Schistosomiasis Control in China: The successful example of Jiangxi province [1st ed. 2019] 978-3-030-25601-2, 978-3-030-25602-9

Table of contents :
Front Matter ....Pages i-xi
Schistosomes: Trematode Worms That Endanger Still Today Millions of Humans and Animals (Heinz Mehlhorn)....Pages 1-17
The History and Experiences of Schistosomiasis Control in China (Zhongdao Wu)....Pages 19-24
Epidemic Characteristics of Schistosomiasis in Jiangxi Province (Yiwen Liu, Jun Ge, Zhaojun Li)....Pages 25-49
The Course of Schistosomiasis Control in Jiangxi (Jun Ge, Yifeng Li)....Pages 51-75
Experiences and Cases on Schistosomiasis Control Research (Dandan Lin, Xiaojun Zeng, Shangbiao Lyu, Xiao Yan, Guanhan Hu, Jing Zhang et al.)....Pages 77-186
Eliminating Plan and Challenges (Yifeng Li, Shangbiao Lyu)....Pages 187-201
Epilogue (Zhongdao Wu)....Pages 203-204

Citation preview

Parasitology Research Monographs 11

Zhongdao Wu Yiwen Liu Heinz Mehlhorn Editors

Schistosomiasis Control in China The Successful Example of Jiangxi Province

Parasitology Research Monographs Volume 11

Series Editor Heinz Mehlhorn Department of Parasitology Heinrich Heine University Düsseldorf Germany

This book series “Parasitology Research Monographs” presents carefully refereed volumes on selected parasitological topics. Parasites have an increasing impact on animal and human health in the present times of globalization and global warming. Parasites may be agents of diseases and- often at the same time- vectors of other agents of disease such as viruses, bacteria, fungi, protozoa and/or worms. The growth in knowledge of parasitic physiology, cell structure, biotechnological and genetic approaches, ecology, therapeutic capabilities, vaccination, immunology, diagnosis, transmission pathways and many other aspects of parasitology is increasing dramatically, even in the face of the breakthroughs that have already been made. Reflecting these most recent achievements and the importance of parasites as a threat to human and animal health, the series’ broad scope concentrates on particularly hot topics that were recently covered by review articles in the journal “Parasitology Research” or in other journals. These reviews offer compact but intense insights into the ongoing research and into the methods and technologies used to control parasites. The volumes in the series build on these topics, and the volume editors are well-known experts in their respective fields. Each volume offers 10 to 20 comprehensive reviews covering all relevant aspects of the topic in focus.

More information about this series at http://www.springer.com/series/8816

Zhongdao Wu • Yiwen Liu • Heinz Mehlhorn Editors

Schistosomiasis Control in China The Successful Example of Jiangxi Province

Editors Zhongdao Wu Zhongshan School of Medicine Sun Yat-sen University Guangzhou, China

Yiwen Liu Jiangxi Provincial Institute of Parasitic Diseases Qingshanhu District, Nanchang Jiangxi, China

Heinz Mehlhorn Department of Parasitology Heinrich Heine University Düsseldorf, Germany

ISSN 2192-3671 ISSN 2192-368X (electronic) Parasitology Research Monographs ISBN 978-3-030-25601-2 ISBN 978-3-030-25602-9 (eBook) https://doi.org/10.1007/978-3-030-25602-9 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Schistosomiasis is an ancient parasitic disease endangering humans living along the rivers and lakes for thousands of years. Schistosome eggs were found in an ancient corpse dating back to the Western Han Dynasty in China, confirming the prevalence of schistosomiasis in China more than 2150 years ago. In 1905, the first Chinese patient was diagnosed in Changde, Hunan Province. According to the surveys of the 1950s, 12 provinces in China were reported to be endemic areas: Jiangsu, Zhejiang, Anhui, Jiangxi, Fujian, Shanghai, Hunan, Hubei, Guangdong, Guangxi, Yunnan, and Sichuan. More than 12 million people were found to be infected with schistosomiasis in China at that time. In addition, 1.2 million buffalos were found to be infected in an area of 14.8 billion square meters contaminated with vector snails endangering a population of more than 100 million people. The harmful effects of schistosomiasis on people’s health and on the social and economic development of the whole country attracted the attention of the Chinese government. In 1955, Chairman Mao Zedong called for “the elimination of schistosomiasis” and kicked off the campaign for the prevention and treatment of schistosomiasis in China. Due to the relentless efforts of several generations, the prevention and control of schistosomiasis in China has made remarkable achievements, and a complete disease prevention and control system has been established. Among the 12 endemic provinces, Guangdong, Shanghai, Fujian, Guangxi, and Zhejiang have announced the complete elimination of schistosomiasis. Sichuan Province has reached the standard of blocking the transmission of schistosomiasis in 2017, including Jiangsu, Anhui, Jiangxi, and Hubei. Five provinces such as Hunan reached the control standard for schistosomiasis transmission in 2015. The prevention and control of schistosomiasis in China over the past 70 years has accumulated rich experiences and broad technology by adhering to government-led, departmental cooperation and participation of the population, which has consolidated the painstaking efforts of several generations of Chinese field workers and researchers on the prevention and control of schistosomiasis. Jiangxi province was once one of the most seriously afflicted schistosomiasis provinces in China. The characteristic occurrence of lakes and marshland as well as v

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Foreword

hilly endemic areas are typical representatives of most endemic areas in China. Thus, the prevention and control of schistosomiasis has a unique status and function in China. In 1958, Chairman Mao Zedong wrote a famous poem “Seven Rhythms and Say farewell to the Ghost of Diseases” about the establishment of China’s antischistosomiasis “first red flag” in Yujiang County, Jiangxi Province. In 2004, in Jinxian County (Jiangxi Province), the comprehensive strategy of controlling the source of infection was successfully explored, and this has become the leading strategy in the process of eliminating schistosomiasis in China. In 2018, China's schistosomiasis control memorial hall was established in Yujiang as another platform for external exchanges and worldwide cooperation in the work of schistosomiasis control. The prevention and control of schistosomiasis in Jiangxi Province which has passed through the same stages of prevention and control methods as the whole country proved its unique prevention and control characteristics. A fairy tale says that a glimpse of a pot may announce a lurking leopard. In a similar way, this book documents the challenges and strategies for completely eliminating schistosomiasis in Jiangxi Province by learning from the past, by evaluating the present situation of schistosomiasis, and by using all measurements of schistosomiasis prevention and treatment and treated people. The success of the measurements of schistosmiasis prevention and control in China is documented in this book and is based on the constant accumulation of knowledge during the project. Thus, there is good hope that the publication of this book will provide useful references for the prevention and control of global tropical diseases and offer practical experience for other schistosomiasis endemic countries to achieve the UN's goal of sustainable development by 2030.

Department of Health Jiangxi Provincial Government Nanchang, Jiangxi Province, P. R. China 9 June 2019

Xiaoqun Ding

Preface

The flukes of the genus Schistosoma received their recent genus name describing the unique lifelong partnership between males and females, whereby the male transports lifelong the female inside a channel, which is formed by the upfolded lateral borders of the males. For many centuries, these worms endangered millions of humans and their animals in tropical and subtropical regions. Since humans in these regions could not avoid contact with water, wherein the vector snails live—e.g., in lakes and rivers—infection rates and numbers of human deaths had always been very high endangering the survival of human populations in many regions of the world. With the worldwide introduction of praziquantel (a drug marketed under different names) starting around 1980, physicians had a “weapon” to cure slight infections. However, drugs alone could not solve the problem. Therefore, industrialized countries like Japan and China had started anti-schistosomiasis campaigns 15–20 years ago, which now bear the fruits of the enormous efforts needed in many fields of science and economy. Japan has actually declared full eradication of these worms and China is on the brink of it. This book contains reports on the problems and solutions to help China become free of schistosomiasis in the near future.

Düsseldorf, Germany Guangzhou, China January 2019

Heinz Mehlhorn Zhongdao Wu vii

Acknowledgments

We are thankful for the assistance from Dr Xiaoying Wu who is a researcher at the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.

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Contents

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Schistosomes: Trematode Worms That Endanger Still Today Millions of Humans and Animals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heinz Mehlhorn

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The History and Experiences of Schistosomiasis Control in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zhongdao Wu

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Epidemic Characteristics of Schistosomiasis in Jiangxi Province . . . . Yiwen Liu, Jun Ge, and Zhaojun Li

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The Course of Schistosomiasis Control in Jiangxi . . . . . . . . . . . . . . . Jun Ge and Yifeng Li

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Experiences and Cases on Schistosomiasis Control Research . . . . . . Dandan Lin, Xiaojun Zeng, Shangbiao Lyu, Xiao Yan, Guanhan Hu, Jing Zhang, An Ning, Huiqun Xie, and Yun Xu

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Eliminating Plan and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Yifeng Li and Shangbiao Lyu

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Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Zhongdao Wu

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Chapter 1

Schistosomes: Trematode Worms That Endanger Still Today Millions of Humans and Animals Heinz Mehlhorn

Abstract The clinical symptoms (bloody urine and/or bloody feces) of the disease, which today is called schistosomiasis, are due to infections with rather small and tiny trematode worms of only 1–2 cm in length being known already since the times of the Egyptian Ramses kings (1290–1157 BC). However, the descriptions of these worms in the blood vessels of humans are not older than 160–170 years, and really successful treatment started not earlier than 1974, when the chemical compound praziquantel came onto the market. Eradication programs are very difficult, since these worms infect not only humans but also a broad spectrum of free-living vertebrate and evertebrate hosts, wherein the parasites may hide themselves during eradication trials among humans and various animals. This chapter reports details of the life cycle stages of these worms, which have been targeted by different control measurements during the last few decades in China, Japan, and several Asian countries. Keywords Schistosoma species · Life cycle · Diseases

The present genus name Schistosoma (¼ twisted body) was created in the year 1858 by the German zoologist David Friedrich Weinland to characterize a genus of dioecious (digenean) flatworms, which in contrast to other species of this group have developed male and female individuals. However, these worms do not occur as single individuals in the blood vessels of their hosts, but always as pairs, whereby the flattened male worm harbors lifelong the string-like female in a so-called canalis gynaecophorus (Figs. 1.1 and 1.2). The present genus name Schistosoma has its origin in the Greek terms schizein ¼ divide and soma ¼ body. The history of the discovery of the adult worms leading to the so-called schistosomiasis of our days has two sources:

H. Mehlhorn (*) Department of Parasitology, Heinrich Heine University, Duesseldorf, Germany e-mail: [email protected] © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_1

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Fig. 1.1 Life cycle of Schistosoma mansoni and typical eggs and intermediate hosts of S. haematobium and S. japonicum (According to Piekarski 1987). A Final host: man; site of the adult worms: mesenteric vessels. 1a Sexually mature pair of flukes of S. mansoni (Sambon 1907). b Mature egg of S. mansoni (lateral spine). 2 Miracidium. B Intermediate hosts: aquatic snails (Planorbidae, e.g., Planorbis boissyi, Australorbis glabratus). 3a Sporocyst of the first type (mother

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1. The German physician Theodor Bilharz (1825–1862) observed in 1851 in Cairo (Egypt) worms (Bilharz 1852; Enigk 1986), which he found in the blood vessels of dead Egyptians and described them as Distomum haematobium worms (¼ two mouths), since he interpreted the second (¼ ventral) sucker also as “mouth” (Fig. 1.2). Later his scientific teacher Carl Theodor von Siebold (1804–1885) honored this finding by renaming these worms and creating the new genus name Bilharzia. After the First World War (1914–1918), the English-dominated literature started to use the genus name Schistosoma and honored the famous English parasitologist Patrick Manson (1844–1922) by naming the Egypt-based species as Schistosoma mansoni (Enigk 1986). The name of the disease remained for long Bilharziasis, but is now worldwide replaced by the term schistosomiasis. 2. Nearly at the same time as Bilharz the Japanese physician Fujii reported in 1847 facts on a human disease that he called Katayama disease, since it occurred commonly in patients living in the Japanese Katayama district. Main symptoms were bloody stools and high fever; however, the connection with a worm infection was only later recognized, when Katsurada (1904), Logan (1905), and Catto (1905) published more details. Today, it is common knowledge that both diseases are due to two different but related worm species (Fig. 1.1): – Schistosoma mansoni (Figs. 1.1 and 1.2a, b) in Egypt and many other countries (Othman and Soliman 2015) and – Schistosoma japonicum (Fig. 1.3) in Japan and many Asian regions. Although these worm couples live inside the blood vessels of their hosts, they are not attacked by the host defense system, since their surface is covered by a surface coat, which keeps the host’s defense cells away, since it is also present in the numerous invaginations of the tegument, which is not subdivided into layers of cells (Fig. 1.4). Furthermore, it is today also common knowledge that there exist worldwide several more Schistosoma species and subspecies, which also may infect humans and/or a broad spectrum of animals. These species have in principle a rather similar life cycle like Schistosoma mansoni and Schistosoma japonicum involving humans and possibly several mammals as final hosts (Table 1.1). The life cycle of these worms always involves several developmental stages (Fig. 1.1):

 ⁄ Fig. 1.1 (continued) sporocyst); 3b Sporocyst of the second order (daughter sporocyst). 4 Free cercaria (forked-tail cercaria). I S. haematobium (Bilharz 1852): the egg containing a miracidium is provided with a terminal spine. Shells of the intermediate hosts of the species: (a) Bulinus truncatus (North Africa) and (b) Bulinus globosus (West Africa). II S. japonicum (Katsurada 1904): egg with miracidium (shell has a very small lateral spine); shells of intermediate hosts of the snail genera (a) Schistosomorpha, (b) Oncomelania, and (c) Katayama

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Fig. 1.2 (a) Scanning electron micrograph of a couple of the species Schistosoma mansoni. The male covers the string-like female inside a so-called canalis gynaecophorus. The surface of the males of this species is—in contrast to that of males of S. japonicum—equipped with hook-bearing bosses, which help to become fixed in peculiar regions of the host’s blood vessels. These bosses and hooks are not present in several other species such as Schistosoma japonicum. (b) Light micrograph of a stained couple of Schistosoma mansoni. Note the blood-filled, dense appearing intestine

– Adults that live united as couples in the blood vessels of their hosts (Figs. 1.1, 1.2, 1.3, 1.4) – Females that excrete species-specific eggs (Fig. 1.5), which occur either in the feces or in the urine, depending on the species. – Miracidium larvae that look like ciliates (¼ free-living protozoans) and hatch in freshwater as soon as eggs have been entered therein and penetrate into speciesspecific snails (Steinmann et al. 2006) (Fig. 1.6a, b) – Bifurcated cercariae (Figs. 1.7 and 1.8) that leave the intermediate hosts (snails) and are able to enter a broad spectrum of final hosts (mammals, humans), where they grow up to adult females or males, which mate and live in species-specific blood vessels (e.g., inside vessels of the intestinal wall or inside vessels of the urogenital system (Table 1.2). These different positions of the adult worms in the body of humans lead to the fact that the worm eggs are either (mainly) excreted within the feces or in the urine of their hosts. However, many of the numerous daily excreted eggs stick in the tissues and induce therein life-threatening granulomas (Richter et al. 2016) (Figs. 1.9 and 1.10). In all cases, the bifurcated cercariae act as infectious stages, which after leaving the intermediate hosts (¼ snails) swim to a broad spectrum of potential vertebrate hosts, attach there, enter the skin while discharging the bifurcated tail (Figs. 1.7 and 1.8), and finally enter the blood vessels of several organs.

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Fig. 1.2 (continued)

The disease due to infections by Schistosoma species is today no longer called bilharziasis but schistosomiasis and has now obtained the rank of the second most socioeconomically devastating disease following closely behind human malaria. The different species of human schistosomiasis have the highest death rates among the top 10 of most important infectious diseases of humans, following closely behind HIV (AIDS) infections and tuberculosis, since the parasites are still today present in 71 countries having infected at least 200 million humans and also many millions of animal hosts. This broad propagation makes it extremely difficult to eradicate this disease especially in warm and humid rural regions. Since several papers show that humans might also get infected by Schistosoma species, which are mainly found in animals, the number of human infections may constantly increase considerably (Moné et al. 1999; Vercruysse et al. 1985; Webster et al. 2013). Furthermore,

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Fig. 1.3 Light micrograph of a stained couple of Schistosoma japonicum. The dark appearing female has left, at places the canal is gynaecophorous of the male (Source: Prof. Dr. Wei, Wuxi, China)

since human infections may easily occur due to contact with contaminated water (by penetration of cercariae), more than 700 million humans live at the risk of being infected by schistosomes, although there exist significant control methods and excellently acting chemotherapeutics (Mehlhorn et al. 1982, 1983; Mehlhorn 2016; Agrawal 2012; Bian et al. 2015; Cao et al. 2016; Gao et al. 2015; Grys 2016; Liu et al. 2011; Othman and Soliman 2015; Shimada et al. 2010; van Dam et al. 2015; Wang et al. 2012; Weerakoon et al. 2015; Wu 2016; Zheng et al. 2012; Zhong et al. 2014; Zhou et al. 2016). The Asian species Schistosoma japonicum, which was first described in the year 1847 by Fujii and was later confirmed by the German guest professor von Baelz (1849–1913) in the year 1883, has now been documented in many Asian regions (Agrawal 2012; Cao et al. 2016; Grys 2016; Wu 2016; Zhong et al. 2014). The living adult worms appear yellow or yellowish-brownish. The males measure 1.2 cm by 0.5 mm, while females reach a size of 2 cm in length, but only 0.4 mm in width. The females of this species are extremely fertile, since they produce up to 3000 eggs per day, while the females of the African species S. mansoni excrete only about 300 eggs per day and thus have a much lower fecundity (Becker and Mehlhorn 1980; Gönnert 1955; Gönnert and Andrews 1977; Mehlhorn et al. 1982, 1983; Gryseels et al. 2000).

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Fig. 1.4 Electron micrograph of a section through the surface of an adult Schistosoma worm showing the electron-dense surface coat. The noncellular tegument and the protruding spine (hook) are colored in gray

The disease symptoms due to infections with S. japonicum and the related species S. mekongi and S. malayi appear as follows: – Cercarial dermatitis at sites, where the cercariae have entered, occurs as skin inflammations within a few days (Fig. 1.11). – Initial relapsing fever (also called Katayama fever; see Fujii 1847; Ishii et al. 2003) starts after an incubation period of about 4–7 weeks accompanied by swellings of liver and spleen as well as considerable abdominal pain. – Bloody stools may occur about 30–40 days after infection. – Chronic symptoms (diarrhea, obstipation, repeated inflammations, intestinal polyps) are found 3–6 months after the infection. – Liver granuloma, liver swellings, and fibrosis follow as well as lung and brain symptoms and may become extremely severe (Hams et al. 2013; Grimes et al. 2015; Chuah et al. 2014; Gryseels et al. 2000). Recognizing the potentially huge death rates due to schistosomiasis, many Asian countries have long since started intense activities to eliminate these parasites. After initiating such intense control measurements in the year 1978, Japan succeeded finally in the year 1996 to eliminate these parasites practically in all regions (Tanaka and Tsuji 1997). As Zhongdao Wu reported in 2016, China also started very early

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Table 1.1 Morphological criteria of Schistosoma species of humans Characteristics Male, outer surfacea Female, ovary Eggs in uterus Egg shape Egg size (μm) Site of parasitizing Intermediate hosts/snailsb Reservoir hosts

S. japonicuma No tubercles on the tegument Posterior half of body 50–300 With tiny lateral thorn 70–100  55–65 Veins of the intestine Oncomelania species Mice, dogs, cats, pigs, cattle

S. mansoni Large tubercles (bosses) Anterior half of body 1–10 (mostly one) With large lateral thorn 115–180  45–70 Veins of the intestine Biomphalaria species Rats, mice, monkeys

S. intercalatum Tubercles with central hook-free spots Past mid of body

S. haematobium Small tubercles provided with many hooks Midbody region

10–20

20–100

With terminal thorn

With terminal thorn

140–230  50–80

110–170  40–70

Veins of the intestine Bulinus species

Veins of the urogenital system Bulinus species

Goats, sheep, rodents

Monkeys, hamsters

The ovoid eggs of S. mekongi have no thorn and measure only 50–60  30–50 μm, thus being considerably smaller than those of S. japonicum. In Thailand and Malaysia, S. malayensis has been described as own species, which has a similar life cycle like S. japonicum. Truncula snail species are intermediate hosts for S. mekongi, while Robertsiella species are intermediate hosts for S. malayensis b Only very common species are listed here a

Fig. 1.5 Light micrographs of the eggs of four important Schistosoma species (from left S. mansoni, S. japonicum, S. intercalatum, and S. haematobium)

such intense activities to reach the goal to eliminate this risk of deadly infections in those 12 provinces, where many human cases permanently occurred. Although considerable reduction rates have been reached and today only people in five main regions remain endangered, huge efforts are still needed to eliminate this parasite

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Fig. 1.6 (a, b) Scanning electron micrographs of a Schistosoma miracidium larva with the full set of cilia (left) and after removal in order to show the borders of the surface cells (right). AP Apical papilla, C Cilia, PL Plate cells of the tegument

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Fig. 1.7 Diagrammatic representation of a Schistosoma cercaria. AG Excretory ductule, BS Ventral sucker, D Intestine, DR Intestinal gland, DH Gland, EK Excretory channel, EP Excretory pores

from the Chinese map (Gray et al. 2014; Li et al. 2014; Xu et al. 2015; Zou and Ruan 2015; Zhong et al. 2014). Since schistosomes are still common in some countries surrounding China and in faraway countries like those in Africa, where Chinese workers stay for longer periods, reimport of these worms is constantly possible, especially in the present times of intense globalization. Thus, a constant monitoring is needed to avoid an increase of imported schistosomiasis cases and thus to block new infections in clean regions. Bird schistosomes (Table 1.3) may induce inflammations in human skin, leading to severe itching (Fig. 1.11).

1.1

Treatment of Schistosomiasis

Since the 1980s, praziquantel (Fig. 1.12) has been shown to be active against all Schistosoma species by disturbing the energy metabolism of the worms (Gönnert 1955; Gönnert and Andrews 1977; Liu et al. 2011; Becker and Mehlhorn 1980;

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Fig. 1.8 Scanning electron micrograph of a Schistosoma cercaria showing the bifurcal tail and the anterior pole, which later grows up to become the adult worm in the final host (man or vertebrate animals)

Table 1.2 Important Schistosoma species in vertebrate animals—some may occur in humans or at least may enter as cercariae the human skin Species Schistosoma bovis S. curassoni S. indicum S. spindale S. nasale Orientobilharzia turkestania Heterobilharzia americana

Size ♀ mm 12–32

Intermediate host: snails Bulinus spp.

15–25 10–25 10–16 10–12 8–10

Bulinus spp. Indoplanorbis spp. Indoplanorbis spp. Indoplanorbis spp. Lymnaea spp.

Final hosts Cattle, sheep, camels, rodents, monkeys, humans Ruminants Ruminants, camels Ruminants Ruminants Ruminants, horses, camels

10–18

Lymnaea spp.

Racoons, lynx, roe deer, dog, opossum

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Fig. 1.9 Light micrograph of a section through liver tissues showing a shrunk egg (due to preparation) of Schistosoma mansoni

Mehlhorn et al. 1981, 1983; Mehlhorn 2016; Wu 2016; Zhong et al. 2014. Recent tests in China have proven that the combination of praziquantel (PZQ) and artemether will help to close the gap in treatment, if praziquantel alone should reduce activity.

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Comparison of Some Schistosomal Infections

Incubation period S. japonicum S. mansoni S. intercalatum S. haematobium

2–3 weeks 2–3 weeks 4–7 weeks 2–20 months

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Fig. 1.10 Macrophoto of the bladder wall of a person being infected with Schistosoma haematobium. Eggs passing the bladder wall lead to bleedings finally seen in the urine

Prepatent period S. japonicum S. mansoni S. intercalatum S. haematobium

4–5 weeks 4–7 weeks 6–8 weeks 8–12 weeks

Patent period All human Schistosoma species:

5–20 years

Schistosoma genome – – – – – – –

Nuclear genome size: 270 Mb Chromosomes: 8 pairs (¼ 7 pairs autosomes, 1 pair sex chromosomes) Male ZZ Female ZW (¼ heterogametic) Gene copies: ~14,000 Repetitive content: 40–60% Mitochondrial genome: 14,500 nucleotides

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Fig. 1.11 Skin reactions of this type occur after penetration of cercariae Table 1.3 Important schistosomal species in birds (examples)a Species Bilharziella polonica Trichobilharzia szidati T. franki T. regenti a

Size ♀ mm 2 3 4 7

Intermediate host: snails Planorbis, Planorbarius Lymnaea spp. Radix species

Final hosts Goose, ducks, waterbirds Ducks, waterbirds Ducks

The cercariae of these species may enter human skin and induce local inflammations there

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Fig. 1.12 Chemical formula of praziquantel

References and Further Reading Agrawal MC (2012) Schistosomes and schistosomiasis in South Asia. Springer, Heidelberg Baelz E (1883) Über einige neue Parasiten des Menschen (Report on several new parasites of humans). Berl Klin Wochenschr 20:234–238 Becker B, Mehlhorn H (1980) Light and electron microscopic studies in the effect of praziquantel on Schistosoma mansoni, Dicrocoelium dendriticum and Fasciola hepatica. Parasitol Res 63:113–128 Bian CR et al (2015) Serological prevalence of Schistosoma japonicum in China. PLoS One 10:201228896 Bilharz T (1852) Ein Beitrag zur Helminthographis humana (A contribution to the distribution of human helminths). Z Wiss Zool 4:53–76 Cao ZG, Zhao YE, Lee Willingham A, Wang TP (2016) Towards the elimination of schistosomiasis japonica through control of the disease in domestic animals in the People’s Republic of China: a tale of 60 years. Adv Parasitol 92:269–306 Catto J (1905) Schistosoma cattori: a new blood fluke of man. Br Med J 1:11–26 Chuah C, Jones MK, Burke ML, McManus DP, Gobert GN (2014) Cellular and chemokinemediated regulation in schistosome-induced hepatic pathology. Trends Parasitol 30:141–150 Enigk K (1986) Geschichte der Helminthologie (History of helminthology). G. Fischer Verlag, Stuttgart, New York Fujii Y (1847) Katayama disease. Chugai Int Med J 6:91 Gao H, Xiao D, Song L, Zhang W, Shen S, Yin X, Wang J, Ke X, Yu C, Zhang J (2015) Assessment of the diagnostic efficacy of enolase as an indication of active infection of Schistosoma japonicum. Parasitol Res 115:151–164 Gönnert R (1955) Schistosomiasis studies: I. Contributions to anatomy and histology of Schistosoma mansoni. Z Tropenmed Parasitol 6:18–33 Gönnert R, Andrews P (1977) Praziquantel, a new broad-spectrum antischistosomal agent. Parasitol Res 52:129150 Gray DJ et al (2014) A multicomponent integrated approach for the elimination of schistosomiasis in the People’s Republic of China: design and baseline results of a 4-year cluster-randomized intervention trial. Int J Parasitol 44:650–608 Grimes JE et al (2015) The roles of water, sanitation and hygiene in reducing schistosomiasis: a review. Parasit Vectors 8:156–166 Grys PC (2016) Schistosomiasis control in China: diagnostics and control strategies leading to success (Challenges in Public Health). Peter Lang GmbH, Internationaler Verlag der Wissenschaften, Frankfurt/Main Gryseels B et al (2000) Human schistosomiasis. Lancet 368:1106–1118 Hams E, Aviello G, Fallon PG (2013) The Schistosoma granuloma: friend or foe? Front Immunol 4:89. https://doi.org/10.3389/fimmu.2013.00089 Ishii A, Tsuji M, Tada I (2003) History of Katayama disease: schistosomiasis japonica in Katayama district, Hiroshima, Japan. Parasitol Int 52:313–319 Katsurada F (1904) Determination of the cause of a new parasite disease seen in Yamanashi and other prefectures. Tokyo Iji Shinshi 1371:13–32

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Li YS et al (2014) The Schistosoma self-cure phenomenon in water buffaloes: potential impact on the control and elimination of schistosomiasis. Int J Parasitol 44:167–171 Liu R, Dong HF, Guo Y, Zhao QP, Jiang MS (2011) Efficacy of praziquantel and artemisinin derivatives for the treatment and prevention of human schistosomiasis: a systematic review and meta-analysis. Parasit Vectors 4:201–218 Logan OT (1905) A case of dysentery in Hunan Province caused by the trematode Schistosoma japonicum. Chin Med J 19:243–245 Mehlhorn H (ed) (2016) Encyclopedia of parasitology, 4th ed. Springer, New York, 3 volumes Mehlhorn H, Becker B, Andrews P, Frenkel JK (1981) In-vivo and in-vitro experiments on the effects of praziquantel on Schistosoma mansoni. Arzneimittelforschung 31:544–554 Mehlhorn H, Frenkel JK, Andrews P, Thomas H (1982) Light and electron microscopical studies on Schistosoma mansoni granulomas following treatment with praziquantel. Trop Med Parasitol 33:229–239 Mehlhorn H, Frenkel JK, Bunnag G, Rim A (1983) Ultrastructural investigations of the effect of praziquantel on human trematodes from Asia (Clonorchis sinensis, Metagonimus yokogawai, Opisthorchis viverrini, Paragonimus westermani, Schistosoma japonicum). Drug Res 33:91–98 Moné H, Mouahid G, Morand S (1999) The distribution of Schistosoma bovis Sonsino, 1876 in relation to intermediate host mollusc-parasite relationships. Adv Parasitol 44:99–138 Othman AA, Soliman RM (2015) Schistosomiasis in Egypt: a never ending story? Acta Trop 148:179–190 Piekarski G (1987) Medical parasitology in plates. Springer, Heidelberg Richter J, Azoulay D, Dong Y, Holtfreter MC, Akpata R, Calderaro J, El-Scheich T, Breuer M, Neumayr A, Hatz C, Kircheis G, Botelho MC, Dietrich CF (2016) Ultrasonography of gallbladder abnormalities due to schistosomiasis. Parasitol Res 115:2917–2924 Shimada M, Kirinoki M, Shimizu K, Kato-Hayashi N, Chigusa Y, Kitikoon V, Pongsasakulchoti P, Matsuda H (2010) Characteristics of granuloma formation and liver fibrosis in schistosomiasis: a morphological comparison between Schistosoma mekongi and S. haematobium. Parasitology 137:1781–1789 Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J (2006) Schistosomiasis and water resources development: systematic review, meta-analysis and estimates of people risk. Lancet Infect Dis 6:411–425 Tanaka H, Tsuji M (1997) From discovery to eradication of schistosomiasis in Japan: 1847–1996. Int J Parasitol 27:146–1480 van Dam GJ, Odermatt P, Acosta L, Bergquist R, de Dood CJ, Kornelis D, Muth S, Utzinger J, Corstjens PL (2015) Evaluation of banked urine samples for the detection of circulating anodic and cathodic antigens in Schistosoma mekongi and S. japonicum infections: a proof-of-concept study. Acta Trop 141:198–203 Vercruysse J, Fransen J, Southgate VR, Rollinson D (1985) Parasitology of Schistosoma curassoni infection in sheep. Parasitology 91:291–300 Wang W, Wang L, Liang YS (2012) Susceptibility or resistance of praziquantel in human schistosomiasis. Parasitol Res 111:1871–1877 Webster BL, Diaw OT, Seye MM, Webster JP, Rollinson D (2013) Introgressive hybridization of Schistosoma haematobium group species: species barrier break down between ruminant and human schistosomes. PLoS Negl Trop Dis 7:e2110 Weerakoon KG, Gobert GN, Cai P, McManus DP (2015) Advances in the diagnosis of human schistosomiasis. Clin Microbiol Rev 28:939–967 Wu Z (2016) Schistosomes. In: Mehlhorn H (ed) Encyclopedia of parasitology, 4th edn. Springer, New York Xu J, Xu JF, Li SZ, Zhang LJ, Wang Q, Zhu HH, Zhou XN (2015) Integrated control programs for schistosomiasis and other helminth infections in P.R. China. Acta Trop 141:332–341 Zheng H, Zhang LJ, Zhu R, Xu J, Li SZ, Guo JG, Xiao N, Zhou XN (2012) Schistosomiasis situation in People’s Republic of China in 2011. Zhongguo Xue Xi Chong Bing Fang Zhi Za Zhi 24:621–626

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Zhong F, Liu C, Zhang X (2014) Guideline adherence for the treatment of advanced schistosomiasis japonica in Hubei, China. Parasitol Res 113:4535–4541 Zhou XN, Li SZ, Utzinger J, Bergquist R (eds) (2016) Schistosomiasis in the People’s Republic of China: from control to elimination. Elsevier, Oxford Zou L, Ruan S (2015) Schistosomiasis transmission and control in China. Acta Trop 143:51–57

Chapter 2

The History and Experiences of Schistosomiasis Control in China Zhongdao Wu

Abstract This chapter looks at the history of the spreading of a very important lifethreatening disease, which in former times was named bilharziasis, but now it is called schistosomiasis referring to the Greek terms schistos ¼ divided and soma ¼ body, which describes the fact that the male worm covers the female lifelong. Keywords Schistosomiasis in China · History · Local peculiarities

China is a civilization of more than 5000 years, both ancient and modern country. It is located in Asia and its territory lies between latitudes 18 and 54 N, and longitudes 73 and 135 E. The landscapes vary significantly across its vast width. In the east, along the shores of the Yellow Sea and the East China Sea, there are extensive and densely populated alluvial plains, while on the edges of the Inner Mongolian plateau in the north, broad grasslands predominate. Southern China is dominated by hills and low mountain ranges, while the central-east hosts the deltas of China’s two major rivers, the Yellow River and the Yangtze River. Other major rivers include the Pearl River, Mekong, Brahmaputra, and Amur. China’s climate is mainly dominated by dry seasons and wet monsoons, which lead to pronounced temperature differences between winter and summer. In the winter, northern winds coming from highlatitude areas are cold and dry; in summer, southern winds from coastal areas at lower latitudes are warm and moist. The climate in China differs from region to region because of the country’s highly complex topography.

Z. Wu (*) Department of Parasitology, Zhongshan School of Medicine, Guangzhou, People’s Republic of China e-mail: [email protected] © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_2

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History of Schistosomiasis Control in China

Schistosomiasis was endemic in China and its history can be traced back to 2000 years ago. In the 1970s, the eggs of Schistosoma japonicum from the mummy of the western Han dynasty tombs in Hubei Jiangling and Hunan were discovered (in liver, gut). This finding confirms the epidemic history of schistosomiasis in China for at least 2100 years. Although the Chinese traditional medicine carried out a certain amount of research and exploration of schistosomiasis, due to the limitations of science and technology at that time, there was a lack of systematic research on the etiology, pathogenesis, and treatment of the disease. Only symptoms of the disease have left some records in the books of traditional Chinese medicine. It was not earlier than 1905, when Logan, a physician at Changde Guangde Hospital, discovered Japanese schistosomiasis eggs in an 18-year-old farmer’s stool samples and reported the case in a professional magazine (Chinese Medical Journal of English, 1905, 19: 243–245). Later, foreign and Chinese medical pioneers did some investigations on schistosomiasis and gradually mastered the basic situation of schistosomiasis epidemic. The data show that the schistosomiasis endemic areas are situated along the Yangtze River and in the southern regions including Jiangsu, Zhejiang, Anhui, Jiangxi, Hunan, Hubei, Shanghai, Sichuan, Yunnan, Fujian, Guangdong, and 12 Guangxi provinces (autonomous regions and municipalities directly under the central government), whose endemic areas were north to Baoying County of Jiangsu province (north latitude 33 150 ), south to Yulin City of Guangxi (north latitude 22 50 ), east to Shanghai Nanhui (east longitude 121 510 ), and west to Yunlong County of Yunnan province (east Longitude 99 500 ). The lowest elevation of the regions was zero (Shanghai), nd highest was up to 3000 m (Yunnan province). From Yichang of Hubei province to the lower sites of the Yangtze River in the Shanghai regions, the endemic areas were closely connected, while the other endemic areas were scattered or completely isolated. The prevalence of schistosomiasis seriously jeopardized the general health of the local population and destroyed many villages in the endemic areas. Therefore, Chairman Mao described in a poem “Thousands of village people left the house, ten thousand ghosts are singing.” This is exactly the true portrayal of schistosomiasis in old China. After the founding of People’s Republic of China, the government has profoundly realized the dangers of schistosomiasis. In the summer of 1955, Chairman Mao presided and the Central Committee proposed that the central government has to set up a leading group for the prevention and treatment of schistosomiasis and called for “the elimination of schistosomiasis.” This was the starting point of the schistosomiasis control in China (Thirteen-Five National Schistosomiasis Control Program). For more than 50 years, with the high attention and leadership of the CPC Central Committee and the State Council, with the close cooperation of relevant departments, schistosomiasis control measurements made remarkable achievements. First, the endemic areas were gradually staged. Starting 1995, among 12 epidemic provinces (autonomous regions and municipalities), schistosomiasis was controlled in

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five provinces successively, including Guangdong, Shanghai, Guangxi, Fujian, and Zhejiang provinces. Among the 433 endemic counties (cities and districts), 260 counties reached the transmission-block standard, and 63 counties reached the transmission control standard. In the popular provinces, popular counties, towns, and villages, the infection rates have decreased by 42%, 75%, and 74%, respectively. Thus, the epidemic was significantly reduced. According to the epidemic report, in 2004, the number of patients with schistosomiasis was only 843,000 compared with the early stage of the control program (11,612,000 patients). Thus, the cases had been decreased by 92.7%. Among patients with advanced symptoms, a decrease of 95.2% was noted compared to the early days of the founding of the People’s Republic of China, when 600,000 persons had been in the advanced stage. Third, the snail-infested areas were greatly reduced. In 2004, a total of 3.85 billion square meters of snail-infested areas had been found across the endemic areas. This is a decrease of 73.14% compared to the early years of the founding of the People’s Republic of China. In 2015, among the 12 endemic provinces, five provinces (Shanghai, Zhejiang, Fujian, Guangdong, and Guangxi province or municipality/autonomous region) had achieved full transmission interruption, and seven provinces including Sichuan, Yunnan, Jiangsu, Hubei, Anhui, Jiangxi, and Hunan had achieved transmission control by the end of 2015. There were 453 endemic counties (city, district) covering 252 million people, specifically including 29,980 endemic villages of 68.61 million people at risk of infection. Among the 453 endemic counties (city, district), 75.72% and 24.28% reached the criteria of transmission interruption and transmission control, respectively. By the end of the year 2015, 77,194 cases of schistosomiasis were estimated. Thus, the infection rate decreased by 33.23% compared to 115,614 cases in the year 2014. No acute schistosomiasis cases were reported in 2015. 30,843 advanced schistosomiasis cases were documented in 2015. A total of 8,736,036 patients received schistosomiasis examinations and 3606 individuals were found positive. Thus, the infection rate had decreased by 56.40% compared to 8270 cases in 2014. In 2015, an Oncomelania hupensis snail survey was performed in 19,965 endemic villages and specimens of these snails were found in 5609 villages (28.09% of total villages), with 31 newly detected villages with snails. The snail survey covered an area of 593,572.66 hm2 and snails were found in an area of 173,462.50 hm2, including a newly detected area of 666.04 hm2. No infected snails were found in 2015. A total of 879,373 bovines were raised in the schistosomiasis endemic regions. Of them, 526,062 bovines received stool examinations, resulting in 315 infected animals. 170,438 schistosomiasis cases of cattle received drug treatment in 2015, with 2,449,696 individuals undergoing expanded chemotherapy. There were 318 bovines with schistosomiasis receiving drug treatment, with 483,213 bovines undergoing expanded chemotherapy. A total of 144,305.52 km2 area was subject to snail control by using molluscicides, with an actual molluscicidetreated area of 69,221.57 hm2, and 4572.06 hm2 snail habitats were treated by environmental modification. Based on the data from the 457 national schistosomiasis surveillance sites, the mean infection rate was 0.05% in humans and 0.04% in

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bovines, respectively. No infected snails were found in all the surveillance sites. The results demonstrate a decline in the endemicity of schistosomiasis in China. Thus, the country reached the criteria of transmission control at the national level. In 2016, in order to provide a scientific basis for the evaluation of schistosomiasis control effects, 454 national surveillance sites were selected in counties (cities or districts) with schistosomiasis prevalence. Infections of residents, floating populations, domestic animals, and Oncomelania snails were monitored and analyzed in four types of endemic counties. There was a stable endemic situation in China in 2016. However, in some provinces snails appeared for the first time or reemergence was detected.

