Introduction
Schistosomiasis is a neglected tropical disease (NTD) caused by parasitic blood flukes, schistosomes, which live in the venous system of definitive mammalian hosts (Nation et al., Reference Nation, Da’dara, Marchant and Skelly2020; World Health Organization, 2022b). To complete their lifecycle, schistosomes also require development within certain freshwater intermediate snail hosts such that it is a water-based parasitic disease and often capable of infecting various animals, inclusive of livestock (Giovanoli Evack et al., Reference Giovanoli Evack, Kouadio, Achi, Bonfoh, N’Goran, Zinsstag, Utzinger and Balmer2024). Most cases of schistosomiasis occur in sub-Saharan Africa, where access to clean and potable water for daily use is limited or unavailable (Adenowo et al., Reference Adenowo, Oyinloye, Ogunyinka and Kappo2015; Tchuenté et al., Reference Tchuenté, Rollinson, Stothard and Molyneux2017). Globally, approximately 1 billion people are at risk of infection with schistosomiasis in endemic areas, and more than 250 million people are currently infected (Borlase et al., Reference Borlase, Rudge, Léger, Diouf, Fall, Diop, Catalano, Sène and Webster2021). The World Health Organization (WHO) aspires to eliminate schistosomiasis as a public health problem (EPHP) in all endemic countries by 2030 (World Health Organization, 2020; Díaz et al., Reference Díaz, Walker and Webster2023).
There are 2 major types, or forms of schistosomiasis, urogenital schistosomiasis known to be caused by Schistosoma haematobium species (Ekpo et al., Reference Ekpo, Laja-Deile, Oluwole, Sam-Wobo and Mafiana2010) and intestinal schistosomiasis caused by various species; for the latter in the African context include Schistosoma mansoni, Schistosoma intercalatum and Schistosoma guineensis are abundant (Oyeyemi et al., Reference Oyeyemi, de Jesus Jeremias and Grenfell2020; Buonfrate et al., Reference Buonfrate, Ferrari, Adegnika, Stothard and Gobbi2025). Indeed, several species of African schistosome exist and some are capable of zoonosis (infecting humans and animals) (Webster et al., Reference Webster, Diaw, Seye, Webster and Rollinson2013).
Urogenital schistosomiasis occurs when the eggs of S. haematobium are deposited within the urinary and the genital system causing immune responses leading to various forms of systemic or organ-specific morbidity (Orish et al., Reference Orish, Morhe, Azanu, Alhassan and Gyapong2022). Migration and deposition of S. haematobium eggs in the urinary system such as the bladder and the urethra result in macro or micro haematuria in those affected and is referred to as urinary schistosomiasis (Colley et al., Reference Colley, Bustinduy, Secor and King2014) while migration and deposition of S. haematobium eggs in the genital system such as the cervix, uterus, vaginal, scrotum and penis causes irritation and inflammation resulting to female genital schistosomiasis (FGS) and male genital schistosomiasis (MGS), respectively; as such each were previously known broadly as genital schistosomiasis (GS) (Wright et al., Reference Wright, Chiphangwi and Hutt1982; Kjetland et al., Reference Kjetland, Ndhlovu, Mduluza, Gomo, Gwanzura, Mason, Kurewa, Midzi, Friis and Gundersen2005; Toller et al., Reference Toller, Scopin, Apfel, Prigenzi, Tso, de Azevedo Focchi, Speck and Ribalta2015; Kayuni et al., Reference Kayuni, Lampiao, Makaula, Juziwelo, Lacourse, Reinhard-Rupp, Leutscher and Stothard2019).
In the wider context of public health, this paper explores the challenges in managing both MGS and FGS. We propose 3 strategic interventions to facilitate their initial prevention and its eventual elimination.
