Extent of morbidity associated with schistosomiasis infection in Malawi: a review paper
Identifieur interne : 000878 ( Pmc/Corpus ); précédent : 000877; suivant : 000879Extent of morbidity associated with schistosomiasis infection in Malawi: a review paper
Auteurs : Austin H N. Mtethiwa ; Gamba Nkwengulila ; Jared Bakuza ; Daniel Sikawa ; Abigail KazembeSource :
- Infectious Diseases of Poverty [ 2049-9957 ] ; 2015.
Abstract
Data on the extent of the burden due to schistosomiasis is sparse in most Sub-Saharan African countries. However, this data is crucial for triggering medical attention. A review of extent of morbidity and determinants associated with schistosomiasis in Malawi was therefore conducted to quantify the infection in order to concretise the need for medical intervention. A systematic and traditional search strategy was used to find literature for the review, whilst exclusion and inclusion criteria were used to identify appropriate articles. Logistic regression curves of epidemiological model Y = (
The online version of this article (doi:10.1186/s40249-015-0053-1) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/s40249-015-0053-1
PubMed: 25954507
PubMed Central: 4423108
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PMC:4423108Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Extent of morbidity associated with schistosomiasis infection in Malawi: a review paper</title><author><name sortKey="Mtethiwa, Austin H N" sort="Mtethiwa, Austin H N" uniqKey="Mtethiwa A" first="Austin H N" last="Mtethiwa">Austin H N. Mtethiwa</name><affiliation><nlm:aff id="Aff1">Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda Campus, PO Box 219, Lilongwe, Malawi</nlm:aff></affiliation></author><author><name sortKey="Nkwengulila, Gamba" sort="Nkwengulila, Gamba" uniqKey="Nkwengulila G" first="Gamba" last="Nkwengulila">Gamba Nkwengulila</name><affiliation><nlm:aff id="Aff2">Zoology Department, University of Dar es Salaam, College of Natural and Applied Science, PO Box 35064, Dar es Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Bakuza, Jared" sort="Bakuza, Jared" uniqKey="Bakuza J" first="Jared" last="Bakuza">Jared Bakuza</name><affiliation><nlm:aff id="Aff3">Biological Sciences Unit, Dar es Salaam University College of Education (DUCE), PO Box 2329, Dar es Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Sikawa, Daniel" sort="Sikawa, Daniel" uniqKey="Sikawa D" first="Daniel" last="Sikawa">Daniel Sikawa</name><affiliation><nlm:aff id="Aff1">Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda Campus, PO Box 219, Lilongwe, Malawi</nlm:aff></affiliation></author><author><name sortKey="Kazembe, Abigail" sort="Kazembe, Abigail" uniqKey="Kazembe A" first="Abigail" last="Kazembe">Abigail Kazembe</name><affiliation><nlm:aff id="Aff4">University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25954507</idno><idno type="pmc">4423108</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423108</idno><idno type="RBID">PMC:4423108</idno><idno type="doi">10.1186/s40249-015-0053-1</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000878</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000878</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Extent of morbidity associated with schistosomiasis infection in Malawi: a review paper</title><author><name sortKey="Mtethiwa, Austin H N" sort="Mtethiwa, Austin H N" uniqKey="Mtethiwa A" first="Austin H N" last="Mtethiwa">Austin H N. Mtethiwa</name><affiliation><nlm:aff id="Aff1">Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda Campus, PO Box 219, Lilongwe, Malawi</nlm:aff></affiliation></author><author><name sortKey="Nkwengulila, Gamba" sort="Nkwengulila, Gamba" uniqKey="Nkwengulila G" first="Gamba" last="Nkwengulila">Gamba Nkwengulila</name><affiliation><nlm:aff id="Aff2">Zoology Department, University of Dar es Salaam, College of Natural and Applied Science, PO Box 35064, Dar es Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Bakuza, Jared" sort="Bakuza, Jared" uniqKey="Bakuza J" first="Jared" last="Bakuza">Jared Bakuza</name><affiliation><nlm:aff id="Aff3">Biological Sciences Unit, Dar es Salaam University College of Education (DUCE), PO Box 2329, Dar es Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Sikawa, Daniel" sort="Sikawa, Daniel" uniqKey="Sikawa D" first="Daniel" last="Sikawa">Daniel Sikawa</name><affiliation><nlm:aff id="Aff1">Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda Campus, PO Box 219, Lilongwe, Malawi</nlm:aff></affiliation></author><author><name sortKey="Kazembe, Abigail" sort="Kazembe, Abigail" uniqKey="Kazembe A" first="Abigail" last="Kazembe">Abigail Kazembe</name><affiliation><nlm:aff id="Aff4">University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi</nlm:aff></affiliation></author></analytic><series><title level="j">Infectious Diseases of Poverty</title><idno type="eISSN">2049-9957</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Data on the extent of the burden due to schistosomiasis is sparse in most Sub-Saharan African countries. However, this data is crucial for triggering medical attention. A review of extent of morbidity and determinants associated with schistosomiasis in Malawi was therefore conducted to quantify the infection in order to concretise the need for medical intervention. A systematic and traditional search strategy was used to find literature for the review, whilst exclusion and inclusion criteria were used to identify appropriate articles. Logistic regression curves of epidemiological model Y = (<italic>a</italic> + <italic>bx</italic><sup><italic>c</italic></sup>)/(1 + <italic>bx</italic><sup><italic>c</italic></sup>) and the recommendation that schistosomiasis prevalence can be used to estimate morbidity were employed to quantify morbidity at various infection stages. Morbidity was quantified as a direct proportion of the population and the respective national schistosomiasis prevalence. Findings showed that both S<italic>. mansoni</italic> and <italic>S. haematobium</italic> are present in Malawi with the latter highly prevalent (50%). Furthermore, out of the estimated population of 16,829 million, approximately 8.4 million have schistosomiasis, with about 4.4 million of these aged 18 years and below. The most frequent manifestation is Katayama syndrome, while ascites is the lowest, impacting about 3.0 million and 960 individuals, respectively. Localised studies on association of schistosomiasis infection to risk factors such as occupation, age and gender found odds ratio (OR) ranging from 1.29 to 5.37. Morbidity due to schistosomiasis is high in Malawi. It is therefore recommended that a more detailed study on the determinants of high schistosomiasis and re-evaluation of the current control measures be conducted if the current morbidity statistics are to be remarkably reduced.