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Analyzed the data: ZT. Wrote the paper: ZT. Critically read the manuscript: SC. Contributed to the protocol, treated the population, critically read the manuscript: AG. Monitored field studies, performed all ultrasound examinations: ZT. Participated in field studies, critically read the manuscript: HM AM. West African Programme manager for SCI, critically read the manuscript: EB. Assessment of malarial infection, critical reading of the manuscript: MI JD. Investigator coordinator of the studies, contributed to data analysis and interpretation, critically read the manuscript: PB.
In the framework of the monitoring and evaluation of the Nigerien schistosomiasis and soil-transmitted helminth control programme, a follow-up of children took place in eight sentinel sites. The objective of the study was to assess the evolution of Schistosoma haematobium infection and anaemia in schoolchildren after a single administration of praziquantel (PZQ) and albendazole.
Pre-treatment examination and follow-up at one year post-treatment of schoolchildren aged 7, 8, and 11 years, including interview, urine examination, ultrasound examination of the urinary tract, and measurement of haemoglobin. Before treatment, the overall prevalence of S. heamatobium infection was 75.4% of the 1,642 enrolled children, and 21.8% of children excreted more than 50 eggs/10 ml urine. Prevalence increased with age. The overall prevalence of anaemia (haemoglobin <11.5 g/dl) was 61.6%, decreasing significantly with increasing age. The mean haemoglobinemia was 11 g/dl. In bivariate analysis, anaemia was significantly more frequent in children infected with S. haematobium, although it was not correlated to the intensity of infection. Anaemia was also associated with micro-haematuria and to kidney distensions. In a sub-sample of 636 children tested for P. falciparum infection, anaemia was significantly more frequent in malaria-infected children. In multivariate analysis, significant predictors of anaemia were P. falciparum infection, kidney distension, and the village. One year after a single-dose praziquantel treatment (administered using the WHO PZQ dose pole) co-administered with albendazole (400 mg single dose) for de-worming, the prevalence of S. haematobium infection was 38%, while the prevalence of anaemia fell to 50.4%. The mean haemoglobinemia showed a statistically significant increase of 0.39 g/dl to reach 11.4 g/dl. Anaemia was no longer associated with S. haematobium or to P. falciparum infections, or to haematuria or ultrasound abnormalities of the urinary tract.
The high prevalence of anaemia in Nigerien children is clearly a result of many factors and not of schistosomiasis alone. Nevertheless, treatment of schistosomiasis and de-worming were followed by a partial, but significant, reduction of anaemia in schoolchildren, not explainable by any other obvious intervention.
The World Health Organization's recommendation for the control of urinary schistosomiasis is to reduce morbidity by reducing the prevalence of heavy infections. In Niger, where urinary schistosomiasis is endemic along the Niger River valley and in proximity to ponds, a national control programme for schistosomiasis and soil-transmitted helminth was launched in 2004 with the financial support of the Gates Foundation through the Schistosomiasis Control Initiative. In the framework of the monitoring and evaluation of the control programme, a follow-up of school children took place in eight sentinel sites. The aim of this study was to assess the evolution of Schistosoma haematobium infection and associated morbidity after a single-dose administration of praziquantel and albendazole. Before treatment, the overall prevalence of S. heamatobium infection was 75.4% and anaemia (haemoglobin <11.5 g/dl) was present in 61.6% of the study sample. One year after a single-dose praziquantel treatment (administered by dose-pole) co-administered with albendazole (400 mg single dose) for de-worming, all morbidity markers of the infection decreased significantly. This study shows how a schistosomiasis control programme can benefit populations by improving their health status.
Schistosoma haematobium is endemic in Niger, particularly throughout the Niger River valley and in villages in close proximity to permanent and temporary ponds [1]–[3]. The prevalence of infection is highly variable from one village to another. School-aged children are more often and more heavily infected than adults [4]. Overall, urinary schistosomiasis is an important public health problem in Niger. Thanks to portable ultrasound technology, urinary tract lesions due to S. haematobium infection can be easily identified in large epidemiological surveys [5]–[8]. Nevertheless, the relationship between other frequent pathologies, such as anaemia and S. haematobium infection, are less thoroughly documented [9]. Different studies have found a statistically significant association between urinary schistosomiasis and anaemia [10],[11]. However, many other factors, such as malaria, soil-transmitted helminthiasis, nutritional deficiencies and sickle-cell anaemia, are also frequently associated with anaemia [12]–[15] and controversial statements have been made about the real impact of schistosomiasis on haemoglobin status.
In the framework of the evaluation of the Nigerien national schistosomiasis and soil-transmitted control programme, launched in 2004 with the financial support of the Schistosomiasis Control Initiative (SCI), a longitudinal survey was implemented prior to the first round of mass treatment. This treatment consisted of the administration of praziquantel and albendazole to all the target population (school-aged children and high risk groups) determined by the programme. The double aim of this survey was to collect baseline data on parasitological and morbidity indicators and to monitor their evolution.
Eight villages located in schistosomiasis endemic regions were randomly selected to represent the two main transmission patterns in Niger: six villages located near permanent (Tabalak, Kokorou) or semi-permanent (Kaou, Mozague, Rouafi, and Sabon Birni) ponds and two (Saga Fondo, Sanguile) located along the Niger River. The villages represented the south-western region (Tillabéry) and the central-northern region (Tahoua) of the country, with four villages from each region. One village is located in the Sudanian climatic zone and the seven others are in the Sahelian climatic zone.
Transmission is permanent along the river and near permanent pond settings while it is intermittent near temporary pond setting. The cold season (November to March) represents the high transmission period for both transmission patterns [16].
