A feasibility test of a large-scale implementation of schistosomiasis elimination under China-Zimbabwe cooperation: a pilot study protocol

A feasibility test of a large-scale implementation of schistosomiasis elimination under China-Zimbabwe cooperation: a pilot study protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A feasibility test of a large-scale implementation of schistosomiasis elimination under China-Zimbabwe cooperation: a pilot study protocol Yingjun Qian, Nicholas MIDZI, Shizhu LI, Masceline Jenipher MUTSAKA-MAKUVAZA, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4120546/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Schistosomiasis is amongst the leading Neglected Tropical Diseases in terms of its public health significance in Africa accounting for up to 90% of the global burden. Zimbabwe is endemic for Schistosoma haematobium and S. mansoni infection. Despite mass drug administration with a focus on school age children, other interventions are not yet in place at national level. China has set up a mechanism of public health cooperation with African countries targeting at schistosomiasis and other infectious diseases. A detailed methodological description of the pilot study for schistosomiasis is presented to make the protocol applied to expanded surveys in similar settings. Methods/Design: This pilot study was designed as a project and considered as an entry point for China-Africa cooperation on schistosomiasis control and elimination. It aimed to test the feasibility of a large-scale collaborative project between China and Zimbabwe. A cross-sectional study on schistosomiasis and snail survey was planned to understand the distribution of the disease at community level. The survey was designed to cover all the 14 villages in the target area (Chevakadzi ward). A simple random sampling was applied to enroll participants and convenient sampling for snail survey was carried out. The feces and urine samples were microscopically examined by the Kato-Katz and urine filtration respectively. At the same time, a capacity and needs assessment was carried out to understand the local pattern of disease control strategy. Discussion This pilot study is expected to generate important epidemiological information and indicators about schistosomiasis transmission at sub-district level. It will be used to determine the feasibility and practicality in China-Zimbabwe cooperation investment at a larger scale. China Zimbabwe Schistosomiasis China-Zimbabwe cooperation Elimination Figures Figure 1 Background Ancient but neglected, schistosomiasis (SCH) is a vector-borne and water-borne zoonotic parasitic disease amongst a diverse group of ‘Neglected Tropical Diseases’ (NTDs) [ 1 – 3 ], caused by the flatworms of genus Schistosoma and can lead to acute and chronic conditions. Humans contract SCH when they get into contact with infested fresh water sources, where cercaria, the infectious free-swimming larvae of schistosome penetrate their skin. SCH is recognized as a disease of poverty because it is generally prevalent in low-income, remote communities where clean water source, basic sanitation and health care are inadequate or inaccessible, which exacerbates its burden on the impoverished population and keep them trapped in generational cycles of poverty. Of the 5 species that infect human health, S. haematobium causes a urogenital form of disease while S. mansoni , S. japonicum, S. mekongi and S. intercalatum are responsible for intestinal and hepatic SCH [ 4 ]. Alternatively known as bilharziasis, SCH mainly refers to urogenital and intestinal SCH caused by the two major species of S. haematobium and S. mansoni most prevalent in sub-Saharan Africa [ 2 , 5 ]. Globally, human SCH has been endemic in 78 countries with at least 90% of global disease burden in Africa, where the highest morbidity and mortality occur [ 6 , 7 ]. According to the Global Burden of Disease (GBD) estimation, SCH accounted for 1.5 million years lived with disability worldwide in 2016 despite its increasing visibility and continuous global investment [ 8 – 10 ]. More than ever, COVID-19 increased the uncertainty to achieve targets set by 2030 NTD roadmap, especially in Africa [ 11 – 14 ]. The disease compromises public health by contributing to malnutrition in children, preventing them from attending school, impairing cognitive development, and increasing high risk of getting HIV especially in women [ 2 , 7 , 15 , 16 ]. Although given present effective interventions, SCH remains the second to malaria in terms of its public health significance [ 8 , 17 , 18 ]. Professional and domestic activities such as farming, bathing, washing, and playing expose local dwellers to infection [ 19 – 22 ]. The World Health Organization (WHO) advocates for treatment of all at-risk populations, preventive chemotherapy (PC) through mass drug administration (MDA) with a priority focus on school-aged children (SAC) to control of SCH as the mainstay strategy [ 23 ]. In 2021, WHO estimated that only 30% of people requiring treatment were reported to be treated in 2021, showing a big gap between the actual needs and provision of medicines [ 24 ]. Apart from PC, a comprehensive intervention has been advocated to include access to safe water, improved sanitation and hygiene, education and snail control for SCH control and elimination [ 23 , 25 ]. With the development of China, in 2000, the first ministerial conference of Forum on China-Africa Cooperation (FOCAC) was held in Beijing. Since then, China and Africa continuously develop the public health cooperation through this channel. In 2018, the Summit of FOCAC adopted the Beijing Action Plan (2019–2021) focusing on the implementation of eight major initiatives to strengthen the cooperation between China and Africa, including disease control programs in Africa focused on malaria, HIV/AIDS, and SCH [ 26 , 27 ]. A China-Zimbabwe cooperation on SCH was developed under this framework [ 28 ]. Zimbabwe has a long history of SCH [ 29 ]. Schistosoma haematobium and S. mansoni are the two schistosome species of major public health importance leading to hospital admissions in the country [ 30 – 33 ]. Previous studies showed the disease pattern and its focal transmission especially in northeastern areas [ 31 – 33 ]. The most recently conducted national survey showed 22.7% prevalence with over 3 million population affected nationwide in all provinces [ 34 ]. Based on the results, the primary strategy for SCH control in Zimbabwe shifted from passive treatment at health facility level to MDA during 2012–2017 but this has been suspended since 2018 [ 35 , 36 ]. However, the provision of praziquantel relies extremely on donor support in African countries [ 37 , 38 ]. Of many interventions, snail control by molluscicide was proved to be effective in Zimbabwe, but was not sustainable because of logistics, finance, and environment [ 31 , 39 ]. No other complementary strategies including snail control, provision of safe water and sanitary facilities and health education have been embraced into the national policy of SCH control and elimination. Additionally, due to the dearth of field applicable tools, test and treat strategy for intestinal SCH is not implemented. On the other hand, China was found endemic with SCH at the beginning of 20th century and has rigorously designed and implemented appropriate strategies to control and eliminate schistosomiasis over a long period [ 40 – 42 ]. The control of SCH in China is an ever-uninterrupted phased campaign moving from morbidity control, infection control, transmission control to transmission interruption, elimination and eradication according to the China’s criteria [ 43 – 45 ]. The control efforts were driven by snail control in the very early stage, followed by MDA [ 40 ]. The current strategy has been driven by a source-of-infection centered policy since 2004, currently ‘one health’ [ 46 ], which is highly in return [ 47 – 51 ]. Praziquantel-based chemotherapy has been a widely used intervention with slight side effects in China to control transmission [ 52 ]. It is encouraging that a study in Zanzibar showed no difference of efficacy in treating S. haematobium between China-made praziquantel and that from Merck KGaA [ 53 ]. Moreover, China has never stopped the research and development to eliminate SCH, including scientific innovation of diagnostics, intervention tools, advanced modelling, as well as fine-tuned strategic policies, while adapting to the decreasing infection of SCH [ 54 – 59 ], many of which are used in routine work and show great prospects to be translated to other endemic countries [ 26 , 60 – 62 ]. In this context, we carried out a pilot study driven by the China-Africa health cooperation in Zimbabwe. The aim of the pilot study was to assess the feasibility of implementing a large-scale integrated SCH control and elimination project through SCH mapping at sub-district level and a capacity needs assessment in the aspect of bilateral cooperation. Methods Study design Zimbabwe is a landlocked country in the southeast of Africa. The major rivers of Zimbabwe include the Zambezi, Limpopo, Sabi, and Runde. The climate is generally sub-tropical, with a hot, humid, and rainy season from mid-November to March, and a dry season from April to mid-November. Zimbabwe boasts of 8 rural based provinces and 2 metropolitans. This pilot study was designed as a combined project and considered as an entry point for the China-Africa cooperation on SCH control and elimination. It aimed to test the feasibility of a large-scale project between China and Zimbabwe. The study was made up of three parts. Firstly, according to the baseline national SCH and soil transmitted helminthiasis (STH) survey conducted in 2010, Shamva district in Mashonaland Province had the highest prevalence of SCH in the country [ 34 ]. There are 29 wards (sub-districts) in Shamva district. Among these, SCH has never been mapped in Chevakadzi ward. Notable is that Zimbabwe has implemented mass praziquantel treatment for schistosomiasis targeting school aged children on 6 successive years (2012–2017). MDA was suspended from 2018–2019 during which the impact assessment survey was conducted. MDAs were planned in 2020 but failed to take place because of COVID-19 pandemic which lasted until 2022. Thus, a cross-sectional study was planned purposely in Chevakadzi ward to provide baseline data for schistosomiasis prevalence in the ward. Secondly, a snail survey was implemented to understand the distribution of transmission sites in the ward. Thirdly, to understand the environment favorable for bilateral cooperation, a capacity and needs assessment was subsequently conducted. Here we report on the protocol which was used to assess the feasibility of the methodologies that will be employed at a larger scale in Zimbabwe. Study area and population The pilot study was conducted in Chevakadzi ward, Shamva district, Mashonaland Province in Zimbabwe (Fig. 1 A, B and C). The community is in the middle west of Shamva with high rainfall and temperature in summer. The ward has a dam and several