</p><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/s40249-015-0053-1) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Bowie, C" uniqKey="Bowie C">C Bowie</name></author><author><name sortKey="Purcell, B" uniqKey="Purcell B">B Purcell</name></author><author><name sortKey="Shaba, B" uniqKey="Shaba B">B Shaba</name></author><author><name sortKey="Makaula Perez, M" uniqKey="Makaula Perez M">M Makaula Perez</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kapito Tembo, Ap" uniqKey="Kapito Tembo A">AP Kapito-Tembo</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Infect Dis Poverty</journal-id><journal-id journal-id-type="iso-abbrev">Infect Dis Poverty</journal-id><journal-title-group><journal-title>Infectious Diseases of Poverty</journal-title></journal-title-group><issn pub-type="epub">2049-9957</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25954507</article-id><article-id pub-id-type="pmc">4423108</article-id><article-id pub-id-type="publisher-id">53</article-id><article-id pub-id-type="doi">10.1186/s40249-015-0053-1</article-id><article-categories><subj-group subj-group-type="heading"><subject>Scoping Review</subject></subj-group></article-categories><title-group><article-title>Extent of morbidity associated with schistosomiasis infection in Malawi: a review paper</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Mtethiwa</surname><given-names>Austin H N</given-names></name><address><email>amtethiwa@bunda.luanar.mw</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Nkwengulila</surname><given-names>Gamba</given-names></name><address><email>gamba@udsm.ac.tz</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Bakuza</surname><given-names>Jared</given-names></name><address><email>bakuzaj@duce.ac.tz</email></address><xref ref-type="aff" rid="Aff3"></xref></contrib><contrib contrib-type="author"><name><surname>Sikawa</surname><given-names>Daniel</given-names></name><address><email>danielsikawa@gmail.com</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Kazembe</surname><given-names>Abigail</given-names></name><address><email>kazembeabigail@kcn.unima.mw</email></address><xref ref-type="aff" rid="Aff4"></xref></contrib><aff id="Aff1"><label></label>Lilongwe University of Agriculture and Natural Resources (LUANAR), Bunda Campus, PO Box 219, Lilongwe, Malawi</aff><aff id="Aff2"><label></label>Zoology Department, University of Dar es Salaam, College of Natural and Applied Science, PO Box 35064, Dar es Salaam, Tanzania</aff><aff id="Aff3"><label></label>Biological Sciences Unit, Dar es Salaam University College of Education (DUCE), PO Box 2329, Dar es Salaam, Tanzania</aff><aff id="Aff4"><label></label>University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi</aff></contrib-group><pub-date pub-type="epub"><day>4</day><month>5</month><year>2015</year></pub-date><pub-date pub-type="pmc-release"><day>4</day><month>5</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>4</volume><elocation-id>25</elocation-id><history><date date-type="received"><day>15</day><month>6</month><year>2014</year></date><date date-type="accepted"><day>9</day><month>4</month><year>2015</year></date></history><permissions><copyright-statement>© Mtethiwa et al.; licensee BioMed Central. 2015</copyright-statement><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0">http://creativecommons.org/licenses/by/4.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><p>Data on the extent of the burden due to schistosomiasis is sparse in most Sub-Saharan African countries. However, this data is crucial for triggering medical attention. A review of extent of morbidity and determinants associated with schistosomiasis in Malawi was therefore conducted to quantify the infection in order to concretise the need for medical intervention. A systematic and traditional search strategy was used to find literature for the review, whilst exclusion and inclusion criteria were used to identify appropriate articles. Logistic regression curves of epidemiological model Y = (<italic>a</italic> + <italic>bx</italic><sup><italic>c</italic></sup>)/(1 + <italic>bx</italic><sup><italic>c</italic></sup>) and the recommendation that schistosomiasis prevalence can be used to estimate morbidity were employed to quantify morbidity at various infection stages. Morbidity was quantified as a direct proportion of the population and the respective national schistosomiasis prevalence. Findings showed that both S<italic>. mansoni</italic> and <italic>S. haematobium</italic> are present in Malawi with the latter highly prevalent (50%). Furthermore, out of the estimated population of 16,829 million, approximately 8.4 million have schistosomiasis, with about 4.4 million of these aged 18 years and below. The most frequent manifestation is Katayama syndrome, while ascites is the lowest, impacting about 3.0 million and 960 individuals, respectively. Localised studies on association of schistosomiasis infection to risk factors such as occupation, age and gender found odds ratio (OR) ranging from 1.29 to 5.37. Morbidity due to schistosomiasis is high in Malawi. It is therefore recommended that a more detailed study on the determinants of high schistosomiasis and re-evaluation of the current control measures be conducted if the current morbidity statistics are to be remarkably reduced.</p><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/s40249-015-0053-1) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Schistosomiasis</kwd><kwd>Morbidity</kwd><kwd>Risk factors</kwd><kwd>Quantification</kwd><kwd>Burden</kwd><kwd>Extent</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2015</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Multilingual abstracts</title><p>Please see Additional file <xref rid="MOESM1" ref-type="media">1</xref> for translations of the abstract into the six official working languages of the United Nations.