MGS and FGS burden and impact
MGS and FGS occurs when the eggs of schistosomes deviate from their normal pathway (i.e. exit via urinary or gastro-intestinal tracts), becoming trapped within the genital tracts and organs (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022). FGS occurs when the eggs of S. haematobium are trapped in the various parts of the female reproductive tract such as the cervix, fallopian tube and around the ovaries. FGS has recently gained global attention due to severe hardship experienced by those affected (Kjetland et al., Reference Kjetland, Poggensee, Helling-Giese, Richter, Sjaastad, Chitsulo, Kumwenda, Gundersen, Krantz and Feldmeier1996; Yirenya-Tawiah et al., Reference Yirenya-Tawiah, Amoah, Apea-Kubi, Dade, Ackumey, Annang, Mensah and Bosompem2011; Ekpo et al., Reference Ekpo, Odeyemi, Sam-Wobo, Onunkwor, Mogaji, Oluwole, Abdussalam and Stothard2017; Schuster et al., Reference Schuster, Randrianasolo, Rabozakandraina, Ramarokoto, Brønnum and Feldmeier2022). Women with FGS may have a 2- to 4-fold risk of HIV (Kjetland et al., Reference Kjetland, Mduluza, Ndhlovu, Gomo, Gwanzura, Midzi, Mason, Friis and Gundersen2006; Downs et al., Reference Downs, Mguta, Kaatano, Mitchell, Bang, Simplice, Kalluvya, Changalucha, Johnson and Fitzgerald2011). Untreated FGS can lead to several complications including infertility, miscarriage, abortion and ectopic pregnancy (Helling-Giese et al., Reference Helling-Giese, Kjetland, Gundersen, Poggensee, Richter, Krantz and Feldmeier1996; Downs et al., Reference Downs, Mguta, Kaatano, Mitchell, Bang, Simplice, Kalluvya, Changalucha, Johnson and Fitzgerald2011). Infertility in women is a major psychosocial issue, especially in settings in which the social status of a woman is associated with fertility and reproductive capacity (Oluwole et al., Reference Oluwole, Bettee, Nganda, Piotrowski, Fapohunda, Adejobi, Soneye, Kafil-Emiola, Soyinka, Nebe and Ekpo2023). As some FGS symptoms may resemble sexually transmitted infections (STIs), many women are afraid of seeking care because of the fear of stigma from immediate family (husband, relatives), friends and health care workers (Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022; Mazigo et al., Reference Mazigo, Samson, Lambert, Kosia, Ngoma, Murphy and Matungwa2022; Schuster et al., Reference Schuster, Randrianasolo, Rabozakandraina, Ramarokoto, Brønnum and Feldmeier2022). Those who seek medical care may encounter a healthcare provider who is not knowledgeable about the condition, most times leading to incorrect diagnosis and judgemental attitudes, which can further exacerbate the patient’s concerns (Kukula et al., Reference Kukula, MacPherson, Tsey, Stothard, Theobald and Gyapong2019; Mazigo et al., Reference Mazigo, Samson, Lambert, Kosia, Ngoma, Murphy and Matungwa2022)
Similarly, MGS occurs when the eggs of schistosomes are trapped in the various parts of the male genital organs, affecting the prostate, seminal vesicles, vas deferens, testis and scrotum (Cerqua, Reference Cerqua1930; Makar, Reference Makar1937; Gelfand and Davis, Reference Gelfand and Davis1940). Haemospermia has been reported as the major symptom of early-stage MGS, which results from egg penetration and release into seminal vesicle lumen, causing ulceration of mucosal lining, and pain during coitus and ejaculation (Feldmeier et al., Reference Feldmeier, Leutscher, Poggensee and Harms1999; Kayuni et al., Reference Kayuni, Alharbi, Makaula, Lampiao, Juziwelo, LaCourse and Stothard2021). MGS has also been reported to cause hormonal imbalance (testosterone), testicular tissue damage and genital ductal system obstruction resulting in infertility and stigmatization (Mabey et al., Reference Mabey, Gill and Weber2013; Abdel‐Naser et al., Reference Abdel‐Naser, Altenburg, Zouboulis and Wollina2019). There is also an association between MGS and HIV-1 shedding in semen (Midzi et al., Reference Midzi, Mduluza, Mudenge, Foldager and Leutscher2017; Kayuni et al., Reference Kayuni, Alharbi, Shaw, Fawcett, Makaula, Lampiao, Juziwelo, LaCourse, Verweij and Stothard2023, Reference Kayuni, Musaya and Stothard2024)
Genital schistosomiasis imposes a financial burden on those affected. Both men and women with MGS and FGS are afraid of seeking care (Schuster et al., Reference Schuster, Randrianasolo, Rabozakandraina, Ramarokoto, Brønnum and Feldmeier2022; Roure et al., Reference Roure, Vallès, Pérez-Quílez, López-Muñoz, Chamorro, Abad, Valerio, Soldevila, España, Hegazy and Fernández-Rivas2024); hence, may resort to private pharmacies, paying inflated prices for medicine or ineffective alternatives without getting an appropriate solution to the problem (Amir-Azodi et al., Reference Amir-Azodi, Setayesh, Bazyar, Ansari and Yazdi-Feyzabadi2024). In rural areas, where traditional healers are often the first point of contact, affected individuals may spend money on ineffective herbal remedies or harmful interventions before accessing proper medical care (Glasziou et al., Reference Glasziou, Straus, Brownlee, Trevena, Dans, Guyatt, Elshaug, Janett and Saini2017).