creeks and streams, which favors the transmission of SCH. The total area of Chevakadzi (ward 15) is 315km 2 . It has 1,275 households and a total population of 6470, which accounts for 4.98% of the total population in Shamva (165,641) [ 63 ]. Of those, 14.7% (952) are under 5 years old, 32.0% (2073) are 5–14 years old and 53.2% (3445) are adults (15 years old and above). The total ratio of male and female is 1:1.02. The major economic activity is farming and gardening. The coverage of boreholes and ventilated pit latrines is 44.0% and 51.0%, respectively. The average family members is 4 for each household. The target population was the whole local people in Chevakadzi but study population was selected participants. The life expectancy is 49 years. Sample size The pilot study sample size was estimated on the basis of households. The standard error (SE) of the household sample size (n) was computed using the following formula: SE = √[(1/mn){(1/(4k)+τ 2 + nσ 2 }] where m stands for the number of villages in Chevakadzi; k is the number of participants that may be sampled per household; σ 2 means variations of prevalence between village; and τ 2 is variations of prevalence between household within one village. Table 1 shows that the more important determinant of precision is σ; increasing n shows diminishing returns beyond 30. It is therefore recommended to randomly sample an average of 30 households per village. Thus, basing on the above argument, the sample size is generated by 14 x 30, which equals to 420 households. According to the Zimbabwe National Statistical Agency, an average household in Zimbabwe has 4 people, thus, the total number of participants expected to be sampled in this study is 14 villages x 30 households x 4 persons/household, which is 1680 participants. Table 1 Methodology for calculation of sample size n = 10 n = 30 n = 60 n = 90 σ= 0.01 0.023 0.013 0.010 0.008 σ= 0.05 0.027 0.020 0.017 0.016 σ = 0.10 0.037 0.032 0.030 0.030 Sampling method Chevakadzi has 14 villages in total, 4 primary schools primary and 3 secondary schools. A simple random sampling method was used to select households per village in Chevakadzi. Initially, in each village, all the names of the households were written on pieces of paper and put on a plate. After thoroughly mixing, an individual randomly picked one piece of paper out of the plate until the required number of households per village was reached. This exercise was repeated in 14 villages. Inclusion and exclusion criteria From the selected households, members aged 1 year and above were included as participants. Critically ill and mentally challenged individuals were excluded. Household members who were not able to give specimens were also excluded. Sample collection Each participant was asked to provide approximately 50 ml of urine and 1g of stool samples. The sample collection was performed between 1000 and 1400 hours, a period when peak egg excretion is expected [ 64 – 66 ]. Each sample was collected and labeled in a unique container and was processed within 12h. For young children who were not able to provide samples on their own, sample containers were provided to caregivers [ 22 ]. A blood sample was also collected in a 10ml plain tube for each participant and stored in a cooler box until they were processed at the laboratory. No more than 5ml of blood was collected per child for children below 5 years old. At the laboratory the blood samples were centrifuged at 3000rpm for 5 minutes and serum was transferred into a 2ml cryotube and frozen at -20℃before testing. Diagnosis of SCH Morbidity of S . haematobium infection was measured by visible haematuria in the urine on naked eye from macrohaematuria, and two urinalysis reagent strips for microhaematuria in the urine. One strip was from Zimbabwe (***) and another from China (URIT Medical Electronic Co., Ltd, URIT1V 8 , China). Microhaematuria detection was performed using a urinary dipstick reagent strip following manufacturer’s instructions. For women who indicated menstruating, blood in urine was not considered as haematuria due to infection. After that, urine samples were processed using the urine filtration technique and the prepared slides were examined under the microscope with 10X objective [ 64 , 65 ]. Egg intensity was expressed as the number of S. haematobium eggs /10ml of urine. Intestinal schistosomiasis ( S. mansoni) and STH were diagnosed using the 2 stool smears prepared through the Kato Katz technique [ 6 , 65 ]. A mean of S. mansoni eggs/STH species eggs per person was estimated by dividing a sum of eggs counted in slide A and Slide B by 2 and the result was multiplied by 24 to estimate the egg intensity of intestinal helminthes (eggs/gram stool). Snail survey Intermediate hosts were collected to determine their distribution, infection status and diversity. Coordinates of each water contact site were recorded using a global positioning system (GPS). Environmental variables comprised of waterbody types, geographical information, contact activity and the description of site substratum were recorded. The snail sampling was carried out based on the WHO protocol [ 67 ]. A maximum of 100 scoops were performed at each water contact site and the snails collected were pooled, counted, and classified by species. Prior to testing, all snails were classified by water contact point and kept in water covered with wet cotton wool. Snails were morphologically identified and screened for schistosome infection by cercarial shedding [ 68 ]. Emerging cercariae were inspected by both naked eye and dissecting microscope. Bulinus globosus and Biomphlaria pfeifferi were considered as infected if they shed bifurcated cercariae. Then the snails were checked for pre-patent infection through placing each one between clean slides and crushing it by applying pressure on the two slides. The snail shell pieces were removed and the snail was examined under the dissecting microscope at low magnification to check the presence of cercariae and/or sporocysts. Interviews and group discussion A socio-demographic questionnaire including information on family composition, socio-economic status and water contact practice was administered to the head of each household. The knowledge, attitude and practice questionnaire was administered to individuals aged 7 years and above. Attitudes and perceptions towards SCH, sanitary practices, water contact activities, knowledge of current and past occurrences of infection, transmission of SCH, symptoms, and prevention methods of infection were assessed for each individual participant. A patient satisfaction survey questionnaire was carried out on volunteer patients at health facilities in Shamva district to assess the impact of knowledge and health provision satisfaction. Confirmed case investigation questionnaire was administered only to positive cases to assess the efficacy of treatment. Healthy capacity survey to assess the capacity of health facility to treat, prevent and test as well as the availability of human and equipment resources committed to SCH treatment, control and prevention was assessed at the peripheral health facility level. The focus group discussions of SCH were conducted at national level down to the ward level. The focus group discussions followed a guide to explore issues around SCH. Questions were administered to homogenous technical staff involved in the management, prevention, and control of SCH. On average the sample size for each focus group discussion was 6 participants and a total of six focus group discussions were conducted. Participants included multidisciplary teams from Madziwa Rural Hospital, Chevakadzi clinic, Shamva District Hospital, Provincial Medical Directorate, Ministry of Health and Childcare Head office and World Health Organization country office in Zimbabwe. Disease mapping Data was double entered into a Microsoft Excel sheet, cleaned, and exported to Stata version 15 (Stata statistical software 2017; Stata Corp, College Station, TX). Descriptive statistics was used to calculate the morbidity, prevalence and infection intensity of both SCH and STH, as well as the identification and infection of snails. Chi-square or Fisher’s exact tests was used to compare frequencies/proportions/categorical variables. Logistic regression analysis was used to identify predictors of SCH infection. The mean egg counts for S. mansoni , and STH was compared between gender, age groups, households and villages using Fisher’s exact test. The distribution of SCH, STH, as well as snails was mapped by ArcGIS Pro version 3.0. Capacity and needs assessment Thematic analysis was used following the principles of Braun & Clarke, 2006. This required transcription of audio recordings from the FGD. This was followed by other coding phases. Transcripts were read several times to identify potential themes. The next level of analysis involved generation of initial codes. Efforts were made to retain the diversity of the initial codes while in the process of searching for higher level subthemes. Quotes that were congruent with themes were identified. Themes were outlined, clarified, named and finalized. Data collectors, laboratory technicians, and principal investigators The principal investigators were responsible for decision making, resource allocation, monitoring and reporting. The research group was composed of 4 sub-groups responsible for household surveys and sample collection and 1 team for snail survey. Each of the 4 sub-groups consisted of 5 personnel, namely: a laboratory scientist, a laboratory assistant, a nurse, a village health worker and a driver. The laboratory scientists were the team leaders for each team. Lab scientists and assistants were responsible for recording household coordinates, collection of urine and stool, diagnosis of urinary and intestinal SCH, administration of the questionnaires as well as seeking informed consent at each household. The required number of laboratory technicians was calculated based on the assumption that 1 technician could examine 50 slides per day. Nurses were responsible for the blood sampling and treatment thereafter. The village health workers guided the teams into the villages and from one household to another. They also mobilized the community for sample donation. The environmental health officer and environmental health technician were responsible for guiding the snail survey team around the villages identifying water contact sites, scooping snails and recording geocordinates. The research team members was drawn from the National Institute of Health Research, Mashonaland province, Shamva district and Chevakadzi ward. Training A 6-day training workshop was organized in June, 2023.Laboratory scientists, laboratory assistants, nurses, environmental health personnel and village health workers were trained. The training program set the norms and standard for conducting field investigations and covered the following areas: objectives of the study, communication skills, interviewing techniques, filling in the questionnaire, data collection and cleaning, transport of specimens, and laboratory