Advocacy, policies and practicalities of preventive chemotherapy campaigns for African children with schistosomiasis

Figures & data

Figure 1. Natural history of infection with schistosomiasis begins soon after birth often by exposure to domestic water collected from environmental sources.

(A) As the child gains independence, exploration of these water bodies continues and infections are accrued. Upon reaching school, where treatment is given, worm burdens are reduced by treatment with praziquantel, however, the child will become re-infected upon subsequent water contact. (B) Conceptualization of treatment study measuring the performance of praziquantel. Children within a school are selected and offered treatment. These same children are re-examined typically 24 days later and cure rate is determined as a percentage of those who have stopped shedding parasite eggs. Cure rates typically range from absolute (100%) down to 75%, but in some instances can be much lower.

Figure 2. International advocacy, policy and control programme reporting in action.

Screen shots of the WHO website that highlight recent decisions taken for disease control (A) and data contained within the Preventive Chemotherapy Database for Madagascar illustrating administered treatments (B).

Figure 3. Implementation map of Uganda, as of 2012, highlighting the different agencies involved in control of schistosomiasis, taken from Research Triangle Institute international website.

Figure 4. Generic information, education and communication materials produced by WHO for implementing preventive chemotherapy within schools.

(A) Front cover of teacher training booklet for deworming school children. (B) On-site tools needed for administration of deworming tablets to children: potable water, drinking cups and praziquantel height pole is needed alongside treatment registers for recording treatments and noting any noncompliance or side effects.Figure taken from [14].

Figure 5. Systematic review of literature, review and filtering.

To qualify for inclusion, study design had to be a longitudinal study enrolling individuals (0–22 years of age) infected with Schistosoma haematobium and/or Schistosoma mansoni, as determined microscopically: for S. haematobium, eggs in a standard filtrate of 10 ml of urine, for S. mansoni, eggs in standard Kato–Katz smears (at least a single smear); patients had to be treated with praziquantel, 40 mg/kg single dose; the sample size (number. treated or diagnosed) was reported; the temporal interval between baseline and reassessment had to be reported; the population age ranges were reported and primary outcome (cure rate achieved) had to be reported. Exclusion criteria were: study participants were not human; incomplete information; duplicate publications; full article not accessible; reviews and follow-up period exceeded 90 days or less than 20 days. The following information was independently extracted by two reviewers (AMD Navaratnam and JC Sousa-Figueiredo) and was checked together. The extracted information included: first author’s name and year of publication, country studied, participants age, Schistosoma species, diagnostics methods, follow-up time, raw dichotomous data of efficacy assessment (number. treated/number. positive upon follow-up), cure rate and other outcomes (egg reduction rate). In surveys were the same population was followed-up multiple times, the outcome considered was the one gathered closest to the latest acceptable time period (i.e., 90 days).

Figure 6. Cross study comparison of the performance of praziquantel across Africa in terms of parasitological cure.

Figure 7. Relationship between observed cure rate and local prevalence of schistosomiasis.

(A) Species cure rates for Schistosoma mansoni and Schistosoma haematobium. (B) Cure rates for children in two age ranges (0–6 years and aged 6 plus) differ with cure rates within younger children decreasing quickly with increasing local prevalence highlighting that for preschool-aged children the performance of praziquantel is to be optimized.

Table 1. WHO-recommended treatment strategy for schistosomiasis.

Category	Baseline prevalence among school-aged children	Action to be taken^†
High-risk community	50% by parasitological methods^‡ (intestinal and urogenital schistosomiasis) or 30% by questionnaire for history of hematuria	Treat all school-aged children (enrolled and not enrolled) once a year	Also treat adults considered to be at risk (from special groups^§ to entire communities living in endemic areas)
Moderate-risk community	10% but <50% by parasitological methods (intestinal and urogenital schistosomiasis) or <30% by questionnaire for history of hematuria	Treat all school-aged children (enrolled and not enrolled) once every 2 years	Also treat adults considered to be at risk (special groups^§ only)
Low-risk community	<10% by parasitological methods (intestinal and urogenital schistosomiasis)	Treat all school-aged children (enrolled and not enrolled) twice during their primary schooling age (e.g., once on entry and once on exit)	Praziquantel should be available in dispensaries and clinics for treatment of suspected cases

^†Equivalent to: high-risk community – all school-aged children and adults require preventive chemotherapy annually; moderate-risk community – 50% of school-aged children and 20% of adults require preventive chemotherapy annually; low-risk community – 33% of school-aged children require preventive chemotherapy annually.

