The validity of haematuria in the community diagnosis of urinary schistosomiasis infections

The validity and reliability of haematuria when used as screening criteria in community diagnosis of urinary schistosomiasis is presented. Between May and July, 1998, 1173 persons were screened for haematuria and examined for the presence of eggs of Schistosoma haematobium in their urine from all participating households in the Ozitem area of Bende Local Government Area, Abia State, Nigeria. Haematuria showed a sensitivity rate of 41.0% and specificity of 82.0% when used to identify cases of urinary schistosomiasis. Some factors that influenced the validity of haematuria as a diagnostic criterion are discussed. The use of haematuria amongst subjects in the first twenty years of their life is recommended.     

Schistosomiasis in Cross River State, Nigeria: 1. Prevalence and intensity of infection in Adim, Akamkpa Local Government Area

Mid-stream urine was randomly collected from 248 subjects in Adim. Blood and protein concentrations were determined semi-quantitatively using Combi-7 reagent strips. The urine samples were then processed and any ova of Schistosoma haematobium present were counted per 10 ml urine. Fresh stool samples were also randomly collected, processed and examined for S. masoni and other helminthic ova. The prevalence of S. haematobium in the area was 43.5% and this was found to be age-related but not sex-related. Mean egg count was 137.2 per 10 ml urine. Intense haematuria of 250 ery/microliters and proteinuria of 500 mg/dl accompanied the high egg counts. The stool examination showed no cases of Manson's schistosomiasis but polyparasitism with other intestinal helminths was common particularly among children under 10 years old. This is the first report of urinary schistosomiasis in this area and the high prevalence rate is consistent with the rice farming occupation of the natives of the area. The sensitive nature and the case of application of the reagent strips in determining heavy infections by measuring haematuria and proteinuria is once again confirmed.     

Endemicity, focality and seasonality of transmission of human schistosomiasis in Amagunze Village, eastern Nigeria

The pattern of transmission of human schistosomiasis was studied in Amagunze Village, eastern Nigeria, during 1986-1987. The prevalence of Schistosoma haematobium in 119 schoolboys aged 5-12 years was 79%. The geometric mean of intensity of infection was 49 eggs/10 ml urine and the frequency of visible haematuria was 25.2%. No S. mansoni infections were demonstrated. A marked seasonality in population density of Bulinus truncatus, B. forskalii and Biomphalaria pfeifferi was demonstrated with reduced densities during the late rainy and early dry seasons. Schistosoma sp. infected B. truncatus were found in the late dry and early rainy seasons in 2 out of 7 major human water contact sites studied. Seasonality and focality of transmission of S. haematobium and its high endemicity in the area were thus demonstrated.     

Genitourinary schistosomiasis among pre-primary schoolchildren in a rural community within the Cross River Basin, Nigeria

In Africa, most schistosomiasis control programmes defined the age 5-19 years as the target population for nationwide control through the school systems, excluding the under fives. A study was therefore undertaken to determine the prevalence and intensity of genitourinary schistosomiasis in children aged 0-5 years (pre-primary) in Adim, a rural and endemic community within the Cross River Basin, Nigeria. Of the 126 children examined, 25 (19.8%) were infected with Schistosoma haematobium, with no significant difference (P > 0.05) in infection rates between boys (21.1%) and girls (18.2%). Both prevalence and intensity of infection increased significantly (P 0.05) between intensity in boys (6.2 eggs/10 ml urine) and girls (5.6 eggs/10 ml urine). A total of 32.5 and 27.8% of the children had haematuria and proteinuria, respectively; it was not gender specific (P > 0.05). Six species of snail were encountered, with Bulinus globosus being the most abundant and widespread. The results of this study have shown that pre-primary schoolchildren are a source of transmission of schistosomiasis in endemic communities and should be integrated into any control intervention.     

The diagnostic value of haematuria and proteinuria in Schistosoma haematobium infection in southern Nigeria.