practices. Detailed protocols for the community-based investigation were explained to the data collectors, with a focus on the methods of obtaining informed consent, administering the questionnaire, and collecting specimens. The training was key to ensure that procedures could be properly conducted and standardized throughout the study. Lab technicians were trained with a focus on the methods of examining urine and stool samples, rapid diagnostic test and mollusciciding. An operational manual of the study protocol, questionnaire, informed consent, and SOPs were developed and disseminated to all implementers. Standard laboratory techniques were used to conduct the required investigations. Laboratory settings The field laboratory was established in Madziwa Rural Hospital, Shamva District with 2 centrifuges, 1 water bath, 1 dissecting microscope, 1 fridge, and 10 microscopes. Ethical considerations Ethical review and approval from the National ethical regulatory board: the Medical Research Council, Zimbabwe (MRCZ/A/3049) was obtained. Approval was also obtained from the Ministry of Health and Child Care and the Ministry of Primary and secondary education. Sensitization The Provincial Medical Director went to the Shamva district for introduction of the pilot study to the local community leadership and the community. The researchers also conducted meetings with the various groups in the target communities at various points to explain the study before implementation. The village headmen and village health workers went on to sensitize their communities. These mobilizations ended with high community turn out and buy in to the project. On the day of survey, the purpose and details of the survey were explained to the head of each household before he or she would be requested to provide written informed consent to participate. If consent was granted, the details of the study were explained to each participant who met the inclusion criteria for informed decision to participate in the study. Household members willing to participate were requested to sign the informed consent forms or assent forms (for children aged 7–17 years). For children between the ages of 7–17 years, parental consent was initially sought followed by the child assent. For children aged 1 to 6 years, only parental informed consent was sought. Only participants with signed informed consent and or assent forms were enrolled into the study. Table 2 provides details of the sensitization stages from the National level to the ward level. Table 2 Table Mobilization and sensitization Target Place Purpose/action Representative Ministry of Health Harare Briefing the pilot study and ask for support Acting Permanent Secretary Ministry of Primary and Secondary Education Harare Briefing the pilot study and ask for support Permanent Secretary Government of Mashonaland Central Bindura Introduction of the purpose of the pilot study Health and education executives Shamva District Hospital Shamva Introduction of the pilot study and its methodology District administrators and executives, District medical officer Communities Chevakadzi Introduction of the public health importance of SCH and the purpose of the visit Ward councilor, School authorities, Village heads, Village health workers Families Village Introduction of the purpose and sampling procedure Head delegates Treatment of positive cases Confirmed cases with either SCH or any of the STH received fruit juice and bread to eat after which they simultaneously received a single dose of praziquantel and/or albendazole in tablet form following WHO recommendations [ 69 ]. The drugs used were all donated by the WHO in Zimbabwe prior to this pilot study. Discussion This is the first study implemented in Africa being the China -Africa Cooperation for SCH elimination and control. Zimbabwe is the first beneficiary landlocked country for the China -Africa cooperation for SCH control and elimination. The study provided a platform for the Chinese counterpart to learn the different cultures and expectations of developing countries in such a cooperation. It also made it possible for the Zimbabwean counterparts to learn to collaborate closely with the Chinese researchers and to learn from their way of doing things. This mix of different culture in a team brought a good start in the China – Africa initiative for the control and elimination of schistosomiasis. This study is expected to generate baseline information and indicators of SCH that can inform control strategies at community level in Zimbabwe. It will also demonstrates whether it is feasible to carry out such project at a larger scale, providing a good opportunity to determine the efficiency and cost-effectiveness of integrated intervention strategies including treatment, behavior change communication, and snail control. WHO has advocated including adults and pre-school age children in MDA strategies [ 70 ]. However, the common practice of a baseline study of SCH and STH is based on school investigation [ 23 , 69 , 71 ]. This study was the first time to include all-age participants from the age of 1 year old to visualize a precise estimate of SCH prevalence at the community level, which will be useful to facilitate further policy formulation and updates of control strategies. The community-based survey will identify key findings related to epidemiological features and risk factors. The results will be used as a baseline for measuring the effects of MDA other than school-age children as before. The information generated can be used by the program and government to advocate for policy changes and the mobilization of extra resources in support of control efforts. The results are expected to identify gaps and/or priority areas of health systems for further implemental research and exploration in a broader view. The distribution and infection status of intermediate host snails play a pivotal role on local SCH transmission. Controlling snails is one among the complementary strategies for SCH control and elimination recommended by WHO [ 67 , 72 ]. This study opened a window for intermediate host snail mapping which can inform vector control interventions at sub-district level in Zimbabwe. The study was conducted during June and July, which is the cold, dry season in Zimbabwe. This could have influenced shrinking of waterbodies especially in seasonal water sources, and reduction in snail reproduction and hence low snail densities by site. Low temperature also negatively affects snail cercarial shedding potential making it difficult to determine snail infectivity under field conditions. There have been some challenges or limitations of this study. First was the resource restriction. Because the pilot study had no funds to build an appropriate field-based laboratory, use was made of a consulting room (existing facilities) at Madziwa Rural Hospital for sample storage, conducting disease diagnosis and to apply interventions. All devices and consumptions were carried from the capital. Although 4 vehicles were rented to reach the villages, it was sometimes difficult to reach remote areas. Secondly, it was found out that the praziquantel was out of stock in the target area. The praziquantel used to treat schistosomiasis cases during the study was sought from the nearest district (Centenary) in the same province of Mashonaland Central province. There is no local manufacturing company for praziquantel in Zimbabwe and Africa at large, yet this region harbors 91% of the global burden of schistosomiasis. Currently praziquantel used for MDA is donated by WHO and the annual donations are only targeting school aged children. The quantities of donated praziquantel and albendazole are not adequate to cater for communitywide MDA except for the school age population. This gap reverses the gains made in control of SCH in the school aged population since the untreated age groups share the same contaminated environment (water sources) with the school age children, a condition that sustain transmission of schistosomiasis and hence re-infection of the highly mobile school age children despite the availability of medicines for annual school-based MDA. The Chinese SCH elimination story was premised on the comprehensive package for SCH control and elimination since the country manufactured its own praziquantel in large quantities enough to reach high community wide treatment coverages, snail control through molluscicide application, mechanization, improved sanitation, provision of safe water and health education. Above all this China made a lot of progress in improving the socio-economic status making every household adequately supplied (national wealth creation) which improved quality of life of its nation. Reducing the level of poverty is therefore key to elimination of SCH an NTDs (disease of poverty). Since there is no manufacturing factory in Zimbabwe, the drugs are all donated by WHO. Although the medicine was provided by adjacent district, it indicated the shortage of drug supply in this study area. The pilot study was able to demonstrate the huge gap in access to praziquantel by the affected communities and by all age groups. Thus, for SCH, unless the country is assisted to produce its own praziquantel manufacturing company which will produce adequate quantities of praziquantel to cater for communitywide praziquantel MDA reaching ≥ 75% coverage as stipulated in the latest WHO guideline [ 25 ], the country may fail to reach the milestone of eliminating SCH as a public health problem by 2030. To accelerate elimination of SCH in Zimbabwe and the African region, the China- Zimbabwe cooperation project is expected to provide a platform for exploring the establishment of China -Zimbabwe praziquantel manufacturing company that will supply medicines for all age groups living in high-risk areas/affected by SCH. Failure to bridge this gap by local manufacturing of praziquantel in Zimbabwe, will be a huge failure in accelerating SCH elimination in the African region. Thus, through the China-Zimbabwe cooperation, Zimbabwe is set to be a powerhouse for the production of praziquantel which will be consumed locally but more so throughout the African region. Initial discussions in this regard have been made with the Chinese praziquantel manufacturing company with greater possibilities for the cooperation between the two countries in this regard, through the pilot study. The joint cooperation is set to create employment and wealth for the two countries. Following lessons leant through the pilot study, it is strongly recommended and encouraged that the Government of the People’s Republic of China releases funding for the large implementation of the large-scale project. It is also recommended that further exploration for the establishment of the China -Zimbabwe praziquantel manufacturing company be given high priority. Snail control using the Chinese produced molluscicides is recommended as this will accelerate elimination of SCH in Zimbabwe. Surveillance of schistosomiasis will made possible by the production of the point of care (OPC) diagnostic tests with high sensitivity and