Madagascar Medical Expedition 2015

This year a team of students went on a life changing trip to Madagascar to help educate and treat Schistosomiasis in the area. Here’s an account of their adventures.


 

What is Schistosomiasis and why did MADEX do this project?

Madagascar Medical Expedition 2015 was a student-led research expedition, which set out to screen school children for schistosomiasis in one of Madagascar’s most remote and isolated areas.  We wanted to treat those with the disease and run health education programmes to teach the children ways of preventing re-infection.

Schistosomiasis is a parasitic disease caused by the Schistosoma fluke which is the second most important parasite-born disease after malaria. It is found in tropical, humid climates. People become infected through contact with water infested with the parasite larvae. There are three main species that infect people: Schistosoma haematobium which causes urinary schistosomiasis, and S. mansoni and S. japonicum which causes intestinal schistosomiasis.

The World Health Organisation (WHO) considers schistosomiasis to be the second most important parasite-born disease, second only to malaria in terms of global socio-economic impact. Approximately 166 million people are infected worldwide across 78 endemic countries and it is thought it causes around 20,000 to 200,000 deaths/year. The disease has a particularly serious impact on children as they become too ill to go to school. This impact on education has a major impact on the economy. For this reason the reduction of schistosomiasis is in line with the Millennium 2020 objectives for global health set out by the WHO. Control of schistosomiasis is based on treatment with Praziquantal (an anti-helminthic drug), improved sanitation and health education.

In Madagascar in 1987, approximately 16 million people were thought to be infected in a total population of 24 million. The WHO advises treatment via Mass Drug Administration every 6 months to any population which has greater than 50% prevalence; however in 2009 approximately just 20% of the population in Madagascar had received treatment.

Planning the expedition, and collaboration

This was the first ever student-led medical research expedition from The University of Manchester (UoM), and took over two years of planning. With the backing of The Ministry of Health Madagascar, we put together a proposal, and negotiated with Manchester Medical School to let us use the project for part of our university course. We organised training in microscopy and schistosomiasis identification with Professor Andrew MacDonald’s team and were supplied with brilliant education resources from Dr Sheena Cruickshank in the Manchester Immunology Group.

Four UoM students went to Madagascar: Stephen Spencer (Founder, Head and Lead Coordinator of the team), Anthony Howe (logistics and finances), Hannah Russell (medical, health and safety officer) and James Penney (research lead, and as a French speaker, in charge of international communications)

We also nurtured a collaborative link between UoM and The University of Antananarivo. We selected two recent medical graduates to join the field team: Daniel and Anjara. As well as being an extra pair of hands, they translated, took over the health education programme, and conducted interviews with local health workers, headteachers and village chiefs to investigate the health burden and health beliefs of the area, and so were absolutely crucial to the success of the expedition.

The research

The research was based in the district of Marolambo, one of Madagascar’s most remote locations, situated in central East. We screened six schools from six villages in this district.  This involved hiking between villages, sometimes up to 24km, through forested areas with nearly a quarter of a tonne of equipment.

We screened a total of 399 children from 6 schools, across 6 villages in the district. We looked for schistosomiasis by three different methods: 1) looking for eggs in stool samples 2) looking for eggs in urine samples and 3) using CCA antigen testing, to test for presence of the CCA antigen (given off by all schistosome species) in urine samples. In this way we tested for both urinary and intestinal schistosomiasis.

We found an overall prevalence of 94%, with our data showing that all of this was intestinal rather than urinary schistosomiasis. We also recorded extremely high egg counts, well over the WHO threshold for ‘intense’ infection, and on discussion of these results with experts, it is likely that if some of these eggs remain in the patient’s intestines then severe problems like liver cancer and splenomegaly could occur. Infection, if left untreated, can cause serious damage and even death, so it is critical to intervene with anti-parasite medicine and education. Further to this we ran health education programs to the school children, teaching them about schistosomiasis, how to avoid re-infection, and raising awareness to the local community.

What lies ahead for MADEX?

Our long-term goal is to control schistosomiasis in the Marolambo region.

We have met with the Ministry of Health of Madagascar in Antananarivo, who are keen for the work to continue. As well as ensuring complete treatment amongst this community, we would like to re-screen these populations to study the re-infection rates here.  In addition to this, with follow-up projects, we also aim to reduce the disease burden by focussing on improving education about the disease.

