Schistosomiasis

Introduction
Epidemiology
RiskforTravellers
Transmission
SignsandSymptoms
Treatment
Prevention
References
ReadingList

Introduction
Schistosomiasis,orbilharzia,iscausedbyworms(termedflukes)thathavea
complexlifecycleinvolvingfreshwatersnailsashosts.Severalspeciesexist,of
whichthemostprevalentareS.mansoni,S.japonicum,andS.haematobium.
Schistosomiasisispresentworldwide,butoccursmostfrequentlyinsubSaharan
Africa,Brazil,southernChina,andthePhilippines.
Backtotop

Epidemiology
Globalepidemiology
Schistosomiasisisoneofthemostwidespreadofallparasiticinfectionsofman.The
WorldHealthOrganization(WHO)estimatedthatschistosomiasisandsoil
transmittedhelminthsrepresentmorethan40%oftheglobaldiseaseburdencaused
byalltropicaldiseases,excludingmalaria[1].
Schistosomiasisisthemostcommonparasitetransmittedthroughcontactwithfresh
water.Itisendemicinmorethan70lowincomecountrieswhereitoccursinrural
areasandthefringesofcities.Over650millionpeoplegloballyareatriskof
infection,withmorethan200millionpeopleinfected.Ofthese,120millionare
estimatedtohavesymptoms,with20millionpeopleexperiencingserious
consequences.Theeconomiceffectsandhealthimplicationsofschistosomiasisare
extensive.Higherdiseaseratesoccurinchildren[2]withinfectionfrequentlyfound
inthoseunder14yearsinmanyriskareas[3].

NaTHNaC

March 2008

Figure1:Globaldistributionofschistosomiasis(MapcourtesyofUSCenters
forDiseaseControlandPrevention[8])

S.mansoni,S.haematobium,andS.japonicumarethespeciesofschistosomathat
causethemajorityofhumandiseasetheypredominateindifferentareasofthe
world.OtherspeciescausinghumaninfectionareS.intercalatum,S.mekongi,S.
malayensis,andS.mattheei,buttheseoccurinlimitedfoci.
S.mansoni(hepatic/intestinal)isdistributedthroughoutsubSaharanAfricaandthe
MiddleEast,butisalsofoundinsomeCaribbeanislands,Brazil,Venezuelaandthe
coastofSuriname(Figure1).S.haematobium(urinary)isariskinmorethan50
Africancountries(andismostprevalentineastAfrica,particularlyLakeMalawi),the
islandsofMadagascarandMauritius,andtheMiddleEast.Itisalsoknowntooccurin
afewsmallareasofIndia.S.japonicum(hepatic/intestinal)isfoundineastand
SouthEastAsiaandthewesternPacific,predominantlyinChina,Indonesiaandthe
Philippines.S.intercalatum(hepatic/intestinal)isfoundinjungleareasofcentraland
westernAfrica.
Amajorfactorassociatedwiththeintensificationofschistosomiasisiswater
developmentprojects,particularlymanmadelakesandirrigationschemes,which
canleadtoshiftsinsnailvectorpopulations[4].Populationmovementhasalso
extendedtherangeofthediseaseinsomeareas.Ruralurbanmigration,forced

NaTHNaC

March 2008

displacementandtheriseofecotourismhaveallcontributedtotheincreasein
schistosomiasis[3].
Backtotop

SchistosomiasisinUKtravellers
Figure2:Laboratoryreportsofschistosomiasis,England,Wales,and
NorthernIreland:19962005

160

Laboratoryreports

140
120
100
80
60
40
20

20
04

20
05

20
02

20
03

20
00

20
01

99

19

19
97

19
98

19
9

Year
Datasource:HealthProtectionAgency

CasesofschistosomiasisreportedinEngland,Wales,andNorthernIrelandhave
beendecreasingsince1999(Figure2),thereasonforwhichisunclear.S.
haematobiumhasbeenthemostidentifiedorganismincasesinEngland,Walesand
NorthernIrelandinrecentyears.Between2003and2005,of213casesreportedin
total,116(54%)wereduetoS.haematobium,43(20%)toS.mansoniandthe
remainderhadnospeciesstated[5].

NaTHNaC

March 2008

Table:Laboratoryreportsofschistosomiasisbycountryoftravel,England,
Wales,andNorthernIreland:20032005
Country
Africaunspecified
Africa,Asia
Burundi
Congo
CtedIvoire
Egypt
Eritrea,Sudan
Ethiopia
Ghana
India
Kenya
LakeMalawi
LakeVictoria
Madagascar
Malawi
Mali
Nigeria
Rwanda
SierraLeone
Somalia
Sudan
Uganda
Zambia
Zimbabwe
Countrynotstated
Total

20032005
3
1
1
1
1
2
1
1
5
1
2
1
1
2
12
1
3
2
2
1
2
3
2
12
150
213

Datasource:HealthProtectionAgency

SchistosomiasisisnotfoundintheUK,soallcasesareacquiredabroad.However,
thetravelhistoryinUKtravellersisconsistentlyunderreportedandonlyabouta
thirdofreportsstatecountryoftravel(seetableabove).Nearlyallcasesstating
countryoftravelhadvisitedsubSaharanorsouthernAfrica.From2003to2005
MalawiandZimbabwewerethemostreportedcountriesoftravel[5].
Backtotop

Riskfortravellers
Travellersareatriskofschistosomiasisiftheywadeorswiminfreshwaterin
endemicareas.Althoughschistosomiasisisfoundthroughouttropicalregions,
schistosomiasisintravellersisacquiredalmostexclusivelyinAfrica.Theabsenceof
casesintravellerstootherendemicareasmaybebecauseschistosomiasisisoftena
focaldiseaseandisnotfoundinlocationsfrequentedbytravellerstoSouthAmerica
andtheFarEast[6].OutbreakshaveoccurredinadventuretravellersonAfrican
rivertripsaswellasexpatriategroups.SwimminginLakeMalawiisanimportant
riskfactorfortravellers[7].

