Resurgence of Schistosomiasis Mansoni in Oman

Letters to the Editor women are over-reporting vaginal discharge because of the deep cultural meanings of the symptom. This is leading to inappropriate treatment of women with antibiotics, with all its attendant consequences. This issue needs urgent attention. The syndromic approach to the treatment of STDs is costly, and in the setting of South Asia, it is clearly not an appropriate use of scarce resources. K Trollope-Kumar MD PhD West End Health Associates, 1827 Main Street West, Hamilton, Ontario L8SlH6, Canada E-mail: trolloak@mcmaster.ca References 2 Nichter M. Idioms of distress: alternatives in the expression of psychosocial distress: a case study from South India. Culture Med Psychiatry 1981;5:379-408 Hawkes S, Morison L, Foster S, et al. Managing reproductive tract infections in women in low-income, low-prevalence situations: an evaluation of syndromic management in Matlab, Bangladesh. Lancet 1999;354:1776-81 Resurgence of schistosomiasis mansoni in Oman The Sultanate of Oman is currently promoting tourism as part of its strategy for economic growth. An increasingly popular destination is the coastal town of Salalah, located in southern Dhofar province, the original source of frankincense, which is the only region in the Arabian Peninsula to be affected by the summer mosoon. (An added attraction for overseas tourists is its vicinity to the fabled 2000-year old 'lost city of Ubar', referred to by T E Lawrence as the 'Atlantis of the Sands'.) Daily rain and mist occur during this cool period (mean daily temperature 28°C), and the surrounding mountains become lush with green vegetation'. In the foothills are numerous springs and freshwater pools, ideal for picnics, reached by a short drive from Salalah. Unfortunately, Schistosoma mansoni was detected for the first time in 1979 in this region, appearing first in irrigated farmland/. Suitable vector Biomphalaria arabica snails had been present in the district since 18963, and it was suspected that the parasite had been recently introduced by Egyptian farm labourers or Omanis of East African origin. Control measures, including identification and treatment of patients, and an extensive search for snail vectors and mollusciciding, were immediately instituted, but a further study in 1989, indicated that low level transmission was continuing'', The control programme was intensified and by 1994, the disease appeared to have been eradicated'. However, regular mollusciciding and surveillance of eight known snail-infested sites continued. Warning signs in Arabic and English, advised that snails were present, that swimming was dangerous, and that contamination of water with faeces or urine was prohibited. Farmworkers and schoolchildren living near these sites had annual stool examination, but in 1999, no cases were identified". Unfortunately, there is recent evidence that schistosomiasis has been reintroduced to one of the freshwater springs, and several residents of the district have developed acute infection. Case 1 In June, 1999, a 9-year-old village boy from the Salalah hills had bloody diarrhoea, 4 weeks after bathing in freshwater springs at Wadi Sahanout, a well-known Tropical Doctor July 2001, 31 locality for B. arabica snails (a wadi is a watercourse). Apparently, some unknown person or persons had removed the warning notice at the pool. Six weeks later, he developed acute Katayama syndrome with fever, with progression to acute, areflexic, flaccid paraplegia, with a sensory level at TIO, and with impaired bladder and bowel sphincter function. His white blood count was 37.0 x 109 / L, with 27.0 x 109/L eosinophils. His stool contained abundant S. mansoni ova, and examination of the cerebrospinal fluid (CSF) showed 50 lymphocytes/mm', protein 0.9 g/I, and normal glucose level. Unfortunately, anti-schistosomal antibodies were not measured in the first CSF sample, and the father refused to allow a second lumbar puncture. Magnetic resonance imaging (MRI) scan revealed oedema of the spinal cord from the first thoracic vertebral level to the conus medullaris. As soon as schistosomiasis was diagnosed, he was given praziquantel (40 mg/kg), and treated with methyl prednisolone 400 mg daily for 3 days, followed by a diminishing dose for 6 weeks. He began to recover motor function within a few days of treatment, and could walk with support after 2 weeks, but sensory recovery was delayed, and at 3 months, he had persisting bladder and bowel sphincter impairment with inability to pass urine and incontinence of faeces. Case 2 The patient's father, aged 38 years, had bloody diarrhoea 4 weeks after bathing on the same day in June 1999, in the same springs. He reported that other village children bathing at the same time had also had bloody diarrhoea. He was asymptomatic when evaluated in August, but stool examination revealed light infection, and he was treated with praziquantel. Case 3 A 22-year-old woman who swam at Wadi Sahanout in August, 1999, developed severe swimmer's itch. She remained otherwise well, but in April 2000, was referred from Salalah for evaluation of persistent eosinophilia. The history of exposure to freshwater and subsequent swimmer's itch was obtained (for the first time), and stool examination revealed light infection with S. mansoni. She was treated with praziquantel. The patient reported that other people including children, were bathing at the same time, and that no warning notice was present. Comment The presentation of acute, flaccid paraplegia in association with Katayama syndrome in our first patient, is an unusual but well-recognized complication of early schistosomiasis. This is attributed to the immunological response to maturing Schistosoma adults and egg antigens in the mesenteric or vesical veins, and it is usually selflimiting. (In established schistosomiasis, myelopathy is caused by granuloma formation around ectopic egg deposition, often involving the conus mcdullaris/.) The cellular response in the CSF may be lymphocytic or eosinophilic, and immunological tests for Schistosoma in the CSF are likely to be positive. Presumably, in this patient the inflammatory reaction in the conus proceeded to patchy ischaemia and infarction. Following report of these new cases, the public health authorities replaced the warning notice at Wadi