Treatment and Control of Schistosomiasis

1. Treatment and Control of Schistosomiasis Village of São Pedro

2. General Objectives • To assess potential problems with treatment of schistosomiasis • Population of 262 treated patients in São Pedro, Brazil • To examine treatment administration through data from patient interviews • To determine recommendations for and the influence on local health policy

3. Background • Treatment of Schistosomiasis infection • Two drugs available- Praziquantel and Oxamnique • Praziquantel is cheaper and safer and therefore, more widely used • Praziquantel (WHO Dosage = 40mg/kg) • Cheap – produced by Brazil Ministry of Health (MOH), costs approximately $ 0.65 (R$1,1) per treatment • Safe – WHO approved for pregnant women and young children • Easily administered in pill form • Acts within 1 hour of ingestion by killing mature worms • No reported resistance, but remains a concern • Organizational problems of PCE result in irregular use of praziquantel in endemic areas in Brazil

4. Background • Side effects of Praziquantel according to medical literature • Mild: Nausea, vomiting, malaise, abdominal pain, dizziness, cutaneous rash • In heavy infections: Acute colic and bloody diarrhea • WHO Recommended administration • Single dose of 40 mg/kg • Follow-up after 4-6 weeks • 70-100% of patients cease to excrete eggs after first single dose

5. Treatment in São Pedro • Administered at São Pedro basic health unit • Only individuals screening positive for eggs receive treatment • Prevalence (44,7%) below 50% threshold for mass treatment • Screening test has moderate sensitivity (70-85%) • Pregnant and breastfeeding women not treated • Forbidden by Brazilian MOH, although WHO approves it

6. Treatment in São Pedro • Single dose of Praziquantel (50mg/kg) • Follow-up dose if patient screens positive again in 40-50 days • Patients received treatment this week • Last treatment was administered in 2002 by Funasa

10. Analysis of Treatment Methods in São Pedro • Utilized patient information databases made by Dr. Gazzinelli and team • Developed questionnaire regarding: • Basic patient knowledge of schistosomiasis • Treatment history • Side Effects • Improvement of symptoms • Interviewed 94 residents of São Pedro out of 262 that were treated for schistosomiasis

11. Age distribution of study population Results and Observations n = 94

12. High proportion of residents reporting side effects 73.3% of study population Results and Observations

13. No patients reported severe side effects, such as acute colic or bloody diarrhea Older patients reported more side effects Mean age with side effects was 26.9 years versus 17.8 years without side effects Majority of residents (83.7%) would take treatment again No association between patients with side effects and willingness to take treatment Results and Observations

14. Results and Observations • Symptoms improved in 58.1% of patients • 28.7% of patients expressed fear prior to treatment • 84% of these patients experienced side effects, compared to 73.3% of the total study population

15. Results and Observations • Lack of knowledge on how to contract schistosomiasis • 51% suggested they could be infected from stream water • However, there were many common misconceptions including: • Walking around with bare feet • Eating unwashed produce • Contact with pig feces • Contact with standing water

16. Study Limitations • Recall Bias • Possible exaggeration of side effects • Only 22.3% of patients regularly use other medication • Primarily for lowering blood pressure • Population inexperienced with medication use • Desire to please health care officials • Underpowered study • Selection Bias • Not a random sample • Interviews often selected based on availability

17. Future Research • Compare our study population to data for general population • Do São Pedro patients have significantly more side effects • Determine more efficient treatment methods for São Pedro • For example, annual treatment administered in school or church • Analysis of patients who stated they would not take treatment again

18. Influence on Health Policy • Treatment requires supervision to be effective • Current treatment model ensures patients take recommended dosage • Data indicates that patients will continue to accept treatment from health unit despite side effects • Lack of disease awareness hinders advances in treatment of schistosomiasis • Residents unlikely to seek treatment on their own • Unlikely to take pills without supervision

19. Recommendations • Seek other control methods • Treatment very unlikely to control schistosomiasis problem • Requires successful mass treatment of all residents • Necessitates treatment of pregnant women • Health education is key to controlling schistosomiasis • Enhance awareness programs in local schools • Explain infection and complications to patients

20. Recommendations • Increase awareness of possible symptoms of schistosomiasis • Treatment is imperative for severe disease cases • Can cause paralysis, bleeding, physical disability, malnourishment, poor performance, anemia, and even death • May encourage residents to seek treatment on their own in the future

21. Acknowledgements Thank you to all the residents of São Pedro; the employees of the basic health unit; the Secretary of Health, Mayor, and residents of Jequitinhonha; Andrea Gazzinelli and Rodrigo Correa Oliveira and their team; and our group leaders and colleagues.