**5. Mass drug administration and its inadequacy to control**  *Schistosomiasis* **in Africa**

*Schistosomiasis* control and elimination involve several strategies ranging from disease treatment to managing complications and controlling disease transmission with a combination of preventive chemotherapy dispersed through MDAs, and water, sanitation, and hygiene (WASH) programs [7, 19, 49, 50]. The focus of the WHO plan for *schistosomiasis* control and elimination is on preventive chemotherapy, particularly MDAs in sub-Saharan Africa [51]. Although some progress has been made such as partnerships with donor foundations, interventions of international organizations like Merck the producer of *praziquantel,* and the exercise of large-scale treatments [7, 52]. There is because *Praziquantel* has been considered cost-effective, relatively safe, inexpensive, and effective; with donor organizations willing to provide the drug at no cost making it the only viable choice for the treatment of *schistosomiasis* [19].

*Praziquantel* is the key bullet for *schistosomiasis* control and elimination, however, Onasanya and colleagues [51], observed that in practice is reactive instead of proactive and is an unavoidable consequence of a one-size-fits-all approach. According to them, this reactive approach is limiting for several reasons. They stated that firstly, despite the "efforts at making *praziquantel* available to those in need and Merck KGaA's commitment to *praziquantel* donations, targets for MDAs coverage have still not reached all people at risk who require treatment" [51, 53]. This they said, "may indicate an under-representation or undercount of cases based on low-level awareness" [8, 12, 54], the disease may be introduced to new or previously eliminated areas due to our migratory patterns [4, 55, 56], it is safe to assume that the similarity of the disease makes its transmission easy across different tropical regions and countries. For example, countries like Nigeria have prioritized *praziquantel* for SAC but leave out adults and preschool children during MDAs [54]. In this context, it implies that *schistosomiasis* cannot be effectively eliminated in communities where MDAs treatment is on-ongoing.

Secondly, it was noted that, although there is a commitment to the donation of *praziquantel*, there is a high chance of recrudescence of disease to pre-MDAs levels once donations reduce or cease, or even during MDAs programs [57, 58]. Thirdly, "*praziquantel* itself has not demonstrated 100% curative ability in both single-dose and multi-dose regimens in various settings, implying that relying only on *praziquantel* treatment use during MDAs is not an effective strategy for control and elimination of this disease" [59–61]. Fourthly, "given the neglected nature of the disease in most healthcare systems in sub-Saharan Africa, there is currently inadequate funding for the disease from the national governments which is likely to persist or worsen in the future once the current external funding and support are reduced. They also noted that there is also a potential for donor fatigue as current gains in treatment to be reversed when donation stops because countries do not have sustainable strategies to own and incorporate programs within their current healthcare systems" [62].

Lastly, Onasayan and colleagues submitted that the disease context is complex with an interplay of social, economic, political, and cultural factors that may affect achieving the goals of the NTD 2021–2030 Roadmap [56, 63, 64]. Affirming that in light of the daunting challenges, there is a need to revisit the current top-down approach to *schistosomiasis* control among sub-Saharan African countries irrespective of the level of the endemicity. From the angle of WHO, there have been several resolutions over time toward the control and elimination of *schistosomiasis*, including renewing interest, addressing partnerships, for example in 2012, the need to attach importance to both preventative and control strategies by developing applicable plans with progressive targets was initiated [20]. Moreover, "in 2013, the WHA66.12 resolution on NTDs focused on advocating for continuous country ownership of programs for NTD prevention, control, elimination, and eradication" [7, 49]. "The current roadmap for 2021–2030 for NTDs also reiterates the importance of community-based and applied research for effective NTD programs, it highlights the need to integrate

#### *Dancing in a Cycle: Global Health Agenda and* Schistosomiasis *Control in Africa DOI: http://dx.doi.org/10.5772/intechopen.103164*

mainstream approaches into national healthcare systems, coordinate action across sectors, and close coordination and multi-sectoral action across all sectors" [50].

We may wonder if enough literature has not been done on *schistosomiasis* control. But Mazigo and colleagues [65], simply noted that planning and implementation of *schistosomiasis* control activities requires an understanding of the prevalence, intensity of infection, and geographical distribution of the disease in different epidemiological settings. It is safe to assume that the reasons why preventive chemotherapy strategy for *schistosomiasis* fails sometimes are the lack of understanding of the geographical distribution of the disease and the infection level in endemic communities living in different geographical settings [65]. For effectiveness, therefore, Mazigo and colleagues [65], pointed out the importance of identifying areas where infections have continued to be a public health problem despite repeated rounds of MDAs. Noting that this will allow the development of focused integrated control measures. Generalizing from Tanzania research, they affirmed that in many of the *schistosomiasis* endemic countries, there is inadequate attention given to research on the geographical distribution of *schistosomiasis* in other areas outside the historically known and highly researched areas.