Challenges in genital schistosomiasis management
Praziquantel is a proven and effective treatment for resolving the symptoms of FGS at early onset, using the WHO recommended single dosage of 40 mg/kg (Richter et al., Reference Richter, Poggensee, Kjetland, Helling-Giese, Chitsulo, Kumwenda, Gundersen, Deelder, Reimert, Haas and Krantz1996; Arenholt et al., Reference Arenholt, Randrianasolo, Rabozakandraina, Ramarokoto, Jøker, Kæstel Aarøe, Brønnum, Bundgaard Nielsen, Sørensen, Lumholdt and Jensen2024). However, it is less effective in long-standing cases or persons with advanced lesions, for example, conglomerations of fibrotic or scar tissues. Early treatment with praziquantel is therefore recommended before the establishment of FGS lesions (Piotrowski et al., Reference Piotrowski, Oluwole, Fapohunda, Adejobi, Nebe, Soneye, Kafil-Emiola, Gideon, Ekpo, Ahmed and Abdussalam2023; Arenholt et al., Reference Arenholt, Randrianasolo, Rabozakandraina, Ramarokoto, Jøker, Kæstel Aarøe, Brønnum, Bundgaard Nielsen, Sørensen, Lumholdt and Jensen2024; Kabengele et al., Reference Kabengele, Mwangelwa, Kilembe, Vwalika, Inambao, Moonga, Himukumbwa, Secor, Parker, Tichacek and Bustinduy2024). Also, for MGS, repeated doses or higher doses of 60 mg/kg seem to be more effective (Alonso et al., Reference Alonso, Muñoz, Gascón, Valls and Corachan2006; Pérignon et al., Reference Pérignon, Pelicot and Consigny2007). Hence, a higher dose alongside shorter intervals between retreatments, for example, 2–3 times a year is recommended (Lang et al., Reference Lang, Minion and Wong2017).
Despite the availability of treatment, many at-risk groups cannot access it because the current strategy employed by most endemic countries targets mostly school-aged children (5-14 years) through school-based deworming programmes (WHO Expert Committee on the Control of Schistosomiasis, 2002; Faust et al., Reference Faust, Osakunor, Downs, Kayuni, Stothard, Lamberton, Reinhard-Rupp and Rollinson2020). The drug supply chain does not provide for praziquantel availability in high-risk communities outside school-based mass drug administration (MDA) campaigns. Consequently, praziquantel is not available at most health facilities in endemic communities (Orish et al., Reference Orish, Morhe, Azanu, Alhassan and Gyapong2022).
While MDA programmes have reduced schistosomiasis prevalence, the current focus on school-aged children leaves other at-risk populations untreated, allowing reinfection cycles to persist and not reaching elimination goals (Njenga et al., Reference Njenga, Mwandawiro, Muniu, Mwanje, Haji and Bockarie2011; Faust et al., Reference Faust, Osakunor, Downs, Kayuni, Stothard, Lamberton, Reinhard-Rupp and Rollinson2020). The school-aged children only represent 20-30% of the population at risk of schistosomiasis infection. The remaining 80-70% of people left untreated and continue to be a source of re-infection to the treated school-aged children (Njenga et al., Reference Njenga, Mwandawiro, Muniu, Mwanje, Haji and Bockarie2011). As a result, those left untreated are at risk of having MGS and FGS. In countries like China, Egypt and Zanzibar, Tanzania where schistosomiasis has been eliminated or close to eliminating it as a public health problem, one of the key strategies employed is treatment of all persons at risk of infection with praziquantel (Song et al., Reference Song, Wu, Sacko and Wu2016; Abou-El-Naga, Reference Abou-El-Naga2018; Trippler et al., Reference Trippler, Knopp, Welsche, Webster, Stothard, Blair, Allan, Ame, Juma, Kabole and Ali2023; El-Kassas et al., Reference El-Kassas, Sheemy and Elbadry2024).