specificity for S. haematobium and S. mansoni and these are distributed in health facilities in remote communities for quick and low-cost field surveillance of SCH. At the moment there are no field applicable tests of high sensitive and specific for SCH in the African region and this is a huge gap that should be prioritized if surveillance and reporting of SCH outbreaks or test and treat strategy is to be implemented in areas whose prevalence is < 10% in line with the latest WHO guideline for SCH elimination (WHO, 2022). Declarations Acknowledgements We sincerely appreciate the support of the National Health Commission of the Peoples’ Republic of China and the Ministry of Health and Child Care, Zimbabwe. We are also grateful for the fieldwork and support of the staff from the National Institute of Health Research, Zimbabwe, The Provincial Medical Directorate- Mashonaland Central, Zimbabwe, The Shamva District health management, Madziwa health Centre and Chevakadzi Clinic, Zimbabwe, Hunan Institute of Schistosomiasis Control and Jiangsu Institute of Parasitic Diseases. Author contributions YJQ was responsible for the study design and drafted the first manuscript. NM and XNZ designed the study and are joint correspondences, who are the project leaders on both sides. MJMM, SL, ZJ and SZL provided technical support. YJQ, NM, MJMM, WS, ZQQ, HML, LT, CLL, XLY and SL contributed to the implementation. NM, MJMM, SZL and XNZ made critical improvement of the manuscript. All authors read and approved the final manuscript. Funding Supported by the China-Africa Cooperative Project on Schistosomiasis funded by the National Health Commission of the People’s Republic of China (No. 2020-C4-0001-2). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Availability of data and materials Not applicable. Ethics approval and consent to participate This study was approved by the Medical Research Council of Zimbabwe (MRCZ/A/3049. All patients gave oral or written consent for data collection and analysis when they registered in the field study, and the analysis was fully anonymized. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Di Bella S, et al. History of schistosomiasis (bilharziasis) in humans: from Egyptian medical papyri to molecular biology on mummies. Pathog Glob Health. 2018;112(5):268–73. Aula OP et al. Schistosomiasis with a Focus on Africa. Trop Med Infect Dis, 2021. 6(3). World Health Organization. Accelerating work to overcome the global impact of neglected tropical diseases – A roadmap for implementation . 2012. 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Residence Time, Water Contact, and Age-driven Schistosoma mansoni Infection in Hotspot Communities in Uganda. Am J Trop Med Hyg. 2021;105(6):1772–81. Perera DJ, et al. A low dose adenovirus vectored vaccine expressing Schistosoma mansoni Cathepsin B protects from intestinal schistosomiasis in mice. EBioMedicine. 2022;80:104036. Gruninger SK, et al. Prevalence and risk distribution of schistosomiasis among adults in Madagascar: a cross-sectional study. Infect Dis Poverty. 2023;12(1):44. Amuta EU, Houmsou RS. Prevalence, intensity of infection and risk factors of urinary schistosomiasis in pre-school and school aged children in Guma Local Government Area, Nigeria. Asian Pac J Trop Med. 2014;7(1):34–9. Lee J et al. Prevalence of Schistosomiasis and Soil-Transmitted Helminthiasis and Their Risk Factors: A Cross-Sectional Study in Itilima District, North-Western Tanzania. Life (Basel), 2023. 13(12). Mutsaka-Makuvaza MJ, et al. Urogenital schistosomiasis and risk factors of infection in mothers and preschool children in an endemic district in Zimbabwe. Parasit Vectors. 2019;12(1):427. World Health Organization. WHO Recommended Strategies for the Prevention and Control of Communicable Diseases . 2001. World Health Organization. Schistosomiasis: large-scale treatment decreases prevalence by 60% among school-aged children. 2021; Available from: https://www.who.int/news/item/03-12-2021-schistosomiasis-large-scale-treatment-decreases-prevalence-by-60-among-school-aged-children . World Health Organization. WHO guideline on control and elimination of human schistosomiasis. Geneva: World Health Organization; 2022. Tambo E, et al. China-Africa Health Development Initiatives: Benefits and Implications for Shaping Innovative and Evidence-informed National Health Policies and Programs in Sub-saharan African Countries. Int J MCH AIDS. 2016;5(2):119–33. Forum on China-Africa Cooperation . Available from: http://www.focac.org/eng/ . Gao L, Xu J. Public health engagement: new opportunities and challenges in 60 years of China's health aid to Africa. BMJ Glob Health, 2023. 8(8). Mutapi F. Getting a GRiPP on everyday schistosomiasis: experience from Zimbabwe. Parasitology. 2017;144(12):1624–32. Chandiwana SK, Taylor P, Matanhire D. Community control of schistosomiasis in Zimbabwe. Cent Afr J Med. 1991;37(3):69–77. Chimbari MJ. Enhancing schistosomiasis control strategy for zimbabwe: building on past experiences. J Parasitol Res, 2012. 2012: p. 353768. Ndhlovu P, Chandiwana SK, Makura O. Progress in the control of schistosomiasis in Zimbabwe since 1984. Cent Afr J Med. 1992;38(8):316–21. Taylor P, Makura O. Prevalence and distribution of schistosomiasis in Zimbabwe. Ann Trop Med Parasitol. 1985;79(3):287–99. Midzi N, et al. Distribution of schistosomiasis and soil transmitted helminthiasis in Zimbabwe: towards a national plan of action for control and elimination. PLoS Negl Trop Dis. 2014;8(8):e3014. Mduluza T, et al. Six rounds of annual praziquantel treatment during a national helminth control program significantly reduced schistosome infection and morbidity levels in a cohort of schoolchildren in Zimbabwe. PLoS Negl Trop Dis. 2020;14(6):e0008388. World Health Organization. Country Disease Outlook . 2023. Merck. Living our commitment . [cited 2024 Jan 15]; Available from: https://www.merckgroup.com/en/sustainability/health-for-all/schistosomiasis/living-our-commitment.html . Elphick-Pooley T, Engels D. Uniting to Combat, World NTD Day 2022 and a new Kigali Declaration to galvanise commitment to end neglected tropical diseases . Infect Dis Poverty. 2022;11(1):2. Evans AC. Control of schistosomiasis in large irrigation schemes by use of niclosamide. A ten-year study in Zimbabwe. Am J Trop Med Hyg. 1983;32(5):1029–39. Zhou Y, Chen Y, Jiang Q. History of Human Schistosomiasis (bilharziasis) in China: From Discovery to Elimination. Acta Parasitol. 2021;66(3):760–9. Faust EC. Schistosomiasis in China: Biological and Practical Aspects. Proc R Soc Med, 1924. 17(Sect Trop Dis Parasitol): p. 31–43. Maegraith B. Schistosomiasis in China. Lancet. 1958;1(7013):208–14. Zhou XN et al. [Role of the new version of the Control and Elimination Criteria for Schistosomiasis in acceleration of the schistosomiasis elimination program in China]. Zhongguo Xue Xi Chong Bing Fang Zhi Za Zhi, 2013. 25(1): p. 1–4. Standard CN. Control and elimination of schistosomiasis . 2015, General Administration of Quality Supervision, Inspection and Quarantine of the People's Republic of China Standardization Administration of the People's Republic of China. p. 5. Administration NDCaP. In: Administration, et al. editors. Action Plan for the Elimination of Schistosomiasis (2023–2030). Editors: Beijing; 2023. N.D.C.a.P . Hong Z, et al. Elimination of Schistosomiasis Japonica in China: From the One Health Perspective. China CDC Wkly. 2022;4(7):130–4. Wang LD, et al. China's new strategy to block Schistosoma japonicum transmission: experiences and impact beyond schistosomiasis. Trop Med Int Health. 2009;14(12):1475–83. Liu R, Dong HF, Jiang MS. The new national integrated strategy emphasizing infection sources control for schistosomiasis control in China has made remarkable achievements. Parasitol Res. 2013;112(4):1483–91. Yang Y, et al. Integrated Control Strategy of Schistosomiasis in The People's Republic of China: Projects Involving Agriculture, Water Conservancy, Forestry, Sanitation and Environmental Modification. Adv Parasitol. 2016;92:237–68. Wang X, Wang W, Wang P. Long-term effectiveness of the integrated schistosomiasis control strategy with emphasis on infectious source control in China: a 10-year evaluation from 2005 to 2014. Parasitol Res. 2017;116(2):521–8. Gray DJ, et al. A multi-component integrated approach for the elimination of schistosomiasis in the People's Republic of China: design and baseline results of a 4-year cluster-randomised intervention trial. Int J Parasitol. 2014;44(9):659–68. Chen MG. Use of praziquantel for clinical treatment and morbidity control of schistosomiasis japonica in China: a review of 30 years' experience. Acta Trop. 2005;96(2–3):168–76. Wang XY, et al. Efficacy of China-made praziquantel for treatment of Schistosomiasis haematobium in Africa: A randomized controlled trial. PLoS Negl Trop Dis. 2019;13(4):e0007238. Lv C et al. Molecular Techniques as Alternatives of Diagnostic Tools in China as Schistosomiasis Moving towards Elimination. Pathogens, 2022. 11(3). Qin ZQ et al. Field Evaluation of a Loop-Mediated Isothermal Amplification (LAMP) Platform for the Detection of Schistosoma japonicum Infection in Oncomelania hupensis Snails. Trop Med Infect Dis, 2018. 3(4). Chen L, et al. Health Education as an Important Component in the National Schistosomiasis Control Programme in The People's Republic of China. Adv Parasitol. 2016;92:307–39. Wang W, et al. Discovery of the pyridylphenylureas as novel molluscicides against the invasive snail Biomphalaria straminea, intermediate host of Schistosoma mansoni. Parasit Vectors. 2018;11(1):291. Zhou L. The cultural policies of schistosomiasis control in China: a historical analysis. Parasitol Res. 2023;122(11):2457–65. Zhang LJ, et al. The Establishment and Function of Schistosomiasis Surveillance System Towards Elimination in The People's Republic of China. Adv Parasitol. 2016;92:117–41. Tambo E, et al. The value of China-Africa health development initiatives in strengthening One Health strategy. Glob Health J. 2017;1(1):33–46. Hotez PJ. Whatever happened to China's neglected tropical diseases? Infect Dis Poverty. 2019;8(1):85. Abe EM, et al. Approaches in scaling up schistosomiasis intervention towards transmission elimination in Africa: Leveraging from the Chinese experience and lessons. Acta Trop. 2020;208:105379. Agency ZNS. 2022 Population and Housing Census: Priliminary Report on Population Figures . 2024. World Health Organization. Basic laboratory methods in medical parasitology . 1991. World Health Organization, Bench Aids for the diagnosis of intestinal parasites, second edition. 2019, Geneve: World Health Organization: World Health Organization. Engels D, Sinzinkayo E, Gryseels B. Day-to-day egg count fluctuation in Schistosoma mansoni infection and its operational implications. Am J Trop Med Hyg. 1996;54(4):319–24. World Health Organization. Field use of molluscicides in schistosomiasis control programmes: an operational manual for programme managers. Geneva: World Health Organization; 2017. Mutsaka-Makuvaza MJ, et al. Molecular diversity of Bulinus species in Madziwa area, Shamva district in Zimbabwe: implications for urogenital schistosomiasis transmission. Parasit Vectors. 