Am. J. Trop. Med. Hyg., 84(3), 2011, pp. 364–369
Copyright © 2011 by The American Society of Tropical Medicine and Hygiene
Female urogenital schistosomiasis (FUS) is predominantly
caused by Schistosoma haematobium and has been estimated
by the World Health Organization (WHO) to affect up to 45
million women living in sub-Saharan Africa. 1 Adult S. haemato-
bium worms inhabit blood vessels surrounding the urinary blad-
der and female genital tract and lay eggs that migrate through
tissue of proximate organs, causing chronic granulomatous
inflammation most commonly in the urinary bladder, ureters,
cervix, and vagina. Because the urinary and genital tracts are
almost always both affected, the WHO has recently renamed
this disease urogenital schistosomiasis, with detection of S. hae-
matobium in the urine or genital tract being diagnostic. 1
Chronic female genital-tract inflammation caused by S. hae-
matobium has been associated with vaginal itching and dis-
charge, 2 post-coital bleeding, 3 genitopelvic discomfort, 4 marital
discord, 5 and infertility. 6, 7 Genital S. haematobium infection has
been associated with human immunodeficiency virus (HIV)
infection in one cross-sectional study 7 and has been postulated
to be a risk factor for HIV infection. 8, 9
Tanzania’s Lake Victoria region in northwestern Tanzania
borders Kenya, Uganda, and Rwanda and is believed to have
among the highest prevalence of S. haematobium in the world,
with a prevalence of 50–90% reported in young schoolchil-
dren. 10 The prevalence of S. haematobium infection has not
been quantified in women of reproductive age, the population
at risk for increased HIV infection. Therefore, we conducted
a study in Tanzania’s Lake Victoria region to determine the
prevalence and identify risk factors for FUS among women of
MATERIALS AND METHODS
Study sites and subjects. This cross-sectional study was
conducted between August 2009 and May 2010 near Lake
Victoria in northwest Tanzania in partnership with a cervical
cancer screening program being conducted at local health
centers. Women who were receiving free cervical cancer
screening between the ages of 18 and 50 years who provided
written consent were invited to participate in the FUS
prevalence study. Women who were menstruating or refused
gynecologic examination were excluded. Pregnant and
breastfeeding women were included.
Urine and gynecologic examination. A single urine sample
was collected from women between 10 AM and 2 PM, and
it was filtered and examined microscopically by a trained
parasitologist for Schistosomal ova. A subset of the urine
samples was read by two parasitologists for quality control.
Women who provided informed consent underwent a gyne-
cological examination. A swab of vaginal secretions was col-
lected for wet preparation and microscopic examination for
diagnosis of Candida (using a potassium hydroxide prepara-
tion), Trichomonas vaginalis (using warm normal saline), and
bacterial vaginosis by Amsel’s criteria. 11 Next, a cervical smear
was collected using a plastic spatula. Smears were stained with
0.5% Trypan Blue and examined for schistosomal ova while
fresh. Acetic acid was then applied to the face of the cervix
and was followed by inspection for abnormal areas after 1 min-
ute. Abnormal cervical lesions were biopsied. Specimens were
stained with Hematoxylin and Eosin (H&E) for histopatho-
logical examination and Trypan Blue to examine for schisto-
somal ova using the crush technique previously described. 6, 12
Biopsies were not performed on pregnant women.
FUS was defined using WHO criteria: the presence of at
least one schistosomal ovum seen in the urine sample, cervical
smear, or cervical biopsy. 1
Other laboratory studies. Single stool samples for S. mansoni
ova were processed by the Kato–Katz technique. HIV volun-
tary counseling and testing were offered to all participants.
For those who agreed to be tested, blood was collected and
tested using a rapid test (SD Bioline, Standard Diagnostics,
Inc., South Korea). Testing was performed in the field, and
patients received their results immediately. Venous blood was
also collected and tested for syphilis using the rapid plasma
reagin (RPR) test, and positive tests were confirmed with the
Treponema pallidum particle agglutination assay (TPPA).
