I.

INTRODUCTION
Schistosomiasis is infection with blood flukes of the genus Schistosoma,
which are acquired transcutaneously by swimming or wading in contaminated water.
Schistosoma is the only trematode that invades through the skin; about 200 million
people are infected worldwide.
Schistosomiasis, also known as bilharzia, is a disease caused by parasitic
worms. Bilharzia is a human disease caused by parasitic worms called
Schistosomes. Over one billion humans are at risk worldwide and approximately 300
millions are infected. Bilharzia is common in the tropics where ponds, streams and
irrigation canals harbor bilharzia-transmitting snails. Parasite larvae develop in snails
from which they infect humans, their definitive host, in which they mature and
reproduce. Although the worms that cause schistosomiasis are not found in the
United States, more than 200 million people are infected worldwide. In terms of
impact this disease is second only to malaria as the most devastating parasitic
disease. Schistosomiasis is considered one of the Neglected Tropical Diseases
(NTDs).
Neglected Tropical Diseases (NTDs) are a group of parasitic and bacterial
diseases that cause substantial illness for more than one billion people globally.
Affecting the world's poorest people, NTDs impair physical and cognitive
development, contribute to mother and child illness and death, make it difficult to
farm or earn a living, and limit productivity in the workplace. As a result, NTDs trap
the poor in a cycle of poverty and disease.
The parasites that cause schistosomiasis live in certain types of freshwater
snails. The infectious form of the parasite, known as cercariae, emerge from the
snail, hence contaminating water. You can become infected when your skin comes
in contact with contaminated freshwater. Most human infections are caused by
Schistosoma mansoni, S. haematobium, or S. japonicum.

People become infected when larval forms of the parasite – released by

freshwater snails – penetrate the skin during contact with infested water.
Transmission occurs when people suffering from schistosomiasis contaminate
freshwater sources with their excreta containing parasite eggs, which hatch in water.
In the body, the larvae develop into adult schistosomes. Adult worms live in the
blood vessels where the females release eggs. Some of the eggs are passed out of
the body in the faeces or urine to continue the parasite’s lifecycle. Others become
trapped in body tissues, causing immune reactions and progressive damage to
organs.
 II. EPIDEMIOLOGY

Schistosomiasis, or snail fever, is one of the more severe disease problems in

the Philippines. Primarily rural, schistosomiasis has socioeconomic ramifications
because it affects mostly farmers and their families, and thus hampers agricultural
productivity. There are about half-a-million endemic cases of Schistosoma japonicum
distributed in 24 endemic provinces including: Oriental, Mindoro; Sorsogon, Luzon;
the 3 provinces in Samar; Leyte and Bohol in the Visayas; and all the provinces of
Mindanao except Misamis Oriental and Sulu. In these provinces, the human
population at risk is 5.1 million and there are 2,987 known snail colonies with an
approximate area of 28,731 hectares. The exposed human population in the 1,160
barangays (villages) is about 1.5 million. Climatic Factors

There is a definite relationship between geographical distribution of the disease and

the annual rainfall pattern. This is supported by the observation that the affected
provinces are limited to areas that fall under either Type II or IV of the PAGASA
classification of climate in the Philippines. The Type II does not have a dry season
but has a very pronounced maximum rainfall from November to January, while Type
IV has a rainfall more or less evenly distributed throughout the year. The type of
rainfall is a contributing factor to the existence of the snail intermediate host.
The overall prevalence of schistosomiasis as of 1990 in the 24 affected provinces is
6.6%. According to studies in Leyte, the annual mortality rate due to schistosomiasis
is 1.78% of the estimated positive cases.

