Take a look at the Recent articles

A one health approach to reducing schistosomiasis transmission in Lake Malawi

Jay Richard Stauffer

Forest Resources Building, Penn State University, University Park, USA

South African Institute for Aquatic Biodiversity, Grahamstown, South Africa

Henry Madsen

Faculty of Health and Medical Sciences, University of Copenhagen, Denmark

DOI: 10.15761/PMCH.1000115

Article Info
Author Info
Figures & Data


Objective: To review what we know about urinary schistosomiasis in Lake Malawi and summarize our attempts to use fishes as a biological control of the intermediate hosts.

Conclusions: A One Health approach must be employed to effectively control urinary schistosomiasis in Lake Malawi. Health clinics must be supplied with praziquantel for distribution. Education centers must emphasize the need for sanitation and clearly state precautions (e.g., avoid swimming between 1000-1500). Additionally, the importance of snail-eating fishes to control the intermediate hosts must be emphasized. If biological controls are to be implemented, alternate food sources (agriculture, aquaculture) must be made available. A true One Health approach must be utilized to effectively control the transmission of schistosomiasis along the lake shores of Lake Malawi.

Key words

urinary schistosomiasis, Lake Malawi, biological controls, one health


Zoonosis are diseases that can be naturally transmitted between non-human animals and humans and include bacteria, viruses, or parasites (World Health Organization, www.who.int/topics/zoonoses/en/). Conversely, reverse zoonosis or zooanthroponosis is when humans transmit diseases to non-human animals [1]. The transmission of infections among species is intensified by the convergence of humans, other animals, and the environment [2]. Of the 1,461 diseases now recognized in humans, approximately 60% are multi-host pathogens and over the past 30 years 75% of the emerging human infectious diseases were zoonotic [2]. Gibbs [3] listed six interconnected parameters that have increased the rate of emerging diseases including: global trading and tourism; speed of mass transportation; exposure to new pathogens through ecosystem disruption; intensification and monoculture in farming; sophistication of food processing, and evolutionary pressures through overpopulation.

Trematode species have complex life cycles alternating between a final host where sexual reproduction occurs and a first intermediate host where asexual multiplication transpires. Adult trematodes in the final hosts (humans and possibly reservoir hosts) deposit eggs which exit the host via feces or urine. For some species, eggs that reach freshwater hatch to a miracidium that subsequently infect a snail, while eggs of other species are eaten by an appropriate snail inside which, they will hatch and continue their development (e.g., eggs of Clonorchis sinensis and Opisthorchis spp. as well as intestinal trematodes, i.e., Heterophyidae). Through asexual multiplication, a new infective stage develops inside the snail and upon release from the snail, cercariae can either infect the final host directly through skin penetration (e.g., Schistosoma spp. causing schistosomiasis [4]; or they infect its second intermediate host such as fish where they develop into metacercariae (e.g., fish-borne zoonotic trematodes causing clonorchiasis or opisthorchiasis and intestinal flukes causing heterophyasis and crustacean borne trematodes causing paragonimiasis [5-6] ) while for other species, cercariae, the larval stage produced in snail host upon release encyst on aquatic plants (e.g., liver flukes such as Fasciola spp. causing fascioliasis in domestic animals and sometimes humans [7]). Final hosts become infected consuming metacercariae with fish, crustaceans, or aquatic plants.

Certainly, the control of infections by trematodes, which are transmitted from non-human animals (i.e., snails, the first intermediate host or for some species from a second intermediate host) to humans must employ a One Health [8-9] approach such that the parasite is attacked at all stages of its life cycle.

Trematode caused diseases are serious problems of both public health and veterinary importance. Although infections by some of these trematodes in the final hosts can be effectively reduced through medical treatment, reinfection appears very quickly [10-13]. Thus, it is necessary to take a holistic approach to control.

Treatment of infections by trematodes involves the understanding of the multiple host species, environmental control, and behavior modifications and includes several scenarios.

  1.  Interventions to reduce the contamination of water bodies with trematode eggs. Probably, the most effective means of reducing egg contamination would be medical treatment of the final hosts (humans and possibly reservoir hosts). This could also involve sanitary improvements to reduce contamination of waterbodies with human feces or urine; prevention of reservoir hosts to have access to the water bodies e.g. dogs, cats and wild birds for some of the fish borne zoonotic trematodes. In aquaculture, avoiding the use of manure from domestic animals could be an important way of reducing egg contamination as could prevention of rain run-off into the ponds [13].
  2.  Reduce the chance of eggs or miracidia infecting the first intermediate host (freshwater snail) and this could be attempted through snail control using either habitat modification, chemical control, or biological control. Obviously, what is feasible depends on the type of habitat.
  3.  Reducing the likelihood that cercariae or metacercariae infecting a final host. Snail control would reduce cercariae production in transmission sites. For schistosomiasis this could be through reducing water contact through supply of safe water supply. For fish-borne zoonotic trematodes (FZT) this would be attempted through behavioral changes, e.g., not eating raw fish, cooking fish remains before feeding it to animals (pigs, dogs and cats). Preventing these animals from getting to the ponds.