2.2

Plan to Eradicate Schistosomiasis in China

The Chinese government has attached great importance to control schistosomiasis, and many regulations and plans have been made and put into effect, such as “Regulations on Prevention and Control of Schistosomiasis,” “Work Plan for the Mid and Long-term of National Schistosomiasis Control Programme from 2004 to 2015,” and “Thirteen-Five National Schistosomiasis Control Program.” In 2017, China was looking forward to eliminate schistosomiasis until 2030 based on the “Healthy China 2030” project. Planning Objectives By the end of 2020, five provinces (Sichuan, Jiangsu, Yunnan, Hubei, and Hunan) will have reached the transmission interruption criteria (Zhou 2016): (1) no local new case of schistosomiasis is found in five consecutive years; (2) no local schistosome-infected livestock is found in five consecutive years; (3) no positive Oncomelania hupensi snail is detected in five consecutive years; and (4) a sensitive and effective county-based surveillance system is established, and the endemic counties have reached the elimination criteria: after reaching the criteria of transmission interruption, no local infected humans and livestock are found in another five consecutive years accounting for at least 95%, 85%, 60%, 55%, and 35% of the total, respectively. Anhui and Jiangxi provinces will have a decrease of more than 90%, and 70% of the endemic counties reach the transmission interruption standard, and the endemic counties that reach the elimination standards account for 45% and 60% of the total, separately. By the end of 2030, all the endemic counties should have reached the standard of eradicating schistosomiasis in China. Current Status and Challenges Though great achievements in prevention and control of schistosomiasis have been made in China, it remains a tough task to reach the goal of eradicating schistosomiasis until 2030 (Zhang et al. 2017). The challenges are listed as follows:

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Livestock The numbers of livestock such as cattle and sheep in the endemic areas of schistosomiasis in China are large, and livestock movement (e.g., through livestock trade or movement to new grazing fields) occurs frequently in these areas. Human With China’s rapid economic development and urbanization over the past few decades, it has witnessed its largest human movement. The control of infectious sources is difficult, due to the increasing number of migrant workers and the continuous development of tourism. Snails The distribution of Oncomelania hupensis snails is wide, and the environment of breeding is complicated. Newly discovered or reemerging snail areas are repeatedly reported, and sometimes their size is even bigger than the area already under control. Institutions The conditions in schistosomiasis control stations and animal epidemic prevention and control institutions are still far from satisfactory. There is a need of more professionals and equipment. Natural Disasters Floods and earthquakes occur at times. Thus, schistosomiasis as a waterborne disease is difficult to eliminate completely and the risk of schistosomiasis transmission remains. Strategies Adherence to the comprehensive strategy putting an emphasis on the control of infectious sources for the prevention and control of schistosomiasis. Strengthen monitoring and early warning, early detection, and disposal of epidemics. Strengthen regional prevention and control, and establish a sound mechanism for joint prevention and control. Make guidance and take measures according to local conditions. Measures – Control and elimination (n.d.) – Plan for healthy China (n.d.) Those not reaching transmission interruption: emphasize the control and management of infection sources, namely, grazing prohibition, using machines instead of cattle, improving drinking water and lavatories, perfecting living environment, etc. Having reached transmission interruption/elimination: pay attention to environmental modifications of snails and strengthen surveillance by evaluating transmission risk of schistosomiasis regularly, early detection, and disposal of epidemics. Surveillance spots: in areas with potential transmission risk like in the South-toNorth Water Diversion and in the Three Gorges Dam regions, more emphasis should be put on the monitoring of imported schistosomiasis patients and Oncomelania hupensis snails.

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References Control and elimination of schistosomiasis GB 15976-2015. http://www.nhfpc.gov.cn/ewebeditor/ uploadfile/2015/07/20150731103220667.PDF Outline of the Plan for Healthy China 2030. http://www.nhfpc.gov.cn/guihuaxxs/s3586s/201610/ 21d120c917284007ad9c7aa8e9634bb4.shtml Thirteen-Five National Schistosomiasis Control Program. http://www.nhfpc.gov.cn/jkj/s5873/ 201703/e785950591bf4276bbbdf4239d455af9.shtml Zhang LJ, Xu ZM, Qian YJ et al (2017) Endemic status of schistosomiasis in People’s Republic of China in 2016. Chin J Schistosomiasis Control 29(6):669–677. https://doi.org/10.16250/j.32. 1374.2017204 Zhou XN (2016) Implementation of precision control to achieve the goal of schistosomiasis elimination in China. Chin J Schistosomiasis Control 28(01):1–4

Chapter 3

Epidemic Characteristics of Schistosomiasis in Jiangxi Province Yiwen Liu, Jun Ge, and Zhaojun Li

Abstract This chapter offers insights into former and present situations of the spreading of the worms and the status of the control of the disease in former and recent times in the Chinese province, Jiangxi, which is the blueprint for other provinces and can be used in other countries, too. Keywords Epidemiological conditions · History of spreading of disease

3.1

Brief Introduction of Jiangxi Province

Jiangxi Province is located in the southeastern part of China, on the south bank of the middle and lower reaches of the Yangtze River, 24
290 –30
050 north latitude, 113
350 – 118
290 east longitude, with an area of 167,000 km2. The resident population of the province is 45.923 million, including the rural population of 21.538 million which accounts for 46.9% of the total population (2016). The province has jurisdiction over 11 cities with districts and 100 counties (municipalities and autonomous regions). The terrain of Jiangxi Province is high in the south and low in the north, with surrounding mountains on the margin, undulating hills in the middle, and flat plains in the north. The slopes of the surrounding areas are gradually inclined to the Poyang Lake, forming a basin-like terrain based on the Poyang Lake, with a narrow south and a wide north. The water system in the province is well developed, with more than 2400 large and small rivers. Ganjiang River, Fuhe River, Xinjiang River, Rao River, and Xiuhe River are the five major rivers running through the whole province. These five rivers flow out to the Yangtze River at the lake outlet after flowing into the Poyang Lake. Located near the Tropic of Cancer, Jiangxi Province is a subtropical humid monsoon climate zone with mild climate, abundant sunshine, and plentiful water. The annual mean temperature is between 13 and 16
C, and the average precipitation is between 1341 and 1940 mm. The most extreme precipitation period in the whole

Y. Liu (*) · J. Ge · Z. Li Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_3

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year is from May to June, and the average monthly precipitation is above 200–350 mm. The precipitation generally follows the trend that is more in the south and less in the north, more in the east and less in the west, and more in the mountains and less in the basins. Jiangxi is a large agricultural province of rich agricultural byproducts. Rice is mainly grown in the middle and south of the province, while rice and cotton are mainly grown in the north of the province. The main livestock is cattle, pigs, dogs, cats, sheep, etc., and poultry includes chickens, ducks, and geese. The sideline is dominated by fisheries, especially in the Poyang Lake region. The natural environment such as climate and vegetation in Jiangxi Province is suitable for the breeding of Oncomelania hupensis and the transmission of schistosomiasis, which causes Jiangxi Province to become one of the most serious provinces of schistosomiasis epidemic in China. Located in the northern part of Jiangxi Province, Poyang Lake is the largest freshwater lake in China and is water-carrying and influent-effluent lake. From April to June every year, the water level rises to form floodplain and enlarges the lake area, with the inland river flooding and entering into the lake. From July to September, the water level maintains peak and the lake area has a vast view, as a result of the jacking and intrusion effects when the Yangtze River rises. From October to November the flood water subsides, and the water area of the lake shrinks with the marshlands reemerging. The landforms of the lake region can be divided into a waterway, beach, island, inner lake, branching stream, and so on. There are numerous marshlands and flourishing vegetation in the lake area. The elevation is mostly between 14 and 17 m and the area is 133,400 hm2. The Poyang Lake region is a very suitable place for the breeding of Oncomelania hupensis and the transmission of schistosomiasis due to its ecological environment and frequent activities of livestock and human, causing the Lake region has long been the most serious area with schistosomiasis epidemic in Jiangxi Province.

3.2 3.2.1

The Endemic History and Current Status of Schistosomiasis in Jiangxi Province The Endemic History of Schistosomiasis in Jiangxi Province

The exact time of schistosomiasis epidemic in Jiangxi Province has not been conclusive so far, due to the lack of archaeological basis. During the Ming and Qing Dynasties, there were some similar descriptions of the schistosomiasis symptoms in some county annals, traditional Chinese medicine (TCM), ancient books, and ballads in Jiangxi Province. In 1909, Jiujiang customs doctor A.C. Lambert recorded the symptoms occurring commonly among the foreign population in Jiujiang County in detail for the first time in the Jiujiang Health Report. The patients manifested unexplained fever and

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rubella, and the symptoms were called Jiujiang fever or Rubella fever. It was reported that these cases have found Schistosoma japonica eggs in 1911 and were confirmed to be schistosomiasis, which were the earliest cases of schistosomiasis diagnosed by modern medicine in Jiangxi Province. In 1924, American scholars E.C. Faust and H.E. Meieney reported the finding of schistosomiasis patients in Hukou, Jiujiang, De’an, Yongxiu, and Poyang counties by sending an investigation letter to each missionary hospital in Jiangxi Province. In 1937, schistosomiasis patients and Oncomelania hupensis were found in Dexing County, which was the first time Oncomelania hupensis was discovered in Jiangxi Province, confirming that Jiangxi Province was a schistosomiasis endemic area. In 1940, Wu Guang and Xu Bangxian listed the counties where schistosomiasis was distributed in the document The Probable Distribution of schistosomiasis in China, which includes Jiujiang, Hukou, Shahe (now Lianxi District, Jiujiang), De’an, Yongxiu, Nanchang, and Poyang in Jiangxi Province. In 1942, patients and Oncomelania hupensis was found in Taihe County, confirming that it was a schistosomiasis endemic county. From 1946 to 1949, schistosomiasis patients were successively discovered in Yujiang, Fengcheng, and Guangfeng counties, and Oncomelania hupensis was found in Fengcheng County. Before 1949, schistosomiasis cases were distributed in 12 counties in the province, and Oncomelania hupensis were discovered in 2 counties. In 1956, a large-scale survey was conducted in the province. The results showed that the endemic range of schistosomiasis in Jiangxi Province included 33 counties (municipalities and autonomous regions) of 8 cities with districts, such as Nanchang, Jiujiang, Shangrao, Yichun, Yingtan, Jingdezhen, Ji’an, and Ganzhou, 437 townships (towns), and 2715 administrative villages. The survey also indicated that the threatened population was more than seven million, patients were about 530,000, diseased animals were about 200,000, and snail-infested area in history was 2374.52 million square meters. Finally, the endemic range was defined as 39 counties (municipalities and autonomous regions) with the adjustment of administrative divisions and the discovery of new endemic areas in Jiangxi Province.

3.2.2

The Endemic Status and Current Situation of Schistosomiasis in Jiangxi Province

3.2.2.1

The Epidemic Situation of Schistosomiasis

Before 1949 During the Republic of China era, Jiangxi Province only carried out investigations on schistosomiasis investigation, prevention, and control in Dexing County. The schistosomiasis epidemic in the province was not known because of the lack of comprehensive systematic investigation. In 1937, a schistosomiasis survey was carried out in Dexing County. The results showed that Oncomelania hupensis and patients infected with schistosomiasis were discovered in 15 villages, accounting for

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31% of the surveyed villages (15/49). In Daban Village, a highly-endemic area of schistosomiasis, the infective rate of O. hupensis snails was as high as 65%, and the infection rate of schistosomiasis in residents was 16.7% (112/669). 1950 to Early 1980 From 1950 to 1955, the government organized an investigation team to conduct investigations in key areas. For example, in 1953, in Magang and Nigui of Yujiang County, the positive rate of stool examination was 18.72%; in the Qinghua and Licun of Wuyuan County, 149 people were investigated, with a positive rate of 25.74%. According to a survey conducted in 29 counties in 1955, a total of 91,883 residents were examined by stool examination and 13,233 residents with egg positives were found. The average positive rate of stool examination was 14.4%. It was estimated that the number of patients with schistosomiasis in Jiangxi in 1955 reached to 320,000. In 1956, a comprehensive survey based on intradermal experiments was conducted in 1136 townships in 32 counties and cities across the Jiangxi Province. According to the results of the crowd survey, the average positive rate of blood tests in the province was 27.1% (379,853/1,397,546), the highest was in Pengze County (48.37%), and the lowest was in Anyi County (14.3%). The positive rate of stool examination was 12.6%, the highest was Guangfeng County (54.93%), and the lowest was Wan’an County (1.08%). According to the blood test findings, it was estimated that the number of patients was about 530,000. The results of the Oncomelania hupensis survey showed that the province had a total infested area with snails of 18,786.77 hm2, which could be divided into marshland and lake regions and hilly regions according to the main breeding and distribution. There were 18 counties and cities in the marshland and lake regions including Poyang, Yugan, and Jinxian. The infested area with snails was 124,667.29 hm2, accounting for two-thirds of the total in the province. The maximum density of O. hupensis snails is 150/0.1 m2. The infection rate of O. hupensis snails was 0.5–38%. There were 15 counties and cities in the hilly regions, such as Yushan, Guangfeng, and Gao’an. The distribution area accounted for about one-third of the infested area with snails in the province. The maximum density of O. hupensis snails was 495/0.1 m2, and the infection rate of O. hupensis snails was 0–30.1%. From 1956 to 1957, the investigation of livestock infections in Ruichang, Jiujiang, and Shangrao proved that not only cattle, pigs, sheep, dogs, and other animals were infected with schistosomiasis, but the infection rate was very high. For example, in 1956, the infection rate of cattle was as high as 57.4%, and that of water buffalo was as high as 31.3% in three farms in Jiujiang City. In 1958, the schistosomiasis livestock prevention and control team organized by the Jiangxi Provincial Department of Agriculture and the Jiangxi Agricultural College investigated 12,029 cattle in five counties including Poyang, Yujiang, De’an, Yongxiu, and Fuliang and discovered 3850 infected cattle while the infection rate of cattle was 31.80%. According to a survey conducted in 29 counties in 1955, 91,883 residents were examined by stool examination, and 13,233 patients with schistosoma eggs were detected. The average infection rate was 14.4% with about 320,000 cases of schistosomiasis in Jiangxi at that time.

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province

29

With the progress of schistosomiasis prevention and control, by the early 1980s, the endemic status of schistosomiasis in the hilly regions was effectively controlled. In 1958, snail survey was conducted in 2523.6 m2 of Yujiang County, and 43 O. hupensis snails were discovered. No infected snail was found. The average density of live snails was 0.0018/0.1 m2. 472 cases underwent stool examination, and 11 cases had stool examination positive, the positive rate of stool examination was 2.33%, and the infection rate of cattle was 5.27%, reaching the criteria for elimination of schistosomiasis at the time (criteria for current epidemic control). From 1977 to 1978, four counties and cities such as Fengcheng, Hukou, De’an, and Jiujiang reached the basic criteria for elimination of schistosomiasis. From 1981 to 1984, nine hilly regions such as Shangyou, Shanggao, Dexing, Shangrao City, Guixi, Jingdezhen, Fengxin, Wuyuan, and Taihe reached the basic criteria for elimination of schistosomiasis. However, the endemic status of schistosomiasis in the Poyang Lake area, especially in eight counties along the lake, was still serious. For example, the positive rate of stool examination in some areas of Poyang County was 23.53% in 1981. The detection rate of eggs in the Changshan Group of the Shuanggang Commune in Poyang County was close to 30%; the prevalence rate of schistosomiasis in the Fisheries Group, Jishan Group, and Dingshan Group of the Wucheng Commune in Yongxiu County was 48%, 35.7%, and 31.1%, respectively. The prevalence rate of schistosomiasis in Aiguo Group and Fengfu Group of Sanli Commune in Jinxian County was 37.7% and 52%, respectively. The average prevalence rate of schistosomiasis in three production teams along the lake in Xingzi Dongguang Group was 39%. At the same time, due to the reform of the production system, the number of persons with water contact increased, and the number of acute schistosomiasis cases increased year by year. From 1976 to 1980, the number of acute schistosomiasis cases increased from 274 to 1507. In addition, the infection rate of livestock in the lake region is also high. According to a survey conducted in Jinxian County in 1980, the infection rate of cattle in the four groups of Sanli Commune was 43%, that of buffalo was 17.7%, and that of pigs was 16.7%. The infection rate of cattle in Wucheng Commune of Yongxiu County in 1981 was 21.87%. Mid-1980s to 2003 In 1989, the first sample survey of the prevalence of schistosomiasis was carried out in 12 villages in 8 counties (cities, districts) of the controlled endemic areas and 23 villages in 13 counties of uncontrolled endemic areas. A total of 6343 cases underwent stool examination in the controlled endemic areas, and no positive of stool examination was detected; 6330 cases underwent blood test, 119 had positive blood test, and the positive rate was 1.88%. There were 24,806 manures in uncontrolled endemic areas, and the infection rate was 5.52%. 397 cattle were examined, the infection rate was 10.83%. 1484 water buffalo were examined, and the infection rate was 7.61%. 201 pigs were examined, and the infection rate was 3.48%. In 1995, the second sample survey of the prevalence of schistosomiasis was conducted in Jiangxi Province. A total of 37 sample villages in the affected areas

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were surveyed, including 14 villages in the controlled endemic areas and 23 villages in the uncontrolled endemic areas. The number of children aged 10–14 years in the controlled epidemic area was 2353, and the positive rate of IHA was 1.49%. No positive result of stool examination was discovered. There were 25,661 residents in uncontrolled epidemic areas, and the infection rate was 3.80%. According to the findings, it was estimated that the estimate of schistosomiasis cases was 100,122, and the estimate of advanced schistosomiasis cases was 5700, while the prevalence rate of schistosomiasis was 0.76%. The infection rates of cattle, water buffalo, and pigs were 4.83%, 3.06%, and 1.15%, respectively. In 1995, Gao’ a City, Guangfeng County, Nanchang City, and Xunyang District of Jiujiang City reached the criteria for elimination of schistosomiasis, and Yushan County, Shangrao County, and Lushan District of Jiujiang City reached the basic criteria for elimination of schistosomiasis. According to statistics in 2003, there were 39 endemic counties (cities, districts) and 2318 endemic villages in the province. The total population of endemic villages was 4,426,600. There were about 130,000 schistosomiasis patients in the province, 5154 patients with advanced schistosomiasis, and 126 patients with acute schistosomiasis. 2004–2015 In 2004, the third sample survey of the prevalence of schistosomiasis was conducted in Jiangxi Province. A total of 16 counties and 23 administrative villages were investigated. The positive rate of ELISA was 14.80% (3480/23,512); 3390 people underwent stool examination, 358 people had stool examination positive, and the average positive rate of stool examination was 3.12%. A total of 1393 livestock underwent stool examination, and the infection rates of cattle, water buffalo, and sheep were 3.33%, 4.45%, and 0, respectively. The total area of sampling environment of snail survey was 3316.2811 hm2, the survey area was 2828.8927 hm2, the infested area with snail was 2011.8565 hm2, the infective area of O. hupensis snails was 36.245 hm2, the average density of O. hupensis snails was 0.6314/0.1 m2, the average density of Schistosome-infected O. hupensis snails was 0.001/0.1 m2, and the infection rate of O. hupensis snails was 0.17%. In 2008, eight counties including Nanchang County, Xinjian County, Jinxian County, Duchang County, Yongxiu County, Xingzi County, Pengze County, Ruichang City, and Gongqing City met the national criteria for transmission control of schistosomiasis. During the period 2004–2013, High-tech District of Nanchang City, Development District of Jiujiang City, De’ a County, Shangrao County, Xinzhou District, and Fengcheng City successively reached the communication blocking standard. In 2015, the province reached the criteria for transmission interruption.

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province

3.2.2.2

31

Current Situation of Schistosomiasis in Jiangxi Province

Until 2016, there were 39 endemic counties (cities, districts) in Jiangxi Province with a total population of 19,468,700; there were 317 endemic townships and 2182 endemic administrative villages, and the population of endemic villages was 4,950,700. The estimate of schistosomiasis cases was 12,212 in the province, and the estimated number of advanced schistosomiasis cases was 5101. No cases of acute schistosomiasis were discovered. A total of six cases of positive stool examination were discovered. Oncomelania hupensis survey was conducted in a total of 108,356.99 hm2, and the infested area with snail was 31,668.6 hm2. No schistosomeinfected O. hupensis snail was discovered. In 2016, there were 101,630 cattle in the endemic area, a total of 61,808 cattle, and 5 cattle had schistosomiasis infections according to positive stool examination. In 2016, the number of cattle in the endemic areas in Jiangxi totaled 101630, of which, 61808 received stool examination. And five infected cattle were detected. In 2016, there were 78,486.86 hm2 of infested area with snails in the province, of which marshland and lake regions were 76,056.54 hm2, and hilly regions were 2430.22 hm2, accounting for 97% and 3%, respectively. The total area of mollusciciding was 121,15,300 m2, of which the actual mollusciciding area was 8314.86 hm2, and the environmental transformation area was 216.70 hm2. Compared with the beginning of schistosomiasis prevention and control, schistosomiasis cases, infected animals, and snail-infested area decreased by 97.7%, 99%, and 64.9%, respectively. It reached the national criteria for transmission control of schistosomiasis in Jiangxi Province in 2015. Among the 39 endemic counties, 10 counties reached the national criteria for elimination of schistosomiasis, 14 counties reached the criteria for transmission interruption, and 15 counties were in the stage of transmission control.

3.3

The Endemic Characteristics of Schistosomiasis in Jiangxi Province

Jiangxi Province is a severe endemic area of schistosomiasis in China. In the 1950s, the snail-infested area was investigated to be 17,078,817 m2 in total in the province. The maximum density of Oncomelania hupensis snails was 150 snails/0.1 m2 in the region most suitable for snail breeding in Poyang Lake, such as fork beach, islet beach, and river beach. The infective rate of Oncomelania hupensis snails was 0–53.8%. In 15 hill-type counties and municipalities such as Yushan, Guangfeng, and Gao’an, the Oncomelania hupensis mainly breed in the drainage and irrigation ditch, pond, paddy field, waste land, and other environments. The distribution area accounted for about one-third of the infested area with snail in the province, the maximum density of Oncomelania hupensis snails was 495/0.1 m2, and the infection rate was 0–30.1%. The distribution area of Oncomelania hupensis—the intermediate

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host of schistosomiasis—in Jiangxi Province, the northernmost part, is Mianchuan Township, Pengze County (east longitude 116
400 , north latitude 30
040 ), the southernmost part is Dongshan Town, Shangyou County (east longitude 114
320 , north latitude 25
480 ), east to Xiazhen Township, Yushan County (east longitude 118
250 , north latitude 28
380 ), and west to Yingqian Township, Shangyou County (east longitude 114
170 , north latitude 25
560 ). As far as the distribution elevation of Oncomelania hupensis (Wusong elevation), the highest is Xiaoyangtang Pond, Baxiandong Village, Zihu Township, Yushan County, with an elevation of 783 m. The lowest is Banghu Lake marshland in Xingzi County of Poyang Lake Region (before 2003 when the Three Gorge Dam project), with an elevation of 13.5 m. In 1955, a series of stool examinations of 91,883 people were conducted in 29 counties and municipalities, 13,233 positive cases were detected, and the infection rate was 14.4%. According to these statistics, the number of schistosomiasis patients in the endemic areas was estimated to be about 320,000. In 1956, according to incomplete statistics in 32 counties and municipalities of endemic areas, and in 1136 townships, 1.39 million people received the skin test, the average positive rate was 27.1%, and the number of people inspected accounted for 64.5% of the total population of the endemic area. Based on these statistics, it is estimated that there were about 530,000 patients in the province. The number of residents examined by stool microscopy totaled about 110,000, with 12.6% an average positive rate of stool test. Before 1952, there were no records of livestock infection with schistosomiasis. During 1956–1958, a series of investigations on the counties of Jiujiang, Ruichang, Shangrao, Boyang, Yujiang, De’an, Yongxiu, Fuliang, etc., found that cattle, pigs, sheep, dogs, and other animals were infected with schistosomiasis with very high infection rate. Especially, the infection rate in 3 cattle farms in Jiujiang was as high as 96.49%. In 1958, a total of 12,029 farm cattle were investigated, and 3850 infected cows with schistosomiasis were found, with an infection rate of 31.8%. Based on the characteristics of the geographical environment, the distribution of snails, and the transmission of schistosomiasis, the schistosomiasis endemic areas in Jiangxi Province can be roughly classified two types, i.e. lake-marshland regions and hilly regions. By the end of 2016, among the 39 schistosomiasis endemic counties (municipalities and autonomous regions) in Jiangxi Province, 24 of them had reached the criteria for transmission interruption of schistosomiasis successively, 4 had reached the criteria for elimination of schistosomiasis, and 11 had reached the criteria for transmission control of schistosomiasis. The endemic status of schistosomiasis in the province has dropped to the lowest level in history.

3.3.1

Hilly Endemic Regions

There are 22 counties (cities, districts) in Jiangxi Province, mainly in hilly endemic areas. By the end of 2016, Wuyuan, Yujiang, Changjiang, and Fuliang counties

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province

33

reached the criteria of elimination, and 15 counties achieved transmission interruption. Yushan, Pengze, and Ruichang counties reached the criteria of transmission control. The epidemic status in hilly endemic areas of schistosomiasis was under control (Table 3.1).

3.3.1.1

Source of Infection

Population Infection The infection rate of the residents in the hilly endemic regions was positively correlated with the infection rate of local Oncomelania hupensis, and the size of the Oncomelania hupensis areas did not directly affect. Age, gender, education level, and other factors of the population are not important factors influencing the difference of schistosomiasis infection in different seasons. This may be related to the fact that there is no significant difference in the intensity and frequency of people’s exposure to water contaminated with cercariae in different seasons. However, the infection rate of farmers in summer is significantly higher than that of students in summer, which is mainly caused by exposure to water contaminated with cercariae during the summer harvest and planting period. In some areas, the distribution of schistosomiasis patients showed obvious family aggregation. In the 1950s, there were a total of 15,466 residents in Gucheng District in Yushan County, of which 11,000 were infected with schistosomiasis, accounting for 72% of the total. Especially in Shangyangban Village of Taiping Township, of 148 residents in 47 households, 113 residents were infected with schistosomiasis, with an infection rate of 76.4%, and 305 people died in the village during 1940–1954 due to schistosomiasis infection. Eleven youths aged 16–23 years with schistosomiasis become dwarves. The infection rate of young residents aged 10–24 years in the township was up to 72.8%. In 1992, the population infection rate of Hengtang Village in Yushan County was 3.40%, of which the infection rate of children aged 7–14 years was 7.26%; there was no positive patient in Siguqiao Village. In 1992, the population infection rate of Jindi Village in Ruichang City was 11.98%, and that of children aged 7–14 years was 8.18%. The population infection rate of Datang Village was 2.68%, and that of children aged 7–14 years was 2.44%. No infection was found in the population of Tanshan Village. In 1958, Yujiang County, a hilly endemic region in Jiangxi Province, was the first to reach the criteria for elimination of schistosomiasis. In succession, counties such as Shangyou, Wuyuan, Fuliang, Fengxin, Taihe, and so on achieved the eradication of schistosomiasis, while 12 counties such as Yushan reached the basic criteria for elimination of schistosomiasis. The hilly endemic regions of schistosomiasis can effectively reduce the infection of the population through the implementation of comprehensive measures. No patients with positive stool examination were found in Yujiang, Guangfeng, De’an, and Shangrao in 1958, 1987, 1982, and 2000, respectively (Table 3.1).

Province (city, district) Yujiang County Shangyou County Fengxin County Fuliang County Guixi City Shanggao County Dexing City Wuyuan County Taihe County Wuning County Wanan County Anyi County Guangfeng County

0

0

0

0 0

0 0

0

0

0

1

4

2

5

4

1 15

9 3

12

5

5

18

39

No. of endemic villages 14

No. of endemic villages at present 0

15.3

5.21

1.29

1.67

1.98

2.17 0.70

0.3 2.39

0.72

0.69

0.93

No. of people living in endemic villages 3.08

82

56

0

28

0

60 52

0 21

14

62

0

No. of advanced schistosomiasis cases 0

317.42

223.00

130.00

2994.00

450.38

610.76 53.08

12.00 233.00

107.22

758.00

7.38

Total area detected snails in history (hm2) 97.40

Table 3.1 Current endemic situation of schistosomiasis in Jiangxi Province, 2016

2.51

1.00

0

0

0

0 0

0 0

0

0

0

Area detected snails at present (hm2) 0

1995

1987

1987

1986

1984

1984 1984

1983 1983

1983

1981

1981

Year achieved transmission interruption 1958

2015

2010

1984

1981

1981

1974 1992

1963 1998

1970

2004

1968

Year detected snails the last time 1983

1987

1997

1977

1983

1976

1977 1990

1963 1974

1981

1981

1979

Year detected infected residents the last time 1958

1984

1997

1977

1983

1974

1973 1990

1963 1965

1981

2004

1979

Year detected infected cattle the last time 1958

34 Y. Liu et al.

Gaoan County Dean County Changjiang County Xinzhou County Fengcheng City Shangrao County Yushan County Pengze County Ruichang County Total

0

1

0

1

0

0

76

111

77

271

34

11

1

28

91

61

158

161

104

781

182.56

19.53

30.31

36.04

21.03

22.78

8.63

0.16

1.79

5.80

1721

209

154

248

270

196

82

4

25

158

34190.62

6979.21

14347.03

6190.60

1665.79

6918.00

131.17

18.37

756.00

2769.00

2957.77

849.64

1941.52

158.43

0

0

0.67

0

4

0

2010 – – – –

– – – –

2010

2009

2003

2015

2012

2013

2011

2011

2006

2004

1995

–

2014

2017

2012

2000

2009

1979

1984

1994

1985

–

2011

2015

2012

2007

2005

1979

1984

1994

1985

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province 35

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Y. Liu et al.

Due to the impact of the end of the World Bank Loan Project and the severe flood in 1998, the Oncomelania hupensis have spread, but under the influence of strengthening control measures, the population infection rate is declining. In Shangrao County, no patients with positive stool examination were found after 2000, and the positive rate of IHA in the population also fluctuated at a low level of irrigation channel > cultivated land > waste-glass land. Particles of soil and silt sand (0.02–0.002 mm), soil’s total content of phosphorus, and soil humidity are the most important factors that affect the growth of Oncomelania. The infectious Oncomelania is distributed in different susceptible environment, mainly in ditches, secondly in or around farmland, mudland, pond and river channels. The peak seasons of the appearance of infected snails are usually in summer and autumn (from April to October). Water surveys showed that the infection rate of Oncomelania ranged from low to high from upstream to downstream. Infected Oncomelania has also been found in some areas where residents have less activities, which may be related to the activities of wild animals and their feces pollution. But

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Y. Liu et al.

local Oncomelania hupensis is less likely to be infected by foreign Schistosoma japonica miracidium. The total area detected snails of Yujiang county is 97.4 hm2. From 1958 to 1983, 35 remaining snails’ sites were found one after another 52 times. The accumulated snail area in Yujiang County is 97.4 hm2. During 1958–1983, 35 remnant snailinhabited spots were found one after another, and no new snail spot has been found since 1983. Biological Characteristics of Oncomelania Precipitation and heat are generally low in hilly areas. In hilly areas, the accumulated temperature is relatively low, which leads to the arrested development of Oncomelania at the junction of autumn and winter. The snails are smaller and shorter than those living in the waterway network and marshland and lake regions. But they are slightly larger than the smooth-shelled Oncomelania living in Yunnan and Sichuan. The height of Oncomelania is between 5.8 and 6.9 mm, and the width is no more than 2.85 mm, only with shallow costate lines. The lifespan of most Oncomelania is 1 year, while few of them may live up to 3 years. The mating, egging, and development of snail area affected by multiple factors such as water temperature, air temperature, and soil, vegetation, etc. Due to the difference in climate, snails in different places have different mating times. 15–20
C is the most suitable temperature for them to mate. While the space between snails is 0.5 m or within 1738 cm2, they have the biggest chance to mate. The proper temperature of the soil for it to lay eggs is between 20 and 25
C and suitable soil humidity is 40.1%. The development of Oncomelania needs water. Only in the water or wetland can it hatch. When the temperature ranges from 13 to 23
C, time that it needs to hatch changes. The higher the temperature, the shorter time that it needs to hatch. It takes approximately 2.5 months for it to hatch and mature, mainly due to local climate, environment, and other factors.

3.3.1.3

Route of Transmission

Residents living in the hilly regions generally contact water through the activities of agricultural production and daily life, such as transplanting rice, plowing farmland, washing clothes, vegetables and agricultural tools, etc. They generally use water from streams in front and behind the house and near the farmland. If there are Oncomelania hupensis breeding nearby, there is a risk of contracting schistosomiasis; in summer, children and young children are often infected by swimming in ponds, rivers, and streams, playing in the water, or catching fish and shrimp. The many ways of residents getting infection by productive activities include transplanting rice, fertilizing, weeding, harvesting rice and dredging rivers, irrigation, aquaculture, grazing, which need residents to contact water.

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province

3.3.1.4

39

Endemic Factors

The main ways for people to contact the water with cercariae include daily life activities and agriculture production activities. The Oncomelania hupensis are mainly distributed in irrigation ditches, and the water contaminated with cercariae can enter rice fields, rivers, and ponds with irrigation. Therefore, people get infected with schistosomiasis when they come into contact with water contaminated with cercariae in the process of productive labor in rice fields, washing agricultural tools and washing hands and feet in ditches, and washing clothes in ponds, etc. Children are infected mainly by playing with water in the ditches.

3.3.2

Marshland and Lake Endemic Regions

The endemic areas and endemic status of schistosomiasis in Jiangxi Province are mainly concentrated in 12 counties (cities, districts) along the coast of Poyang Lake. The area of patients, affected animals, and Oncomelania hupensis accounted for 81.0%, 78.3%, and 96.9% of the province, respectively. It has always been the focus and difficulty of the prevention and control of schistosomiasis in Jiangxi Province.

3.3.2.1

Source of Infection

Population Infection The original schistosomiasis patients in the Poyang Lake region were 340,000. After more than 60 years of active prevention and control, especially since the implementation of the new strategy, the number of patients has dropped to the lowest point in history. In 2016, there were only 12,212 patients and 6 patients with positive stool examination. From 1982 to 1993, there were 7809 cases of acute schistosomiasis in the lake region, accounting for 99.3% of cases in the whole province. The number of cases dropped significantly since 1992, and no cases of acute schistosomiasis were found since 2012, which is related to the vigorous implementation of new comprehensive prevention and control measures by the Chinese government. In the Poyang Lake region, the main population infected with schistosomiasis include fishermen, boatmen, herdsmen farmers who have to contact cercariae contaminated water frequently for their production and living. Poyang Lake is rich in aquatic resources, and fish production accounts for more than 70% of the province. Therefore, there are many fishing boats and fishermen in the Poyang Lake region, which are widely distributed and have a wide range of popularity. According to the survey results in July 2010, there are 17,690 fishing boats, 42,387 fishermen, and 259 large-scale distribution centers in 11 counties (districts) along the Poyang Lake. Due to their production activities needing contact water frequently, the infection rate of schistosomiasis in fishermen and boatmen has always ranked first in all

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Y. Liu et al.

occupations with more than 30% of prevalence. However, with the increase of prevention and control and the growth duration of low water level in Poyang Lake, the infection rate of fishing boat people has shown a downward trend. Poyang Lake can be used for fishing all year round. The main fishing season is from January to March and from July to September. 64.6% of the fishermen come in contact with water contaminated with cercariae for about 9 months. During the water operation, 91.8% of the waste of fishing boat people is discharged directly into the waters. Humans, livestock, and other wild mammals are the definitive hosts of schistosomiasis, and the period of infection with schistosomiasis is mainly concentrated in the spring and autumn (March to June and September to October). Younger children, adolescents, and people from non-endemic areas lack acquired immunity, so they are more susceptible to schistosomiasis infection, and are prone to acute schistosomiasis, and clinical symptoms are more serious. During 30 years before 1949, 15,027 households in 334 villages in the Poyang Lake region were destroyed and 70,328 people died due to schistosomiasis. In the 1950s, the epidemic status of schistosomiasis in the Poyang Lake region was almost as same serous as before. The positive population rate of stool examination in many villages near the lake region was as high as 30%, and the population prevalence rate in some villages reached over 80%. The endemic status in Islet beach-type of an endemic area in the Poyang Lake was the most serious. In 1960 and 1966, the positive rate of stool examination in Nanjishan was 60.2% and 57.9%, respectively, and that in natural villages was as high as 79.8%. The distribution of infection rate was higher in males than in females. There was no significant difference in the infection rate among all age groups. People over 5 years old have been infected. In the 1980s, 5% of villages in the lake region had a population infection rate of 30–40%, and the population infection rate of Nanji Township in Xinjian County was as high as 57.9%. According to a survey in 1987, the population threatened by schistosomiasis in the Poyang Lake region is 2.5 million. There are 930 endemic administrative villages, 129 severely affected villages with the schistosomiasis infection rate of the residents >20%, accounting for 14.3%. There are 200,000 patients, including more than 3000 cases of advanced schistosomiasis and about 1000 cases of acute schistosomiasis every year. The results of the stool examination in the 1990s showed that the schistosomiasis infection rate of village residents reached 55.6%, the male infection rate was higher than that of females, and the infection rate peaked at young adults (15–40 years old). Among the occupational groups, the semi-agricultural and semi-fishing population had the highest infection rate of 80.7%, which was significantly different from other occupational groups ( χ 2 ¼ 16.1482, P < 0.01). Since the implementation of the World Bank Loan Project in 1992, the endemic status in various endemic areas in Poyang Lake region has been significantly reduced. The average infection rate of the population in the villages with severe and moderate endemic areas has dropped from 16.6% and 4.8% in 1992 to 6.8% and 1.4% in 1999, with a decrease of 59.0% and 70.8%, respectively. Due to the devastating floods in 1998, the population infection rate in some areas of the lake

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region increased from 2001 to 2002, and the positive rates of stool examination in the three villages of Yufeng, Aiguo, and Hongwei in Nanchang County, Jinxian County, and Xinjian County increased significantly, reaching 3.08%, 13.67%, and 13.38%, respectively. In 2005, after the implementation of a comprehensive strategy with emphasis on infection source control in Poyang Lake region, the prevention and treatment effect was remarkable. In 2016, the number of schistosomiasis patients fell to 10,301, a decrease of 89.64% compared with 2005, showing a downward trend year by year. The number of cases of acute schistosomiasis infection decreased significantly and did not appear after 2013; the population infection rate decreased significantly by 99.45%. The results of national surveillance points showed that the adjusted infection rate of schistosomiasis in the Poyang Lake region generally declined, from 5.43% in 2005 to 0 in 2015. During the period from 2005 to 2007, the decrease was higher. After 2009, it remained below 1% and gradually decreased. In 2016, it rebounded slightly but decreased significantly compared with 2005 ( χ 2 ¼ 171,673, P < 0.05). The infection rate of fishing boat people also dropped significantly. The results of the surveillance points of fishing boat people showed that the positive rate of blood test and the positive rate of pathogens in the fishing boat people in 2016 were 7.10% and 0.07%, respectively, which were 73.52% and 97.13%, respectively, lower than those in 2012. The adjusted infection rate decreased year by year. Only one case of positive stool examination was detected in 2016, and the adjusted infection rate was 0.005%; the difference was statistically significant compared with 2012 ( χ 2 ¼ 63,386.78, P < 0.05). Reservoir Host Infection Situation In addition to human, the Poyang Lake region has livestock such as cattle, sheep, and pigs, as well as wild animals such as hares, deer, wild boars, crickets, and rats, all of which can be infected with schistosomiasis. In this region, the reservoir hosts with the epidemiological significance of schistosomiasis transmission are mainly livestock, especially cattle as the main reservoir host and infectious source, which play an important role in the prevalence of schistosomiasis. In 1956, the infective rates of cattle and buffalo in the four farms in Jiujiang were 27.3% and 5.5%, respectively. In 1958, the average infective rates of Yongxiu cattle and buffalo were 45.1% and 13.3%, respectively, and in the same year, the average infective rate of cattle in six counties includind Poyang was up to 31.8%. Due to the self-healing phenomenon of buffalo, the positive rate of cattle is generally higher than that of buffalo under normal circumstances. The infection of cattle is not related to gender, but it is closely related to age. The infective rate under 3 years old is higher than 3 years old. In 1957, the infective rate of cattle within 1 year of age in Jiujiang County was as high as 73.5%. A survey of Poyang Lake and Dongting Lake in 1998 showed that schistosomiasis eggs from cattle within 2 years old accounted for 74% of the total contaminated eggs. A survey from 1996 to 2002 of two administrative villages in Wucheng town and Yongxiu county showed that cattle in this area were the main infection source, with infected cattle under 3 years old accounting for 89.0% of the total number of infected cattle.