</p></sec><sec id="Sec2" sec-type="introduction"><title>Introduction</title><p>There are both urinary and intestinal schistosomiasis present in Malawi, but their prevalences vary widely in space and magnitude [<xref ref-type="bibr" rid="CR1">1</xref>,<xref ref-type="bibr" rid="CR2">2</xref>]. Despite the existence of the disease, officially harmonised morbidity, mortality, or associated mortality and morbidity data are not readily available. This paper is a review of the relevant studies conducted on schistosomiasis in Malawi with special focus on morbidity, prevalence and determinants (risk factors, and knowledge, attitude and practices [KAP]) of the disease.</p><p>Malawi is a country located in Southern Africa and occupies an area of approximately 119,000 km<sup>2</sup>. It has an estimated population of 16,829 million [<xref ref-type="bibr" rid="CR3">3</xref>,<xref ref-type="bibr" rid="CR4">4</xref>]. The country is bordered by Zambia in the west, Tanzania in the north and northeast, and Mozambique in the east, south and southwest. It is subdivided into three administrative regions: Southern, Central and Northern [<xref ref-type="bibr" rid="CR3">3</xref>].</p><p>Schistosomiasis, also known as bilharziasis or bilharzia [<xref ref-type="bibr" rid="CR5">5</xref>], is one of the chronic parasitic diseases caused by digenetic trematodes of the genus <italic>Schistosoma</italic>. Humans can acquire it through contact with cercariae-infested freshwaters. It is endemic in 78 countries and is caused by at least seven schistosome species which include <italic>S. haematobium, S. mansoni, S. japonicum, S. intercalatum, S. malayensis, S. mekongi</italic> and <italic>S. sinensium</italic> [<xref ref-type="bibr" rid="CR5">5</xref>,<xref ref-type="bibr" rid="CR6">6</xref>]. <italic>Schistosoma haematobium</italic> and <italic>S. mansoni</italic> are the two species most endemic in Sub-Saharan Africa causing urinary and intestinal schistosomiasis, respectively [<xref ref-type="bibr" rid="CR7">7</xref>]. <italic>Bulinus</italic> and <italic>Biomphalaria</italic> species are the intermediate host snails for <italic>S. haematobium</italic> and <italic>S. mansoni</italic>, respectively [<xref ref-type="bibr" rid="CR8">8</xref>].</p><p>The life cycle requires surface freshwater in which the parasite eggs from infected humans will hatch into miracidia. The miracidia penetrate an appropriate aquatic snail where they mature into cercariae. The cercariae then leaves the snail and penetrates the human skin and develops inside the body to maturity [<xref ref-type="bibr" rid="CR9">9</xref>,<xref ref-type="bibr" rid="CR10">10</xref>]. The matured schistosomes have separate sexes and the male body has a groove where the female is held for the rest of its life, releasing fertilised eggs [<xref ref-type="bibr" rid="CR10">10</xref>]. Among the common signs, intestinal schistosomiasis causes fatigue, abdominal pain, diarrhoea and blood-stained stools, while urinary schistosomiasis causes dysuria, frequent urination and terminal haematuria [<xref ref-type="bibr" rid="CR11">11</xref>]. Schistosomiasis can be diagnosed microscopically by examining schistosome eggs in the stool (<italic>S. mansoni</italic>) or urine (<italic>S. haematobium</italic>) [<xref ref-type="bibr" rid="CR12">12</xref>]. In addition, urinary schistosomiasis can be detected by the presence of blood in the urine and intestinal schistosomiasis by blood in the stool [<xref ref-type="bibr" rid="CR9">9</xref>]. A number of the symptoms and signs of schistosomiasis infection are common to other diseases, and as such, it is not easy to isolate and estimate the extent to which schistosomiasis can cause morbidity in the human population [<xref ref-type="bibr" rid="CR13">13</xref>]. It is with this background that this review was conducted to quantify the morbidity due to schistosomiasis in Malawi.</p></sec><sec id="Sec3" sec-type="materials|methods"><title>Review</title><p>An integrated literature search, comprising traditional and systematic literature search and review approaches, was used. The retrieved literature was screened and synthesised according to a set of predetermined criteria. The systematic literature search was conducted using PubMed, Global Health, HINARI and World Health Organization (WHO) databases and relevant journals, whilst a traditional literature search collected information from different institutions, Google, bibliographies of identified papers and grey literature. Institutions that were consulted in Malawi included the Ministry of Health (MoH), the Bilharzia Control Programme office, College of Medicine Library and various individuals. A decision tree for inclusion and exclusion of articles was used, as described in [<xref ref-type="bibr" rid="CR14">14</xref>] and outlined in Figure <xref rid="Fig1" ref-type="fig">1</xref>.<fig id="Fig1"><label>Figure 1</label><caption><p>Decision tree showing inclusion and exclusion criteria for identifying of studies.</p></caption><graphic xlink:href="40249_2015_53_Fig1_HTML" id="MO1"></graphic></fig></p><sec id="Sec4"><title>Screening of relevant articles</title><p>Inclusion and exclusion criteria were used to select articles to include in the review. These were based on dates, languages, titles and content. The search included articles written in English between 1970 and 2014. Studies conducted either in Malawi or within the Malawi region, or with international coverage but that had relevant information to this review, were selected. Forty-six articles were identified and of these, 18 met the inclusion criteria. To identify relevant studies, text strings ‘<italic>Bulinus/Biomphalaria</italic> or Malawi’, ‘<italic>S. haematobium</italic> or Malawi’, ‘<italic>S. mansoni</italic> or Malawi’, ‘burden or Malawi’, ‘prevalence’, ‘Malawi’ or ‘<italic>schistosom</italic>*’ and ‘urinary’ or ‘Malawi’ were used.</p><p>Literature was screened in two phases. The first phase was based on titles and abstracts of the retrieved articles, whilst the second stage was applied to studies that passed the first phase and focused on content, methodology and outcomes. Full-text papers that passed the second stage were reviewed and interpreted against the objectives of this review. The final list of the identified studies/articles on schistosomiasis is outlined in Table <xref rid="Tab1" ref-type="table">1</xref>.