Both male and female schoolchildren aged 7, 8 and 11 years were the study population. These particular ages were selected to be included in the monitoring and evaluation surveys because the control programme supported by the SCI targets schoolchildren and therefore these age groups would be the most representative. The chosen study population would also have the lowest likelihood of high drop-out rates over the survey years, particularly those aged 7–8 years at baseline who will stay in primary school until they the age of 11–12 years old. Furthermore, if an improvement is evident in the study population than there is a higher probability that morbidity in adults can be prevented.
The recommended sample size was 60 children by age group in S. haematobium zones. When the sample size could not be attained with enrolled schoolchildren, further school-aged children were recruited from the village.
The study was approved by the National Ethics Committee of Niger and the National Health System Local Research Ethics Committee of St. Mary's Hospital, London, prior to data collection. Once institutional consent obtained, meetings were held in all targeted villages in order to clearly present the objectives and the methods of the study to the families. They were invited to give their consent prior to inclusion of their children in the survey and they were made aware that they could refuse to permit their children from participating in the study or to remove their children without any consequences. The consent sought was verbal because of the high illiteracy rate in rural population, and the National Ethics Committee of Niger approved this method of consent.
Participating schoolchildren underwent a standardized interview focusing on clinical signs of urinary or intestinal schistosomiasis and on previous anti-schistosomal treatment.
From each child, a urine sample was collected between 10:00 AM and 2:00 PM and the presence of blood was noted, according to a standardized colorimetric scale coding from 0 to 6. Gross haematuria was defined as a visual quantification coded >3. Reagent strips (Hemastix Bayer Diagnostics Division, Tarrytown, NY, U.S.A) were used for diagnosing microscopic haematuria. Codes ranging from 0 to 5 were attributed according to the manufacturer interpretation scale and micro-haematuria was defined as urines coded ≥3.
Parasitological examination of urine and S. haematobium eggs count were performed after filtration of 10 ml of urine using Nytrel filters. The intensity of infection was categorized into two classes: light-intensity infection (egg count <50/10 ml) and heavy-intensity infection (egg count ≥50/10 ml). The geometric mean egg count of excreting individuals was used to assess the infection at community level.
S. mansoni infections were determined by preparing two 41.7 mg Kato-Katz thick smears from a single fresh stool specimen [17]. All stool specimens were also analysed for Ascaris lumbricoides, Trichuris trichiura, Enterobius vermicularis, Taenia spp and hookworm.
A Hemocue photometer (HemoCue AB, Ängelholm, Sweden) was used to determine haemoglobin concentration from a capillary blood drop collected from the finger tip of each child, using sterile single-use material. Children were considered anaemic when haemoglobin was less than 11.5 g/dl [18].
A thick smear was made for the search of Plasmodium falciparum, but this examination was performed in the four villages of the region of Tahoua only. Children with asymptomatic malaria infection during dry season are supposed to have greater risk of chronic anaemia, knowing the great role played by malaria in the physiopathology of anaemia [13],[19].
All the children underwent an ultrasound examination of the urinary tract to assess morbidity due to schistosomiasis using a portable ultrasonographer Aloka SSD 500 (Aloka, Tokyo, Japan) with a 3.5 MHz convex transductor. Bladder and urinary tract abnormalities were assessed and reported according to the WHO/Niamey protocol [20]. Bladder lesions were scored 0, 1 or 2, ureteral lesions were scored between 0, 3 or 4, and kidney distension was scored between 0, 6 or 8. By adding these elementary scores, an Echographic Severity Index (ESI) was calculated. In total, there were four classes of ESI: 1=light impact, 2–4=moderate impact, 5–9=severe impact, ≥10=very severe impact [16].
According to the national control programme procedures, praziquantel and albendazole were administered by a local team at the community level during the mass drug administration campaign, following the baseline data collection and 1 year later during the second mass drug administration campaign, following the control survey.
Praziquantel (using dose-pole corresponding to 40 mg/kg) and Albendazole (400 mg) were given to the target population regardless of infection status, during the mass drug administration campaign that took place 3–4 weeks after the surveys were conducted. Trained community drug distributors delivered the treatment in several distribution points in the villages. Schoolchildren were treated by teachers at school. Drugs were swallowed in presence of the drug distributor. Coverage rate reported by the national programme was approximately 68% for all the targeted regions (coverage rate was higher in school-based treatment than through community-based treatment).
EpiInfo and SPSS software was used for data management and analysis. The Pearson's χ2, the Fisher's exact test, the Student's t test or the Kruskal-Wallis' test were used whenever appropriate. For paired analysis, the McNemar's χ2 was used. A p value <0.05 was considered significant. Logistic regression was used for multivariate analysis to identify the risk factors of anaemia.
A total of 1642 schoolchildren were enrolled in the study. The overall sex ratio (male to female) was 1.27: 1, but the sex distribution varied greatly according to the village, ranging from 14.9% to 73.3% for girls. The overall mean age was 8.7 years, without any significant difference between schools. The number in each age group was 532, 546 and 565 for the 7, 8 and 11 years old respectively.
The most commonly reported symptoms were bloody urine (41.8%), abdominal pain (28.5%) and pain when urinating (24.5%). A previous treatment against schistosomiasis was reported by 4.5% of the schoolchildren. No previous treatment had been administered at community level in any of the eight villages.