In 2021, a coalition of organizations established the FGS integration group, which seeks to increase awareness of FGS and train health professionals in sub-Saharan Africa to ensure proper diagnosis and integration of FGS treatment and management into other sexual and reproductive health practices. (https://www.eliminateschisto.org/fig-female-genital-schistosomiasis-integration-group). However, there are currently no advocacy groups for MGS except a few interested researchers (Faust et al., Reference Faust, Osakunor, Downs, Kayuni, Stothard, Lamberton, Reinhard-Rupp and Rollinson2020; Bustinduy et al., Reference Bustinduy, Randriansolo, Sturt, Kayuni, Leutscher, Webster, Van Lieshout, Stothard, Feldmeier and Gyapong2022). In January 2022, the WHO published a policy brief, advocating for regular treatments of adolescent girls and women of reproductive age (World Health Organization, 2022a).
Furthermore, the precise burden of MGS and FGS, particularly at district or sub-district levels, is unknown. Many endemic countries do not have data on MGS and FGS making it difficult to provide needed intervention (Engels et al., Reference Engels, Hotez, Ducker, Gyapong, Bustinduy, Secor, Harrison, Theobald, Thomson, Gamba and Masong2020). The lack of point-of-care diagnostics for MGS and FGS at primary healthcare makes these conditions difficult to diagnose (Arenholt et al., Reference Arenholt, Aaroe, Norderud, Lumholdt, Randrianasolo, Ramarokoto, Rabozakandraina, Broennum, Feldmeier and Leutscher2022; Lamberti et al., Reference Lamberti, Bozzani, Kiyoshi and Bustinduy2024). Data from the Multi-country Prevalence Assessment of FGS (MAP-FGS) study, which is currently underway in West Africa will be useful for generating predictive maps of FGS to better inform how future healthcare services and MDA can be targeted (Mwinzi et al., Reference Mwinzi, Chimbari, Sylla, Odiere, Midzi, Ruberanziza, Mupoyi, Mazigo, Coulibaly, Ekpo and Sacko2025).
Recommendations for eliminating genital schistosomiasis
To protect the young people and future generations living in schistosomiasis endemic regions from the menace of GS, we propose key recommendations that should be actioned to accelerate towards elimination of MGS and FGS and its associated problems. These recommendations have been employed in countries like China and Egypt where schistosomiasis has been eliminated.
Recommendations 1: Expand mass drug administration to all at-risk groups
Following several recommendations by experts, in 2022, the WHO has recommended scaling up of praziquantel treatment to all age groups from 2 years and above including pregnant women after their first trimester (Oluwole et al., Reference Oluwole, Ekpo, Nebe, Akpan, Jacob, Amazigo and Stothard2022; World Health Organization, 2022b). However, the lack of praziquantel and high additional costs to deliver MDAs remains a significant barrier for many diseases endemic countries.
Scaling-up treatment to all age groups as recommended by the WHO guidelines means that everyone living in schistosomiasis endemic community, aged 2 years and above will have access to praziquantel and will be treated during a single timepoint (World Health Organization, 2022b). One dosage of praziquantel (40 kg/kg) administered during MDA is effective in reducing the population of adult worms in the system of the infected persons, reducing morbidity and the release of eggs by adult worms (Sacko et al., Reference Sacko, Magnussen, Traoré, Landoure, Doucoure, Reimert and Vennervald2009). If implemented effectively, ensuring that all at risk individual receive treatment and without zoonotic transmission, the transmission of schistosomiasis should reduce drastically after 5-10 rounds of MDA, as there will be little or no eggs (of schistosome) shed by anyone who receives the treatment, and no new miracidium will be available to continue the transmission. If treatment is effective (>90% coverage) for the next 5-10 years, transmission will be significantly reduced (Berhanu et al., Reference Berhanu, Atnafie, Ali, Chekol and Kebede2022) and the chance of eliminating the disease would be increased, thereby preventing the onset of MGS and FGS and eventually resulting in elimination. It is important to note that MGS and FGS is a complication from schistosome infections and not a stand-alone disease condition (Orish et al., Reference Orish, Morhe, Azanu, Alhassan and Gyapong2022). Hence if we eliminate schistosome infections, these actions will eventually eliminate MGS and FGS.
