Rabies

1

• A 10-year-old boy was brought to the ED because
  of abdominal pain.
• The family had arrived in the United States from
  Yemen just the day before presentation
• The boy had crampy abdominal pain for 1 month
  (mid-epigastric region).
• Although there was intermittent abdominal
  distention, he had no fever, nausea, vomiting,
  diarrhea, constipation or gross blood in the
  stools.
• The child had lost 20 pounds during this time.

2

• PMH
• Received immunizations, but no documentation was
  available
• No hospitalization or surgery
• History of contact with cows and goats and a
  questionable consumption of unpasteurized milk.
• The water supply was reportedly clean
• No history of swimming in fresh water.
• The patient walked barefoot outside.
• No household members had similar symptoms.

3

• Physical examination
• A thin, cooperative boy in no acute distress. V/S
  were NL.
• HN normal. No lymphadenopathy
• Heart regular rate and rhythm, with no murmurs.
• The lungs were clear to auscultation bilaterally.
  
• The abdomen was soft, but mildly distended, and
  bowel sounds were present. There was no rebound
  tenderness, guarding, ascites or masses. The
  liver was nontender and smooth, with the edge
  palpable 8 cm below the right costal margin. The
  spleen was not palpable.
• The rest of the physical examination was
  unremarkable.

4

• Labs
• WBC 15 000/mm3 (4 bands, 8N, 41 L, 2 M, 44
  E and 1 B).
• HB 12.9 g/dl, platelet count was 494K
• Serum electrolytes, coagulation profile, liver
  enzymes, bilirubin and urine analysis were
  normal.
• Computed tomography of the abdomen showed
  hepatomegaly.
• Esophagogastroduodenoscopy revealed esophagitis,
  but no varices.

5

• Hepatitis A and hepatitis B serology indicated
  past infection.
• Hepatitis C IgG negative.
• Serum immunoglobulins
• Normal IgM,
• Slightly elevated IgA and IgG.
• IgE was 23 010 IU/ml, 10 times the upper end of
  normal (normal 1 to 240 IU/ml).

6

• Serology for Toxocara species and Trichinella
  spiralis was negative.
• Filariasis was excluded.
• There were no ova or parasites in the stools on
  three separate occasions.
• Stool and urine examinations were negative for
  schistosomiasis.
• The diagnosis was made only after a more invasive
  study.

7

• Because this boy had
• Persistent gastrointestinal complaints
• Came from an endemic area
• Walked barefoot
• Had eosinophilia
• Extremely elevated serum IgE value,
  schistosomiasis was suspected and a rectal biopsy
  was done.

8

• The biopsy showed ellipsoid eggs, each with a
  lateral spine, characteristic of Schistosoma
  mansoni . Pediatr Infect Dis J. 1999
  Jun18(6)556, 572-3

9
Schistosomiasis

• Nahed Abdel-Haq, M.D
• Division of Infectious Diseases
• Childrens Hospital of Michigan

