Schistosomiasis in Lake Malawi

Abstract

Background: In 1992 two US Peace Corps volunteers (PCVs) developed central nervous system schistosomiasis due to infection with Schistosoma haematobium following recreational water exposure at Cape Maclear on Lake Malawi, an African lake considered by many to be free of schistosomiasis. To determine the transmission potential and risk for aquiring schistosomiasis in Lake Malawi, a cross-sectional survey of resident expatriates and visitors to Malawi was done during March and April, 1993.

Methods: A volunteer cohort of expatriates and visitors representing a cross-section of Malawi's foregn population answered detailed questions about freshwater contact and provided blood specimens to determine the seroprevalence of S haematobium and S mansoni by ELISA and immunoblot analyses. A survey for vector snails was conducted along Lake Malawi's southwestern shore.

Findings: The study population of 955 included 305 US citizens and 650 non-US foreign nationals. 303 of the study population had serological evidence of current or past schistosome infection. Seroprevalence was 32% (141/440) among expatriates whose freshwater exposure was limited to Lake Malawi; S haematobium antibodies were found in 135 of 141 (96%) seropositive specimens. Risk of seropositivity increased with the number of freshwater exposures at Lake Malawi resorts. Although many resort areas in the southwestern lake region posed a significant risk, Cape Maclear was the location most strongly associated with seropositivity (OR 2.9, 95% Cl 1.6-5.1). Schistosome-infected Bulinus globosus, the snail vector of S haematobium in Malawi, were found at Cape Maclear and other locations along the lakeshore.

Interpretation: S haematobium infection is highly prevalent among expatriates and tourists in Malawi. Recreational water contact at popular resorts on Lake Malawi is the most likely source of infection. Transmission of schistosomiasis is occurring in Lake Malawi, a previously under-recognised site of transmission.

PIP: Schistosomiasis is a parasitic infection caused by trematodes. Humans are infected through skin contact with free-swimming cercariae which develop in freshwater snails. Schistosomiasis has been endemic to Malawi for several decades, but the open waters and shores of Lake Malawi have long been thought to be risk-free with regard to schistosomiasis transmission. However, in 1992, two US Peace Corps volunteers developed central nervous system schistosomiasis due to infection with Schistosoma haematobium following recreational water exposure at Cape Maclear on Lake Malawi. In light of these infections, a cross-sectional survey of resident expatriates and visitors to Malawi was subsequently conducted during March-April 1993 to determine the transmission potential and risk for acquiring schistosomiasis in the lake. 305 US citizens and 650 non-US foreign nationals participated in the study. Serological evidence of current or past schistosome infection was identified in 303 subjects. Indeed, seroprevalence was 32% among expatriates whose freshwater exposure was limited to Lake Malawi; S. haematobium antibodies were found in 135 of 141 seropositive specimens. The risk of seropositivity increased with the number of freshwater exposures at Lake Malawi resorts. While many resort areas in the southwestern lake region posed a significant risk, Cape Maclear was the location most strongly associated with seropositivity. Schistosome-infected Bulinus globosus, the snail vector of S. haematobium in Malawi, were found at Cape Maclear and other locations along the lakeshore.