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Submitted by:

Stephanie Ann M. Mag-iba


NR-32

Submitted to:
Mr. Ben de Paz
Professor
SCHISTOSOMIASIS

Schistosomiasis (bilhariasis or snail fever) has long been one of the


important tropical diseases in our country. It is caused by a blood fluke,
Schistosoma Japonicum that is transmitted by a tiny snail oncomelani
quadrasi. Since it affects mostly farmers and their families in the rural area,
and due to the chronicity of the disease, it results in manpower losses and
lessened agricultural productivity. Hence, schistosomiasis is not a public
health but also socio-economic problem.

The disease is endemic in 10 regions, 24 provinces, 183 municipalities and


1,212 barangays with an estimated exposed population of 6.7 million. In
these areas, there are about 3,391 snail colonies with an approximate area
of 11,250 hectares.

There is high prevalence of schistosomiasis in Region 5 (Bicol) Region 8


(Samar & Leyte) and Region II (Davao).

Signs and Symptoms

• Diarrhea

• Bloody stools

• Enlargement of abdomen

• Spleenomegaly

• Weakness

• Anemia

• Inflamed liver

Infectious Agents:

Schistosoma mansoni. S. haematobium and 51: japonicum are the major


species causing human disease. Schistosoma japonicum is endemic in the
Philippines.
The male and female parasites (s. japonicum) live in the blood vessels of the
intestines and liver. The eggs of the parasite are laid in the terminal capillary
vessels in the submucosa of the intestines and through ulcerations reach the
lumen of the intestines and pass out with the feces and upon contact with
fresh water hatches into a larva (miracadium). The free-swimming larva
seeks and penetrates the soft part of the intermediate host – a tiny snail
called oncomelania quadrasi, multiplies and within two months becomes the
infective stage called cercaria. This fork-tailed larva emerges from the snail
into the water and enters the skin of man and other warm blooded animals
as cows, dogs, carabaos, cats, rats, horse and goats who come in contact
with infected water. Through the lymphatic and then the veins, it eventually
goes to the heart, systemic circulation, and into the intrahepatic portal
circulation where they mature, copulate and start laying eggs in about one
month’s time.

Mode of Transmission

Infection occurs when skin comes in contact with contaminated fresh water
in which certain types of snails that carry schistosomes are living. It is the
free swimming larval forms (cercariae) of the parasites that penetrate the
skin.

Fresh water becomes contaminated by schistosoma eggs when infected


people urinate or defecate in the water. The eggs hatch, and if certain types
of snails are present in the water, the parasites grow and develop inside the
snails. The parasites leaves the snail and enters the water where it can
survive for about 48 hours. Schistosoma parasites can penetrate the skin of
persons who are wading, swimming, bathing, or washing in contaminated
water. Within several weeks, worms grow inside the blood vessels of the
body and produce eggs. Some of these eggs travel to the bladder or
intestines and are passed into the urine or stool.

Methods of Control

a. Preventive Measures

• Educate the public in endemic areas regarding mode of


transmission and methods of protection.
• Dispose of feces and urine so that viable eggs will not reach
bodies of fresh water containing intermediate snail host. Control
of animals infected with S. japonicum is desirable but usually not
practiced.

• Dispose of feces and urine so that viable eggs will not reach
bodies of fresh water containing intermediate snail host. Control
of animals infected with S. japonicum is desirable but usually not
practiced.

• Improve irrigation and agriculture practices: reduce snail habitats


by removing vegetation or by draining and filling.

• Treat snail-breeding sites with molluscicides. (cost may limit use


or these agents)

• Prevent exposure to contaminated water (e.g. use of rubber


boots). To minimize cercarial penetration after brief or accidental
water exposure, towel dry, vigorously and completely, skin
surfaces that are wet with suspected water. Apply 70 % alcohol
immediately to the skin to kill surface cercariae.

• Provide water for drinking, bathing, and washing clothes from


sources free cercariae include water treatment iodine or chlorine,
or the use of paper filters. Allowing water to stand 48-72 hours
before use is also effective.

• Treat patients in endemic areas to prevent disease progression


and to reduce transmission by reducing egg passage.

• Travelers visiting endemic areas should be advised of the risks


and informed about preventive measures.

b. Control of Patient, Contacts and the Immediate Environment

• Report to local health authority in selected endemic areas

• Isolation: None

• Concurrent disinfection: Sanitary disposal of feces and urine

• Quarantine: None
• Immunization of contacts: None

c. Investigation of contacts and source of infection: Examine


contacts for infection from a common source. The search for a
source is a community effort.

• Specific treatment: Praziquantel (Biltricide) is the drug of choice


against all species. Alternative drugs are Oxamniquine for S.
mansoni and meyrifonate for haematobium.