Interview. Women also participated in a 20-minute structured
interview about water contact, gynecologic symptoms, sexual
Urogenital Schistosomiasis in Women of Reproductive Age in Tanzania’s Lake Victoria Region
Jennifer A. Downs ,* Charles Mguta , Godfrey M. Kaatano , Katrina B. Mitchell , Heejung Bang , Harusha Simplice ,
Samuel E. Kalluvya , John M. Changalucha , Warren D. Johnson Jr. , and Daniel W. Fitzgerald
Weill-Cornell Medical College, New York, New York; Weill-Bugando University College of Health Sciences, Mwanza, Tanzania;
National Institute for Medical Research—Mwanza Research Centre, Mwanza, Tanzania;
New York Presbyterian Hospital Weill-Cornell Medical Center, New York, New York;
Sengerema Regional Hospital, Sengerema, Tanzania
Abstract. We conducted a community-based study of 457 women aged 18–50 years living in eight rural villages in
northwest Tanzania. The prevalence of female urogenital schistosomiasis (FUS) was 5% overall but ranged from 0% to
11%. FUS was associated with human immunodeficiency virus (HIV) infection (odds ratio [OR] = 4.0, 95% confidence
interval [CI] = 1.2–13.5) and younger age (OR = 5.5 and 95% CI = 1.2–26.3 for ages < 25 years and OR = 8.2 and 95% CI =
1.7–38.4 for ages 25–29 years compared with age > 35 years). Overall HIV prevalence was 5.9% but was 17% among
women with FUS. We observed significant geographical clustering of schistosomiasis: northern villages near Lake Victoria
had more Schistosoma mansoni infections ( P < 0.0001), and southern villages farther from the lake had more S. haemato-
bium ( P = 0.002). Our data support the postulate that FUS may be a risk factor for HIV infection and may contribute to
the extremely high rates of HIV among young women in sub-Saharan Africa.
* Address correspondence to Jennifer A. Downs, Center for Global
Health, Weill-Cornell Medical College, 440 East 69th Street, New
York, NY 10065. E-mail: email@example.com
FEMALE UROGENITAL SCHISTOSOMIASIS IN TANZANIA
history, and depression. The interview was administered by
a nurse in Kiswahili. Women were asked to use a four-point
Likert scale to quantify how much, over the past 4 weeks, they
had been bothered by dyspareunia, vaginal discharge, post-
coital bleeding, abdominopelvic pain, infertility, menstrual
abnormalities, genital itch, and incontinence. Using a five-point
Likert scale to assess sexual dysfunction, women were also
asked how much they worried about pain during intercourse,
made excuses to avoid intercourse, had experienced decreased
frequency or quality of intercourse, and were concerned about
partner infidelity. We assessed the responses to these questions
as binary variables, where answers of very much or somewhat
were considered positive and answers of rarely or not at all
were considered negative.
Depression was evaluated using a nine-item depression
scale, the patient health questionnaire-9 (PHQ-9), that has
been previously translated and validated in Kiswahili in several
patient populations. 13, 14 The PHQ-9 consists of nine questions,
each designed to assess for one of nine symptoms of depres-
sion delineated by the Diagnostic and Statistical Manual-IV
(DSM-IV) for depression. These include anhedonia, sleepless-
ness or excessive sleep, hopelessness, poor or excessive appe-
tite, difficulty concentrating, and feelings of failure. Participants
receive between 0 and 3 points on each question, with 0 indi-
cating that they experienced a given symptom not at all and
3 indicating that they experienced the given symptom nearly
every day. A total score of 5–9 indicates mild depression, 10–14
indicates moderate depression, 15–19 indicates moderately
severe depression, and above 20 indicates severe depression. 15
Ethical considerations. The study was explained to women
in a large group and subsequently one on one by a trained
study nurse fluent in the local language. To participate in the
study, women were asked to provide written informed consent
or place their mark on the consent form. At the local level,
permission was obtained from the District Medical Officers
and clinicians stationed at participating dispensaries and health
centers. Ethical approval was granted by the research ethics
committee at Bugando Medical Center, the Medical Research
Coordinating Committee of the National Institute for Medical
Research in Tanzania, and the Institutional Review Board at
Weill-Cornell Medical College.
Women diagnosed with urogenital or intestinal schistosomi-
asis, syphilis, trichomoniasis, candidiasis, or bacterial vagino-
sis received free treatment. Women with trichomoniasis were
given medication both for themselves and their sexual part-
ners. Women with syphilis and their sexual partners received
three intramuscular injections of penicillin at the clinic.
Patients diagnosed with HIV were referred to nearby district
or regional hospital-based clinics for free care and treatment.
