#1GENITAL. FEMALE Ond ISÉ LOOGUN ÌSÉ STATE NEGLECTED TROPICAL DISEASES (NTD) IN REPRODUCTIVE HEALTH WITH FOCUS ON FEMALE GENITAL SCHISTOSOMIASIS (FGS) 2/16/2022 Event: Ondo State NTDs Technical Review and Planning Meeting 15th June, 2022 Speaker: Dr. Ibirongbe Demilade O. Community Medicine Dept., University of Medical Sciences Teaching Hospital Complex (UNIMEDTHC), Ondo; School of Public Health, University of Medical Sciences (UNIMED), Ondo SOCIETY OF NIGERIA#2Objectives of this short training session • • • • • To know what Neglected Tropical Diseases (NTDs) are. To have a broad overview of female genital schistosomiasis (FGS) To understand the risk factors, symptoms and pathogenesis of FGS To understand the challenges of diagnosis and management of FGS To identify steps needed and resources available to tackle the identified challenges ⚫ Introducing the Nigerian FGS network and inviting participants to join. 2/16/2022#3Introduction: What are Neglected Tropical Diseases? • Group of disease caused by bacteria, protozoan, helminthes and virus They affect the poorest of the poor people • There called neglected because less attention is given to them when compared with other disease like malaria • There are about 22 of them that has been listed by WHO Chagas Disease Leishmaniasis Neglected Tropical Diseases Viruses Helminth Protozoa Rabies Cysticercosis Dengue & Chikungunya Guinea-worm Echinococcosis Foodborne trematodiases Bacteria Lymphatic Filariasis Buruli Ulcer Leprosy Schistosomiasis River Blindness Trachoma Yaws Human African Trypanosomiasis Soil-trasmitted helminthiases 2/16/2022 Image credit: SITNBoston#4● ● . Introduction: What is Schistosomiasis? Schistosomiasis is a water-borne disease, caused by worms that live in infected water (such as lakes and rivers). People become infected when they come into contact with this water when the parasitic worm is present. It is an acute and chronic disease caused by blood flukes parasite (trematode worms) of the genus Schistosoma. Prevalent in tropical and subtropical areas. The disease is present in 75 countries and over 200 million people are infected: 95% of infected persons are in Sub- Saharan Africa (WHO). 2/16/2022 https://doi.org/10.1371/journal.pone.0143667#5• • Introduction: What is Schistosomiasis? Nigeria has the highest burden of the disease worldwide, with around 29 million cases across the country (Salwa Dawaki et al 2015). Infection occurs during routine agricultural, domestic, occupational and recreation activities which expose people to infected water. It is typically prevalent among persons in rural environments where access to adequate sanitation and hygiene is poor Because there is often little attention given to this disease, it is considered a neglected tropical disease by the World Health Organization (WHO) 2/16/2022 https://doi.org/10.1371/journal.pone.0143667#6The causative agent: schistosomes P Cercariae Snail Miracidia S. haematobium eggs from urine . It is caused by the trematode worm cause Schistosoma and the common species are Schistosoma haematobium, Schistosoma mansoni, Schistosoma japonicum Visible clinical signs is blood in urine or bloody stool oral sucker oesophagus male. gynaecophoric- canal female- place of fusion- of crura yolk glands- Eggs Fig. 2 The life cycle of S. haematobium. Adapted from Countdown (https://countdown. Istmed.ac.uk). The life cycle of the parasite intestine -yolk glands Adult schistosome acetabulum ovary Image credit: http://www.abdn.ac.uk Cercaria (the infective stage)#7How schistosomiasis affects people: medical • There are two forms of schistosomiasis: Intestinal (S. mansoni) and urogenital (S. haematobium) that can affect both males and females Intestinal Worms in blood vessels that surround the intestine Symptoms include diarrhoea, abdominal pain and swelling, tiredness, and blood in faeces Urogenital Worms in blood vessels of the bladder, and cause inflammation Typical symptom is often blood in urine 2/16/2022 Photo Credits: Dr. Oluwole Stephen#8Relevance: Why Female Genital Schistosomiasis? 450 million people living at-risk Approx. 56 million women and girls in vulnerable circumstances S. haematobium ☐ S S Distribution of S. Haematobium Infection in Africa from the World Health Organization. Source: APUD: Hotez, Peter & Fenwick, Alan & Kjetland, Eyrun. (2009). Africa's 32 cents solution for HIV/AIDS. PLOS neglected tropical diseases. 3. e430. 