• Epidemic measures: Examine for schistosomiasis and treat all


who are infected, but especially those with moderate to heavy
intensities of egg passage; pay particular attention to children.

• Motivate people in these areas to have annual stool examination.

• Public health nurse in endemic areas participates actively n the


above preventive and control measures.
Schistosomiasis Control

Control of Schistosomiasis, as with control of any infectious organism, aims to


prevent new infections, usually by interruption of the parasites lifecycle. This may
be achieved by a number of methods;

1) Acting to eliminate the intermediate host

2) Elimination of the parasite from the definitive host

3 Prevention of infection of the definitive host

4) Prevention of infection of the intermediate host, including;

5) The eventual use of a vaccine

Each of these methods may be effective, but all have different advantages and
disadvantages, depending on the parasitic organism.

• Elimination of the Intermediate Host

In terms of schistosomiasis this means elimination of the snail hosts. There are a
number of ways of doing this.

By application of molluscicides - This method of control is the main one used under
this heading, and may be successful in control of schistosomiasis. But it also has a
number of major disadvantages, including the expense of molluscicides, and, very
importantly the toxicity of the chemicals used, which may kill other aquatic
organisms such as the fish the affected populations may rely on.

Alteration of the aquatic environment - This includes altering the rate of flow of the
water, clearance of vegetation and drainage (for example of canals) at certain times
of the year. Disadvantages of these methods may include impracticality for
economic or environmental reasons, damage to fish populations (e.g. by clearance
of vegetation), and altering the environment such that it is then suitable for other
disease organisms, for example, increasing rate of water flow may inhibit snail
populations, but may then be suitable for colonisation by Simulium larvae, the
vectors for river blindness.

Biological control - For example by introduction of competitor snail species. For


example the snail Marisa cornuarietis will both compete with Biomphalaria snails for
food, and eat its eggs, and has been used in Puerto Rico as a control agent. Other
methods have been suggested such as the introduction of snail eating fish. Also
growth of certain plants on the sides of waterways has been used to control snail.
The berries of endod (Phytolacca dodecandra) have been shown to be naturally
molluscicidal when the fall into the water, and its presence on the sides of rivers in
Ethiopia has been shown to be associated with a reduction in local snail population.
• Elimination of the Parasite from the definitive Host

This is carried out by chemotherapeutic cure, and is currently the main control
method for schistosomiasis. The two main drugs used are Oxamniquine and
Praziquantel. These drugs are relatively safe to use, are the development of drug
resistance by schistosomes is not a problem. The major disadvantages to the use of
drugs to control schistosomiasis are firstly the cost, and second and more
importantly the need to repeat drug treatment at relatively short intervals. This
control method however is the most widely used with respect to schistosomiasis.

• Prevention of infection of the definitive host

Environmental Infrastructure - Various preventative control methods are used,


principally reducing contact between at risk populations and contaminated water,
by construction of wash houses and other safe water supplies. These methods have
the added advantage in reducing or eliminating other water borne infectious
diseases at the same time as reducing schistosomiasis. Disadvantages include the
large cost of implementing these schemes.

The use of a Vaccine - An important control measure that has been successfully
used with many other infectious diseases (e.g. smallpox) is the use of a vaccine.
However, for schistosomiasis, there is as yet no effective vaccine for human use
currently available. The identification of schistosome antigens that may form the
basis is a major priority of the research carried out in our laboratories. To be an
effective vaccine against schistosomiasis, (or indeed any tropical disease), the
vaccine must have the following features:

i) It must be cheap - The countries affected by schistosomiasis include some of the


poorest in the world, and for them to be able to use the vaccine, they must be able
to afford it, especially when this expenditure is in competition with other major
health costs.

ii) It must be effective in terms of protection - Protect of a large percentage of those


people vaccinated is essential to interrupt transmission of the parasite.

iii) It must be stable - For use in many of the affected countries it must be able to
survive storage as it is transported to isolated endemic populations.

iv) It should ideally be effective with a single application - This is important as a


means of keeping the costs of the mass vaccination schemes needed to a minimum.

• Prevention of infection of the intermediate host

These control methods at present are principally in this case introduction of latrines,
thereby reducing or eliminating contamination of the populations water supplies
with human faeces containing eggs. The disadvantages of these methods are
therefore also the same as those detailed above for prevention of human infection,
namely the large costs involved. Interestingly - infection of the snail with other
larval trematodes, particularly those of echinostomes, has been shown to protect
the snails from infection by larval schistosomes, and although these might not
eliminate schistosomes from endemic areas, they may to some extent limit
intensity of snail infections.

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