<table-wrap id="Tab1"><label>Table 1</label><caption><p><bold>List of articles that met the inclusion criteria for the review</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>SN</bold></th><th><bold>Topic</bold></th><th><bold>Year</bold></th><th><bold>Region</bold></th><th><bold>Sample size</bold></th><th><bold>Burden (DALYs)</bold></th><th><bold>Morbidity</bold></th><th><bold>Mortality</bold></th><th><bold>Prevalence</bold></th></tr></thead><tbody><tr valign="top"><td>A1</td><td>Schistosomiasis Morbidity and management cases in Africa</td><td>2003</td><td>Africa (Review paper)</td><td>--</td><td>1.3</td><td>--</td><td>--</td><td>0-89</td></tr><tr valign="top"><td>A2</td><td>Global burden of diseases due to schistosomiasis</td><td>2003</td><td>World (Review paper</td><td>--</td><td>1.7</td><td>220,000</td><td>--</td><td>--</td></tr><tr valign="top"><td>A3</td><td>National survey on the prevalence of schistosomiasis and soil helminths in Malawi</td><td>2004</td><td>Malawi</td><td>1,664</td><td>--</td><td>--</td><td>--</td><td>6.9</td></tr><tr valign="top"><td>A4</td><td>Prevalence, distribution and risk factors of S. haematobium infection in schoolchildren in Blantyre Malawi</td><td>2009</td><td>Malawi, Blantyre</td><td>1,139</td><td>--</td><td>--</td><td>--</td><td>0-46</td></tr><tr valign="top"><td>A5</td><td>Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk</td><td>2006</td><td>Africa (review paper)</td><td>--</td><td>4.7</td><td>--</td><td>--</td><td>0-67</td></tr><tr valign="top"><td>A7</td><td>Schistosomiasis Control Programme - Community Health Surveillance Unit (1997–2001): Lakeshore Schistosomiasis Control Project.</td><td>2001</td><td>Malawi</td><td>--</td><td>--</td><td>--</td><td>--</td><td>40-50</td></tr><tr valign="top"><td>A8</td><td>Analysis of Schistosomiasis haematobium Infection Prevalence and Intensity in Chikhwawa, Malawi: An Application of a Two Part Model.</td><td>2013</td><td>Malawi, Chikhwawa</td><td>1642</td><td>--</td><td>--</td><td>--</td><td>14.3</td></tr><tr valign="top"><td>A9</td><td>2008 Population and housing census, Minister of Economic Planning and Development, National Statistical Office, Malawi.</td><td>2008</td><td>Malawi</td><td>~14,000,000</td><td>--</td><td>--</td><td>--</td><td>--</td></tr><tr valign="top"><td>A10</td><td>The schistosomiasis intermediate host <italic>Bullinus nyassanus</italic> is a preferred food for cichlid fish-<italic>Tramacranus placodon</italic> at Cape Maclear, Lake Malawi.</td><td>2006</td><td>Malawi, Mangochi</td><td>--</td><td>--</td><td>--</td><td>--</td><td></td></tr><tr valign="top"><td>A11</td><td>National Survey to find out difficulties people face in taking regular antischistosomal drugs in Malawi.</td><td>2003</td><td>Malawi</td><td>--</td><td>--</td><td>--</td><td>--</td><td>--</td></tr><tr valign="top"><td>A12</td><td>The burden of disease in Malawi.</td><td>2006</td><td>Malawi</td><td>--</td><td>--</td><td>--</td><td>--</td><td>--</td></tr><tr valign="top"><td>A13</td><td>Measuring the global burden of disease</td><td>2013</td><td>187 countries (A review paper)</td><td>--</td><td>1.7-4.7</td><td>--</td><td>--</td><td>0-67</td></tr><tr valign="top"><td>A14</td><td>Schistosomiasis in Lake Malawi</td><td>1994</td><td>Malawi</td><td>--</td><td>--</td><td>--</td><td>--</td><td>32</td></tr><tr valign="top"><td>A15</td><td>Schistosomiasis in Lake Malawi and the Potential Use of Indigenous Fish for Biological Control</td><td>2012</td><td>Malawi</td><td>487</td><td>--</td><td>--</td><td>--</td><td>43</td></tr><tr valign="top"><td>A16</td><td>Schistosomiasis in Lake Malawi Villages</td><td>2011</td><td>Malawi</td><td>487</td><td>--</td><td>--</td><td>--</td><td>94</td></tr><tr valign="top"><td>A17</td><td>Bulinus nyassanus is an intermediate host for Schistosoma haematobium in Lake Malawi</td><td>2001</td><td>Malawi</td><td>--</td><td>--</td><td>--</td><td>--</td><td>--</td></tr><tr valign="top"><td>A18</td><td>Sentinel surveillance of Lymphatic filariasis, Schistosomiasis, Soil transmitted helminths and Malaria in rural southern Malawi</td><td>2010</td><td>Malawi</td><td>1,903</td><td>--</td><td>--</td><td>--</td><td>94</td></tr></tbody></table></table-wrap></p></sec><sec id="Sec5"><title>Occurrence and prevalence</title><p>Schistosomiasis has been endemic in Malawi for decades [<xref ref-type="bibr" rid="CR15">15</xref>] and has been recognised for more than 80 years [<xref ref-type="bibr" rid="CR16">16</xref>]. Current statistics show high infection rates in children aged between five and 15 years, with prevalences of 90–100% in highly endemic areas. This is due to children’s higher exposure and dependence on the infected water bodies, as well as the fact that children are less resistant than adults because of the children’s low exposure to worm antigens [<xref ref-type="bibr" rid="CR17">17</xref>-<xref ref-type="bibr" rid="CR19">19</xref>]. Currently in Malawi, it is estimated that the national prevalence for schistosomiasis is between 40% and 50% [<xref ref-type="bibr" rid="CR17">17</xref>], as reported in [<xref ref-type="bibr" rid="CR18">18</xref>,<xref ref-type="bibr" rid="CR20">20</xref>]. However, other findings show that 80% of the Malawian population is at risk of infection with most of those infected living in rural areas [<xref ref-type="bibr" rid="CR17">17</xref>]. Research has shown that there has been a sharp increase in prevalence from the mid-1980 along the lakeshore areas of Lake Malawi [<xref ref-type="bibr" rid="CR21">21</xref>]. Furthermore, Chitipa, Karonga, Nkhata Bay, Kasungu, Nkhotakota, Salima, Mangochi, Machinga, Zomba, Chikwawa and Nsanje are districts that have recorded high prevalences [<xref ref-type="bibr" rid="CR22">22</xref>]. High prevalence rates are presumably enhanced by either their proximity to large water bodies (lakes and rivers), rice farming and sources of water for domestic use [<xref ref-type="bibr" rid="CR14">14</xref>]. Consequently, most of the districts in Malawi do not have local estimates [<xref ref-type="bibr" rid="CR2">2</xref>].</p><p>Literature further revealed that in Malawi, <italic>S. haematobium</italic> is highly prevalent and more predominant in the southern region, while <italic>S. mansoni</italic> is more prevalent in the central and the northern regions [<xref ref-type="bibr" rid="CR15">15</xref>]. This can be due to variations in the abundance and distribution of the <italic>Biomphalaria</italic> and <italic>Bulinus</italic> snail, which is an effect of selective introductions and climatic factors within different ecological zones [<xref ref-type="bibr" rid="CR23">23</xref>]. Multiple/mixed infections with <italic>S. haematobium</italic> and <italic>S. mansoni</italic>, hookworms and <italic>Ascaris</italic> have been reported in a number of studies, with a prevalence of about 12% [<xref ref-type="bibr" rid="CR1">1</xref>,<xref ref-type="bibr" rid="CR18">18</xref>]. However, prevalence in communal water reservoirs has not been adequately documented.