10.1371/journal.pntd.0000430. WHO (from page 16 in [41], image WHO 92721).doi:10.1371/journal.pntd.0000430.90 8#9● Female Genital Schistosomiasis (FGS): Overview Female Genital Schistosomiasis (FGS) is a common complication of schistosomiasis caused by the presence of eggs in genital tissue • FGS is a manifestation of urogenital schistosomiasis disease in a female (affects both urinary and genital tract) of infected individuals. • The major causative organism of urogenital: Schistosoma hematobium. Women doing domestic chores in infected water at risk. • It is not sexually transmitted Schistosoma egg Ovary Uterine cavity Fimbria Uterus Fallopian tube Internal os Endocervical canal Cervix Endocervix External os Ectocervix Vagina 2/16/2022 Image credits: 1.Haytham M.S et al (Schistosoma egg) 2. Pinterest.com (Female genital system Female genital system#10Female Genital Schistosomiasis (FGS): Overview Left untreated, the damage that FGS causes include infertility, miscarriage, ectopic pregnancies, spontaneous abortions, social stigma, depression, and genital and cervical lesions It is described as one of the most neglected sexual and reproductive health diseases in sub Saharan Africa. 56 Million women and girls affected in sub-Saharan African. (WHO) • In Nigeria it is estimated that 70% of female living in schistosomiasis endemic area have FGS Schistosoma egg Ovary Uterine cavity Fimbria Uterus Fallopian tube Internal os Endocervical canal Cervix Endocervix Ectocervix External os Vagina 2/16/2022 Image credits: 1.Haytham M.S et al (Schistosoma egg) 2. Pinterest.com (Female genital system Female genital system#11Pathogenesis of Female Genital Schistosomiasis (FGS): • Female Genital Schistosomiasis (FGS) is a common complication of schistosomiasis caused by the presence of eggs in genital tissue A FALLOPIAN TUBE Schistosoma egg Miscarriage preterm delivery, infertility & menstrual rider Ectopic pregnancy and infertility UTERUS Infertility, retarded Womas puberty, menstrual disorders & early menopause Schistosoma eggs TRENDS in Parastology Image credits: OVARY ENDOMETRIUM Coital bleeding Lesions predisposes to secondary infections Key VAGINA CERVIX Infertility, Irregular bleeding & carcinoma -S. haematobium eggs in affected areas 2/16/2022 1. Kjetland et al (www.science direct.com) 2. Female genital part: https://www.researchgate.net/profile/Takafira-Mduluza Female genital part#12How does FGS present? • Common symptoms of FGS can be quite general to other gynecological diseases, including vaginal discharge, vaginal bleeding, vaginal discomfort and pain during sex • Since symptoms mimic sexually transmitted disease, it is thus misdiagnosed and untreated. Therefore, although FGS may be the most common gynecological condition in schistosomiasis-endemic areas, it remains undiagnosed in most cases. 2/16/2022 Image credits: 1. Eyrun Kjetland (researchgate.net) 2. Dr. Edwin P. Ewing Jr (www.BioMed Central) B D#13Who is at risk of developing FGS? a a a alamy Women and girls living in areas with poor access to potable water coupled with poor sanitation and hygiene practices 2/16/2022 Women and girls living in fishing and agriculture communities Photo credits: Dr. Akinola Oluwole Stephen alamy a#14Medical What are some of the consequences of FGS? Social Bleeding during intercourse (contact bleeding) • Social stigma and embarrassment Depression and feelings of shame Isolation and fear of losing social • Pain during sexual act • Genital ulcers • Nodules in vulva • Tumors or swelling (vulva, vagina, cervix) • Involuntary urination when coughing, laughing or jumping, etc. • Infertility • Abortion (Miscarriages) Ectopic pregnancy • Increased risk of HIV and Human papilloma infections from non-heal ulcer created by the parasites. (3 times higher risk of HIV) network 2/16/2022#15• What are some of the challenges affecting early and effective diagnosis and treatment of FGS (facility)? General focus on MDA strategies in schools - girls not attending school may miss opportunity for treatment Current lack of evidence work exploring health workers understanding and management of the disease • • Challenge obtaining praziquantel outside of MDA Lack of awareness among health workers - misdiagnoses and stigmatization Lack of diagnostic tools suitable for primary health care 2/16/2022#16What are some of the challenges affecting early and effective diagnosis and treatment of FGS (personal)? Girls and women affected by FGS have no idea of what is wrong with them Many young girls affected