Women with cervical dysplasia or cancer were referred to
tertiary institutions for further management, and all of them
accessed care successfully.
Statistical methods. Data were entered into a research elec-
tronic data capture (REDCap) database (Vanderbilt University,
Nashville, TN). Continuous variables were summarized by
median and interquartile range, and categorical variables were
summarized by frequency and percentage. Regional disparity of
infections was assessed by Fisher’s exact test; the association of
infection status and region was evaluated using northern versus
southern designation (in a 2 × 2 table) as well as individual
regions (in a 2 × 8 table). Factors that were associated with
the endpoint (i.e., FUS) were examined by multiple logistic
regression. Backward elimination was adopted to reach the
final parsimonious model that included significant factors
only—starting from a full model with all of the candidate
predictors (all factors presented in Tables 1 – 3 ) and deleting the
least significant factor one at a time until only the predictors
with P value < 0.05 remain in the model. We also confirmed
that the automatic variable selection procedures (e.g., stepwise,
forward, and backward selection) yielded the same final model.
We analyzed age in two different ways—using a continuous
variable and categorized variables (with 25, 30, and 35 years
as cutoff points, which approximately corresponded to lower
quartile, median, and upper quartile, respectively).
Association between factors and the endpoint was summa-
rized in odds ratio (OR) along with 95% confidence interval
(CI) and the associated P value. We also computed the area
under the receiver-operating characteristic curve (AUC) to
ascertain the discrimination capability of the factors for FUS
cases versus non-cases—AUC of 0.5 means that the discrimi-
nation capability is no better than chance, and 1 means perfect
SAS 9.2 (Cary, NC) was used for data analyses. Two-sided
hypotheses/tests were assumed for computation of all CIs and
Patient characteristics. Of 550 eligible women who pre-
sented to primary care clinics and were invited to participate
in the study, 457 women (83.1%) consented to participate
and completed all study procedures. Characteristics of study
participants are shown in Table 1 . The median age was
30 years (interquartile range [IQR] = 24–35 years). The great
majority was married, had at least one child, and worked in
Baseline characteristics of 457 women attending primary care clinics
for schistosomiasis screening in Mwanza, Tanzania
Age in years median (interquartile range)
Marital status (number)
Living with partner
Having at least one child (number)
People living in household (number)
More than 10
Agriculture and/or petty trade
Went to bed hungry in the past month (number)
Number of water contacts per day median
(interquartile range) †
Ever treated for schistosomiasis (number)
Received an artemesinin-containing medication
for malaria in the past 3 years (number)
10 (2.2%) *
* Percentages were calculated using a denominator of the total sample size of 457. Missing
data are present in some variables (with < 7%). Age was missing for six women, and water
contact data were missing for 21 women.
† Water contact behaviors combined the following information (swimming, bathing oneself
or a child, washing clothes, hands, animals, or dishes, collecting water for use in the home, fish-
ing, using water for crops, wading in water to cross it, and cultivating rice) by summing their
frequencies and dividing by 30.
DOWNS AND OTHERS
farming and petty trade. Participants had a median number of
14 contacts with potentially infectious water per day, and no
woman reported zero contacts. One-third reported receiving
treatment for schistosomiasis in the past.
Prevalence of S. haematobium and S. mansoni infections.
The prevalence rates for S. haematobium and S. mansoni
are presented in Table 2 , and a map of the area with the
villages where screening took place is shown in Figure 1 . The
prevalence of S. haematobium infections was higher among
women living in southern inland villages than in northern
villages along the shores of Lake Victoria. The prevalence in
the south was 13 of 120 (10.8%) compared with 10 of 337 (3%)
in women who lived in northern lakeside villages ( P = 0.002).
Of the 23 women with urogenital schistosomiasis included in
the analysis, 16 had S. haematobium ova detected in the urine
only, 6 had S. haematobium ova detected in a genital specimen,
and 1 had S. mansoni ova visualized on a cervical smear.
S. mansoni infection, by contrast, was only detected among
women living in northern villages near the lake. Among
337 women living in northern lakeside villages, 31 (12.2%)
were infected with S. mansoni , and among 120 women in
southern inland villages, none were infected ( P < 0.0001).