NaTHNaC

March 2008

Backtotop

Transmission
Schistosomaeggsareexcretedinhumanfaeces(S.mansoniandS.japonicum)or
urine(S.haematobium),theeggshatchinfreshwaterandthelarvae,knownas
miricidia,infectsnails.AnotherlarvalformofSchistosoma,termedcercariae,emerge
fromthesnails.Theyarefreeswimmingandarecapableofpenetratingtheskinofa
humanhost.Oncetheyhavepenetratedskin,thecercariaeundergodevelopment
andmigratetotheliverandthenviathevenoussystemtothecapillariesofthe
bowel(S.mansoniandS.japonicum)orbladder(S.haematobium)wheremature
wormsmateandbegintoproduceeggs.Theeggsarethenpassedintothe
environmentviathefaecesorurine.
Backtotop

Signsandsymptoms
Initialcontactwithcercariaecancauseanitchy,papularrash,knownasswimmers
itch.
Onceinfectionhasbeenestablished,clinicalmanifestationscanoccurwithin23
weeksofexposure,butmanyinfectionsareasymptomatic.
Thesymptomatic,acutephaseofillnessisknownasKatayamafeverandpresents
withfever,malaise,urticariaandeosinophilia[6].Othersymptomscaninclude
cough,diarrhoea,weightloss,haematuria,headaches,jointandmusclepain,and
enlargementoftheliverandspleen.
ChronicinfectionwithS.mansoniandS.japonicumcausesperiportalliverfibrosis
andportalhypertensionwithascitesandoesophagealvarices.Longterminfection
withS.haematobiumisassociatedwithbladderscarring,renalobstruction,chronic
urinaryinfection,andpossiblybladdercarcinoma.
Diagnosiscanbemadebyfindingschistosomeeggsonmicroscopicexaminationof
stoolorurine,byfindingeggsonrectalbiopsy,orwithserologydetectingantibodies
toschistosomalantigensortheantigensthemselves.
Backtotop

Treatment
Patientsshouldbereferredtoaninfectiousdiseasesortropicalmedicinespecialist
fortreatment.Thedrugofchoiceforallspeciesofschistosomiasisispraziquantel[2,
8].
Backtotop

NaTHNaC

March 2008

Prevention
Thereisnovaccineavailableforschistosomiasisandnodrugchemoprophylaxis.
Travellersshouldbeadvisedtoavoidswimmingandwadinginriversandlakesor
otherfreshwatercontactinendemiccountries.Thisincludespopulardestinations
suchasLakeMalawi.Topicalapplicationofinsectrepellentbeforeexposuretowater,
ortoweldryingafteraccidentalexposuretoschistosomiasisarenotreliablein
preventinginfection.Chlorinationkillsschistosomesthereforethereshouldbeno
riskinwellmaintainedswimmingpools.Schistosomiasiscannotbecontracted
throughseawater.Cercariaealsodieafter48hoursinstandingwaterorfollowing
heatingwaterto50Cforfiveminutes.Filteringwaterwithfinemeshfiltersmay
alsoeliminatetheparasite[8].
Schistosomiasisintravellersiscommonlyasymptomatic.Thereforethosewhoswam
orbathedinfreshwaterinendemicareasmayhavebeenexposedtotheinfection
andshouldbeadvisedtoundergoscreeningtestswithatropicalmedicinespecialist
[9].
Backtotop

References
1. WorldHealthOrganization.Schistosomiasisandsoiltransmittedhelminth
infectionspreliminaryestimatesofthenumberofchildrentreatedwith
albendazoleormebendazole.WklyEpidemiolRec.200681:14564.
2. GryseelsB,PolmanK,Clerinxetal.HumanSchistosomiasis.Lancet
2006368:110618.
3. WorldHealthOrganization.Schistomiasis.FactSheetNo115.Geneva,July,
2007.Availableat:
http://www.who.int/entity/mediacentre/factsheets/fs115/en
4. PatzJ,GraczykT,GellerNetal.Effectsofenvironmentalchangeonemerging
parasitediseases.IntJParasitol200030:1395405.
5. HealthProtectionAgency.Foreigntravelassociatedillness.England,Wales
andNorthernIreland2007report.London:HPA2007.Availableat:
http://www.hpa.org.uk/publications/2007/travel/travel_2007.pdf
6. MeltzerE,ArtomG,MarvaEetal.Schistsomiasisamongtravelers:New
AspectsofanOldDisease.EmergInfectDis.200612:16961700.Available
at:http://www.cdc.gov/nciod/EID/vol12no11/060340.htm
7. MooreE,DohertyJ.SchistosomiasisamongtravellersreturningfromMalawi:
acommonoccurrence.QJMed200598:6970.
8. USCentersforDiseaseControlandPrevention.Schistosomiasis.Health
InformationforOverseasTravel2008.Elsevier:Atlanta,2007.297300.
9. SchwartzE,KozarskyP,WilsonMetal.Schistosomeinfectionamongriver
raftersonOmoRiver,Ethiopia.JTravMed.200512:38.
Backtotop

NaTHNaC

March 2008

ReadingList
KingCH.Schistosomiasis.In:GuerrantRL,WalkerDHandWellerPF,eds.Tropical
InfectiousDiseases.Principles,Pathogens&Practice.2nd ed.Elsevier,Philadelphia,
2006:2:13411348.
Backtotop

NaTHNaC

March 2008