### **5.1 Use of preventive chemotherapy and proposition for Africa traditional medication to control** *Schistosomiasis*

If *schistosomiasis* affects the intestine and is not attended to in the time it can become complex and lead to critical organ failure [66, 67]. To prevent this, the single dose of *praziquantel* (PZQ ) has been prescribed as a first-line treatment since 2005 with the remarkable success achieved against *schistosomiasis* through targeted mass chemotherapy [52]. According to Moon [68], PZQ was discovered in the 1970s and approved for human use in the United States of America in 1982. For effectiveness and in pursuant of elimination of *schistosomiasis*, preventive treatment should be repeated over several years, to reduce and prevent morbidity [6].

Some progress has been recorded by the World Health Organization (WHO), in 2017 for example, it was estimated that out of at least 290.8 million infected people, and about 98.7 million were treated for *schistosomiasis* [69]. The statistics account for less than 30% of the infected population receiving treatment. What possible factors could be responsible for the low coverage? Hotez, and colleagues [70] attributed the inadequate coverage to cost. Other scholars argued that PZQ has its limitations. For instance, it has the property that reduced *prophylactic* effect at the recommended doses against immature stages [71, 72]. Others claimed that there is little data on PZQ safety and efficacy in preschool children leading to the exclusion of this age group from chemotherapy preventive control programs [73], and others said that there is no oral formulation for infants and preschool children [74]. It was even concluded that the drug has no effect if the liver and spleen are seriously affected [33].

A report from Nigeria shows treatment once annually with *praziquantel* for *schistosomiasis* infections, which is said to be effective for the treatment of all species of *schistosomiasis* [39]. According to some scholars [75], this program was said to have been achieved through school-based deworming (SBD) carried out by the State Ministries of Health in collaboration with the Federal Ministry of Health Nigeria (FMoH), WHO, and other nongovernmental organizations (NGOs). This program according to research [30], offers treatment of all school children in the country. However, due to the poor environment as well as poor hygiene behavior by individuals, reinfection occurs rapidly after treatment.

Though PZQ appears safe and effective against all adult *Schistosomiasis* species in general [76], further research is needed to understand the efficacy and safety of various doses for different *Schistosoma* species. "Some studies reported PZQ therapeutic failure up to 40%" [77, 78]. What should be the main concern? First is the heavy reliance on the single available drug, which studies show has been in use for the past 40 years. Secondly, is the tendencies for drug resistance which is an eventual scenario for any drug, and PZQ cannot be an exception [79]. Hence, there is a need to search for novel drugs against all *schistosomiasis* lifecycle, (see **Figure 1**) and the stages of the parasite with considerations for both pediatric and adult use.

Onasanya and colleagues seem confused because of the lack of clarity on how sub-Saharan African countries would achieve the targets beyond the desire for easy wins through the use of *praziquantel* as a reactive way to achieve the aims of control and elimination of *schistosomiasis* [51]. They stated that if *schistosomiasis* control is to be attained, then it will require a dynamic approach that incorporates more proactive and holistic strategies beyond the current top-down approach. Affirming that such an approach most of the necessity incorporates the socio-cultural, epidemiological, economic, and geographical dynamics within each country to create a mix-set of feasible strategies for *schistosomiasis* control.

Consequently, the WHO calls for the need to eliminate *schistosomiasis* by 2030, and proposed the development of new intervention tools and alternative drugs to PZQ [52].

**Figure 1.**

*Schistosomiasis life cycle. Sources: CDC [10]. Available at: https://www.cdc.gov/parasites/schistosomiasis/biology. html.*

#### *Dancing in a Cycle: Global Health Agenda and* Schistosomiasis *Control in Africa DOI: http://dx.doi.org/10.5772/intechopen.103164*

Scholars are of the view that most modern drugs have their root in traditional medicine, as noted that nearly 30% or more of the modern pharmacological drugs are derived directly or indirectly from plants [80, 81]. Notably, African people are majorly from low-income countries relying heavily on traditional medicine for the treatment of all forms of ailment including *schistosomiasis* and other parasitic diseases [26]. In Ethiopia a large number of communities, particularly in rural areas, rely on traditional medicinal plants to fight several diseases including *schistosomiasis* [82, 83], this is not different from Ghana, Nigeria, Mali, Senegal, and other African countries. One scholar argued that the reasons why people practice traditional medicine are the high cost of modern drugs, paucity and inaccessibility of modern health services, and cultural acceptability of traditional medicine [82]. However, observation shows that in health pathways some African combine both modern and traditional medicine in health help-seeking behavior. Some participants in Nigeria affirmed that there are medicinal plants that have already shown therapeutic efficiency against *schistosomiasis* infection [26]. When will the goal of total elimination of *schistosomiasis* be achieved?