^‡For urogenital schistosomiasis, detection of hematuria by chemical reagent strips gives results equivalent to those determined by urine filtration.

^§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.

Table 2. WHO vision, goals and objective for control of schistosomiasis.

Vision	A world free from schistosomiasis
Goals	To control morbidity due to schistosomiasis by 2020To eliminate schistosomiasis as a public health problem by 2025To interrupt transmission of schistosomiasis in the region of the Americas, the eastern Mediterranean region, the European region, the south-east Asia region, and the western Pacific region, and in selected countries of the African region by 2025
Objectives	To scale up control and elimination activities in all endemic countriesTo ensure an adequate supply of praziquantel and resources to meet the demand

Data taken from [4].

Table 3. List of key needs and resources for deworming at the school site.

Needs	Formal acceptance of treatment compliance by headteacherPrior community sensitization with appropriate parental dialogueTrained teachers able to administer medicines safelyFormal recording of medications received, rejections and side-effectsA designated timetable for coordination of local resourcesFeedback to communities after treatment with future sensitization
Resources	Culturally appropriate health education materialsTreatment register booklets and PZQ dosing polesAdequate drug stocks, with small surplus for any contingenciesSufficient amounts of potable water, drinking cups and on-site foodProvision of a safe and orderly treatment station, with sick-bay if neededStand-by activation of local health centre(s) for referrals

Table 4. Summary of characteristics of trials selected after systematic review evaluating single dose praziquantel (40 mg/kg) treating urogenital and intestinal schistosomiasis in children.