</p></sec><sec id="Sec6"><title>The burden of schistosomiasis in Malawi</title><p>Recent global findings rank schistosomiasis as one the 25 leading diseases [<xref ref-type="bibr" rid="CR24">24</xref>]. In Malawi, schistosomiasis is among the top 20 diseases causing high outpatient attendances at health facilities [<xref ref-type="bibr" rid="CR22">22</xref>]. Beside this, the disease ranks second only to malaria among the parasitic diseases in terms of the number of people infected and at risk in endemic areas [<xref ref-type="bibr" rid="CR22">22</xref>,<xref ref-type="bibr" rid="CR25">25</xref>]. It leads to a loss of 1.7–4.5 million disability-adjusted life years (DALYs) in the world [<xref ref-type="bibr" rid="CR6">6</xref>]. Consequently, schistosomiasis contributes approximately 0.1% and 0.4% to the Sub-Saharan Africa and global disease burden, respectively [<xref ref-type="bibr" rid="CR13">13</xref>]. However, considering the large number of people that are infected, the small estimated contribution by schistosomiasis to the disease burden may not be a true reflection, and may be masked by the immerse burden of HIV/AIDS, malaria, childhood diseases, diarrhoeal diseases and tuberculosis [<xref ref-type="bibr" rid="CR13">13</xref>]. Furthermore, isolating morbidity caused by schistosomiasis from that caused by other diseases is complicated [<xref ref-type="bibr" rid="CR2">2</xref>]. One method to achieve this is to identify all diseases that cause a certain common morbidity in a population and treat each separately. The morbidity rate that remains can then be attributed to schistosomiasis. A complication again arises as some of the drugs are active against several morbidities and/or diseases. The burden of schistosomiasis has not been determined in Malawi using DALYs.</p><p>Based on the current population of 16 million and a schistosomiasis prevalence of 50% [<xref ref-type="bibr" rid="CR17">17</xref>,<xref ref-type="bibr" rid="CR20">20</xref>], it can be estimated that about eight million people are infected in Malawi. It further translates that about 7.2 million of the infected population are found in rural areas since about 90% of Malawians live in these areas [<xref ref-type="bibr" rid="CR3">3</xref>]. Approximately 4.2 million (52%) of the infected population is aged 18 years and below because 52% of the Malawi population is within that age range [<xref ref-type="bibr" rid="CR3">3</xref>]. The implication of this is that the country will end up with a sick, unproductive generation if schistosomiasis patients are not treated on time. Amongst school-age children, prevalence is higher in males than in females due to behavioural and occupational variabilities that lead to differences in the frequency of visits to water bodies. Studies have shown that those who frequent water bodies for various activities are at a higher risk of contracting the disease than their non-visiting counterparts [<xref ref-type="bibr" rid="CR2">2</xref>].</p></sec><sec id="Sec7"><title>Morbidity</title><p>Morbidity is a non fatal outcome while mortality is a fatal outcome of an ailment [<xref ref-type="bibr" rid="CR4">4</xref>,<xref ref-type="bibr" rid="CR13">13</xref>,<xref ref-type="bibr" rid="CR26">26</xref>]. Schistosomiasis morbidity exhibits in various stages, as shown in Table <xref rid="Tab2" ref-type="table">2</xref>.<table-wrap id="Tab2"><label>Table 2</label><caption><p><bold>Schistosomiasis morbidity at various infection stages</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Stage</bold></th><th><bold>Pathology</bold></th><th><bold>Morbidity due to</bold><bold><italic>S. mansoni</italic></bold></th><th><bold>Morbidity due to</bold><bold><italic>S. haematobium</italic></bold></th></tr></thead><tbody><tr valign="top"><td>Invasion</td><td></td><td>Cercarial dermatitis</td><td>Cercarial dermatitis</td></tr><tr valign="top"><td>Acute</td><td>As a result of antigens and metabolites excreted with egg production</td><td>Katayama fever, weakness, weight loss, headache, anorexia, nausea, vomiting, diarrhoea, dry cough, hepatosplenomegaly, bloody diarrhoea, urticaria, periorbital oedema, bronchospasm</td><td>Katayama fever, chills, weakness, weight loss, headache, haematuria, pain on micturition, urinary dribbling and incontinence,</td></tr><tr valign="top"><td><bold>Early</bold></td><td>Colonic focal fibrosis and granulomatous inflammation</td><td>(Bloody) diarrhoea, blood in stool, abdominal pain</td><td>haematuria</td></tr><tr valign="top"><td><bold>Early and late</bold></td><td></td><td>Anaemia</td><td></td></tr><tr valign="top"><td><bold>Late</bold></td><td>Portal hypertension</td><td>Hepatosplenomegaly ascites, oedema, oesophageal varices haematemesis, liver failure, corpulmonale</td><td>Bladder cancer, obstructive uropathy, hydronephrosis, renal parychyma impared, kidney disfunction</td></tr><tr valign="top"><td><bold>Subtle</bold></td><td>Ectopic lesions (CNS)</td><td>Convulsions, paralysis, reduction of growth, impaired cognitive development, reduced physical fitness</td><td>Uropathy, kidney failure</td></tr><tr valign="top"><td><bold>Mortality</bold></td><td>Portal hypertension</td><td>Liver failure, corpulmonale Haematemesis</td><td>Kidney failure, ascetic renal failure, bladder cancer, kidney necrosis</td></tr></tbody></table><table-wrap-foot><p>Source: [<xref ref-type="bibr" rid="CR9">9</xref>,<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR40">40</xref>,<xref ref-type="bibr" rid="CR41">41</xref>].</p></table-wrap-foot></table-wrap></p><p>Using a relationship (regression) model<sup>a</sup>: Y = (<italic>a</italic> + <italic>bx</italic><sup><italic>c</italic></sup>)/(1 + <italic>bx</italic><sup><italic>c</italic></sup>), which stipulates that prevalence of a specific morbidity is a function of prevalence of the national schistosomiasis infection [<xref ref-type="bibr" rid="CR26">26</xref>], and a recommendation that ‘prevalence of an infection is the only readily available epidemiological parameter that can be used to estimate morbidity’ [<xref ref-type="bibr" rid="CR13">13</xref>], the prevalence of a specific morbidity at each stage of schistosomiasis infection can be estimated. The proportion of individuals with a specific morbidity is estimated from the community or national prevalence rates, as outlined in Table <xref rid="Tab3" ref-type="table">3</xref>.