Prevalence of other infections. Of the 457 women examined,
33 had bacterial vaginosis (7.2%), 22 had candidiasis (4.8%), and
15 had trichomoniasis (3.3%). Twenty-seven women were HIV-
infected (5.9%), and 33 had reactive syphilis serology (7.2%).
Prevalence of gynecologic symptoms, sexual dysfunction,
and depression. Gynecologic symptoms reported most
commonly by women included abdominopelvic pain (75.5%),
menorrhagia (56.0%), genital itching (54.5%), dysmenorrhea
(54.3%), dyspareunia (42.9%), and foul-smelling discharge
(31.1%) ( Table 3 ). The majority of women stated that they
made excuses to avoid sexual intercourse (66.1%), and 40.9%
of women were worried that their partner would have sexual
relations outside of the relationship. Notably, 77% of women
met criteria for depression based on the PHQ-9 scale. Of the
457 women, 259 (57%) were mildly depressed, and 92 (20%)
had moderate to severe depression.
Factors associated with FUS. We examined associations
between baseline characteristics, other infectious diseases,
and female urogenital schistosomiasis. Younger age was
significantly associated with FUS ( Table 4 ). As a continuous
variable, age in years showed an OR of 0.92 (95% CI = 0.86–
0.98), which may be interpreted as approximately an 8%
decrease in odds of disease per 1 year increase in age. As a
categorized variable, age had an OR of 5.5 (95% CI = 1.2–26.3)
for women who were younger than 25 years old, 8.2 (95% CI =
1.7–38.4) for those who were 25–29 years old, and 1.2 (95% CI =
0.16–8.4) for those who were 30–34 years old compared with
women who were 35 years old or older (reference group).
HIV was also significantly associated with FUS, with an
OR of 4.0 (95% CI = 1.2–13.5). Of the 23 women with FUS,
4 (17.4%) were HIV-infected compared with 23 (5.3%) of
434 women without FUS. There were no significant differ-
ences among women with and without FUS in the overall rates
of other vaginal or sexually transmitted infections including
candidiasis, trichomoniasis, bacterial vaginosis, or syphilis, and
there were no other significant differences in other variables.
The final regression model with the two risk factors—age and
HIV status—resulted in AUC of 0.732 (age as continuous vari-
able) and AUC of 0.72 (age as categorical variable), which are
much higher than null value of AUC = 0.5.
Prevalence of gynecologic symptoms, sexual dysfunction, and depres-
sion in 457 women in Mwanza, Tanzania
Number (percent) *
Gynecologic symptoms †
Difficulty becoming pregnant
Foul-smelling vaginal discharge
Sexual dysfunction ‡
Fearful of pain during sexual intercourse
Makes excuse to avoid sexual intercourse
Decrease in quality or frequency of sexual relations 242 (53.0%)
Worry that partner will have sexual relations
outside of relationship
Score on depression scale
No depression (0–4 points)
Mild depression (5–9 points)
Moderate depression (10–14 points)
Moderately severe or severe depression (≥ 15 points)
* Percentages were calculated using a denominator of the total sample size (457) to capture
existing symptoms. Depression score was missing for 58 women, whereas less than 5.5% of
data was missing for all other variables.
† Includes women that answered that they were somewhat or very much bothered by the
‡ Includes women that answered I agree or I agree completely that they experience the
Prevalence of schistosomiasis and HIV in eight villages in the Mwanza region of Tanzania’s Lake Zone
No. with HIV
No. with S. haematobium
No. with S. mansoni
of S. haematobium
of S. mansoni
P value *
10/337 (3.0%)41/337 (12.2%)
13/120 (10.8%)0/120 (0%)
< 0.0001 † 0.002 < 0.0001
* All P values were computed by Fisher’s exact test.
† For this specific P value, Monte Carlo estimation of exact P values instead of direct exact P value computation was used because of time and memory problems encountered for exact
FEMALE UROGENITAL SCHISTOSOMIASIS IN TANZANIA
Figure 1. Map of the Mwanza region in Tanzania’s Lake Victoria region with village locations. Northern villages nearer to Lake Victoria,
with lower rates of S. haematobium and higher rates of S. mansoni , are depicted with yellow dots. Southern villages, with higher rates of
S. haematobium and no S. mansoni infection detected, are depicted with red dots.
FUS affects young women, is associated with HIV infec-
tion, and is prevalent in inland villages of the Lake Victoria
region of Tanzania. Our study builds on the findings of a previ-
ous study in Zimbabwe, which showed an association between
HIV infection and S. haematobium detected in cervical speci-
mens, with an OR of 2.9 (95% CI = 1.2–3.5). 7 The authors of
the earlier study postulated that genital schistosomiasis may
pre-dispose to HIV infection. Our work extends this finding
by showing an association between HIV infection and the
newly expanded WHO case definition of urogenital schistoso-
miasis. This finding, in light of the high prevalence of FUS in
women of reproductive age, may have important public health
implications for prevention of HIV infection.
