title: Using the hierarchical ordinal regression model to analyse the intensity of urinary schistosomiasis infection in school children in Lusaka Province, Zambia.
abstract: BACKGROUND
  Urinary schistosomiasis has been a major public health problem in Zambia for many years. However, the disease profile may vary in different locale due to the changing ecosystem that contributes to the risk of acquiring the disease. The objective of this study was to quantify risk factors associated with the intensity of urinary schistosomiasis infection in school children in Lusaka Province, Zambia, in order to better understand local transmission.
  
  
  METHODS
  Data were obtained from 1 912 school children, in 20 communities, in the districts of Luangwa and Kafue in Lusaka Province. Both individual- and community-level covariates were incorporated into an ordinal logistic regression model to predict the probability of an infection being a certain intensity in a three-category outcome response: 0 = no infection, 1 = light infection, and 2 = moderate/heavy infection. Random effects were introduced to capture unobserved heterogeneity.
  
  
  RESULTS
  Overall, the risk of urinary schistosomiasis was strongly associated with age, altitude at which the child lived, and sex. Weak associations were observed with the normalized difference vegetation index, maximum temperature, and snail abundance. Detailed analysis indicated that the association between infection intensities and age and altitude were category-specific. Particularly, infection intensity was lower in children aged between 5 and 9 years compared to those aged 10 to 15 years (OR = 0.72, 95% CI = 0.51-0.99). However, the age-specific risk changed at different levels of infection, such that when comparing children with light infection to those who were not infected, age was associated with a lower odds (category 1 vs category 0: OR = 0.71, 95% CI: 0.50-0.99), yet such a relation was not significant when considering children who were moderately or heavily infected compared to those with a light or no infection (category 2 vs category 0: OR = 0.96, 95% CI: 0.45-1.64). Overall, we observed that children living in the valley were less likely to acquire urinary schistosomiasis compared to those living in plateau areas (OR = 0.48, 95% CI: 0.16-0.71). However, category-specific effects showed no significant association in category 1 (light infection), whereas in category 2 (moderate/high infection), the risk was still significantly lower for those living in the valley compared to those living in plateau areas (OR = 0.18, 95% CI: 0.04-0.75).
  
  
  CONCLUSIONS
  This study demonstrates the importance of understanding the dynamics and heterogeneity of infection in control efforts, and further suggests that apart from the well-researched factors of Schistosoma intensity, various other factors influence transmission. Control programmes need to take into consideration the varying infection intensities of the disease so that effective interventions can be designed.
authors.affiliation: Ministry of Health, Ndeke House, Haile Selassie Avenue, P.O. Box 30205, Lusaka, Zambia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Simoonga
authors.affiliation: Mathematical Sciences Department, Chancellor College, University of Malawi, P.O. Box 280, Zomba, Malawi. lkazembe@yahoo.com.|Statistics and Population Studies Department, University of Namibia, Private Bag 13301, Windhoek, Namibia. lkazembe@yahoo.com.
authors.forename: Lawrence N
authors.initials: LN
authors.lastname: Kazembe
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000818:Animals; D002648:Child; D006801:Humans; D016015:Logistic Models; D015995:Prevalence; D012044:Regression Analysis; D012307:Risk Factors; D012548:Schistosoma haematobium / Q000502:physiology*; D012553:Schistosomiasis haematobia / Q000453:epidemiology* / Q000469:parasitology; D012737:Sex Factors; D013334:Students; D015024:Zambia / Q000453:epidemiology
keywords: Bayesian analysis; Intensity of infection; Ordinal logistic regression; Urinary schistosomiasis; Zambia