2020;13(1):14. World Health Organization. Preventive chemotherapy in human helminthiasis. Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers. Geneva: World Health Organization; 2006. World Health Organization. Schistosomiasis: progress report 2001–2011, strategic plan 2012–2020 . 2001. World Health Organization. Helminth control in school-age children: a guide for managers of control programmes. World Health Organization; 2011. World Health Organization. Ending the neglect to attain the Sustainable Development Goals: A road map for neglected tropical diseases 2021–2030 . 2020. 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Diseases","correspondingAuthor":false,"prefix":"","firstName":"Xiaonong","middleName":"","lastName":"ZHOU","suffix":""}],"badges":[],"createdAt":"2024-03-18 06:38:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4120546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4120546/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53417119,"identity":"dd4f4fb1-7c46-4d3b-ba5f-d993170076b8","added_by":"auto","created_at":"2024-03-25 18:02:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1076454,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Mashonaland central Province (A), Shamva district (B) and Chevakadzi ward (C)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4120546/v1/435c0666423f04415f8c189d.jpeg"},{"id":53420805,"identity":"c9663250-a64f-4cce-8fa8-81f5035a5c60","added_by":"auto","created_at":"2024-03-25 18:26:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":582568,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4120546/v1/f4f53fa3-58d1-4831-a414-eeea05b149c2.pdf"}],"financialInterests":"","formattedTitle":"A feasibility test of a large-scale implementation of schistosomiasis elimination under China-Zimbabwe cooperation: a pilot study protocol","fulltext":[{"header":"Background","content":"\u003cp\u003eAncient but neglected, schistosomiasis (SCH) is a vector-borne and water-borne zoonotic parasitic disease amongst a diverse group of \u0026lsquo;Neglected Tropical Diseases\u0026rsquo; (NTDs) [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], caused by the flatworms of genus \u003cem\u003eSchistosoma\u003c/em\u003e and can lead to acute and chronic conditions. Humans contract SCH when they get into contact with infested fresh water sources, where cercaria, the infectious free-swimming larvae of schistosome penetrate their skin. SCH is recognized as a disease of poverty because it is generally prevalent in low-income, remote communities where clean water source, basic sanitation and health care are inadequate or inaccessible, which exacerbates its burden on the impoverished population and keep them trapped in generational cycles of poverty. Of the 5 species that infect human health, \u003cem\u003eS. haematobium\u003c/em\u003e causes a urogenital form of disease while \u003cem\u003eS. mansoni\u003c/em\u003e, \u003cem\u003eS. japonicum, S. mekongi and S. intercalatum\u003c/em\u003e are responsible for intestinal and hepatic SCH [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Alternatively known as bilharziasis, SCH mainly refers to urogenital and intestinal SCH caused by the two major species of \u003cem\u003eS. haematobium\u003c/em\u003e and \u003cem\u003eS. mansoni\u003c/em\u003e most prevalent in sub-Saharan Africa [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, human SCH has been endemic in 78 countries with at least 90% of global disease burden in Africa, where the highest morbidity and mortality occur [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. According to the Global Burden of Disease (GBD) estimation, SCH accounted for 1.5\u0026nbsp;million years lived with disability worldwide in 2016 despite its increasing visibility and continuous global investment [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. More than ever, COVID-19 increased the uncertainty to achieve targets set by 2030 NTD roadmap, especially in Africa [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The disease compromises public health by contributing to malnutrition in children, preventing them from attending school, impairing cognitive development, and increasing high risk of getting HIV especially in women [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although given present effective interventions, SCH remains the second to malaria in terms of its public health significance [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Professional and domestic activities such as farming, bathing, washing, and playing expose local dwellers to infection [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The World Health Organization (WHO) advocates for treatment of all at-risk populations, preventive chemotherapy (PC) through mass drug administration (MDA) with a priority focus on school-aged children (SAC) to control of SCH as the mainstay strategy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In 2021, WHO estimated that only 30% of people requiring treatment were reported to be treated in 2021, showing a big gap between the actual needs and provision of medicines [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Apart from PC, a comprehensive intervention has been advocated to include access to safe water, improved sanitation and hygiene, education and snail control for SCH control and elimination [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith the development of China, in 2000, the first ministerial conference of Forum on China-Africa Cooperation (FOCAC) was held in Beijing. Since then, China and Africa continuously develop the public health cooperation through this channel. In 2018, the Summit of FOCAC adopted the Beijing Action Plan (2019\u0026ndash;2021) focusing on the implementation of eight major initiatives to strengthen the cooperation between China and Africa, including disease control programs in Africa focused on malaria, HIV/AIDS, and SCH [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A China-Zimbabwe cooperation on SCH was developed under this framework [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eZimbabwe has a long history of SCH [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. \u003cem\u003eSchistosoma haematobium\u003c/em\u003e and \u003cem\u003eS. mansoni\u003c/em\u003e are the two schistosome species of major public health importance leading to hospital admissions in the country [\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Previous studies showed the disease pattern and its focal transmission especially in northeastern areas [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The most recently conducted national survey showed 22.7% prevalence with over 3\u0026nbsp;million population affected nationwide in all provinces [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Based on the results, the primary strategy for SCH control in Zimbabwe shifted from passive treatment at health facility level to MDA during 2012\u0026ndash;2017 but this has been suspended since 2018 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, the provision of praziquantel relies extremely on donor support in African countries [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Of many interventions, snail control by molluscicide was proved to be effective in Zimbabwe, but was not sustainable because of logistics, finance, and environment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. No other complementary strategies including snail control, provision of safe water and sanitary facilities and health education have been embraced into the national policy of SCH control and elimination. Additionally, due to the dearth of field applicable tools, test and treat strategy for intestinal SCH is not implemented. On the other hand, China was found endemic with SCH at the beginning of 20th century and has rigorously designed and implemented appropriate strategies to control and eliminate schistosomiasis over a long period [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The control of SCH in China is an ever-uninterrupted phased campaign moving from morbidity control, infection control, transmission control to transmission interruption, elimination and eradication according to the China\u0026rsquo;s criteria [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The control efforts were driven by snail control in the very early stage, followed by MDA [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The current strategy has been driven by a source-of-infection centered policy since 2004, currently \u0026lsquo;one health\u0026rsquo; [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], which is highly in return [\u003cspan additionalcitationids=\"CR48 CR49 CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Praziquantel-based chemotherapy has been a widely used intervention with slight side effects in China to control transmission [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. It is encouraging that a study in Zanzibar showed no difference of efficacy in treating \u003cem\u003eS. haematobium\u003c/em\u003e between China-made praziquantel and that from Merck KGaA [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Moreover, China has never stopped the research and development to eliminate SCH, including scientific innovation of diagnostics, intervention tools, advanced modelling, as well as fine-tuned strategic policies, while adapting to the decreasing infection of SCH [\u003cspan additionalcitationids=\"CR55 CR56 CR57 CR58\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], many of which are used in routine work and show great prospects to be translated to other endemic countries [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, we carried out a pilot study driven by the China-Africa health cooperation in Zimbabwe. The aim of the pilot study was to assess the feasibility of implementing a large-scale integrated SCH control and elimination project through SCH mapping at sub-district level and a capacity needs assessment in the aspect of bilateral cooperation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eZimbabwe is a landlocked country in the southeast of Africa. The major rivers of Zimbabwe include the Zambezi, Limpopo, Sabi, and Runde. The climate is generally sub-tropical, with a hot, humid, and rainy season from mid-November to March, and a dry season from April to mid-November. Zimbabwe boasts of 8 rural based provinces and 2 metropolitans. This pilot study was designed as a combined project and considered as an entry point for the China-Africa cooperation on SCH control and elimination. It aimed to test the feasibility of a large-scale project between China and Zimbabwe. The study was made up of three parts. Firstly, according to the baseline national SCH and soil transmitted helminthiasis (STH) survey conducted in 2010, Shamva district in Mashonaland Province had the highest prevalence of SCH in the country [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. There are 29 wards (sub-districts) in