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The high infection rate of the calf is not only related to the lack of nasal wear leading to the inclination of missed diagnosis or treatment, but also related to their susceptibility. In addition, bovine schistosomiasis can be infected through the placenta. The infection rate of in pigs is related to rearing ways, higher in regions where pigs are reared outside pens than in pens. In 1958, the infective rate of schistosomiasis in pigs in Wucheng Town and Yongxiu County was 51.8%. In 1983, the infection rate of schistosomiasis in pigs in Poyang Lake marshland in Yugan County was 29.87%. The infective rate of schistosomiasis in dogs was relatively high, and acute symptoms such as blood in stool appeared after infection, also with more eggs in stool. In 1958, 60 dogs were examined with the infection rate of 56.7%, and the average infection rate of dog in six counties of Jiangxi province was 49.3%. The infection rate of schistosomiasis in sheep is generally higher. The average infective rate of schistosomiasis in the sheep of 6 counties including Poyang investigated by Jiangxi Agricultural College in 1958 was 1.2%, and the infective rate of goats was 3.2%. The species of wild animals infected with schistosomiasis in Poyang Lake region vary from region to region. In the 1950s and 1960s, there were many infections of small rodents, and the dominant species was Rattus norvegicus with the relatively high infective rate. The second species was the hare and the infective rates were low for Rattus rattus and Apodemus. In 1960, the infective rates of Lepus sinensis, muntjacs, and hydro poles in the Xingzi County of Jiangxi Province were 26.1%, 87.6%, and 16.7%, respectively. After decades of prevention and control, the infective rate of livestock schistosomiasis in the Poyang Lake region has decreased significantly. In 1989, a sample survey of schistosomiasis in Jiangxi Province showed that the infective rates of cattle, buffalo, and pigs in the marshland and lake regions were 10.83%, 7.61%, and 3.48%, respectively. In 1995, the survey showed that the infective rates were 4.83%, 3.06%, and 1.15%, respectively. In 2003, the survey showed that the infective rates of cattle, buffalo, and other livestock in the marshland and lake regions decreased further, which are 3.33% and 4.45%, respectively (pigs were not investigated due to their captive breeding). In addition, with the population growth in the lake region, the increase of the frequency of human activities and the changes of the ecological environment, the types, and quantity of mammalian wild animals in the lake region are gradually reduced, while the rodents played little role in the infection source of schistosomiasis due to their small amount of feces. Therefore, the role of wild animals in the transmission of schistosomiasis in the Poyang Lake region is of little significance. In summary, schistosomiasis infection in livestock in the lake region is widespread, but the degree of infection is different. The infective rates of cattle and pigs in the lake region are higher than that of other livestock. However, as pigs have been generally reared in pigpens in recent years, cattle are the main infection source of schistosomiasis in Jiangxi province at present. The epidemiological significance of the infection source is mainly determined by the transmission energy, which is not only related to the quantity of the infection source, but also related to the infection rate, the degree of infection, the defecation frequency, and the amount of feces discharged. The season of the event is also related.

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The snail-infested area in Poyang Lake region is 78,933 hm2, with large snail area and wide distribution of snails. The snail-infested marshland is also a natural pasture for cattle and other livestock. At present, the number of cattle in Poyang Lake region is 74,132, of which 28,409 are grazing freely in the marshland of lake region. According to reports, the average daily defecation of a buffalo, cattle, a pig, and a human being is 25 kg, 20 kg, 3 kg, and 0.15 kg, respectively, so the amount of defecation of cattle is huge. In the lake region, the marshlands were a natural pasture in spring and autumn, and are grazed by cattle for 6–8 months in a year. Therefore, the cattle feces in marshland is seriously polluted. Studies have shown that more than 90% of the schistosomiasis infections in the Poyang Lake marshland originate from free-range cattle. The serious contamination of Schistosoma eggs in cattle feces in the marshland has caused widespread infection source. The survey results show that in most marshland and lake endemic regions, the amount of feces and eggs discharged from cattle are much higher than those from human. More than 95% of the animal feces in the marshland is from livestock. The number of eggs in the cattle feces accounts for more than 95% of the total number of eggs in the animal feces, and the eggs in feces of human and other wild animals are less than 5%. Between 1987 and 1989, investigations on the pollution of animal feces in eight representative areas including Poyang Lake and Dongting Lake showed that feces of pig, cattle, and dog accounted for 68.7%, 14.3%, and 17.1%, respectively. Of the annual index of real contamination (IRC), foreign livestock accounted for 29.3%, while local livestock accounted for 70.7%; in the fork beach type of endemic area, cattle feces accounted for 99.3%, while human feces accounted for 0.7%, and 367 positive animal feces were all cattle feces. The cattle feces accounted for 75.5% of the annual IRC, of which the foreign cattle accounted for 53.9%; of the animal feces in the endemic lake embankment region, the feces of cattle, pig, dog, and human accounted for 90.4%, 8.4%, 1.1%, and 0.1%, respectively, positive animal feces accounted for 85.4%, 11.9%, 0.9%, and 1.8%, respectively, and cattle accounted for 69.8% of the annual IRC, while human accounted for 21.4%. In addition, the piles of cattle feces are not easy to dry after being discharged. In regions of low temperature and humid climate, the Schistosoma eggs in the cattle feces can still hatch into miracidium after several months. The snail-infested marshland with concentrated grazing cattle herd is also the region with the highest infective rate of Oncomelania hupensis snails and the maximum density of snails and is also the root cause of the formation of susceptible regions. The abovementioned results indicate that cattle play a major role in the prevalence of schistosomiasis in the Lake regions. Field investigations show that the infective rate of Schistosoma in cattle in Poyang Lake region is high and is closely related to the infective rate of humans. In areas with high infective rate of schistosomiasis in farm cattle, the infective rate is also high in humans. In recent years, field experiments have further confirmed the important role of cattle in the transmission of schistosomiasis in the Poyang Lake region. From 1996 to 2002, two islet beach-type villages in Wucheng Town of Poyang Lake were studied. One village (Jishan Village) treated all residents and buffaloes while another village (Hexi Village)

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only treated all the residents. After 4 years of observation, the infective rate of residents in Jishan Village had decreased, while it increased in Hexi Village. The infective rate of schistosomiasis in the third year was reduced by 70% in Jishan Village (P ¼ 0.027); it is particularly noteworthy that the infective rates of cattle under 3 years in Jishan Village and Hexi Village were 2% and 18%, respectively, and the infection rates of cattle older than 3 years were 0% and 2.9%, respectively, indicating that cattle less than 3 years have a greater role in transmission; the mathematical model established in this study determined that the role of buffalo in the transmission of schistosomiasis in Jishan Village accounted for 75.0%. With the improvement of people’s living standards, the increase in the demand for meat and the implementation of the policy “returning farmland to lake, returning the grain plots to forestry” in the lake region, the area of the river beach in the Poyang Lake region has expanded, and the development of herbivores such as cattle and sheep has developed greatly. The prevention and control of animal schistosomiasis in epidemic areas has become a key and difficult point. The opening of freeranging cattle in the marshland has become the main contradiction in the prevention and control of schistosomiasis in the lake region. During the period of 2005–2016, the number of farm cattle decreased from 138,637 to 68,159 with a range of 50.84%, and the number of infected cattle dropped sharply from 2893 to 5 with a range of 99.83%. However, the number of cattle in 2016 has increased compared with 2015 and there was a problem of rehabilitation of cattle after elimination in the Poyang Lake region.

3.3.2.2

Biological Characteristics of Oncomelania

Distribution of Oncomelania hupensis The ecological research of Oncomelania shows that lakeshore of Poyang Lake, which is described as “dry in winter but soggy in summer,” is the ecological environment that decides their lives. The foundation of the bottomland soil is mainly sediment, and the soil is meadow soil. The layer is deep. The soil body is loose and porous, with good permeability. It is rich in organic content and it has flourish vegetation, making it suitable for the breeding of Oncomelania. Due to the vast area of bottomland, the snails gather together, presenting a flaky distribution. In some places, they present two linear distribution (the highest line detected snails and the lowest line detected snails), and three zonal distribution (the upper band with few snails, the band with high density, and the lower band with few snails). At present, the Oncomelania mainly distributes in lake type of epidemic area in Jiangxi province, with an snail-inhabited area take up 96.90% of the total. The Three Gorges Hydroelectric Power Station is the biggest hydro-junction project in the world as well as the key project to control, develop, and protect the Yangtze River. It serves for preventing flood, generating electricity, shipping, and replenishing water. This project was put into operation in 2013. It experienced cofferdam and impoundment stage, initial cofferdam stage, and experimental cofferdam stage one after another, and it has made a huge profit. Meanwhile, it greatly

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impacted the hydrological condition of midstream and downstream. The Oncomelania mainly distributes in bottomland of 11–16 m before 2003. Usually, there was a band with a high density of snails (the Yellow Sea level) of 12–15 m high. At the same time, the global climate change has led to an increase in Poyang Lake’s low and dry water level operation time, which resulted in the moving of distribution of Oncomelania “two lines and three bands.” At present, the distribution of snails in the south of the lake varied greatly compared to that lives in the north with the difference of 2 m in the band that is close to thewater. Meanwhile, the highdensity band of snails changes. The Oncomelania in the south of bottomland distributes in 11–16 m, with 2 high-density bands, which are 12–13 m and 15–16 m high. In the meantime, snails living in the north distribute in 9–16 m, with only one high-density band, which is 12–14 m high. The survey on Oncomelania living in some of the bottomland of Poyang Lake showed that the average density of it is 7.4/0.1 m2 in 1979 and it dropped to 0.8/ 0.1 m2 in 1980 due to land reclamation and mollusciciding. The occurrence rate of the frame-detected snails decreased from 57.7% to 27.5%. The average density of Oncomelania living in bottomland without any snail control increased from 0.42/ 0.1 m2 to 1.83/0.1 m2, and the occurrence rate of the frame-detected snails increased from 14.9% to 72.5%. So, only when we adopt appropriate measures in different bottomland can we control the density of Oncomelania effectively. In the 1980s, the average density of snails was approximately 0.54/0.1 m2, among which the snails living in the weeds had the highest average density up to 0.72/ 0.1 m2. No Oncomelania was found in bottomland used to cultivate and store water. From 2005 to 2012, the comprehensive data of 12 epidemic monitoring stations of the whole province showed a sharp decrease in the average density of living snails and infected snails, from 1.4411/0.1 m2 in 2015 to 0.0835/0.1 m2 in 2012. In the 1950s, the infection rate of Oncomelania in Poyang Lake reached up to 53.8%. In the 1980s, 747 infected Oncomelania were found in 615 bottomlands and the average infection rate was 0.0026%. The snails infected with Schistosoma japonica cercariae presented an agminated distribution, matching on the negative binomial distribution and Polya-Eggenberger distribution. It often appeared in the bottomland that is 5–6 km away from the villages, and it was positively related to the pollution degree of human and animal excrement and density of Oncomelania. It was the reason why bottomland with many human activities, severe fecal pollution, and breeding of snails was likely to be susceptible to schistosomiasis. According to the Oncomelania monitoring data, no infection Oncomelania was found after 2014, mainly due to the promotion of comprehensive prevention and control, which focused on controlling the infection source. In 2005, there were 99 villages in total in the Poyang Lake area, taking up 61.49% of the number of epidemic villages (99/161). The proportion dropped to 56.58% (86/152) in 2016. In 2005, 80 villages with snails were detected, accounting for 81.63% (80/98) of the number of villages surveyed. This proportion decreased to 59.09% (65/110) significantly in 2016 when compared to that in 2005 (x2 ¼ 16.76, P < 0.05). From 2005 to 2016, the total area with Oncomelania in Poyang Lake

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fluctuated between 75,604.08 to 77,866.50 hm2, and accumulated new area with snails during this period was 166.14 hm2. Biological Characteristics of Oncomelania The Oncomelanian is the only intermediate host of Schistosoma japonica. It is a kind of freshwater snail, which is gonochoristic and amphibious. It is approximately 10 mm long and 4 mm wide. It would lay eggs after male and female Oncomelania mate, and eggs would hatch after a month after spawning. The hatching time of juvenile snails is related to temperature, humidity, and light. In some warm areas, juvenile snails can be found as early as February and March. The peak time to find them in April and May and the probability for finding them decreased gradually after October. The hatched snails can develop into adult snails in 2 months as long as the growing environment is suitable. The lifespan of Oncomelania is usually 1 year, but some of them can live for 2–3 years. The water level of Poyang Lake changes seasonally. Having a moderate climate and sufficient rainfall, the Poyang Lake is described as “dry in winter but soggy in summer.” Not only does it have humid and rich soil, but also overgrown with weeds and reeds, making it suitable for Oncomelania to breed. Perhaps due to the rich soil and abundant food, the snails in marshland and lake regions are bigger than those living in the plain regions with waterway network as well as hilly and mountainous areas. Usually, it is over 7.5 mm high. Sometimes it can reach up to 10 mm in length. The Oncomelania is 3.2 mm wide, with a thick shell and deep whorl. The existence and distribution of Oncomelania in lake regions are related to many microecological environmental factors, such as flood time, underground water level, and moisture content of the soil, vegetation, and light intensity. Long flood time, high underground water level, and high content of moisture in the soil increase the density of Oncomelania. Among all these factors, the level of underground water matters most. Research showed that the distribution of snails in the bottomland was significantly related to the level of underground water. When it was approximately 32 cm, the density of snails and the occurrence rate of frame with snails reach the highest due to the reason that the soil moisture content of 28–38% was the most suitable environment condition for snails to grow. The change in water level can affect the environment in which Oncomelania lives as well as the characteristics of the microecological environment. Meanwhile, it can change the activities and distribution of snails, thus affecting the transmission of schistosomiasis. It is hard to find snails in lower bottomland with more than 8 months annual flood time or upper bottomland with less than 3 months annual flood time. The locations where the Oncomelania breeds have luxurious plant growth mainly are hygrophilous vegetation, such as sand-glass, sedge, and weed. The distribution of Oncomelania is positively related to the soil pH and vegetation, while their numbers are mostly related to the soil pH.

3 Epidemic Characteristics of Schistosomiasis in Jiangxi Province

3.3.2.3

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Route of Transmission

Water and Oncomelania hupensis play an important role in the transmission of Schistosoma. The dropping of feces containing eggs, the breeding of Oncomelania hupensis, and the exposure of humans and livestock to infected water (containing cercariae) are essential for the transmission of schistosomiasis. From April to June every year, it is the “intersection point” where Schistosoma spreads between the definitive host and the intermediate host. At this time, the beach is in the shallow water period, and the female snails lay a large number of eggs (from March to April). The snail eggs hatched young snails in shallow water (April to May), and the newborn snails in the beaches increased sharply (June). Then (June to July), most of the old snails died and were replaced by new snails, thus maintaining the survival and reproduction of the snail species. At the same time, the droughtstricken infectious old snails continue to escape after being exposed to water for 2–3 months before death, infecting humans and livestock. Due to the frequent activities of humans and livestock on the beaches at this time, the animal feces pollution is serious, and the eggs in the feces quickly hatch the miracidium after entering the water, and reinfect the new snails (the main season of the miracidium invading the Oncomelania hupensis), so that the Schistosoma can continue to grow, develop, and reproduce after replacement of the generations of Oncomelania hupensis. From July to August, due to the death of a large number of old snails, there were no large numbers of mature cercaria in new snails, which made humans and livestock less likely to get infected. At this time, livestock grazing was also suspended. There is no opportunity for animal feces to spread the miracidium to the Oncomelania hupensis, which is a non-susceptible season for schistosomiasis. From September to October, the new snail produced cercariae in large quantities, and the density of the water surface cercariae has increased sharply, which is another susceptible season for humans and livestock infection. From November to March of the next year, the Schistosoma spread ceased during the dry season of the beach. Therefore, Schistosoma uses water as a medium of transmission to form a cyclical process of transmission, making schistosomiasis “passaged from generation to generation.” The breeding and reproduction of Oncomelania hupensis and the prevalence and spread of schistosomiasis are not only closely related to water, but also susceptible to the influence and control of hydrodynamic conditions and changes in the regional hydrological situation in the endemic areas.

3.3.2.4

Endemic Factors

The vast lake beach marshland in the Poyang Lake region is a good breeding ground for Oncomelania hupensis, which is the only intermediate host in the transmission chain of schistosomiasis; humans, livestock, and other wild mammals are the definitive hosts of schistosomiasis, and the sick cattle and water buffalo infected with schistosomiasis and grazing in beach of Poyang Lake and the patients going to

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the beach for activities are the main source of schistosomiasis in the lake region. Humans and livestock are infected by contact with water containing cercariae through the skin and mucous membranes. The main ways of contact infested water with cercariae include recreational activities (swimming, playing water, etc.), living activities (washing clothes and hands, etc.) and productive activities (fishing, farming, etc.). Such repeated circulation has formed a serious endemic of schistosomiasis in the Poyang Lake region.

Further Reading Chen H, Lin D (2004) The prevalence and control of schistosomiasis in Poyang Lake region, China. Parasitol Int 53:115–125 Chen HG, Lin DD (2006) Schistosomiasis control and prevention strategy in Jiangxi Province/ / Wang LD, History and Prospect of schistosomiasis control in China – 100th anniversary selections of schistosomiasis in China. People’s Medical Publishing House 2006:150–158 Chen HG, ZX, Xiong JJ et al (2009) Study on comprehensive schistosomiasis control strategy with emphasis on infectious source control in Poyang Lake areas. Chin J Schistosomiasis Control 21:243–249 Chen HG, Gu X, Zeng XJ et al (2013) Prevalence and control of schistosomiasis in Jiangxi Province during 2002–2012. Chin J Parasitol Parasitic Dis 31:449–463 Chen HG, Zeng X, Lin DD et al (2013) The changes of hydrological regime in Poyang Lake after runs of Three Gorges Project and its impact on prevalence of schistosomiasis in the lake region. Chin J Schistosomiasis Control 25:444–450 Department of Endemic Disease Prevention and Control of the Ministry of Health (1998) Prevalence of schistosomiasis in China – 1995 National Sampling Survey.Nanjing Publishing House 1998:40–47 Faust EC (1924) Studies on schistosomiasis Japonica. JAMA 1924:83 Guo DZ, Chen J, Liu YD, Yao H, Han FA, Pan J (2011) A high-performance molluscicidal ingredient against Oncomelania hupensis produced by a rhizospheric strain from Phytolacca acinosa Roxb. Pharmacogn Mag 7:277–283 He JC, QG, Deng YJ et al (2006) Study on the human schistosoma infection pattern in different seasons in a hilly area of Nanling county. J Trop Dis Parasitol 4:164–166 Hu FLS, Li YF et al (2017) Study on distribution status of Oncomelania hupensis – intermediate host of Schistosoma japonicum in Jiangxi Province: I. Analysis of distribution of O. hupensis in Poyang Lake area. Chin J Schistosomiasis Control 29:544–549 Jiang QW, ZJ, Liu ZD et al (1995) Study on status of acute schistosomiasis in Jiangxi province from 1982 to 1993. Chin J Schistosomiasis Control 7:138–140 Jiangxi Provincial People’s Government Office of leading group for schistosomiasis endemic disease control. (1991) Compilation of statistical data on schistosomiasis control in Jiangxi Province Jiangxi Research Committee for schistosomiasis. Schistosomiasis research (1956–1985) Lambert AC, Kiukiang CM (1911) Fevers with urticaria and eosinophilia and their relation to infection with schistosomum japonicum. Trans R Soc Trop Med Hyg 5:38–45 Lin DD, Lv S, Gu XN et al (2013) Retrospective investigation on changes of endemic situation before and after reaching criteria of schistosomiasis transmission controlled or interrupted in hilly endemic areas of Jiangxi Province. Chin J Schistosomiasis Control 25:462–466

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Lu lT, ZR, Zhang LJ et al (2013) Evolution of schistosomiasis control and prevention strategies in hilly regions with schistosomiasis endemic in China. Chin J Schistosomiasis Control 25:528–532 Medical Research Committee of the Ministry of Health. Schistosomiasis research abstracts (1950–1958). (1959) Member of the CPC Jiangxi provincial party history information collection Committee. (1996) Schistosomiasis control in Jiangxi Province. Central Party Literature Press Survey of schistosomiasis in Dexing County. Jiangxi Provincial Health Department (1939) Tang LH (2012) Prevention and treatment of schistosomiasis in China. Beijing Science & Technology Press. 2012:1152–1165 The Jiangxi provincial Party committee of the Communist Party of China eliminating seven pets and six diseases Command Office. Compilation of data on schistosomiasis control in Jiangxi Province (1858–1952) (1958) Wang LD, Chen H, Guo JG, Zeng XJ, Hong XL, Xiong JJ, Wu XH, Wang XH, Wang LY, Gang X (2009) A strategy to control transmission of Schistosoma japonicum in China. New Engl J Med 360:121 Xiao JW, YW, Xiao JC (2009) A preliminary study on the epidemic history of schistosomiasis in Jiangxi Province. Jiangxi J Trad Chinese Med 40:11–14 Xu BX, WG (1941) The distribution of schistosomiasis in China. Natl Med J China 27:553–564 Zhang SJ (1983) Epidemiological characteristics and control strategies of schistosomiasis in Poyang Lake District. Jiangxi J Trad Chin Med 3:11–15 Zhang SJ, Lin DD, Hu F et al (1999) Schistosomiasis in Poyang Lake District of China. Chin J Schistosomiasis Control 11:196–198 Zhang LJ, XZ, Qian YJ et al (2017) Endemic status of schistosomiasis in People’s Republic of China in 2016. Chin J Schistosomiasis Control 2017:669–677 Zhong B, WZ, Chen L et al (2013) Strengthening the achievements of schistosomiasis control in hilly regions of China. Chin J Schistosomiasis Control 23(1):10–13 Zhou B (1997) Jiangxi Health Journal. Mount Huangshan Pressing

Chapter 4

The Course of Schistosomiasis Control in Jiangxi Jun Ge and Yifeng Li

Abstract This chapter systematically describes the course of schistosomiasis control in Jiangxi province from 1950s up to now. There are three stages for schistosomiasis control in Jiangxi. The control strategy focusing snail control was carried out in the first stage from 1950s to mid-1980s. In the second stage, the strategy shifted to focusing large-scale chemotherapy of population and cattle from late 1980s to 2004. In the third stage, the strategy focusing on infectious sources control has been implemented from 2004 to now in line with the change of schistosomiasis epidemic situation. The effects of schistosomiasis control in each stage were also described in this chapter. Keywords Schistosomiasis control · Snail control · Chemotherapy of disease

4.1

Preliminary Stage of Schistosomiasis Control

Jiangxi is one of the provinces where schistosomiasis is the most prevalent. Schistosomiasis has an extremely negative influence on people’s health and economic development in endemic areas. According to statistics on endemic status, 360,000 people died of schistosomiasis, 22,658 families became extinct, and 1362 villages were destroyed 30 years in Jiangxi before the foundation of the People’s Republic of China. The government laid great emphasis on the harm caused by schistosomiasis to humans since 1949. In 1950s, in order to crack down the disease, the schistosomiasis control administrative groups at all level were found in Jiangxi, as well as the professional institutions for schistosomiasis research and control. Meanwhile, a large amount of funds was allocated for the control. In this period, a large-scale survey was carried out to map the disease in Jiangxi. Various measures, including mollusciciding, feces control, water source management, individual protection, and patient treatment, were experimented to find the effective methods for schistosomiasis control. J. Ge (*) · Y. Li Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_4

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Foundation of Administrative Offices and Professional Institutions

During this period, party committees at all levels from province to township all set up leading groups for schistosomiasis control, headed by the party secretary. And to assist in daily work, offices were founded for leading groups above the county level. Also, committees consisting of many departments like health, agriculture, water conservancy, and culture and education for schistosomiasis control were established by governments above the township level in the endemic area, so that every department could cooperate to control schistosomiasis. From 1952, professional institutions and teams for schistosomiasis control began to be built. By the end of 1958, there were one province-level institute, 27 county-level stations, and 117 township-level teams for schistosomasis control established in Jiganxi with a total of 1702 professionals. Besides, the government also encouraged research on schistosomiasis control. They built research committee for schistosomiasis control composed of researchers from medical and health, agriculture, and water conservancy. There were five research teams under the committee for snail control, including the prevention and control team, the clinic team, the drug research team, the Traditional Chinese Medicine team, and the veterinary medicine team. The researchers in the committee conducted various studies for schistosomiasis prevention and treatment, such as schistosomiasis epidemiological survey, Oncomelania hupensis ecological study, experiments on killing snail, study on the treatment effect of Traditional Chinese Medicine and oral antimony agent, etc.

4.1.2

Large-Scale Surveys and the Formulation of a Future Plan

From 1950 to 1955, Jiangxi Province conducted surveys on schistosomiasis in some areas. Then in 1956, a professional research team including 1840 people was built. After short-term training, they conducted a thorough large-scale survey focused on intradermal tests and stool examinations covering 32 counties and 1136 townships. Among the 1,390,000 people receiving serological tests, the average infection rate is 27.1%, and among the 110,000 people receiving stool examinations, the infection rate is 12.6%. Based on the endemic status of schistosomiasis, the government made a Five-year plan for schistosomiasis control in Jiangxi Province, trying to eliminate schistosomiasis in 7 years. Then, 3 specific measures were raised: First, manage feces and water to cut down the spread of schistosomiasis; second, eliminate Oncomelania hupensis in order to destroy the growth environment of Schistosoma japonica cercaria; and third, cure infected people by medical skills.

4 The Course of Schistosomiasis Control in Jiangxi

4.1.3

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Publicity and Education

Relevant authorities carried out publicity and education in many ways such as telling real stories, real exhibitions, lantern slides, films, blackboard newspaper, debate, symposiums, interviews, and propaganda to impart scientific knowledge of schistosomiasis control. Through these ways, the masses can abandon feudal and superstitious beliefs and learn how to manage feces and water, how to control Oncomelania hupensis, and how to prevent themselves from being infected. As a consequence, people will have strong confidence on schistosomiasis control and the early prophylaxis work will go well.

4.1.4

Snail Control

According to statistics, the areas of snail control reached 962,400,000 m2 from 1952 to 1958 with the help of laborers. The ways of snail control mainly include three methods: first, using farmland irrigation and water conservancy constructions, such as digging new channels, landfilling old channels, and building ridges; second, using agricultural production to control snail like cutting grass to compost, burning, changing paddy fields to dry fields, water–dry rotation, and embanked reclamation; third, plant molluscicides, such as tea seed, lime, were used to kill snails in rice fields combined with fertilization, and chemical molluscicides, such as santobrite, calcium arsenate, were also used for snail control.

4.1.5

Management on Feces and Water Combining Patriotic Health Campaign

Relevant authorities also strengthened the management on feces, improved health condition, and tore down worn-out and unclean toilets and dung depositaries, combining with patriotic health campaign. To manage feces, they have to manage cesspit uniformly, compost at high temperature to kill eggs, and build public toilets, pigsties, and cattle pens. In the lake region, they stipulated fishermen to dump feces and wash closestool ashore. For managing water sources, villagers were asked and encouraged to dig wells for drinking water and disinfecting the water. Through feces and water management, the water in the endemic areas was protected from schistosome egg contamination, and the infection of residents was decreased. As a statistic, 71,408 unclean toilets and dung depositaries were removed, 116,898 toilets and dung depositaries were up to the standard, and 5776 wells were managed from 1952 to 1958. Otherwise, other works like digging new ponds, dividing ponds, and disinfecting drinking water also went well.

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Treatment for Patients with Schistosomiasis

Total 200,000 patients with schistosomiasis were received treatment in 1950s. Before 1957, wards were set up in epidemic areas to treat patients in a centralized and unified way by using antimony 20-day therapy. In this way, each patent had to stay in the ward for at least one month. After 1958, doctors went into villages to deliver medicine to patients or make a tour to visit patients. In this way, antimony 2-day or 3-day therapy was used by doctors. Through measures mentioned above, the significant progress for schistosomiasis control was made in Jiangxi in 1950s. The prevalence of schistosomiasis was under control to some extent, and the experience on schistosomiasis control was accumulated and learned. In May, 1958, Yujiang County became the first county to eliminate schistosomiasis in China. Chairman Mao Zedong heard this news and wrote a famous poem, “Farewell to the God of Plague.” By the end of 1959, schistosomiasis had been eliminated in six cities (counties) in Jiangxi, including Shangyou County, Taihe County, Wuyuan County, Fuliang County, Fengxiang County, and Nanchang City. Meanwhile, in the whole province, 200,000 patients with schistosomiasis were treated; the snail-inhabited areas of 96,240 hm2 were molluscicided; 71,408 unsanitary toilets were removed; 116,898 manure storages and 5776 wells were managed effectively; health education were carried out extensively in the epidemic areas.

4.2 4.2.1

The First Stage: Snail Control Background

From the 1960s to 1970s, schistosomiasis prevention and control in Jiangxi Province developed tortuously. From 1960 to 1963, all aspects of development got into trouble. To overcome difficulties, the government of Jiangxi Province called upon people to get food from lake regions, so that large-scale agricultural development can be conducted at Poyang Lake District. Due to lack of effective protective measures, a large number of acute infection cases were diagnosed and the endemic status rebounded slightly. As the Cultural Revolution broke out in 1966, schistosomiasis prevention and control in Jiangxi Province was influenced seriously. In 1968, all institutions for schistosomiasis control in the province were closed and every specialized person was forced to go into the country. Consequently, schistosomiasis prevention and control came to a halt. Fortunately from 1970, the provincial offices and institutions for schistosomiasis control were started again and specialized person returned in succession. Schistosomiasis prevention and control was conducted again.

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Solutions

During this period, the main protective strategy was to control Oncomelania hupensis to cut down the spread of schistosomiasis. In the hilly and mountainous regions, farmland irrigation and water conservancy constructions were still used to control snail. In the marshland and lake regions, a large area of snail-inhabited environment has been transformed for rice planting and fishing farming combining with the agricultural development in Poyang Lake. The main methods for snail control in the lake include embanking marshlands for rice cultivation, reclaiming marshlands for rice cultivation without embankment, blocking river branch for fish culture, spraying chemical molluscicide by plane, and ploughing marshlands by tractors. As a result, total snail area of 91,999.1 hm2 in Poyang Lake was eliminated, including 65,333.7 hm2 by embanking marshland for rice cultivation and blocking river branch, 13,333.2 hm2 by reclaiming withered grassland for cultivation and 13,333.2 hm2 by chemical mollusciciding and tractor-ploughing.

4.2.3

Results

By the end of 1979, there were still 200,000 infected people in Jiangxi Province, among which 140,000 lived in Poyang Lake District. The total areas in the whole province for Oncomelania hupensis growth are only 528,000,000 m2. Schistosomiasis in the hilly regions was controlled effectively. In lake and marshland region, some places had closely reached the criteria of schistosomiasis transmission control where snail control can easily be carried out and achieve mollusciciding effect. Though the intensity of infection had already declined in some regions close to snailinfested lake areas, the infection rate decreased slowly but the endemic status in places around the lake was still severe. For example, there were 47 townships in Jiujiang region where the infection rate of residents was over 15%. The infection rate of residents in Hexi village in Yongxiu County was even up to 72%. In the whole province, there were nearly 1000 acute cases occurred each year during 1960–1979, with 1013 acute cases in 1960, 3000 acute cases in 1962, and 1195 acute cases in 1970. In addition, the infection rate of livestock around the lake was still high, with 21.8% in cattle and 29.9% in pigs in Wanhu area of Yugan County, for example. During this period, the status in Jiujiang County, De’ a County, Fengcheng County, Xunyang District, Guangfeng County, Gao’ an County, Hukou County, Wan’an County, and Anyi County reached criteria for transmission control.

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4.3 4.3.1

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The Second Stage: Chemotherapy for Human and Livestock Background

From the 1960s to the beginning of 1980s, Jiangxi Province developed strategies to control schistosomiasis mainly by controlling Oncomelania hupensis, and it started a mass movement of controlling snail at a large scale, which made a difference under the historical background at that time. However, the measures of snail control have limited effect in the Poyang lake areas due to its large snail-infested marshlands. Meanwhile, snail control also caused the damage and pollution of natural environment in the lake. The data showed that the activity of reclaiming lake marshlands to rice field, which was an important measure for snail control in the lake areas, had caused the reduction of water area of the lake by 1011.57 km2 in 1954–1984, directly affecting the function of water regulation and storage of the lake as a reservoir. As well, using chemical molluscicide for snail control also led to the pollution of the lake and death of fishes due to its toxicity. In addition, in the mid-1980s, the epidemic situation of schistosomiasis tended to rise sharply in Jiang Xi Province. Some villages around the Poyang Lake region had infection rates of over 90%. Over 95% of animal feces in the marshland were cattle and pig manure, serving as the important infection source of schistosomiasis. As the number of people with water or marshland contacts increased day by day, the acute infection showed an increasing tendency, which implied the severe situation of schistosomiasis control.

4.3.2

Strategy and Goal of Prevention and Control

In 1984, when WHO Experts Committee of schistosomiasis was adjusting the strategies and goals of schistosomiasis control, Jiangxi Province adjusted the strategy into comprehensive measures of “Mass and livestock chemotherapy” in the 1980s. The implementation of this strategy was divided into two stages in Jiangxi Province. The first stage was the control of schistosomiasis in the large Poyang Lake region. Aiming at the rising epidemic situation of schistosomiasis in the Poyang Lake region, Jiangxi Province drew up the “General plan of schistosomiasis control in large Poyang Lake region,” as well as the implementation rules of chemotherapy, snail control, and system management. The general mission was to reach the goals of “eliminate,” “basically eliminate,” “transmission control,” “infection control,” and “disease control” in different parts of epidemic areas by means of 5-year active prevention and reduction of epidemic areas, situation, and harm. The goals and strategies adopted by different kinds of epidemic areas were as follows:

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1. For the places with smaller snail region and a milder epidemic situation like Hukou County, De’ a County, and the suburbs of Nanchang City, the standard of “eliminate” should be strived to reach. Only a few areas with the severe epidemic situation, like Lushan District of Jiujiang City, could aim at “basically eliminate,” taking “exterminate Oncomelania hupensis and conduct active diagnosis and treatment for both human and animals” as a main prevention strategy. Having reached the “eliminate” standard, Wannian County was required to enhance surveillance and to consolidate its achievement on schistosomiasis control. 2. For three counties located at the upstream of Poyang Lake, Nanchang, Xinjian, and Jinxian, which had a nice working basis of prevention, the strategy of “chemotherapy for human and livestock in the large area, combined with largescale snail control in the susceptible zone,” which meant to treat and molluscicide simultaneously. Except for few highly epidemic areas, all other regions took “control transmission” as standard. 3. For most rural areas around the lake, comprehensive snail control was hard to conduct. As a result, general or selective chemotherapy aiming at main infection source, together with small-scale snail control in susceptible zones, was chosen to implement in order to reach “infection control” and “disease control.” The second stage was the World Bank Loan Project for schistosomiasis control (hereafter referred as “World Bank Loan Project”) (1992–1998). Jiangxi was a relatively economically underdeveloped province, with a serious shortage of funds restricting the works of prevention and control. These factors, as well as the epidemic trend of schistosomiasis, contributed to the increasing rate of the epidemic situation. Adding investment on prevention and treatment, adjusting schistosomiasis control strategies, and actively reducing or controlling the epidemic condition had become the most urgent and prominent problems to be solved on schistosomiasis prevention at that time. The provincial party committee and the provincial government had taken into account that the use of World Bank loans for schistosomiasis control could not only make up for the serious shortage of funds, but also introduce advanced foreign management experience and methods to improve the working ability and level of staff. Therefore, the World Bank Loan Project was introduced to control schistosomiasis in 1992. The main contents of the project were disease control, disease surveillance, health education, scientific research, training, project management, information management, and project evaluation. The overall goal of the project is to reduce the population infection rate and the cattle infection rate by 40%, the snail infection rate, and the infectious snail density by 50–60%. Besides, classify according to the population infection rate, and implement different prevention strategies for different popular areas. At the same time, fixed surveillance points and mobile surveillance points were set up to carry out epidemic monitoring.

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1. Highly endemic area (first layer): Referred to an administrative village with a population infection rate greater than or equal to 15%. a. Population chemotherapy: The population between 6 and 60 years old were administered general chemotherapy each year, covering over 90% regions; the high-risk population frequently exposed to infected water received treatment twice a year. b. Cattle chemotherapy: Treatment was conducted for all farm cattle once a year, instead of examination. c. Snail survey and control: Each year, 40% susceptible areas were surveyed, with snails not less than 1000 boxes, and mollusciciding was conducted in areas where the infectious snail density was greater than 0.005/0.1 m2. 2. Moderately endemic area (second layer): Referred to an administrative village with a population infection rate of less than 15%, but greater than 3%. a. Population diagnosis and treatment: IHA screening was performed on 50% of the target population in this area and those with positive results received treatment; the high-risk population frequently exposed to infected water received treatment twice a year. b. Cattle chemotherapy: Treatment was conducted once a year for 25% farm cattle as well as those grazed in susceptible regions (changed to 50% after 1995). c. Snail survey and control: Each year, 40% of susceptible areas were surveyed, with snails not less than 1000 boxes, and mollusciciding was conducted in 50% of the surveyed areas. 3. Mildly endemic area (third layer): Referred to an administrative village with a population infection rate of less than or equal to 3%. a. Population diagnosis and treatment: Serological method was performed on 7–14 years old children every other year and those with positive results received treatment; the serological method was performed on high-risk population frequently exposed to infected water once a year, and those with positive results received treatment. b. Diagnosis and treatment for farm cattle: Stool examination was performed once a year on farm cattle dung from the epidemic area, and grazed in snail areas, under 2 years age. Those with positive results received treatment. c. Snail survey and control: Sample surveys were conducted in 50% of the snail breeding areas every year, with snails not less than 1000 boxes. Mollusciciding was conducted in all the snail areas.

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4.3.3

Implementation Condition and Effects

4.3.3.1

Implementation Circumstance

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According to relevant statistics, after adjusting the prevention and control strategy and before the implementation of the World Bank Loan Project (mainly referred to 1984–1990), a total of 473,000 people were investigated, 370,700 people received expanded chemotherapy, 949,500 patients were investigated, and 129,900 cattle were investigated. The snail survey number was 4.895 billion m2 and the snail control number was 398 million m2. During the World Bank Loan Project, the cumulative population of the disease was 4.5751 million, the number of population chemotherapy was 1.5827 million, the cattle diagnosis number was 490,000, the cattle chemotherapy number was 328,800, the snail survey number was 17630.67 hm2, and the snail control number was 39491.40 hm2. There are 88 environmental protection and snail control projects, including 29 hardening reconstruction projects for ditches and ponds, 21 short-wall storage and fish-raising projects, 21 short-stem scorpions, and 17 projects like waterchange-to-drought and sluicing gates. (However, due to the extraordinary floods in 1998 and 1999 for 2 consecutive years, 26 projects in the province were partially or completely destroyed.)

4.3.3.2

Implementation Effects

In the 1990s, during the implementation of World Bank Loan Project, the “Eighth Five-Year Plan” and “Ninth Five-Year Plan” for schistosomiasis, 53 townships in 4 counties (districts) including Gao’an, Guangfeng, Nanchang suburbs, and Xunyang District, reached the transmission blocking standard; 25 townships in 3 counties (districts) including Yushan, Shangrao, and Lushan District reached the transmission control standard. The epidemic status of schistosomiasis, which severely rose up in the mid-1980s, was effectively controlled. The average population infective rate in epidemic areas in the province dropped from 7.6% to 2.7% with a decrease of 64.91%. The total number of patients, the number of advanced stage patients, and the number of acute infections decreased from 218,000, 6692, and 287 at the start of the project to 145,000, 4575, and 152, respectively, by the end of project; the infection rate of cattle decreased from 4.4% to 2.7%, and the density of infectious Oncomelania hupensis decreased from 0.0032/0.1 m2 to 0.0006/0.1 m2. The scope of highly endemic areas has further narrowed. By 1999, the number of villages with schistosomiasis infection rate greater than 15% had dropped from 241 to 93. The average infection rate of the first- and second-layer villages decreased from 16.6% and 4.8% in 1992 to 6.8% and 1.4% in 1999, with the decline of 59.0% and 70.8%, respectively. In the third-layer villages, only in 1998 positive cases of stool examination were found, and no positive cases were found in other years.