<table-wrap id="Tab3"><label>Table 3</label><caption><p><bold>Estimates of morbidity ratios at respective schistosomiasis prevalence</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Morbidity/infection</bold></th><th><bold>0.15</bold></th><th><bold>0.50</bold></th><th><bold>0.85</bold></th></tr></thead><tbody><tr valign="top"><td colspan="4"><bold><italic>S. mansoni</italic></bold></td></tr><tr valign="top"><td>Katayama</td><td>0.012</td><td>0.002</td><td>0.091</td></tr><tr valign="top"><td>Diarrhoea</td><td>0.0001</td><td>0.001</td><td>0.072</td></tr><tr valign="top"><td>Blood stool</td><td>0.001</td><td>0.02</td><td>0.24</td></tr><tr valign="top"><td>Hepatomegaly (MSL)</td><td>0.01</td><td>0.07</td><td>0.14</td></tr><tr valign="top"><td>Hepatomegaly (MCL)</td><td>0.01</td><td>0.06</td><td>0.12</td></tr><tr valign="top"><td>Splenomegaly</td><td>0.011</td><td>0.047</td><td>0.089</td></tr><tr valign="top"><td>Haematemesis ever</td><td>0.002</td><td>0.006</td><td>0.011</td></tr><tr valign="top"><td>Ascites</td><td>0.0004</td><td>0.0012</td><td>0.0021</td></tr><tr valign="top"><td colspan="4"><bold><italic>S. haematobium</italic></bold></td></tr><tr valign="top"><td>Katayama</td><td>0.062</td><td>0.232</td><td>0.387</td></tr><tr valign="top"><td>Haematuria</td><td>0.031</td><td>0.197</td><td>0.349</td></tr><tr valign="top"><td>Incontinence</td><td>0.011</td><td>0.047</td><td>0.089</td></tr><tr valign="top"><td>Bladder cancer</td><td>0.01</td><td>0.06</td><td>0.12</td></tr><tr valign="top"><td>Kidney failure</td><td>0.01</td><td>0.07</td><td>0.14</td></tr></tbody></table><table-wrap-foot><p>Source: [<xref ref-type="bibr" rid="CR13">13</xref>,<xref ref-type="bibr" rid="CR24">24</xref>,<xref ref-type="bibr" rid="CR26">26</xref>].</p></table-wrap-foot></table-wrap></p><p>Based on the national prevalence of 50% and 10% for <italic>S. haematobium</italic> and S<italic>. mansoni</italic>, respectively [<xref ref-type="bibr" rid="CR2">2</xref>,<xref ref-type="bibr" rid="CR20">20</xref>], and subsequent proportions outlined in Table <xref rid="Tab3" ref-type="table">3</xref>, the number of individuals with specific schistosomiasis morbidity is estimated and presented in Table <xref rid="Tab4" ref-type="table">4</xref>. The estimates show that in Malawi, there are about 2.5 million people inflicted with Katayama and about two million with haematuria. However, Van der Werf [<xref ref-type="bibr" rid="CR26">26</xref>] estimated that 20% (3.2 million) of the Malawi population experience schistosomiasis-related dysuria and haematuria. The estimate by this study is lower than that estimated by Van der Werf [<xref ref-type="bibr" rid="CR26">26</xref>]. The difference could be as results of disease intervention over the 10 years after the estimate. Besides this, considering that 52% of Malawians are below 18 years of age, it can be said that more that half of those inflicted by these ailments are children. Mortality models are not available hence estimates of mortality caused by schistosomiasis could not be calculated.<table-wrap id="Tab4"><label>Table 4</label><caption><p><bold>Number of individuals with various</bold><bold><italic>S. haematobium</italic></bold><bold>and</bold><bold><italic>S. mansoni</italic></bold><bold>morbidity in Malawi at respective prevalence*</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Morbidity/infection</bold></th><th><bold>0.15</bold></th><th><bold>0.50</bold></th><th><bold>0.85</bold></th></tr></thead><tbody><tr valign="top"><td><bold><italic>S. haematobium</italic></bold></td><td></td><td></td><td></td></tr><tr valign="top"><td>Katayama</td><td></td><td>2,256,800</td><td></td></tr><tr valign="top"><td>Haematuria</td><td></td><td>1,654,800</td><td></td></tr><tr valign="top"><td>Incontinence</td><td></td><td>394,800</td><td></td></tr><tr valign="top"><td>Bladder cancer</td><td></td><td>504,000</td><td></td></tr><tr valign="top"><td>Kidney failure</td><td></td><td>588,000</td><td></td></tr><tr valign="top"><td><bold><italic>S. mansoni</italic></bold></td><td></td><td></td><td></td></tr><tr valign="top"><td>Katayama</td><td>126,219</td><td></td><td></td></tr><tr valign="top"><td>Diarrhoea</td><td>2,520</td><td></td><td></td></tr><tr valign="top"><td>Blood stool</td><td>2,520</td><td></td><td></td></tr><tr valign="top"><td>Hepatomegaly (MSL)</td><td>27,768</td><td></td><td></td></tr><tr valign="top"><td>Hepatomegaly (MCL)</td><td>27,768</td><td></td><td></td></tr><tr valign="top"><td>Splenomegaly</td><td>27,768</td><td></td><td></td></tr><tr valign="top"><td>Haematemesis ever</td><td>5,048</td><td></td><td></td></tr><tr valign="top"><td>Ascites</td><td>1,009</td><td></td><td></td></tr></tbody></table><table-wrap-foot><p>*Morbidity = morbidity ratio (at respective national schistosomiasis prevalence) x number of individual infected by schistosomiasis.</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec8"><title>Control strategies for schistosomiasis</title><p>A number of measures are employed aimed at preventing new infections, usually by interrupting the parasite’s life cycle [<xref ref-type="bibr" rid="CR27">27</xref>]. This has been done by using methods that either eliminate the intermediate host or the parasite from the definitive host, or prevent infection of the definitive host or of the intermediate host [<xref ref-type="bibr" rid="CR9">9</xref>,<xref ref-type="bibr" rid="CR21">21</xref>,<xref ref-type="bibr" rid="CR22">22</xref>,<xref ref-type="bibr" rid="CR28">28</xref>]. Apart from the chemotherapy intervention, an integrated approach is employed where several control measures are combined. An essential component of the integrated control strategy, as outlines by the WHO, is the provision of ultimate health care to patients in hospitals [<xref ref-type="bibr" rid="CR29">29</xref>].</p><sec id="Sec9"><title>Elimination of intermediate host snails</title><p>In Malawi, there is sketchy information on the biological and chemical approaches for the control of the intermediate host snail. Biologically, the <italic>Trematocranus placodon</italic> fish of the family <italic>Cichlidae,</italic> which feeds on <italic>Bulinus</italic> and <italic>Biomphalaria</italic> snails species, has been studied and used to control snails on an experimental basis, however, results have not been remarkable [<xref ref-type="bibr" rid="CR21">21</xref>,<xref ref-type="bibr" rid="CR30">30</xref>]. Decline in the <italic>T. placodon</italic> population due to heavy artisanal fishing and its possible preference for soft foods to snails have been indicated as the setbacks for the success of the intervention [<xref ref-type="bibr" rid="CR30">30</xref>]. Unless research on this is intensified, its application in the field in Malawi remains uncertain.