This document discusses female genital schistosomiasis (FGS) in Ghana and the challenges it poses for women's health. It notes that while Ghana's NTD program has made progress against other diseases, FGS prevalence remains high in some districts. FGS can cause serious reproductive health issues like infertility, increased risk of HIV, and cancers. However, health systems remain poorly informed and lack focus on diagnosing and treating FGS. The document calls for engaging health directors, advocating for FGS to be addressed in public health programs, improving capacity to diagnose and treat FGS, and ensuring women can access prevention and care for this neglected condition.

1. The double jeopardy of having
Female Genital Schistosomiasis in
poorly informed and resourced
health systems in Africa
Margaret Gyapong, Benjamin Marfo, Sally Theobold, Kate
Hawkins, Samantha Page, Mike Osei Atweneboanaa, Russell
Stothard

2. Background
• In the last decade Ghana NTD Program
successfully
– Interrupted transmission for LF in 69 out of 98
districts
– Reduced Onchercerca prevalence from 45.2% in
2007 to 2.7 %
– Reduced community microfilaria load from 20.1%
to 0%.
– Eliminated Trachoma
– Implemented School based distribution of
Praziquantal in 107 out of 240 districts

3. Background
• Successes due to
– Massive drug donations for as long at it takes to
eliminate the target diseases
– Massive support from donors to finance the
administration of the drugs
– Use of Mass Drug Administration through a
community directed approach with Community
Drug Distributors as the main agents
– Health care providers playing only a supervisory
role in MDA

4. Challenge
• Despite progress, program has concerns about
Schistosomiasis and its consequences for women
– 49 districts in Ghana have a prevalence of over 50%
for schistosomiasis
– 10 of these districts are co-endemic with LF and
Onchocerciasis.
– A recent study of the Volta Basin of Ghana estimates a
24.8% prevalence among women aged 15-49 years.
– Due to lack of funds and drugs the NTD program in
Ghana focuses only on school based distribution of
praziquantel, rather than employing community based
mass treatment.

5. Programme of implementation research to inform the effective and
sustainable scaling-up of integrated Neglected Tropical Disease (NTD)
control initiatives

6. Rationale for research themes and approaches
Addressing bottlenecks
in scale-up
and
acceleration towards
2020 targets
?

7. Rationale for research themes and approaches
Liberia
Cameroon
Ghana
Years of MDA
10 20 300
Trachoma
Soil-transmitted helminthiasis
Schistosomiasis
Lymphatic filariasis
Onchocerciasis
WEST
control elimination
Loa loa
CENTRAL

8. %
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SU H U M
KO F OR ID U A
N SA W A M
AKR OP ON G AK W A PIM
SO M AN Y A
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BEG O R O
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Kw am e D w am en ak r om
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Da ngb e W es t
No r th To ngu
Kw a hu No r th
A fra m Plains
1000000 1100000 1200000 1300000
700000 700000
800000 800000
900000 900000
1000000 1100000 1200000 1300000
400000 400000
500000 500000
600000 600000
MAP SHOWING THE STUDY C OMM UNITIES
%
Study Comm unities
Legend
%
District C apital
Feeder Road
District Boundary
Study Dis tric t
Water Body Te l 23 3 21 50 030 1
Fa x 2 33 21 50 03 10
Univers ity of Ghana
Legon
CERSGIS
Com pos ed by
Loc a ti on M a p
10 0 10 20 30 Kilo me te rs
1:8 000 00
N
Map showing the
Volta Basin and
surrounding
communities
1993 – Prev. 46.3%,
2010 – Prev. 10,4%

9. Schistosomiasis
A DISEASE OF POVERTY
• Farmers around irrigation areas
• Fresh water fishing
• Fetching of water from rivers for household use
• Performing household chores around water
bodies
• Children playing in water bodies

10. Urogenital Schistosomiasis
• Classical Sign
– Haematuria
• In women and children
– lesions of the cervix and vagina
– Nodules in the vulva
– female genital schistosomiasis (FGS)

11. Organ affected Consequences
Ovaries Hypogonadism, retarded puberty,
infertility (primary and secondary)
Fallopian tubes Ectopic/tubal pregnancy
Uterus Anemia due to chronic blood loss,
metaplasia, miscarriage, preterm
delivery
Cervix Anaemia, carcinoma, risk of STIs
Vagina/Vulva Destruction of the hymen/clitoris,
vesico-vaginal fistula, risk of STIs
Consequences of FGS

12. Reported reproductive health concerns
conditions

13. Why are we still talking about it
today?

14. More than a decade ago
Anyangwe et al. (1992) - Sequelae from FGS such as
infertility have an important social if not pathological
impact

15. Feldmeier et al., 1993
• Condition may be under-diagnosed because women
would be more likely to present to a gynecologist than
an infectious diseases specialist, and FGS is not well
recognized
• FGS increases the risk of HIV infection because the
lesion provides easier access to deeper vaginal cell
layers during intercourse with an infected partner
• Major gaps in our understanding of the genital
manifestations of schistosomiasis, including a lack of
data on the possible psychological effects of
dyspareunia and postcoital bleeding in women with
genital lesions

16. Feldmeier et al., 1995; Polderman, 1995
• Genital, rectal and ectopic localization of
schistosomiasis
• Evidence a damaged vaginal epithelium has for
sexually transmitted infections
• Genital lesions may either resolve spontaneously or
may become chronic and result in ulceration that
destroys the hymen and clitoris, with the most
debilitating sequelae being incontinence and vesico-
vaginal fistula

17. The gender agenda in the control of
tropical diseases: a review of current
evidence
Allotey and Gyapong,
2005

18. Socio Cultural Context
• Marginalised and voiceless women in Africa
and Middle East
–Suffer silently
–Cannot talk about issues related to their
sexuality
• Children
–Who listens to them and who do they talk
to?
–How do they describe what is wrong?
–What is the response to the child?

19. Socio-cultural Context
• Blood in urine among men sign of male maturity
• In women????
– Bleeding between periods
– Long period of menses
– Bleeding after sex
• Infertility
– Women to blame
– Various tests
– Various interventions
• Stigma
– No child
– Not having sex due to pain and bleeding
– Polygamy

20. Clinical Context
• In MDA or school based treatments, no
physical examination is done
• Health care providers untrained to look at
Schistosomiasis and its complications within
Maternal and Child Health
• Gynaecologists may either classify as cancer or
unknown

21. • Serious Reproductive Health Issues
that impact on Maternal Health
Outcomes
• Plausible association with HIV
• Plausible association with cancers
Implications

22. We are dealing with not just
blood samples and statistics but
with people who have names and
faces. Their suffering is
unacceptable in the 21st century.

23. Putting FGS on the maternal health
agenda
COUNTDOWN is working with country programs
and scientists
• Present the evidence
– Socio-cultural
– Clinical
– Health system
• Identify the gaps
– Diagnosis and treatment
• Tell the compelling stories

24. • Engage all directors of health services in the
country esp. Family Health
• Advocate for the active involvement of FGS
in Public Health Programs
• Advocate for a high clinical suspicion of FGS
• Make available diagnostics, surveillance
tools and resources for management of FGS
• Build capacity in the recognition, diagnosis
and treatment for FGS at all levels of the
health system
Active engagement

25. So women and their children can
access prevention, treatment and care
when and where they need it.