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Large-scale continuous chemotherapy for many years had significantly improved residents’ disease status in epidemic areas. After 1–2 years of continuous chemotherapy, the degree of hepatomegaly, splenomegaly, and liver fibrosis was changed into good status for about 50% of patients. At the same time, as social economy developed and people’s living level improved, the appearance of epidemic areas has also undergone remarkable changes.

4.3.4

Experience and Problems

4.3.4.1

Main Experience

1. The government’s effort served as an important guarantee of schistosomiasis control. During the implementation of the strategy, Jiangxi Provincial Party Committee and the Jiangxi government issued a series of documents to strengthen the prevention and control of schistosomiasis, including “Notice on Further Strengthening the Prevention and Control of Schistosomiasis and Endemic Diseases” and “Decision on Strengthening the Prevention and Control of Schistosomiasis.” The documents required all levels of government to increase investment and to implement control measures, which offered a strong guarantee for schistosomiasis prevention. 2. The World Bank Loan Project was an important force in accelerating the process of schistosomiasis control. The World Bank Loan Project supplemented the shortage of funds for prevention and control in Jiangxi Province, improved the prevention and control strategy, and made the prevention and treatment more purposeful and scientific. Accepting advanced management and evaluation methods, it also improved the level of scientific research and prevention skills. These promoted the reduction of epidemic status, which caused a historic change in the epidemic situation of schistosomiasis in Jiangxi. 3. The establishment of monitoring points was an important method to evaluate the effectiveness of the project. Set up fixed and mobile surveillance points in project areas: Through continuous monitoring, comprehensively grasp the horizontal and vertical dynamic changes of schistosomiasis status among the whole province, providing a reliable scientific basis for timely adjustment of prevention and control strategies. 4. Properly carrying out the environmental transformation project was an important supplement to the snail control process. The 88 environmental transformation projects for snail control were implemented in suitable places, not only controlling and reducing the sail area, but also protecting the residents in epidemic areas from the threat of schistosomiasis. In addition, they increased the area of cultivated and farmland, increasing the income of people in epidemic areas.

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Main Problems

1. Prevention and control efforts were not sustainable. After the World Bank Loan Project, the investment in prevention fell sharply, and it was hard to carry out large-scale human and animal chemotherapy consistently. In addition, national chemotherapy in highly endemic areas for many years made it difficult for some residents in epidemic areas to accept it persistently. 2. The prevention strategy was not sustainable. The practice of schistosomiasis control confirmed that chemotherapy measures could only reduce the risk of schistosomiasis in human and animals, rather than block the transmission of schistosomiasis. Although human and livestock chemotherapy could treat schistosomiasis, it could not solve the reinfection. Besides, it was also a controversial issue in the academia whether large-scale chemotherapy would lead to drug resistance. 3. The compression of the snail region in the epidemic areas is not ideal because the control strategy was mainly based on human and livestock chemotherapy, which contributes little to improve the susceptible marshlands, the small-scale environmental transformation, and snail control project carried out at a later stage could only deal with a very small part of snails. Due to the large area of snails still existing, the phenomenon that human and cattle had contacts with susceptible marshlands in epidemic areas could not be changed in a short period of time. The weakening of prevention and control, as well as the lack of sources of chemotherapy drugs, had caused repeated epidemics.

4.4

The Third Stage: Management of Infection Source

4.4.1

Background and Objective

4.4.1.1

Background

After the end of World Bank Loan Project for schistosomiasis control, investment in the prevention and control efforts of schistosomiasis in Jiangxi Province was significantly reduced. The intensity and coverage of chemotherapy were reduced. In addition, because of a severe flood along the Yangtze River Basin occurred in 1998, a flood control policy of “remove embankment for flood discharge, turn marginal farmland to forests and lake marshlands, immigrate residents near lakes to safety homes in new towns, etc.” was implemented in epidemic lake areas in Jiangxi, causing significant changes in natural environment conditions in the lake areas. With the project of “remove lakeside embankments for releasing floods, return grain plots to forestry, relocate settlements, and construct new towns” implemented, snail-infested area in endemic areas increased. The opportunity of people in endemic areas coming in contact with water contaminated with cercaria increased. The local population had increased the risk of infection by schistosomiasis. Due to

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enlargement of snail areas and decreased funds for schistosomiasis control, the prevalence of schistosomiasis had rebounded in Jiangxi during 1998–2003. According to statistics, the rebound in the endemic status was mainly manifested by a sharp increase in the number of acute schistosomiasis cases and an increase in the infested area with a snail. The total number of patients, the number of advanced schistosomiasis cases, and the number of acute schistosomiasis cases increased from 115,000, 2538, and 48 in 1999 to 311,200, 3659, and 126 in 2003; the infested area with snail increased from 68,315 hm2 in 1999 to 77,534 hm2 in 2003. At the same time, the endemic situation of other endemic areas in the country has also rebounded: the number of schistosomiasis patients remained high, infested area with snail increased obviously, the distribution of Schistosome-infected O. hupensis snails gradually expanded, and new schistosomiasis patients were found in some controlled endemic areas where the endemic status had reached the standard, and there was a trend of spreading to the city. It posed a threat to people’s health, economic development, and social progress.

4.5

Objective

In 2004, the State Council set up a leading group for the Schistosomiasis Control, issued the “Notice of the State Council on Further Strengthening the prevention and Control of schistosomiasis,” and forwarded the Ministry of Health and other departments of the National “Medium- and Long-Term Plan for Prevention and Control of schistosomiasis (2004–2015).” The National Conference on Prevention and Control of schistosomiasis was held to deploy the prevention and control of schistosomiasis in the country, and the specific prevention and control targets and prevention measures in 2008 and 2015 were proposed. The government of Jiangxi Province formulated and issued the “Medium and Long-term Plan for Prevention and Control of schistosomiasis in Jiangxi Province (2004–2015),” building the whole objective to maintain the results of schistosomiasis prevention and control, prevent the endemic status from picking up, compress the scope of the endemic area, greatly reduce the infection rate of humans and animals, eliminate schistosomiasis in possible places. It was clear: By the end of 2008, there were 11 uncontrolled endemic counties (cities, districts), Nanchang County, Xinjian County, Jinxian County, Duchang County, Xingzi County, Yongxiu County, and Open Development District of Gongqing City, Poyang County, Yugan County had reached the criteria for endemic control of schistosomiasis; Pengze County and Ruichang City had reached the criteria for transmission control of schistosomiasis; High-tech Development District of Nanchang City, De’ a County, Jiujiang County, Hukou County, Economic and Technological Development District of Jiujiang City, Shangrao County, Yushan County, and Fengcheng City reached the criteria for transmission interruption. By the end of 2015, Nanchang County, Xinjian County, Jinxian County, Duchang County, Xingzi County, Yongxiu County, Open Development District of Gongqing City, Poyang County,

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and Yugan County would strive to reach the criteria for transmission control of schistosomiasis; Pengze County, Ruichang City, and Lushan District of Jiujiang City reached the criteria for transmission interruption. At the same time, it put forward specific objectives in reducing the infection rate of schistosomiasis, reducing the endemic area and the snail-infested area, accelerating the construction of rural tap water and harmless toilets, enhancing people’s awareness of disease prevention, and strengthening the management of livestock grazing.

4.5.1

Control Strategies and Measures

4.5.1.1

Control Strategies

During the twenty-first century, Jiangxi Province continued to adopt the disease control strategy based on mass and livestock chemotherapy, supplemented by snails’ control and health education in the susceptible zone, and it strengthened research on a comprehensive strategy with emphasis on infection source control. Pilots of cattle breeding and rotational grazing bans were carried out in the Poyang Lake region and achieved results. In addition, six counties including Nanchang County, Poyang County, Yugan County, Duchang County, and so on were implemented to implement comprehensive treatment pilots to achieve the goal of comprehensive improvement of schistosomiasis control benefits, economic benefits, and ecological benefits. Since 2005, a comprehensive pilot project for schistosomiasis prevention and control has been carried out in Jinxian County, where schistosomiasis is severely endemic in the Poyang Lake region. The project’s main control strategy was to control the cattle as infection source, the intervention was based on “replacing cattle with machine, cattle breeding, and snail control,” and measures were the renovation of sanitary conditions such as water sources and toilets, adjustment of the agricultural industrial structure, and strengthening population prevention and health education. Through researching of the pilot project, we will gradually establish a new strategy with emphasis on infection source control, supplemented by comprehensive measures to reduce exposure, and promote the strategic adjustment of prevention and control strategies in Jiangxi Province and China, and finally determined “a comprehensive strategy with emphasis on infection source control.” The implementation of this strategy has mainly experienced three stages in Jiangxi Province. The first stage was the pilot stage, which was a comprehensive stage with emphasis on infection source control implemented by the State Council of Sanli Township, Jinxian County, in 2005. The integrated control measures focusing on controlling cattle, the main infection source of schistosomiasis, were carried out in the pilot township, for the purpose of prevent S. japonica eggs in human and livestock feces from contaminating the snail-inhabited environment. The pilot successfully implemented the modern concept of schistosomiasis control from

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“biological mode” to “bio-social-environmental model,” which provided a model for comprehensive prevention and control of schistosomiasis in China. The second stage is the demonstration stage, which was the implementation stage of the comprehensive pilot project for prevention and control of schistosomiasis in the south bank of Poyang Lake implemented in 2010. In September 2010, the provincial government held a provincial schistosomiasis prevention and control conference, deciding to comprehensively promote the comprehensive strategy with emphasis on infection source control, and started the construction of the comprehensive prevention and control demonstration zone for schistosomiasis in the south bank of Poyang Lake. And the measures targeting infection sources control were implemented in 66 villages of 4 townships in Jiangxian County, Nanchang County, and Yugan County. These measures included replacing cattle with machine, forbidding grazing of livestock on marshlands, constructing road for tractor, health education, developing the economy of lake region by aquaculture and poultry husbandry rather than livestock husbandry, all for the purpose of pushing the course of schistosomiasis control in Poyang Lake areas. The demonstration area further promoted the implementation of the new strategy and provided evidence for the effectiveness of the new strategy (Fig. 4.1). The third stage is the promotion stage, which was the implementation stage of the comprehensive prevention and control for schistosomiasis in promotion region of Poyang Lake region implemented in 2011. During this stage, the new strategy was gradually implemented in all the endemic counties (cities, districts) in the Poyang Lake region, whose core was replacing of farming cattle and establishing the organization for forbidding the depasturage of livestock on marshlands, with the

Fig. 4.1 Launching ceremony of schistosomiasis comprehensive control demonstration area

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Fig. 4.2 Project launch of schistosomiasis comprehensive control extension area

measures of strengthened epidemic monitoring, and other conventional prevention and control. All were to achieve further control the source of infection, reduce the endemic burden, and finally achieve the criteria for elimination of schistosomiasis (Fig. 4.2).

4.5.1.2

Control Measures

The essence of the comprehensive strategy with an emphasis on infection source control was to prevent the environment polluted by S. japonica eggs. On the basis of clarifying the main source of infection, we adopted the measures, “replacing cattle with machine,” “forbidding the depasturage of livestock on marshlands,” “renovating latrines,” and so on, supplemented by health education, treatment survey, snail survey, and implementation of agriculture, forestry, water conservancy, national soil and schistosomiasis control, and other measures to achieve the purpose of controlling the spread of schistosomiasis. The main measures include the following aspects: 1. Eliminate cattle. Through the form of government subsidies, the people in the endemic areas were encouraged to eliminate farm cattle and farmers to eliminate beef cattle, to reduce the number of major infection sources. 2. Replace cattle with the machines. Through the government subsidies to purchase agricultural machinery, the problem of agricultural production after the elimination of farm cattle in the endemic areas would be solved, and the efficiency of agricultural production would be improved to prevent the re-raising of farm cattle (Fig. 4.3).

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Fig. 4.3 Government officials inspect “replacement of cattle with the machine”

Fig. 4.4 Warning sign of “marshland isolation and farming prohibition” in Poyang Lake

3. Livestock in captivity. Forbid the depasturage of livestock on marshlands. According to the National and Provincial Regulation for Schistosomiasis Control, various measures were made to reduce the infection of livestock and prevent environmental contamination from eggs produced by schistosome-infected livestock, such as forbidding grazing of livestock on marshlands through establishing supervision and management offices and construction of livestock and poultry pens in epidemic areas in Jiangxi (Fig. 4.4).

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Fig. 4.5 Internal working drawing of Three—form toilet

Fig. 4.6 Doctor treating schistosomiasis patients

4. Change the water supply and the toilet. Combined with the central subsidy project, such as rural drinking water safety projects and toilet reforms, the project would be implemented in the endemic area of schistosomiasis to provide safe water for the people in the endemic area, improve the toilet environment, change the hygiene habits, and carry out the harmless treatment of the feces to achieve the purpose, such as reducing the opportunity to come in contact with water contaminated with cercaria and preventing the eggs from contacting the water (Fig. 4.5). 5. Conventional control. Through the traditional methods of disease detection, treatment, snail survey and control, the purpose of continuing to prevent human and animal from diseases and control snails was achieved (Fig. 4.6). 6. Health education. Through the use of various forms such as the distribution of posters, health education supplies for schistosomiasis control, screening of popular science films, brushing slogans, and knowledge classes of schistosomiasis

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Fig. 4.7 Schistosomiasis control professionals conduct the health education to primary school students

control, the knowledge of schistosomiasis was popularized among residents and primary and middle school students of the endemic areas, so as to achieve the purpose, such as increasing awareness of the rate of schistosomiasis among endemic populations and knowledge of schistosomiasis prevention and control (Fig. 4.7). 7. Comprehensive governance. Through the special schistosomiasis prevention and control projects in agriculture, forestry, water conservancy, land and other departments, and other projects, we would carry out rice field–upland field rotation, snail control by fish farming, river treatment, hardening slope protection, building forest for snail control and schistosomiasis prevention, land leveling, water conservancy farmland construction, etc. to achieve the purpose of changing the snail environment.

4.5.2

The Implementation and Effect

4.5.2.1

The Implementation

Completion of the Comprehensive Project with Emphasis on Infection Source Control Since 2004, it has actively implemented the comprehensive strategy with an emphasis on infection source control various measures in Jiangxi Province. Since the building of the comprehensive prevention and control demonstration zone for schistosomiasis in the south bank of Poyang Lake in 2010, 85 townships in

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16 counties (cities, districts) have been included in the demonstration zone and promotion zone, and the 430 million m2 infested grass with a snail in Poyang Lake region has been included. 85 management offices for forbidding the depasturage of livestock on marshlands were established in townships and villages, 77,440 farm cattle were eliminated, 230 km of grazing fences were built, and 1462 km of simple machine farms were built. Completion of Schistosomiasis Prevention Projects for Hygiene Since 2004, the health departments at all levels in Jiangxi Province have carried out various prevention and control work in a scientific, orderly, and standardized manner in accordance with the objectives and tasks determined by the plan, in accordance with the requirements of the technical plan. They earnestly performed their duties and comprehensively completed various tasks. In terms of investigation and treatment, the cumulative population in schistosomiasis survey was 14.15 million, 3,372,700 received mass chemotherapy, and the cumulative population who received treatment for advanced schistosomiasis was 51,000. In terms of snail control, snail survey was implemented in the cumulative area of 6.797 billion m2, and mollusciciding was implemented in the cumulative area of 1.029 billion m2. In terms of toilets, a total of 1,250,500 non-hazardous toilets were built, 11,700 harmless public toilets were built, and 81 non-hazardous toilets were built in distributing center. In terms of health education, more than 607,000 health education materials and more than 146,800 protective materials were distributed; more than 3140 times of media dissemination were conducted; 469 training classes for village cadres were completed; 953 training classes for teachers in primary and secondary schools were also completed; 16000 warning signs were set up; and more than 34900 slogans were posted in epidemic areas in Jiangxi. In terms of fixed-point inspection of fishermen, since it was beginning in 2012, a total of 53 fixed points have been set up, 380 fixed-point inspections have been carried out, 27,238 fishermen population information has been registered, 18,490 person-times have been investigated for schistosomiasis, 15,344 person-times chemotherapy and preventive medications have been taken, and 81 water body infection tests have been carried out. Completion of Schistosomiasis Prevention Projects for Agriculture Since 2004, the agricultural departments of Jiangxi Province have actively implemented various prevention and control measures. In terms of the survey and treatment of livestock, the cumulative number of livestock inspections was more than 1.1639 million, and the total number of treated livestock was more than 692,700. In terms of paddy–upland rotation, the total area was 6289.33 hm2. In terms of control snail by fish farming, the cumulative area was 1350.09 hm2. In addition, the completion of the machines to replace the cattle were 400,900, the transformation area of the breeding environment of Oncomelania hupensis is 7557.1 hm2, the construction area of livestock and poultry house was 52.1 hm2, the number of non-susceptible water birds farmed was 120 million, and more than 85,000 biogas tanks were constructed. With the enhancing of comprehensive

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treatment measures, the production and living environment of the epidemic areas was effectively improved. Completion of Schistosomiasis Prevention Projects for Water Since 2004, the completion of the prevention and control of schistosomiasis by water conservancy departments at all levels in Jiangxi Province mainly includes river management projects: 60 river treatment projects completed; the length of hardened slope protection was 125.44 km; the sink snail facilities have completed 28; the irrigation district reconstruction project was completed in 111 places; the length of the hardened slope protection was 886.88 km; and the rural drinking water safety project has completed the water supply population of 1,255,200. Completion of Schistosomiasis Prevention Projects for Forestry Since 2004, the forestry departments at all levels in Jiangxi Province have completed 1.174 billion m2 of forestry built for snail control, schistosomiasis prevention, and disease prevention, forest construction, 33.33 hm2 was for Alamo, 13.33 m2 was for mulberry, and 23.33 hm2 was for Zhongshansha. Completion of Schistosomiasis Prevention Projects for the Nation Since 2004, the land and resources department has organically combined land remediation and schistosomiasis prevention and control, and effectively promoted schistosomiasis prevention and control in Jiangxi Province by the engineering measures such as land leveling, irrigation and drainage, constructed field roads, farmland protection, and ecological maintenance in the schistosomiasis control planning area. The area of land consolidation totaled 76,765.03 hm2, including land-leveling area of 20,783.9 hm2, constructing field road of 3667.84 km, irrigation (drainage, ditch, and pipeline) of 6069.20 km, and 175 snail retention tanks.

4.5.2.2

The Effect

The Scope of the Endemic Area Was Gradually Compressed Through the implementation of a comprehensive strategy with an emphasis on infection source control, schistosomiasis prevention and control had achieved great results in Jiangxi Province, and the scope of the endemic area had gradually been compressed. By the end of 2016, there were 39 endemic counties in the province, including 15 counties (cities, districts) such as Nanchang city, Xinjian County, Jinxian County, Pengze County, Ruichang County, Lianxi County, Chaisang County, Hukou County, Duchang County, Lushan County, Yongxiu County, Gongqing City, Yugan County, and Poyang County, reaching the criteria for transmission control of schistosomiasis. 20 counties (cities, districts) such as communication control standards, High-tech District of Nanchang City, change economic and Technological Development District of Nanchang City, Anyi County, Xunyang District of Jiujiang City, De’an County, Development District of Nan-

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Fig. 4.8 Distribution diagram of schistosomiasis in Jiangxi Province in 2016

chang City, Wuning County, Shangrao County, Dexing City, Wannian County, Guangfeng County, Xinzhou County, Fengcheng County, Fengxin County, Shanggao County of Gao’an City, Guixi County, Wan’an County, Taihe County, and Shangyou County reached criteria for transmission interruption, Wuyuan,

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Yujiang, Changjiang, Fuliang, etc. 4 counties (cities, districts) achieve the criteria for elimination of schistosomiasis (Fig. 4.8). The Overall Condition of the Disease Was Declining 1. The total number of patients and infected animals had decreased. At the initial stage of the comprehensive strategy with an emphasis on infection source control, the total number of schistosomiasis patients in Jiangxi Province reached 132,800, the number of acute schistosomiasis cases reached 119, and the total number of infected animals reached 4555. By the end of 2016, the total number of schistosomiasis patients in the province decreased to 12,200 cases, the number of acute schistosomiasis cases fell to 0, and the number of infected animals fell to 5. 2. The prevalence rate of schistosomiasis patients and infected animals had dropped significantly. During the implementation of the strategy, the prevalence rate of schistosomiasis patients and infected animals in the province showed a significant downward trend. The positive rate of serological test and the egg positive rate of stool examination in residents decreased from 12.07% and 2.86% in 2004 to 2.79% and 0.01% in 2016, respectively. And the infection rate of cattle decreased from 4.77% in 2004 to 0.06% in 2016, a drop of 98.74%. The O. hupensis Snail-infested Area Was Effectively Controlled In 2004, an infested area with snail was of 78,931.83 hm2 in the province, the infested area with O. hupensis snail was of 290.34 hm2, and the infested point with O. hupensis snail was of 346. By the end of 2016, the O. hupensis snail-infested area had dropped to 0. Up to now, no infected O. hupensis snail had been found for 4 years.

4.5.3

The Experience and Problems

4.5.3.1

Main Practices and Experience

1. The party and the government attached great importance to schistosomiasis prevention and control. Firstly, organizational leadership was continuously strengthened. The provincial leading institutions and offices of schistosomiasis control had always retained in Jiangxi Province, which had effectively established a good working mechanism led by the government and departments to ensure that the government’s organizational leadership of schistosomiasis prevention and control was not relaxed. Secondly, findings were continuously increasing. During the period of implementing the 11th Five-year plan (2005– 2009) and the 12th Five-year plan (2010–2015) for schistosomiasis control, the financial department of Jiangxi Province continued to increase investment to ensure the smooth implementation of the plans. From 2011 to 2017, the government of Jiangxi Province arranged 30 million yuan each year for a total of 180 million yuan for the construction of the demonstration zone and promotion

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zone for the comprehensive strategy with an emphasis on schistosomiasis infection source control in the Poyang Lake region. The special provincial funds for schistosomiasis prevention and control in associated departments had also increased. Thirdly, the working mechanism was continuously innovating. The member of the office of Leading Group for schistosomiasis and Other Endemic Diseases Control of Provincial People’s Government units had established a system of contact with the endemic areas (cities, districts) of schistosomiasis to supervise and help the local schistosomiasis prevention and control. Moreover, combining the nature and characteristics of each unit’s work, the government would provide help with projects, funds, and other aspects. 2. Fully implement the comprehensive strategy with emphasis on infection source control. Firstly, a demonstration zone for infection source control was established. In 2010, the provincial government set up a leading group for the construction of demonstration zones consisting of departments of health, development, finance, agriculture, forestry, and water conservancy, and issued the “Action Plan for the Construction of the Demonstration Zone on the South Bank of Poyang Lake” to implement the promotion of infectious sources control in the whole township. The leading group had achieved the goal of reaching the criteria for transmission control of schistosomiasis in the demonstration zone in 2013, laying a solid foundation for the province totally to implement the comprehensive strategy with emphasis on infection source control. Secondly, the government gets successful experience to promote the demonstration zone to be built. In 2012–2017, on the basis of consolidating the work results of demonstration zone schistosomiasis prevention and control in the Poyang Lake south bank and summarizing the successful experience of the demonstration zone, the Jiangxi Provincial Government decided to promote the implementation of the comprehensive strategy with an emphasis on infection source control in the Poyang Lake region and other suitable areas. And the government decided to continue to implement the comprehensive strategy by measures such as forbidding the depasturage of livestock on marshlands, replacing cattle with the machine, and so on. 3. Consolidate the foundation for schistosomiasis prevention and control. Firstly, schistosomiasis control regulations should be revised and improved. In order to adapt to the requirements of schistosomiasis prevention and control under the new situation, the province’s schistosomiasis control regulations were not only compatible with national regulations, but also in line with the current situation in Jiangxi Province, providing legal protection for schistosomiasis prevention and control. “Schistosomiasis prevention and control regulations in Jiangxi Province” was revised in 2012. The regulations were officially implemented on January 1, 2013. The newly revised regulations included forbidding the depasturage of livestock on marshlands, and further clarified the responsibilities of governments at all levels and relevant departments, and stipulated that the township people’s government should establish a long-term mechanism for forbidding the depasturage of livestock on marshlands, and clearly stipulated the right to punish whoever against forbidding the depasturage of livestock on marshlands. And the

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newly revised regulations played a very important role in strengthening the management of forbidding the depasturage of livestock on marshlands and strengthening the control of infectious sources. Secondly is to carry out a fixedpoint inspection of fishermen living in fishing boats. In order to strengthen the prevention and management of fishermen living in fishing boats in the Poyang Lake region, the government of Jiangxi Province started the inspection project for fishermen living in fishing boats and expanded from 20 points in 11 counties in 2012 to 33 points in 15 counties in 2015. The Office of Leading Group for schistosomiasis and Other Endemic Diseases Control of Provincial People’s Government (hereinafter referred to as “the Provincial Department of schistosomiasis prevention and control,” the same below) jointly developed the “Fishermen Fixed Point Detection Management Information System” and the mobile client with the Provincial Health Information Center. The system realized dynamic information management of 50,000 fishermen in the Poyang Lake region. Through this system, the information on schistosomiasis of fishermen can be inspected on the spot to improve the effectiveness and pertinence of schistosomiasis prevention and control.

4.5.3.2

Comprehensive Issues in Implementation

1. It was difficult to implement the measures for infectious source control. The marshland in the Poyang Lake region was rich in resources and the breeding cost was low. Depasturage of livestock on marshlands had always been an important source of income for local residents. The working mechanism of forbidding the depasturage of livestock on marshlands was still not perfect, and the people’s legal awareness was not strong, making it difficult for forbidding the depasturage of livestock on marshlands. 2. The snail control was difficult. First, the area of the Poyang Lake region is large, the environment of hilly regions is complex, and the effect of mollusciciding is not obvious. In addition, due to environmental protection constraints and water conditions, the snail-infested area in Jiangxi Province remained high and even rose. Second, the integration of comprehensive treatment projects was not enough, the project was scattered, the resources could not be integrated, and the benefits could not be fully utilized. 3. The construction of the institutional team needed to be strengthened. Since the construction of the institution of schistosomiasis control had not been included in the national CDC construction project, it had not been improved in terms of infrastructure, laboratory equipment, etc., and the work methods were backward. The working conditions of the grassroots institution of schistosomiasis control were arduous, the technical personnel for schistosomiasis control was aging, and the team stability was poor, so the country was in urgent need to formulate corresponding policies to strengthen the construction of institutions and teams of schistosomiasis control.

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4. Blocking regional work had been weakened. As the endemic status of schistosomiasis declined year by year, the harm of schistosomiasis to people’s production and life was significantly reduced, the awareness of schistosomiasis in the endemic areas was weakened to varying degrees. It affected the implementation of schistosomiasis control, professional schistosomiasis control was paralyzed, and the work was prone to negligence and sloppiness. The awareness of the people in the endemic area had faded, and the compliance and initiative of the investigation and work had gradually weakened, which had made it more difficult to consolidate the results of schistosomiasis prevention and control.

Further Reading Chen HG, XS, Zeng XJ, Huang XB, Wang TP et al (2011) Current endemic situation and control strategy of schistosomiasis in lake and marshland regions in China. Chin J Schistosomiasis Control 23:5–9 Li YF, HC, Hu F et al (2017) Role of new strategy in transmission control of schistosomiasis in Poyang Lake region. Chin J Schistosomiasis Control 29:689–694, 715 Lin DD, HF, Liu YM, Chen HG (2004) Analysis of schistosomiasis epidemic situation after World Bank loan in Poyang Lake area and its countermeasures. Chin J Epidemiol 25:579–581 Lin DD, ZX, Chen HG et al (2009) Cost-effectiveness and cost-benefit analysis on the integrated schistosomiasis control strategies with emphasis on infection source in Poyang Lake Region. Chin J Parasitol Parasitic Dis 21:293–302 Ministry of health’s local disease prevention and Control (1987) Annual report on prevention and control of endemic diseases in China Wang LD (2006) History and prospect of schistosomiasis control in China. People’s Medical Publishing House, Beijing Wang LD, ZX, Chen HG, Guo JG, Zeng XJ, Hong XL, Wu XH et al (2009) A new strategy to control transmission of Schistosomia japonicum. Eng Sci 11:37–43 Wang LD, CH, Guo JG, Zeng XJ, Hong XL, Xiong JJ, Wu XH, Wang XH, Wang LY, Xia G, Hao Y, Chin DP, Zhou XN (2009) A strategy to control transmission of Schistosoma japonicum in China. N Engl J Med 360:121–128 Xie ZM (1990) Discussion on strategies for schistosomiasis control in Poyang Lake District. Chin J Schistosomiasis Control 2:69–71 Xue H (1990) Control of schistosomiasis in Poyang Lake area. People’s Medical Publishing House, Beijing Zhou XN, WT, Guo JG et al (2004) The current status of schistomiasis epidemics in China. Chin J Epidemiol 25:555–558

Chapter 5

Experiences and Cases on Schistosomiasis Control Research Dandan Lin, Xiaojun Zeng, Shangbiao Lyu, Xiao Yan, Guanhan Hu, Jing Zhang, An Ning, Huiqun Xie, and Yun Xu

Abstract This chapter describes details on ongoing measurements needed to keep schistosomiasis under control shown by the example of the activities in the Yujiang County. It is obligatory that susceptible zones must be constantly controlled and that health education of the population is obligatory. Furthermore, test methods and treatment of infected people must be constantly improved. Keywords Control measurements · Susceptible zones · Test methods · Treatment of infected people · Education of people

5.1

Yujiang County Experience

Yujiang County is located in the eastern part of Jiangxi Province and the middle and lower reaches of the Xinjiang River. As a major river in the territory, the Baita River runs through the county from the south to the north and flows into the Xinjiang River from the Jinjiang River, which is part of the Poyang Lake Basin. Before the liberation, schistosomiasis in Yujiang County was raging. After the founding of New China, under the great attention and leadership of the party and the government, the people of Yujiang and schistosomiasis had an arduous struggle. In 1958, they were the first in the country to eliminate schistosomiasis. Chairman Mao Zedong was pleased to write the famous poems of “To Send The Plague God Away, two poems to the tune of Will,” which has inspired the prevention and control of schistosomiasis in the country. Under the background that successive county party committees and county government leaders of Yujiang County have attached great importance to consolidating the achievements of schistosomiasis prevention and control, and solidly implementing the measures to prevent and control schistosomiasis, the first red flag for schistosomiasis prevention and control in Yujiang County has been

D. Lin (*) · X. Zeng · S. Lyu · X. Yan · G. Hu · J. Zhang · A. Ning · H. Xie · Y. Xu Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_5

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flying high for more than half a century. In 2016, Yujiang County became the first county in Jiangxi Province to eliminate schistosomiasis.

5.1.1

Endemic Status of Schistosomiasis in Yujiang County

5.1.1.1

Endemic History

When schistosomiasis began to be endemic in Yujiang County, there was no record in history. According to the masses, during the Qing Dynasty and the Republic of China era, there were epidemics of the “large belly disease” in places such as the Magang Village, Xifan Village, and Lantianfan Village on both sides of the Baita River in the county. According to the “Wu Family Genealogy” of Xifan Village in Ziyun Township and the “Genealogy” compiled by Yangjiache Village in September of the 45th year of the Qianlong of Qing Dynasty (1780), the record statistics and literary expressions of the large population deaths were reported. In view, it is inferred that schistosomiasis of the county may have been prevalent before the year of Qianlong of Qing Dynasty. The earliest and clear official record of the testable evidence is that in 1946 (35th year of the Republic of China), “Yujiang County Government Work Report” recorded that the county’s Shiyan Township (part of Maquan Township and Dengbu Township after the founding of the People’s Republic of China) had discovered Schistosoma japonica, indicating that Yujiang County has been confirmed by the government as the endemic area in 1946. However, according to the statistics after 1949, it can be known that before the liberation, schistosomiasis in Yujiang County was seriously prevalent. In the 30 years before liberation, 29,000 people in the county died of schistosomiasis, 42 villages were destroyed, and more than 20,000 acres of farmland were uncultivated. There were more than 500 households and more than 2200 people in Jiantou Village originally, which was known as “Jiantou Prefecture.” At the time of liberation, there were only 8 households and 24 people, which became the Jiantou Group. Located in the east bank of the Baita River, the Shanghuang Village of Magang Brigade (Magang Township in the early days of the founding of the People’s Republic of China) in Dengbu Town moved from the Peace Group of Fujian Province; there were more than 500 households and more than 2200 people when developed to the 34th generation (in the early nineteenth century). However, after the 35th generation, due to the impact of the endemic disease, the population gradually decreased, and the number of households without offspring gradually increased. In the 5 years before the liberation (1945–1949), only 13 people were born, while 40 died. At the beginning of the liberation, more than 500 households had been reduced to 46, and there are 48 widows in the village, which is called the “widow village.” “Hundreds of weeds-crawled hamlets are ridden with men’s wastes, Thousands of forlorn households hear the singing of ghosts” is the true portrayal of Yujiang’s old appearance.

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Fig. 5.1 Baita River in Yujiang County and the legendary source of the plague Lion Mountain

5.1.1.2

Endemic Area Confirmation

After the liberation of Yujiang County, the party and the government attached great importance to the suffering of the people and placed the prevention and control of schistosomiasis in a prominent position. In March 1951, the Health Department of Jiangxi Province sent a doctor Zhang Zuxian and an inspector Qi Shaowu to Yujiang County for a preliminary investigation, which confirmed the prevalence of schistosomiasis. The investigation confirmed that the endemic area of schistosomiasis in Yujiang County is mainly centered on Baita River, involving 95 villages of 5 townships (towns, fields) and 14 village committees. The area of endemic areas is 223 km2, accounting for 23.67% of the total area of the county. At that time, there were more than 4000 patients with schistosomiasis, and more than 30,000 people were threatened by schistosomiasis. The area of Oncomelania hupensis reached 78 km2, and the highest density of snails was 264/0.1 m2. The serious harm of schistosomiasis has led to the reduction in the local population, the decline in productivity, and the living poverty (Fig. 5.1).

5.1.2

The Process of Eradicating Schistosomiasis in Yujiang County

Since 1953, the prevention and control of schistosomiasis in Yujiang County have been actively promoted for nearly 6 years and have achieved remarkable success. In

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May 1958, it became the first county in China to eliminate schistosomiasis. Its work to eradicate schistosomiasis generally went through the following processes:

5.1.2.1

Establishing Professional Institutions to Investigate the Endemic Status and Carry Out Scientific Research to Prevent and Control

In February 1953, Yujiang County established the first grassroots leading organization for schistosomiasis prevention and control: the committee for schistosomiasis prevention and control in Shanghuang Village, Magang Township. Since then, it has successively set up the committee for schistosomiasis prevention and control in Yujiang County (April 1955) and the station for schistosomiasis prevention and control in Yujiang County schistosomiasis (April 1956). In April 1953, in order to strengthen prevention and control work, the schistosomiasis Control Institute of Jiangxi Province moved from Fuliang County to Dengbu Town, Yujiang County. First, the endemic status was investigated. During this period, the endemic status was investigated mainly by going to the villages, making house-to-house visits, registering each person, and conducting disease examination and snail survey. Through investigation, the endemic status was clarified, and it was realized that the single treatment could not be cured, so the public should be actively mobilized to carry out the prevention work while treating the disease, and the “two managements and one elimination” (i.e., the management of feces and water and the elimination of Oncomelania hupensis) should be put on the agenda. In addition, the institute also set up prevention and control experimental area in Magang Township to carry out prevention and control experiments, which opened the prelude to the prevention, control, and research of schistosomiasis in Yujiang County (Fig. 5.2).

5.1.2.2

Publicizing and Popularizing Prevention and Control Knowledge

Due to the backwardness of science and culture and the thoughts of feudal superstitions at the time, it was rumored that the “large belly disease” was because of drinking the “rust water” that flows down the Lion Rock, and it was destined and “feng shui is bad” in the village. Nothing is known about the clinical response to schistosomiasis, and the route of transmission of schistosomiasis is even more unknown. To this end, in the early stage of prevention and control, the schistosomiasis Control Institute of Jiangxi Province organized the masses to popularize the prevention and control knowledge through various forms and lively publicity. For example, (1) using advanced and attractive photographs and slides at that time, men and women, old and young, all came to listen to “foreign drama” and to see “local movies” to expand publicity; (2) using microscopes and other equipment, the Oncomelania hupensis seized and the stools sent for inspection were publicly inspected. Let the masses see the schistosomiasis eggs in their feces and the cercariae in the Oncomelania hupensis, and thus be educated; (3) using the experiences of

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Fig. 5.2 Yujiang County established the station for schistosomiasis prevention and control

patients who have been cured and so on, so that the local people can get out of the superstition, and actively cooperate with the treatment, and consciously into the management of water and feces and the snail survey and control in the mass campaign of schistosomiasis control. At the same time, they actively carried out the training of schistosomiasis prevention and control professionals, and started two training courses, training more than 120 people. After graduation, the students will be assigned to various places to carry out schistosomiasis prevention and control work (Figs. 5.3, 5.4, 5.5).

5.1.2.3

Conducting Prevention and Control Experiments

From 1953 to 1955, the schistosomiasis Control Institute of Jiangxi Province used Magang Township and the farm as experimental bases, and a series of experiments were carried out to eliminate snails, manage feces, and treat advanced schistosomiasis. In order to completely eliminate Oncomelania hupensis, according to the characteristics of the snails’ distribution in a ditch, a number of snail elimination experiments such as artificially capturing snails, fire-burning snails, and team-killing snails were carried out successively in the Magang Township experimental area, and the results were not satisfactory. Subsequently, the experiment of repairing ditch and controlling snails was carried out, combined with autumn grass shoveling and

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Fig. 5.3 Microscopical demonstration of the Schistosoma eggs to the rural public

Fig. 5.4 Publicize the knowledge of schistosomiasis prevention and control through the newspaper in the place of mass activities, disseminate the knowledge of schistosomiasis prevention and control to the masses

composting to repair ditch and control snails, that is, the “three alls” grass shoveling and composting snail control test, and found that it has a certain effect on reducing the Oncomelania hupensis density (the average density of Oncomelania hupensis from 28/0.1 m2 before repairing ditch dropped to 7.5/0.1 m2), combined with the characteristics of composting; in line with the wishes of the masses, there are the

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Fig. 5.5 Professional training session of inspectors, feces managers, and health workers

value and possibility of promotion. After that, according to the fact that the compost suffocated the Oncomelania hupensis, the experimental group combined with the winter renovation of water conservancy and carried out the experiment of “opening new ditch, filling old ditch, and embedding snails” at Magang Township and farms of Dengjiabu, respectively (referred to as “opening new and filling old”). And its large area large-scale promotion of the experiments, found that this method is not only economical, snail control effect is good, but also easy to promote combined with water conservancy.

5.1.2.4

Formulating and Implementing a Plan to Eliminate Schistosomiasis

In 1955, after the first national schistosomiasis prevention and control work conference proposed the strategic policy of eliminating schistosomiasis in seven years, the Yujiang County Committee carefully summarized the experience and lessons of prevention and control work in previous years, analyzed the favorable conditions for prevention and control of schistosomiasis, and proposed a 2-year plan for the elimination of schistosomiasis in the whole county with “half-year preparation, one year of fighting, half a year to sweep the tail.” The first document issued by the county committee on schistosomiasis control plan (CPC Yujiang County committee on the plan for the prevention, control, and elimination of schistosomiasis,

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December 7, 1955, the county committee (55) No. 69) has been issued since the launch of schistosomiasis prevention and control work in the county. On January 19th, 1956, the county commission held a swearing-in meeting to eliminate schistosomiasis in the county in Dengbu Town. Since then, the work of eliminating schistosomiasis has officially started.