Shamva district. Among these, SCH has never been mapped in Chevakadzi ward. Notable is that Zimbabwe has implemented mass praziquantel treatment for schistosomiasis targeting school aged children on 6 successive years (2012\u0026ndash;2017). MDA was suspended from 2018\u0026ndash;2019 during which the impact assessment survey was conducted. MDAs were planned in 2020 but failed to take place because of COVID-19 pandemic which lasted until 2022. Thus, a cross-sectional study was planned purposely in Chevakadzi ward to provide baseline data for schistosomiasis prevalence in the ward. Secondly, a snail survey was implemented to understand the distribution of transmission sites in the ward. Thirdly, to understand the environment favorable for bilateral cooperation, a capacity and needs assessment was subsequently conducted. Here we report on the protocol which was used to assess the feasibility of the methodologies that will be employed at a larger scale in Zimbabwe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy area and population\u003c/h2\u003e \u003cp\u003eThe pilot study was conducted in Chevakadzi ward, Shamva district, Mashonaland Province in Zimbabwe (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B and C). The community is in the middle west of Shamva with high rainfall and temperature in summer. The ward has a dam and several creeks and streams, which favors the transmission of SCH. The total area of Chevakadzi (ward 15) is 315km\u003csup\u003e2\u003c/sup\u003e. It has 1,275 households and a total population of 6470, which accounts for 4.98% of the total population in Shamva (165,641) [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Of those, 14.7% (952) are under 5 years old, 32.0% (2073) are 5\u0026ndash;14 years old and 53.2% (3445) are adults (15 years old and above). The total ratio of male and female is 1:1.02. The major economic activity is farming and gardening.\u003c/p\u003e \u003cp\u003eThe coverage of boreholes and ventilated pit latrines is 44.0% and 51.0%, respectively. The average family members is 4 for each household. The target population was the whole local people in Chevakadzi but study population was selected participants. The life expectancy is 49 years.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eThe pilot study sample size was estimated on the basis of households. The standard error (SE) of the household sample size (n) was computed using the following formula:\u003c/p\u003e \u003cp\u003eSE = \u0026radic;[(1/mn){(1/(4k)+τ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;+\u0026thinsp;nσ\u003csup\u003e2\u003c/sup\u003e}] where m stands for the number of villages in Chevakadzi; k is the number of participants that may be sampled per household; σ\u003csup\u003e2\u003c/sup\u003e means variations of prevalence between village; and τ\u003csup\u003e2\u003c/sup\u003e is variations of prevalence between household within one village. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that the more important determinant of precision is σ; increasing n shows diminishing returns beyond 30. It is therefore recommended to randomly sample an average of 30 households per village. Thus, basing on the above argument, the sample size is generated by 14 x 30, which equals to 420 households. According to the Zimbabwe National Statistical Agency, an average household in Zimbabwe has 4 people, thus, the total number of participants expected to be sampled in this study is 14 villages x 30 households x 4 persons/household, which is 1680 participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMethodology for calculation of sample size\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;90\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eσ=\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eσ=\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eσ\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSampling method\u003c/h2\u003e \u003cp\u003eChevakadzi has 14 villages in total, 4 primary schools primary and 3 secondary schools. A simple random sampling method was used to select households per village in Chevakadzi. Initially, in each village, all the names of the households were written on pieces of paper and put on a plate. After thoroughly mixing, an individual randomly picked one piece of paper out of the plate until the required number of households per village was reached. This exercise was repeated in 14 villages.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eFrom the selected households, members aged 1 year and above were included as participants. Critically ill and mentally challenged individuals were excluded. Household members who were not able to give specimens were also excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample collection\u003c/h2\u003e \u003cp\u003eEach participant was asked to provide approximately 50 ml of urine and 1g of stool samples. The sample collection was performed between 1000 and 1400 hours, a period when peak egg excretion is expected [\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Each sample was collected and labeled in a unique container and was processed within 12h. For young children who were not able to provide samples on their own, sample containers were provided to caregivers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A blood sample was also collected in a 10ml plain tube for each participant and stored in a cooler box until they were processed at the laboratory. No more than 5ml of blood was collected per child for children below 5 years old. At the laboratory the blood samples were centrifuged at 3000rpm for 5 minutes and serum was transferred into a 2ml cryotube and frozen at -20℃before testing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis of SCH\u003c/h2\u003e \u003cp\u003eMorbidity of \u003cem\u003eS\u003c/em\u003e. \u003cem\u003ehaematobium\u003c/em\u003e infection was measured by visible haematuria in the urine on naked eye from macrohaematuria, and two urinalysis reagent strips for microhaematuria in the urine. One strip was from Zimbabwe (***) and another from China (URIT Medical Electronic Co., Ltd, URIT1V\u003csup\u003e8\u003c/sup\u003e, China). Microhaematuria detection was performed using a urinary dipstick reagent strip following manufacturer\u0026rsquo;s instructions. For women who indicated menstruating, blood in urine was not considered as haematuria due to infection. After that, urine samples were processed using the urine filtration technique and the prepared slides were examined under the microscope with 10X objective [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Egg intensity was expressed as the number of \u003cem\u003eS. haematobium\u003c/em\u003e eggs /10ml of urine. Intestinal schistosomiasis (\u003cem\u003eS. mansoni)\u003c/em\u003e and STH were diagnosed using the 2 stool smears prepared through the Kato Katz technique [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. A mean of \u003cem\u003eS. mansoni\u003c/em\u003e eggs/STH species eggs per person was estimated by dividing a sum of eggs counted in slide A and Slide B by 2 and the result was multiplied by 24 to estimate the egg intensity of intestinal helminthes (eggs/gram stool).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSnail survey\u003c/h2\u003e \u003cp\u003eIntermediate hosts were collected to determine their distribution, infection status and diversity. Coordinates of each water contact site were recorded using a global positioning system (GPS). Environmental variables comprised of waterbody types, geographical information, contact activity and the description of site substratum were recorded. The snail sampling was carried out based on the WHO protocol [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. A maximum of 100 scoops were performed at each water contact site and the snails collected were pooled, counted, and classified by species. Prior to testing, all snails were classified by water contact point and kept in water covered with wet cotton wool.\u003c/p\u003e \u003cp\u003eSnails were morphologically identified and screened for schistosome infection by cercarial shedding [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Emerging cercariae were inspected by both naked eye and dissecting microscope. \u003cem\u003eBulinus globosus\u003c/em\u003e and \u003cem\u003eBiomphlaria pfeifferi\u003c/em\u003e were considered as infected if they shed bifurcated cercariae. Then the snails were checked for pre-patent infection through placing each one between clean slides and crushing it by applying pressure on the two slides. The snail shell pieces were removed and the snail was examined under the dissecting microscope at low magnification to check the presence of cercariae and/or sporocysts.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInterviews and group discussion\u003c/h2\u003e \u003cp\u003eA socio-demographic questionnaire including information on family composition, socio-economic status and water contact practice was administered to the head of each household. The knowledge, attitude and practice questionnaire was administered to individuals aged 7 years and above. Attitudes and perceptions towards SCH, sanitary practices, water contact activities, knowledge of current and past occurrences of infection, transmission of SCH, symptoms, and prevention methods of infection were assessed for each individual participant. A patient satisfaction survey questionnaire was carried out on volunteer patients at health facilities in Shamva district to assess the impact of knowledge and health provision satisfaction. Confirmed case investigation questionnaire was administered only to positive cases to assess the efficacy of treatment. Healthy capacity survey to assess the capacity of health facility to treat, prevent and test as well as the availability of human and equipment resources committed to SCH treatment, control and prevention was assessed at the peripheral health facility level. The focus group discussions of SCH were conducted at national level down to the ward level. The focus group discussions followed a guide to explore issues around SCH. Questions were administered to homogenous technical staff involved in the management, prevention, and control of SCH. On average the sample size for each focus group discussion was 6 participants and a total of six focus group discussions were conducted. Participants included multidisciplary teams from Madziwa Rural Hospital, Chevakadzi clinic, Shamva District Hospital, Provincial Medical Directorate, Ministry of Health and Childcare Head office and World Health Organization country office in Zimbabwe.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDisease mapping\u003c/h2\u003e \u003cp\u003eData was double entered into a Microsoft Excel sheet, cleaned, and exported to Stata version 15 (Stata statistical software 2017; Stata Corp, College Station, TX). Descriptive statistics was used to calculate the morbidity, prevalence and infection intensity of both SCH and STH, as well as the identification and infection of snails. Chi-square or Fisher\u0026rsquo;s exact tests was used to compare frequencies/proportions/categorical variables. Logistic regression analysis was used to identify predictors of SCH infection. The mean egg counts for \u003cem\u003eS. mansoni\u003c/em\u003e, and STH was compared between gender, age groups, households and villages using Fisher\u0026rsquo;s exact test. The distribution of SCH, STH, as well as snails was mapped by ArcGIS Pro version 3.