We hope to make this a long-term project, and to continue the collaboration between The Universities of Manchester and Antananarivio, by sending out students year on year. Planning for an expedition in summer 2016 is underway.

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Acknowledgements

Thanks to: Professor Anthony Freemont & Manchester Medical School, Dr Ed Wilkins & Infectious Diseases Unit (North Manchester General Hospital), Professor Andrew MacDonald, Dr Sheena Cruickshank & Manchester Immunology Group (University of Manchester), Dr Jane Wilson-Howarth, Anglo-Malagasy Society, Jayne Jones & Liverpool School of Tropical Medicine, Herizo Andrianandrasana & Durrell Wildlife Conservation Trust, Dr Peter Long (University of Oxford), Dr Shona Wilson (University of Cambridge), Schistosomiasis Control Initiative, Natural History Museum London, World Health Organization, Royal Geographical Society, East Lancashire Hospitals NHS Trust, Mission Aviation Fellowship, Dr Alain Rahetilahy & Madagascar Ministry of Health, Prof Luc Samison & University of Antananarivo, Dr Clara Fabienne & Institut Pasteur (Madagascar), Zochonis Enterprise Award, British Medical and Dental Schools’ Trust.

Scientists one step closer to understanding the body’s response to worms and allergies

Faculty scientists now have a better understanding of how bodies react to allergies and parasites. The team, led by Professor Andrew MacDonald, have discovered a new way that immune cells control inflammation during worm infections and in allergic responses to diseases like asthma. The finding is important because inflammation can cause long-term damage and so understanding how it is controlled will help mitigate its effects. Dendrite To do this, the team studied dendrites in both animal and lab models. Dendrites are specialised cells of the immune system that play a vital role in the initial response to both allergens and parasites. Their main function is to recognise infection and switch on channels to combat it – one of which is inflammation. How these channels were switched on by dendrites was previously unknown. What the team found was that a particular protein called Mbd2 plays a key role in allowing dendrites to produce an inflammatory response. When the proteins were removed, radically different cells were formed and these cells had a significantly impaired ability to switch on inflammation. It was also discovered that Mbd2 was an epigenetic regulator, meaning that it could modify the function of many different genes without altering their DNA structure. Professor MacDonald explains:

“For the first time we have identified that this protein is a key controller of dendritic cells during inflammation against parasitic worms or allergens. It’s an important step, as all inflammation is not identical, and scientists try to understand which specific cells and chemicals are more important in the body’s response to particular infections. In the past, medicines have had a broad approach, affecting all aspects of a condition rather than being targeted. In the future it might be possible to create medicines that control the inflammation caused specifically by an allergy or a parasitic worm, rather than by a virus such as a common cold.”

Professor MacDonald continues:

“With billions of people affected by both allergies and worm infections around the world it is vital that we develop better methods of treatment. It’s also important to tackle the inflammation caused by these conditions, as it has been shown to play a role in the development of longer term diseases such as asthma.”

Faculty researcher shortlisted for national award

Sheena CruickshankA project led by Faculty researcher Dr Sheena Cruickshank was shortlisted in the Engage Competition 2014, run by the National Coordinating Centre for Public Engagement (NCCPE). The project, entitled ‘Educating Community Groups about Parasite Infection and its Impact,’ was praised for its work informing UK immigrants about how infections are transmitted.

Alongside Indira Mclean of Bolton College, Dr Cruickshank devised an education programme that is being used by language schools. The programme teaches people from around the world about how parasitic infections such as toxoplasma, whipworm, malaria, and schistosomes are caught, and how they can be prevented. Dr Cruickshank said:

“Globally, the biggest killer of people under 50 is infection. In countries where infections that are caused by gut worms are still very common, it is the main reason why children don’t get an education. We focused on explaining how people catch these infections, their global significance (in terms of prevalence and effects on global health and economy), and how they can be prevented.”

The programme underwent a pilot run during ESOL classes at Bolton College. The participants were of mixed nationalities including African, Iraqi, and Indian. Dr Cruickshank said:

“Apart from providing a vital information service, this is an incredible opportunity to learn from these people’s experiences. Hearing about worm infections and their impact on daily life has motivated many of us to change our research.”