5.1.2.5

Establishing a Leadership System and Prevention and Control Mechanism

In order to ensure the realization of the 2-year plan, the party and government at all levels in Yujiang County and the endemic area have strengthened their specific leadership on the work of schistosomiasis prevention and control. Firstly, established the “CPC Yujiang County Committee for the Prevention and Control of Schistosomiasis Five-Member Group (referred to as the County Committee for Schistosomiasis Control Five-Member Group) and the County Prevention and Control Committee. The first team leader of the Yujiang County Committee for Schistosomiasis Control Five-Member Group was appointed by the county committee member and deputy county magistrate Wu Hansun (January 21, 1956, to October 15, 1956), followed by Li Junjiu, the first secretary of the county committee. All districts, townships, towns, farms, and agricultural communities subsequently established the “Schistosomiasis Control Three-Member Group” led by the party secretary and the Administrative Committee of Prevention and Control. The party committee formed a strong top-down leadership system in the work of schistosomiasis control. At work, schistosomiasis control work was listed as one of the important contents, requiring party and government at all levels and its schistosomiasis control institutions, to achieve “four unifications” (i.e., unified leadership, unified arrangements, unified inspection, and unified reporting) and “four adherences” (i.e., adhering to schistosomiasis control work, included in the party and government agenda, researching and deploying together with production and other major work; adhering to the leadership of secretary, designated responsible person, departmental cooperation; adhering to the combination of production to carry out schistosomiasis control work; and adhering to the regular meeting reporting system).

5.1.2.6

Carrying Out a Large-Scale Mass Schistosomiasis Control Campaign Based on “Snails Elimination”

When implementing the plan to eliminate schistosomiasis, it was in the winter of 1955 that there was a climax of agricultural cooperation, and the private ownership of land was replaced by socialist collective ownership, which provided favorable conditions for large-scale snail control work such as “opening new and filling old.” To this end, the Yujiang County Committee carried out large-scale popularization and application of the preliminary prevention and control experiment results, combined with the winter construction of water conservancy to carry out large-scale

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Fig. 5.6 Opening new ditches and filling old ditches for snail control

opening new ditch and filling old ditch for snail control, combined with agricultural composting to carry out “three alls” shoveling grass for snail control, combined with spring to send fertilizer and make fertilizer to carry out fecal fermentation for killing eggs, etc.; set off the climax of the mass schistosomiasis control campaign with the mobilization of the whole party and the participation of the whole people. Through three large-scale “opening new and filling old” snail control assaults successively, 90% of the snail area in Yujiang County was eliminated. At the same time, the disease was examined and treated, the labor was treated during the slack seasons of farming, the women, children, and fishermen were treated during the busy seasons of farming, and many public toilets, wells, and other “two managements” infrastructure were newly built (Figs. 5.6, 5.7, 5.8, 5.9).

5.1.2.7

Identification and Acceptance

On July 30, 1957, the Office of the CPC Central Committee for the Prevention and Control of Schistosomiasis Nine-Member Group and the Office of the CPC Jiangxi Provincial Committee for the Prevention and Control of Schistosomiasis FiveMember Group jointly conducted a systematic investigation on the effect of schistosomiasis prevention and control in Yujiang County. With a solid fact and a large amount of data, it is fully demonstrated that Yujiang County has reached the basic criteria for elimination of schistosomiasis. On February 7, 1958, the Central Committee for the Prevention and Control of Schistosomiasis Nine-Member Group reapproved the “investigation report on the basic elimination of schistosomiasis in

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Fig. 5.7 Composting for snail control

Fig. 5.8 Artificial fire-burning used for snail control

Yujiang County” submitted by the Central and Provincial Joint Investigation Group, and the method of “opening new and filling old, soil burying and eliminating snails” was officially approved. In order to completely eliminate schistosomiasis, the county

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Fig. 5.9 Scientific groups and village population checking the amount of the snails in the 1950s. Various methods of snail control adopted in the 1950s

committee mobilized again, devoted 30 days of hard work, eradicated 1.3 hm2 residual Oncomelania hupensis area, and treated more than 30 patients. From May 12 to 22, 1958, it was reviewed and confirmed by the provincial committee for the prevention and control of schistosomiasis leading group, confirmed that Yujiang County reached the criteria for elimination of schistosomiasis, and issued the “Certificate of Identification for the Elimination of schistosomiasis,” which became the first county in China to eliminate schistosomiasis. From May 25 to 28, 1958, Fang Zhichun, secretary of the provincial committee, visited Yujiang County to host the victory ceremony for schistosomiasis elimination in Yujiang County and the provincial schistosomiasis control on-the-spot meeting. The Jiangxi Provincial Committee approved the on-the-spot meeting report to promote Yujiang schistosomiasis control experience; on June 5, 1958, the Ministry of Health of the People’s Republic of China called to express warm congratulations. On June 30, 1958, People’s Daily reported the news of the elimination of schistosomiasis in Yujiang County with the title of “The First Red Flag.” At that time, Chairman Mao was in Hangzhou (Figs. 5.10, 5.11, 5.12). That night, after reading this report, he “was too excited by the news to fall into sleep, but into a stream of thoughts instead, and then was pleased to order his pen for composing these poems,” and wrote a magnificent and glorious poem “To Send The Plague God Away.”

5.1.3

The Main Measures to Eradicate Schistosomiasis

Under the economic and scientific conditions at that time, the eradication of schistosomiasis in Yujiang County was based on the formulation of plans, the

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Fig. 5.10 The “Certificate of Identification for the Elimination of schistosomiasis issued by the CPC Jiangxi Provincial Committee”

Fig. 5.11 The “First Red Flag” report published by the People’s Daily in 1958

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Fig. 5.12 Mao Zedong’s “Two Poems of Sending the God of Plague” published in the People’s Daily in 1958

establishment of confidence, and the exertion of enthusiasm for the work, adopting a series of economic and effective prevention and control measures such as snail control combined with water treatment, combined treatment of patients, sick livestock, feces, and water management.

5.1.3.1

Snail Control Measures

The snail control is the main measure in the eradication stage of Yujiang County. At this stage, various snail control measures were adopted, especially unified planning, the snail control plan into the water conservancy plan was incorporated, and the total area of snail control was 966,640 m2. Opening a New Ditch and Filling Old Ditch for Snail Control This method is the most important measure to eliminate the breeding environment of Oncomelania hupensis in Yujiang County. From 1956 to 1958, three large-scale “opening new ditch and filling old ditch for snail control” activities were carried out successively, and 90% of the snail area in Yujiang County was cleared. “Opening new ditch and filling old ditch” means that the water in the sulcus pond with snails is drained first, and the thorn trees on the banks of the ditch are removed, then the grass mud on both sides of the ditch are shoveled to the bottom of the ditch from top to bottom, from top to bottom, and then fill the compaction with the soil excavated by

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the new ditch; the new ditch needs to maintain a certain distance from the old ditch. If the new ditch passes through the old ditch, the intersection should be specially treated. “Three Alls” Grass Shoveling and Composting for Snail Control For some of the larger projects and low density of snails, it is temporarily difficult to fill the ditch (pond); then “three alls” grass shoveling and composting for snail control is adopted. The method is to first dry the water in the sulcus pond with snails and expose it to the sun for 1 or 2 days to prevent the infection of the cercaria. In turn, the two sides and the bottom grass mud are shoveled 3 to 5 inches, and picked up to the shore to compost, and mixed with lime and sealed using wet mud without snail. The Paddy Field Is Changed to the Dry Field for Snail Control The method is first to drain the field, open the drainage ditch around, the ditch is 2 to 3 feet deep, and then use the tractor to turn the soil, and then make the deep ditch narrow furrow, each furrow about 1 cent of land, width about 5 city feet, height about 1.5 city feet. After the formation of the field, planted various dry crops such as jute, sweet potato, and soybean. The method is good for snail control in rice fields. In the place where the soil is buried and the “three light” snails are difficult to use completely, the drug calcium phosphate is used to kill the snail. Mollusciciding for Snail Control In places where the soil burial and the “three alls” for snail control are difficult to eliminate the snails completely, the drug calcium phosphate is used to kill the snails.

5.1.3.2

Treating Patients and Sick Cattle

At that time, patients were treated with L-antimony potassium tartrate (C8H4K2O12Sb2), and medical staff was encouraged to experiment boldly and to improve the treatment of tincture. The course of treatment was 20 days, 3 days, and 7 days respectively, of which 80% were treated with 20 days of therapy and 20% by short-course therapy. Advanced patients are treated by a combination of Chinese and Western medicine. They are treated with TCM syndrome differentiation, improve symptoms, eliminate ascites, enhance physical fitness, and then use sputum or surgery. In the 1958 census, 60 sick cattle were treated with sputum (3 days therapy, 7 mg/ kg) except for 3 old cattle without treatment value (Fig. 5.13).

5.1.3.3

Implementing the “Two Managements” Measures

In the early stage of prevention and control, there were no public toilets in Yujiang County. The private manure and toilets were uncovered, which did not meet the hygiene requirements, and the fertilization habits that feces were picking up at any time when needed, making the Schistosoma eggs in the feces one of the main sources

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Fig. 5.13 Treatment of schistosomiasis by a combination of Chinese and Western medicinal preparations

Fig. 5.14 Rural residents using well water

of infection. To this end, Yujiang County implemented the measures of public toilets and regular storage and septic of manure, abolished old manure sputum, built manure management facilities and concluded a manure management convention by village, selected manure managers, and implemented the special person responsibility system. At the same time, the water wells that do not meet the sanitary standards will be reconstructed to achieve the “five haves” of the wells, that is, there will be a good platform, well ring, well column, public bucket, and drainage ditch to achieve the purposes of using sanitary water (Fig. 5.14).

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Table 5.1 Status of schistosomiasis infection in the early stage of prevention and control in Yujiang County Township (town, field) Pingding Township County Agricultural Institute Dengbu Dengjiabu Town Maquan Township Zhanggongqiao Farm Rice field Fishery Total

Endemic villages count 3 1 4 8 3 3 23 2 47

Population infection rate (%) 18.73 18.73 20.26 14.45 20.59 20.59 33.29 31.98 26.14

5.1.4

Changes of Endemic Schistosomiasis Status in Yujiang County

5.1.4.1

Schistosomiasis Status

In the early days of liberation, schistosomiasis infection was severe among residents in the endemic areas, and the resident infection rate was as high as 30% or more (Table 5.1). From 1953 to 1958, a total of 4750 schistosomiasis patients were identified by investigating the endemic status. A total of 5810 person-times were treated before 1958. After its eradication in 1958, the diagnosis and treatment of diseases were mainly to monitor the source of infection and the remaining sources of infection. For those who have missed out in the eradication stage and those who have not been treated for history, they will be filled out the registration form and regularly examined and followed up. After 1958, 1610 patients (times) were found, including 712 new patients, but no patients were detected by again stool examination after stool examination or blood test since 1973 (Table 5.2). Before 1958, total 65 infected cattle with schistosome were found, of them, 5 in 1956, 60 in 1958, and 1 sick dog in 1956 were diagnosed with schistosomiasis in the county. After the announcement of the eradication of schistosomiasis, only 1 and 7 positive farm cattle were detected in 1959 and 1964, respectively.

5.1.4.2

Snail Status

The total snail area in Yujiang’s history is 97.46 hm2. In May 1958, the cumulative snail area was 96.04 hm2, accounting for 98.54% of the total snail area in history. According to the survey from 1954 to 1955, the Oncomelania hupensis infection rate was the highest with the ditch, reaching 38.59%. Within 3–5 years after the eradication of schistosomiasis, a comprehensive and detailed investigation was carried out, which was conducted annually in spring with

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Table 5.2 Status of schistosomiasis cases detected every year during schistosomiasis eradication in Yujiang County Year 1959 1960 1961 1962 1963 1964 1965 1966 1968 1969 1970 1971 1972

No. exam 22,837 30,429 19,766 10,324 11,691 13,977 7399 8005 382 2707 3160 3669 3901

No. egg+ 138 80 309 151 267 418 32 173 1 7 3 23 8

Egg+ (%) 0.60 0.26 0.56 1.46 2.28 2.99 0.44 2.16 0.26 0.26 0.09 0.63 0.21

No. new egg+ 69 44 159 80 82 150 7 94 0 5 3 13 6

New egg+ (%) 0.30 0.14 0.80 0.77 0.70 1.07 0.10 1.17 0.00 0.18 0.09 0.35 0.15

the cooperation and cross-examination of the schistosomiasis control professionals and the masses and reviewed in autumn. Between 1963 and 1986, the system sampling with a 5-m frame distance was combined with the environmental sampling method to conduct annual rounds of one-third of five townships (towns and fields) in endemic areas. From 1987 to 1989, the complex environment and suspicious zone of the original snail area were checked for 2 consecutive years using a systematic sampling method of 5 m frame distance. In addition, all boats returning from fishing in endemic areas and introduced aquatic plants are listed as surveillance points, and boats and fishing-nets are spot-checked. In the 7 years from June 1958 to 1965, 32 residual snail points were found, with an area of 13,482 m2. In the 12 years from 1971 to 1983, three remaining snail points were found, covering an area of 1236 m2 (Table 5.3).

5.1.5

Experience of Schistosomiasis Control in Yujiang County

5.1.5.1

Experience of Eradicating Schistosomiasis

The great victory of 2 years’ great efforts to eradicate schistosomiasis in Yujiang County was a great innovation in the history of medical science at that time. It was also a pioneering work by the masses to use science and technology to transform nature and eliminate the disease. The experience of eradicating schistosomiasis in Yujiang County mainly includes: The party and the government attach great importance to it, and the secretary of the county party committee personally participates. The county party

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Table 5.3 Status of snails found in Yujiang County in each year

Year 1958 1959 1960 1961 1962 1963 1964 1965 1971 1972 1983

Snail survey area (m2) 1,248,990 9,543,112 4,344,661 9,987,413 6,187,811 6,541,132 4,156,711 6,676,614 4,567,814 5,846,317 345,531

Snail area (m2) 1030 1558 7329 2384 112 1000 9 60 168 600 468

No. snail points 2 3 11 8 2 3 2 1 1 1 1

No. live snail 19 32 1089 2271 798 989 55 186 307 61 579

No. infected snails 0 0 9 6 0 2 2 0 0 0 0

Oncomelania hupensis infection rate (%) 0 0 0.93 0.28 0 0.6 3.64 0 0 0 0

committee and the county government take eliminating schistosomiasis as a major political task to promote production and improve people’s living standards. From 1956, all county committee meetings and various major reports have included schistosomiasis work in important meetings, and the secretary of the county party committee also often goes to the township, do it by himself, from the typical cases to general, from the middle to both sides, making the schistosomiasis control work appear at every meeting, be combined with every season, be deployed in every work. The personal participation of the secretary is a reliable assurance to achieve eradication of schistosomiasis in Yujiang County. Schistosomiasis control work and production are closely combined and promoted simultaneously. In the process of eradicating schistosomiasis, Yujiang County always adheres to the guiding ideology of taking production as the center and schistosomiasis control as the key point. Schistosomiasis control and production work are closely combined, and adjusted with local conditions, such as winter water conservancy combined with opening new ditch and filling old ditch for snail control, summer cutting grass and composting combined with “three alls” for snail control, agricultural arrangements and treatment arrangements staggered, etc., receiving an effect of diminishing infection risks. Mass participation, brainstorm, and force. The party committees at all levels in Yujiang County use various forms such as true story and the old and new contrast and advise others by using one’s own experience to raise awareness of the dangers of schistosomiasis and the importance of prevention and control and, at the same time, use various meetings, short-term training, on-site teaching, and typical demonstrations, etc., pass on prevention knowledge and technology to the masses, and mobilize the masses into prevention and control work consciously. From point to the surface, sum up experience and guide comprehensive. Before implementing each measure, pilot projects will be carried out first, and the combination of cadres, prevention and control personnel, and the masses will be

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implemented to develop various experimental research on prevention and control jointly, explore the experience, and then promote it in an all-around way. Implement the project acceptance system to ensure quality. In the large-scale mass snail control campaign, the quality is strictly required. Each site is equipped with schistosomiasis control and water-conserving technical personnel to serve as technical guidance. According to the appraisal system during acceptance, the quality and quantity of the prevention and control work are taken into consideration, and the engineering specifications are met. At the same time, the implementation of the “three guarantees” work management system of elimination, examination, and consolidation will ensure the long-term consolidation of the snail control effect. Departments cooperated, schistosomiasis control together. Under the unified leadership of the county party committee, all departments actively cooperated. For example, the water conservancy department took out water conservancy technicians to participate in the measurement, design, and site technical guidance of opening new ditch and filling old ditch for snail control project; the civil affairs and banks allocated relief funds to support the endemic areas; propaganda departments carry out schistosomiasis control publicity; the Communist Youth League and the Women’s Federation actively organize youth and women to participate in prevention and control campaigns.

5.1.5.2

Experience of Consolidating Schistosomiasis Control Results

After eradication of schistosomiasis in Yujiang County, only 52 remaining snails were found in 35 places from 1958 to 1983. Since then, no new snail points have been found. After 1973, no newly infected schistosomiasis patients and sick livestock were found. The results of schistosomiasis control are consolidated. The Degree of Attention Is Not Decreased After the eradication of schistosomiasis in Yujiang County, in October 1958, Yujiang County Committee promptly put forward the 16-word policy of “longterm observation, regular review, repeated struggles, and consolidation of victory.” Over the past 60 years, the successive Yujiang county committees and governments have fully recognized the long-term, arduous, and complex nature of consolidating the achievements in schistosomiasis control and have always regarded the consolidation of schistosomiasis control achievements, the protection of the people’s health, and the promotion of social and economic development as an important political task. It has achieved “the mind is not loose, the organization is not withdrawn, the team is not scattered, and the work is not stopped” to ensure the smooth implementation of the schistosomiasis control work. After 2005, the county government emphasizes the deployment of schistosomiasis control work in the form of “No. 1” documents each year, further improves the government responsibility system of target management for schistosomiasis control work, and determines the April 30th of each year as the leading cadre “snail survey day.” On this day each year, the leaders of the four groups of the county participated

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in the snail survey activities together with the cadres and the masses, and guided the broad cadres and the masses in the county to actively participate in the schistosomiasis control activities, and created a good schistosomiasis control atmosphere for consolidating the achievements of schistosomiasis control. Monitoring Does Not Stop The county schistosomiasis control station conducts schistosomiasis examination for population and livestock in the endemic areas every year and regularly visits the fishing team (fishing in Poyang Lake) to inspect and cure the disease and insists on conducting daily outpatient examinations. At the same time, it will strengthen the monitoring of people in the endemic areas, livestock, and fishing boats, fishing gear, and aquatic products. Every year, we insist on the monitoring of snails in spring and autumn and carry out snail surveys on the two sides of the non-endemic area with a history of snail environment and potential risk of transmission. In order to strengthen the monitoring of residual snails, accomplish early detection, early reporting, and early elimination, and increase the enthusiasm of the people to check the snails, in April 1986 and October 2004, the Yujiang County People’s Government issued the “Report on reward people’s announcement of snail” twice. If the snail announced by the masses was first discovered in the county, they could be rewarded. The prizes were raised from the initial 30 yuan to 300 yuan, and the behavioral incentive mechanism for the mass to check snails was established. In the past few decades, hundreds of people have discovered suspicious snails in time to report to the county schistosomiasis control station, but they are not Oncomelania hupensis, and no one has received this award. Implementation of a Comprehensive Schistosomiasis Control Project After the eradication of schistosomiasis, in the practice of consolidating the achievements in schistosomiasis control, Yujiang County has always adhered to the “four combinations,” that is, the combination of schistosomiasis control work and water conservancy construction, agricultural production, environmental reconstruction, and patriotic health, completely transforming the snail environment. As a result, the appearance of the endemic area has also changed dramatically. By combining water conservancy projects, the Baita Canal (east and west) water conservancy was reconstructed, the water system was adjusted, the bends was straightened, and no mud on all three sides, making it difficult for the snails to survive. By combining the farmland basic construction and agricultural machinery promotion projects, guiding the masses to adjust the agricultural industrial structure, promoting the “water to drought” and “water and drought rotation” farming mode, and hardening the ditches, the farmland was turned into grid, ditches were turned into rows, barren hills and desert beaches were transformed into fertile fields and orchards, and paddy fields were transformed into dry land; through the combination of patriotic health campaign and new rural construction, the construction of three-compartment harmless household toilets, the construction of tap water and hand-pressed wells, and the remediation of the surrounding environment of the village, the phenomenon of

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“dirty, chaotic, and poor” was completely changing, and the appearance was completely new. Strengthen the Schistosomiasis Control Awareness of the Whole People Conduct health education of schistosomiasis control in various forms, put up posters in endemic areas, write permanent propaganda slogans, play special videos on schistosomiasis control, and open schistosomiasis control classes in schools; hire the old schistosomiasis control personnel, the old advanced models, and the old schistosomiasis patients to go to schools and communities to carry out schistosomiasis control history education. The county radio and television station opened up a special column on schistosomiasis control and broadcast regularly, fully exerted the role of the “schistosomiasis Control Memorial Hall” patriotic education base, and organized the county’s broad cadres, masses, soldiers, and students to visit the memorial hall, receive education, and strengthen the schistosomiasis control awareness of the whole people.

5.1.6

The Significance of Schistosomiasis Control Experience in Yujiang County

5.1.6.1

Establishing Confidence for the National Schistosomiasis Control and Set off the Climax of the Nation’s “Sending the God of Plague” Campaign

In 1958, Yujiang County eradicated schistosomiasis, its many creative schistosomiasis control experiences, for example, the schistosomiasis control mode of environmental reconstruction combined with water conservancy and opening new ditch and filling old ditch for snail control, the value of the application of those measures to promote in the national schistosomiasis endemic areas, especially hilly endemic regions, is beyond doubt. In particular, the publication of Mao Zedong’s “To Send The Plague God Away” greatly inspired the national morale of schistosomiasis control, “schistosomiasis, in the past people thought that there is no way to deal with it, and now there are ways to deal with it,” and set off the climax of the “To Send The Plague God Away” campaign.

5.1.6.2

Establishing a Model for the Nation to Consolidate the Achievements of Schistosomiasis Control and Eliminate Schistosomiasis

In 1958, Yujiang County took the lead in realizing the great pioneering work of eradicating schistosomiasis in counties and set up the first red flag on the schistosomiasis control battlefront. In 1978, Yujiang County was awarded the

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“schistosomiasis Elimination” achievement award by the National Science Conference. So far, Yujiang County has continuously consolidated the achievements of schistosomiasis control for 60 years. In 2006, Vice Premier Wu Yi attended the National Conference on Schistosomiasis Prevention and Control held in Yujiang County. He praised Yujiang County for setting a good example for consolidating the achievements of schistosomiasis control. The schistosomiasis control spirit of Yujiang County that “fighting the sky and fighting the earth, daring to be the first and never ending until reaching the goal” is a precious treasure for us to do a good job in schistosomiasis control. Since 2015, after completing the prevention and control target of schistosomiasis transmission control, China’s schistosomiasis control work has entered a new era with the comprehensive implementation of elimination of schistosomiasis as the new target and the implementation of monitoring response as the main intervention measures. “The schistosomiasis control spirit of Yujiang County” will become the source power of China’s schistosomiasis control to schistosomiasis elimination.

5.1.6.3

Public Health and Endemic Prevention System with Chinese Characteristics Is One of the Magic Weapons for China’s Great Achievements in Schistosomiasis Control

Although the “huge-crowd strategy” for the prevention and control of schistosomiasis has been withdrawn from the historical stage, many of the spirits in the fiery years marked by the “first red flag” are still cherished, collected, and remembered by future generations, especially the grassroots public health and endemic prevention system demonstrated by the experience of Yujiang County, such as the postscript of Mao Zedong’s “To Send The Plague God Away,” “the communist party organization, scientists and the masses, combined together, the Plague God had to walk” proves that it has universal value in the prevention and control of schistosomiasis in China. Establish a system of prevention and control leadership at all levels under the leadership of the party committee, implement extensive social mobilization and public participation, scientific prevention and control by professionals is a magic weapon for public health and endemic prevention system with Chinese characteristics, and also for China’s schistosomiasis control to achieve world-renowned achievements. The schistosomiasis elimination in the Yujiang County is a successful example of the tough efforts on the part of the modern China of our days (Fig. 5.15).

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Fig. 5.15 The widow village of those years is today a new safe countryside

5.2 5.2.1

Experience of Schistosomiasis Control from Jinxian County Background

The measures of schistosomiasis control in China were adjusted twice before 2000. The first time is to view interruption as the main purpose and Oncomelania hupensis elimination as prevention and control methods from the 1950s to early 1980s. The second time is to consider people protection and disease control as purpose, mass and livestock chemotherapy as main methods, and snail control in the susceptible zone and health education as auxiliary methods from the mid-1980s to early twentyfirst century. However, the abovementioned measures are impossible to interrupt the spread of schistosomiasis in the marshland and lake regions, considering that schistosomiasis is expected to be eliminated thoroughly and effectively in a large region. According to the reports of the endemic status of schistosomiasis nationwide from 2000 to 2004, the number of infected people and cattle in the marshland and lake regions is 85% and 70%, respectively, of the total number of the nation. Obviously, the control of the endemic status of schistosomiasis in the marshland and lake regions plays an important role in national schistosomiasis control. Poyang Lake, the largest freshwater lakes in China, is the endemic area of schistosomiasis in the marshland and lake regions. There were more than 2,500,000 people and over 140,000 farm cattle under the threat of being infected by schistosomiasis in 2004, and the infected area with snail is 78,931.83 ha2, which is 97.8% of the total infected area of the province. There exist three difficulties in the

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control of endemic status in the marshland and lake regions. The first one is Oncomelania hupensis control. Snail control by drugs aiming at transmission interruption is hard to be applied well because of the shortage of drugs to cover the large marshland of the lake region and the limitation by environmental protection. These bring enormous troubles on transmission interruption. The second is infection source control, which is mainly to control the farm cattle in marshland. However, farm cattle are the main tool for farming and production of farmers in the lake region and an important source of income. Researches show that more than 90% of schistosomiasis infection sources in marshland in Poyang Lake District is farm cattle bred freely, whose feces containing Schistosoma japonica eggs extremely pollute the marshland causing the spread of infection source. Three is severe reinfection of people and livestock. The main reason is inefficient control of schistosomiasis infection source in these regions. People are inevitably exposed to endemic water for production and living. Lying in upstream of Poyang Lake, Aiguo Village, Xinhe Village, and Guanghui Village of Sanli Township, Jinxian County is the endemic area in the marshland and lake regions. The three incorporated villages are close to Ruihong Town, Yugan County, in the east and are connected to Xinlian Township, Nanchang County, by a lake in the north, having a total population of 7319 people. Residents there mainly live on planting dryland crops like peanut, soybean, and oilseed rape and sometimes depend on fishing, farming, and long-distance selling and transportation, earning about 2400 yuan per year every person. Villagers are exposed to endemic water due to fishing, cutting Artemisia Selengensis, washing clothes, farming, and washing hands. There are 2156 farm cattle grazing in marshland perennially whose average infective rate was 10.96% in this experimental area in 2004, while the average infective rate of people is 9.33%. Niu Marshland and Liulingwei Marshland are around the experimental area whose density of infective snail is 0.034/0.1 m2, which is the first-tier susceptible zone. Except for farm cattle, there is no livestock in the marshland. This region became the comprehensive pilot project for prevention and control with emphasis on infection source control, having a remarkable effect (Fig. 5.16).

5.2.2

Solutions for Infection Source Control

The key methods of infection source control include replacing cattle with machine to reduce infection source, forbidding the depasturage of livestock on marshlands and raising livestock in fence to prevent eggs in feces from polluting marshland with snail, rebuilding harmless toilets for eliminating Schistosoma japonica eggs in feces, and strengthening the management of feces of fishermen to stop feces from contaminating areas with snail. The assertion technological methods included disease survey and cure of people and livestock, health education, engineering reform of safe domestic water, improvement of living environment, and industrial restructuring in society.

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Fig. 5.16 Satellite image of Jinxian district in Jiangxi showing huge water sites that are used for snails

5.2.2.1

Substitution of Machines for Bovines

In the first half of 2005, 2156 farm cattle in three pilots were killed or received chemotherapy by praziquantel, and the government would give 700 yuan for one cattle as a subsidy. To solve the problems of farming tools, the government equipped farmers with 488 farming machines, giving support in maintenance and after-sales service. More than 500 farm mechanic were trained. The three villages achieved mechanization of farming and production preliminarily (Fig. 5.17).

5.2.2.2

Bans on Grazing

Forbidding the depasturage of livestock on marshlands is in effect in the marshland around pilots. Any livestock is forbidden to be grazed on marshland. Mechanism of prevention and control conducted by regions around is founded. Farming prohibition boards stood and workers for farming prohibition were employed. A 38.8-ha2 forest for isolation of schistosomiasis control is built in the regions near a lake in the villages to strengthen the monitoring of livestock raising in the fence and farm cattle grazing cross the border (Fig. 5.18).

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Fig. 5.17 Government officials inspect the project “replacement of cattle by machines”

Fig. 5.18 Isolating greenbelts

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Fig. 5.19 Bin placed on very small ships to collect feces

5.2.2.3

Management on Feces

1043 harmless three-cell family latrines, 11 harmless public toilets, 232 household biogas digester, and 4 large and medium biogas digester were built. Toilets were built in wharf and every boat was equipped with special toilet to dispose of feces of fishermen. A professional person will give disease survey to residents exposed to endemic water by serological methods once after infection season every year. The infected people will be given praziquantel chemotherapy, and the high-risk groups like fishermen should receive chemotherapy twice a year (Fig. 5.19).

5.2.2.4

Health Education

Permanent billboard of schistosomiasis control and Three-Character Classic of schistosomiasis Control in Lake Regions is built in the main crossing, and warning boards are put in places with a large flow of people like ferries and wharves. In the primary school of villages, health education of schistosomiasis control for pupils and activities about the establishment of non-patient of schistosomiasis school are conducted. Training courses of schistosomiasis control knowledge are held for prevention and treatment of high-risk groups like fishermen and herdsmen (Figs. 5.20 and 5.21).

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Fig. 5.20 Three-Character Classic of schistosomiasis control

Fig. 5.21 Health education of schistosomiasis control

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Fig. 5.22 Finless eel aquaculture with cages

5.2.2.5

The Renovation Project on Domestic Water

Simple tap water supply was built in 943 families to prevent farmers from being exposed to infested water because of using water for living such as washing clothes and bathing.

5.2.2.6

Adjustment of Industrial Structure

Develop aquaculture of special species. The scale of traditional finless eel aquaculture with cages is enlarged to reduce residents’ opportunities of being infected by schistosomiasis in the progress of catching fish in the lake. Farmers in pilots founded Cooperative for Aquaculture of Poyang Lake in 2008 to organize those who breed finless eel to charge for the production, epidemic prevention, and sale of finless eel. This industry enlarged to endemic towns and townships around from 2009. The output increased from 4000 boxes in 2005, 8000 in 2006, and 50,000 in 2007 to 70,000 in 2008, and 100,000 in 2009. If the net income is 400 yuan per box, the total net income increases by 9.280 million yuan for this project only (Fig. 5.22). Build a base for poultry production. There raise 120,000 ducks and geese every year making full use of water and plants of marshland. If the net income is 10 yuan of a duck or goose, the annual income is 1.2 million yuan (Fig. 5.23). Establish a base for mushroom production. The base covers an area of 6000 m2, producing 60,000 kg of mushroom every year. The annual income is 240,000 yuan if the net income is 4 yuan per kilogram.

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Fig. 5.23 Poultry production base on marshland

The effects of bringing by adjustment of industrial structure solve the income problems of farmers after stopping farm cattle raising, increasing the local per capita income from 2400 yuan in 2004 to 6690 yuan in 2009 with the increase of 4290 yuan. The collective income of village is up to 180,000 yuan per year, increasing by 345.9% compared with that in 2004. These methods make good economic benefits that support the implementation of comprehensive measures for schistosomiasis control greatly, motivating the sustainable development of schistosomiasis prevention and control.

5.2.3

Effects

5.2.3.1

The Decline in Infection Rate

The infection rate of schistosomiasis of residents in pilots decreased rapidly after interventions of infection source control were conducted (Table 5.4). The infection rate in Aiguo Village decreased from 11.35% in 2004 to 7.33% in 2005. The rate decreased to 1.76% in 2006 and continued to decline. People infection rate has kept at zero for 9 years after 2009. People infection in Xinhe Village and Guanghui Village still happened until 2008 and 2006; then the infection rate has kept at zero for 10 and 12 years, respectively. The intensity of infection of people in the three villages has decreased by years as infection rate. There are no people with positive stool examination in the three villages after 2009. The infected patients diagnosed

After

Before

Time exam 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Aiguo County No. No. exam (+) 450 59 300 34 793 90 519 38 512 9 447 3 551 1 450 0 503 0 528 0 438 0 669 0 371 0 535 0 1733 0 1106 0

% 13.7 11.3 11.35 7.32 1.76 0.67 0.18 0 0 0 0 0 0 0 0 0

Intensity (+) 1.46 1.52 1.33 1.33 1.08 0.02 0.01 0 0 0 0 0 0 0 0 0

Table 5.4 Infection rates of residents from three experimental villages Xinhe County No. No. exam (+) 150 12 300 20 300 12 353 3 359 2 325 3 348 0 328 0 429 0 427 0 397 0 552 0 431 0 453 0 1168 0 776 0 % 8 6.7 4 0.85 0.56 0.92 0 0 0 0 0 0 0 0 0 0

Intensity (+) 1.07 1.05 1.14 1.03 1.02 0.02 0 0 0 0 0 0 0 0 0 0

Guanghui County No. No. exam (+) – – – – – – 352 4 342 0 243 0 373 0 302 0 451 0 403 0 369 0 493 0 311 0 463 0 1076 0 530 0

% – – – 1.14 0 0 0 0 0 0 0 0 0 0 0 0

Intensity (+) – – – 1.04 0 0 0 0 0 0 0 0 0 0 0 0

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after 2006 in pilots are fishermen working the waters, whose range of activity is not limited to the local water area. The suggested people infection rate decreases sharply after one or two infection seasons; then it has kept at zero for nine years, which shows the stable effect of control. The results above suggest that the local status of infection and reinfection of people has been controlling well and the effect of the new measure is remarkable and durable.

5.2.3.2

Change in the Growth of Oncomelania hupensis

The infected area with snail can be detected every year in Niu Marshland and Liulingwei Marshland of pilots before the implementation of the new measure. A total of 49 infected areas with snail were detected in the two marshlands in April 2005, where the infective rate of Oncomelania hupensis snail is 1.04% and 0.52%. The number of infected areas with snail has decreased rapidly after the implementation of interventions of infection source control. There are 13 infected snail spots in the two marshlands in 2006 and only one infected snail spot with snail in Niu Marshland in 2007 when no infected Oncomelania hupensis snails were found in Lilongwe Marshland. There are no infective Oncomelania hupensis snails in Niu Marshland and Liulingwei Marshland for eleven and ten years in 2017 (Table 5.5). The change of snail status confirms that the comprehensive strategy with emphasis on infection source control can cut down the key link that the breeding environment of Oncomelania hupensis contaminated by eggs effectively. Compared with other measures for prevention and control, this strategy is more efficient.

5.2.3.3

The Decrease in Acute Schistosomiasis Cases

There are 2 cases, 1 case and 2 cases of acute infection happening in Aiguo Village every year respectively from 2002 to 2004 before becoming pilot. Xinhe Village had two acute infection cases in 2002, and Guanghui Village has none. After the implementation of new comprehensive strategy with emphasis on infection source control, only 2 cases were reported in Aiguo Village in 2005, and there were no acute infection cases of schistosomiasis reported in the three pilots from 2006 to 2017.

5.2.3.4

Monitoring of Water Around Experimental Villages

Sentry mouse method is used to monitor the infective of water in the water area of marshland with a snail in Liulingwei and Liuerwu Marshland where residents active frequently around pilots. After the implementation of interventions of infection source control, the water infectivity decreases rapidly. The infection rate of sentry mouse and average larval burden are up to 79.31% and 15.35 per mouse. The data decreased to 2.22% and 0.24 per mouse in 2006. And infected sentry mice have not

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Table 5.5 Condition of Oncomelania hupensis in marshland around experimental villages Marshland Niu Marshland

Before

After

Liulingwei Marshland

Before

After

Time 2002.4 2003.4 2004.4 2005.4 2006.3 2007.4 2008.4 2009.4 2010.4 2011.4 2012.4 2013.4 2014.4 2015.4 2016.4 2017.4 2002.4 2003.4 2004.4 2005.4 2006.4 2007.4 2008.4 2009.4 2010.4 2011.4 2012.4 2013.4 2014.4 2015.4 2016.4 2017.4

No. exam 909 631 804 1054 1067 917 987 1056 1220 1060 977 921 983 946 658 686 5993 3736 4251 6683 1822 1171 1541 1030 3001 2248 2097 6896 2336 6073 6723 3185

Density 0.58 0.58 0.71 3.74 2.36 1.56 0.11 0.07 0.0008 0.019 0.003 0.011 0.001 0 0 0.011 0.27 0.3 0.47 0.75 0.54 1.18 0.13 0.13 0.15 0.23 0.08 0.12 0.03 0.016 0.0077 0.009

Density (+) 0.0044 0.0047 0.005 0.0389 0.0094 0.0011 0 0 0 0 0 0 0 0 0 0 0.0035 0.0032 28 0.0039 0.0016 0 0 0 0 0 0 0 0 0 0 0

% 0.81 0.81 0.7 1.039 0.397 0.07 0 0 0 0 0 0 0 0 0 0 1.25 1.04 0.6 0.517 0.3 0 0 0 0 0 0 0 0 0 0 0

No. site (+) 4 3 4 23 10 1 0 0 0 0 0 0 0 0 0 0 21 12 12 26 3 0 0 0 0 0 0 0 0 0 0 0

been found for 11 years from 2007 in this water area (Table 5.6), which shows that the infected risk in this water area is eliminated.

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Table 5.6 Water infectivity of pilots Time 2005.8 2006.8 2007.8 2008.8 2009.8 2010.8 2011.8 2012.8 2013.8 2014.8 2015.8 2016.8 2017.8

5.2.4

No. exam 58 45 61 110 170 88 75 97 64 81 98 74 61

No. infected 46 1 0 0 0 0 0 0 0 0 0 0 0

% 79.31 2.22 0 0 0 0 0 0 0 0 0 0 0

Worm number per mouse Average Maximum 15.38 67 0.24 11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Experience

A comprehensive strategy of schistosomiasis control with emphasis on infection source control like replacing cattle with the machine and forbidding the depasturage of livestock on endemic areas in the marshland and lake regions is successful. These give us some experience.

5.2.4.1

Key: Domination of Government

The provincial party committee and government of Jiangxi Province pay great attention to the work in pilots. The person in charge from provincial government held meetings with departments like health, agricultural, water conservancy, and forestry and people in charge from Nanchang municipal government and Jinxian county government to discuss the deployment and coordinate practical problems. Provincial Health Department assists the government to organize the formulation of working scheme and take charge of coordination and technical guidance in the progress of implementation. Teams for technological guidance for pilots are founded, in charge of quality control and hygienic evaluation of the project. Meanwhile, the government of Nanchang City and Jinxian County organized relevant departments to go deep into the pilots to guarantee the implementation of organization and fund assurance and management measures. The leaders of municipal, county, and township party committee, government, and relevant authorities solve the troubles and problems of working in person in the process of advancing pilots. Nation-Leading Group for Comprehensive Pilot for schistosomiasis Control is founded in Jinxian County, in charge of the organization and leading of the work in pilots. The leader of the group is county magistrate, the deputy magistrate in

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charge of agricultural and health is appointed as deputy leader and the chief persons in charge from relevant departments such as government office, health, and agricultural are membership, whose task is to take charge of work of the project. Daily management of eliminating cattle and forbidding the depasturage of livestock on marshlands are in charge of township government of Sanli Township. Office for depasturage prohibition is built. And the deputy township head administering schistosomiasis control is in charge of supervision.

5.2.4.2

Condition: Cooperation with the Relevant Department

The functions and division of work of relevant departments of government should be made certain to establish linkage mechanism so that every department can cooperate and take charge, respectively. The health department should strengthen technological guidance to work in pilots and administer evaluation of the effect of schistosomiasis. Patriotic Sanitation should solve the subsidy of toilets transformation. Agricultural department is expected to take charge of agricultural machine selection and technological training, construction, and service for biogas digester, implementation of the agricultural development project, subsidy for machine purchase, and biogas digester constriction and implementation of schistosomiasis control of livestock combining with the adjustment of the structure of planting and breeding. Water conservancy department ought to organize, guide, and perform the project of water transformation. Forest department is in charge of the guidance and implementtion of the planting and management of the isolated forest. The arrangement of funds is in charge of the financial department. In addition, health education for students from primary school and middle school will be held by the education department. The implementation of all projects above will be administered by the chief person in charge from Sanli Township.

