University of Florida College of Public Health and Health Professions April 11, 2014

1. Research Project and Internship Reporton the Investigation of Schistosomiasis (S. mansoni) in Haiti Presented by Kevin J. Talbot University of FloridaCollege of Public Health and Health ProfessionsApril 11, 2014

2. Background of Research Project and Internship Initiation in Haiti • Early awareness of “Project Haiti” with UF and other opportunities with AHS upon program entry • Introduction to Dr. Madsen Beau De Rochars (PHHP) in early 2013 • Initial proposition and development of Schistosoma mansoni investigation in Summer of 2013

3. Schistosomiasis Background • The global impact : 2nd to malaria only in parasitic diseases prevalence • Affects ~200 million people in addition to the 800 million people at risk • Annually: 70 million disability adjusted life years • NTDs affect at least 149 countries • Approximately 534,000 annual deaths

4. General Symptoms Depends on the Schistosoma spp. Involved (Big: 5 : S. mansoni,, S. japonicum, S. mekongi, S. intercalatum, S. haemotobium) • Katayama Syndrome • Bladder and liver function impairment and scarring • Hepatosplenomegaly • Gastrointestinal cancers with chronic exposure • HIV infection increased in infected women • In children: anemia, growth retardation, mental retardation, impaired renal function and other diarrheal symptoms

5. Schistosoma spp. Reproductive Cycle Source: CDC

6. Rationale & Foundation for SchistosomamansoniInvestigation in Haiti • No official lab confirmed cases • Proximal geographical endemics-DR • Need for re-evaluation/current state of NTDs in Caribbean, (PAHO) • Intermediate host snails of Schistosoma spp. in Northern Haiti • Increased risk of infectious/parasitic diseases post-earthquake • Increased travellers post-earthquake

7. Main Goal of the S.mansoniInvestigation in Haiti • To investigate the potential existence of schistosomiasis in Haiti as caused by the trematodeSchistosomamansoniutilizing an existing community of health partnerships and a cohort of school-aged children through the diarrheal surveillance program.

8. Research Project Methods and Data Attainment • Utilization of an existing cohort from the diarrheal surveillance program • Existing program structure and IRB protocols • Existing community health partnerships and agreements • Existing sample collection system • Existing laboratory installations

9. Research Project Methods and Data Attainment (continued…) • Rationale for the selection of the Kato-Katz technique • USAID, WHO : stool examination still the gold standard for parasitic screening • Ease of utilization in the field • Reasonable sustaining costs • Continuity of endeavors by staff • Ability to screen other parasites

10. Research Project Methods and Data Attainment (continued…) Brief description of the Kato-Katz technique: Based on WHO Parasitic Bench Aid Recommendations Slightly modified to suit specific Gressier, Haiti Lab needs

11. Research Project Methods and Data Attainment (continued…) The stool samples for this research study were: • collected Jan 5 to Feb 7, 2014 • 5 different sites (de-identified) • collected during the dry season • processed within ~8 hours or less of collection • Microscopically examined within 24 hours of collection and processing

12. Research Project Methods and Data Attainment (continued…) Sample Sites Distribution

13. Results: Summary of Findings Summary of Sample Site Collection (Total : 169)

14. Results: Summary of Findings S. mansoniInvestigation Results False positives • No lab confirmed cases of S. mansoni in samples examined • 2 suspected cases reviewed by Dr. Song and Dr. Davies

15. Results: Summary of Other Findings Relevant key findings • 21.9% of all samples collected (37/169) were positive for parasite infection • Most cases originated from Petit-Gouave and Jacmel

16. Results: Summary of Other Findings

17. Discussion: Summary of Findings Clearly, the results of this initial pilot study indicated no lab confirmed cases of S. mansoni in Haiti from the 169 samples analyzed through the Kato-Katz technique and microscopy examination. However, the results from this small scale pilot study are not sufficient to exclude the presence of S. mansoni in Haiti for several reasons including key limiting factors of the current study format as enumerated as follow:

18. Discussion: Limitations of Study

19. Discussion: Limitations of Study

20. Strengths of Study

21. Other Internship Activities : At a Glance • Strengthening of local health partnerships • Dissemination of findings to professionals • Development of research protocols • Training of Gressier lab personnel & beyond • Extensive translation work

22. Other Internship Activities : At a Glance • Environmental scan for Biomphalaria spp. and fresh water • Prepared inventory supplies list for S. mansoniresearchexpansion • Prepared a correspondence for the intent of the Haitian Health Ministry • Assisted with cholera water sample surveillance

23. Public Health Competencies Acquired/Reinforced Through The Project • Monitoring health status to identify and solve community health problems • Diagnosing and investigating health problems and health hazards in the community using an ecological framework • Informing, educating, and empowering people about health issues • Mobilizing community partnerships and taking actions to identify and solve health problems • Conducting research for new insights and solutions to health problems • Communicating effectively with public health constituencies in oral and written forms • Effectively managing public health programs and projects • Demonstrating ability to manage, analyze & interpret epidemiologic data

24. Conclusion

25. Acknowledgement • UF –CPHHP- • Dr. Beau De Rochars • Dr. Liang Song • Dr. Tony Maurelli • Dr. Stephen Davies • Meer Talam • UF Gressier Staff • Susan White • Slande Celeste Thank You !!

26. References • Benjamin E. et al ( 2011). Principles and Practice of Disaster Relief: Lessons From HaitiMt Sinai J Med 78:306–318, 2011 • Centers for Disease Control and Prevention (June 2011). Neglected Topical Disease. Online URL: http://www.cdc.gov/globalhealth/ntd/ • Centers for Disease Control and Prevention (Nov 2012). Parasites – Schistosomiasis. Online URL : http://www.cdc.gov/parasites/schistosomiasis/ • King CH, Dickman K, Tisch DJ. Reassessment of the cost of chronic helminthic infection: a meta-analysis of disability-related outcomes in endemic schistosomiasis. Lancet 2005;365:561-9. • PAHO/WHO (2007). Schisto PAHO/WHO Preparatory Meeting on Epidemiological Data Needed to Plan Elimination of Schistosomiasis in the Caribbean (St. George, Grenada, 13–14 December 2007) • Raccurt C.P., et al (1985). Biomphalariaglabrata in Haiti. Trans R Soc Trop Med Hyg.1985;79(4):455-7. • Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J. (2006). Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk. Lancet Infect Dis2006;6:411-25

27. References • WHO (2014). 10 Facts on malaria. Online URL: http://www.who.int/features/factfiles/malaria/en/