10
                                                
                   Editorial
Mind over matter Heroes overcome special needs  
                        Chris Burke A hero
with trisomy-21.
A question was raised by many of The Ambassadors
Magazine's readers. Why not dedicate an issue of
the MEGASTARS section to people with special
needs? In previous issues we've focused on and
reported several stories about individuals who
have succeeded over debilitating ailments to
accomplish, in some cases, remarkable
achievements. One such story was that of Goodwill
Ambassador for the National Down Syndrome
Society, Chris Burke. Other notables with
trisomy-21 whose lives were explored in the pages
of the Ambassadors include Nigel Hunt
(England), Sheenagah Hardie (Scotland) and Omar
A. Al-Awadi (Kuwait). This issue's feature story
is no different. This time we look at 1.5 million
Americans who are affected by short stature and
some of their achievements in all facets of life
despite all obstacles. This section, however, is
reserved for a tribute to a selection of persons
across time and place who have defeated their
'special needs' and proved that resilience and
ambition can help conquer most obstacles.   Presid
ent Franklin D. Roosevelt defeating poliomyelitis
                           President FDR with
Eddie Cantor
President Franklin D. Roosevelt (FDR), himself a
polio survivor, was confined to a wheelchair most
of his later years. However, this obstacle didn't
stop him from pursuing and achieving the highest
seat in the nation. A much-loved, politician,
strategic tactician, able diplomat and devoted
leader, FDR dedicated much of his efforts to
supporting polio research, raising in 1937
1-million at the annual Presidential ball alone.
Roosevelt's friend, celebrity Eddie Cantor,
recommended that he continue the fund-raising by
asking each American to contribute a dime "The
March of Dimes." And so, in one of FDR's famous
weekly radio addresses, he asked each citizen to
send a dime to the White House to help fund
polio-research. 1938, Roosevelt created the
National Foundation of Infantile Paralysis (March
of Dimes), was the name used for the fund-raising
itself and the foundation mission was to prevent
and cure polio. The foundation supported the
discovery of both Salk Sabin's vaccines for
polio prophylaxis. The March of Dimes foundation
continued its medical research towards other
disabling conditions, as a result of which, ten
of its scientists have become Noble Prize
laureates. President FDR, who was stricken with
the polio virus when he was 39, affecting both
his lower limbs causing flaccid paraplegia,
succeeded to regain the use of his legs through
swimming. As a direct result of FDR's initiative,
polio is now vanishing all over the world. Eng
and Cheng The Famous Siamese Twins
(1811-1874) Few birth defects have become as
sensationalized more than Siamese twins, and none
more popularized than the astonishing story of
Eng and Cheng. On May 11, 1811 Chang and Eng were
born in China, where there was much excitement
among the midwives and neighbors attending the
historic birth when they learned that the twins
were connected by a short, flexible, fleshy band
or ligament, breastbone to breastbone. It wasn't
long before the initial excitement turned to
fright and no one would touch them. However,
their mother appears to have been quite sensible.
She untwisted them and straightened the band, and
bathed them. Thus began the life of the famous
conjoined twins who gave the world the term
"Siamese twins". The consensus among the doctors
was that the twins could not be separated..
                                            Sal
lie, Eng, Cheng, Adelaide, and sons Patrick
Henry and Albert (1865).
Chang and Eng moved to USA and soon became good
friends with a neighbor, and eventually married
two of his daughters (Sallie and Adelaide).
Originally they setup housekeeping in one house,
but as the children started coming, one household
was not big enough. Chang and Adelaide had ten
children. Eng and Sallie had eleven children.
Eventually they moved into separate houses
spending three days at each other's house. In
January 1874, Chang died during the night. The
next morning, Sallie sent one of the children
racing to get Dr. Hollingsworth to separate Eng
from Chang. A formerly healthy Eng complained of
being "very bad off." He was rational but
terrified and complained of agonizing pain and
distress, especially in his limbs. Finally, he
lapsed into a coma-like stupor. An hour later, he
died at 63 years of age. The uniqueness of End
and Cheng's story and their ability to forge
somewhat normal lives is in itself a remarkable
achievements. The Blind Mountain-climber Erik
Weihenmayer
                             Erik Weihenmayer
(left)
Abdel-Halim Hafez, the popular Arabic musician
and singer
Napoleon after coronation as Emperor of France 
What could they have in common? Akhnaton, was
allegedly diagnosed with bilharziasis or
schistosomiasis.  Some also mentioned that
Napoleon Bonaparte was infected with this
parasite after swimming in Egypt. The famous
Egyptian singer, Abdel Halim Hafez died with
complications of this disease
On June 18, 2001, TIME magazine chose 33-year-old
to be the subject of a special feature story and
put the blind hero on its issue cover. For some
persons just crossing the street can be a risky
venture. Erik Weihenmayer, who was the victim of
a rare hereditary disease of the retina
(retinoschis), causing his blindness since he was
thirteen. This year Erik became the first
sightless person to scale Mount Everest's killer
peak, a heroic accomplishment by every measure.
Plenty of sighted people walk through life with
less poise and grace than Erik, unsure of their
steps, and second-guessing their every move. On
his Everest climb, Erik humbly exclaims that "If
a blind guy can do it, anyone can." But even the
many able-sighted weren't as lucky as Erik.
Almost 90 of Everest climbers have failed to
reach the summit. Horrifyingly, since 1953, at
least 165 never returned from the climb. Erik and
his wife Ellie and their one-year-old daughter,
Emma, celebrated his climb. Akhnaton, Napoleon,
and Abdel Halim Hafez
An ancient Egyptian pharaoh, a French emperor and
an Arabic musical icon. What could they have in
common? The Ancient Egyptian Pharaoh, Akhnaton,
was allegedly diagnosed with "AAA-disease" (known
as bilharziasis or schistosomiasis).  This
endemic parasitic disease was first described in
Cairo by the German scientist, Theodor Bilharz in
1851. Some also mentioned that Napoleon Bonaparte
was infected with this parasite after swimming in
Egypt. It is well known that the famous Egyptian
singer, Abdel Halim Hafez died with complications
of this disease. Bilharziasis has high 
prevalence among rural farmers and can cause
liver cirrhosis, enlarged spleen, cancer bladder,
etc. With the disease's victims dating back 4,000
years, the Egyptian government launched a mass
campaign headed by Prof. Ismail Sallam (Minister
of Health and Population) to eradicate the
disease. During my recent visit to Egypt to offer
lectures to family doctors in four provinces, I
found that the prevalence of bilharziasis in
Munofia province has dropped to less than 2. Our
sincere congratulations and acknowledgement to
all those who have contributed to this
campaign.   By  presenting the brief stories of
persons with different special needs, from
Akhnaton to Roosevelt it is clear that a dream
can conquer any and all involuntary limitations.
We have to search together in order to find
preventive tools for all environmental and
genetic problems which could affect our children
and grandchildren while continuing to encourage
those around us who suffer with such ailments to
aspire and dream. Below, I have borrowed from the
words of the acknowledged poet Hala El-Banna to
inspire us all to search the depths for the
pearls within I'll keep searching in the deepest
ocean,I'll keep looking everywhere I go,I'll
keep hoping for that ray of lightthe one
that'll brighten my days and nights.I'll keep
dreaming, for maybe one dayI'll reach a long
sought dreamAnd turn abstract into concrete
             The Ambassadors
11
Schistosomiasis