5.2.4.3

Guarantee: Transition and Innovation of Rural Production Ways

The attendance of masses is the basis for the successful conduct and continuation of a comprehensive strategy. The cadres from county, township, and village conducted the work of publicizing, encouraging, and organizing masses considering the benefit of masses. They try to improve their health consciousness, making them understand and support the work of pilots. And they also need to encourage masses to involve in the work of pilots to find the new methods for growing wealthy together. The methods like replacing cattle with machines, forbidding the depasturage of livestock on marshlands, and raising livestock in the fence will inevitably bring adjustment and change to production structure and method of farmers in the endemic area. So the key to implement and keep of this strategy and every method is the acceptance and cooperation of farmers. The effective ways to solve this problem are to guide farmers actively and support them properly. The main practice is adjusting

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industrial structure properly, training farmers to use machines, improving the assurance of machine maintenance and mountings supplement, strengthening the measures of forbidding the depasturage of livestock on marshlands, and building an administrative mechanism to promote the sustainable development of schistosomiasis control. Otherwise, it is important to guarantee the decontamination of marshland and achieve a non-infection-source state in a controlled area for cutting down the spread chain of schistosomiasis. Residents enthusiasm for marshland administration is aroused by the methods such as government guidance, health government formulation, and masses involvement. According to the methods, resources of marshland in pilots are exploited and sesame and trees are planted following the principle of “those who administer will receive a benefit.” Finally, we gained triple effects including depasturage prohibition, snail control, and farmers income increasing.

5.2.4.4

Technological Assurance: Specialized Technical Guidance, Monitoring, and Evaluation

Provincial health department organized specialists to formulate a scheme to monitor schistosomiasis control in pilots. Monitoring and evaluation of the state of illness, snail status, and harmless disposal of feces are conducted by provincial, municipal, and county institutions for schistosomiasis. These abovementioned methods are to strengthen the technical guidance and quality control of the project.

5.2.4.5

Method: Cutting off the Elimination of Schistosoma japonicum Eggs

The infected Oncomelania hupensis in marshland is controlled thoroughly after the implementation of the new strategy. The infection rate of sentry mouse decreased to zero by 2007, and the number of infected areas with snail decreased to zero after 4 years as well. These show that infection source control in the lake region can obviously decrease the number of infected Oncomelania hupensis in marshland and eliminate infectivity of water to people and livestock. After the conduct of the new measure, the infection rate of people and Oncomelania hupensis both decreases rapidly and keeps stable for a long time, which cannot be achieved with the use of old strategy. Many types of research suggest that Oncomelania hupensis infected by Schistosoma japonica miracidium can only survive for 1 year. This means that if infection sources are controlled thoroughly, the newborn Oncomelania hupensis next year will not be infected. In this circumstance, though people and livestock continue to touch Oncomelania hupensis and lake water, the infection rate of people will still decrease to a low level or there will be no infection. Pilots in Sanli Township, Jinxian County, confirm that the key link of preventing Oncomelania hupensis from infection is to stop Schistosoma japonica eggs from contaminating

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the infected area snail for the first time. And this is also one of the most efficient ways to cut down the spread of schistosomiasis.

5.2.5

Significance

The comprehensive strategy and technological measures with emphasis on infection source control of schistosomiasis conducted in Jinxian County are highly thought of by leaders and specialists from the State Council, generalized in the nation as a leading strategy of schistosomiasis control in China. The key technological measures focused on infection source control like replacing cattle with the machine, forbidding the depasturage of livestock on marshlands, raising livestock in the fence, and renovating latrines; water and healthy environment are accepted into Regulations for schistosomiasis Control revised newly, generalized in the national endemic area as government regulations. The comprehensive strategy with emphasis on infection source control provides a scientific basis for Medium and Long-term Development Plans for schistosomiasis Prevention and Control formulated by the State Council. These play an important role in reaching criteria for transmission control of schistosomiasis nationwide in 2015. The implementation of a comprehensive control strategy with emphasis on infection source control in schistosomiasis endemic areas in the marshland and lake regions successfully practices the modern idea that changing schistosomiasis prevention and control from biological model to biological-social-environmental model, providing a theoretical framework and practical data for a comprehensive model of Chinese schistosomiasis prevention and control. The strategy is generalized in key counties for schistosomiasis control in Poyang Lake District and the whole nation after the meeting for national schistosomiasis control in 2006. It leads the direction of plans and a new strategy of schistosomiasis control in the new period of China, exerting a significant influence on the progress of schistosomiasis prevention and control in China.

5.3 5.3.1

The Research of Susceptible Zone of Schistosomiasis Research Background

In the 1980s, residents of Poyang Lake region were exposed to water contaminated with cercaria and the susceptible high-risk environment of schistosomiasis due to seasonal fishing, mowing, grazing, and other production or living reasons, causing the high incidence of infection and reinfection. The human and livestock’s infection rate of schistosomiasis in the Poyang Lake region stayed at a high level, which seriously affects the health and life quality of local residents. It was common that livestock was scatter-fed on the marshland in Poyang Lake region. Therefore, cattle,

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pigs, and dogs infected with schistosomiasis were scattered randomly on the marshland and became the main infection source of schistosomiasis. Among them, farm cattle were the main tools of production and important sources of increasing income for farmers in the lake region, and they were the most widely scattered on the marshland of Poyang Lake. The superposition of the abovementioned main endemic factors of schistosomiasis caused the Poyang Lake region to become one of the most severe schistosomiasis endemic areas in China in the 1980s and difficulty in the prevention and control of schistosomiasis in the Poyang Lake region. It seriously affected the health of humans and livestock in the lake region and the development of social economy, as well as seriously hindering the comprehensive project for prevention and control, and the development and utilization of the Poyang Lake region. At that time, the endemic status and current situation of schistosomiasis in Poyang Lake exhibited the following two aspects. On the one hand, the endemic status of schistosomiasis in Poyang Lake was mainly characterized by the uneven distribution. Investigation and research data in various aspects indicated that the highly endemic areas of schistosomiasis in Jiangxi Province were mainly distributed in the marshland and lake regions of Poyang Lake. In such a vast area, the uneven distribution of endemic status mainly appeared in the following 4 aspects. The first one was the uneven distribution of the intermediate host of Schistosoma— Oncomelania hupensis, especially schistosome-infected Oncomelania hupensis snails—in different types of beach, different regions, and different units of Poyang Lake beach, due to the comprehensive effects of many endemic factors of schistosomiasis. The second was the difference of active mode and frequency in the beach land with snails between human and livestock, so their contact frequency and intensity with the water with cercaria and the contamination to the beach land were significantly different. The third was the infection of human and livestock, especially acute and new infection, regionally gathered in different levels. The fourth was the uneven harm extended to human and livestock, and the uneven effects of schistosomiasis transmission due to different types, regions, and units of endemic focus. The uneven distribution of endemic status was mainly attributed to the following three reasons. Firstly, the different natural conditions of the beach land with snails, such as the type, elevation, water level, vegetation, rainfall, temperature, the distance from the residential area, and the degree of environment openness, not only determined the appropriateness for the breeding of Oncomelania hupensis snails, but also greatly influenced the activities of humans and animals, the selection of countermeasures, and the control effect of schistosomiasis. Secondly, the imbalanced progress for prevention and control was another important reason. Many factors affected the selection and implementation of prevention and control measures, and the progress and results of prevention and control, leading to imbalance progress in prevention and control. The various factors included the abovementioned social factors, such as the natural factor, actual prevention and control input, production mode, economic condition and cultural level of Poyang Lake beach, technical factors such as available prevention and control methods, and the contradiction between some comprehensive prevention control measures and

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environmental protection, wetland protection, ecological balance, aquaculture, and flood storage and discharge. Thirdly, the range and quantity of human and livestock movements have increased enormously after the reform of the agricultural production system. Moreover, the regional differences of the change about human and livestock movements further exacerbated the uneven distribution of endemic status. On the other hand, there was a huge gap between the power and the investment of all-around prevention and control in the Poyang Lake region. In particular, it is considered unrealistic to eliminate the snails completely from the marshland and lake regions in the near-term for the purpose of transmission interruption. The gradual improvement and implementation of the wetland conservation regulations in Poyang Lake also did not allow the schistosomiasis prevention and control department to carry out mollusciciding on a large scale. Therefore, there was a huge gap between the power of mollusciciding in Poyang Lake and the actual snail’s control area. In summary, due to the vast infested area with a snail in the Poyang Lake beach region, it was very difficult to control schistosomiasis by comprehensive snail control, and it was difficult for mollusciciding to comprehensively cover the entire Poyang Lake marshland both in power and in the economy.

5.3.2

Study on Classification Standard of Susceptibility Zone of Schistosomiasis of Poyang Lake

In order to develop a strategy suitable for the prevention and control of schistosomiasis in the lake region, Zhang Shaoji et al. (1980) clarified the law of snail distribution in the Poyang Lake region, as well as the relationship between infected snails and acute infection of schistosomiasis through comprehensive snail investigation and the susceptibility zone of schistosomiasis and suggested the classification criteria, zoning, stability of schistosomiasis susceptible zones, and the variability after taking control measures. The reference standard clarifies the regional distribution and scope of the susceptible zones, and concentrates the existing schistosomiasis preventing forces, and implements prevention and control measures for “hazardous areas” to provide scientific basis and important guiding role for the prevention and control of schistosomiasis in the lake region of Jiangxi Province, which strongly promotes and guides the prevention and control of schistosomiasis in Poyang Lake region.

5.3.2.1

Investigation on the Distribution of Snails in Poyang Lake Region

In Jiangxi Province, from 1982 to 1984, 400 professionals were organized for 3 consecutive years to carry out a systematic and in-depth investigation on the

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snail distribution and acute schistosomiasis infection sites for the 81,240 hm2 of 8 counties around Poyang Lake. The Method of Snail Investigation According to the 1:10,000 topographic map of Poyang Lake District of Jiangxi Province and the original map in the schistosomiasis prevention stations of the 8 counties along the lake, the topographic map of each lake beach is drawn, and its area, up-and-down elevation and current development and utilization are recorded. In the spring or autumn of each year, the snails are surveyed in frames of 10 m
50 m or corresponding to the area of the lake beach. The survey was designed at a distance of 5–10 m to check snails at special terrains such as ditch, pond, pothole, and river port. The snails found were crushed by frame to determine their activity and examined under a microscope to check their infectivity, and the frequency of frames of live snails, average density of live snails, snail infective rate, and the average density of infected snails in each lake beach were counted. The snail points and infectious snail points were marked on the topographic maps of various lake beaches. The changes of snail situation in 6 lake beaches were observed in the longitudinal period of 2–3 year. The Results of the Snail Investigation 1. Snail distribution There are 615 lake beaches in the 8 counties of the Poyang Lake region that may breed snails, which have a total area of 81,527.07 hm2, of which 195 lake beaches, with an area of 18,433.42 hm2, have not found snails, accounting for 31.1% of the total number of lake beaches and 22.6% of the total area. Therefore, the actual area with snails has an area of 63,093.65 hm2. The area of the lake beach is the largest of three counties, Poyang, Duchang, and Nanchang, accounting for 53.2% of the total area. The area of lake beach with snails is the largest in Duchang, Yugan, and Poyang, accounting for 55.2% of the area (Table 5.7). Among the various types of lake beaches, marshland has the largest area, accounting for 88.8%, followed by the once-cultivated or mechanical-cultivated Table 5.7 Area distribution of lake beaches and lake beaches with snails in the Poyang Lake region Counties Poyang Duchang Nanchang Yugan Xinjian Xingzi Jinxian Yongxiu Total

No. Lake beach 132 29 133 75 49 58 74 65 615

Lake beach Area (hm2) 15,853.41 14,213.40 13,300.07 12,146.73 9426.71 6500.03 5513.36 4573.36 81,527.07

Proportion (%) 19.45 17.44 16.31 14.9 11.56 7.97 6.76 5.61 100

Lake beach with snails Area (hm2) Proportion (%) 10,806.72 17.13 12,513.40 19.83 3993.35 6.34 11,500.06 18.22 9346.71 14.82 5646.69 8.95 4753.36 7.53 4526.69 7.18 63,086.98 100

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Table 5.8 Statistics on the area of snails in various types of lake beaches Lake beach Type of Lake beaches Marshland Deserted Mechanicalcultivated Cultivated Reed beach Total

No. 513 35 36

Area (hm2) 70,107.02 4513.356 2853.348

Proportion (%) 85.99 5.53 3.5

28 7 619

2306.678 1746.675 81,527.07

2.83 2.15 100

Lake beach with snails Area Proportion No. (hm2) (%) 372 56,013.61 88.78 17 2706.68 4.28 29 2526.68 4.01 1 5 424

166.67 1680.01 63,093.65

0.27 2.66 100

Note: There are 4 lake beaches combined with marshland, reed beach, and cultivated beach; thus the actual number of lake beaches is 615

deserted beach, accounting for 4.28% of the total area. Mechanical-cultivated lake beach and reed lake beach accounted for 4.01% and 2.66%, respectively. The cultivated lake beach is only 0.27% (Table 5.8). Most of the snails in lake beaches of Poyang Lake region are distributed in the area of 14–17 m elevation zone (Wusong benchmark, the same below), no snail below 13 m, 3.45% below 14 m, 2.0% above 17 m, and density is also highest in the 14–17 m elevation. 2. Snail density Except for lake beach without snails, the occurrence rate of frames of live snails and the average density of live snails in different lake beaches are different, and there is no obvious law. In lake beach with snails, the lowest incidence of frames of live snails is 0.095%, the highest is 100%, and the median value is 11.34%. The average density of live snails is 0.0004/0.1 m2, the highest is 10.96/ 0.1 m2, the average is 0.515/0.1 m2, and the median is 0.358/0.1 m2. The average density of live snails in various types of beaches surveyed was highest as 0.85/ 0.1 m2 in reed beaches, followed by 0.51/0.1 m2 in marshland, and 0.40/0.1 m2 in the mechanical-cultivated beach. The once-cultivated or mechanical-cultivated deserted beach was 0.29/0.1 m2; at present, only one cultivated beach found snails, with a very low density of 0.40/0.1 m2. It shows that the elevation zone in reed beach or where reed beach is located is a good breeding place for snails. The perennial cultivation of the lake beach is conducive to the consolidation of the snail control effect. The average density of live snails in special terrains such as ditch, pond, and potholes of 30 lake beaches randomly surveyed was compared with that in the beach area in the same lake beach, which was 3.0–12.1 times higher, indicating that this type of terrain is suitable for the generation and reproduction of snails (Table 5.9). 3. Schistosome-infected Oncomelania hupensis snails Among the 615 lake beaches surveyed, 142 were found to have infected snails, with an incidence rate of 23.1%. A total of 292,882 live snails were dissected, and 747 infected snails were found, with an average infective rate of 0.00255%. In the lake beach with infected snails, the natural infection rate of snails varies from 0.01

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Table 5.9 The snail situation in special terrain Terrain Mound Ditch Pond Short dike Pothole

No. Surveyed 1 12 4 2 11

The average density of live snails (/0.1 m2) Special terrain The same beach 1.84 0.14 3.81 0.64 3.6 0.63 1.22 0.22 3.85 0.97

Ratio 13.1 5.9 5.7 5.5 4

Table 5.10 The incidence of infected snails in various types of lake beaches Type of lake beached Reed beach Marshland Mechanical-cultivated Deserted Cultivated Total

No. lake beach 7 513 36 35 28 619

Lake beached with snails No. beach Constituent ratio (%) 4 57.1 130 25.3 6 16.7 2 5.7 0 0 142 22.6

Note: There are 4 lake beaches combined with marshland, reed beach, and cultivated beach, thus the actual number of lake beaches is 615

to 16.67%. In the lake beach of Poyang Lake region, there was a significant positive correlation between the average density of live snails and the average density of infected snails (r ¼ 0.606, P < 0.05), and the linear regression equation was Y^ ¼ 0.001289X + 0.000502. There was a significant negative correlation between the distance from the residential area and the average density of infected snails (r¼0.662, P 0.05); after the 1-year intervention, it was 98.91% and 49.37%, with statistical difference (P < 0.01). The correct rate of attitude in the experimental group was greatly improved (79.54%) after the intervention, while there was no remarkable change in the control group. (3) Behaviors of water contacts: Before intervention, the water-contact rate in the experimental group and control group was 14.55% and 13.92%, respectively, and there was no statistical difference (P > 0.05); after 1-year intervention (1993), it was 1.87% and 13.34%, with a significant decline of 87.15% compared with before (P < 0.01). There was no remarkable change in the control group (P > 0.05). Before the intervention, entertaining (swimming and playing) water contacts was the main way in two groups, while the productive (fishing, grass cutting, and grazing) and living (washing clothes) water-contact rate were relatively low. After the 1-year intervention, for experimental group, there was an obvious decline in entertaining, productive, and living water-contact rate compared with before, especially the former one, while there was no remarkable change in control group. (4) Infection condition of Schistosoma japonicum: As the results of baseline survey in February 1993 showed, the prevalence rate of schistosomiasis in experimental group and control group was 13.53% and 13.64%, respectively, and there was no statistical difference (P > 0.05); after 1-year intervention (1993), for experimental group, it was 2.27%, with obvious decline of 83.22% compared with before (P < 0.01), while there was no remarkable change in control group. (b) Long-term intervention effect: Intervention for 2–7 years (1994–1999) (1) The rate of contacting infected water: 1.81%, 2.19%, 1.49%, 0.60%, 0.50%, and 1.21%.

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(2) Prevalence rate with schistosomiasis: 1.16%, 1.95%, 1.05%, 1.14%, 1.19%, and 1.04%. Compared with the results of the baseline survey in 1992, there was a remarkable decline in the infection rate in the experimental group, from 13.53% in 1992, down to 1.04% in 1999. During this period, 1–2 infected patients were detected every year, but no acute schistosomiasis case was discovered. 2. Intervention effect of Model B (a) Short-term intervention effect After 1-year intervention (2000) to all the school students in the experimental group (103 people), no contacts of infected water and infected patients were detected. (b) Long-term intervention effect During the intervention of 2–7 years (2001–2007), 92, 96, 87, 91, 89, 94, and 127 school students in the experimental group were investigated respectively, and no contacts of infected water and infected patients were detected. (c) Promotion and application effects Observed the promotion and application effects with another 8 primary schools in Poyang Lake region chosen. The contents of the baseline survey (2005) included: investigation of schistosomiasis control knowledge; investigation of schistosomiasis control attitude; 8-day investigation of watercontact frequency every month during April to October; and investigation of schistosomiasis infection by the end of the year. Model B was used for an intervention to all the students from 8 schools during 2006 to 2007. Assessment of effect was made after 1-year intervention (2006), whose contents, methods, and standards were all the same as those of the baseline survey; only water-contact frequency of target population and infection condition of Schistosoma japonicum were conducted in the second year after intervention (2007). (1) Schistosomiasis control knowledge: The awareness rate of the target population from 8 schools was at a low level of 15.83% on average before the intervention. One year after intervention (2006), the awareness rate had a massive increase of 98.3% on average when compared with before, which led to a difference with statistical significance (P < 0.01). (2) Schistosomiasis control attitude: The correct rate of the target population from 8 schools is 15.5% on average. After 1-year intervention, it went to 99.3% with great improvement compared with before, and there was statistical significance (P < 0.01) (Fig. 5.36). (3) Frequency of water contacts: Before the intervention, 96,936 people from 8 schools in total, and 5069–22,960 people from each school were investigated. 7,361,249 people had water-contact experience, with the contact rate of 12.12–23.03%. 91,840 and 91,112 people in total, and 4760–21,952, and 4144–20,944 people in each school were investigated

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Fig. 5.36 Government officials on their way to inspect “schistosomiasis-free schools” in 2006

in the first and second year after intervention, respectively. No person with water-contact experience was detected. (4) Infection condition of Schistosoma japonicum: Before intervention, the average infection rate of the target population from 8 schools was 9.14%. The statistics of 8 schools were 11.21% (46/410), 7.78% (22/283), 10.90% (11/101), 6.52% (21/324), 9.32% (9/97), 7.69% (7/91), 9.54% (24/252), and 10.36% (18/173), respectively. 1640 and 1627 people in total (85–392 and 74–374 people each school) were taken to stool examination one and two years after the intervention. No infection was detected. Then this model was generalized and used in another 20 schools, and similar intervention effects were observed. “Schistosomiasis-free schools” were built up first and successfully in serious epidemic areas of China. In summary, “Creating non-infection school by Information dissemination + Behavior participation + Behavior motivation” (Model B) not only made both short-term and long-term intervention reach significant effects, but had broad prospects of promotion and application in future. Intervention Effect of Adult Females 1. Short-term intervention effects (a) Knowledge of schistosomiasis control: Before intervention (1992), the awareness rate of experimental group and control group was 55.34% and 54.46%, respectively, and there was no statistical difference (P > 0.05); after 1-year intervention (1992), it was 84.45% and 57.28%, which showed a remarkable increase in the experimental group (P < 0.01). There was no remarkable change in the control group (P > 0.05). (b) Value of schistosomiasis control: The correct rates of values in the experimental group were 67.96% before intervention and 95.96% one year after intervention. The rates in the control group were 68.32% and 71.84%,

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respectively, at the same period. The increase of 41.20% (P < 0.01) was observed one year after intervention in the experimental group, while there was no difference with statistical significance after the intervention (P > 0.05). (c) Behaviors of water contacts (1) The frequency of water contacts: Before the intervention, the watercontact rate in the experimental group and control group were 9.47% and 10.69%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, it was 5.07% and 11.48%, with significant decline compared with before (P < 0.01). Among this, water contacts through washing clothes covered 3.76% after intervention and 7.20% before intervention, with a decline of 47.78% (P < 0.01). There was no remarkable change in the control group (P > 0.05). (2) Way of water contacts: Before intervention, washing clothes (contact rate was 7.20% and 8.19% in experimental group and control group, respectively) was the main way of water contacts in two groups, while contact rate of grazing, fishing, and swimming (1.72%/0.36%, 0.19%/1.99%, 0.23%/0.28%, respectively) were relatively low. After the 1-year intervention, for experimental group, the contact rate for washing was 3.76%, with a decline of 47.78 (P < 0.01) compared with 7.20% before. Besides, there was also an obvious decrease (P < 0.05, P < 0.01) on contact rate of grazing and swimming (0.77% and 0). However, there was no remarkable change (P > 0.05) for contact rate of fishing (0.54%). For the control group, the contact rate of washing, grazing, fishing, and swimming were 9.35%, 1.81%,0.14%, and 0.19%, respectively, one year after the intervention, from which no remarkable change (P > 0.05) was observed compared with before. (3) Infection condition of Schistosoma japonicum: Before the intervention, the prevalence rate of schistosomiasis in the experimental group and control group were 19.42% and 15.15%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, it came to 7.14% and 21.05% in two groups. For the experimental group, there was a decline of 63.23% compared with before (P < 0.05), while there was no remarkable change in the control group (P > 0.05) in the same period. 2. Long-term intervention effect (a) Frequency and way of water contacts With a total of 2208 people investigated 3 years after the intervention of the experimental group (1995), the total water contact rate was proved to be 4.94%. Among this, the contact rate for washing, grazing, fishing, and swimming were 3.49%, 0.86%, 0.54%, and 0.05%, respectively; 5 years after intervention (1997), 2208 was investigated and the total contact rate was 5.48%, among which the contact rate for washing, grazing, and fishing was 3.67%, 1.04%, and 0.77%, respectively. Those who had water contacts

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Fig. 5.37 Washing clothes in the river water had been the main source for infections

through swimming were not observed; washing clothes were still the main way for target population from the experimental group to have water contacts, but its contact rate kept in a low level (Fig. 5.37). (b) Infection condition of schistosomiasis In 1995, 1997, 1999, 2001, 2003, 2005, 2007, and 2009, the infection rate of schistosomiasis of target population in the experimental group were 7.69%, 6.38%, 6.93%, 8.10%, 5.05%, 6.54%, 7.14%, and 7.41%, respectively, which showed stable interventional effects. (c) Promotion and application effects Another two villages in Poyang Lake region were chosen as sites of promotion and application. They were randomly divided into experimental group and control group, and this model was used in experimental group. (1) Knowledge of schistosomiasis control The awareness rate of experimental group and control group was 44.75% and 46.18%, respectively, before intervention (1998), with no statistical significance (P > 0.05). One year after the intervention, the awareness rate had a massive increase compared with before (P < 0.01), running up to 95.67%. On the contrary, there was no significant difference observed in the control group (P > 0.05), whose awareness rate was 45.57%. (2) Value of schistosomiasis control: The correct rate of experimental group and control group was 21.83% and 22.02%, respectively, before the intervention, with no statistical significance (P > 0.05). After 1-year intervention it went to 78.24% for experimental group, which was much higher than that of the control group (23.11%) (P < 0.01).

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(3) Frequency of water contacts: The contact rate of experimental group and control group was 42.19%/47.43% before the intervention and 15.18%/ 49.52% after intervention. After intervention there was a great decline in experimental group (P < 0.01), while there was no change with statistical significance observed in the control group (P > 0.05). Among this, the contact rate of wash in experimental group went down to 4.61% from 25.58% after intervention (P < 0.01). (4) Infection condition of Schistosoma japonicum: For the experimental group, the infection rate of schistosomiasis had a massive decrease from 23.54% before intervention down to 6.25% (P < 0.01). While for the control group, the infection rate before and after intervention were 27.04% and 28.57%, respectively, with no significant difference (P > 0.05). Thus, it can be seen that, health education model of “Information dissemination + Protection skills training + Behavior motivation” could serve as a long-term and effective way to control the schistosomiasis infection of adult females in serious epidemic regions. It also had great values of on-site promotion and application. Intervention Effect of Adult Males 1. Short-term intervention effect (a) Knowledge of schistosomiasis control: Before intervention (1992), the awareness rate of experimental group and control group were 67.35% and 63.39%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, they were 91.92% and 67.29%, which showed a remarkable increase in experimental group (P < 0.01). There was no remarkable change in the control group (P > 0.05). (b) Attitude to chemotherapy of schistosomiasis Before the intervention, the correct rate of experimental group and control group were 56.44% and 64.29%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, they were 97.98% and 66.36%, which showed a remarkable increase in experimental group (P < 0.01). There was no remarkable change in the control group (P > 0.05). (c) Compliance to schistosomiasis examination Before the intervention, the compliance rate of experimental group and control group were 71.91% and 77.55%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, they were 85.23% and 65.18%, which showed a remarkable increase in experimental group (P < 0.05). There was no remarkable change in the control group (P > 0.05). (d) Compliance with schistosomiasis chemotherapy Before the intervention, the compliance rate of experimental group and control group was 46.46% and 51.40%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, they were 92.08% and 47.12%, which showed a remarkable increase of 98.19% in the

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experimental group (P < 0.01). There was no remarkable change in the control group during the same period (P < 0.01). (e) Water contacts (1) Frequency of water contacts: Before the intervention, the water-contact rate in the experimental group and control group were 38.39% and 38.22%, respectively, and there was no statistical difference (P > 0.05). After the 1-year intervention, they were 41.41% and 38.22%, with no significant difference (P > 0.05). For two groups after the intervention, there was increase/maintenance of water contact rate compared with before, but there was no significant difference (both P > 0.05). (2) Way of water contacts: Before the intervention, fishing was the main way for water contacts in both the groups, while grazing and swimming was relatively rare. After the intervention, fishing was still the main way for water contacts. Although there was a remarkable decline for contact frequency of swimming in the experimental group, the productive (fishing) contact frequency grew rather than shrank (P < 0.01). There was no decline in total contact frequency. (f) Protecting behavior Before intervention, there was no protecting behavior taken by the target population in two groups when they had water contacts; after the intervention, 30.39% target population in the experimental group had productive water contacts with rubber pants, but only three people insisted on long-term use. There were no protecting measures observed in the control group. (g) Infection condition of Schistosoma japonicum: Before the intervention, the prevalence rate of schistosomiasis in the experimental group and control group were 29.59% and 20.72%, respectively, and there was no statistical difference (P > 0.05). There were 3 cases of past advanced schistosomiasis patients in the experimental group observed. After the intervention, it came to 41.41% and 29.46% in two groups, with no significant difference between them (P > 0.05). For both the groups after the intervention, there were increases of infection rate compared with before, but there was no significant difference (both P > 0.05). 2. Long-term intervention effect (a) Compliance behavior of schistosomiasis chemotherapy The compliance rates of the target population in the experimental group after intervention were all above 90% during 1995–2009. (b) Infection condition of schistosomiasis The infection rate of target population in the experimental group in 1995, 1997, 1999, 2001, 2003, 2005, 2007, and 2009 were 21.78%, 25.25%, 32.28%, 29.36%, 42.31%, 27.68%, 33.33%, and 30.08%, respectively, all of which stood in a high level, but no new advanced schistosomiasis patient was observed.

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(c) Control of hepatomegaly, splenomegaly, and liver fibrosis During 1994 to 1996, continuous health education combined with chemotherapy was conducted for 3 years, and most of the target population had improved and steady condition on hepatomegaly, splenomegaly, and liver fibrosis. 3. Intervention effect of promotion and application Another four villages located in the highly epidemic area of schistosomiasis in Poyang Lake region were chosen as research sites. (a) Knowledge of schistosomiasis prevention and control. After 1-year intervention (2005), there were increases on the awareness rate of the target population in the experimental group from three villages, from 73.79%, 67.97%, and 79.56% before intervention (2004), up to 93.29%, 96.88%, and 94.16% (P < 0.05). (b) Attitude to an examination of schistosomiasis. The correct rate of examination rose from 53.05%, 42.97%, and 49.64% before intervention, to 92.07%, 88.28%, and 90.51% (P < 0.05). (c) Attitude to chemotherapy of schistosomiasis. The correct rate of attitude rose from 57.93%, 52.34%, and 62.77% before intervention, to 95.73%, 91.41%, and 94.16% (P < 0.05) (Fig. 5.38). (d) Compliance behavior of schistosomiasis examination. The compliance rate of examination rose from 41.46%, 31.25%, and 37.23% before intervention, to 90.24%, 85.16%, and 88.32% (P < 0.01). (e) Chemotherapy behavior of schistosomiasis. The compliance rate of chemotherapy rose from 46.95%, 38.28%, and 40.88% before intervention, to 92.07%, 89.84%, and 91.24% (P < 0.01). (f) The main way of water contacts and infection condition of schistosomiasis. The main way of water contacts was fishing, before and after the intervention, without changes observed. There was no decline in the infection rate. The changes of all the indexes of the control group before or after the intervention had no statistical significance (P > 0.05). The abovementioned results showed that the Model of “Information dissemination + Behavior participation + Protecting skills training” performed remarkable effects on short-term, long-term, and promotion/application intervention. Greatly improving the compliance of schistosomiasis examination and chemotherapy of adult males living in highly epidemic areas and effectively control the disease, it had an important value of promotion and application.

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Fig. 5.38 Information of the youth

5.5.2

The Development and Application of Schistosomiasis Participatory Health Education Material

5.5.2.1

Research Background

Poyang Lake is the largest freshwater lake in China as well as one of the most serious endemic areas of schistosomiasis in China (Fig. 5.39). The transmission Schistosoma japonica is closely related to water. The fishermen in Poyang Lake Basin are one of the special groups that most frequent in contact with water. The fishermen often contact the water with cercaria and are repeatedly infected by Schistosoma due to the need for production and living. The results from surveillance points of schistosomiasis in Jiangxi Province showed that the schistosomiasis infection rate and infectiosity of fishermen were significantly higher than those of common residents and were always at the top place among the various occupational population. The survey showed that the fishermen worked in the rivers and lakes all the year round, most of them lacked effective stool management measures, and the stool with Schistosoma eggs was directly dumped into water body, which directly caused Oncomelania hupensis infection and forms susceptible zones of schistosomiasis. Therefore, fishermen are currently one of the main infection sources of schistosomiasis transmission in the lake region. At the same time, previous epidemiological investigation data showed that the annual fishermen’s coverage rate of once expanded chemotherapy was only 41.4%, and the annual coverage rate of chemotherapy twice was 51.6%. That means a considerable number

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Fig. 5.39 Sites for potential infections

Fig. 5.40 Potential contact of fishermen to the water with cercaria

of fishermen worked in the lake with the disease. The fishermen generally lack the awareness of disease risk and schistosomiasis prevention. The compliance of survey and treatment is poor and the management is difficult. It is also one of the difficulties of schistosomiasis prevention and control in Jiangxi Province (Fig. 5.40). Schistosomiasis infection is largely caused by people’s misconduct, which means that schistosomiasis is a behavioral disease. In order to improve the self-prevention awareness and develop healthy behavioral habits of fishermen, to reduce the risk of Schistosoma infection, the Institute of Parasitic Diseases Prevention and Control of Jiangxi Province carried out research in the fishermen population of the endemic schistosomiasis area in Poyang Lake. The research was in terms of participatory schistosomiasis health education guided by behavioral change, and the study and design of health education material suitable for fishermen—the high-risk groups in endemic schistosomiasis areas.

5.5.2.2

Materials and Methods

The Purpose and Principle of the Design of Participatory Health Education Material The design idea of this research is to make the key elements of the health education material meet the schistosomiasis control problem in the real life of the target group, guide them to think and pay attention to the unhealthy behavior, thus promote the change of their action, and ensure the material can achieve the health education

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purpose for fishermen to promote the formation of idea “health is for ourselves.” Therefore, in the process of material planning, development, and designing, the wisdom of local knowledge and local personnel should be addressed attention to, as well as the target group should participate in all aspects of the design, development, and application of health education material, and it can reach an integration of knowledge between researchers and target groups. Finally, the schistosomiasis health education material, which is easy-to-understand and easy for the target group to accept, can be developed. The Development and Design of the Material Adopting the integrated designed KABP questionnaire to investigate the schistosomiasis control knowledge, attitudes, beliefs, and behavioral status of the target group, the behavioral characteristics of schistosomiasis control among the fishermen can be determined. At the same time, by using semi-structured interviews, fishbone diagrams, problem tree and SWOT analysis methods, and fully communicating with representatives of fishermen composed of village cadres, village doctors, village teachers, fishery association presidents, fishermen, and other personnel at all levels in the pilot village, the difficulties and obstacles in the change of unhealthy behaviors of the target group and core schistosomiasis control information to be spread can be determined, and the formation of schistosomiasis health education material can be selected, including the form, theme, content, and information expression (language, drawing, etc.) of the material (Fig. 5.41). Application and Effect Evaluation The fishermen village of Houshan Village, Ruihong Town, Yugan County, in the endemic schistosomiasis area of Jiangxi Province is selected as a field application pilot, to conduct application pretest on participatory health education material and to evaluate the effect.

Fig. 5.41 The baseline survey on schistosomiasis control knowledge, beliefs, and behaviors of fishermen

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Results

Content and Form of Health Education Material The core information of health behavior characteristics for fishermen to control schistosomiasis and health education is to determine the behavioral characteristics related to schistosomiasis control through the investigation of the knowledge, attitudes, and practice of the target group. Among the 292 fishermen surveyed, 86.64% (253/292) of them have the education level of junior high school or below, and 35.27% (103/292) do not know that human and livestock excreta entering the water could lead to the spread of schistosomiasis, 16.1% (47/292) do not know the main harm of schistosomiasis to the human body. Only 26.63% (69/292) of the fishermen would be personally protected when fishing and washing, and in the infection season, only 47.6% (139/292) of them would remind family members and relatives to pay attention to schistosomiasis when entering the water. According to the behavioral characteristics of the target group, the first draft of the form and core content of the health educational material is drafted. The form and content of material are determined by conducting semi-structured interviews in terms of the first draft with the village representatives (consisted of the cadres, the doctors of the village health center, the president of the fishery association—the prestige of the clan, the headmaster of the village school, women the director, and other 16 people with relatively high level of education and composed of influential and prestigious fishermen in the pilot village), and by considering the opinions of the fishermen representatives about the scoring and ranking of the form and core content of the health education material. Through two rounds of Delphi expert consultation, the form and content of the series of health education material are further audited and revised, and finally finalized and published. The Composition of Participatory Health Education Material Using local knowledge and local talents, and adapting to local conditions, the series of participatory health education material are developed and designed, including two posters featuring local fishermen, two pieces of participatory puzzles reflecting the real life, two sketches in local language about schistosomiasis prevention and control, a song about schistosomiasis prevention and control, and a set of colorfilling cards for students. 1. The participatory posters featuring local fishermen and reflecting the real life The ordinary fishermen in the pilot village fishermen distributing center are used as the material for the posters. The picture is of the familiar working scenes and the fishermen fellows familiar to the fishermen in the pilot village. That can deliver the concept that the recurrent infection of schistosomiasis is highly likely to occur when fishing without protection in the target group. The size of the poster is 60 cm
50 cm (Fig. 5.42). 2. Participatory puzzles with the purpose of changing the behavior Targeting to the blind spot of the core schistosomiasis control knowledge in the target group and the health behavior problems existing in the daily production

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Fig. 5.42 Community discussing schistosomiasis control and community health education

Fig. 5.43 Community mobilization projects

and life, the two pieces of participatory jigsaw puzzles are designed, named “health education ship for schistosomiasis control,” and “Living in the endemic area of schistosomiasis, What kind of person do you want to be?” (Healthy people or schistosomiasis patients) focusing on fishermen. The design of “schistosomiasis control health education ship”: The jigsaw puzzle is a magnetic whiteboard in 45 cm
45 cm. The background of the jigsaw puzzle is a line drawing vessel hull, and contains 8 schistosomiasis knowledge points closely related to the fishermen production and life. The movable magnetic patches are the correct answers of these knowledge points. If all eight questions are answered correctly, a complete fishing vessel will be assembled (Fig. 5.43). The design of Living in the Endemic area of schistosomiasis, What kind of person do you want to be? (Healthy people or schistosomiasis patients): The jigsaw puzzle is a magnetic whiteboard in 45 cm
45 cm. In the left of the background are objects fishermen familiar to such as marshland, farm cattle, Oncomelania hupensis snails, and magnifying Schistosoma cercariae. In the right are the cartoon images of healthy people and schistosomiasis patient (the typical ascitic patient familiar to people in the endemic area). In the middle are two blank zones for the puzzle. The movable magnetic patches are six pictures of real life about healthy or unhealthy behaviors to prevent schistosomiasis for the target group to choose (Fig. 5.44). 3. Creating and performing local sketches and songs of schistosomiasis prevention and control

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Fig. 5.44 Schematic diagram of the participatory posters featuring local fishermen and reflecting their real life

With the improvement of the economic level, there are more and more temple fairs and clan festivals in rural communities, and a number of cultural and entertainment organizations and women’s organizations are keen on and active in performances. During the implementation of the project, the project team made full use of the advantages and enthusiasm of the entertainment group in the pilot village and on the basis of exchanging and discussing the purpose, significance, and value of using local language to create and perform the sketches, the villagers were encouraged to develop and design these sketches about schistosomiasis prevention and control. During the implementation of the project, the fishermen’s executive and the schistosomiasis control professionals repeatedly exchanged ideas to promote the integration of the schistosomiasis knowledge and local knowledge. The villagers created two sketches—fisherman and Schistosoma and parents-in-law taking about schistosomiasis prevention and control, and a song happiness feeling of fishermen participating in schistosomiasis control, deriving from the familiar fishermen life and focusing on the life cycle of Schistosoma, the symptoms of schistosomiasis, and policies or measures at the national and provincial levels in the new era and so on (Figs. 5.45, 5.46, 5.47). 4. Participatory color-filling cards of schistosomiasis control for elementary school students in the fishermen’s school The student participatory color-filling cards of schistosomiasis control are divided into two parts: the question card and the answer card. The question card includes 15 core schistosomiasis questions (10 knowledge questions, 3 attitude questions, and 2 behavior questions) and a maze figure with numbers. Each alternative answer to each question is set to a different color. After the student determines the answer, the color corresponding to the answer will be filled in the corresponding space of the maze, and finally the hidden pattern in the maze will be presented. In the answer card, a flower pattern will be presented when 15 questions are all correctly answered. If there is a wrong answer, there will be an incongruous flower pattern with unsuitable colors (Fig. 5.48).