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCapacity and needs assessment\u003c/h2\u003e \u003cp\u003eThematic analysis was used following the principles of Braun \u0026amp; Clarke, 2006. This required transcription of audio recordings from the FGD. This was followed by other coding phases. Transcripts were read several times to identify potential themes. The next level of analysis involved generation of initial codes. Efforts were made to retain the diversity of the initial codes while in the process of searching for higher level subthemes. Quotes that were congruent with themes were identified. Themes were outlined, clarified, named and finalized.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData collectors, laboratory technicians, and principal investigators\u003c/h2\u003e \u003cp\u003eThe principal investigators were responsible for decision making, resource allocation, monitoring and reporting. The research group was composed of 4 sub-groups responsible for household surveys and sample collection and 1 team for snail survey. Each of the 4 sub-groups consisted of 5 personnel, namely: a laboratory scientist, a laboratory assistant, a nurse, a village health worker and a driver. The laboratory scientists were the team leaders for each team. Lab scientists and assistants were responsible for recording household coordinates, collection of urine and stool, diagnosis of urinary and intestinal SCH, administration of the questionnaires as well as seeking informed consent at each household. The required number of laboratory technicians was calculated based on the assumption that 1 technician could examine 50 slides per day. Nurses were responsible for the blood sampling and treatment thereafter. The village health workers guided the teams into the villages and from one household to another. They also mobilized the community for sample donation. The environmental health officer and environmental health technician were responsible for guiding the snail survey team around the villages identifying water contact sites, scooping snails and recording geocordinates. The research team members was drawn from the National Institute of Health Research, Mashonaland province, Shamva district and Chevakadzi ward.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTraining\u003c/h2\u003e \u003cp\u003eA 6-day training workshop was organized in June, 2023.Laboratory scientists, laboratory assistants, nurses, environmental health personnel and village health workers were trained. The training program set the norms and standard for conducting field investigations and covered the following areas: objectives of the study, communication skills, interviewing techniques, filling in the questionnaire, data collection and cleaning, transport of specimens, and laboratory practices. Detailed protocols for the community-based investigation were explained to the data collectors, with a focus on the methods of obtaining informed consent, administering the questionnaire, and collecting specimens. The training was key to ensure that procedures could be properly conducted and standardized throughout the study. Lab technicians were trained with a focus on the methods of examining urine and stool samples, rapid diagnostic test and mollusciciding. An operational manual of the study protocol, questionnaire, informed consent, and SOPs were developed and disseminated to all implementers. Standard laboratory techniques were used to conduct the required investigations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory settings\u003c/h2\u003e \u003cp\u003eThe field laboratory was established in Madziwa Rural Hospital, Shamva District with 2 centrifuges, 1 water bath, 1 dissecting microscope, 1 fridge, and 10 microscopes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e Ethical review and approval from the National ethical regulatory board: the Medical Research Council, Zimbabwe (MRCZ/A/3049) was obtained. Approval was also obtained from the Ministry of Health and Child Care and the Ministry of Primary and secondary education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSensitization\u003c/h2\u003e \u003cp\u003eThe Provincial Medical Director went to the Shamva district for introduction of the pilot study to the local community leadership and the community. The researchers also conducted meetings with the various groups in the target communities at various points to explain the study before implementation. The village headmen and village health workers went on to sensitize their communities. These mobilizations ended with high community turn out and buy in to the project.\u003c/p\u003e \u003cp\u003eOn the day of survey, the purpose and details of the survey were explained to the head of each household before he or she would be requested to provide written informed consent to participate. If consent was granted, the details of the study were explained to each participant who met the inclusion criteria for informed decision to participate in the study. Household members willing to participate were requested to sign the informed consent forms or assent forms (for children aged 7\u0026ndash;17 years). For children between the ages of 7\u0026ndash;17 years, parental consent was initially sought followed by the child assent. For children aged 1 to 6 years, only parental informed consent was sought. Only participants with signed informed consent and or assent forms were enrolled into the study.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides details of the sensitization stages from the National level to the ward level.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTable Mobilization and sensitization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarget\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePurpose/action\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRepresentative\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHarare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBriefing the pilot study and ask for support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eActing Permanent Secretary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinistry of Primary and Secondary Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHarare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBriefing the pilot study and ask for support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePermanent Secretary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment of Mashonaland Central\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBindura\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction of the purpose of the pilot study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth and education executives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShamva District Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShamva\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction of the pilot study and its methodology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDistrict administrators and executives, District medical officer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChevakadzi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction of the public health importance of SCH and the purpose of the visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWard councilor, School authorities, Village heads, Village health workers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamilies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction of the purpose and sampling procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead delegates\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTreatment of positive cases\u003c/h2\u003e \u003cp\u003eConfirmed cases with either SCH or any of the STH received fruit juice and bread to eat after which they simultaneously received a single dose of praziquantel and/or albendazole in tablet form following WHO recommendations [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The drugs used were all donated by the WHO in Zimbabwe prior to this pilot study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study implemented in Africa being the China -Africa Cooperation for SCH elimination and control. Zimbabwe is the first beneficiary landlocked country for the China -Africa cooperation for SCH control and elimination. The study provided a platform for the Chinese counterpart to learn the different cultures and expectations of developing countries in such a cooperation. It also made it possible for the Zimbabwean counterparts to learn to collaborate closely with the Chinese researchers and to learn from their way of doing things. This mix of different culture in a team brought a good start in the China \u0026ndash; Africa initiative for the control and elimination of schistosomiasis.\u003c/p\u003e \u003cp\u003eThis study is expected to generate baseline information and indicators of SCH that can inform control strategies at community level in Zimbabwe. It will also demonstrates whether it is feasible to carry out such project at a larger scale, providing a good opportunity to determine the efficiency and cost-effectiveness of integrated intervention strategies including treatment, behavior change communication, and snail control.\u003c/p\u003e \u003cp\u003eWHO has advocated including adults and pre-school age children in MDA strategies [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. However, the common practice of a baseline study of SCH and STH is based on school investigation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. This study was the first time to include all-age participants from the age of 1 year old to visualize a precise estimate of SCH prevalence at the community level, which will be useful to facilitate further policy formulation and updates of control strategies. The community-based survey will identify key findings related to epidemiological features and risk factors. The results will be used as a baseline for measuring the effects of MDA other than school-age children as before. The information generated can be used by the program and government to advocate for policy changes and the mobilization of extra resources in support of control efforts. The results are expected to identify gaps and/or priority areas of health systems for further implemental research and exploration in a broader view. The distribution and infection status of intermediate host snails play a pivotal role on local SCH transmission. Controlling snails is one among the complementary strategies for SCH control and elimination recommended by WHO [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. This study opened a window for intermediate host snail mapping which can inform vector control interventions at sub-district level in Zimbabwe.