Lessons from the eHealth Africa-Emory University Schistosomiasis Study

By Tolulope Oginni and Emerald Awa-Agwu

Schistosomiasis and nineteen other diseases are classified by the World Health Organization as Neglected Tropical Diseases. It is an acute and chronic parasitic disease caused by blood flukes called schistosoma. People become infected when larval forms of the parasite (worms) penetrate their skin during contact with infested water. 

The disease can present in two main forms: intestinal and urogenital schistosomiasis. Intestinal schistosomiasis can result in abdominal pain, diarrhea,  blood in the stool, and liver and spleen enlargement in advanced cases. The most distinguishing symptom of urogenital schistosomiasis is haematuria (blood in urine). Fibrosis of the bladder and ureter, kidney damage, genital lesions and vaginal bleeding in women, and pathology of the seminal vesicles, prostate and other organs in men. In later stages, urogenital schistosomiasis may lead to bladder cancer and infertility.

The disease is endemic to Nigeria and existing data places Nigeria as home to the highest number of recorded cases in the world. While there are insufficient research data and medical records to paint a true picture of the disease burden in Nigeria, it is estimated that 29 million Nigerians are infected with the disease and almost half of this number are children.

In June and July, eHealth Africa partnered with Emory University on a study to compare three diagnostic methods to determine their effectiveness in detecting acute and chronic schistosomiasis in low-resource settings. Accurate diagnostics are crucial to yield more information about the disease and ultimately, to achieve the goal of eliminating the disease. One of the major challenges facing the elimination of schistosomiasis is that very few infected people present at the health facilities for treatment. This can be attributed to a myriad of reasons including stigma, insufficient medical services, affordability of medical services, low knowledge of the signs and symptoms of the infection, and local perceptions and myths about the disease. The wider effect of this passive case finding (that is, cases are discovered only when infected persons visit the health facilities for treatment) and poor health-seeking behavior is that there is inadequate data to support the prioritization of schistosomiasis control by decision-makers and health program planners. In addition, medical laboratory scientists and researchers are unable to make improvements to diagnostic procedures for schistosomiasis because very few patients visit health facilities to access treatment.

During this study, eHealth Africa and two Emory University MPH students also trained 10 community health workers to administer questionnaires aimed at assessing the knowledge, attitudes, and perceptions about Schistosoma haematobium infection(urinary schistosomiasis) among communities in five Local Government Areas in Kano State.

Training of Community Health Workers

Training of Community Health Workers

The responses from the survey yielded astounding local interpretations of the symptoms of urinary schistosomiasis. Community members saw red urine (haematuria or blood in the urine) as a normal and rather harmless phenomenon, a rite of passage or a sign of manhood for young boys. It was also linked to the menstrual cycle for girls or women. Yet another misconception was that it could be caused by staying long hours under the sun. Among women especially, underreporting of the disease was exacerbated by socio-cultural norms and beliefs that prevent them from handling urine samples in public.

Administering questionnaires at Sani Marshal Government Arabic Secondary School, Kura LGA, Kano State

Administering questionnaires at Sani Marshal Government Arabic Secondary School, Kura LGA, Kano State

With this understanding and the results of the study, eHA and Emory University hope to influence policies, strategies and plans around the diagnosis and control of Schistosomiasis in Nigeria.

eHealth Africa and Emory University take on Schistosomiasis in Kano State, Nigeria

Chibuzor Babalola and Angela Udongwo with eHA’s Tolulope Oginni (center)

Chibuzor Babalola and Angela Udongwo with eHA’s Tolulope Oginni (center)

Schistosomiasis (Snail fever) is one of twenty communicable diseases classified by the World Health Organization as Neglected Tropical Diseases. The disease has dire health and economic consequences including disability, infertility, stunting in children and death.

Its close link with poor hygiene and sanitation, make its burden higher in poor, rural communities. Schistosomiasis is contracted when people are exposed to water infested by parasitic worms called Schistosomes. According to the World Health Organization, over 250 million people worldwide are affected by this disease and 90% of them live in Africa.

This public health impact drove Emory University Masters students, Angela Udongwo and Chibuzor Babalola, to partner with eHealth Africa’s Kano Lab to conduct a two-month research study in Kano State Nigeria. In this interview, they share the inspiration behind the study and their expectations for the research.

Why Schistosomiasis? What inspired this project?

We were inspired to conduct this study because of the public health impact of schistosomiasis. Nigeria is one of the Schistosomiasis-endemic countries and in fact, has the highest number of cases worldwide. Kano state is one of the five states with the highest burden of the disease in Nigeria. There is a need for more cost-effective, accurate and sensitive field applicable diagnostics to achieve the goal of eliminating the disease.

What's the purpose of this research study?

The purpose of this research is to compare the sensitivities and specifities of three diagnostic methods—polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP) and microscopy—for detecting Schistosoma haematobium (urinary blood fluke). The research will examine the appropriateness of these methods for field diagnosis in low-resource settings and for detecting both acute and chronic schistosomiasis. We are also administering questionnaires to assess the communities' knowledge, attitudes, and perceptions about schistosomiasis.

How did you end up doing this in Kano at eHealth Africa?

eHealth Africa was accepting interns from Emory University for summer research and having introduced my research idea to one of the co-founders at a previous event in my school, I applied. eHealth Africa is providing us with the lab space and equipment to conduct this research. Our project activities are supervised by the Lab team here in Kano and we are truly blessed to have this opportunity.

Their project is supervised by eHealth Africa’s Lab coordinator, Tolulope Oginni

What do you hope to accomplish at the end of the study?

The end goal of this study is to develop a device that is capable of detecting schistosomiasis among people with a low burden of infection. We intend to use the results of this research as preliminary data for future research and grant-funded projects. In the long term, we also hope that it will provide evidence to influence the improvement of policies on field diagnosis of schistosomiasis.