</p><p>Use of molluscicides in Malawi has been largely on individual farms, especially fishponds, with no formal documentation on its implementation, coverage and success. Whilst this approach may be reliable, it has portrayed a number of major shortfalls among which are severe toxicity non-target soft bodied aquatic organisms [<xref ref-type="bibr" rid="CR31">31</xref>]. Niclosamide is the only commercially available molluscicides recommended by the WHO for large-scale use in schistosomiasis control programmes [<xref ref-type="bibr" rid="CR27">27</xref>,<xref ref-type="bibr" rid="CR32">32</xref>].</p></sec><sec id="Sec10"><title>Chemotherapy</title><p>In Malawi, 60% of the health services are provided by the Ministry of Health and Population, 37% by the Christian Health Association of Malawi (CHAM), 1% by the Ministry of Local Government and 2% by other providers [<xref ref-type="bibr" rid="CR3">3</xref>,<xref ref-type="bibr" rid="CR22">22</xref>]. Chemotherapeutically, praziquantel has been used for years to treat and control schistosomiasis in Malawi. However, studies have shown that 30% of the population cannot access the drug [<xref ref-type="bibr" rid="CR22">22</xref>]. This is because the drug is either not available at government health units, is expensive in the private pharmacies, or that long distances discourage and preclude people from getting to the government health units where the drug is provided [<xref ref-type="bibr" rid="CR22">22</xref>,<xref ref-type="bibr" rid="CR30">30</xref>]. Beside this, like in other countries, free drugs are mostly available to school children only [<xref ref-type="bibr" rid="CR22">22</xref>,<xref ref-type="bibr" rid="CR33">33</xref>]. Despite this, the Malawi National Schistosomiasis Control Programme does not have well-documented evidence of when and where the universal drug treatment has been offered [<xref ref-type="bibr" rid="CR1">1</xref>]. One of the problems with this approach is re-infection that can happen after visiting the cercariae-infested waters after treatment, a probable problem in the country.</p></sec></sec><sec id="Sec11"><title>Social determinants of schistosomiasis infection</title><p>The community’s knowledge, attitudes and practices (KAP) and risk factors influence acquisition, transmission and thus persistence of schistosomiasis in the community [<xref ref-type="bibr" rid="CR34">34</xref>]. As such, a good understanding of local KAP is central to the development of effective control measures that would thwart further transmission [<xref ref-type="bibr" rid="CR15">15</xref>]. Communities, especially children, lack understanding on the transmission of schistosomiasis [<xref ref-type="bibr" rid="CR15">15</xref>,<xref ref-type="bibr" rid="CR33">33</xref>]. In Tanzania, for instance, the prevalence of the disease remained as high as 62%, although 82% of the children were treated for it [<xref ref-type="bibr" rid="CR35">35</xref>]. This may be attributed to a lack of knowledge on the transmission of schistosomiasis and unchanged behaviour in many of the school children [<xref ref-type="bibr" rid="CR35">35</xref>,<xref ref-type="bibr" rid="CR36">36</xref>].</p><p>Studies have unveiled that communities perceive schistosomiasis as a normal physiological development in growing children, a disease that recurs however you treat it, a disease for males, a sexually transmitted disease and as a disease better treated with herbs [<xref ref-type="bibr" rid="CR34">34</xref>,<xref ref-type="bibr" rid="CR35">35</xref>,<xref ref-type="bibr" rid="CR37">37</xref>]. In light of these attitudes, it is unlikely that patients will seek treatment from hospitals [<xref ref-type="bibr" rid="CR33">33</xref>]. In essence, KAP on schistosomiasis has not been adequately studied in Malawi.</p><sec id="Sec12"><title>Risk factors</title><p>Localised studies in Malawi identified occupation, age, education, gender, socioeconomic status, proximity and frequency of visits to water bodies or sources of water as common risk factors [<xref ref-type="bibr" rid="CR2">2</xref>,<xref ref-type="bibr" rid="CR18">18</xref>]. Furthermore, studies found a strong association of prevalence and risk factors, with an OR ranging from 1.72 to 5.39 [<xref ref-type="bibr" rid="CR2">2</xref>]. These findings mean that these factors would determine the level of acquisition of schistosomiasis in Malawi.</p></sec><sec id="Sec13"><title>Snail intermediate hosts</title><p>The distribution of schistosomiasis is determined, to a larger extent, by the presence or absence of snail intermediate hosts [<xref ref-type="bibr" rid="CR23">23</xref>]. In Malawi, <italic>Biomphalaria</italic> and <italic>Bulinus</italic> have been identified, and at least studied, in the Lake Malawi ecosystems [<xref ref-type="bibr" rid="CR38">38</xref>]. <italic>Bulinus nyassanus</italic>, one of the intermediate host for <italic>S. haematobium</italic> [<xref ref-type="bibr" rid="CR39">39</xref>] is endemic to Lake Malawi and is found on open sandy areas without macrophytes, usually buried 2–3 cm into the gravel. Another snail that is an intermediate host for <italic>S. haematobium</italic> and is most common among aquatic plants is <italic>B. globosus.</italic> Although it is uncommon in Lake Malawi, it has been reported in several sites in the lake, especially near inflowing streams [<xref ref-type="bibr" rid="CR39">39</xref>]. However, there is scanty information on the distribution, seasonality and infectivity of host snails in the communal water reservoirs.</p></sec></sec></sec><sec id="Sec14" sec-type="conclusion"><title>Conclusion</title><p>This review has unveiled alarming schistosomiasis morbidity statistics in Malawi amidst years of chemotherapeutical intervention. It has further revealed that risk factors, and knowledge, attitude and practices on schistosomiasis have not been adequately explored. It is expected that more information about the disease in the country will be disclosed as more studies are being conducted. Re-evaluation of the current control measures and implementation of integrated targeted and effective schistosomiasis control measures are recommended if the current morbidity statistics are to be remarkably reduced.