• Described by Theodore Bilharz in Cairo in 1851
  (Bilharzia)
• 200 M people in 74 countries
• 120 M have symptoms
• 20 M have severe illness
• Despite control programs continues to spread
• Reports of R to praziquantil
• Allen GP et al. NEJM 2002, Volume 3461212-1220

12
Schistosomiasis is second only to malaria in
human impact among tropical diseases and is the
third most prevalent parasitic disease in the
world.
13
Schistosomiasis/Etiology

• Human disease caused mainly by 3 species of flat
  worms
• S. mansoni most common (Africa), intestinal
  disease
• S. japonicum Asia, Pacific, intestinal disease
• S. haematobium affects 54 countries in Africa
  and the Middle East, urinary disease

14
Schistosomiasis/Unusual species

• S. mekongi disease mainly in the Mekong river
  basin,
• Related to S. japonicum
• Disease is similar, milder
• S. intercalatum in central Africa
• Similar to S. manosoni but milder
• S. mattheei and S. bovis mainly animals

15
Schistosomiasis/Distribution

• Schistosoma haematobium, S. mansoni and S.
  intercalatum infections in sub-Saharan Africa
• S. mansoni remains endemic in parts of Brazil,
  Venezuela and the Caribbean
• S. japonicum still occurs in China, Indonesia
  the Philippines
• S. makongi Cambodia Laos (Mekong River)

16
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17
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18
Schistosomiasis/Epidemiology

• Humans are principal hosts for major species
• Intermediate host is the snail
• Appropriate snail is required for maintaining the
  cycle
• Eggs excreted in stools S. mansoni, S. japonicum
• Eggs excreted in urine S. haematobium
• Eggs hatch in fresh water into motile miracidia
  which infect snails

19
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20
Life Cycle of the Schistosome Allen GP et al.
NEJM 2002, Volume 3461212-1220
21
Adult worms males/females
Cercariae infectious stage
22
In endemic areas, most at risk are school-age
children, women, and those involved in
occupations such as irrigation, farming and
fishing.
23
Epidemiology/travelers

• Most in travelers to Africa
• Swimming, wading, bathing in fresh water in areas
  of poor sanitation, snail hosts
• Most cases are in swimmers in
• Lake Malawi
• Lake Kariba
• Zambezi River
• Present with acute schsitosomiasis
• Common early symptoms hematurea, diarrhea
• Rare transverse myelitis

24
Epidemiology/Immigrants

• Immigrants from endemic areas may remain
  infected for 30-40 yrs
• Average life span of schistosome is 5 yrs
• Adult worms may live for decades
• Not notifiable disease in US
• True incidence in immigrants, returned travelers
  is unknown