The overall prevalence of S. haematobium infection was 75.4% [95% Confidence Interval (CI): 73.2–77.5]. The prevalence varied from 43.6% to 97.7%, according to the village. Older children were more frequently infected than were younger ones (p<0.01). The overall prevalence of heavy-intensity infections was 21.8%. Intensity increased with increasing age: 16.4%, 21.8% and 27.0% in children aged 7, 8 and 11 years, respectively (p<0.01). Among the heavily infected children, 50 (13.9%) excreted more than 500 eggs/10 ml of urine. The geometric mean egg count among egg excreting children was 15.5 eggs /10 ml urine. Geometric mean egg counts were 11.7, 16.9 and 17.6 in children aged 7, 8, and 11 years respectively (p<0.01). The prevalence of infection was significantly higher in schools located in the south-western part of the country: 85.3% in the region of Tillabéry compared to 64.8% in the region of Tahoua (p<0.01). The prevalence of S. haematobium infection was significantly associated with reported haematuria and pain during urination (p<0.01).
S. mansoni infection was observed only in 2 schools: Sabon Birni (3%) and Sanguilé (1.1%).
Hookworm infection was observed in 3 schools; Sabon Birni, where the prevalence was 18.8 and in 2 other villages were the prevalence was 0.6%. Hookworm infection was not observed in the schoolchildren of the 5 other villages.
Very low prevalence (0.3 to 0.7%) of Ascaris lumbricoides infection was observed in 5 schools, while 3% of the schoolchildren were infected in 1 school (Sanguile) and no infection was observed in 2 schools (Kaou and Tabalak).
The overall prevalence of P. falciparum infection was 8% in the 636 tested schoolchildren, ranging from 3.8% to 15.8% according to the village (p<0.03). P. falciparum infection was neither associated with age, nor S. haematobium infection.
The overall prevalence of observed gross haematuria was 6.9%, with a significant relationship with S. haematobium infection (p<0.03). Gross haematuria was observed in 21.4% of heavily infected children. The overall prevalence of micro-haematuria was 53.3%, differing significantly according to the village (p<0.03) and increasing significantly with increasing age (p<0.03). The prevalence of micro-haematuria was 9.6% in children not excreting eggs, 56.3% in children with light-intensity infections and 92.8% in children with heavy-intensity infections (p<0.03). Reported history of haematuria and pain during urination were significantly associated with the prevalence of micro- and gross haematuria (p<0.03).
Overall, the mean haemoglobinemia was 11 g/dl (range: 5.3 g–17.3 g). The prevalence of anaemia was 61.6%, without significant difference between sexes. Haemoglobinemia was significantly related to age: 66.5% in children aged 7 years, 64.6% in children aged 8 years and 54.1% in those aged 11 years (p<0.03). Prevalence of anaemia was also statistically different according to the village (p<0.03). Anaemia was significantly associated with micro-haematuria (p<0.02), but not to gross haematuria. Overall, we found a significant association of anaemia with S. haematobium infection coded as a binary variable yes/no (p=0.045), but not with infection coded into 3 levels of intensity. After adjusting for age, the association was present only in 8 year old children, where prevalence of anaemia increased significantly with increasing intensity of infection (p<0.01). The presence of anaemia was significantly associated with P. falciparum infection (p<0.01). Table 1 shows the prevalence of anaemia according to the presence, or absence, of several potential risk factors using bivariate analysis.
The proportion of children presenting at least one ultrasound abnormality of the urinary tract was 45.8%, without significant differences between sexes or transmission patterns, and was significantly associated with age (37.8%, 46.0% and 53.0% in children aged 7, 8 and 11 years, respectively; p<0.03), to the intensity of S. haematobium infection (22.1% in children not excreting eggs, 47.5% in light-intensity infections and 68.1% in heavy-intensity infections; p<0.03) and to the presence of anaemia (p=0.025).
Bladder wall abnormalities, evident in 41.6% of children, were the most frequently reported ultrasound abnormality. Their prevalence increased significantly with increasing age (p<0.03), with increasing intensity of infection (p<0.03), and was not associated with the presence of anaemia. Severe bladder wall abnormalities (either masses or pseudopolyps) were present in 15.5% of the children. Kidney and ureteral distensions were present in 4.2% and 4.1% of the children, respectively. Contrary to ureteral distension, kidney distension was significantly associated with the intensity of S. haematobium infection (p<0.01) and to the presence of anaemia (p<0.03).
The mean ESI, summarizing urinary tract morbidity due to S. haematobium infection, was 1.33 (range: 0–24) and the mean bladder score was 0.8 (range: 0–7). The mean ESI was not different between boys and girls. The mean ESI was significantly higher in pond-related transmission villages than in river-related transmission villages (p<0.03).
Multivariate analysis using logistic regression showed that the risk of anaemia was significantly associated with young age (OR=1.7, 95% CI 1.3–2.2 for age=7 and OR=1.6, 95% CI 1.2–2.0 for age=8), to the presence of ultrasound abnormalities of the kidneys (OR=3.0, 95% CI 1.5–6.0) and to the village. When the same analysis was performed on the sub-sample of 4 villages where P. falciparum infection was documented, the predictors of anaemia were P. falciparum infection (OR=2.5, 95% CI 1.3–4.7), ultrasound abnormalities of the kidneys (OR=2.9, 95% CI 1.2–6.8) and the village (OR=0.6, 95% CI 0.4–0.9 for Tabalak and OR=0.4, 95% CI 0.3–0.7 for Kaou).
A total of 89% of the initial sample group were re-examined one year after baseline data collection and the first round of treatment with praziquantel and albendazole. The mean age was 9.7 years and the sex ratio (male to female) was 1.27:1. A total of 482 eight year olds, 470 nine year olds and 484 twelve year olds were re-examined.
