Epidemiology of gut and liver multimorbidities in the context of chronic intestinal schistosomiasis
Lead Research Organisation:
UNIVERSITY OF OXFORD
Department Name: Population Health
Abstract
Intestinal schistosomiasis is characterised by progressive injury to the gut and liver and caused by an infection of long duration with parasitic blood flukes (Schistosoma mansoni). Most infected individuals live in sub-Saharan Africa. Associated conditions include gut inflammation, hepatosplenomegaly, periportal fibrosis, portal hypertension, upper gastrointestinal bleeding, ascites, anaemia, and undernutrition. Mass drug administration (MDA) of praziquantel is used to treat the blood flukes instead of the conditions, relying on reaching individuals before morbidity develops.
As a group of chronic conditions with complex aetiologies, we propose studying intestinal schistosomiasis as a set of multimorbidities as opposed to the conventional view as a single disease. Multimorbidity is the coexistence of 2+ chronic conditions within an individual irrespective of cause. It is rising worldwide and complicating diagnosis and case management. In Uganda, we recently discovered a high burden of gut and liver conditions despite repeated MDA. To establish the epidemiology of multimorbidities, we propose the following hypothesis. In the context of MDA, the accumulation and clustering of chronic S. mansoni-associated conditions within an individual, even in the short term (few years), is largely explained by interactions of those coexisting conditions and shared social-ecological risk factors between conditions within individuals. In Eastern and Western Uganda, we will establish a longitudinal, community-based cohort of 3,280 individuals for four years with six study periods. With major fieldwork, clinical and social epidemiology, and cutting-edge machine learning, our objectives are to 1) identify common clusters and interactions of gut and liver conditions; 2) develop computational tools to predict social-ecological patterning and condition trajectories; and 3) assess multimorbidities using patient-reported symptoms and priorities, and local health worker knowledge.
As a group of chronic conditions with complex aetiologies, we propose studying intestinal schistosomiasis as a set of multimorbidities as opposed to the conventional view as a single disease. Multimorbidity is the coexistence of 2+ chronic conditions within an individual irrespective of cause. It is rising worldwide and complicating diagnosis and case management. In Uganda, we recently discovered a high burden of gut and liver conditions despite repeated MDA. To establish the epidemiology of multimorbidities, we propose the following hypothesis. In the context of MDA, the accumulation and clustering of chronic S. mansoni-associated conditions within an individual, even in the short term (few years), is largely explained by interactions of those coexisting conditions and shared social-ecological risk factors between conditions within individuals. In Eastern and Western Uganda, we will establish a longitudinal, community-based cohort of 3,280 individuals for four years with six study periods. With major fieldwork, clinical and social epidemiology, and cutting-edge machine learning, our objectives are to 1) identify common clusters and interactions of gut and liver conditions; 2) develop computational tools to predict social-ecological patterning and condition trajectories; and 3) assess multimorbidities using patient-reported symptoms and priorities, and local health worker knowledge.
People |
ORCID iD |
| Goylette Chami (Principal Investigator) |
Publications
Ockenden E
(2024)
The role of point-of-care ultrasound in the assessment of schistosomiasis-induced liver fibrosis: A systematic scoping review
in PLOS Neglected Tropical Diseases
Reitzug F
(2023)
Associations of water contact frequency, duration, and activities with schistosome infection risk: A systematic review and meta-analysis.
in PLoS neglected tropical diseases
| Description | SchistoTrack fact sheet |
| Geographic Reach | Africa |
| Policy Influence Type | Implementation circular/rapid advice/letter to e.g. Ministry of Health |
| Description | Health Data Science CDT |
| Amount | £86,488 (GBP) |
| Funding ID | 2873955 |
| Organisation | Engineering and Physical Sciences Research Council (EPSRC) |
| Sector | Public |
| Country | United Kingdom |
| Start | 09/2023 |
| End | 09/2027 |
| Description | NDPH Pump Priming Scheme |
| Amount | £49,720 (GBP) |
| Organisation | University of Oxford |
| Sector | Academic/University |
| Country | United Kingdom |
| Start | 11/2023 |
| End | 12/2024 |
| Title | Sonography Guidelines to be used in conjunction with the Niamey Protocol |
| Description | Detailed guidelines for how to conduct sonography sweeps of the abdomen to be used with the Niamey protocol for disease staging attributed to intestinal schistosomiasis. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2022 |
| Provided To Others? | No |
| Impact | Yet to be published. However, within the study, this has led to the standardisation of the method by which images and videos are recorded. Therefore, the Niamey protocol, which is a pattern-based protocol to grade the severity of periportal fibrosis, can be applied to the ultrasound images and videos more consistently. The work has also captured the attention of the WHO where an international meeting is to be called on the revision of the Niamey Protocol. |
| Title | Model to predict periportal fibrosis |
| Description | Takes individual and village-level factors including infection indicators, medical history and behaviour, and socio-demographic factors to predict the likelihood of having periportal fibrosis (liver disease) in schistosomiasis endemic communities. |
| Type Of Material | Computer model/algorithm |
| Year Produced | 2023 |
| Provided To Others? | Yes |
| Impact | This model refutes current published WHO guidelines that target treatment to those with the highest burden of parasite burden, namely children. Instead, the model shows that adults, who are not targeted for treatment have the highest burden of disease. Additionally, this model demonstrated the putative link between HIV and periportal fibrosis, which led to the PI Goylette Chami successfully obtaining additional funding to support a separate study to test this hypothesis. |
| URL | https://www.medrxiv.org/content/10.1101/2023.09.15.23295612v1.full.pdf |
| Description | Gastrointestinal consequences of HIV and schistosomiasis: a SchistoTrack pilot study |
| Organisation | University of Oxford |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | SchistoTrack leads the data collection for HIV infection status and clinical histories. This includes the community sensitisation that ran prior to the introduction of HIV diagnostics into the study. |