Study (year, country)	Trial number	Parasite species	Age range	Prevalence (%)	Treated (n)	Formulation	Cure rates (%)	ERR (%)	Follow-up (in days)	Ref.
Adoubryn et al. (2012, Côte d’Ivoire)	1	S.m.	4–15	35.5	137	Tablet	80.9	Not reported	90	[101]
Augusto et al. (2009, Mozambique)	2	S.h.	8–16	54.2	287	Tablet	69.7	33.1	61	[93]
Augusto et al. (2009, Mozambique)	3	S.h.	8–16	51.7	269	Tablet	98.2	68.9	61	[93]
Borrmann et al. (2001, Gabon)	4	S.h.	5–13	42.8	89	Tablet	73.0	Not reported	56	[103]
Coulibaly et al. (2012, Côte d’Ivoire)	5	S.h.	0–6	11.2	18	Tablet	88.9	98.0	21	[104]
Coulibaly et al. (2012, Côte d’Ivoire)	6	S.m.	0–6	21.9	35	Tablet	88.6	96.7	21	[104]
De Clercq et al. (2002, Senegal)	7	S.h.	7–14	90.0	88	Tablet	30.0	80.0	35	[97]
Degu et al. (2002, Ethiopia)	8	S.m.	10–14	50.8	154	Tablet	94.0	97.0	42	[105]
Erko et al. (2012, Ethiopia)	9	S.m.	6–22	74.9	224	Tablet	73.6	68.2	28	[102]
Garba et al. (2012, Niger)	10	S.h.	0–6	Not reported	165	Syrup	85.7	69.4	21	[107]
Garba et al. (2012, Niger)	11	S.m.	0–6	Not reported	96	Syrup	75.0	66.7	21	[106]
Garba et al. (2001, Niger)	12	S.h.	6–16	98.0	311	Tablet	68.0	Not reported	42	[106]
Guyatt et al. (2001, Tanzania)	13	S.h.	8–14	59.0	275	Tablet	94.0	99.0	42	[108]
Inyang-Etoh et al. (2009, Nigeria)	14	S.h.	4–16	38.5	44	Tablet	72.7	79.3	56	[109]
Kahama et al. (1999, Kenya)	15	S.h.	6–17	83.0	147	Tablet	61.5	Not reported	56	[110]
Kahama et al. (1999, Kenya)	16	S.h.	6–17	76.0	149	Tablet	62.1	Not reported	56	[110]
Kahama et al. (1999, Kenya)	17	S.h.	6–15	97.0	117	Tablet	64.9	96.9	61	[111]
Kardaman et al. (1985, Sudan)	18	S.h.	7–11	Not reported	158	Tablet	66.3	Not reported	30	[112]
Kardaman et al. (1985, Sudan)	19	S.h.	7–11	Not reported	158	Tablet	73.2	Not reported	90	[112]
Keiser et al. (2010, Côte d’Ivoire)	20	S.h.	8–16	59.5	26	Tablet	83.0	97	26	[113]
Kihara et al. (2009, Kenya)	21	S.h.	4–18	92.8	158	Tablet	89.9	Not reported	33	[114]
Kihara et al. (2010, Kenya)	22	S.m.	4–18	14.9	79	Tablet	92.6	Not reported	56	[115]
Kihara et al. (2010, Kenya)	23	S.m.	4–18	69.6	361	Tablet	75.8	Not reported	56	[115]
Kihara et al. (2010, Kenya)	24	S.m.	4–18	22.0	85	Tablet	83.8	Not reported	56	[115]
Kihara et al. (2010, Kenya)	25	S.m.	1–18	71.1	342	Tablet	74.7	Not reported	56	[115]
Kihara et al. (2010, Kenya)	26	S.m.	4–18	58.2	223	Tablet	88.1	Not reported	56	[115]
King et al. (2002, Kenya)	27	S.h.	4–23	70.0	125	Tablet	70.0	98.0	42	[117]
Lwambo et al. (1997, Pemba Island)	28	S.h.	5–19	59.9	5616	Tablet	68.0	Not reported	70	[117]
McMahon & Kolstrup (1979, Tanzania)	29	S.h.	7–15	Not reported	33	Tablet	76.0	99.6	84	[118]
Midzi et al. (2008, Zimbabwe)	30	S.h.	2–19	40.4	107	Tablet	90.9	Not reported	42	[119]
Midzi et al. (2008, Zimbabwe)	31	S.h.	5–17	60.0	675	Tablet	88.5	98.2	42	[119]
Mohamed et al. (2009, Sudan)	32	S.m.	8–17	15.9	46	Tablet	100.0	100.0	21	[5]
Mohammed et al., (2006, Sudan)	33	S.h.	7–13	28.0	50	Tablet	58.0	98.0	42	[120]
Mutapi et al. (1998, Zimbabwe)	34	S.h.	6–15	64.9	37	Tablet	100.0	Not reported	42	[99]
Mutapi et al. (2011, Zimbabwe)	35	S.h.	1–5	18.0	18	Tablet	92.0	99.0	42	[121]
Mutapi et al. (2011, Zimbabwe)	36	S.h.	6–10	38.0	135	Tablet	67.0	96.0	42	[121]
Navaratnam et al. (2012, Uganda)	37	S.m.	1–5	27.0	148	Syrup	80.9	86.1	28	[122]
Navaratnam et al. (2012, Uganda)	38	S.m.	1–5	25.9	149	Tablet	81.7	89.0	28	[122]
Obonyo et al. (2010, Kenya)	39	S.m.	6–15	86.0	106	Tablet	65.0	84.1	28	[123]
Olds et al. (1999, Kenya)	40	S.h.	4–18	89.7	98	Tablet	61.5	Not reported	45	[124]
Olds et al. (1999, Kenya)	41	S.m.	6–19	83.7	98	Tablet	56.4	Not reported	45	[124]
Olliaro et al. (2011, Mauritania)	42	S.m.	10–19	18.7	93	Tablet	91.4	89.2	21	[85]
Olliaro et al. (2011, Tanzania)	43	S.m.	10–19	93.0	135	Tablet	86.6	91.9	21	[85]
Pugh & Teesdale (1983, Malawi)	44	S.h.	5–18	23.8	97	Tablet	63.4	99.3	30	[183]
Saathoff et al. (2004, South Africa)	45	S.h.	8–12	68.3	757	Tablet	57.9	95.3	21	[126]
Sacko et al. (2009, Mali)	46	S.h.	7–14	96.0	150	Tablet	37.3	Not reported	84	[127]
Sacko et al. (2009, Mali)	47	S.h.	7–14	89.0	139	Tablet	56.8	Not reported	84	[127]
Scherrer et al. (2009, Côte d’Ivoire)	48	S.m.	4–13	29.0	49	Tablet	97.6	97.7	20	[128]
Sissoko et al. (2009, Mali)	49	S.h.	6–15	26.4	389	Tablet	53.0	95.6	29	[129]
Sousa-Figueiredo et al. (2012, Uganda)	50	S.m.	1–7	37.7	369	Tablet	56.4	96.2	28	[100]
Sousa-Figueiredo et al. (2010, Uganda)	51	S.m.	0–6	16.0	28	Tablet	100.0	100.0	21	[130]
Stete et al. (2012, Côte d’Ivoire)	52	S.h.	7–15	79.0	90	Tablet	95.0	98.5	62	[131]

ERR: Egg reduction rate; S.h.: Schistosoma haematobium; S.m.: Schistosoma mansoni.

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