The overall prevalence of S. haematobium infection was 38% and 4.6% of children had heavy-intensity infections; only three (4.6%) among the latter excreted more than 500 eggs/10 ml. 56.2% of the initially infected children did not excrete eggs and 91.6% of heavy-intensity infections had cleared or become light intensity infection. However, the improvement of infection markers was different according to the village and prevalence was still above 60% in 3 schools (Kaou, Kokorou and Tabalak). In children from Tabalak, only minor changes in the prevalence and intensity of infection were observed (22.7% of heavy-intensity infections at baseline and 18.2% at follow-up).
Assessment of P. falciparum infection in the 4 schools tested in 2005 showed a significant increase of the prevalence from 8.6% to 17.1% (p<0.03). The rise of prevalence of malarial infection was observed in 4 schools, although only statistically significant in Rouafi (paired analysis, p<0.03).
The overall prevalence of all the morbidity markers of S. haematobium had decreased significantly at follow-up (Table 2). Among the 1412 schoolchildren which were re-examined, the overall prevalence of anaemia decreased from 61.9% to 50.4% (paired analysis, p<0.03) and the mean haemoglobinemia showed a significant increase of 0.39 g /dl to reach 11.4 g/dl (paired analysis, p<0.01). However, the change in prevalence of anaemia was not significant in children from Kaou, Kokorou, Mozague and Tabalak. At follow-up, anaemia was not associated with S. haematobium infection. Gross and micro-haematuria decreased from 7.1% to 0.4% (paired analysis, p<0.03) and from 53.5% to 6.0% (paired analysis, p<0.03), respectively. Prevalence of gross and micro-haematuria were each significantly associated with the intensity of S. haematobium infection (p<0.03). Anaemia was neither associated with micro-haematuria nor with gross haematuria. One year after treatment, the overall prevalence of ultrasound abnormalities of the urinary tract and the prevalence of ultrasound abnormalities of the bladder decreased from 45.6% to 15.2% (paired analysis, p<0.03) and from 41.6% to 14.7% (paired analysis, p<0.03), respectively. The mean global ESI showed a significant decrease of 1.04 (paired analysis, p<0.03).
In 2006, the relationship between anaemia and P. falciparum infection was no longer observed.
Compared to those children who remained in the study cohort, the 216 children who dropped out after the initial survey differed significantly in the prevalence of S. haematobium infection (75.4% vs. 78%, respectively), but had less frequently heavy-intensity infections (22.8% vs. 16.5%, respectively). On the other hand, they did not differ in mean age (8.7 vs. 8.9 years, respectively), in the prevalence of anaemia (61.9% vs. 59.7%, respectively) nor in mean haemoglobinemia (11.04 g/dl vs. 11.03 g/dl, respectively).
According to the WHO guidelines [21], the aim of the Nigerien National Schistosomiasis Control Programme is to reduce schistosomiasis-associated morbidity by reducing the prevalence of heavy-intensity infections.
Our study, which compared baseline data collected before treatment and follow-up data collected one year post treatment, aimed to describe the evolution of S. haematobium infection and of anaemia prevalence in schoolchildren in 8 sentinel cohorts.
The predominance of boys in our samples reflects the overall low proportion of girls in full-time education in Niger. Only 11% of children of the initial sample did not take part in the follow-up survey. The characteristics of the children who dropped out of the study, for both ultrasound assessed morbidity and for anaemia, did not differ significantly from children who completed the follow-up. The children who dropped out also had slightly lower prevalence and intensity of infection at baseline.
Our data showed a high prevalence of urinary schistosomiasis at baseline, with a classical increase of both prevalence and intensity of infection with increasing age during childhood. Although studies have shown that both prevalence and intensity of infection is often higher among males in many surveys [22],[23], our data did not show such a relationship.
S. haematobium infection was well correlated to the prevalence of observed gross haematuria, confirming the value of this indicator for rapid assessment of infection at community level, as well as its intensity. Reported history of haematuria and pain during urination were both related to the infection, even if the schoolchildren underestimated it. These markers, have been used for rapid screening of urinary schistosomiasis [24].
According to the operating procedures of the national control programme, the praziquantel and albendazole treatment was administered by school teachers or health agents using the praziquantel "dose-pole" [25],[26] for praziquantel within 3–4 weeks following the baseline data collection (in November-December 2004 in Tillabéry region and in April-May 2005 in Tahoua region). Eleven to twelve months after treatment, the overall prevalence of S. haematobium infection had decreased significantly, from 75.4% to 38% and the prevalence of heavy-intensity infections had drastically reduced by 91.7%. These observations fully confirm the effectiveness of a single dose of praziquantel on infection, as demonstrated over the past two decades [27],[28].
However, in 3 schools, the prevalence of S. haematobium infection remained high, over 60%. In on village, Tabalak, the prevalence of heavy-intensity infections did not change at all. It is unlikely that this was solely due to re-infection, according to previous studies in Niger [16],[29] prevalence is unlikely to reach the initial level of intensity within a year of treatment. However, it has been demonstrated that S. haematobium reinfection patterns may vary strongly according to local epidemiological settings. Mass treatment took place after the high transmission period in the Tahoua region. In Tabalak where the transmission is year-round, the water level in local ponds usually decreases significantly during the hot and dry season. This reduction in water levels can induce a greater parasite concentration and thus a more severe infestation. Some alarming reports have been made since the 1990s about praziquantel treatment failures in S. mansoni infections [30], but despite large scale use of praziquantel in many countries there is currently no evidence to suggest that any S. haematobium has developed resistance to praziquantel as a result of its widespread use [31] and praziquantel can still be considered very effective. Furthermore, in the 4 villages where disappointing results were observed, the absence of mass treatment history should rule out a possible local problem of drug resistance induced by overuse or misuse of praziquantel. Although 75.1% of children in Tabalak reported having received tablets just after the baseline data collection, the absence of prevalence reduction is likely to be explained by the fact that praziquantel treatment was not administered as effectively as had been assumed. For children, confusion between albendazole tablets and praziquantel tablets could be quite easy and the drug delivery system in Tabalak will need to be assessed. In addition, transmission of S. haematobium in Tabalak will also be investigated.