We recognize that scaling up praziquantel to all age groups requires addressing a number of critical challenges. First there are no donated praziquantel medicines for all population groups except school-age children (Adeneye et al., Reference Adeneye, Mafe, Appelt, Idowu and Akande2006; World Health Organization, 2023; Jacob et al., Reference Jacob, Akinbo, Oluwole, Agbana, Omoruyi, Okungbowa, Diehl and Akinbo2025). Second, although substantial progress has been made regarding paediatric praziquantel formulations (Reinhard-Rupp and Klohe, Reference Reinhard-Rupp and Klohe2017) treatment protocol (Bustinduy et al., Reference Bustinduy, Bustinduy, Bustinduy, Edielu, Ayebazibwe, Nakyesige, Victor Anguajibi, Mpooya, Nassuna, Adriko, Elliott, Govert van Dam, Corstjens, Pach, Wu, Colt, Mawa, Muheki, Kabatereine, Webb and Friedman2025) the WHO has not released any updated guidance on paediatric treatment (World Health Organization, 2023).
Therefore, we encourage stakeholders, especially donor agencies, interested in supporting efforts to eliminate schistosomiasis and MGS and FGS, to consider increasing funds to expand access to praziquantel for all population groups.
It is equally important to highlight the need for implementation research on the best and most cost-effective approaches to scale up treatments (Binagwaho et al., Reference Binagwaho, Frisch, Udoh, Drown, Ntawukuriryayo, Nkurunziza, Donahoe and Hirschhorn2019), as scaling up praziquantel treatment may require different approaches in different age groups. For example, pre-SAC (2-5 years) could best be captured by integrating into existing platforms such as routine immunization programmes for these age groups, e.g. ‘child health day’ (Kumapley et al., Reference Kumapley, Kupka and Dalmiya2015; Mwingira et al., Reference Mwingira, Means, Chikawe, Kilembe, Lyimo, Crowley, Rusibamayila, Nshala and Mphuru2016).
Another option is to make praziquantel available within other sexual reproductive health programmes for effective integration of FGS management into other sexual reproductive health care (Umbelino-Walker et al., Reference Umbelino-Walker, Wong, Cassolato, Pantelias, Jacobson and Kalume2023; Pillay et al., Reference Pillay, Umbelino-Walker, Schlosser, Kalume and Karuga2024). This may involve training on schistosomiasis and management of MGS and FGS in the training activities of health professionals who are working within sexual and reproductive health programmes in secondary and tertiary health institutions (Pillay et al., Reference Pillay, Umbelino-Walker, Schlosser, Kalume and Karuga2024). As plans are underway to scale up treatment to reach pre-SAC and adults, we must also secure resources to conduct the necessary impact surveys to slowly shrink the areas of medium-high intensity transmission and reduce the areas that require annual treatment to maximize limited resources (Ekpo et al., Reference Ekpo, Olamiju, Mogaji, Ovia, Oladipupo, Kehinde, Oyediran, Aderogba and Makau-Barasa2025). To do this sustainably, it is necessary to build the capacity of lower-level laboratories to perform diagnostic tests more routinely (Boillot Reference Boillot2009; Yao et al., Reference Yao, Luman, Nkengasong and Maruta2016) and secure funding to support population-based surveys to inform which areas should be targeted for MDA campaigns. There is a novel test currently being developed through the diagnostic Target Product Profile (TPP) for monitoring and evaluation of the schistosomiasis programme (World Health Organization, 2021).
Praziquantel can be made available at health facilities through innovative management of the drug supply chain and reverse logistics by program managers and implementers. This transition requires careful planning and robust stakeholder coordination by the national program (Oluwole et al., Reference Oluwole, Ekpo, Nebe, Akpan, Jacob, Amazigo and Stothard2022). Integrating schistosomiasis control into primary healthcare will make it easy for praziquantel to be available in primary healthcare. Upon balance, the cost of increasing access to praziquantel is far lower than that of managing FGS complications as well as the associated social and psychological consequences that follow chronic FGS lesions and conditions.