Haematuria and proteinuria as detected by chemical reagent strips correlated moderately (r = 0.7) with prevalence and intensity of infection with Schistosoma haematobium in an area of Anambra State, Nigeria. Differences attributable to age and sex were also reflected in a similar pattern, all peaks occurring in the 5-14 year age group. The differences observed with varying levels of intensity and haematuria at both 10 and 50 erythrocytes/microliter (p < 0.001) and proteinuria at 0.3 g/dl (p < 0.01) were statistically significant. At a proteinuria level of 1 g/dl, the observed differences were however not statistically significant (p > 0.5). The percentage of specimens from children (0-14 years) positive for S. haematobium eggs and with at least traces of haematuria and proteinuria (63.4% and 95%, respectively) was higher than in adults (33.3% and 80.2%, respectively). All individuals with more than 50 eggs/10 ml of urine were correctly identified using both indices either separately or in combination. For egg counts of less than 50 eggs/10 ml of urine, false diagnosis occurred in only 5% of all specimens examined. The sensitivity and specificity of haematuria and proteinuria at trace quantities was very high, but haematuria had a higher predictive value for a positive test (PvPt) and was considered the overall better indicator. A combination of both indices did not significantly increase the PvPt. When trace haematuria and moderate proteinuria were combined, both the sensitivity, specificity and PvPt were all above 90%, giving the best overall values in all the combinations made.     

Schistosoma japonicum: the pathology of experimental infection

The pathology of experimental schistosomiasis japonica is reviewed and compared with the pathology of schistosomiasis japonica in man and to some aspects of schistosomiasis mansoni and schistosomiasis haematobia in experimental animals. The induction of granulomas around Schistosoma japonicum eggs depends upon cell mediated immunity, as do the reactions to Schistosoma mansoni and Schistosoma haematobium eggs. However, the modulation of the reaction to S. japonicum eggs can be greatly influenced by antibody, while antibody has no effect on the granulomas around S. mansoni eggs. Adult worm pairs of S. japonicum tend to cluster in the mesenteric venules, and most eggs are laid in a few sites. This leads to large, focal intestinal lesions similar to the discrete lesions produced by S. haematobium in the intestine and urinary tract but in contrast to the widespread, diffuse lesions produced by S. mansoni. Comparison with S. japonicum infection in humans is limited chiefly by our scant knowledge of the pathology produced by S. japonicum in infected persons. Most such comparisons are, in any case, limited by the marked differences in the reactions of various experimental host species to the infection and by differences in the reaction of a given host species to different strains of the parasite.     

Schistosoma haematobium infections in preschool children from two rural communities in Ijebu East, south-western Nigeria

There is an urgent need for information on schistosomiasis in preschool children, who are often excluded in mass treatment programmes. The prevalence and intensity of Schistosoma haematobium infection were determined in preschool children aged ≤ 6 years in two rural communities in Ijebu East, south-western Nigeria. Two urine samples each were collected from 83 preschool children from the two communities, tested for microhaematuria using reagent strips and then processed and examined with a microscope for S. haematobium eggs. Focus group discussions on perceptions of the disease and water contact practices were held in the communities with their guardians, caregivers and preschool children, using an interview guide. The prevalence of S. haematobium in the two communities was 14 (16.9%), with no significant differences (P = 0.661) in infection rate between boys (18.4%) and girls (14.7%). Both prevalence and intensity of infection did not increase significantly with age in both Korede and Obada community. However, there were significant differences in prevalence of infection between the two communities (P = 0.035). There was no association (P = 0.750) between intensity in boys (0.176 eggs/10 ml urine) and girls (0.110 eggs/10 ml urine). Focal group discussions with guardians and caregivers revealed that preschool children acquired infection early in their lives through exposure to infected stream water by their mothers, while the older children visit the stream for playing, bathing and swimming. It has therefore become imperative for preschool children to be included in the planning of schistosomiasis intervention programmes as a means of reducing transmission.     

Geographical distribution of schistosomiasis and soil-transmitted helminths among school children in informal settlements in Kisumu City, Western Kenya