Prevalence According to Age, Sex, and Occupation

The prevalence of S. japonicum in the Philippines, with respect to age, sex,

occupation, and environment, follows a pattern that can be explained on the basis of
contact with parasite infection (Pesigan et al. 1958). It was observed that infection
during childhood and adolescence builds up rapidly until adulthood is reached, then
a general downward trend follows. As far as age and sex distribution of infected
individuals are concerned, there are significant sex differences between age groups
past childhood, with the rates being higher for males than for females. Children of
both sexes run an equal risk, but the differences begin to show up after 14 years,
when males become more active working in the rice fields and run greater chances
of acquiring infection.
Farmers, as an occupational class, have the highest infection rate (74.1%). When
not planting or harvesting rice, they work as fisherman, unskilled laborers, or tuber
gatherers, which would explain the next highest prevalence (more than 60%) among
this group of professions. The occupations that most often brings people in contact
with infected waters are farming and inland fishing. Seagoing fishermen who live
mostly in the coastal division, would naturally be the people less exposed to infection
in rivers, swamps, and streams. The class of workers with the lowest rates (exclusive
of preschool children) are, for obvious reasons, office workers and the professional
group, with an overall infection rate ranging between 16 and 26%. The rest
(students, housekeepers, and "jobless" persons) occupy an intermediate position
between the above two groups, with a range of approximately 51-58%. There are
significant differences in the general prevalence of infection in the three
environments (cities, coastal, and inland), with the highest prevalence rate (61.1%)
in the inland division. The differences, as one would expect, are due to the chances
of infection and the general sociological makeup of the population (Pesigan et al.
1958).
Areas where human schistosomiasis is found include:

Schistosoma mansoni
 Distributed throughout Africa, foci in Middle East: There is risk of infection in
freshwater in southern and sub-Saharan Africa–including the great lakes and
rivers as well as smaller bodies of water. Transmission also occurs in the Nile
River valley in Sudan and Egypt
 South America: including Brazil, Suriname, Venezuela
 Caribbean (risk is low): Dominican Republic, Guadeloupe, Martinique, and
Saint Lucia.
S. haematobium
 Distributed throughout Africa with smaller foci in the Middle East, Turkey and
India: There is risk of infection in freshwater in southern and sub-Saharan
Africa–including the great lakes and rivers as well as smaller bodies of water.
Transmission also occurs in the Nile River valley in Egypt and the Mahgreb
region of North Africa.

S. japonicum
 Asia, mainly in China, the Philippines, Thailand, and Indonesia.
S. mekongi
 Found in Cambodia and Laos; Southeast Asia
S. intercalatum
 Found in parts of Central and West Africa.

Age is also a significant factor in schistosomiasis infections, i.e., there is a reduction

in infection with increasing age after the peak prevalence is reached. This may be
explained on the basis of a host's reaction arising from a humoral response to
infection with a possible immunity mechanism coming into play, or from host-cell
reactions around infiltrated eggs that tend to wall them off in the intestinal tissues, or
from both.
 III. RISK FACTORS

Schistosomiasis is an important cause of disease in many parts of the world,

most commonly in places with poor sanitation. School-age children who live in these
areas are often most at risk because they tend to spend time swimming or bathing in
water containing infectious cercariae.If you live in, or travel to, areas where
schistosomiasis is found and are exposed to contaminate freshwater, you are at risk.
Age is also a significant factor in schistosomiasis infections, i.e., there is a reduction
in infection with increasing age after the peak prevalence is reached. This may be
explained on the basis of a host's reaction arising from a humoral response to
infection with a possible immunity mechanism coming into play, or from host-cell
reactions around infiltrated eggs that tend to wall them off in the intestinal tissues, or
from both.