Although a causal association between FUS and HIV infec-
tion will require a prospective longitudinal study, a number
of factors support the hypothesis that the risk of HIV acqui-
sition is augmented by the presence of FUS. First, schisto-
somal infection is generally acquired during childhood, before
the commencement of sexual activity. Second, it has been
pointed out that genital schistosomiasis may increase the risk
of HIV infection through its disruption of the genital-tract
epithelium. 8 Third, schistosomiasis can stimulate a Th-2–type
immune response similar to other chronic parasitic infections.
This produces changes in cytokines and an accompanying up-
regulation of the HIV coreceptors CC chemokine receptor
5 (CCR5) and CXC chemokine receptor 4 (CXCR4) on
monocytes and lymphocytes, with an overall shift in the body’s
immune response away from the Th-1 immunity that provides
early initial control in HIV infection. 16, 17 Fourth, the inflam-
matory reaction to schistosomal eggs in genital lesions may
increase the numbers of lymphocytes and activated mac-
rophages in the cervical tissue; these are target cells for HIV
infection. Finally, HIV-positive patients with helminth coinfec-
tions seem to have higher viral loads than those without coin-
fections and therefore may experience both higher rates of
HIV transmission and more rapid HIV progression. 17, 18 For all
of these reasons, the WHO and others have suggested that mass
treatment of FUS may be an effective strategy for decreasing
HIV transmission in sexually active women in Africa. 1, 9
The association of FUS with younger age of 18–29 years is
consistent with the natural history of schistosomiasis, and it has
important public health ramifications. The age of peak preva-
lence for S. haematobium infection is between 8 and 15 years
old, with peaks in the later end of this spectrum occurring in
communities with lower prevalence of disease. 19– 21 Repeated
exposure to the parasite over time leads to the development
of at least partial immunity in later adulthood. 19, 21 Our findings
show that, in communities in which the prevalence of disease
is at least moderate in children (50–90% in a previous study), 10
women continue to have urogenital schistosomiasis through-
out their teens and twenties. This is also the age at highest risk
for HIV transmission. 22 Women between the ages of 18 and
29 years are not a focus of school-based anti-schistosomal
treatment campaigns in sub-Saharan Africa, but the substan-
tial burden of FUS in this age group argues strongly for tar-
geted FUS treatment.
Our study suggests that, although S. mansoni may be geo-
graphically isolated near the Lake shores, S. haematobium may
be more widespread in inland villages throughout the region,
placing more women at risk for urogenital schistosomiasis and
Factors associated with female urogenital schistosomiasis
in FUS group
( n = 23)
Number (%) in
( n = 434)
(95% CI) P value
Negative or unknown
5.5 (1.2–26.3) 0.03
8.2 (1.7–38.4) 0.008 *
1.2 (0.16–8.4) 0.887
4.0 (1.2–13.5) 0.024
* Area under the receiver-operating characteristic curve (AUC) = 0.72. When we fitted the
same model using age as a continuous variable, P value for age was 0.082, and AUC was 0.732.
DOWNS AND OTHERS
potentially, increased HIV transmission. A school-based sur-
vey in central Sudan reported a comparable marked variation
in the prevalence and intensity of both infections, even over
short distances within the same province. 23 A compilation of
over 2,000 studies conducted in East Africa between 1980 and
2009 revealed starkly distinct distributions for S. mansoni and
S. haematobium , including the observation that S. mansoni is
most prevalent along the shores of large lakes, including Lake
Victoria. 24 Near Lake Victoria in Tanzania, studies in school-
children have similarly found that the prevalence of S. mansoni
decreased and the prevalence of S. haematobium increased
with increasing distance from the lake. 10, 25 Thus, although our
designation of northern and southern villages was not chosen
a priori , our finding of significantly distinct parasite distribu-
tions in each of these regions is supported by other studies in
This clustering has been attributed to differences in the ecol-
ogy preferred by the intermediate snail vectors Biomphalaria
spp. (for S. mansoni ) and Bulinus spp. (for S. haematobium ).