25
Epidemiology/Animals

• Various animals, such as dogs, cats, rodents,
  pigs, horses and goats, serve as reservoirs for
  S. japonicum, and
• Dogs for S. mekongi 
• Variants in birds

26
Susceptibility

• HLA class I and II antigens more severe
  manifestations of the disease
• HLA-B16 and Cw2 S. haematobium associated
  bladder CA in Egypt
• HLA-DR, DQ, DP protection from hepatic fibrosis
• Advanced fibrosis is related to gamma-interferon
  receptor gene on chromosome 6
• Resistance to re-infection 5q31-q35

27
Schistosomiasis/clinical manifestations

• Maculopapular eruption at site of penetration of
  cercariae
• Develops few hours after infection
• May develop up to one week later
• Similar but less severe than swimmers itch

28
Schistosomiasis/clinical manifestations

• Swimmers itch sensitized individuals exposed to
  non-human schistosomes
• Various avian and mammalian schistosomes cause
  the reaction
• Mild-moderate pruritus at penetration site in few
  hours
• Intermittent pruritus, papular eruption in 5-14 d
• The cycle of infection is not completed in
  humans no systemic complications

29
Acute Schistosomiasis/Katayama Fever

• Areas with high transmission rates
• Immune complex-mediated reaction
• Deposition of eggs in tissues
• Contaminated water exposure 14-84 days earlier
• All patients have eosinophilia
• Not all shed eggs

30
Acute Schistosomiasis/Katayama Fever

• Fever, headache, generalized myalgias
• Right upper quadrant pain, tender hepatomegaly
• Bloody diarrhea
• Respiratory symptoms 70 S. mansoni
• Interstitial pneumonia (radiologic)
• Splenomegaly 30
• Aseptic meningitis

31
Chronic Schistosomiasis

• A results of host immune response to schistosome
  eggs
• Granulomatous reaction to secreted Ag/fibrosis
• Severity depends on
• Amount of Ag release (severity duration)
• Intensity of fibro-obstructive disease
• Granulomas at sites of maximum egg deposition
• S. mansoni S. japonicum intestine liver
• S. haematobium genitourinary tract

32
Chronic Schistosomiasis

• Granulomas may develop in other organs
• Skin
• Lungs
• Brain
• Adrenal glands
• Skeletal muscles
• The inflammatory response assist in migration of
  the eggs to the lumen (GI,UB)
• Egg output is low in immundeficient pts

33
Chronic SchistosomiasisGI

• Gut wall inflammation, hyperplasia, ulcers,
  microabscesses, polyposis
• Colicky pain lower abdomen, left iliac fossa
• Diarrhea common, constipation
• Blood occult, gross
• Colonic, rectal stenosis
• Colonic polyposisprotein-losing enteropathy
• Colorectal CA risk small if any

34
Chronic SchistosomiasisLiver

• Embolization of eggs to the liver
• S. mansoni and S. japonicum
• Presiusoidal inflammation, periportal fibrosis
• Incidence 4-8 of pts
• Takes yrs, heavy infection
• Hepatomegaly granulomatous inflamm., early
• Periportal collagen
• Obstruct blood flow
• Portal hypertension
• Varices, bleeding, splenomegaly

35
Chronic SchistosomiasisLiver

• Periportal fibrosis seen by US, CT, MRI
• Liver synthetic function is preserved until late
• Lobular architecture is retained
• No nodular regenerative hyperplasia
• Quantification of hepatosplenic disease
  clinical, US criteria by WHO
• S. haematobium occasional colonic, hepatic
  disease

36
Chronic SchistosomiasisLiver

• Coinfection with HBV, HCV may occur
• S. mansoni accelerated deterioration
• Higher risk of hepatocellular CA (HBV)
• S. japonicum no significant interaction
• EGYPT
• Mass campaign of parenteral therapy for
  schstosomiasis
• High prevalnce of HCV in the country widespread
  reuse of needles