This cross-sectional study determined the prevalence and distribution of schistosome and soil-transmitted helminth (STH) infections among 1,308 children aged 10-18 years in 34 primary schools in 8 informal urban settlements in Kisumu City, western Kenya. Stool samples were collected and examined for eggs of Schistosoma mansoni and STH (Hookworms, Ascaris lumbricoides and Trichuris trichiura) using the Kato-Katz technique. Haematuria was used as a proxy indicator of urinary schistosomiasis. Schools and water bodies were mapped using a geographical information system. Overall, 34% of children were infected with one or more helminth species whereas 16·2% of children were infected with one or more STH species. Schools in closest proximity to Lake Victoria and River Nyamasaria had the highest S. mansoni prevalence while schools with STH were more homogenously distributed. Mean school prevalence of S. mansoni infection was 21% (range=0-69·7%), S. haematobium 3·6% (range=0-12%), hookworms 6·1% (range=0-20%), A. lumbricoides 4·9% (range=0-18·4%), and T. trichiura 7·7% (range=0-18·6%). Helminth-related morbidities were not associated with infection. Our study demonstrates that schistosomiasis and STH are important health priorities among schools in informal settlements of Kisumu City, and highlights the need for routine deworming in similar settings.     

Transmission of urinary schistosomiasis in Sukumaland, Tanzania. 1. Snail infection rates and incidence of infection in school children

Seasonal density fluctuations of Bulinus nasutus populations with accompanying Schistosoma haematobium infection rates in relation to rainfall and habitat water volumes were studied at Ukiriguru, Mwanza, Tanzania. Alongside the snail investigations, 50 school children initially negative for urinary schistosomiasis were examined regularly to determine seasonal incidence rates for the infection. Of the 17,646 B. nasutus collected in 2 years, 156 (0.88%) were found shedding cercariae. Snail populations fluctuated seasonally as influenced by rainfall through its effects on habitat water volume. Monthly snail infection rates ranged from 0.09% to 3.19% and were highest in February and March, at the time of the short dry period. Monthly incidence of S. haematobium in school children ranged between 2.6% and 12.5%, being highest in April and May. There was a significant linear association between monthly snail infection rates and S. haematobium incidence rates in school children (r2s = 0.65 in 1982/83; r2s = 0.87 in 1983/84) suggesting that the maximum transmission period for urinary schistosomiasis in the area occurs during the short dry period, sometime in February/March so that most of the infections in the community would be detected in April/May.     

Urinary schistosomiasis in southern Ghana: 1. Prevalence and morbidity assessment in three (defined) rural areas drained by the Densu river

Epidemiological studies on urinary schistosomiasis were carried out in eight villages in the Ga and Akuapem South districts in Ghana. Single urine samples were collected from individuals aged 5 years and above between 10.00 and 14.00 h. The samples were examined for the presence of Schistosoma haematobium eggs using a filtration technique. Indirect morbidity was determined as the presence of microhaematuria and proteinuria using reagent strips, and macrohaematuria was recorded with the naked eye. Out of the study population of 3912 subjects, 2562 (65.5%) submitted urine samples. The prevalence of a Schistosoma haematobium infection ranged between 54.8 and 60.0%. Infection rates increased by age with a peak in the 10-19 years category, and decreased with increasing age. Disease prevalence was higher in males aged 15 years and above in Areas 2 (Ntoaso and Sansami Amanfro) and 3 (Dom Faase, Papase, Chento and Gidi Kope), whereas it was higher among males aged 10 years and above in Area 1 (Ayikai Doblo and Akramaman). The intensity of infection was highest among children aged 10-14 years in most of the villages. More than half of egg-positive children in this age group had a heavy infection (100 eggs and above in 10 ml of urine). Although both egg-positive and egg-negative individuals manifested variable degrees of macro- or micro-haematuria, microhaematuria was more prevalent among egg-positives (chi(2)=918.5, d.f.=1, P<0.01). The degree of microhaematuria and proteinuria were significantly associated with the intensity of the infection. These results indicate a high transmission of disease in the study area.     

Schistosoma haematobium Infection and CD4+ T-Cell Levels: A Cross-Sectional Study of Young South African Women

Schistosoma (S.) haematobium causes urogenital schistosomiasis and has been hypothesized to adversely impact HIV transmission and progression. On the other hand it has been hypothesized that HIV could influence the manifestations of schistosomiasis. In this cross-sectional study, we explored the association between urogenital S. haematobium infection and CD4 cell counts in 792 female high-school students from randomly selected schools in rural KwaZulu-Natal, South Africa. We also investigated the association between low CD4 cell counts in HIV positive women and the number of excreted schistosome eggs in urine. Sixteen percent were HIV positive and 31% had signs of urogenital schistosomiasis (as determined by genital sandy patches and / or abnormal blood vessels on ectocervix / vagina by colposcopy or presence of eggs in urine). After stratifying for HIV status, participants with and without urogenital schistosomiasis had similar CD4 cell counts. Furthermore, there was no significant difference in prevalence of urogenital schistosomiasis in HIV positive women with low and high CD4 cell counts. There was no significant difference in the number of eggs excreted in urine when comparing HIV positive and HIV negative women. Our findings indicate that urogenital schistosomiasis do not influence the number of circulating CD4 cells.     

