title: Baseline prevalence and intensity of schistosomiasis at sentinel sites in Madagascar: Informing a national control strategy.
abstract: BACKGROUND
  Schistosomiasis affects more than 800 million people, mostly in sub-Saharan Africa. A baseline sentinel site study was conducted in the Western half of Madagascar to determine the prevalence and intensity of schistosomiasis and soil-transmitted helminth (STH) infections prior to mass drug administration, and to explore the associations between infection and school attendance, and access to water, sanitation and hygiene (WASH) facilities.
  
  
  METHODS
  A three-stage, cluster-randomised cross-sectional study was conducted in 29 sentinel sites in October 2015. Twenty school attending and 4 non-attending children in each of the age groups from 7 to 10 years old were randomly selected at each site for detection of Schistosoma haematobium eggs in a single urine slide by filtration, and of S. mansoni, Ascaris lumbricoides, Trichuris trichiura and hookworm eggs in duplicate Kato-Katz slides from a single stool sample. School attendance was registered individually, and school-level access to WASH facilities was scored through pre-defined observed and reported factors. Logistic regression analysis was performed, adjusting for gender, age and study site. School-level WASH status was analysed using Spearman's rank correlation coefficient.
  
  
  RESULTS
  A total of 1,958 children were included. The prevalence of S. haematobium infection and heavy-intensity infection was 30.5% and 15.1%, respectively. The prevalence of S. mansoni infection and heavy-intensity infection was 5.0% and 0.9%, respectively. The prevalence of any STH infection was 4.7%. There was no significant difference in prevalence of infection or heavy-intensity infection of either schistosome species between attending and non-attending children, apart from heavy-intensity S. mansoni infection that was significantly more common in children who did not attend school regularly (aOR = 7.5 (95% CI = 1.1-49.5); p = 0.037). Only a minority of schools had adequate access to WASH facilities, and in this study, we found no significant association between school-level WASH status and schistosomiasis.
  
  
  CONCLUSIONS
  This study found an alarmingly high prevalence and intensity of schistosomiasis, and the results warrant urgent scale-up of the national NTD control programme that will need to include both non-attending and attending school-age children in order to reach WHO roadmap targets for the control of schistosomiasis by 2020.
authors.affiliation: Ministry of Public Health, Antananarivo, Madagascar. clarafabienner@gmail.com.
authors.forename: Clara Fabienne
authors.initials: CF
authors.lastname: Rasoamanamihaja
authors.affiliation: Ministry of Public Health, Antananarivo, Madagascar. alainrahetilahy@yahoo.fr.
authors.forename: Alain Marcel
authors.initials: AM
authors.lastname: Rahetilahy
authors.affiliation: Ministry of National Education, Antananarivo, Madagascar. ranjatoarivonyb@yahoo.fr.
authors.forename: Bruno
authors.initials: B
authors.lastname: Ranjatoarivony
authors.affiliation: Schistosomiasis Control Initiative (SCI), Imperial College London, London, UK. n.dhanani@imperial.ac.uk.
authors.forename: Neerav
authors.initials: N
authors.lastname: Dhanani
authors.affiliation: Réseau International Schistosomose Environnement Aménagement et Lutte (RISEAL) Madagascar, Antananarivo, Madagascar. landriamaro@conservation.org.
authors.forename: Luciano
authors.initials: L
authors.lastname: Andriamaro
authors.affiliation: World Health Organization (WHO) Madagascar, Antananarivo, Madagascar. andrianarisoas@who.int.
authors.forename: Samuel Hermas
authors.initials: SH
authors.lastname: Andrianarisoa
authors.affiliation: Schistosomiasis Control Initiative (SCI), Imperial College London, London, UK. pmjourdan@yahoo.no.
authors.forename: Peter Mark
authors.initials: PM
authors.lastname: Jourdan
mesh_terms: D000818:Animals; D002648:Child; D003430:Cross-Sectional Studies; D005243:Feces / Q000469:parasitology; D005260:Female; D006801:Humans; D006920:Hygiene; D008270:Madagascar / Q000453:epidemiology; D008297:Male; D015995:Prevalence; D012547:Schistosoma / Q000302:isolation & purification*; D012552:Schistosomiasis / Q000453:epidemiology* / Q000469:parasitology; D012574:Schools; D012987:Soil / Q000469:parasitology
chemical_list: D012987:Soil
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