            We have been studying human urinary schistosomiasis in Lake Malawi for more than two decades [14-26]. The purpose of this paper is to review what we know about human schistosomiasis in Lake Malawi and document our attempts to use biological controls to reduce its prevalence.

Schistosomiasis in lake Malawi

Schistosomiasis is one of a few macro parasitic diseases with aquatic intermediate hosts that fish have been used as biological control agents (see Table 1 in Stauffer et al. [14] for a list of parasitic diseases that may be susceptible to control via fish predation). The prevalence of both urinary and intestinal human schistosomes has been documented in the catchment basin of Lake Malawi for close to 100 years [27-29]. Historically the open shorelines of Lake Malawi were free from human urinary schistosomes [15,21]. The only known intermediate host of urinary schistosomes, Schistosoma haematobium, in Lake Malawi was Bulinus globosus, which is found in inland, slow-moving waters, and limited areas within the lake that are protected [15]. Beginning in the mid-1980s, however, infection of tourists and researchers’ swimming in the open waters of Lake Malawi indicated that transmission was occurring in the open waters [14,30-34]. Open water transmission of schistosomiasis was further supported when the prevalence of infection in school-aged children at Chembe Village jumped from 36% in 1978 to to 87.4% in 2003 [17]. At that time, we speculated that overfishing of molluscivorous fishes (i.e., Mylochromis spp., T. placodon) enabled B. globosus to survive in the open waters of the lake. We revised our conjecture when Madsen et al. [35] discovered an endemic snail, Bulinus nyassanus, infected with human schistosomes in the shallow waters of Nankumba Peninsula in southern Lake Malawi.

In a series of experiments, when B. nyassanus were exposed to eggs retrieved from children from Chembe Village, one snail was infected [19]. We collected 24,775 B. nyassanus from Chembe Village and only found 87 (0.4%) infected. Overall, the prevalence of infection of B. nyassanus by S. haematobium ranged from 0-2% at 10 sites along the shore line of Chembe Village (Nankumba Peninsula) [14]. Although rare, clearly S. haematobium can utilize both B. globosus and B. nyassanus as intermediate hosts. No infected B. nyassanus have been found in the northern portions of Lake Malawi. Stauffer et al. [18] postulated that a strain of S. haematobium from other parts of Africa was introduced into the Cape Maclear region by tourists, hybridized with the local strain, and via introgression produced a variety that could use both B. globosus and B. nyassanus as intermediate hosts.

From 2003-2007, the overall prevalence of urinary schistosomiasis in school-aged children varied between 15.3-57.1% in inland villages in Malawi to 56.2-94.0% in lake shore communities [21]. In 2003, Stauffer et al. [14] initiated a lake-wide survey of snail-eating fishes, intermediate hosts of schistosomes, and prevalence of infection in school-aged children. They determined 1) the density of snail-eating fishes (e.g., Trematocranus placodon) was lower than found in 1978; 2) peak densities of snail-eating fishes shifted to deeper waters than found in 1980; 3) increased prevalence of the disease was coincident with a decrease in density of molluscivorous fishes. Stauffer et al. [14] further concluded that the high incidence of schistosomes in southern Lake Malawi was linked to the schistosome using two intermediate hosts.


Lerner et al. [9] postulated that the concept of health be approached on the individual level, the group or population level, and the ecosystem level. We postulate that only with a One Health program can the prevalence of urinary schistosomiasis be effectively controlled within Malawi. Along the shores of Lake Malawi there are several entities that provide treatment for schistosomiasis. Unfortunately, reinfection occurs extremely rapidly. Serological examination of circulating anodic antigens of school children treated for schistosomiasis demonstrated that approximately 70% of the children became re-infected after one year. We have provided extension publications to explain the disease that are published in both English and Chechewa, distributed them throughout the villages, and posted them on the web [36]. We have worked extensively with the Chief of Chembe Village, the Village Development Committee, and the Beach Committee. The people in the village understand the debilitating effects of the disease, how the disease is transmitted, and the fact that overfishing of the snail-eating fishes will increase transmission. They must ask themselves at least two basic questions – “Do I maybe contract a schistosome infection in the future?” or “Do my family and I go to bed hungry?” Thus, we must be able to provide alternate food sources, if fishing is restricted to certain areas and during certain times of the year.