</p><sec id="Sec15"><title>Study limitations</title><p>Whilst every effort was made to gather all the relevant documents and information, a number of grey literatures on KAP for the study, including those conducted by the Danish Bilharzia Laboratory around the 1990s, could not be accessed. This is because the literature is not readily available in the public domain. However, since this review mostly focused on the quantification of morbidity and the rest of the information is only supportive, the absence of this literature would not significantly change the outcome of this review.</p></sec></sec><sec id="Sec16"><title>Endnote</title><p><sup>a</sup><italic>Y</italic> denotes specific morbidity; <italic>x</italic> denotes schistosomiasis infection; <italic>a</italic> denotes prevalence due to other diseases; <italic>b</italic> and <italic>c</italic> denote degree of association where <italic>b</italic> = (<italic>c</italic>–1)/(c + 1)<italic>.</italic></p></sec></body><back><app-group><app id="App1"><sec id="Sec17"><title>Additional file</title><p><media position="anchor" xlink:href="40249_2015_53_MOESM1_ESM.pdf" id="MOESM1"><label>Additional file 1:</label><caption><p><bold>Multilingual abstracts in the six official working languages of the United Nations.</bold></p></caption></media></p></sec></app></app-group><fn-group><fn><p><bold>Competing interests</bold></p><p>This work stems from PhD research conducted on ‘determinants for burden of schistosomiasis in Malawi’. The Consortium for Advanced Research and Training in Africa (CARTA) and the Lilongwe University of Agriculture and Natural Resources (LUANAR) funded the research. These have no conflicting interest on the research. The authors declare that they have no competing interests.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>The first author, AM, designed the review, carried out the literature search and drafted the first version of the paper. All authors read, extensively contributed and approved the paper.</p></fn></fn-group><ack><title>Acknowledgements</title><p>This research was supported by the Consortium for Advanced Research Training in Africa (CARTA), which is jointly led by the African Population and Health Research Centre and the University of the Witwatersrand, and funded by the Wellcome Trust (UK) (Grant No: 087547/Z/08/Z), the Department for International Development (DFID) under the Development Partnerships in Higher Education (DelPHE), the Carnegie Corporation of New York (Grant No: B 8606), the Ford Foundation (Grant No: 1100–0399), Google.org (Grant No: 191994), Sida (Grant No: 54100029) and the MacArthur Foundation (Grant No: 10-95915-000-INP).</p><p>We sincerely appreciate the support from the Lilongwe University of Agriculture and Natural Resources (LUANAR) for co-funding the research from which this work stemed, and also permitting us to access their libraries and using their internet to access online articles.</p></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bowie</surname><given-names>C</given-names></name><name><surname>Purcell</surname><given-names>B</given-names></name><name><surname>Shaba</surname><given-names>B</given-names></name><name><surname>Makaula Perez</surname><given-names>M</given-names></name></person-group><article-title>A national survey of the prevalence of schistosomiasis and soil transmitted helminths in Malaŵi</article-title><source>BMC Infect Dis</source><year>2004</year><volume>4</volume><fpage>49</fpage><pub-id pub-id-type="doi">10.1186/1471-2334-4-49</pub-id><pub-id pub-id-type="pmid">15546483</pub-id></element-citation></ref><ref id="CR2"><label>2.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kapito-Tembo</surname><given-names>AP</given-names></name><name><surname>Mwapasa</surname><given-names>V</given-names></name><name><surname>Meshnick</surname><given-names>SR</given-names></name><name><surname>Samanyika</surname><given-names>Y</given-names></name><name><surname>Banda</surname><given-names>D</given-names></name><name><surname>Bowie</surname><given-names>C</given-names></name><etal></etal></person-group><article-title>Prevalence distribution and risk factors for schistosoma hematobium infection among school children in Blantyre, Malawi</article-title><source>PLoS Negl Trop Dis</source><year>2009</year><volume>3</volume><issue>1</issue><fpage>e361</fpage><pub-id pub-id-type="doi">10.1371/journal.pntd.0000361</pub-id><pub-id pub-id-type="pmid">19156193</pub-id></element-citation></ref><ref id="CR3"><label>3.</label><mixed-citation publication-type="other">GoM-NSO. 2008 Population and housing census, Minister of Economic Planning and Development, National Statistical Office, Malawi. 2008.</mixed-citation></ref><ref id="CR4"><label>4.</label><mixed-citation publication-type="other">Malawi Population 2014. <ext-link ext-link-type="uri" xlink:href="http://worldpopulationreview.com/countries/malawi-population/">http://worldpopulationreview.com/countries/malawi-population/</ext-link><italic>,</italic> 2014.</mixed-citation></ref><ref id="CR5"><label>5.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Muller</surname><given-names>R</given-names></name></person-group><source>Worms and human disease</source><year>2002</year><publisher-loc>New York</publisher-loc><publisher-name>CABI Publishing</publisher-name></element-citation></ref><ref id="CR6"><label>6.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Olveda</surname><given-names>DU</given-names></name><name><surname>Li</surname><given-names>Y</given-names></name><name><surname>Olveda</surname><given-names>RM</given-names></name><name><surname>Lam</surname><given-names>AK</given-names></name><name><surname>Chau</surname><given-names>TN</given-names></name><name><surname>Harn</surname><given-names>DA</given-names></name><etal></etal></person-group><article-title>Bilharzia: Pathology, Diagnosis, Management and Control</article-title><source>Trop Med Surg</source><year>2013</year><volume>1</volume><issue>4</issue><fpage>1</fpage><lpage>9</lpage><pub-id pub-id-type="doi">10.4172/2329-9088.1000135</pub-id></element-citation></ref><ref id="CR7"><label>7.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Despommier</surname><given-names>D</given-names></name><name><surname>Gwadz</surname><given-names>R</given-names></name><name><surname>Hotez</surname><given-names>P</given-names></name></person-group><source>Book on parasitic diseases. 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