Assessment of schistosomiasis, through school surveys, in the Forest Zone of Pernambuco, Brazil

This work had the objective of assessing the present epidemiological situation regarding schistosomiasis through performing Kato-Katz coproscopic tests on representative samples of schoolchildren from each of the 43 municipality of endemic area of the state of Pernambuco, Brazil. The methodology is recommended by the World Health Organization to conduct sampled surveys among children at elementary school levels, ideal target group for baseline surveys: (i) schools are accessible; (ii) the greatest prevalence of schistosomiasis is found within this group; (iii) the data gathered from this age group can be used for intervention within the community as a whole. The following infection indicators were utilized: positivity (percentage of individuals examined with eggs of Schistosoma mansoni in the feces) and severity (geometric mean number of eggs per gram of feces, epg). These indicators allowed the area in general and the municipalities in particular to be categorized into prevalence and severity classes for S. mansoni. The prevalence classes were: low (<10%), medium (> 10 and < 50%), and high (> 50%); the severity classes were: low (1-99 epg), moderate (100-399 epg), and severe (> 400 epg). For the geohelminthic diseases, the following indicators were used: positivity for each geohelminth (percentage of individuals examined with eggs of geohelminths), and cumulative positivity (percentage of individuals examined with eggs of at least one geohelminth). The municipalities were categorized by means of their cumulative positivity into the following geohelminth prevalence classes (WHO 2002): low (< 50%), medium (> 50 and < 70%), and high (> 70%). The study covered 271 schools in 179 different localities, thus giving a total of 11,234 examinations performed. The overall positivity for S. mansoni was 14.4% and the egg count for this parasite in the feces gave a geometric mean of 67.9 epg which suggests a low general state of infection. These results allow this mesoregion to be categorized as presenting medium prevalence and low severity of schistosomiasis. The overall positivity rates for the geohelminths, Ascaris lumbricoides, Ancylostomidae, and Trichuris trichiura were, respectively, 30.4, 10.1, and 27.8%; the cumulative positivity was 45.4%. These results allow this mesoregion to be categorized as presenting low prevalence of geohelminthic diseases. The data show some municipalities in Pernambuco with prevalence greater than 20%, while others presented parasite loads greater than 100 epg. These indicators attest to the significant morbidity due to schistosomiasis regarding to the severity of infections established in young populations.     

Intestinal helminthiases and schistosomiasis among school children in an urban center and some rural communities in southwest Nigeria

Intestinal helminths and schistosomiasis among school children were investigated in an urban and some rural communities of Ogun State, southwest Nigeria. Fecal samples of 1,059 subjects (524 males, 535 females) aged 3-18 years were examined using direct smear and brine concentration methods between June 2005 and November 2006. The pooled prevalence of infection was 66.2%. Ascaris lumbricoides showed the highest prevalence (53.4%) (P < 0.001) followed by hookworms (17.8%), Trichuris trichiura (10.4%), Taenia sp. (9.6%), Schistosoma mansoni (2.3%), Strongyloides stercoralis (0.7%), Schistosoma haematobium (0.6%), and Enterobius vermicularis (0.3%). The prevalences of A. lumbricoides, hookworms, Taenia sp., S. mansoni, and S. stercoralis in the urban centre were similar (P > 0.05) to those in the rural communities. The fertile and infertile egg ratios of A. lumbricoides in the urban centre and the rural communities were 13: 1 and 3.7: 1, respectively. Each helminth had similar prevalences among both genders (P > 0.05). The prevalence of A. lumbricoides increased significantly with age (P < 0.001). The commonest double infections were Ascaris and hookworms, while the commonest triple infections were Ascaris, hookworms, and Trichuris. The study demonstrates the need for urgent intervention programmes against intestinal helminthiases and schistosomiasis in the study area.     