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Answers

Material object Fig. 5.45 Schematic diagram of jigsaw puzzle named “schistosomiasis control health education ship”

5.5.2.4

Application Effect

The Effect of the Posters Taking the fishermen in the pilot village as the protagonist of the poster, the posters demonstrate and spread the schistosomiasis control healthy behaviors through the familiar scenes and familiar villagers, and the theory of peer demonstration and spread is applied in the schistosomiasis control health education project aiming at behavior change. In the pretest application process, the local community has a very high resonance of the posters. 98.97% (192/194) pretesters believe that if the acquaintances in the village appear on the posters, they will pay more attention to them. They also say that they know the protective methods are to keep healthy, they

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Questions

Answers

Material object Fig. 5.46 Schematic diagram of jigsaw puzzle named Living in the endemic area of schistosomiasis, What kind of person do you want to be?

will use the role as a model to try their best protecting themselves, and they indicate that taking the fishermen fellows as the protagonist of the poster can indeed play the role of demonstration and spread, which is suitable for the target group. Because the posters are deeply affected by the pilot villagers, the designers will add the calendar to them according to the idea of the target group and make them as the form of a calendar. The calendars are distributed to the fishermen, so that the propaganda of

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Fig. 5.47 Live performances of information. (a) parents-inlaw talking about schistosomiasis prevention and control. (b) Fisherman and Schistosoma showing T-Shirts with worm stages

(a)

(b) schistosomiasis control will be posted in the household and the time for propaganda is extended (Fig. 5.49). The Effect of the Jigsaw Puzzles Considering that the fishermen generally have a low education level, the jigsaw puzzles are done by the form of movable magnetic patches. The jigsaw puzzle “schistosomiasis control health education ship” expresses the schistosomiasis control information by the jigsaw puzzle form of the vessel in order to increase the participation interest of the fishermen, thus effectively improving the health education effect. The jigsaw puzzle Living in the Endemic area of schistosomiasis, What kind of person do you want to be? (Healthy people or schistosomiasis patients) emphasize the controllability and preventability of harm or health factors mainly through the positive and negative examples of healthy people and schistosomiasis patients, leading the target group to think, compare, and choose. The pictures of the puzzle are easy to understand, they are the real-life photos closed to the actual life of

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Questions

Answers

Material object

Fig. 5.48 Schematic diagrams showing schistosomiasis control measurements for students

Fig. 5.49 Pretest on participatory health education material field application

the fishermen. When the target group members are in the process of completing the jigsaw puzzles, their initiative and participation are intentionally stimulated through the thinking and choosing. In the pretest process for the villagers, 78.35% (152/194) of the fishermen were impressed on the form and content of the jigsaw puzzles. In the students’ pretest, 80.65% (50/62) was fond of the form and content of the schistosomiasis control jigsaw puzzles (Fig. 5.50). The Effect of Local Language Sketches and Songs of Schistosomiasis Prevention and Control Creating and Performing by Fishermen The two sketches—fisherman and Schistosoma and parents-in-law talking about schistosomiasis prevention and control—and a song happiness feeling of fishermen

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Fig. 5.50 Pretest on fishermen participatory material field application

participating in schistosomiasis control, created and performed by fishermen, display the production and life of local fishermen in a vivid form. At the same time, the protection knowledge of schistosomiasis and the national schistosomiasis control policy are integrated into them. Through interesting storylines, vivid fishermen image, and easy-to-understand performances, the masses can learn knowledge in a relaxed and pleasant atmosphere initiative instead of passively. The participation of local cultural talents in the township not only can enlarge the health education propaganda team, but also can avoid the embarrassment that health education ended after the end of related projects. This provides a new idea for community health education activities. Among the target group, 84.37% (162/192) indicated that they got knowledge and skills of schistosomiasis prevention and control more and clearly, as well as current national schistosomiasis control policies and other important information. The health education had a significant effect. The Effect of Participatory Color-Filling Cards of Schistosomiasis Control for Elementary School Students in the Fishermen’s School The design of participatory color-filling cards of schistosomiasis control stimulates the interest of elementary school students in the way of hands-on exploration; deepens the impressions of students with colors and patterns; makes the schistosomiasis control health information more attractive and interesting through the form of teaching in joy. In the target fishermen village elementary school, 62 students in the fifth and sixth grades were tested for application effects. The results showed that

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Fig. 5.51 Pretest on participatory material field application in the target fishermen village elementary school

56.45% (35/62) elementary school students liked this form of propagation (Fig. 5.51).

5.5.2.5

Application and Significance

Health education is one of the important strategies to prevent and control diseases and improve human health level. Traditional rural health education mainly adopts health knowledge lectures, materials distribution, and other top-down health education methods. It is difficult for target groups to truly integrate into the health education activities themselves as a major participant. In the design process of the materials, this research focuses on the target group, integrates social culture, customs, and group values of the local people in the endemic area, and the target group of fishermen and professionals work together to develop, design, and determine the form and content of health education materials. The whole process that target group participates in the project is a process of participation, empowerment, and self-development. The application results show that if applying the target group’s own image and language to health education materials, combining local language, original local customs and real-life images of target group production and life with schistosomiasis health knowledge and schistosomiasis control policies, the distance between the target group and the content or form of the materials can be eliminated, and the acceptance of materials can be increased. The target group can clearly understand the dangers of wrong production and lifestyle, thus enhancing the urgency of selfprotection. 80.9% (157/194) in the target groups said that they were willing to follow the health education materials to change their behavior, such as wearing protective gloves when washing clothes at the lake, wearing rubber gloves for fishing, cooperating with the doctor promptly inspecting and treating, not excreting stool and urine in the lake, using schistosomiasis control toilets (household toilets), etc. At present, the implementation of various schistosomiasis prevention and control measures, schistosomiasis prevention policy propaganda and schistosomiasis

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prevention health education for rural areas, only depend on the participation of the health department. The participatory self-health management path of the fishermen community should be explored, so that the people in the endemic area can truly participate in the prevention and control of schistosomiasis closely related to their health. In the process of formulating and implementing schistosomiasis health education intervention measures, the fishermen’s own effects and the internal community resources should be paid attention to. Combining local social culture, local wisdom, customs, and group values in the endemic area with schistosomiasis control health content, the development of local language schistosomiasis control sketches and songs, and the designation of schistosomiasis control materials mainly based on the image of the fishermen, to the greatest extent, can mobilize the enthusiasm of various organizations in the community and each villager participating in schistosomiasis prevention and control. Reaching a consensus of the idea “health is for ourselves” in all aspects of the fishermen community leads to the process that the community is entering the self-education, self-management, and self-discipline about schistosomiasis control and health. So, the rural endemic areas can obtain sustained driving force for schistosomiasis control and health development. The understanding and active cooperating with the national schistosomiasis control policy measures and the extensive participation in the schistosomiasis control health career of the base level organizations and the masses in the epidemic areas can not only accelerate the realization of the objectives in the new period of schistosomiasis prevention and control in China, but also effectively improve the utilization efficiency of state capacity (human resource, material resource and financial resource) in rural areas and form a new situation that rural public health undertakings are jointly built and win-win developed. The form of health education for schistosomiasis must keep pace with the times, and the design of health education materials needs to be updated. This study integrates participatory ideas and research methods into the design and production process of health education materials. And it reaches the effects including maximizing the mobilization of community organizations and each resident to participate in the prevention and control of schistosomiasis, achieving the consensus of the idea “health is for ourselves,” forming the atmosphere of health self-education and selfdisciplined, the villages obtaining sustained driving force of health development, promoting the process of prevention and treatment of schistosomiasis in the fishermen community and the realization of community health development goals, and the application practice of the concept in terms of self-health management advocated by the World Health Organization in schistosomiasis endemic areas.

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Treatment for Advanced Schistosomiasis (Including Traditional Medicine) Overview of Advanced Schistosomiasis

Advanced schistosomiasis is a clinical type mainly manifested by liver fibrosis, portal hypertension, colon granuloma, and growth retardation caused by chronic pathological development after repeated infection or infected by a great amount of Schistosoma japonicum cercaria. The patients often have the symptoms of irregular abdominal pain and diarrhea or irregular defecation, poor appetite, and distended upper abdomen after a meal, usually accompanied by sexual disorder. Sometimes, they get a low-grade fever, wasting and fatigue, leading to the decreased labor force. In terms of physical examination, signs may be shown as follows: enlarge and hard liver without tenderness, apparent splenomegaly to reach under the navel and subcutaneous varicose vein of the abdominal wall. The condition can develop further into a gastrointestinal hemorrhage, ascites, jaundice, and even hepatic coma. Worse still, it can become obviously severe when complicated by viral hepatitis due to compromised immunity. Advanced schistosomiasis is divided into six clinical types in Jiangxi Province: (1) Splenomegaly type: The spleen is too large to cross umbilical level vertically or ventrimeson horizontally; (2) Ascitic type: Ascites appears now and then during the course from several years to more than 10 years, which is usually induced by upper gastrointestinal hemorrhage, infection, overwork, or the drug harmful to liver; (3) Colon tumoroid proliferation or colon granuloma type: This is often characterized by abdominal pain, diarrhea, constipation, or alternation between diarrhea and constipation. A lump or cord mass can be palpable on the left lower abdomen, with mild tenderness; (4) Dwarf type: The patient is short with growth retardation because of delayed treatment after repeated infection during childhood. The results of laboratory examination often show anemia, abnormal liver function, and even water electrolyte disorder in severe cases, such as ascites; (5) Ordinary type: Although the patient suffers from severe liver fibrosis, the liver function is in compensation, without any complication of portal hypertension; (6) Hemorrhagic type: Upper gastrointestinal bleeding or severe varicosity of fundus and esophagus along with apparent red sign that is caused by portal hypertension. Among them, clinical types of ascites, splenomegaly, colon tumoroid proliferation and dwarf follow the classification standard of Manual of schistosomiasis Control, and the ordinary type and hemorrhagic type refer to the new clinical classification reported by Deng Weicheng et al. The advanced schistosomiasis patients who meet one of the following situations need to be treated pathologically with the first choice being praziquantel: recent hatching test positive, acquire live eggs or recently degenerated eggs by rectos copy, and three years from the last treatment or positive serological test patients. For the patients with sufficient liver compensatory function, total drug dose of 60 mg/kg for 2 days is advised, while 60 mg/kg for 2 days or 90 mg/kg for 6 days is considered for

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the elder or the one with poor liver function or concomitant diseases. The dose of the drug can be decreased to 50–60 mg/kg for 2 or 3 days when advanced schistosomiasis patients get rid of ascites and keep steady or have no upper gastrointestinal bleeding and obvious gastrointestinal symptoms for more than half a year.

5.6.2

Traditional Medicine and Advanced Schistosomiasis Therapy

This disease was recorded in Traditional Chinese Medicine (TCM) a long time ago. General Treatise on the Cause and Symptoms of Diseases thought that: the obstacle of body fluid circulation and qi stagnation would cause this disease. This disease belongs to tympanites, edema, meteorism in TCM. It is often caused by parasitization and the injury or deficiency of the digestive system, with clinical manifestations of limb weakness, diarrhea, and so on. The early stage of schistosome Liver Fibrosis usually accompanies with the stagnation of liver qi, which will lead to blood stasis, blocking of the meridians and collaterals, and insufficient blood to nourish the liver. At the stage of liver cirrhosis, the blood stasis will deposit in liver and spleen and obstruct the venation. The body fluid circulation and metabolism will be totally disturbed. As a result, the qi, blood, and body fluids cannot move smoothly and stagnate into meteorism. At the end stage of liver cirrhosis, both the liver and spleen are a deficiency. The liver, spleen, and kidney are all injured, leading to the excessive fluid and blood stasis accumulated, resulting in deterioration of the disease. For patients with chronic schistosomiasis, even if they received treatment with deworming, the progression of liver fibrosis still cannot be prevented completely. Praziquantel and other antiparasitics are less effective in treating advanced schistosomiasis, patients with chronic schistosomiasis may still progress to advanced schistosomiasis, although they have the complete insecticidal treatment. As a result, the most important for these patients is anti-fibrosis treatment. TCM believes that, schistosome liver fibrosis is caused by liver-qi stagnation, resulting in blood stasis to block the meridians, and there is not enough blood to nourish the liver. Therefore, the therapeutic principles are promoting blood and qi circulation, removing blood stasis, dredging collaterals, and promoting urination and draining. It depends on activating blood circulation and removing stasis, making blood moving smoothly in the liver and the whole body to treat and prevent liver cirrhosis. According to the theory of treatment based on syndrome differentiation, the syndrome of advanced schistosomiasis can be divided into four classifications in TCM. The first type is blood stasis, which usually shows in advanced splenomegaly patients. The treating principle is to remove blood stasis and dredge collaterals. The second type is water and dampness retention, which shows in advanced ascitic patients. The treating principle for this type is activating yang and promoting diuresis. The third type is yin deficiency of liver and kidney, which also shows in advanced ascitic patients, with the treatment of nourishing both liver and kidney.

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The last type is yang deficiency of liver and kidney, which shows in advanced ascitic and dwarf patients. The treatment for this type is to strengthen the spleen and warm kidney. Many researchers are trying to treat schistosomiasis hepatic fibrosis by using TCM. Recently, studies show that the addition of different kinds of single drug based on traditional prescription may improve the antifibrotic effects, and the mechanism has been verified in vitro. If the patient has a long course of the disease, with hard liver parenchyma, splenomegaly, drastic drugs such as rhizoma sparganii, curcuma zedoary can be added to activate blood stagnation and expel blood stasis. If the patient manifests with water and dampness retention, ascites, edema of both lower limbs, excreting dampness drugs and diuretics such as grifola and rhizoma alismatis are recommended. If the patient shows bleeding gums, lalang grass rhizome, and cacumen biotae can be added for hemostasis. Haobie Yangyin Ruanjian decoction is mainly composed of 9 traditional Chinese medicines, including artemisia apiacea, turtle shell, polygonum cuspidatum, the root of red-rooted salvia, radix curcumae, and so on, which can improve immune cell activity and anti-fibrosis. Among them, artemisinin is a dry aerial part of the genus asteraceae, and the biological structure contains a peroxy bridge. Studies have shown that after artemisinin and its derivatives enter the human intestine, heme and free iron in the body can catalyze the cleavage of the peroxy bridge, generating a large number of free radicals, which will cause damage to the biomembrane of the polypeptide through membrane lipids peroxidation and biological macromolecules alkylation or oxidation. At the same time, in the presence of free iron, artemisinin and its derivatives can significantly reduce the sulfhydryl content in the protein of schistosome. Many proteases in schistosome have active groups of the thiol group, such as glutathione reductase. The thiol group will lose enzyme function after oxidation, leading to schistosome necrosis. However, artemisinin is inconvenient to use and has many side effects, but its derivatives, artemether and artesunate, also show significant inhibitory effects on glutathione reductase and superoxide dismutase of schistosome. The total antioxidant capacity, sulfhydryl levels, and vitamin C levels of schistosome decreased significantly by using artemisinin derivatives, causing schistosome being vulnerable to oxygen free radicals. At the same time, the artemether-based drugs can also act on coenzymes related to glucose metabolism, increase the activity of phosphorylase of schistosome, accelerate the decomposition of glycogen, and inhibit the activity of lactate dehydrogenase and the activity of G-6PD. Finally, it can reduce the lactic acid significantly in schistosome, which is the final product of glycolysis, and kill schistosome. Artemisinin-based drugs also have a therapeutic effect on praziquantel-resistant schistosomiasis because of their different drug mechanisms from praziquantel. Recent studies show that Haobie Yangyin Ruanjian decoction can reduce the expression of α-smooth muscle actin (α-SMA), inhibit the activation and proliferation of hepatic stellate cells (HSC), and inhibit the fibrous tissue proliferation in the portal area and fibrous septum, with the hepatic lobules keeping basically normal structures. Paeoniflorin is a new kind of anti-inflammatory and anti-tumor drugs, which exerts the anti-tumor influence by inhibiting the activity of nuclear transcription factor-κB (NF-κB) to induce cell apoptosis. Chinese scholars established the mice

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liver fibrosis model by infecting them with Schistosoma japonicum cercariae. Researchers found that different concentrations of paeoniflorin could not only reduce liver fibrous tissue proliferation, but also downregulate the expression of connective tissue growth factor (CTGF) and platelet-derived growth factor (PDGF) in mice livers, which may remind us the close relationship between the downregulation of CTGF and PDGF expression and anti-fibrosis effect by paeoniflorin in liver tissues of mice with Schistosoma japonicum katsura. Another study also showed that administration of paeoniflorin before praziquantel could not only significantly reduce hepatic egg granulomas and liver fibrosis level, but also decrease the expression of transforming growth factor (TGF) β1 and αSMA in liver tissues, consequently improving the prognosis of schistosomiasis patients.

5.6.3

Medical Treatment for Advanced Schistosomiasis in Jiangxi Province

5.6.3.1

Background

Advanced schistosomiasis is a major chronic disease that renders labor incapacity, leading to poverty and even death, thus bringing a heavy burden to families and society. In order to alleviate the burden, a general survey of advanced schistosomiasis patients was organized by Jiangxi Province in 2002, whose results showed 5350 confirmed cases, of which 72.3% were the ascitic type and 26.0% were splenomegaly type. On the basis of comprehensive general survey and in-depth investigation, in 2002, Jiangxi Province took the lead in carrying out the rehabilitation operation of advanced schistosomiasis, during which the provincial, municipal, and county governments raised funds respectively to implement free treatment for some advanced schistosomiasis patients in six severely affected areas. As of the end of 2003, a total of 1050 patients had been treated. From 2004 to 2005, the provincial government included the treatment of advanced schistosomiasis as a livelihood project, and 3 million yuan was invested for treatment each year. From 2005, according to the Notice of the State Council on Further Strengthening the Prevention and Control of schistosomiasis, the Ministry of Health and the Ministry of Finance included the treatment of advanced schistosomiasis in the central subsidy for local public health special transfer payment project under the spirit of “temporary relief measure and appropriate subsidies for advanced schistosomiasis patients in poverty.” Thanks to the project, a total amount of 292 million yuan was allocated to Jiangxi Province from 2005 to 2017. Therefore, Jiangxi Province actively promoted the rescue project of advanced schistosomiasis, and established regulatory framework, including successively issuing the Implementation Measures for the Treatment of Advanced schistosomiasis Patients in Jiangxi Province, the Technical Solution for the Treatment of Advanced schistosomiasis Patients in Jiangxi Province, and the Catalogue and Guidelines of Drugs for Advanced schistosomiasis Patients. To institutionalize and standardize the

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management, on-site assessment to determine the designated hospital, regular organization of the experts to supervise the work and regulation of accounting review procedures for the subsidies were also launched.

5.6.3.2

Policy and Measurement

The Advanced schistosomiasis Rescue is a public health service policy that unites and benefits the people’s livelihood and is one of the important measures to prevent residents of endemic areas from poverty due to illness. The rule “provides assistance to advanced schistosomiasis patients who accord with the conditions” in Regulations for schistosomiasis Control and the Regulations for schistosomiasis Control in Jiangxi Province issued by the State Council provides Jiangxi Province strong support for relief of advanced schistosomiasis at the legal level. By adopting relevant management and technique, strictly reviewing medical aid targets, and implementing hospitalization treatments in designated hospitals, patients can be treated on time. Jiangxi Province has revised and improved the measurements and technical solutions for the treatment of advanced schistosomiasis patients for several times, and meanwhile actively explore the rescue system and evaluation system for medical treatment, in order to carry out the whole processing management strategy and technology of medical assistance. To make full use of and integrate medical social resources to help treat schistosomiasis patients, guarantee work of treatment for schistosomiasis is put into effect by the new rural cooperative medical system and civil administration in Jiangxi Province, and the Management of Treatment for Advanced schistosomiasis in Jiangxi Province is formulated based on the current status. This regulation clearly states the situation that needs to be treated as follows: advanced schistosomiasis; surgery for splenomegaly type; critical complications, such as refractory ascites, gastrointestinal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome; schistosomiasis patients with II or III stage of hepatic fibrosis; and cerebral schistosomiasis. The medical institutions for the abovementioned diseases are the secondgrade designated public medical institutions of the new rural cooperative medical system in the county/city/district and the county-level professional institutions for prevention of schistosomiasis. At the same time, the one equipped with the ability of diagnosis, treatment conditions, and high level of diagnosis and treatment technique, or tertiary public medical institutions is selected as a probable designated medical institution. The designated medical institutions are approved by the Office of Leading Group for schistosomiasis and Other Endemic Diseases Control of Jiangxi Provincial People’s Government after examination, assessment, and evaluation by experts on the spot. In order to ensure the quality of treatment, those who meet the conditions should be sent to the designated medical institutions with the consent of the patients.

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Compensation for Medical Cost The maximum amount of the single one disease among that specified in the regulation should be paid. Compensation is affordable when the medical expenses are incurred in the designated medical institutions determined by the Provincial Office of schistosomiasis Prevention. The medical expenses of hospitalization refer to the quota standard, while the actual cost in the new rural cooperative medical system shall be directly subsidized according to the relevant policy. The selfpayment and the part unable to reimburse shall be settled by the provincial special fund. 1. Implementation procedures The rescue work shall be jointly implemented by the local health department, the new rural cooperative medical system in the county/city/district and the designated medical institution. The implementation procedures mainly include case screening—confirming the diagnosis—application for approval—hospitalization—expense settlement. The specific implementation procedures are as follows: (a) Case screening. The designated medical institution lists the list of advanced schistosomiasis patients and submits the application form, the original and copy of the valid second-generation ID card and the recent photo of the naked abdomen. Each department of county/city/district verifies whether the advanced schistosomiasis patient fills out the registration form or not at the beginning of each year, and submits the result to the city-level office where the report is reviewed and sent to the provincial office. Every year, the provincial and municipal officials will conduct on-site supervision in each county/city/district. (b) Determining the diagnosis. For the cases detected by the county/city/district of the project, the patient can go to the local schistosomiasis professional institution to check and confirm the diagnosis, and the local designated medical institution will organize the experts to confirm the cases. The medical institutions designated for medical treatment should carefully organize the work of diagnosis with the spirit of being highly responsible for patients, and strictly follow the indications for the diagnosis. (c) Application for approval. For cases diagnosed and requiring hospitalization, the patient shall bring a valid resident ID card, a household registration book, a new rural cooperative medical system medical certificate, and a diagnosis certificate issued by a designated medical institution to the professional institution of prevention of schistosomiasis in county/city/district for application for hospitalization. (d) Hospitalization. The total amount of cases will be distributed annually according to the provincial office in principle; while the cases approved by professional institutions in the county/city/district should select the designated medical institutions professional of prevention of schistosomiasis for hospitalization.

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(e) Expense settlement: Medical organization department and designated medical institutions should establish reimbursement system and direct compensation window of new rural cooperative medical system, following the principle of “convenient and beneficial to people,” in order to simplify the settlement procedure of medical reimbursement, shorten the time of reimbursement arrival, and allow the designated medical institutions to settle immediately for the discharge patients. In this way, the patients only need to pay for their own expenses, while the compensation from the new rural cooperative medical system and aid fund are paid in advance by designated medical institutions. 2. Expert group for treatment (a) Establish a technical guidance group of experts at the provincial level The expert group is responsible for assisting the Provincial Health and Family Planning Commission and Provincial Office of schistosomiasis Prevention to formulate the Technical Service Specification for schistosomiasis Treatment, execute the plan and determine the maximum payment standard for each disease type, in order to establish a provincial medical cooperation network responsible for the diagnosis and treatment guidance of pilot disease, consultation for difficult cases, technical support, and business training in designated medical institutions. (b) Forming a treatment group of experts from relevant disciplines As for providing convenience services for people, the medical treatment leading group shall be set up, a sound regulation of management shall be established, the construction of a direct subsidy window of new rural cooperative medical system shall be strengthened, and special planes and professional staff shall be prepared in designated hospitals to reinforce the management of treatment work and open up green channels. Setting up a rescue expert group composed of relevant disciplines, organizing medical technicians, strengthening the infrastructure of designated medical institutions, improving wards and monitoring conditions, ensuring that equipment and facilities are in place enable timely diagnosis and hospitalization. Also, to ensure the quality and safety of medical treatment, the following is needed: strictly follow the clinical path of the issued relevant disease types, determine the standardized diagnosis and treatment plan of the pilot disease, and standardize the medical service practice. Treatment of Advanced Schistosomiasis Patients in Poverty in Jiangxi Province Some provincial experts of advanced schistosomiasis organized by Provincial Office of schistosomiasis Prevention carried out an on-the-spot investigation on how to put the treatment of advanced schistosomiasis into the Health and Medical Assistance Program for Poverty Alleviation. The research team went to the village to visit the advanced schistosomiasis patients in poverty households and held talks with the medical staff of the Provincial Office of schistosomiasis Prevention in the county/ city in Lushan, Pengze, Duchang, Hukou, and Ruichang. Specially, the Provincial

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Office of schistosomiasis Prevention of Nanchang, Xinjian, Fuyang, Yugan, Shangrao, and other counties/districts were convened to conduct extensive discussions on the status of advanced schistosomiasis in the province, the management of expenditure, and the need for health and poverty alleviation, for figuring out a more effective countermeasures of health and poverty alleviation. After careful investigation, the Provincial Government Office transmitted the Suggestion on Implementation of Promoting the Health and Poverty Alleviation Project (Jiangxi Provincial Government [2017] No. 132) made by the Provincial Health and Family Planning Commission, the Provincial Poverty Alleviation and Immigration Office, the Provincial Department of Finance, the Provincial Office of Human Resources and Social Security, the Provincial Civil Administration Office, and the Jiangxi Insurance Regulatory Bureau. Furthermore, in order to spread out the essence of the document, carry out the measures precisely and provide assistance to Health and Medical Assistance Program for Poverty Alleviation, the Provincial Office of schistosomiasis Prevention organized the compilation of the Empowerment Plan for Treatment of Poor Advanced schistosomiasis Patients in Jiangxi Province. 1. Purpose From 2018 to 2020, the policy of “Two-Free and One-Subsidy” will be implemented for the poor advanced schistosomiasis patients who have registered to ensure the aid is delivered to the exact person with the exact disease aiming to alleviate the phenomenon of poverty caused by illness. 2. Objects Through the verification and approval of the “Poverty Alleviation Dynamic Management System” and the “Jiangxi Provincial Information Management System for Advanced schistosomiasis,” 430 cases of advanced schistosomiasis patients have filled out the registration form. 3. Policy i. The expenses for hospitalization and outpatient in the designated medical institutions shall be reimbursed according to the reimbursement ratio stipulated in the “Opinions on Improvement Projects of Promoting Health and Poverty Alleviation,” after reimbursement compensation from the basic medical insurance, major illness insurance, and supplementary insurance for urban and rural residents. The remaining expenses shall be arranged in a unified manner in the funds special for the major public health project of schistosomiasis prevention and control. ii. During the hospitalization of poor advanced schistosomiasis patients, the subsidy for food for each person is 30 yuan per day, and each case is capped at 1000 yuan per year. The required expenses are disbursed from the special funds for provincial schistosomiasis prevention and treatment. 4. Organization and implementation i. Strengthen leadership and carry out responsibility. As we all know, an efficacious implementation needs effort from all aspects, financial, medical insurance, poverty alleviation, civil affairs, and other relevant departments.

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The local health and family planning departments should include the advanced schistosomiasis patients in poverty into the objects of the Health and Medical Assistance Program for Poverty Alleviation and make overall arrangements for deployment. Also, a leading group for the treatment shall be established, aiming at formulating detailed implementation rules in light of local conditions. At the provincial level, the performance of advanced schistosomiasis assistance and treatment for the poverty-stricken shall be integrated into the performance appraisal of schistosomiasis prevention and control in the whole province, which will be supervised and inspected from three dimensions including implementation of policy, completion of task, and treatment effectiveness. ii. Strengthen medical quality management and improve the treatment effect. All local designated hospitals for advanced schistosomiasis should follow the principles of quality assurance, convenience, and standardized management to promote medical quality, safety awareness, and optimize various regulations, and meanwhile standardize the clinical behavior of diagnosis and treatment for ensuring medical quality and quality according to the clinical requirements of advanced schistosomiasis. iii. Intensify information reporting and grasp the progression dynamically. All localities should establish a workbook for the treatment of poverty-stricken advanced schistosomiasis patients, for the purpose of summarizing the progress of the work, existing problems and experiences. In terms of monthly report system, all localities should promptly and accurately fill in the “Statistical Table of the Treatment Situation of Advanced schistosomiasis Patients in Poverty in Jiangxi Province” and hand in the data on last month to the Provincial Office of schistosomiasis Prevention on a monthly basis. Auditing of Advanced Schistosomiasis Verification of the existing registered cases had been done from 2014 to 2017 in the whole province, during which the death and cured cases had been removed. As to gradually reduce the registered cases, the following steps should be done to keep the dynamic balance of the number of advanced schistosomiasis cases in the whole province, upgrade the level of medical staff and guarantee the treatment quality and effect: fully implement the Administration of Advanced schistosomiasis Treatment in Jiangxi Province, further carry out all relevant measures, strengthen hospital management, capacity establishment and technique training, and guard the access of new patients’ access. According to Diagnostic Criteria for schistosomiasis (WS261-2006), the registered and suspected advanced schistosomiasis patients should be performed physical examination and ultrasonography at the 31 designated hospital patients, and then be confirmed which clinical type he/she is based on the classification standard in Manual for Schistosomiasis Control. The one who meets the criteria can get an entry to “Management System of Advanced schistosomiasis,” and go through the verification and confirmation by a provincial expert group of advanced schistosomiasis treatment. After that, an epidemiological survey will be conducted on all

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advanced schistosomiasis patients who meet the rescue criteria identified in the “Management System,” the same population of those received treatment in those years, including the patient’s address, name, gender, age, occupation, education level, history of schistosomiasis diagnosis and treatment, expansion of chemotherapy, medical security, assistance hospital, rescue standards, medical expenses, and the outcome of the disease. Digital Information Management of Advanced Schistosomiasis in Jiangxi Province In response to the needs of advanced schistosomiasis assistance and treatment, the “Jiangxi Provincial Advanced schistosomiasis Information Management System” was developed. This work is divided into two phases: The first phase is the stand-alone version. In 2007, Yuanhua Mao and other researchers developed a stand-alone version of “Jiangxi Province Advanced schistosomiasis Assistance and Treatment Information Management System.” This system had information sheets for reporting, treatment, follow-up, and verification, which basically covered advanced schistosomiasis information in the national parasitic disease prevention information management system. According to the Administrative Measures and Technical Plan for the Treatment of Advanced schistosomiasis Patients issued by Health Ministry, the operation included screening, approval, treatment, accounting, funding, follow-up, verification, and other stages of work. Among them, screening, treatment, and accounting and follow-up were accepted by the basic control unit, while approval, funding and verification were accepted at the provincial and municipal levels. For the data transmission, the system needed to be imported and exported in Excel format, and the data supervision was in the static phase. The system had advantages of stable running performance, simple operation and low maintenance cost. This working software for early management of advanced schistosomiasis assistance and treatment information of Jiangxi Province had enabled the administration to enter a digital mode. The second phase is the online version. The “Jiangxi Province Advanced schistosomiasis Assistance and Treatment Information Management System” (standalone version) cannot meet the current requirements of information management, due to the following problems: (1) System download and installation. The countylevel advanced schistosomiasis professional institutions need to download and install the stand-alone version, which is inconvenient to use; (2) Data cannot be reported to the superior in real time. The data of the stand-alone version cannot be reported to the superior in time, instead, after the data is entered, the data needs to be manually exported to the superior, and the upper level is manually imported into the system, which increases the workload and period of data reporting; and (3) Low management efficiency. Lack of unified, convenient, rapid and efficient management of people, objects, and property in the daily work affairs. In order to better solve the above problems, in 2015, the “Jiangxi Province Advanced schistosomiasis Assistance and Treatment Information Management System” (online version) was redeveloped to facilitate an easier and centralized management of daily work and various data, as well as to realize automatic transmission of data between basic and

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superior institutions, therefore promoting comprehensive query and statistical analysis of various types of data and improving the efficiency, work quality, and speed of emergency response. This system enables fluent and real-time check of information on the report, treatment, follow-up, verification, and accounting among all levels of professional institutions from county to province, as a result, the target of comprehensive management has realized. Reporting information, etc., to achieve the goal of the province’s late blood information management. The functions of “Jiangxi Province Advanced schistosomiasis Assistance and Treatment Information Management System” include: report, treatment, follow-up, verification, accounting, manuals, and other functional modules. Through the cooperation of various functional modules, the information submitted by the professional institutions can be smoothly and timely transmitted between the county, city, and provincial agencies. The business functions of the system are as follows: (1) Report: management, covering data entry, modification, inquiry and deletion, query, and statistics of disease information; (2) Treatment: management of treatment information, incorporating data entry, modification, inquiry and deletion, and statistical inquiry on treatment review, treatment staff, treatment process, and treatment reimbursement categories; (3) Follow-up: timely update of follow-up information, including data entry, modification, query, and deletion as well as statistical inquiry according to the conditions; (4) Verification: information management (covering data entry, modification, query, and deletion) of follow-up and screening and statistical inquiry of verification information; and (5) Accounting: Questionnaires and statistics for details of reimbursement (Fig. 5.52). The Research Union of Schistosomiasis Prevention and Treatment in Jiangxi Province In order to further strengthen the anti-schistosomiasis work, improve the level of schistosomiasis prevention and scientific research ability in the province, thoroughly implement the national policy, improve the treatment effect in grassroots, and provide better public hospital resource for the affected areas, an union has been established, under the leadership of the Provincial Office of schistosomiasis Prevention, by the Provincial Parasite Research Institute and the No. 9th Nanchang Hospital (also known as Nanchang Infectious Disease Hospital), acting as an initiator, as well as other 30 basic schistosomiasis prevention institutions from Poyang Lake area. This union is mainly around prevention, treatment, and research of schistosomiasis, for actively exploring the construction of medical association. The research consortium focusing on prevention has truly realized the effective combination of highquality resources of medical and health institutions from provincial, municipal, and county levels. It is the first consortium of disease prevention and control institutions, an innovative move of integration of public health to overall medical reform, and even a measurable benefit to the patients. The medical association not only targets the clinical diagnosis and treatment, but also includes the prevention and control, scientific research, personnel training, and diagnosis and treatment of other major parasitic diseases. It is a trinity of medical, disease control, and scientific research. The establishment of the research union will further promote the work of

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Fig. 5.52 Jiangxi Provincial Information Management System for Advanced schistosomiasis

schistosomiasis prevention and control, improve the treatment effect of schistosomiasis at the grassroots level, improve the prevention and research ability among the grassroots, and realize the transformation from extensive to precise services.

5.6.3.3

Significance and Effectiveness

Since Jiangxi Province took the lead in carrying out the treatment of advanced schistosomiasis in 2002, especially after the central government’s special transfer payment funds used for hospitalization in 2005, and along with the support of various channels, Jiangxi Province has assisted patients with advanced schistosomiasis of 63,000 cases. As of the end of 2017, the province diagnosed 5000 patients with advanced schistosomiasis, which was 22.82% lower than the 6479 cases in 2009. Not only does a large number of patients get timely treatment, but also the patients are cured or have improvement in clinical symptoms and signs. As a

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consequence, some patients recover fully or partially restore their labor ability, prolonging their life expectancy and improving the quality of life greatly.

5.6.3.4

Challenges and Prospects

Due to the different speed of economic and social development, there are large differences in support, financial and service support in various regions. Similarly, diversity appears in the new rural cooperative system insurance and reimbursement ratios, which leads to insufficiency in treatment. Hence, some patients lack timely treatment and some even relapse after cure, eventually resulting in a phenomenon of becoming or returning to poverty due to illness, bringing great pressure to the performance of treatment. The problem of patients with advanced schistosomiasis has not been completely solved, for example, the low clinical cure rate, different degrees of complications or accompanied with other system diseases, and the still heavy burden of medical treatment. These factors have a great impact on the quality of life of patients. With the continued implementation of the advanced schistosomiasis prevention and treatment policy, the characteristics of patients are also constantly changing: the ascitic type is decreasing, while the ordinal type and the one with Grade I liver parenchyma are increased, indicating that the treatment for advanced schistosomiasis patients, especially the ascetic type, has reached certain achievement. At the same time, the population of Grade III liver parenchyma increased and the inner diameter of the portal vein showed a widening trend, demonstrating that though the patients from transmission blocking areas have no possibility of reinfection, the condition can still get worse. In view of aging of advanced schistosomiasis patients, the dominant cause of death turns to chronic diseases. Nowadays, how to prevent the patients with chronic infection from stepping into advanced stage remains a daunting task.