37
The abdomen of an 11-year-old boy with intestinal
schistosomiasis with the size and extent of the
liver and spleen marked, indicating the severity
of infection. The disease has caused a stunting
of the boy's growth, he is only 120cms tall and
weighs 22 kg. WHO
38
Lancet Infect Dis. 2004 Aug4(8)498. Clinical
picture Schistosomal appendicitis Eric Adehossi
and Philippe Parola    ,    Service des
Maladies Infectieuses et Tropicales, CHU Nord,
Marseille, France  
A 24-year-old African man recently emigrated to
France from Sierra Leone was admitted to the
department of surgery of our hospital for a 2-day
history of acute abdominal pain. Physical
examination of the abdomen revealed right iliac
fossa tenderness and guarding, and peritonism.
Standard blood haematology and chemistry values
were within normal limits, except an increased
C-reactive protein (30mg/L). Increased abdominal
pain without any fever was noticed during the
first 2 days of hospitalisation. Abdominal
computed tomography scan showed calcifications
from the initial to the distal part of both
ureters, in the appendix (figure A), in the
seminal vesicles, and within the ureteral wall of
the bladder. This presentation is typical of
genitourinary schistosomiasis due to Schistosoma
haematobium, which is endemic in Sierra Leone,
with schistosomial appendicitis. Neither eggs nor
other parasites were detected in the urine and
stools.
39
Abdominal CT scan showed calcifications from the
initial to the distal part of both ureters and in
the appendix
Histological examination of the appendix showed
numerous S haematobium eggs in submucosa of the
appendix
40
Chronic SchistosomiasisGenitourinary

• Specific for S. haematobium
• Hematurea first sign (10-12wks after infection)
• Graulomatous response eggs in tissue
• Dysurea early and late in disease

41
GenitourinaryLate manifestations

• Proteinurea (nephrotic)
• Bladder calcification
• Obstruction of ureter
• Renal colic
• Hydronephrosis
• Renal failure
• secondary bacterial infection
• Cystoscopy areas of rough mucosa (eggs)
• Structural urinary tract abnormalities

42
GU Schstosomiasis. Plain radiograph showing
Calcification of the distal two thirds of both
ureters and Bladder calcifications. (The
Encyclopaedia of Medical Imaging Volume VII.)
43
Bladder Schstosomiasis. IVP showing Filling
defects in the urinary bladder secondary to
granulomas. (The Encyclopaedia of Medical Imaging
Vol.VII.)
44
Genital schistosomiasis

• 1/3 of infected women
• Isolated internal genital disease is rare
• Vulva, perinium ulcers, fistulas, hypertrophic,
  wart-like lesions
• Tubular infertility rare, late
• May facilitate transmission of HIV

45
Schistosomiasis/Neurologic

• Egg deposits in the CNS aberrant migration of
  worms, embolization
• Not all are symptomatic
• Focal or generalized seizures are typical for S.
  japonicum CNS involvement
• Focal neurologic deficits
• 4.3 of hospitalized Chinese adults have CNS
  disease

46
Schistosomiasis/Neurologic

• Transverse myelitis most common neurologic
  complication of S. mansoni and S. haematobium
• Treatment
• Supportive
• Steroids
• Anticonvulsants long term use rarely needed

47
Schistosomiasis

• In childhood growth retardation, anemia
• Cognitive impairment, memory deficits
• May affect maternal and fetal health
• Praziquantel category B (safe in animals, not
  tested in humans)
• Riskbenefit treat esp. after 4th month of
  gestation

48
Two boys, victims of schistosomiasis showing
typical distension of the abdomen. WHO
49
GenitourinaryLate manifestations

• S. haematobium has role in some bladder CA
• Squamous cell carcinoma (SCC)
• In Egypt SCC 18-28 of all CA
• Mainly male, smokers
• The finding is not consistent in all countries
  with endemic S. haematobium

50
Schistosomiasis/Differential diagnosis

• Toxocara infection
• Trichinella spiralis infection
• Filariasis
• Hepatitis B, C virus infection
• Tuberculosis
• Amebiasis
• Leishmaniasis
• Myeloproliferative disease
• Peptic ulcer disease
• Cancer (GI, GU)

51
Schistosomiasis/diagnosisgeneral lab tests

• CBC with diff. eosinophilia
• Anemia
• Fe-deficiency
• Anemia of chronic disease
• Marocytic
• Hypoalbuminemia
• Elevated BUN/Cr
• Hypergammaglobulinemia

52
Diagnosis

• Detection of eggs in stools or urine Diagnostic
• 3 specimens may be needed intermittent shedding
• Miracidium hatching test
• Concentration of ova on nylon bag, suspend in
  distilled water
• Miracidia hatch from ova microscope
• Kato-Katz thick stool smear rapid, simple, 40-50
  mg of feces, used in field studies