Recommendation 2: Implement a One Health approach to control human and animal reservoirs
Identification of schistosome hybridization and zoonosis has changed our understanding of the epidemiology of schistosomiasis (Stothard et al., Reference Stothard, Kayuni, Al-Harbi, Musaya and Webster2020, Reference Stothard, Juhász and Musaya2025; Borlase et al., Reference Borlase, Rudge, Léger, Diouf, Fall, Diop, Catalano, Sène and Webster2021; Juhász et al., Reference Juhász, Makaula, Cunningham, Jones, Archer, Lally, Namacha, Kapira, Chammudzi, LaCourse and Seto2024) with studies showing severe morbidity among persons infected with hybrid schistosomes compared to those infected by pure breeds (Fall et al., Reference Fall, Lambert, Léger, Yasenev, Garba, Diop, Borlase, Catalano, Faye, Walker and Sene2021; Salas-Coronas et al., Reference Salas-Coronas, Bargues, Fernández-Soto, Soriano-Pérez, Artigas, Vázquez-Villegas, Villarejo-Ordoñez, Sánchez-Sánchez, Cabeza-Barrera, Febrer-Sendra and De Elías-Escribano2024). Most of the hybrids occur between the schistosome species that infect humans and those that infect animals (Leger and Webster Reference Leger and Webster2017; Stothard et al., Reference Stothard, Kayuni, Al-Harbi, Musaya and Webster2020; Borlase et al., Reference Borlase, Rudge, Léger, Diouf, Fall, Diop, Catalano, Sène and Webster2021). Consequently, control efforts targeted only at the human host will not result in the elimination of schistosomiasis (Leger and Webster Reference Leger and Webster2017; Léger et al., Reference Léger, Borlase, Fall, Diouf, Diop, Yasenev, Catalano, Thiam, Ndiaye, Emery and Morrell2020; Stothard et al., Reference Stothard, Juhász and Musaya2025). The time to implement the ‘One Health’ approach for the control of schistosomes is now, taking multisectoral action to eliminate the disease (Díaz et al., Reference Díaz, Walker and Webster2023). Although the WHO and Uniting to Combat NTDs have published articles detailing actions needed to be taken by endemic countries and stakeholders to implement the One Health approach in endemic countries (Kickbusch et al., Reference Kickbusch, Hornidge, Gitahi and Kamradt-Scott2022), actioning these steps has been very slow in most countries (Nzietchueng et al., Reference Nzietchueng, Kitua, Nyatanyi and Rwego2023).
Implementing a One Health approach will require a strong political will by the government of endemic countries (Zhu et al., Reference Zhu, Yap, Utzinger, Jia, Li, Huang and Cai2016; Chen et al., Reference Chen, Xu, Bergquist, Li and Zhou2018). This can be achieved through multisectoral collaboration involving several government ministries of endemic countries, such as health, agriculture, environment, education and water (Yang et al., Reference Yang, Zhou, Song, Li, Zhong, Wang, Bergquist, Zhou and Jiang2016). The One Health approach will require interventions to reduce human contact with infected water bodies through education and awareness creation, treatment of both humans and animals living in endemic communities and providing an alternative water supply, such as pipe-borne water or well. Establishment and enforcement of environmental sanitation laws/policy to discourage indiscriminate defecation and environmental pollution and environmental management (Yuan et al., Reference Yuan, Xu, Dong, Jiang and Zhu2005; Wang et al., Reference Wang, Chen, Guo, Zeng, Hong, Xiong, Wu, Wang, Wang, Xia and Hao2009; Yang et al., Reference Yang, Zhou, Song, Li, Zhong, Wang, Bergquist, Zhou and Jiang2016). This could include building latrines or encouraging communities to build latrines and have waste management containers in their homes, observing an environmental sanitation day to clean the environment, intensive animal management to prevent free range of animals to curb them from entering schistosome contaminated water or from littering the environment with faeces and polluting water bodies (Wang et al., Reference Wang, Chen, Guo, Zeng, Hong, Xiong, Wu, Wang, Wang, Xia and Hao2009). In China, for example animal grazing prohibition in snail infested zones was implemented as part of strategy to eliminate schistosomiasis as a public health problem (Wang et al., Reference Wang, Chen, Guo, Zeng, Hong, Xiong, Wu, Wang, Wang, Xia and Hao2009; Li et al., Reference Li, Hou, Tan, Williams, Gray, Gordon, Kurscheid, Clements, Li and McManus2020).
The Ministry of Environment can hold a meeting with community stakeholders to sensitize them on the role of free-rage animals in the spread of disease and to encourage them to have designated area for animal rearing and grazing e.g. cattle ranches, these places should be fenced using locally sourced materials e.g. bamboo tree, Gliricidia sepium (common name is Mexican lilac or Aaron’s rod).