go to chemist to do self medication instead of going to the health facility because of fear of stigmatization Health implications of FGS such as Infertility and contact bleeding during intercourse result may affect women wellbeing and relationships 2/16/2022#17FGS: What do we need to do? We need to educate the health workers and Health professionals about the challenge of FGS We have developed diagnostic algorithm and treatment care package and training guide for the management of FGS at the primary health care level We need to train the Frontline health workers on the use of the diagnostic algorithm and treatment care package We need to be evaluate the effectiveness of the diagnostic algorithm and treatment care package 2/16/2022#18Diagnosis steps: Using the COUNTDOWN guide 1. Collect bio-data, including weight and vital signs (blood pressure and temperature) 2. Administer the initial symptoms questionnaire and record symptoms in FGS register. 3. If patient answers yes to having vaginal discharge, use vaginal discharge colour chart 4. Conduct the environmental risk assessment 5. Use the severity/other condition checklist on all patients and document as appropriate. 2/16/2022#19COUNTDOWN Initial symptoms questionnaire QUESTION CIRCLE THE RESPONSE Do you have genital itching or burning? Yes No If yes, how severe is the itching/burning? Mild Moderate Severe Do you have vaginal discharge? Yes No If yes, how heavy is the discharge? Mild Moderate Severe Do you have pain during sex? NA N/A Rarely Occasionally All the time Do you have spotting/bleeding during/ after sex? 2/16/2022 Discharge Colour Chart COLOUR DISCHARGE CHART a) Discharge (normal/ abnormal) 1 2 3 4 5 6 7 8 b) Discharge (traces of blood) NA N/A Rarely Occasionally All the time 1 2 3 4 5 6#20Environmental Risk Assessment 2/16/2022 FGS RISK ASSESSMENT QUESTIONS Have you had direct (active) or indirect (passive) contact with river/ stream water now or in the past? Fishing Washing cloth Bathing* Walking through/crossing Severity/Other conditions checklist YES NOT SURE NO 1. Do you involuntarily pass urine? 2. Do you find it difficult to get pregnant? 3. Have you experienced any previous 4 20 pregnancy loss? 4. Do you have any genital sores or genital ulcers? Swimming Defecating 5. If yes, do the ulcers/sores bleed? Have you had painful urination or bloody/cloudy urine in the past? 2 1 0 6. Do you have any genital swelling? Is there anybody in the family or anyone you lived with that has history of blood in urine or reported cloudy urine? 2 1 0 Is there anybody in the community suffering from this? 2 1 0 Refer to the Gynaecologist if client answers 'YES' to any of the above. 2/16/2022#21Diagnosis of female genital schistosomiasis (FGS) . • • No recognizable standard criteria or tools for FGS which has led to serious complication in many women and girls. It requires a high index of suspicious by medical practitioner following unresolved STD treatment. Standard diagnostic technique for urogenital schistosomiasis include a filtration technique using nylon, paper or polycarbonate filter. Colposcopic images suggestive of FGS Homogeneous Yellow Sandy Patch Grainy Sandy Patch Abnormal Vessels Rubbery Papules#22Treatment of female genital schistosomiasis . (FGS) FGS is treatable and preventable. • Use of single dose of Praziquantel at 40mg/kg will stop progression of the disease . There are some symptoms that will not be resolved. • Most lesions identified in the female genital tract cannot be cured by the drug for instance tubal blockage is permanent. However, debilitating symptoms like discharge and bleeding generally resolves. Complicated cases will be treated based on symptoms presented 2/16/2022#23. • • Prevention of female genital schistosomiasis (FGS) GENERAL PREVENTION: • Awareness creation and Health education. • Reduction in contact with water bodies • Provision of safe portable water Use of protective materials when there is need to have contact with water • Improved sanitation • Avoid indiscriminate defecation Appropriate training to healthcare professionals • Participation in local, regional or global efforts at eradicating FGS 2/16/2022#24Prevention of female genital schistosomiasis (FGS) SPECIFIC PROTECTION: • Participation in yearly Mass Drug Administration/Large scale • treatment of at-risk population • • • Preschool aged children School aged children in endemic areas. Adults at risk in endemic areas e.g fishermen, farmers, women exposed to infested water. Entire communities living in highly endemic areas. Early diagnosis and prompt treatment of all form of schistosomiasis with pranziquantel. High index of suspicion in case of STD treatment failure. 