The fish ban (i.e., no-seine-net fishing within 100 m from the shore line) initiated by personnel from the Lake Malawi National Park, was initially met with enthusiasm, but we now have evidence that it is no longer enforced. Although the purpose of the ban was to protect the rock-dwelling small fishes endemic to the park, it also protected the breeding areas of the snail-eating fishes. During the time we were present, we did observe a decrease in prevalence of infection among school-aged children that was associated with an increase in the number of snail-eating fishes. This decrease was probably caused by an interaction between increased numbers of fishes, a reduction in intermediate hosts, and extensive treatment in the village. We proposed a modification of the existing fish ban that would prohibit fishing within 100 m of the shoreline during Jan-Feb and Aug-Sept, when the snail-eating fishes were spawning. During other times of the year, we suggested that the villagers do not line their seines with mosquito nets, thus allowing juvenile and small fishes to escape. If we desire such a fish ban to be successful, however then we must create alternative sources of animal protein during these times; thereby reducing the dependence on fishes harvested from Lake Malawi.

Concluding remarks

In Lake Malawi, transmission of schistosomiasis has been established within the last 20 years along open shorelines with sand or gravel sediment in the southern part of the lake [14,34]. We have evidence that suggests that this is the result of over fishing resulting in a significant decline in densities of molluscivorous fishes; especially seine-net fishing with very fine meshed nets directly from the shore is detrimental to fish populations [17]. Transmission, however, also occurs in the many streams and backwaters which constitute excellent habitats for Bulinus globosus [20]. We intend to address management of these inland waters for aquaculture to reduce fishing pressure in the near shore area of the lake and to control transmission in inland habitats close to the lake.

One solution may be the integrated environmental management required for aquaculture. If properly implemented, such a program could greatly reduce transmission of vector borne diseases (primarily malaria and schistosomiasis). Our research group has many years of experience from working on the Nankumba Peninsula (Mangochi District) through a two-year schistosomiasis control project funded by the Danish International Development Assistance and through an NIH/NSF funded project (5 years) on the relationship between schistosomiasis, snails, and fishes. Some of our ideas for future research on control of schistosomiasis were specifically developed to reduce fishing in the lake primarily through the aforementioned fish ban or structures that physically prevent seine net fishing from the shore and aquaculture in inland habitats. The use of the structures to inhibit fishing was proposed to prevent fishermen from other villages to fish along the shores of Chembe Village. When the fishermen from Chembe Village stopped fishing in the near-shore areas, the number of fishes increased over a five-year period. Subsequently, fishermen from other villages were attracted to Chembe Village and would fish in these near-shore areas. The supply of fish per capita has steadily fallen due to high population growth against declining fish production and this is a real threat to food and nutrition security in Malawi. In 1976, per capita annual fish supply was 12.9 kg. This had fallen to 7.9 kg in the 1990s and then decreased further to 3.6 kg in 2001 (FAO -- http://www.fao.org/fishery/facp/MWI/en#CountrySector-Overview ). Therefore, efforts to supplement production from the natural water bodies would not only increase fish supply but also improve nutrition standards of rural households in the Mangochi District.

People living in the African Region face a heavy and wide-ranging burden of disease, which takes its toll on social and economic development and shortens their life expectancy [37]. Health services in these countries are often not able to address adequately this severe burden of disease. Just as health can drive economic growth, ill-health can push people into poverty and make it very difficult for them to escape the poverty trap [37]. Although poverty can result from ill-health, we believe that poverty alleviation through creation of job opportunities and improved food supply could improve health status, i.e. not only through reduced transmission risk of diseases but also through sensation of self-reliance, job satisfaction, and increased standard of living. Poverty traps are observed in societies too impoverished to generate an economic surplus that can be reinvested to break out of the trap [38]. When societies have no income beyond what is needed for subsistence, infrastructure cannot be built, schools and clinics are insufficient and understaffed, and savings that go towards private enterprise are almost entirely absent [38]. Empowering women is crucial to lifting countries out of poverty and improving health in the Region [37]. Clearly, there is a great need to increase food production in the region. Agriculture will remain a key economic sector for developing countries and agricultural productivity has to increase dramatically, and this requires a multifaceted approach [38]. One of the problems in the health care system is that they are not locally available, and that treatment often is delayed due to costs of transport to higher-level health facilities and thus may be prohibitive. Strengthening local community health centers would result in more prompt health service seeking behavior and if we can improve people’s financial status through creation of job opportunities, health service seeking would also be improved when referral to higher level centers is required, i.e., it is financially possible and not seeking treatment would mean loss of income.