Recommendation 3: Strengthen multi-stakeholder collaboration for water sanitation and hygiene (WASH) implementation
Access to potable water plays a crucial role in the elimination of NTDs and is critical for the sustainability of control and elimination programme efforts, especially for schistosomiasis control (Evan Secor Reference Evan Secor2014: Grimes et al., Reference Grimes, Croll, Harrison, Utzinger, Freeman and Templeton2014; Campbell et al., Reference Campbell, Biritwum, Woods, Velleman, Fleming and Stothard2018). Implementing WASH interventions requires strong political investments and community engagement to be both successful and sustainable (O’Mara-Eves et al., Reference O’Mara-Eves, Brunton, Oliver, Kavanagh, Jamal and Thomas2015; Zhu et al., Reference Zhu, Yap, Utzinger, Jia, Li, Huang and Cai2016).
It will require multisectoral collaboration involving various ministries and parastatals, such as water, environment and health (Yang et al., Reference Yang, Zhou, Song, Li, Zhong, Wang, Bergquist, Zhou and Jiang2016; Zhu et al., Reference Zhu, Yap, Utzinger, Jia, Li, Huang and Cai2016). Community engagement regarding the importance of WASH for disease control and elimination is vital to ensure community acceptability and ownership for the sustainability of the planned intervention (O’Mara-Eves et al., Reference O’Mara-Eves, Brunton, Oliver, Kavanagh, Jamal and Thomas2015).
An important aspect of community engagement is the social and behavioural change (SBC) component which aims to help the community understand and change the behaviour and practices that increase their risk of infection (Njagi et al., Reference Njagi, Nyikuri and Ndembi2024). This involves holistic approaches that include a set of activities, including structural and communication interventions, to increase the likelihood of sustained change (Njagi et al., Reference Njagi, Nyikuri and Ndembi2024). Effective behavioural change programming needs a systematic process that involves in-depth analysis, thorough planning, and sufficient and appropriate human and financial resources (USAID 2021). A good example of a structural intervention is the establishment of a washing point (a cemented area) within the community, where community members can go to wash their clothes after fetching water, which will reduce their contact with water, thereby reducing the risk of infection (Person et al., Reference Person, Knopp, Ali, A’kadir, Khamis, Ali, Lymo, Mohammed and Rollinson2016). Communication interventions may include radio programmes on health, with some focus on WASH. WASH promotion and education materials can also be integrated into many MDA campaigns, as the implementation of WASH is important to tackle many diseases.
Financing is key to successful implementation of the recommendations
It is important to note that implementing these recommendations require adequate funding. The recent closure of NTD programmes previously funded by the US government (ICVA, 2025; Mbah et al., Reference Mbah, Hardgrave, Mbah, Nutt and Russell2025; Ogieuhi et al., Reference Ogieuhi, Ajekiigbe, Aremu, Okpujie, Bassey, Babalola, Gbolagade-Jonathan, Anthony and Bakare2025) and a reduction in funding available from other countries, for example the UK, is a threat to the progress made in eliminating NTDs. Many national programmes that have been dependent on external funding will need to identify domestic funding and advocate for sustainable partnerships with philanthropies and large companies for resource mobilization to support NTD programmes (World Health Organization 2022c). Domestic funding of NTD programmes is a critical step towards country ownership and the sustainability of intervention programmes (Sodahlon et al., Reference Sodahlon, Ross, O’Carroll, McPhillips-Tangum, Lawrence, Tucker, Mpitu, Nicklas, Tangum, Goldberg and Mainardi2024). Mobilizing resources for NTDs will have to go hand-in-hand with wise allocation, allocating the available funds to support the critical interventions that can deliver faster progress to elimination.
Conclusion
Genital schistosomiasis, manifesting as FGS and MGS, remains a significant yet preventable morbidity in disease endemic regions. To eliminate these disease manifestations, national programmes must transition from control to elimination through the expansion of treatment, multi-sectoral collaboration, and improved access to WASH. Urgent implementation of MDA expansion to all at risk group, and community-based interventions is highly recommended. We must take decisive action now to eradicate the deadly and insidious schistosome parasite and protect future generation from the detrimental effect.
Data availability statement
Not applicable.
Acknowledgements
We are grateful to the organizers of the BSP Autumn symposium 2024 for the invitation and encouragement to submit a manuscript for the special issue on parasite of the genitals.
Author contribution
ASO, JRS, RS conceived and wrote the manuscript. All authors reviewed and approved the final version.
Financial support
There was no specific funding for this manuscript.
Competing interests
The authors declare there are no conflicts of interest.
Ethical standards
Not applicable
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