Bulinus snails are capable of aestivation and thus are able to
colonize and survive in temporary water sources that dry up
for months of the year. In contrast, Biomphalaria snails do
not aestivate and therefore require large permanent bodies of
water with at least moderate aquatic vegetation for survival. 26
Because of these characteristics, transmission of S. haemato-
bium is generally more widespread than S. mansoni , but it is
also more seasonal, with highest transmission occurring after
the rainy season when snails are not dormant. 25, 26
Another important finding from this study was the high
prevalence of depression among these women in rural vil-
lages. We found that 20% of women scored 10 or above on the
PHQ-9 scale, consistent with moderate to severe depression.
A PHQ-9 score above 10 is 88% sensitive and 88% specific for
major depression as defined by the DSM-IV criteria. 15 Other
community-based studies in sub-Saharan Africa have reported
a similar, although slightly lower, prevalence of major depres-
sion by DSM-IV criteria in 5–15% of women, with a higher
prevalence in those living in rural settings. 27, 28 Thus, our find-
ings highlight an additional prevalent healthcare need that
affects rural women in sub-Saharan Africa.
This work underscores the significant burden and breadth of
diseases—including parasitic, sexually transmitted, and men-
tal health-related—in women of reproductive age living in
rural northwest Tanzania. Because of resource constraints, we
relied on single urine and stool samples to estimate prevalence
of intestinal and urogenital schistosomiasis. In all likelihood,
had we analyzed urine and stool samples on 3 consecutive
days, the prevalence of these infections would have been even
higher than those that we observed. Schistosomiasis in women
of reproductive age is not currently a focus of public health
screening or treatment, but the infection is common and wide-
spread among this population. It has been pointed out that
control of FUS, and possibly, the opportunity to curtail new
HIV infections, may cost as little as 32 cents per woman. 9
In conclusion, FUS is a geographically clustered infection
that disproportionately affects women younger than 30 years
of age and is significantly associated with HIV infection. These
young women, who also have the highest risk for incident
HIV infection and in whom genital lesions may be revers-
ible if treated early, should be the focus of public health inter-
ventions aimed to reduce the prevalence of S. haematobium
Received October 15, 2010. Accepted for publication December 6,
Acknowledgments: The authors thank Bugando Medical Centre,
Weill-Bugando University College of Health Sciences, and the
National Institute for Medical Research—Mwanza Research Centre
for their invaluable support in the design and conduct of this study.
Financial support: This study was supported by the 2009 Merle A.
Sande/Pfizer Fellowship Award in International Infectious Diseases,
which is awarded annually by the Infectious Diseases Society of
America Education and Research Foundation and the National
Foundation for Infectious Diseases. This work was supported by Grant
T32 HS000066 from the Agency for Healthcare Research and Quality
(AHRQ) and by the Clinical and Translational Science Center Grant
Authors’ addresses: Jennifer A. Downs, Warren D. Johnson Jr., and
Daniel W. Fitzgerald, Center for Global Health, Weill-Cornell Medical
College, New York, NY, E-mails: firstname.lastname@example.org , wdjohnso@
med.cornell.edu , and email@example.com . Charles Mguta, Weill-
Bugando University College of Health Sciences, Mwanza, Tanzania,
E-mail: firstname.lastname@example.org . Godfrey M. Kaatano and John
M. Changalucha, National Institute for Medical Research—Mwanza
Research Centre, Mwanza, Tanzania, E-mails: gmkaatano@yahoo
.com and email@example.com. Katrina B. Mitchell, Department
of Surgery, New York Presbyterian Hospital Weill-Cornell Medical
Center, New York, NY, E-mail: firstname.lastname@example.org . Heejung
Bang, Department of Public Health, Weill-Cornell Medical College,
New York, NY, E-mail: email@example.com . Harusha Simplice,
Sengerma District Hospital, Sengerema, Tanzania, E-mail: hsimplice@
yahoo.co.uk . Samuel E. Kalluvya, Weill-Bugando University College
of Health Sciences and Bugando Medical Centre, Mwanza, Tanzania,
E-mail: firstname.lastname@example.org .
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