| Collaborator Contribution | Provided expertise and clinical knowledge in the creation of new HIV surveys and co-supervision to an MSc student. |
| Impact | The initial data collection has been completed. Participants readily welcomed HIV testing and teams received positive feedback concerning HIV integration into the study. Participants underwent HIV testing, and immunological testing and provided detailed, self-reported medical histories. These data are now available for analysis by the SchistoTrack Team to investigate the role of HIV in the development of periportal fibrosis. |
| Start Year | 2023 |
| Description | The immunology of liver morbidity in chronic schistosomiasis. |
| Organisation | National Institutes of Health (NIH) |
| Country | United States |
| Sector | Public |
| PI Contribution | NIH Oxford-Cambridge joint DPhil student to work on the SchistoTrack study. The PI Goylette Chami provides training and supervision for the student in the epidemiological aspects of the project. This involves focusing on the human immunological indicators of chronic schistosomiasis disease in addition to facilitating the data collection, data handling and storage, and analyses. |
| Collaborator Contribution | NIH Oxford-Cambridge joint DPhil student. Covers all tuition and living costs of the student and provides training and supervision for the student in the immunological aspect of the project. This involves focusing on the immunology of schistosomiasis of pathogenesis within murine models. Significant experience regarding schistosomiasis immunology contributed to the planning of data collection. |
| Impact | Immunological markers from human participants, namely white blood cell differentials and markers for gut inflammation have been collected during fieldwork in 2024. These will be ready for analyses for the joint student when they arrive in January 2025. |
| Start Year | 2023 |
| Description | The role of noncommunicable disease in schistosomiasis morbidity |
| Organisation | University of Oxford |
| Country | United Kingdom |
| Sector | Academic/University |
| PI Contribution | Joint supervision of an MSc student regarding the predictors of alcohol consumption within the cohort and an incoming DPhil student to look at the co-occurrence of non-communicable diseases with schistosomiasis. The PI, Goylette Chami, has collected the data, will provide data-collection supervision and provide expertise into schistosomiasis infection and morbidity. |
| Collaborator Contribution | Joint supervision of an MSc student regarding the predictors of alcohol consumption within the cohort and an incoming DPhil student to look at the co-occurrence of non-communicable diseases with schistosomiasis. The co-supervisor will provide expertise and training in epidemiology and medical statistics of non-communicable diseases. |
| Impact | The MSc student provided a detailed overview of the alcohol-drinking behaviour and Schistosoma infection across the study cohort. They identified key predictors of regular alcohol consumption, Schistosoma infection, and regular alcohol consumption and Schistosoma infection co-occurrence. The incoming DPhil student will expand upon this work. |
| Start Year | 2023 |
| Description | SchistoTrack Community Engagement (District) |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | SchistoTrack study PI (Goylette Chami) and local country team representatives from the Uganda Ministry of Health visited district leadership. At the district level, local policymakers, key neglected tropical disease focal people, health workers, and district officials attended presentations communicating interim study findings and facilitating opportunities to ask questions and provide feedback regarding the findings. The statistics and summaries were made available to the districts so that they could utilise study findings to advocate for additional health resources. This sparked discussions at the district levels on how to better engage with the national ministries. |
| Year(s) Of Engagement Activity | 2023 |
| Description | SchistoTrack Community Engagement (Village) |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Study participants or study members |
| Results and Impact | SchistoTrack PI Goylette Chami and local team representatives from the national and local government visited participants within their villages. Study participants, family members, and community leaders attended. Here, summaries of infection and disease prevalence at the village level were shared. Local HIV counsellors were also present who aided in sensitising and consulting communities about whether they were open for HIV testing to be integrated into the study. There was a positive response to HIV testing and participants asked questions regarding parasite biology, disease management, and infection control in addition to providing feedback to improve how individual participant results are communicated. |
| Year(s) Of Engagement Activity | 2023 |
| Description | SchistoTrack Webpage |
| Form Of Engagement Activity | Engagement focused website, blog or social media channel |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Public/other audiences |
| Results and Impact | Public website aimed at a lay audience to gain insight into the Schistosoma research. Also acts as a reference for other researchers wishing to engage with the group or create further collaborations. |
| Year(s) Of Engagement Activity | 2024 |
| URL | https://www.bdi.ox.ac.uk/research/schistotrack |
| Description | SchistoTrack participation and thanked during world NTD day |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | National |
| Primary Audience | Public/other audiences |
| Results and Impact | In 2024 World Neglected Tropical Disease Day was held in the most deprived study districts, Pakwach. After an invitation from the District Chairman (the political leader of the district), SchistoTrack study team members attended the day and hosted an interactive information booth to provide information about the parasite, how it is transmitted, and the associated disease. This sparked pledges from the Ugandan National Minister of Health, who was in attendance, to work towards ending NTDs by 2030. Highlights of the day were broadcast on national television and featured the chairman of the Pakwach district wearing a SchistoTrack T-shirt (2.31) whilst advocating for reducing schistosomiasis and the Minister of Health (Dr Jane Ruth Aceng) meeting with team members (0.30). |
| Year(s) Of Engagement Activity | 2024 |
| URL | https://www.youtube.com/watch?v=IY8SnD3OeeU |