Sahanout freshwater springs, and intensified mollusciciding. Local 185 Letters to the Editor villagers, particularly children, are being screened for evidence of infection. Clearly, an unknown infected individual had recently contaminated the springs with faeces. This could have been a local resident who was undetected and untreated at the time of the intensive eradication programme 10 years ago (S. mansoni adults can survive for as long as 37 years"), We have recently detected two residents of Salalah with persisting, active schistosomiasis, who reported exposure to freshwater springs a decade ago: the first was a 55-year-old man with hepatosplenic schistosomiasis and portal hypertension, and the other was a 32-year-old man, who presented with anaemia (Hg 9.8 g/dl), thrombocytopenia (platelet count (23 x 109/L), and splenomegaly). Both patients received praziquantel. Infection might also have been introduced expatriate: we have encountered many by an. infect~ expatnates With untreated schistosomiasis, particularly Egyptian patients. The resurgence of schistosomiasis in the Salalah district of southern Oman is a source of serious public health concern. This popular tourist destination is generally free of serious infectious disease risks. Contrary to widespread belief, expressed in many popular travel guide books? the risk of malaria in southern Oman is almost non-existent: the prevalent anopheline mosquito Anopheles custiani a day-biting mosquito, is not anthropophilic. However, a; in other regions endemic for schistosomiasis, tourists visiting southern Oman should be advised to avoid all skin contact with freshwater pools or springs, and this information should be included in all guide books to Oman. This new outbreak of schistosomiasis emphasizes the fact that wherever schistosome infection has been present, as long as vector snails persist, vigilance can never be relaxed, and control measures must continue indefinitely. Euan M Scrimgeour FRACP R Koul MRCP J Sallam PhD M A Idris PhD Department of Medicine, Sultan Qaboos University, PO Box 35, AI-Khod (Muscat), Oman Correspondence to: Dr E M Scrimgeour E-mail: scrim@squ.edu.om References 2 3 4 5 6 7 8 9 186 Thesiger W. Arabian Sands. London: Penguin Travel Library 1999:47-8 ' Shaban MMA. Role of organisational cooperation in schistosomiasis eradication in Dhofar Governorate. Oman Med J 1995;12:17-19 Wright CA, Brown DS. The freshwater molluscs of Dhofar. J Oman Stud 1980;2:97-102 Idris MA, Ruppel A, Numrich P, Eschilbeck A Shaban MA Diesfeld HJ. Schistosomiasis in the southern re~ion of Oman~ vector snails and serological identification of patients in several locations. J Trop Med Hyg 1994;97:205-10 Scrimgeour EM, Mehta FR, Suleiman AJM. Infectious and tropical diseases in Oman: a review. Am J Trop Med Hyg 1999;61:920-5 Datta D. Schistosomiasis in Oman. Commun Health Dis Surveillance Newsl (Oman) 1999;7:1-5 Scrimgeour EM, Gajdusek DC. Schistosoma mansoni and S. hae.matobium infection of the central nervous system: a review, Brain 1985;0:23~ Chabasse D, Bertrand G, Leroux JP, Gauthey N, Hocquet P. A case of Schistosomiasis mansoni detected 37 years after infection. Bull Soc Pathol Exot FilI985;78:643-7 Robinson G. Arab Gulf States. Bahrain, Kuwait, Oman. Qatar, Saudi Arabia and the United Arab Emirates. Melbourne: Lonely Planet, 1993:122-60 Could cultural scarification contribute to the high prevalence of HIV in central Africa? The practice of scarification is widespread within African culture. While the details of these incisions vary between subcultures, the indications for their administration fall broadly into two categories, medicinal or cultural. In Malawi, the term 'Mphini' is used to describe these scarifications. Mphini are administered by tribal herbalists using razor blade incisions at sites determined by the patient's complaint, in a distribution akin to acupuncture. We researched the incidence of scarification on a cohort of the Malawian population. Subjects were in-patients at the Queen Elizabeth Central Hospital, Blantyre, Malawi. Each subject underwent a clinical examination to establish ~he site, quant!ty and size of any Mphini. Using an mterpreter, a history was taken to determine the reason for their administration. Examining 246 patients (149 males, 97 females) revealed that 54.5% of patients in this sample population displayed Mphini, the majority of these being administered for pain relief. It was also noted that our cohort was sourced in an area of relative urbanization, with two hospitals and numerous pharmacies in the area. It is probable that this practice is even more widespread in areas with less access to pharmacological analgesics. During our research we also witnessed the administration of the scarifications by the 'herbalists'. The procedure was seen to 'draw blood' and we witnessed the same razor blade being used on more than one patient, with no form of sterilization between patients. HIV prevalence in Malawi has been estimated at 35%. Over the past 10 years the Malawian government and international health organizations have allocated many resources to HIV education and the promotion of 'safe' medical practice and sex. This education has not addressed this widespread practice of cultural scarification. While the serological effects of cultural tattooing have not been reported, the potential risks were noted previously when considering the epidemiology of other blood borne infections'. With the high prevalence of tattooing found in this study it is our view that these procedures should be addressed when considering the transmission routes of HIV. 5 E Gwilym MBBS BSe' 5 R Linnard MBBS' C Lavy FRCS2 , Royal Free & University College London Medical School, London, UK; 2Malawi Against Polio, Malawi Correspondence to: Dr Stephen Gwilym, Department of Surgery, Middlesex Hospital, Riding House Street, London NWl 3AA, UK E-mail: s..gwilym@yahoo.com Reference Olumi~e EA. The distribution of hepatitis B surface antigen m. Af~lca and the tropics: report of a population study in Nigeria, Int J EpidemioI1976;5:279-89 Anthropometric measurements in children with congenital heart disease Congenital heart disease (CHD) is often associated with malnutrition and failure to thrive, the prevalence being as high as 64% in developed countries of the world I. The Tropical Doctor July 2001, 31