The above must also be coupled with an increase in sanitation throughout the communities along the lake shore. Education of the life cycle of the schistosomes must be taught to both children and adults. Simple behavioral changes such as not entering the water between 1000 and 1500 can be implemented. Health clinics must be established and praziquantel made available to all those who test positive for infection. There truly must be a One Health approach.


  1. Messenger AM, Barnes AN, Gray GC (2014) Reverse zoonotic disease transmission (Zooanthroponosis): A systematic review of seldom-documented human biological threats to animals. Plos One 9: e89055. [Crossref]
  2. King LJ, Anderson AR, Blackmore CG, Blackwell MJ, Lautner EA, et al. (2008) Executive summary of the AVMA one health initiative task force report. J Am Vet Med Assoc 233: 259-261. [Crossref]
  3. Gibbs EP (2005) Emerging zoonotic epidemics in the interconnected global community. Vet Rec 157: 673-679. [Crossref]
  4. Chitsulo L, Engels, D, Montresor A, Savioli L (2000) The global status of schistosomiasis and its control.  Acta Trop 77: 41-51. [Crossref]
  5. Liu Q, Wei F, Liu W, Yang S, Zhang X (2008) Paragonimiasis: an important food-borne zoonosis in China. Trends Parasitol 24: 318-323. [Crossref]
  6. Hung NM, Madsen H, Fried B (2013) Global status of fish-borne zoonotic trematodiasis in humans. Invited review. Acta Parasitol 58: 231-258. [Crossref]
  7. Mas-Coma S, Bargues MD, Valero MA (2005) Fascioliasis and other plant-borne trematode zoonoses. Int J Parasitol 35: 1255-1278. [Crossref]
  8. Gibbs EP (2014) The evolution of One Health: a decade of progress and challenges for the future. Vet Rec 174: 85-91. [Crossref]
  9. Lerner H, Berg C (2015) The concept of health in One Health and some practical implications for research and education: what is One Health? Infect Ecol Epidemiol 5: 10.3402/iee.v5.25300. [Crossref]
  10. Wilkins HA (1989) Reinfection after treatment of schistosome infections. Parasitol Today 5: 83-88. [Crossref]
  11. Kariuki HC, Madsen H, Sturrock RF, Ouma JH, Butterworth AEB, et al.  (2013) Long term study on the effect of mollusciciding with niclosamide in streamhabitats on the transmission of schistosomiasis mansoni after community-basedchemotherapy in Makueni District, Kenya. Parasit Vectors 6: 107. [Crossref]
  12. Lier T, Do DT, Johansen MV, Nguyen TH, Dalsgaard A, et al.  (2014) High reinfection rate after preventive chemotherapy for fish borne zoonotic trematodes in Vietnam. PLoS Negl Trop Dis 8: e2958. [Crossref]
  13. Clausen JH, Madsen H, Van PT, Dalsgaard A, Murrell KD (2015) Integrated parasite management: path to sustainable control of fish borne trematodes in aquaculture. Trends Parasitol 31: 8-15. [Crossref]
  14. Stauffer JR, Arnegard ME, Cetron M, Sullivan JJ, Chitsulo LA, et al.  (1997) The use of fish predators to control vectors of parasitic disease: Schistosomiasis in Lake Malawi - A case history. BioScience 47: 41-49.
  15. Stauffer JR, Madsen H, Webster B, Black K, Rollinson D, et al.  (2008) Schistosoma haematobiumin Lake Malawi: snail hosts (Bulinus globosus, Bulinus nyassanus) susceptibility and molecular diversity. J Helminthol 82: 377-382. [Crossref]
  16. Stauffer JR, Madsen H, Konings A, Bloch P, Ferreri CP, et al. (2007) Taxonomy: A precursor to understanding ecological interactions among schistosomes, snail hosts, and snail-eating fishes. Transactions of the American Fisheries Society 136: 1136-1145.
  17. Stauffer JR, Madsen H, McKaye K, Konings A, Bloch P, et al.  (2006) Schistosomiasis in Lake Malawi: Relationship of fish and intermediate host density to prevalence of human infection. EcoHealth 3: 22-27.
  18. Stauffer JR, Madsen H, Rollinson D (2014) Introgression in Lake Malawi: Increasing the threat of human urogenital schistosomiasis? EcoHealth 11: 251-254. [Crossref]