Further Reading Ai DY, CX (2009) Surveillance of schistosomiasis in Yujiang after 50 years of interruption. Schistosomiasis Control China 21:145–146 Cai WM (2008) Understanding of hepatic fibrosis and advanced schistosomiasis in the past and future. Chin J Schistosomiasis Control 20:235–238 Cao CL, BZ, Zhu HQ et al (2010) Analysis of schistomiasis control requirements in boat fishermen in the lake regions. Chin J Schistosomiasis Control 22:567–571 Cao L, HG, Guo JG et al (2003) Compliance study on mass chemotherapy with praziquantel in schistosomiasis hyper-endemic area of Poyang Lake Region for successive 6 years. Parasitoses Infect Dis 1:153–155 Chen HG, Lin D (2004) The prevalence and control of schistosomiasis in Poyang Lake region. Parasitol Int 53:115–125 Chen HG, ZX, Xiong JJ (2009) Integrated control strategy for schistosomiasis control in Poyang Lake area. Chin J Schistosomiasis Control 21:243–249

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Chen HG, XS, Zeng XJ et al (2011) Current epidemic characteristics and control strategies of schistosomiasis in Lake area of China. Chin J Schistosomiasis Control 23:5–9 Chen HY, HJ, Song KY et al (2008) Longitudinal observation of health education in the control of schistosomiasis for 16 years in students of heavy epidemic areas in Poyang Lake region. Chin J Zoonoses 24:1149–1152 Chen JH, WL, Zhang JF et al (2005) Application of DIGFA, ELISA and IHA for the parallel detection of serum antibodies to Schistosoma japonicum of population in epidemic area of schistosomiasis. Chin J Zoonoses 21:776–778 Chen NG, LD, Xie SY et al (2011) Diagnostic efficiency of Indirect Hemagglutination Assay Kit for antibody detection of schistosomiasis japonica. Chin J Schistosomiasis Control 23:377–380 Chen YQ, ZQ, Li XR et al (2013) Effect of Pulsatilla chinensis (Bunge) Regel saponins against juvenile and adult Schistosoma japonicum in vitro. Chin J Schistosomiasis Control 25:604–609 CPC Jiangxi provincial Party committee information collection Committee (1996) Schistosomiasis control in Jiangxi Province. Central Literature Publishing House CPC Yujiang County Committee of schistosomiasis prevention Leading Group Office. Jiangxi Yujiang County schistosomiasis record (1953–1980) Deng WC, LJ, PG et al (2012) Recommendation of a new clinical classification of advanced schistosomiasis. Chin J Schistosomiasis Control 24:235–236 Department of disease control Moh, People’s Republic of China (2000) Schistosomiasis control manual. Shanghai: Shanghai science and Technology Press, Shanghai Guo JG, NA, Hu GH et al (2005) Experimental study on the control of schistosomiasis transmission in Poyang Lake area by Buffalo chemotherapy. Chin J Zoonoses 21:860–862 Hong XL, WX et al (2012) Control of Oncomelania hupensis with the control of no grazing and no reclamation in the state of snail grass continent. Chin J Schistosomiasis Control 24:364–365 Hu G, Yuan S, Zhou S (1993) Longitudinal observation on epidemiology of schistosomiasis at a typical dam-circle endemic in Poyang Lake region. Chin J Schistosomiasis Control 5:16–19 Hu GH (1997) Health education for schistosomiasis control. Military Science Publishing House, Beijing Hu GH (1999) 160 questions about schistosomiasis control. Military Science Publishing House, Beijing Hu GH, CH, Song KY et al (2009) Establishment and application of school-based health promotion and intervention model of schistosomiasis in lake-type endemic area. Chin J Parasitol Parasitic Dis 27:125–129 Hu GH, CH, Song KY et al (2010) Study on the intervention model of “Schistosomiasis-free infected schools” in heavy endemic area. Chin Preventive Med 44:928–931 Hu GH, LD, Zhang SJ et al (1999) Evaluation on effectiveness of health education for schistosomiasis control in highly endemic area of Poyang Lake Region(2). China Public Health 15:947–894 Hu GH, LD, Zhang SJ et al (2000) The role of health education for schistosomiasis control in heavy endemic area of Poyang Lake region. People’s Republic of China 31(3):467–472 Hu GH, LD, Zhang SJ et al (2000) Studies on intervention modes of health education for schistosomiasis control. Chin J Schistosomiasis Control 12:65–70 Hu GH, LH, Zhou X et al (2005) Development and pretest of the calendar of health education for schistosomiasis control. Chin J Schistosomiasis Control 17:287–289 Hu GH, LJ, Lin DD et al (1997) Role of health education in schistsomiasis control among adultwomen in a lake region. Chin J Parasitol Parasitic Dis 15:301–304 Hu GH, LJ, Zhang SJ (1996) Evaluation on effectiveness of health education for schistosomiasis contol among adult male inhabitants in areas of heavy endemicity. Chin J Parasitic Dis Control 9:195–198 Hu GH, LS, Jiang WS et al (2000) Study on health education intervention model of schistosomiasis among students in lake-type epidemic areas. Chin J Parasitic Dis Control 13:44–47 Hu GH, MH, Zhang SJ et al (1997) Health education strategy and effect observation of schistosomiasis control in primary school students in lake areas. Chin J Preventive Med 31:126–127

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Hu J, ZZ, Hu GH (2010) Observation on effect of health promotion intervention for adult female residents in heavy endemic areas with schistosomiasis in Poyang Lake for 17 years. Chin J Zoonoses 26:982–985 Jiang WS, CN, Huang MJ et al (2013) Development and assessment of Schistosoma japonicum antibody test kit (IHA). Chin J Schistosomiasis Control 25:594–597 Jiangxi schistosomiasis control literature and history (1992) Jiangxi schistosomiasis control literature and history. 1992;43 Khun S, ML et al (2007) Community and school-based health education for dengue control in rural Cambodia: a process evaluation. PLoS Negl Trop Dis 1(3):e143. https://doi.org/10.1371/jour nal.pntd.0000143 Kou YM, LJ, Fang BW et al (2013) Therapeutic effect and its mechanism of Haobie Yangyin Ruanjian prescription on mice with liver fibrosis caused by schistosomiasis. Drugs Clinic 28:288–293 Li HH (2012) Schistosomiasis control in 1950s in China. Contemp Chin Hist Stud 4:63–69 Liu ZH, XG, Liu RH et al (2001) Effect of health education intervention mode on schistosomiasis in primary school students. Chin J Schistosomiasis Control 13:314–315 Long Y, CK, Xiao D et al (2008) Long term trend and influencing factors of schistosomiasis in Hunan Province. J Dis Control 12:1–3 Mao SB (1990) Schistosome biology and prevention and treatment of schistosomiasis. People’s Medical Publishing House, Beijing Mao YH, LD, Ning A et al (2011) Development and application of information management system for advanced schistosomiasis chemotherapy and assistance in Jiangxi Province. Chin J Schistosomiasis Control 23:214–216 Publicity Department of CPC Yujiang county Party committee (1978) Lantian spring and autumn annals. Jiangxi People’s Publishing, Nanchang Qi JC, HG, Peng GH et al (2010) Investigation of schistosome infection among fishermen in the Poyang Lake area. J Pathogen Biol 5(1):71 Qiu CG, HW, Ge J et al (2006) Expanded application of health education for schistosmiasis control in adultmen. Parasitoses Infect Dis 4:173–176 Sheng HF, YY (2011) Neglected tropical diseases: global impacts and preventive measures. People’s Medical Publishing House, Beijing Song KY, YH, Hu GH et al (2010) Longitudinal observation on effect of health education for adult male residents for 18 years in heavy epidemic areas of schistosomiasis around Poyang Lake region. Chin J Schistosomiasis Control 22:242–246 Sun YP, HQ, Cao Q et al (1997) The role of different infectious sources in the transmission of schistosomiasis in the beach area. Chin J Schistosomiasis Control 9(1):44–45 Tang LH, XL, Chen YD et al (2012) Parasitic disease control and research in China. Beijing Science &Technology Press, Beijing Tao WM, MY, Hu F et al (2014) Investigation on current status of advanced schistosomiasis in Shanggao County. Chin J Schistosomiasis Control 26:693–694 Tao XH, FL et al (2011) Health education in interactive way in rural area. J Prev Med Inform 27:469–471 The Jiangxi provincial Party committee of the Communist Party of China eliminating seven pets and six diseases Command Office (1959) Compilation of data on schistosomiasis control in Jiangxi Province Wang EM, ZL, Zhang SQ et al (2009) Effective evaluation of IHA kit the diagnosis of schistosomiasis. J Trop Dis Parasitol 7:203–205 Wang LD (2004) History and prospect of schistosomiasis control in China. People’s Medical Publishing House, Beijing Wang LD (2005) The key to controlling schistosomiasis in China is to manage good and animal feces. Chin J Epidemiol 26:929–930 Wang RB, WT, Wang LY et al (2004) Analysis of the epidemic situation of schistosomiasis control in China. Chin J Epidemiol 25:564–567

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Wang X et al (2013) Historical experience of the CPC leading the work of schistosomiasis prevention in Yujiang in 1950s. J Jiangxi Normal Univ (Philos Soc Sci Ed) 1:109–116 Wang XY, HX, Hu ZH et al (2009) Control of schistosomiasis in a pilot project for comprehensive control of schistosomiasis control in Jinxian County. Chin J Schistosomiasis Control 21:72–73 Wang ZM, WC et al (2011) Analysis of the current situation and countermeasures of rural health education in the process of new rural construction. Rural Econ Sci Technol 22:70–71 White D (2013) Development of a rural health framework: implications for program service planning and delivery. Health Policy 8:27–41 Wu FD, XZ, Yuan SJ et al (1988) Study on the diagnosis of schistosomiasis by indirect hemagglutination test. Chin J Parasitol Parasitic Dis 6(s1):138–141 Wu GL, HJ, Chen SZ, Zhang ZS, Cai SC, Zhao WX (1981) Preliminary analysis of cross-reactive antigens of schistosomiasis and fasciolopsis. Acts Academiae Medieinea Nanji 1981(02):22–24 Wu Yi stressed at the national conference on schistosomiasis control and prevention to consolidate achievements and intensify efforts to ensure that the short-term goal of schistosomiasis control was achieved on schedule (2006) Jiangxi Daily. 2006 May 25, p 1 Xiao H, WH, Yang GB et al (2011) Effects of paeoniflorin on expressions of CTGF, PDGF and TNF-α in mice with hepatic fibrosis due to Schistosoma japonicum infection. Chin J Schistosomiasis Control 23:288–291,349 Xiao SH, KJ, Chen MG, Tanner M, Utzinger J (2010) Research and development of antischistosomal drugs in the People’s Republic of China: A 60-year review. Adv Parasit 73:231–295. https://doi.org/10.1016/S0065-308x(10)73009-8 Xing W, KW, Fang BW et al (2010) Therapeutic effects of Haobie Yangyin Ruanjian prescription on immunity hepatic fibrosis rats. Chin Trad Herbal Drugs 41:1667–1672 Xu LQ (2002) The harm of major parasitic diseases in Western China and reflection on prevention and control. Chin J Parasitic Dis Control 15:1–3 Xu LW, LH, Zhang J et al (2002) Effect of health education intervention mode on schistosomiasis in adult female residents. Chin J Schistosomiasis Control 14:283–284 Xu J, XM, Petlueng P et al (2006) IEC material development for malaria control by working with target populations. Chin J Schistosomiasis Control 2006 Yang PY, SK, Jie XB et al (2009) Application effect of health promotion model of “schools without schistosome infected individuals” in endemic areas of marshland and lake region. Chin J Schistosomiasis Control 21:225–226 Yin H, HG, Chen HY et al (2009) Progress of research on health education for schistosomiasis control. Chin J Schistosomiasis Control 21:337–339 Yuan HC, ZS, Liu ZD et al (1995) Study on epidemic factors and optimal control strategy of schistosomiasis in Lake area. Chin J Schistosomiasis Control 7:193–201 Yue WJ, SB, PQ (1983) Effect of pyquiton derivatives in experimental schistosomissis japonica. Acta Pharm Sin 18:251–255 Zeng X, Chen H, Hong X et al (2012) Midterm effectiveness evaluation of schistosomiasis control strategy based on infection source control in Poyang Lake. Chin J Schistosomiasis Control 24:382–386 Zeng XJ, ZS, Wu FD et al (1996) Longitudinal study on the effect of praziquantel chemotherapy on schistosomiasis control in Poyang Lake epidemic area. Chin J Schistosomiasis Control 9:86–88 Zhang C, WH, Li B, Tang L (2015) Quality evaluation of the Indirect Hemagglutination Assay kit for schistosomiasis antibody detection in Hubei Province. J Public Health Preventive Med 26:53–55 Zhang LJ, XZ, Qian YJ et al (2017) National schistosomiasis report. Chin J Schistosomiasis Control 29:669–677 Zhang J, LD et al (2013) Health education for major parasitic diseases in rural community of China: current status and future development. Chin J Schistosomiasis Control 22:333–336 Zhang SJLZ et al (1988) Study on susceptible areas of schistosomiasis in Poyang Lake area. Chin J Parasitic Dis Control 1:66–67

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Chapter 6

Eliminating Plan and Challenges Yifeng Li and Shangbiao Lyu

Abstract In this chapter, the obligatory needs for an effective control are described as well as the difficulties and challenges that have to be taken into consideration to keep the region mostly free of schistosomiasis. Keywords Future tactics of prevention and action

6.1 6.1.1

Objectives and Tasks Background

The elimination of schistosomiasis is gaining more and more attention. The United Nations Sustainable Development Goal regards schistosomiasis as one of the key diseases for prevention and control. Besides, the World Health Assembly adopted the resolution “Eliminating of Global Health Problem—schistosomiasis in 2025” in 2012. In addition, “the Plan of Health China 2030” clearly requires all schistosomiasis epidemic counties in the country to achieve the elimination standard by 2030 The Party Central Committee, the State Council, and local party committees and governments at all levels have attached great importance to the prevention and treatment of schistosomiasis; consequently, after more than 60 years of hard work, remarkable results have been achieved. By the end of 2016, 5 of the 12 schistosomiasis epidemic provinces in China, Shanghai, Zhejiang, Fujian, Guangdong, and Guangxi, had passed the assessment of maintaining schistosomiasis elimination status. What’s more, the other seven provinces, Sichuan, Yunnan, Jiangsu, Hubei, Anhui, Jiangxi, and Hunan, have reached the standards of transmission control. So as to further promote the schistosomiasis prevention and treatment work, the National Health and Family Planning Commission, the Ministry of Finance, the Ministry of Land and Resources, the Ministry of Water Resources, the Ministry of

Y. Li (*) · S. Lyu Jiangxi Provincial Institute of Parasitic Diseases, Nanchang, P. R. China © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_6

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Agriculture, and the State Forestry Administration jointly issued the “13th Five-Year Plan for the Prevention and Control of schistosomiasis in the Country.” Focusing on the objectives of the “Plan of Health China 2030” and the “Plan of Health Jiangxi 2030”, in order to implement the “13th Five-Year Plan for the Prevention and Control of schistosomiasis in the Country,” accelerate the prevention and control of schistosomiasis in Jiangxi Province, effectively protect the health of the public, and promote the coordinated economic and social development of schistosomiasis endemic areas, the Jiangxi Provincial Health and Family Planning Commission, the Department of Finance, the Department of Land and Resources, the Water Resources Department, the Agriculture Department, and the Forestry Department jointly issued the “13th Five-Year Plan for the Prevention and Control of schistosomiasis in Jiangxi Province,” which proposes the planning objectives, main tasks, and indication.

6.1.2

Objectives of the Plan

According to the 13th Five-Year Plan for the Prevention and Control of Schistosomiasis in Jiangxi Province, by the end of 2020, 24 epidemic counties (cities and districts) in Jiangxi Province have reached the elimination standard, six have reached the standard of blocking transmission, and nine have consolidated the achievements of transmission control. Epidemic counties (cities and districts) that meet the criteria of transmission interruption and elimination account for more than 77% and 60% of the total number of epidemic counties (cities and districts), respectively (Tables 6.1 and 6.2).

6.1.3

Tasks and Measures

To achieve the goals set in the “13th Five-Year Plan for the Prevention and Control of schistosomiasis in Jiangxi Province” and ultimately achieve the elimination of schistosomiasis all over the province, it is essential to adhere to the comprehensive prevention and control strategy mainly based on the control of infectious sources and apply district targeted strategies which means adapting the measurements on the basis of local conditions. At the same time, the departments of health, agriculture, water conservancy, forestry, and land should coordinate and cooperate to implement prevention measures and complete major tasks.

9

4

2 2

2 1 39

Jiujiang

Shangrao

Yichun

Yingtan Jingdezhen

Ji’an Ganzhou Total

15

3

Poyang, Yugan, Yushan

Duchang, Lushan, Yongxiu, Pengze, Ruichang, Gongqing, Hukou, Chaisang, Lianxi

13

Name of the city Nanchang

9

Endemic area in 2015 Total Transmission control amount of endemic Count County (District) counties 6 3 Nanchang, Xinjian, Jinxian

2 1 24

2 2

4

6

4

Count 3

Wanan, Taihe Shangyou

Shangrao, Wuyuan, Dexing, Wannian, Guangfeng, Xinzhou Fengcheng, Fengxin, Shanggao, Gaoan Yujiang, Guixi Changjiang, Fuliang

County (District) Gaoxin, Anyi, Economics Development Zone Wuning County, Xunyang, Dean, Development Zone

Transmission blocking

Table 6.1 “13th Five-Year” Jiangxi Province schistosomiasis control plan and target plan list

9

Duchang, Lushan, Yongxiu, Pengze, Gongqing Boyang County, Yugan County

Transmission control Nanchang, Jinxian

6

Yushan

Hukou, Chaisang, Lianxi, Ruichang

Transmission blocking Xinjian

Target for 2016 to 2020

Shangrao, Wuyuan, Dexing, Wannian, Guangfeng, Xinzhou Fengcheng, Fengxin, Shanggao, Gaoan Yujiang, Guixi Changjiang, Fuliang Wanan, Taihe Shangyou 24

Elimination Gaoxin, Anyi, Economics Development Zone Wuning, Xunyang, Dean, Development Zone

6 Eliminating Plan and Challenges 189

Ganzhou Total

Jian

4

Wanan, Taihe Shangyou 6

Guixi

Yujiang Changjiang, Fuliang

Yingtan Jingdezhen

Wuning

Elimination

2017

Shanggao

Wuyuan

Elimination

2016

Yichun

Shangrao

Jiujiang

Name of the city Nanchang

2

Hukou, Lianxi

2018 Transmission blocking

5

Dexing, Wannian Fengxin, Gaoan

Elimination Anyi

2

Yushan

Chaisang

2019 Transmission blocking

7

Elimination Economics Development Zone, Gaoxin Zone Dean, Xunyang, Development Zone Guangfeng, Xinzhou

Table 6.2 Planning target schedule of 13th Five-Year Jiangxi Province schistosomiasis prevention and control

2

Ruichang

2020 Transmission blocking Xinjian Zone

2

Fengcheng

Shangrao

Elimination

190 Y. Li and S. Lyu

6 Eliminating Plan and Challenges

6.1.3.1

191

Hygiene and Schistosomiasis Control

• Screening and treatment of schistosomiasis in the population. Conduct screening and treatment and strengthen case investigation, case management, and disposal of epidemics. • Investigation and control of Oncomelania hupensis. Promote informatization management of the Oncomelania hupensis existing areas in the whole province and additionally strengthen the investigation during which alternating surveys are conducted on the existing and suspicious Oncomelania hupensis breeding environment every 3 years to reconfirm it. For the susceptible environment or part of the confirmed areas, researches and eradication should be done once or twice every year. • Free-pollution disposal toilets. Further raise funds, promote reform, and provide technical guidance and service for construction of rural harmless sanitary toilets. • Epidemic monitoring and early warning. Strengthen the reporting and management of schistosomiasis epidemics, and establish monitoring points at national and provincial levels as well as in demonstration areas (also known as promotion areas) and key waters. Furthermore, it is necessary to set up monitoring and early warning platforms throughout the province and perform communication risk assessment, epidemic investigation, and early warning at regular intervals. • Health education and health promotion. Carry out various forms of health education, especially among primary and middle school students and key populations in endemic areas, so that schistosomiasis prevention knowledge and awareness of the epidemic areas can be improved overall.

6.1.3.2

Agricultural Schistosomiasis Control

• Investigation and treatment of schistosomiasis in livestock. Organize and implement the census of the livestock in the epidemic areas, while conduct “two checks and two treatments” around the key areas of Poyang Lake so as to block the spread of disease and reduce the rate of livestock infection. In terms of management of livestock trading market and temporary storage areas, treatment is prior to inspection to prevent the infected animals from entering the non-endemic areas. • Control and management of livestock infection sources. Firstly, vigorously promote the livestock housing and captivity to block the source of animal-borne infections. Secondly, promote mechanization of agricultural farming, which means applying machine instead of cattle, to increase the proportion of mechanical farming. Thirdly, according to the construction of new countryside, ecological homestead, and new energy development in rural areas, building biogas pool for energy is useful for the harmless treatment of human and animal manure. Lastly, develop non-susceptible poultry, transform traditional farming habits, and adjust farming structure.

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• Agricultural project on snail control. In combination with the adjustment of agricultural planting structure, the tillage methods of the arable land capable of Oncomelania hupensis breeding can be changed from paddy to dryland or into paddy-upland rotation form, and the ditch can be hardened, in order to reduce the breeding area. Also, dig ponds to raise fish in low-lying swamps (also known as nonbasic farmland) where snails are easy to grow, for the sake of high-quality aquaculture and snail control by store water for fish farming. • Monitoring of the endemic status of livestock. Set up epidemic monitoring points; dynamically keep abreast of the epidemic situation. Next, establish a network for detecting and warning of information on schistosomiasis livestock throughout the province, essential to digital and informatization management. Eventually, regular risk assessment of transmission of schistosomiasis in livestock should be carried out.

6.1.3.3

Water Conservancy and Schistosomiasis Control

• Comprehensive river management. When constructing, rebuilding, or strengthening dike and remediating rivers and lakes in popular areas, carry out the following measurements taking into account the local characteristics: hardening slope protection, filling ponds, construction of anti-snail platforms or belt, building anti-snail isolation trenches, lifting continents, transforming culverts’ resistance to snail, plugging the branches, immersing snails, etc. All the abovementioned methods are aimed at changing the breeding environment and controlling the spread of Oncomelania hupensis along the water system, thus achieving snail control. • Renewal of irrigation area. In terms of new-building, expanding, and reforming the irrigation and drainage systems in popular areas, measures such as hardening slope protection, reconstructing culverts (including adding snail blocking facilities), culverts or pipes, excavating new canals, hardening channel, and sinking snails are considered to change the breeding environment and prevent the snail from spreading along the irrigation and drainage system. • Drinking water in the countryside. Consistent with the national requirement of drinking water safety in rural areas, improve the drinking water safety in endemic areas.

6.1.3.4

Land Resources and Schistosomiasis Control

• Land remediation project. When carrying out land remediation, combined with the projects of land leveling, irrigation and drainage engineering, field roads, farmland protection, and ecological environment maintenance, the snail’s retention tanks and other snail killing facilities are constructed at the same time to change the breeding environment of Oncomelania hupensis.

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• Moving the village for augmenting cultivated land project. For some places where the endemic status is serious, the snails around the village are complicated, and the snails are difficult to eliminate, the resettlement project will be prioritized, and the village will be selected in a safe zone.

6.1.3.5

Forestry and Schistosomiasis Control

• Construction of snail prevention and schistosomiasis prevention forest. Establish a forestry ecological safety system of schistosomiasis control with the snail-proof and schistosomiasis-preventing forest as the core so as to change the snail breeding environment. Different methods are chosen in accordance with the local situation. In the major endemic areas which are suitable for afforestation, we will continue to build those forests. In the conditional afforestation plots, we will construct a complex system consisting of medicine, forestry, and agriculture. As for the lakeshore and ditch areas, we will create biological isolation zones to block the entry of people and animals. • Ecological environment monitoring. Strengthen ecological environment monitoring and early warning in areas suitable for snail breeding. Joining wetland protection and restoration projects together with wildlife protection and nature reserve construction projects is beneficial to consolidate monitoring of snail conditions in protected areas and establish anti-transmission facilities.

6.1.3.6

Schistosomiasis Control Work in Relevant Departments

• The transportation department assists the health department in the investigation and treatment of schistosomiasis among floating workers such as fishermen, strengthening prevention management, and implementing relevant measures. In addition, fecal collection containers should be installed on ships in consideration of concentrate harmless treatment for the collected faeces. • The content of schistosomiasis prevention and control arranged by the education department is taught to primary and secondary school students to prevent schistosomiasis. • The press, publisher, radio, and television departments carry out nonprofit schistosomiasis education activities in popular areas, widely publicizing schistosomiasis prevention knowledge and policies, improving self-protection awareness, and arousing enthusiasm for the participant (Table 6.3).

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Table 6.3 Main task table for indicator No. 1 2 3 4 5 6 7 8 9 10 11

6.2

Indicator Schistosomiasis screening rate in the population Schistosomiasis screening rate in livestock Endemic area treatment rate Livestock captivity rate The grazing-free rate in the area with snails River management rate in the area with snails Snail-proof and schistosomiasis control forest coverage rate Mollusciciding rate Harmless sanitary toilets popularity rate The rate of primary and secondary school students’ awareness of prevention knowledge Monitoring task completion rate

2020 90% 90% 100% 90% 100% 90% 95% 90% 85% 95% 95%

Difficulties and Challenges

Although remarkable results have been achieved after decades of integrated control program conducted by the government, but it is still faced with the complex situation of social factors, environmental factors, and a variety of health habits of residents in epidemic areas. The risk of schistosomiasis transmission still exists.

6.2.1

Management on Sources of Infection

Livestock like cattle are the main infection sources of schistosomiasis, having 75–90% impact in the spread of schistosomiasis. In Jiangxi Province, especially the Poyang Lake region, the number of livestock like cattle and sheep is large. According to statistics in 2017, there were 105,200 cattle in the whole province, among which 60,000 were in the Poyang Lake region. Limited by production and living methods nowadays and the development of economy and society, the habit of raising cattle personally is difficult to abandon due to the abundant resources in marshland and the low cost of farming. Lack of a proper alternative industry for economic development, cattle and sheep farming and grazing on the bottomland is still an important economic source of locals. These add to the difficulties of grazing supervision and infection sources control. In some less developed regions, because of the shortage of funds and attention on industrial restructuring, the methods for infection source control such as cattle elimination, replacement of cattle by machines, stopping grazing in snail growth regions, and livestock in captivity are difficult to put into practice. The phenomena like farming again after elimination and grazing prohibition and the loose supervision power of grazing prohibition appeared, which extremely influenced the effect of infection source control. Otherwise, there are still many susceptible population like fishermen and boatmen in the endemic

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areas. Especially, the number of people like fishermen and boatmen is up to 80,000 in the Poyang Lake region. These people are difficult to manage due to their strong fluidity. They are not only infected people at high risk of schistosomiasis, but an important transmitter of schistosomiasis. The government still needs to lay emphasis on how to use effective methods to put on measures of infection source control. Relevant departments are expected to cooperate to solve problems as well.

6.2.2

Tough Oncomelania hupensis Control

Due to the complex landform, ample plant, and the changeable water level of the Poyang Lake region, the breeding environment of Oncomelania hupensis in the Poyang Lake region is difficult to change thoroughly. The distribution environment of Oncomelania hupensis is complicated in Jiangxi Province, and snails mainly grow in the Poyang Lake region, regions around the Yangtze River, and Huaiyu Mount District. Oncomelania hupensis spread by seasonal flood because of the large infected areas with snails and the changeable water level, causing the infected areas with snails to increase constantly in the Poyang Lake region. The change of water regimen in Poyang Lake and Yangtze River after the operation of the Three Gorges Project makes the problems in areas increasingly clearer. Vacuums of snail control appeared in consequence of a shortage of drugs and exhibition on snail control by drugs in wetlands and reserves. The breeding environment of Oncomelania hupensis is complex in the hilly regions. The infected areas with snail are hard to decrease by the current economic and technical methods. The density of Oncomelania hupensis rebounded largely as the environment of hilly regions improved. Meanwhile, the flaw in comprehensive measures for prevention and control and the lack of the coverage of environment change make Oncomelania hupensis difficult to control thoroughly. Some regions that had eliminated snails even find Oncomelania hupensis again. According to 2017, the remaining snail area in the province is 834 million m2, ranking second in the country. In addition, the areas in five counties around Poyang Lake cover nearly 100 million square meters, covering an area of over 60% of the total snail growth areas in the whole province. Those make it difficult for snail control. How to control Oncomelania hupensis in the lake regions and the hilly regions still depends on researches on new environmental protection drugs and implementation of comprehensive measures for prevention and control.

6.2.3

Unstable Endemic Status

Though the endemic status has decreased to a stage that we have never seen before, it is still unstable. The marshland and lake regions have a large area of wetland, which is proper for Oncomelania hupensis growth. Moreover, the hilly regions have a complicated environment, which is difficult to control snails. Meanwhile, the

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management of infection source is hard to be conducted well. Those all show that the risk of disease spread still exists in some regions. The risk monitoring in 2017 conducted by institutes of parasitic diseases in Jiangxi Province shows that among 22 environments investigated, 5 places were found to be risky (positive animal feces or Oncomelania hupensis with positive Schistosoma nucleic acid by the LAMP). The five places are in Xinjian, Jinxian, Pengze, Duchang, and Sanqing Mountain county (district). As for the 22 environments, 9.1% (2/22) were detected infected snails and 18.2% (4/22) were found infection in animal feces. The results demonstrate that the achievements of disease control are still susceptible. If we relax on schistosomiasis control slightly, the achievements may be destroyed, and the disease may come back.

6.2.4

Difficult Comprehensive Treatment

To achieve the effect of a comprehensive strategy with emphasis on infection source control, we should remember that the main work is infection source control and comprehensive management is just an auxiliary work. But the two complement one another so that we cannot abandon any one of them. Only putting on them into practice can we get maximum effect from new measures. However, though departments including agricultural, forestry, water resources, and land and resources all make a significant investment in comprehensive management, the management of projects is loose and is hard to coordinate and integrate. The unreasonable and unscientific implementary place and the poor integrity and synchronicity of comprehensive management of schistosomiasis control make it difficult for comprehensive management project to benefit schistosomiasis control.

6.2.5

Shortage of Facilities and Professionals for Institutions

The provincial, municipal, and county professional institutions for schistosomiasis control possessed by Jiangxi Province now are still not included by Nation Disease Control and Prevention Project, whose infrastructure and laboratory equipment have not been improved for many years. Some basic professional institutions and institutions for animal epidemic prevention even still possess old houses and humble equipment, which is extremely improper for the important schistosomiasis control tasks currently. Otherwise, the lack of new people for schistosomiasis control teams because of the hardworking condition and poor wages causes many troubles such as aging population structure, poor team stability, and weak professional skills. The condition is even worse in the regions that have already reached the criteria for elimination or transmission interruption of schistosomiasis, which limits the persistence of schistosomiasis prevention and control and the consolidation of the effect of schistosomiasis control.

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Poor Scientific Research Level of Schistosomiasis Control

Similar to other endemic areas in the nation, Jiangxi Province still uses old methods for schistosomiasis control used several decades ago. The key technology of prevention and control like snail survey and control, disease survey and monitoring, and early warning still need improving, and breakthrough of relevant researches is expected. Ineffective manual investigation and artificial recognition are still used in snail survey, the sensitive early detection technique is lacking in disease survey, and modern technology and data information system are expected in early warning. With the progress of the elimination of schistosomiasis, it is urgent to speed up the research and breakthrough in the application of schistosomiasis control, and to develop rapid diagnostic reagents, rapid and sensitive snail detection techniques and high efficiency and low toxicity snail control drugs. The technical support is required for schistosomiasis elimination.

6.3

Expectation

After more than 60 years of active preventions and treatments in Jiangxi province, remarkable achievements have been made in the prevention of schistosomiasis. In 2005, the whole Jiangxi province reached the standard of transmission control of schistosomiasis. At present, 39 epidemic counties (municipal districts) and 10 counties (municipal districts) have reached the standard of elimination, and 14 counties (districts) have met the standard of blocking. In the future, the stations for preventing schistosomiasis in Jiangxi province will focus on the goals of the “13th Five-Year Plan for the National Prevention and Control of schistosomiasis” and the “Plan of Health Jiangxi 2030,” insisting on the law-based, science, and comprehensive preventions. Meanwhile, it shall speed up the transformation of achievements and carry out precise prevention, thus going all out to achieve the ambitious goal of eliminating schistosomiasis in the whole province.

6.3.1

Escort “the Outline of the Plan for Healthy Jiangxi Province in 2030”

In 2006, “Plan of Health Jiangxi 2030” was published by Jiangxi Province, demanding us to insist in comprehensive prevention measures focus on controlling transmission sources, and establish a long-term management system of forbidding the depasturage of livestock on marshlands, thus reinforcing the effect of comprehensive control on schistosomiasis. We shall integrate agriculture, forestry, water conservancy, land, and other resources, thus accelerating the process of modifying the

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environment that breeding snails. Besides, we should improve the surveillance system and pre-warning system and go all out to reach the criteria for elimination of schistosomiasis in 2030. As an important part of the construction of healthy Jiangxi Province, the prevention of schistosomiasis shall deeply understand our purpose, which is “common schistosomiasis control, common business, and common health,” and it is our belief to eliminate schistosomiasis. The stations for schistosomiasis control in Jiangxi Province must prevent it from breaking out in a well-grounded way. The prevention shall be carried out in accordance with the deploys and requirements of the provincial party committee as well as provincial government, focusing on the goal of “Plan of Health Jiangxi 2030,” and center in protecting the security of people living in the epidemic areas as well as taking the improvement of the comprehensive ability to prevent schistosomiasis as the principal thing. Thus, we can build a solid foundation for building a moderately prosperous society and a wealthy, beautiful and happy, and healthy Jiangxi Province. Also, it can convey and do its bit to help with the aim of “Plan of Health Jiangxi 2030.”

6.3.2

Help Accelerating the Progress of the National Strategy “The Belt and Road”

The national strategy of “the Belt and road” clearly points out that we shall carry out pragmatic cooperation with boundary countries in the field of schistosomiasis, using the successful experience of preventions and treatments of schistosomiasis in China. As part of international aid to Africa, the preventions and treatments of schistosomiasis will be an example of China’s cooperation with WHO to enhance international aid to Africa in the public health area. In addition, it would be a cooperation model; thus it could provide big support for international cooperation such as “The Belt and road” and international aid to Africa. The stations for schistosomiasis control use the thoughts of “The Belt and Road” for reference, sparing no effort to build up that of schistosomiasis control. In the “Plan of Health Jiangxi 2030,” Jiangxi Province points out that it would innovate the pattern of cooperation. The new pattern would be combined with global health strategy and meet the need of “The Belt and Road.” And it shall promote cultural and educational exchanges, strengthen South–South cooperation, and make the cooperation between China and Africa workable. Besides, the government would send medical units to developing countries, enhance the medical assistance including maternal and children health care, and support the establishment of diseases controlling system, helping African countries to carry out the work of schistosomiasis control. Thus, the stations for “Plan of Health Jiangxi 2030” would carry out extensive cooperation and communication with parasitology researchers from Asia, Africa, and other places all over the world under the guidelines of “The Belt and Road” and make contributions to countries concerning “The Belt and Road” and prevention of schistosomiasis in African countries. At the beginning of 2016, the

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research institutions of preventions and treatments of schistosomiasis in Jiangxi Province signed an agreement named “the memorandum of Cameroon and institutions in Jiangxi province working together to eliminate schistosomiasis” with University of Yaounde, Cameroon. This agreement launches the project in which Jiangxi Province offers assistance of both the control and elimination of schistosomiasis in Africa. In October 2016, two specialists from parasites research institutions of Jiangxi Province went to Cameroon to carry out the first project meeting, talking about how to make “the memorandum of Cameroon and institutions in Jiangxi working together to eliminate schistosomiasis” workable with Louis Albert, the director of control and elimination of schistosomiasis at the University of Yaounde, Cameroon. During the meeting, both sides confirmed that it would launch the cooperation through a pilot project and precisely pointed out that our province would offer assistance in technology training, health education, and development of reagent used for diagnosing and treatments and drew up a work plan. In March, 2017, Louis Albert, the director of control and elimination of schistosomiasis at the University of Yaounde, Cameroon, invited our specialists once again to participate in the first meeting of schistosomiasis control in Cameroon and discussed the work plan of our cooperation. Jiangxi Province could make use of the successful experience of control technology, infection source control technology, and reagent used for diagnosis, health education, and devoted ourselves into the work of schistosomiasis control in Africa, thus helping to accelerate the progress of the strategy “The Belt and road.”

6.3.3

Makes Ecological Civilization Construction Even Better

The schistosomiasis control is a complex project of the social system. The epidemic of it, especially in the marshland and lake region, is greatly affected by social, economic, and natural, ecological factors. Therefore, the outbreak of it is often brought back due to the relaxation of a certain link of work. Therefore, the prevention of schistosomiasis shall be closely combined with the construction of ecological civilization, based on the bearing capacity of resources and environment, and based on the law of nature, aim at sustainable development. Besides, it should be driven by the innovation of environmental protection systems and mechanisms and spare no effort to set up the mechanisms of schistosomiasis prevention in a new age. The construction of the ecological civilization of schistosomiasis prevention means to promote the prevention of schistosomiasis to the level of green development, thus promoting the implementation of prevention of it from the perspective of construction of ecological civilization. Therefore, in schistosomiasis epidemic areas, the funds for the development of ecological agriculture and tourism, pollution control, and preservation of soil and water shall be arranged as a whole. Besides the funds for channel improvement, afforestation, and natural reserve, modification of cleaner production technology should be arranged as a whole as well. Moreover, we ought to carry out ecological snails control measures, such as that of agricultural

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engineering, water conservation, and forestry engineering. So, we should eliminate the remaining snails continuously, reduce the areas where snails have been detected, and reduce the environmental pollution caused by drugs used for the control of snails gradually. We need to modify the breeding environment of snails continuously, so we could change it completely. Therefore, we could maintain the ecological and natural state of Poyang Lake. Based on the growth in living standards and economic level of people living in epidemic areas, cultural quality is increasing day by day. Also, there is the development of schistosomiasis prevention and control technology, the improvement of the level of modernization of agriculture and fishery, as well as the renovation of planting industry and breeding industry. Moreover, the selfprotection awareness of farmers, fishermen, primary and secondary students, and housewives have enhanced. Therefore, the comprehensive prevention and treatment strategy of schistosomiasis that focuses on controlling the infection sources would be completely workable and it could greatly promote the reinforcement of the achievement of schistosomiasis prevention and treatment as well as promote the elimination progress of it. In order to leave more ecological resources instead of leaving regrets, we choose to “plant trees for the benefits of posterity.” We believe that, with the high-speed development of the social economy of Jiangxi Province, continuous development and application of scientific research as well as the new technology of the prevention of schistosomiasis would become possible. We shall stick to the policy that focuses on prevention and treatment for both symptoms and root causes, comprehensive management, mass prevention as well as treatment, and joint defense as well as joint control. We should perfect the system of control and prevention of schistosomiasis and attach importance to the education of it. Besides, we ought to pay attention to the combination of agriculture, water conservancy, and forestry. Besides, we ought to attach importance to the screening and treatment of schistosomiasis as well as the control of feces. Moreover, we need to pay more attention to the reinforcement of mass prevention, minor drainage basin management, and regional prevention as well as treatment, making the “Regulations for schistosomiasis control in Jiangxi” workable. The scene “Paper boats are burnt by the candle flames toward the sky,” which represents sending away the god of plague, can surely come true in epidemic areas in Jiangxi Province. The successful experience of eliminating schistosomiasis in our province can be a model and benchmark for other parasites’ prevention.

Further Reading Guo JG, Xu X, Zhu R et al (2013) Overcoming the global impact of neglected tropical diseases and challenges. Chin J Schistosomiasis Control 25:121–124 Jiangxi Provincial People’s Government. “13th Five-Year” plan for schistosomiasis control in Jiangxi Province. http://www.jiangxi.gov.cn. Accessed 23 Apr 2018 Li YS, Cai K et al (2004) Trends and challenges of schistosomiasis in China. Chin J Epidemiol 25:553–554

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Liang XY, WN, Yuan XB et al (2008) Problems and strategies of comprehensive measures with controlling infection sources as predominance for schistosomiasis control. Chin J Schistosomiasis Control 20:313–314 Lei ZL, Zhou X et al (2015) Eradication of schistosomiasis: a new target and a new task for the National Schistosomiasis Control Program in the People’s Republic of China. Chin J Schistosomiasis Control 27:1–4 People’s Republic of China National Health and Health Committee. National schistosomiasis control plan in 13th Five-Year. http://www.nhfpc.gov.cn. Accessed 23 Apr 2018 Zheng J (2003) Schistosomiasis control and its prospect in China. Chin J Schistosomiasis Control 15:1–2 Zhou XN (2016) Implementation of precision control to achieve the goal of schistosomiasis elimination in China. Chin J Schistosomiasis Control 28:1–4

Chapter 7

Epilogue Zhongdao Wu

Abstract Remarkable achievements had been made during the past 65 years. China’s experience in rapid screening, detection, and treatments is now tested in Zanzibar, Africa, to control schistosomiasis transmission there. More and more African countries now have established intimate collaborations with the Chinese government in the fight against schistosomiasis. China–Africa cooperation will make a tremendous contribution to schistosomiasis control or elimination.

Since the 1950s, Jiangxi Province has carried out large-scale schistosomiasis prevention and control work and achieved remarkable results. In 1958, Yujiang County took measures to eliminate schistosomiasis through environmental transformation and control of snails. It provided useful experience for controlling the epidemic of schistosomiasis in mainland China and became a banner for the prevention and control of schistosomiasis in China. In the last century, the pilot research on the prevention and control measures based on the elimination of infectious sources in Jiangxi Province has achieved remarkable results, providing a practical basis for the comprehensive promotion and implementation of chemotherapy-based schistosomiasis control in China. In 2016, Jiangxi Province launched a project to assist Cameroon, Africa, to control and eliminate schistosomiasis and signed a memorandum of cooperation. This indicates that the successful experience of schistosomiasis control program in Jiangxi can be translated and applied in African countries to eliminate schistosomiasis among African people. In November 2017, the Jiangxi Provincial Government issued the “Opinions on Further Strengthening the Prevention and Control of Schistosomiasis in the New Period,” clarifying that by 2025, the criteria for schistosomiasis transmission interruption should be met, and by 2030, the goal of eliminating schistosomiasis should be achieved. In order to achieve this goal, the opinion is clear that the province should combine the structural adjustment of agriculture and aquaculture and Z. Wu (*) Department of Parasitology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People’s Republic of China e-mail: [email protected] © Springer Nature Switzerland AG 2019 Z. Wu et al. (eds.), Schistosomiasis Control in China, Parasitology Research Monographs 11, https://doi.org/10.1007/978-3-030-25602-9_7

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implement measures such as “change paddy fields to dryland,” “paddy-upland rotation,” “dig ponds for fish farming,” and “store water to control snail” to reduce the snail breeding area; vigorously develop modern agriculture and guide farmers to change their production and lifestyle; and the construction unit should apply to the Department of Health for environmental assessment before building a large-scale construction project in the endemic areas of schistosomiasis and take measures to prevent and control schistosomiasis. We should adhere to the principles of scientific prevention and comprehensive management and adjust measures to local conditions. We are supposed to improve the ability and level of schistosomiasis prevention and control at the grass roots, implement comprehensive measures for schistosomiasis prevention and control based on infection sources, and put patient treatment and prevention plans or measures into effect continuously. We reasonably believe that under the correct leadership of the party and the government, as long as we persist in the above measures, we will certainly achieve the goal of eliminating schistosomiasis by 2030.