The socio-economic effects of tropical diseases in Nigeria

Urinary schistosomiasis is the most prevalent of the endemic tropical diseases: 48% of the population is afflicted in the study area. The socio-economic, environmental and health-seeking behavioural characteristics of the population are conducive to the spread of urinary schistosomiasis. The attitudes considered include knowledge of what causes the disease and how to control it, attitude toward the disease, care of oneself, hygiene and sanitation. The effect of such social variables as stigmatisation, and environmental variables such as water source is also considered. We find that a unit increase in the hygiene/sanitation index for adult males and adult females lead to a reduction of about 7.3 and 4.0 eggs S. haematobium in 10 ml urine sample, respectively. Thus, simple hygienic activities such as keeping the immediate environment of the household free from human wastes contribute substantially to disease control. Furthermore, prevalence of the disease is higher among males. Losses from work attributed to urinary schistosomiasis are high. Average values of key socio-economic variables-labour flow for land clearing, farm size and cash income-computed for farm families with high urinary schistosomiasis intensity in the sample are 1085 h, 1.4 ha and N 1,432 (US dollars 65) respectively. The corresponding figures for farm families free from the disease are significantly higher: 1325 h, 1.9 ha and N 3,759 (US dollars 171), respectively.     

Diagnostic Mr31/32,000 Schistosoma mansoni proteins (Sm31/32): reaction with sera from Sudanese patients infected with S. mansoni or S. haematobium

Sera of Sudanese patients with active infections of Schistosoma mansoni or S. haematobium were tested in immunoblots for their reactivity with Mr31/32,000 proteins of adult S. mansoni (Sm31/32). All sera from patients with intestinal (n = 123) and all but one from those with urinary schistosomiasis (n = 35) had antibodies against Sm31/32. These and additional data suggest that both specificity and sensitivity of Sm31/32 to detect schistosome infections are close to 100%. Antibodies against these proteins developed also in monkeys after experimental infection with S. haematobium. Sm31/32 antigens reacted in immunoblots as a doublet with most S. haematobium-patient sera and as a broad band with many S. mansoni-sera suggesting that at least two components are present in the molecular weight region of Mr31/32,000. The data demonstrate the potential use of Sm31/32 from adult worms to diagnose patients with intestinal or urinary schistosomiasis in endemic areas.     

Schistosoma haematobium: the pathology of experimental infection

The pathologic changes in experimental animals infected with Schistosoma haematobium are reviewed and compared to the pathology in infected humans. The clinically important lesions in persons infected with S. haematobium are generally confined to the urogenital system. In experimental animals, functionally important lesions of the urogenital system are the exception but do occur in a significant proportion of infected primates. The acute lesions of the urinary tract in primates are similar to those in infected persons. Chronic lesions characterized by the extensive submucosal accumulation of calcified eggs are common in infected humans but uncommon in S. haematobium-infected animals.     

Human intestinal parasites in Subsaharan Africa. III. Pemba Island (Zanzibar-Tanzania)

The authors carried out a coprological survey in Pemba Island, analysing, by modified Ritchie technique, 413 stools samples. The specimens were collected among the population from apparently healthy subjects chosen at random in a number equal to 2% of the whole population. The examined subjects were divided in 3 age groups, 211 were males, 202 females. The following results were obtained (in order of prevalence): a) Protozoa: Entamoeba coli 35.6%, Giardia intestinalis 5.6%, Endolimax nana 4.3%, E. histolytica 3.1%, Chilomastix mesnili 2.9%, Iodamoeba buetschlii 4.3%, E. hartmanni 0.7%; b) Helminths: Trichuris trichiura 87.9%, Ancylostomatidae 67.5%, Ascaris lumbricoides 39.7%, Strongyloides stercoralis 18.9%, Schistosoma haematobium 1.9%, S. mansoni 0.2%, S. fuelleborni 0.2%, Enterobius vermicularis 0.2%. The high moisture of soil and the rain distribution during the year could be favouring the high prevalence of T. trichiura and Ancylostomatidae. The case of schistosomiasis due to S. mansoni reported, seems to be imported from the Mainland, while the case of S. fuelleborni could be autochtonous. Totally, 392 subjects (94.4%) were found positive for pathogenic species (Helminths and Protozoa).     