  19. Stauffer JR, Madsen H, Webster B, Black K, Rollinson D, et al.  (2008) Schistosoma haematobium in Lake Malawi: susceptibility and molecular diversity of the snail hosts Bulinus globosus and B. nyassanus. J Helminthol 82: 377-382. [Crossref]
  20. Madsen H, Stauffer JR, Bloch P, Konings A, McKaye KR, et al.  (2004) Schistosomiasis transmission in Lake Malawi. African Journal of Aquatic Sciences 29: 117-119.
  21. Madsen H, Bloch P, Makaula P, Phiri H, Furu P, et al. (2011) Schistosomiasis in Lake Malawi villages. EcoHealth 8: 163-176.
  22. Madsen H, Stauffer JR (2011) Density of Trematocranus placodon (Pisces: Cichlidae): A predictor of density of the schistosome intermediate host, Bulinus nyassanus (Gastropoda: Planorbidae), in Lake Malawi. EcoHealth 8: 177-189. [Crossref]
  23. Madsen H, Stauffer JR (2012) The burrowing behaviour of Bulinus nyassanus, intermediate host of Schistosoma haematobium, in Lake Malawi. African Journal of Aquatic Science 37: 113-116.
  24. Evers BN, Madsen H, McKaye KR, Stauffer JR (2006) The schistosome intermediate host, Bulinus nyassanus, is a preferred food for the cichlid fish, Trematocranus placodon, at Cape Maclear, Lake Malawi. Ann Trop Med Parasitol 100: 75-85. [Crossref]
  25. Evers BN, Madsen H, Stauffer JR (2011) Crush-resistance of soft-sediment gastropods of Lake Malawi: Implications for prey selection by molluscivorous fishes. Journal of Freshwater Ecology 26: 85-90.
  26. Lundeba M, Likongwe JS, Madsen H, Stauffer JR (2007) Potential of Metriaclima lanisticola for biological control of schistosome intermediate host snails. African Zoology 42: 45-49.
  27. Lundeba M, Likongwe JS, Madsen H, Stauffer JR (2011) Oral shelling of Bulinus spp. (Mollusca: Planorbidae) by the Lake Malawi cichlid, Metriaclima lanisticola (Pisces: Cichlidae). Journal of Freshwater Ecology 27: 1-5.
  28. Dye WH (1924) Splenomegaly and schistosomiasis in Central Africa. Journal of the Royal Army of Medical Corps 43: 161-181.
  29. Cullinan ER (1945) Medical disorders in East Africa. Trans R Soc Trop Med Hyg 39: 353-368. [Crossref]
  30. Ransford ON (1948) Schistosomiasis in the Kota Kota district of Nyasaland Trans R Soc Trop Med Hyg 41: 617-628. [Crossref]
  31. Harries AD, Fryatt R, Walker J, Chiodini PL, Bryceson AD (1986) Schistosomiasis in expatriates returning to Britain from the Tropics: a controlled study. Lancet 327: 86-88. [Crossref]
  32. Whitworth JAG (1993) Schistosomiasis. May be contracted through swimming in Lake Malawi. BMJ 307: 936. [Crossref]
  33. Pollner H, Schwartz A, Kobrine A, Parenti DM (1994) Cerebral schistosomiasis caused by Schistosoma haematobium: case-report. Clin Infect Dis 18: 354-357. [Crossref]
  34. Cetron MS, Chitsulo L, Sullivan JJ, Pilcher J, Wilson M, et al.  (1996) Schistosomiasis in Lake Malawi. Lancet 348: 1274-1278. [Crossref]
  35. Madsen H, Bloch P, Kristensen TK, Furu P (2001) Bulinus nyassanus is and intermediate host for Schistosoma haematobium in Lake Malawi. Ann Trop Med Parasitol 95: 353-360. [Crossref]
  36. Madsen H, Stauffer JR, Makaula P, Bloch P, Konings A, et al.  (2006) Bilharzia in Lake Malawi - what are the facts. Available at: ecosystems.psu.edu/research/labs/stauffer/lake-malawi/general/bilharzia.
  37. (2006) WHO Report of the scientific working group meeting on schistosomiasis, Geneva, 14-16 November 2005. TDR/SWG/07
  38. (2004) United Nations Systems Standing committee on nutrition Nutrition and the millennium development goals. SCN News. No. 28.

Editorial Information


Article Type

Research Article

Publication history

Received date: August 20, 2018
Accepted date: September 05, 2018
Published date: September 10, 2018


© 2018 Stauffer JR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Stauffer JR, Madsen H (2018) A one health approach to reducing schistosomiasis transmission in lake Malawi. Prev Med Commun Health. 1: DOI: 10.15761/PMCH.1000115

Corresponding author

Stauffer Jay Richard

Forest Resources Building, Penn State University, University Park, PA 16802 USA

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

No Figures