53
S. manosni egg prominent lateral spine Ovoid
(140X61µ)
S. haematobium egg prominent terminal spine,
ovoid (150X62µ)
S. japonicum egg lateral spine obscured, round
(100X60µ)
Morphology of the Eggs of the 3 Key Schistosomes
That Infect Humans Allen GP et al. NEJM 2002,
Volume 3461212-1220
54
Diagnosis/biopsy

• The most sensitive diagnostic test for
  schistosomiasis is
• Rectal or bladder biopsy
• Perform on patients with typical clinical
  findings but negative feces and urine samples

55
Eggs in the venules of the intestinal mucosa
shed into the intestinal lumen and the
environment where they release their miracidia to
parasitize the snails. The eggs are about 150
microns in max diameter. The lateral spine cannot
be seen in this section..
56
Schistosomiasis/Serology

• Useful in specific circumstances
• Antibodies persist after parasitologic cure
• Useful in pts with no eggs Katayama fever
• Helpful in field studies
• Commercially available assays Less sensitive and
  specific than multiple stool sample exams
• Immunoblot assays to detect circulating egg or
  worm Ag highly sensitive and specific

57
Hepatic fibrosis markers

• Serum procollagen peptide III, IV
• P1 fragment of laminin
• Hyaluronic acid
• Fibrosin
• Markers may decrease with prazequantel treatment
• Persistent elevation after parasitlogic cure
  R/out HBV, HCV
• Liver biopsy may be needed

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59
Schistosomiasis/Treatment

• Praziquantel mainstay of treatment and control
  programs
• Used since 1970s
• Causes tetanic contractions in the worm detach
  from the vein and die
• Safe, effective
• Absorbed well, extensive 1st pass metabolism
• Secreted in breast milk
• Metabolized by the liver
• Antibodies by host are critical for efficacy

60
Praziquantel

• Dose 20 mg/kg/dose X 2-3 doses
• Give Q 6-8hrs with food
• Community-based programs single dose of 40 mg/kg
• Use higher doses for S. japonicum 60 mg/kg total
• Reexamination of stool or urine one month after
  treatment to assess efficacy

61
Praziquantel

• Cure rates
• Parasitologic cure rate 80
• Decrease in egg count 95-99
• If cont. to shed eggs retreat with same dose
• Causes regression of hepatomegaly, reversal of
  pathology
• Chronic complications no reversal

62
Praziquantel/Resistance

• Rare but may be emerging
• Not so far a significant clinical or public
  health issue
• Reports of failed treatment from Egypt Kenya
  heavy use
• Altered tegumental structure of the worm

63
Praziquantel/alternatives

• Oxaminiquine only alternative for S. mansoni
  infection
• Metrifonate S. haematobium
• May have role in emerging Praziquantel resistance

64
Schistosomiasis/Treatment

• Steroids
• Cerebral disease associated with surrounding
  edema
• Severe Katayama fever
• Supportive care chronic disease
• Standard medical and surgical therapy for chronic
  liver disease, varices
• Pts tolerate several episodes of hematemesis
  w/out encephalopathy

65
Schistosomiasis/prophylaxis

• Praziquantel is a poor choice
• Short ½ life (1-1.5h)
• Cannot kill schistosomula (migrating larvae 3-21
  d old)
• Artemether
• Antimalarial
• Kill schistosomula during first 21d in body
• Effective if given Q 2 weeks

66
Artemether

• Not used in malaria endemic areas resistance may
  emerge
• Have been used against S. japonicum transmission
  in China
• Dose 6 mg/kg Q 15 days
• PraziquantelArtemether synergistic killing of
  adult worms
• Target groups in endemic areas
• Flood relief workers
• Tourists
• fishermen

67
Scistosomiasis/vaccine

• Target Ags of schistosomula
• Animal studies in mice, pigs, buffalos
  protective levels
• Bith type 1,2 T-cell responses are involved
• Human studies schistosome derived molecule (S.
  haematobium glutathione S-transferase) Bilhvax
• Safe, immunogenic

68
Scistosomiasis/vaccine

• Other vaccines S. japonicum antigens paramyosin
  (Sj-97) and Sj-GST-26
• Future recombinant, synthetic peptide, DNA
  vaccines
• Vaccines to target transmitting hosts
• Vaccines will only be effcetive with control
  programs

69
Control programs

• Large scale population based chemotherapy
• Environmental modification
• Controlling snail habitat
• Use of molluscicides
• Behavioral modification
• Difficult and costly to sustain

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74

• Thank You