The very low prevalence of soil-transmitted helminth infection is in accordance with previous observations made in Niger [32] and in 2 other African countries, Mali and Chad [22],[33], areas that are subjected to climatic conditions comparable to the most inhabited regions of Niger. The single school where hookworm infection prevalence was over 1% was located in the Sudanian climatic zone, in the southern-most part of the country.
The nature and the frequency of ultrasound-assessed urinary tract abnormalities, observed in 46.2% of schoolchildren, with an association with both intensity of infection and with age are fully consistent with results from other studies [5],[34].
The effect of treatment on reducing the prevalence of both bladder and ureteral lesions was 78.2% and 96.3% respectively, a clear confirmation of the relevance of the control strategy. Previous surveys in Niger reported similar favourable results, showing the rapid regression of ultrasound-assessed bladder and ureteral lesions [16],[29],[35]. Many studies in other endemic areas also demonstrated the invaluable benefit of praziquantel administration on S. haematobium associated bladder morbidity [36].
At baseline, the prevalence of ultrasound assessed-kidney lesions was low (4.1%), compared to results from other studies which reported up to 43% of hydronephrosis in schoolchildren in hyperendemic village in the Niger River valley. Other results reported between 20.9% and 23.2% upper urinary tract lesions in two villages in an irrigated area of Niger [16],[29]. Contrary to other observations [37], in our study sample kidney dilatations were significantly associated with the intensity of S. haematobium infection. Although ultrasound-assessed kidney dilatations are not specific to urinary schistosomiasis, their regression following praziquantel treatment strengthens the likelihood of their relationship with infection. According to the literature, the observed clearance rate of kidney dilatations following praziquantel treatment may vary greatly, from low [38],[39] to very satisfactory [35],[40]. This may be explained by many factors, such as the length of the post-treatment follow-up or the age of lesions.
Anaemia is considered a severe public health problem when its prevalence is over 40% within a population [41]. Anaemia is very common in developing countries and a multi-country survey in sub-Saharan Africa showed that it was generally a serious problem in schoolchildren [42]. Our results, showing a prevalence of 61.2%, confirm that anaemia in schoolchildren is a worrying public health problem in Niger.
Various causes can lead to anaemia including infections, low dietary iron intake, sickle-cell anaemia, malnutrition and inflammatory diseases. Although many cross-sectional studies and a small number of randomized controlled trials have addressed the relationship between schistosomiasis and anaemia, the conflicting results make the magnitude of the relationship unclear. Urinary schistosomiasis had been associated with anaemia in many studies. In a study in Niger, S. haematobium egg count and intensity of haematuria were negatively correlated to haemoglobin level, to haematocrit and to transferrin saturation, and positively associated with anaemia and iron deficiency [11]. Another Nigerien survey concluded that S. haematobium infections increased the risk of anaemia by 30% [10]. In Tanzania, haemoglobin concentration in infected children was 0.4 g/dl lower than in uninfected ones [43]. In Kenya, the intensity of S. haematobium infection was negatively correlated with haemoglobin level on a cross sectional basis [44]. On the other hand, a survey in Cameroon, in a context of concurrent malarial and schistosomal infections [15], did not establish a relationship between schistosomiasis haematobia and anaemia while anaemia correlated significantly with malaria infection. In Mali, in a survey focusing on interactions between helminth and malarial infections in children, results showed haemoglobin was similar in children infected with S. haematobium compared to those not infected [45]. Likewise, in a survey on anaemia in Tanzania, no relationship was observed with S. haematobium, whereas anaemia was significantly associated with hookworm infection [46].
Our results, showing a significant relationship between schistosomiasis haematobia and anaemia, were bordering on statistical significance in a bivariate analysis, and anaemia was not related to intensity of infection. In a previous analysis using an alternative haemoglobin threshold for anaemia (11 g/dl instead of 11.5, data not shown), no relationship was observed between infection and anaemia. Also, it is worthy to note that the prevalence and intensity of S. haematobium infection increased with increasing age, contrary to anaemia that was more prevalent in the youngest schoolchildren. The latter observation is consistent with the results found in Chad [22].
Our results showed that micro-haematuria increases with age as does the prevalence of schistosomiasis and that the prevalence of anaemia decreases with age. These findings raise the question about the significance of micro-haematuria in the prevalence of anaemia. By which mechanism does micro-haematuria contributes to anaemia? Why anaemia prevalence is higher in the age group where micro-haematuria is lower?
Lastly, in multivariate analysis, S. haematobium infection was not associated with anaemia. However, anaemia could be related to S. haematobium in an indirect way as it was significantly associated with micro-haematuria. The significant improvement of haemoglobin levels one year after praziquantel and albendazole treatment suggests that S. haematobium can contribute significantly to anaemia. In Burkina Faso where the SCI-supported schistosomiasis control programme provides also large-scale chemotherapy with praziquantel and albendazole, Koukounari and others found significant reduction in the prevalence of anaemia and a significant increase in haemoglobin concentration [47]. This confirms our findings on the benefit of praziquantel on anaemia.
Due to the study design, the causality cannot be formally established, but one can note that the 3 schools were anaemia did not improve corresponded to the 3 of 4 schools were S. haematobium infection showed only minor changes one year after praziquantel treatment. The overall very low prevalence of hookworm infection can rule out a significant contribution of hookworm in schoolchildren anaemia in Niger. Lastly, the observed improvement of anaemia is unlikely explained by the fact that some children dropped out of the survey before follow-up, as they did not differ significantly from the others, neither for S. haematobium infection, nor for anaemia prevalence.