2/16/2022#25FGS Society of Nigeria E GENITAL FEMALE SOCIETY FGS society of Nigeria is a group of scholars, researchers and stakeholders created with the aim of generating awareness about FGS. It has grown to cut across the six geo- political zones, some states and LGAs in Nigeria and it is currently on the process of been registered with Nigerian Corporate Affairs Commission as Female Genital Schistosomiasis Society of Nigeria. • It welcomes individuals from all walk of life who is passionate about elimination of FGS. . There is an Ondo State branch SCHISTOSOMIASIS NIGERIA 2/16/2022#26E GENITAL SCHISTOSOMIASIS NIGERIA FGS Society of Nigeria Vision FEMALE SOCIETY A world free of female genital schistosomiasis and neglected tropical diseases. Mission To eliminate FGS and related infectious diseases and cancers in Nigeria and world Values Collaboration, community engagement, equity, scientific rigor and transparency. 2/16/2022#27E GENITAL SCHISTOSOMIASIS NIGERIA FGS Society of Nigeria Partners Bridges to Development The Geneva learning foundation Fast Package With support from The Task Force for Global Health Membership FEMALE SOCIETY OF Open to all frontline health workers, health administrators, public health specialists, academicians, students, civil societies and everyone passionate about eradicating female genital schistosomiasis in our communities and nation. 2/16/2022#28E GENITAL FEMALE FGS Society of Nigeria Why should you join the society? SOCIETY OF • To harness efforts across all cadres to eliminate FGS, since we are all affected by FGS (through its complications in women). · • ● What value is in it? Your efforts will be added to efforts of others which can have an exponential effect. We will network for motivation of our members and for provision of resources together to combat this disease. More information is available on our website: www.fgssofnigeria.com.ng Or you can contact us by email: [email protected] 2/17/2022 SCHISTOSOMIASIS NIGERIA#29• • • • Conclusion - Take home message Schistosomiasis is a water-borne disease, prevalent in tropical and subtropical areas, caused by blood parasite, Schistosoma that live in infected water. FGS is a common complication of schistosomiasis caused by the presence of eggs in the urogenital tissues of females It can cause infertility, miscarriage, ectopic pregnancies, spontaneous abortions, social stigma, depression, and genital and cervical lesion FGS is one of the most neglected sexual and reproductive health issues in sub-Saharan Africa FGS remains highly prevalent and under-diagnosed due a low index of suspicion among health-care professionals. FGS Society of Nigeria seeks to create awareness about FGS. Let's all work together to eradicate FGS.#30References 1. COUNTDOWN (2020) Nigeria training guide for health workers on the management of women and girls with FGS. 2. Jacobson, J., Pantelias, A., Williamson, M. et al. Addressing a silent and neglected scourge in sexual and reproductive health in Sub-Saharan Africa by development of training competencies to improve prevention, diagnosis, and treatment of female genital schistosomiasis (FGS) for health workers. Reprod Health 19, 20 (2022). https://doi.org/10.1186/s12978-021-01252-2 3. Hotez PJ, Engels D, Gyapong M, Ducker C, Malecela MN. Female Genital Schistosomiasis. N Engl J Med. 2019 Dec 26;381(26):2493-2495. doi: 10.1056/NEJMp1914709 4. World Health Organization. (2015). Female genital schistosomiasis: a pocket atlas for clinical health-care professionals. World Health Organization. https://apps.who.int/iris/handle/10665/180863 2/16/2022#31Acknowledgements 1. Dr. Akinola Oluwole, Lead researcher COUNTDOWN Nigeria FGS project (for major contributions to the slide) 2. Prof. Ekpo, Federal University of Agriculture Abeokuta. 3. Dr. Islamiyyat Soneye, Ogun State NTD department, MoH Ogun State 4. Dr. Rabiu Ibraheem, President, Nigerian FGS society network 5. Dr. Julie Jacobson, Head, Bridges to Development organization 6. Isis Umbelino, Project Manager, Bridges to Development 7. Dr. Hameedat Abdussalam, VP1 and Training Coordinator, Nigerian FGS society network. 2/16/2022#32FEMALE GENITAL SCHISTOSOMIASIS A POCKET ATLAS FOR CLINICAL HEALTH-CARE PROFESSIONALS Thank World Health Organization Thank you