E antigen (HBeAG) and surface antigen (HBsAg) in bladder schistosomiasis

The problem of the relationship between surface B antigen and schistosomiasis or other parasitic infections which are transmitted though the skin is not still resolved. Serum samples from 54 Somalian patients infected by Schistosoma haematobium were tested for the presence of the surface B antigen (HBsAg) and the e-antigen (HBeAg). The HbsAg was found in 14.8 per cent of these patients, while among controls (47 cases) the frequency was of 34.0 p]er cent; no e-antigen was found among the patients and controls, the prevalence of anti-HBs antibodies was of 57.4 per cent among the patients with urinary schistosomiasis and of 44.6 per cent among the controls; a low rate of anti-e antibodies was found in the patients (7.4%) and in the controls (10.6%). These observation seem to indicate that the problem of an increased frequency of hepatitis B virus markers among patients with urinary schistosomiasis needs for further investigation.     

Therapeutic failure of praziquantel in the treatment of Schistosoma haematobium infection in Brazilians returning from Africa

Several cases of therapeutic failure of praziquantel used for the treatment of urinary schistosomiasis have been reported. Alternative drugs, like niridazol and metrifonate, have shown a lower therapeutic effect and more side effects than praziquantel. Twenty-six Brazilian military men (median age of 29 years) with a positive urine parasitological exam who were part of a United Nation peace mission in Mozambique in 1994 were treated with 40 mg/kg body weight praziquantel, single dose. They swam in Licungo river (Mocuba city, Mozambique) during the weekends. After this, they presented haematuria, dysuria, polakiuria, and lumbar pain. Control cystoscopy examinations carried out between 6 and 24 months after each treatment (including two additional treatments at a minimum interval of 6 months) revealed the presence of viable eggs. Granulomas in the vesical submucosa were observed in 46.2% (12/26) of the individuals. A vesical biopsy confirmed the presence of granulomas in all of these patients and the presence of viable eggs in 34.3% (9/26) of individuals who no longer excreted eggs in urine. The eggs filled with miracidia showed characteristics of viability. Histopathological examination using different strains demonstrated therapeutic failure and the need for repeated treatment. In this study, we demonstrated a low efficacy of praziquantel in the treatment of schistosomiasis haematobia, and the necessity of the urinary bladder biopsy as criterion of cure.     

Urinary schistosomiasis on Zanzibar: application of two novel assays for the detection of excreted albumin and haemoglobin in urine

As part of a urinary schistosomiasis control programme on Zanzibar, an aged cross-sectional survey of 305 children from three schools on Unguja was conducted to investigate the relationships between levels of excreted albumin and haemoglobin in urine and Schistosoma haematobium infection status. Diagnosis was determined by standard parasitological methods, dipstick reagents for microhaematuria, visual inspection for macrohaematuria as well as collection of case-history questionnaire data for self-diagnosis. Prevalence of infection as determined by parasitology was 53.9% and approximately, one quarter of the children examined were anaemic (<11 g dl(-1)). A statistically significant negative association of blood haemoglobin levels of boys and S. haematobium infection intensity status was observed (rs=-0.23, P=0.005). Through sensitivity analysis of urine-albumin values it was determined that a concentration of above >40 mg l(-1), as measured with the HemoCue urine-albumin photometer, had sensitivity, specificity, positive and negative predictive values of 0.90, 0.83, 0.86 and 0.89 respectively against 'gold-standard' parasitology. There was a clear association of reported pain upon micturition for children with elevated urine-albumin levels, with an odds ratio of 20 to 1. Levels of excreted blood in urine were quantified with the HemoCue Plasma/Low Hb photometer. However, dipsticks remain the method of choice for urine-haemoglobin of 0.1 g l(-1) and below. Urine parameters over a 24-h period were assessed in a small sub-sample. Reductions in both albumin and haemoglobin excretion were observed in 11 children 54 days after praziquantel treatment. It was concluded that these rapid, high-through-put, portable HemoCue assays could play a role in better describing and monitoring the occurrence, severity and evolution of urinary schistosomiasis disease. The urine-albumin assay has particular promise as a biochemical marker of S. haematobium induced kidney- and upper urinary tract-morbidity.