The simultaneous delivery of several drug packages within the framework of the integrated neglected tropical disease control programmes (schistosomiasis, lymphatic filariasis, intestinal worms, trachoma, onchocerciasis) which are currently being implemented in several sub-Saharan African countries will probably involve an additional improvement of the prevalence of anaemia and the global health of the populations by the synergistic actions of the drugs on the worms, the ectoparasites and certain bacteria. Our study showed that anaemia can be a useful indicator for the monitoring of the impact of programs NTD as suggested by Bates et al. and Molyneux et al [48],[49].
Malarial infection is a well documented cause of anaemia in African children [13],[19]. The multivariate analysis performed on the sub-sample of 4 schools where data on P. falciparum infection were available showed that asymptomatic carriage of P. falciparum, kidney distension and the village were the only predictors of anaemia, while no relationship was found with S. haematobium infection. In Niger, 83.9% of children <5 years had an haemoglobinemia of <11 g/dl in a nationwide survey in 2006, with only minor differences between rural and urban settings [50], although both prevalence and intensity of S. haematobium infection are usually low in this age group. In total, S. haematobium alone cannot explain the high prevalence of anaemia in Nigerien schoolchildren. Actually, with 8.1% of children carrying P. falciparum at baseline, malarial infection could hardly explain the entire problem of anaemia in Nigerien children. Dietary iron availability should be investigated, as well as the prevalence of other known risk factors, such as sickle cell anaemia.
Both S. haematobium and anaemia are highly prevalent in schoolchildren in Niger. Before treatment, anaemia was significantly associated with infection in a bivariate analysis, but this association was not observed in a multivariate analysis, while malarial infection was a significant predictor of anaemia. One year after systematic praziquantel treatment, we observed a significant decrease of the prevalence and intensity of infection and of morbidity. Though the prevalence of anaemia significantly reduced, prevalence was still 50.5%. The high prevalence of anaemia in Nigerien schoolchildren is likely a result of the combination of many risk factors and should be thoroughly investigated. The role of schistosomiasis on anaemia clearly deserves more studies. It would be interesting to study the interactions of malarial infection, schistosomiasis, soil-transmitted helminthiasis as well as nutritional status in the mechanisms of anaemia. Even though schistosomiasis represents only one of multiple causes of anaemia, the effect of praziquantel treatment on morbidity clearly indicates the benefits of schistosomiasis control programmes, which must be perpetuate.
We gratefully acknowledge the Schistosomiasis Control Initiative for funding this study, and Alan Fenwick, Howard Thompson, Jean Roux and Ali Djibo for their helpful comments and contributions to implement this survey in Niger. Our thanks are extended to Artemis Koukounari for her statistical comments. We are indebted to the teachers who kindly welcomed the study team in their schools, and to all participating children.
The authors have declared that no competing interests exist.
The Schistosomiasis Control Initiative funded this study and chose the study design. The funders had no role in data collection and analysis, decision to publish, or preparation of the manuscript.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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I need to speak to a family law lawyer about a dcf case in
Customer Question
I need to speak to a
family law
lawyer about a dcf case in fl that was closed/dissmissed but there are some issues with it . please respond I really need your help. i understand law. im studying law, i just dont knw everything. I havent been able to see or tal to my son since july of last year please someone have compassion and help me out thank you
1 year ago.
Family Law
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replied 1 year ago.
Hello. I'm a licensed attorney with 36 years' experience. I specialize in family law and appeals, and I have many years' experience with landlord-tenant issues, contract law, and other types of law. I also have written hundreds of legal articles. I look forward to helping you today.Please note:This is general information and is not legal advice. No specific course of action is proposed herein, and no attorney-client relationship or privilege is formed by speaking to an attorney on this site. Oh, keep in mind that at the end of this discussion I'm going to ask you to please rate me as that's the only way I get credit for my time here today. Are you okay with rating me at the end of our discussion? Thanks!
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replied 1 year ago.
How can I help you today? What can you tell me about your case?
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replied 1 year ago.
If you have some basic issues you can tell me, that will be great. If you want to do a phone call, we can do that but first I'd need to know about the case and the issues to make sure I can help you with your case.
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replied 1 year ago.
I had a DCF case. I represented myself cause I have been studing law for quite a while am=nd am working on becoming a paralegal as we speak. On oct of 2015 the case was closed dissmissed. I had put in 2 motion to have the case closed due to several different reasons. i had been working my fingers to the bone for over a year with out hardly any sleep and when i turned in themotons forgot to attach the evidence. on the day my case was heard the dcf attorney guardian adlightem attorney and the attorney they had given to the dad who had NEVER been in my sons life until I sent him to live there with him in arizona cause I was afraid they were gnna try some bs and take my rights away so i contacted the dad and had a
paternity test
done and sent my son to live with his father last july. On oct 15th dcf here waived. I didnt lose my rights and they closed/dismissed ther case, but hand written they wrote that I was still to have supervised phone calls by castlehere and they were informed I was planning to move to arizona and be with my sn and his father and stated that he could not supervise that i was to be supervised by whatever was equivilent to dcf here until or if they felt i needed it. I have no case in fl. Ive spoken to arizona and they have no idea what im talking about but my fiance my sons father doesnt want to take the chance that they could come and take our son from us if i move there. How can they put stipulations on another state when they closed /dismissed the case. I cant even talk to my son because castle says there is no open case on me... I have all my
parental rights
i need to know what to do because this is ridiculous that i havent been able to talk or see my son that i raised alone all by myself thru my pregnancy and until he was 3 when dcf got involved and removed him. I brought the evidence to the courts and thats why they closed/dismmissed my case not taking away my parental rights but as I said my fiancee is afriad that if i move there someone is gonna come take our son. what do i dosorry about my spelling Ive been working all day and night. Please let me know what I can do i can upload you the paperwork they gave aftre my court date and my case was dismissed /closed. I am positive I still have my full parental rights and Im positive the case here in fl was dismissed /closed on oct of2015 on oct 15th in martin county. Arizona has no case on me. How can they closed/dismiss a case and then try to put some stipulation on it for another state. this state castle whothey said would need to supervise my phone calls looked and said my case is closed so they cant do it. arizona has never heard of me and my fiancee just wants something showing that when I move there they cant just up and come take our son. ive tried to explain it to him but when it comes to law if you dont know it , you might as well be speaking chinese to someone that doesnt speak chinese and he doesnt know law. i understand law, and i have always studied criminal law where they actually have statue and laws dependency law just has guidelines and its completely ridiculous. they have kept me and my son away from each other for over a year. but im learning but I still need help hence why im asking this question
replied 1 year ago.
