programmes

Schistosomiasis Control: Leave No Age Group Behind

Despite accelerating progress towards schistosomiasis control in sub-Saharan Africa, several age groups have been eclipsed by current treatment and monitoring strategies that mainly focus on school-aged children. As schistosomiasis poses a threat to people of all ages, unfortunate gaps exist in current treatment coverage and associated monitoring efforts, preventing subsequent health benefits to preschool-aged children as well as certain adolescents and adults. Expanding access to younger ages through the forthcoming pediatric praziquantel formulation and improving treatment coverage in older ages is essential. This should occur alongside formal inclusion of these groups in large-scale monitoring and evaluation activities. Current omission of these age groups from treatment and monitoring exacerbates health inequities and has long-term consequences for sustainable schistosomiasis control

An assessment of implementation and effectiveness of mass drug administration for prevention and control of schistosomiasis and soil-transmitted helminths in selected southern Malawi districts.

Background Mass drug administration (MDA) is one of the key interventions recommended by WHO for prevention and control of neglected tropical diseases (NTD). In Malawi, MDA is widely carried out annually since 2009 for prevention and control of schistosomiasis and soil-transmitted helminths (STH). No study has been carried out to assess effectiveness of the MDA approach and to document perceptions of health providers and beneficiaries regarding use of MDA. This study was done to understand how well MDA is being implemented and to identify opportunities for improvement in MDA delivery in Malawi. Methods Designed as a cross-sectional and multi-methods research, the study was carried out in three southern Malawi districts of Chiradzulu, Mangochi and Zomba. In each district, four health centres and 16 villages were randomly selected to participate. A mixed-methods approach to data collection focusing on quantitative data for coverage and knowledge, attitudes and practices assessments; and qualitative data for assessing perceptions of health providers and beneficiaries regarding MDA was used. Quantitative data were processed and analyzed using IBM SPSS software version 26 while qualitative data were analysed using NVivo 12 for Windows. Results Knowledge levels about schistosomiasis and STH in the districts varied according to disease aspects asked about. Majority are more knowledgeable about what schistosomiasis is (78%) and whether STH are treatable with drugs (97%); with least knowledgeable about the organism that transmits schistosomiasis (18%), types of schistosomiasis (11%) and what causes STH (20%). In 2018 and 2019 the districts registered high coverage rates for praziquantel and albendazole using community-based MDA (73–100%) and using school-based MDA (75–91%). Both the health authorities and community members perceived the MDA approach as good because it brings treatment closer to people. Conclusion With the high MDA coverage obtained in communities and schools, the effectiveness of MDA in the target districts is satisfactory. There are, however, several challenges including disproportionate knowledge levels, which are hampering progress towards attainment of the 2030 global NTD goals. There is a need for promotion of community participation and partnerships as well as implementation of other recommended interventions for sustainable prevention and control of schistosomiasis and STH