\u003c/p\u003e \u003cp\u003eThe study was conducted during June and July, which is the cold, dry season in Zimbabwe. This could have influenced shrinking of waterbodies especially in seasonal water sources, and reduction in snail reproduction and hence low snail densities by site. Low temperature also negatively affects snail cercarial shedding potential making it difficult to determine snail infectivity under field conditions.\u003c/p\u003e \u003cp\u003eThere have been some challenges or limitations of this study. First was the resource restriction. Because the pilot study had no funds to build an appropriate field-based laboratory, use was made of a consulting room (existing facilities) at Madziwa Rural Hospital for sample storage, conducting disease diagnosis and to apply interventions. All devices and consumptions were carried from the capital. Although 4 vehicles were rented to reach the villages, it was sometimes difficult to reach remote areas. Secondly, it was found out that the praziquantel was out of stock in the target area. The praziquantel used to treat schistosomiasis cases during the study was sought from the nearest district (Centenary) in the same province of Mashonaland Central province. There is no local manufacturing company for praziquantel in Zimbabwe and Africa at large, yet this region harbors 91% of the global burden of schistosomiasis. Currently praziquantel used for MDA is donated by WHO and the annual donations are only targeting school aged children. The quantities of donated praziquantel and albendazole are not adequate to cater for communitywide MDA except for the school age population. This gap reverses the gains made in control of SCH in the school aged population since the untreated age groups share the same contaminated environment (water sources) with the school age children, a condition that sustain transmission of schistosomiasis and hence re-infection of the highly mobile school age children despite the availability of medicines for annual school-based MDA. The Chinese SCH elimination story was premised on the comprehensive package for SCH control and elimination since the country manufactured its own praziquantel in large quantities enough to reach high community wide treatment coverages, snail control through molluscicide application, mechanization, improved sanitation, provision of safe water and health education. Above all this China made a lot of progress in improving the socio-economic status making every household adequately supplied (national wealth creation) which improved quality of life of its nation. Reducing the level of poverty is therefore key to elimination of SCH an NTDs (disease of poverty). Since there is no manufacturing factory in Zimbabwe, the drugs are all donated by WHO. Although the medicine was provided by adjacent district, it indicated the shortage of drug supply in this study area. The pilot study was able to demonstrate the huge gap in access to praziquantel by the affected communities and by all age groups. Thus, for SCH, unless the country is assisted to produce its own praziquantel manufacturing company which will produce adequate quantities of praziquantel to cater for communitywide praziquantel MDA reaching\u0026thinsp;\u0026ge;\u0026thinsp;75% coverage as stipulated in the latest WHO guideline [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the country may fail to reach the milestone of eliminating SCH as a public health problem by 2030. To accelerate elimination of SCH in Zimbabwe and the African region, the China- Zimbabwe cooperation project is expected to provide a platform for exploring the establishment of China -Zimbabwe praziquantel manufacturing company that will supply medicines for all age groups living in high-risk areas/affected by SCH. Failure to bridge this gap by local manufacturing of praziquantel in Zimbabwe, will be a huge failure in accelerating SCH elimination in the African region. Thus, through the China-Zimbabwe cooperation, Zimbabwe is set to be a powerhouse for the production of praziquantel which will be consumed locally but more so throughout the African region. Initial discussions in this regard have been made with the Chinese praziquantel manufacturing company with greater possibilities for the cooperation between the two countries in this regard, through the pilot study. The joint cooperation is set to create employment and wealth for the two countries.\u003c/p\u003e \u003cp\u003eFollowing lessons leant through the pilot study, it is strongly recommended and encouraged that the Government of the People\u0026rsquo;s Republic of China releases funding for the large implementation of the large-scale project. It is also recommended that further exploration for the establishment of the China -Zimbabwe praziquantel manufacturing company be given high priority. Snail control using the Chinese produced molluscicides is recommended as this will accelerate elimination of SCH in Zimbabwe. Surveillance of schistosomiasis will made possible by the production of the point of care (OPC) diagnostic tests with high sensitivity and specificity for \u003cem\u003eS. haematobium\u003c/em\u003e and \u003cem\u003eS. mansoni\u003c/em\u003e and these are distributed in health facilities in remote communities for quick and low-cost field surveillance of SCH. At the moment there are no field applicable tests of high sensitive and specific for SCH in the African region and this is a huge gap that should be prioritized if surveillance and reporting of SCH outbreaks or test and treat strategy is to be implemented in areas whose prevalence is \u0026lt;\u0026thinsp;10% in line with the latest WHO guideline for SCH elimination (WHO, 2022).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely appreciate the support of the National Health Commission of the Peoples\u0026rsquo; Republic of China and the Ministry of Health and Child Care, Zimbabwe. We are also grateful for the fieldwork and support of the staff from the National Institute of Health Research, Zimbabwe, The Provincial Medical Directorate- Mashonaland Central, Zimbabwe, The Shamva District health management, Madziwa health Centre and Chevakadzi Clinic, Zimbabwe, Hunan Institute of Schistosomiasis Control and Jiangsu Institute of Parasitic Diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYJQ was responsible for the study design and drafted the first manuscript. NM and XNZ designed the study and are joint correspondences, who are the project leaders on both sides. MJMM, SL, ZJ and SZL provided technical support. YJQ, NM, MJMM, WS, ZQQ, HML, LT, CLL, XLY and SL contributed to the implementation. NM, MJMM, SZL and XNZ made critical improvement of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupported by the China-Africa Cooperative Project on Schistosomiasis funded by the National Health Commission of the People\u0026rsquo;s Republic of China (No. 2020-C4-0001-2). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Medical Research Council of Zimbabwe (MRCZ/A/3049. All patients gave oral or written consent for data collection and analysis when they registered in the field study, and the analysis was fully anonymized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDi Bella S, et al. History of schistosomiasis (bilharziasis) in humans: from Egyptian medical papyri to molecular biology on mummies. Pathog Glob Health. 2018;112(5):268\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAula OP et al. Schistosomiasis with a Focus on Africa. 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Geneva: World Health Organization; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. \u003cem\u003eSchistosomiasis: progress report 2001\u0026ndash;2011, strategic plan 2012\u0026ndash;2020\u003c/em\u003e. 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Helminth control in school-age children: a guide for managers of control programmes. World Health Organization; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. \u003cem\u003eEnding the neglect to attain the Sustainable Development Goals: A road map for neglected tropical diseases 2021\u0026ndash;2030\u003c/em\u003e. 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"China, Zimbabwe, Schistosomiasis, China-Zimbabwe cooperation, Elimination","lastPublishedDoi":"10.21203/rs.3.rs-4120546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4120546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSchistosomiasis is amongst the leading Neglected Tropical Diseases in terms of its public health significance in Africa accounting for up to 90% of the global burden. Zimbabwe is endemic for \u003cem\u003eSchistosoma haematobium\u003c/em\u003e and \u003cem\u003eS. mansoni\u003c/em\u003e infection. Despite mass drug administration with a focus on school age children, other interventions are not yet in place at national level. China has set up a mechanism of public health cooperation with African countries targeting at schistosomiasis and other infectious diseases. A detailed methodological description of the pilot study for schistosomiasis is presented to make the protocol applied to expanded surveys in similar settings.\u003c/p\u003e\u003ch2\u003eMethods/Design:\u003c/h2\u003e \u003cp\u003eThis pilot study was designed as a project and considered as an entry point for China-Africa cooperation on schistosomiasis control and elimination. It aimed to test the feasibility of a large-scale collaborative project between China and Zimbabwe. A cross-sectional study on schistosomiasis and snail survey was planned to understand the distribution of the disease at community level. The survey was designed to cover all the 14 villages in the target area (Chevakadzi ward). A simple random sampling was applied to enroll participants and convenient sampling for snail survey was carried out. The feces and urine samples were microscopically examined by the Kato-Katz and urine filtration respectively. At the same time, a capacity and needs assessment was carried out to understand the local pattern of disease control strategy.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThis pilot study is expected to generate important epidemiological information and indicators about schistosomiasis transmission at sub-district level. It will be used to determine the feasibility and practicality in China-Zimbabwe cooperation investment at a larger scale.\u003c/p\u003e","manuscriptTitle":"A feasibility test of a large-scale implementation of schistosomiasis elimination under China-Zimbabwe cooperation: a pilot study protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-25 18:02:32","doi":"10.21203/rs.3.rs-4120546/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e5d934a-b95d-4b51-8a87-e75e2590713b","owner":[],"postedDate":"March 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-25T18:02:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-25 18:02:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4120546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4120546","identity":"rs-4120546","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}