Wow, you do indeed have a lot going on. What is castle -- what does that refer to? Is that a supervisory agency?Were the DCF charges neglect or abuse or something along that order -- and then whatever it was, it was dismissed? How long has your child been with the father in AZ? I see now it looks like last July?The problem is now the father has the child and that can entail a lot. He can get custody, he can request limited
or supervised for you, etc.Right now the case is subject to FL law, not AZ. That is for right now. Sooner or later though, the child is going to be in AZ long enough for the father to file for custody out there. Soon AZ, if not already, AZ is going to be the child's home state and the father can file cases out there, including custody.
Ask Your Own Family Law Question
replied 1 year ago.
The handwriting by the judge is going to be taken as a bench order or the equivalent of it, because it requires supervised phone calls.
Ask Your Own Family Law Question
replied 1 year ago.
My concern is that the child has been there awhile and the father can do what he wants in AZ by filing for custody, for
supervised visitation
for you, etc. If there's no case in AZ now, there will be.
Ask Your Own Family Law Question
replied 1 year ago.
I want to help you but I can't without some bot***** *****ne information. First -- moving out there, you have more to worry about the father than the state of AZ. The father can now sue for custody, and it's likely he'll get it, whether you live in AZ or Fla unless you can show why you sent the child to live with the father.
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replied 1 year ago.
I'm not hearing from you so I"m going to opt out right now and let someone else take this. Good luck!
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4 comments:
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I'm thinking of traveling to South Africa soon. What is the best time of year to visit? Also, what airline has the cheapest airline tickets?
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- 16 June 2015 at 12:46


text:
Although, President Goodluck Jonathan even earlier in the week parried questions as to whether he would or would not contest the 2015 presidential polls, but his recent tour of opposition controlled states is perceived by many as tacit campaign strategy to provide a soft template for his 2015 outing.
As expected the recent tour of President Goodluck Jonathan to mainly the opposition controlled All Progressives Congress (APC) states was greeted with mixed feelings. It was largely seen as part of the President's strategy to bolster his chances of victory in the forthcoming 2015 presidential elections.
But the visits were garbed in such niceties as receiving the 'big-shot' decampees into the ruling Peoples Democratic Party (PDP) and also, to pay homage to select traditional rulers of the states visited.
The President who is expected to visit Kwara next week started his tour from Sokoto, where the major attraction in company of Vice President Namadi Sambo, Senate President David Mark, PDP National Chairman, Adamu Mu'azu, and some ministers and PDP governors was to receive the former governor of the state, Alhaji Attahiru Bafarawa on February 8.
Bafarawa had on January 25 announced his decamping from APC to PDP since, the state governor Aliyu Wamakko who was one of the G7 PDP governors, decamped to APC. The move led to the polarisation of the party in the state between the pro- Bafarawa and Pro Wamakko APC until Bafarawa decided to move to PDP.
The President's visit was however seen more as a move towards his re-election bid in 2015 despite the PDP's assertion that the visit was not to campaign for any position but to receive Bafarawa into PDP.
However, many speakers at Bafarawa's welcoming event had made reference to the 2015 election and President Jonathan's re-election bid nearly overshadowed the reception for Bafarawa.
Deputy Governor of Sokoto State Mukhtari Shagari who did not decamp to the APC with Governor Wamakko assured the President that "Nigerians will in 2015 whether you want to run or not, we will drag you out, you will run, you will get the vote of the people of Sokoto state and all Nigerians. You are a good leader you have been patient, you have been calm, you have been cool.That shows how good a leader you are and we at the PDP in Sokoto state are proud of you. Don't worry yourself for 2015; we will by the grace of Allah send you back to Aso Rock and you will be president of Nigeria once more."
Former Governor Attahiru Bafarawa categorically assured the president of working for his victory saying; "Mr. President as far as Sokoto is concerned go and sleep. You don't have any problem. We have been winning elections but we have been rigged out. But now that we are back to PDP which I believe, there is no any party that will get councillor in Sokoto come 2015."
For Jonathan, with the entry of Bafarawa into, and Shagari with other strong politicians in the PDP, Sokoto State is for PDP.
The President, gladdened by the large turnout of people the PDP mobilized to welcome him, had declared: "In Sokoto State, now we are waiting for next election, we will deliver the PDP in all elections. In 2007 Shagari was the young man who won the PDP primaries but one way or the other some adjustments were made, but of course you know that he had been your great political leader".