IV. PATHOGENESIS

Causal Agents:
Schistosomiasis is caused by digenetic blood trematodes. The three main
species infecting humans are Schistosoma haematobium, S. japonicum, and S.
mansoni. Two other species, more localized geographically, are S. mekongi and S.
intercalatum. In addition, other species of schistosomes, which parasitize birds and
mammals, can cause cercarial dermatitis in humans.
 Eggs are eliminated with feces or urine . Under optimal conditions the eggs
hatch and release miracidia , which swim and penetrate specific snail intermediate
hosts . The stages in the snail include 2 generations of sporocysts and the
production of cercariae . Upon release from the snail, the infective cercariae swim,
penetrate the skin of the human host , and shed their forked tail, becoming
schistosomulae . The schistosomulae migrate through several tissues and stages
to their residence in the veins ( , ). Adult worms in humans reside in the
mesenteric venules in various locations, which at times seem to be specific for each
species . For instance, S. japonicum is more frequently found in the superior
mesenteric veins draining the small intestine , and S. mansoni occurs more often
in the superior mesenteric veins draining the large intestine . However, both
species can occupy either location, and they are capable of moving between sites,
so it is not possible to state unequivocally that one species only occurs in one
location. S. haematobium most often occurs in the venous plexus of bladder , but it
can also be found in the rectal venules. The females (size 7 to 20 mm; males slightly
smaller) deposit eggs in the small venules of the portal and perivesical systems. The
eggs are moved progressively toward the lumen of the intestine (S. mansoni and S.
japonicum) and of the bladder and ureters (S. haematobium), and are eliminated
with feces or urine, respectively . Pathology of S. mansoni and S.
japonicum schistosomiasis includes: Katayama fever, hepatic perisinusoidal egg
granulomas, Symmers’ pipe stem periportal fibrosis, portal hypertension, and
occasional embolic egg granulomas in brain or spinal cord. Pathology of S.
haematobium schistosomiasis includes: haematuria, scarring, calcification,
squamous cell carcinoma, and occasional embolic egg granulomas in brain or spinal
cord.
Human contact with water is thus necessary for infection by schistosomes.
Various animals, such as dogs, cats, rodents, pigs, horse and goats, serve as
reservoirs for S. japonicum, and dogs for S. mekongi.
Infection occurs when skin comes in contact with contaminated freshwater in
which certain types of snails that carry the parasite are living. Freshwater becomes
contaminated by Schistosoma eggs when infected people urinate or defecate in the
water. The eggs hatch, and if the appropriate species of snails are present in the
water, the parasites infect, develop and multiply inside the snails. The parasite
leaves the snail and enters the water where it can survive for about 48
hours. Schistosoma parasites can penetrate the skin of persons who come in contact
with contaminated freshwater, typically when wading, swimming, bathing, or
washing. Over several weeks, the parasites migrate through host tissue and develop
into adult worms inside the blood vessels of the body. Once mature, the worms mate
and females produce eggs. Some of these eggs travel to the bladder or intestine and
are passed into the urine or stool.
Symptoms of schistosomiasis are caused not by the worms themselves but by
the body’s reaction to the eggs. Eggs shed by the adult worms that do not pass out
of the body can become lodged in the intestine or bladder, causing inflammation or
scarring. Children who are repeatedly infected can develop anemia, malnutrition, and
learning difficulties. After years of infection, the parasite can also damage the liver,
intestine, spleen, lungs, and bladder.
Worms wriggling in your veins

Adult Schistosomes worms are about 1 cm long and hang out in mesenteric veins
(the small veins that carry blood from the intestine to the liver). The worms feed on
red blood cells and dissolved nutrients such as sugars and amino acids. This can
cause anemia and decreased resistance to other diseases.

Schistosomes live in pairs, the male holding and protecting the female inside his
ventral groove. Once paired, the two remain in constant copulation. The female lays
hundreds of eggs each day, which find their way out of the human body through the
urine or the faeces, depending on the species. The pathology is mostly caused by
the large number of eggs becoming stuck in various body parts, in particular the liver
(causing liver enlargement and malfunction) and the kidneys (causing kidney
damage, detectable by blood in the urine).
Worms transmitted by snails
Schistosomes eggs are evacuated from the human body via faeces or urine. When
sanitation is poor, they can reach rivers or lakes. They hatch into tiny swimming
larvae called miracidia. These swim about until they locate a snail and bore into its
body. Over a period of 3 to 4 weeks, miracidia develop into hundreds of sporocysts,
which each produce thousands of cercariae, the next infective stage. A single snail
can shed thousands of cercariae each day.
Can I catch Bilharzia from someone infected?

No - unless you are a snail !

Schistosomes must alternate between humans and snails to complete their life cycle.
This means that Bilharzia can only caught from snails.

Under the tropics, any body of water containing vegetation could contain bilharzia-
transmitting snails. Washing, swimming or paddling in that water therefore exposes
you to infection by the parasite.
 V. Signs and Symptoms
Common Symptoms
Most people have no symptoms when they are first infected. However, within
days after becoming infected, they may develop a rash or itchy skin. Within 1-2
months of infection, symptoms may develop including fever, chills, cough, and
muscle aches.
Acute Schistosome dermatitis
Most infections are asymptomatic. A pruritic papular (cercarial dermatitis) can
develop where cercariae penetrate the skin in previously sensitized people.
Acute Katayama Fever
Katayama fever may occur with onset of egg laying, typically 2 to 4 weeks
after heavy exposure. Symptoms include fever, chills, cough, nausea, and abdominal
pain, malaise, myalgia, urticarial rashes, and marked eosinophilia, resembling serum
sickness. Manifestations are more common and usually more severe in visitors than
in residents of endemic areas and typically last for several weeks.
Chronic schistosomiasis
Without treatment, schistosomiasis can persist for years. Signs and symptoms
of chronic schistosomiasis include: abdominal pain, enlarged liver, blood in the stool
or blood in the urine, and problems passing urine. Chronic infection can also lead to
increased risk of bladder cancer.
Rarely, eggs are found in the brain or spinal cord and can cause seizures,
paralysis, or spinal cord inflammation.

VI. INTERVENTIONS

DIAGNOSIS
Stool or urine samples can be examined microscopically for parasite eggs (stool
for S. mansoni or S. japonicum eggs and urine for S. haematobium eggs). The eggs
tend to be passed intermittently and in small amounts and may not be detected, so it
may be necessary to perform a blood (serologic) test.

TREATMENT
Safe and effective medication is available for treatment of both urinary and intestinal
schistosomiasis. Praziquantel, a prescription medication, is taken for 1-2 days to
treat infections caused by all Schistosoma species.
PREVENTION AND CONTROL
Prevention
No vaccine is available.
The best way to prevent schistosomiasis is to take the following steps if you are
visiting or live in an area where schistosomiasis is transmitted:

 Avoid swimming or wading in freshwater when you are in countries in which

schistosomiasis occurs. Swimming in the ocean and in chlorinated swimming
pools is safe.
 Drink safe water. Although schistosomiasis is not transmitted by swallowing
contaminated water, if your mouth or lips come in contact with water containing
the parasites, you could become infected. Because water coming directly from
canals, lakes, rivers, streams, or springs may be contaminated with a variety of
infectious organisms, you should either bring your water to a rolling boil for 1
minute or filter water before drinking it. Bring your water to a rolling boil for at
least 1 minute will kill any harmful parasites, bacteria, or viruses present. Iodine
treatment alone WILL NOT GUARANTEE that water is safe and free of all
parasites.
 Water used for bathing should be brought to a
 rolling boil for 1 minute to kill any cercariae, and then cooled before bathing to
avoid scalding. Water held in a storage tank for at least 1 - 2 days should be safe
for bathing.
 Vigorous towel drying after an accidental, very brief water exposure may help to
prevent the Schistosoma parasite from penetrating the skin. However, do not rely
on vigorous towel drying alone to prevent schistosomiasis.

Those who have had contact with potentially contaminated water overseas should
see their health care provider after returning from travel to discuss testing.

Control
In countries where schistosomiasis causes significant disease, control efforts usually
focus on:

1. reducing the number of infections in people and/or

2. eliminating the snails that are required to maintain the parasite’s life cycle.

For all species that cause schistosomiasis, improved sanitation could reduce or
eliminate transmission of this disease. In some areas with lower transmission levels,
elimination of schistosomiasis is considered a "winnable battle" by public health
officials.
Control measures can include mass drug treatment of entire communities and
targeted treatment of school-age children. Some of the problems with control of
schistosomiasis include:
1. Chemicals used to eliminate snails in freshwater sources may harm other
species of animals in the water and, if treatment is not sustained, the snails may
return to those sites afterwards.
2. For certain species of the parasite, such as S. japonicum, animals such as cows
or water buffalo can also be infected. Runoff from pastures (if the cows are
infected) can contaminate freshwater sources.

VII. REFERENCE:

(n.d.). Retrieved from

https://www.cdc.gov/parasites/schistosomiasis/health_professionals/index.html
(n.d.). Retrieved from https://www.cdc.gov/globalhealth/ntd/
Porter, M. R., Kaplan, M. J., & Pearson, M. R. (2016). MSD Manual. North Wales,
PA, USA.