The APC in the state however alleged that the president's visit was clearly part of his moves for re-election. Mallam Ibrahim Adamu Tudun Doki, an APC stalwart in Sokoto said; "The contractors working for him in Sokoto just want to show him they are on ground and can deliver Sokoto for him but we don't know if they will be able to make 25 percent .The crowd was a rented one, mobilized from all states in the Northwest, the governors came with them. APC is not worried, not shaking. After that, what are they doing?"
Also, the Interim Chairman of the APC Sokoto State, Inuwa Abdulkadir described Jonathan's visit to the state as a political jamboree, wondering why the President should have left serious government business in Abuja at a time that burning issues in the country such as insecurity and others should be given concerted attention.
To him, the visit will not translate into any electoral value for the PDP, but will expose those he alleged are being paid to undertake a political agenda against the people of Northern Nigeria.
However, the determination of the PDP to take back power from the APC in Imo State in 2015 clearly played out during a rally that attracted the who-is-who in the party to receive President Jonathan. Both the leadership, members of the National Working Committee (NWC) including the Board of Trustees of the party emptied themselves in Owerri using the arranged platform meant for the reception of some key personalities and their supporters in the state back into the party to converse for support of Imo people for the President who was also accompanied by Vice President Namadi Sambo.
Others present at the event included the Senate President, David Mark, Deputy Senate President Ike Ekweremadu, National Chairman of the PDP Alhaji Muazu, the BOT Chairman of PDP Chief Tony Anini, Deputy Speaker House of Representatives, Emeka Ihedioha, the chairman of PDP Governors Forum Godwin Akpabio. Governors Liyel Imoke of Cross Rivers, Theodore Orji of Abia, Idris Wada of Kogi, and Martin Elechi of Ebonyi were in Imo State also. The event also had Minister for Economy and Finance Mrs. Ngozi Okonjo Iweala, Supervising Minister for Foreign Affairs, Prof. Viola Onwuliri among others.
Though the PDP rally in Owerri was meant to receive some former members of the party who before that day abandoned the party because of the injustice meted to them, the platform was mostly used to also canvass support for President Jonathan's re-contesting in 2015.
Though on arrival, the President, his Vice and their entourage were received at the Sam Mbakwe International Cargo Airport, Owerri by Governor Rochas Okorocha, it was amidst negative impressions and criticisms by the members of the PDP in the state.
The President recalled that Imo State from inception of the present dispensation has been a PDP state and promised to return the state to the party.
National Chairman of the PDP, Alhaji Muazu recalled that before 2011 election, the PDP has always swept the state in elections, regretting that due to internal wranglings, the party lost to another party. He reminded those aspiring for any positions in the party that power comes from God while urging them to work together for the interest of the party in the state.
The APC in the state said the visit of Mr. President has no benefit and any economic value.
Chairman of the party in the state Prince Marshal Okaforanyanwu regretted that President Jonathan only came to Imo to commission people, as against commissioning any project that may have been sited and completed by the Federal Government in the state.
The South/East APC youth led by Hon. Festus Bethel Onyekwulisi described the visit of President Jonathan to Imo as a disappointment to the people of the state. He also regretted that Mr. President only commissioned people and left and could not commission any single project initiated and completed by the Federal Government for Imo people.
The women in the state were not left in this mission as they took to the streets of Owerri in protest against the PDP rally, which culminated in applying broom to sweep the foot of the PDP loyalists out of the city. The protests almost paralyzed both commercial and economic activities in Owerri the capital of Imo state, a reminiscent of the defunct ACN sweeping of former President Olusegun Obasanjo out of Lagos State.
Reacting to the ultimatum givien by the President to former Vice President Atiku Abubakar and the defecting governors and others to return to the PDP or risk losing "their seniority" in the PDP, the spokesman of the defunct New Peoples Democratic Party (nPDP) said the possibility of Atiku and the dissenting governors who defected to the APC returning to the PDP is zero.
"With due respect, President Jonathan is simply playing to the gallery. For the avoidance of doubt, Atiku, Amaechi and the other patriots who left the sinking and undemocratic PDP have no intention of returning to the party, either now or in the future. They are happy in the APC, so Mr. President can keep his seniority as Atiku and the rest do not need it. Only a mad fellow will run away from a sinking ship and run back to such a ship," Eze said in a statement.
President Jonathan is expected to make more tour of states ostensibly for the 2015 elections, which he is seen to be interested in running, which is one of the reasons that has polarised his party. His recent visit to the opposition state is largely seen as a bold step to realise his ambition and would be used as a soft template for his campaigns, even though he yet to officially declare his intention to run in 2015.
The President later went to Kano, Oyo, Osun and Lagos States respectively on visits to the paramount rulers of the states. Thereafter, he proceeded to Imo and Anambra States to receive decampees and new members into the PDP and also to pay homage to the traditional rulers there including the Obi of Onitsha.


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This property has been removed by the agent. It may be sold or temporarily removed from the market
3 bedroom cottage for saleResidential or Commercial Opportunity, in a prominent town centre location. Rental Opportunity
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Property Description
Full description
Yvonne Fitzgerald and RE/MAX Premier are delighted to bring to the market this prominent property, which was previously used as a family home. Although currently utilised as a commercial building, subject to the necessary planning consents, it would not take too much to transform this building back to residential use.
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Location The market town of Dingwall lies approximately 14 miles from Inverness and is the main retail and service centre for the Ross-shire area. The property is located in Hill Street in Dingwall in the center of Dingwall. Local amenities include Hospital, Banks, Post office, Council office, Service point, Dentists, Supermarkets, Train and bus links with regular services to Inverness, Thurso and Wick to name a few.
EPC Rating - G
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