Abstract

Objective:

To analyze the epidemiological and clinical aspects involved in the transmission and manifestation of schistosomiasis in a community of fishermen from the endemic area of Alagoas.

Methods:

Epidemiological, transversal, prospective, descriptive, quantitative study. The coproparasitological survey included 275 family units of fish workers and the epidemiological and clinical ones, those with a positive diagnosis for S. mansoni.

Results:

The prevalence of schistosomiasis was 13.9% (fishermen), 2.1% (shellfish) and 2.1% (family members). The occurrence of the infection varied according to gender, age, ethnicity and socioeconomic status. Exposure occurred near the home. Autochthonous and predominant low parasite burden, intestinal clinical presentation, abdominal pain and diarrhea were observed. There were no nutritional and pressure changes associated with parasitosis. Adherence to drug therapy and use of the schistosomicidal drug was feared.

Conclusion:

Fish workers are at high risk for contracting the disease with clinical hepatointestinal manifestation, which requires more intense health actions.

Keywords:
Schistosomiasis; Epidemiology; Vulnerable populations

Resumen

Objetivo:

Analizar los aspectos epidemiológicos y clínicos involucrados en la transmisión y manifestación de la esquistosomiasis en una comunidad de pescadores de área endémica de Alagoas.

Métodos:

Estudio epidemiológico, transversal, prospectivo, descriptivo, cuantitativo. La encuesta coproparasitológica contempló 275 unidades familiares de los trabajadores de la pesca y el epidemiológico y clínico, aquellos con diagnóstico positivo para S. mansoni.

Resultados:

La prevalencia de la esquistosomiasis fue 13,9% (pescadores), 2,1% (marisqueras) y 2,1% (familiares). La ocurrencia de la infección varió según el género, edad, etnia y condición socioeconómica. La exposición ocurrió cerca del domicilio. Se observó autoctonía y predominio de carga parasitaria baja, presentación clínica intestinal, dolor abdominal y diarrea. No hubo alteraciones nutricionales y presión arterial asociadas a la parasitosis. Existia el temor de la adhesión a la terapia medicamentosa y al uso de la droga esquistomicida.

Conclusión:

Los trabajadores de la pesca presentan alto riesgo para contraer la enfermedad con manifestación clínica hepatointestinal, lo que requiere acciones de salud más intensas.

Palabras clave:
Esquistosomiasis; Epidemiología; Poblaciones vulnerables

Resumo

Objetivo:

Analisar os aspectos epidemiológicos e clínicos envolvidos na transmissão e manifestação da esquistossomose em uma comunidade de pescadores de área endêmica de Alagoas.

Métodos:

Estudo epidemiológico, transversal, prospectivo, descritivo, quantitativo. O inquérito coproparasitólogico contemplou 275 unidades familiares de trabalhadores da pesca e o epidemiológico e clínico, àqueles com diagnóstico positivo para S. mansoni.

Resultados:

A prevalência da esquistossomose foi 13,9% (pescadores), 2,1% (marisqueiras) e 2,1% (familiares). A ocorrência da infecção variou conforme gênero, idade, etnia e condição socioeconômica. A exposição ocorreu próxima ao domicílio. Observou-se autoctonia e predominância de carga parasitária baixa, apresentação clínica intestinal, dor abdominal e diarreia. Não ocorreram alterações nutricionais e pressóricas associadas à parasitose. Houve receio na adesão à terapêutica medicamentosa e ao uso do fármaco esquistossomicida.

Conclusão:

Os trabalhadores da pesca apresentam alto risco para contrair a doença com manifestação clínica hepatointestinal, o que requer ações de saúde mais fortalecidas.

Palavras-chave:
Esquistossomose; Epidemiologia; Populações vulneráveis

INTRODUCTION

Parasitic diseases are recognized as a public health problem and thousands of people are affected worldwide, among which the schistosomiasis is distinguished, resulting from a web of relationships between the man, the aquatic environment and the Schistosoma sp helminths.¹1 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Coordenação-Geral de Desenvolvimento da Epidemiologia em Serviços. Guia de Vigilância em Saúde. 2ª ed. Atual. Brasília (DF): Ministério da Saúde; 2017.

2 Calijuri ML, Santiago AF, Camargo RA, Moreira Neto RF. Estudo de indicadores de saúde ambiental e de saneamento em cidade do Norte do Brasil. Eng Sanit Ambient [Internet]. 2009 Jan/Mar; [cited 2017 Dec 18]; 14(1):19-28. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-41522009000100003
http://www.scielo.br/scielo.php?script=s... ^-33 Cardim LL, Ferraudo AS, Pacheco STA, Reis RB, Silva MMN, Carneiro DDMT, et al. Análises espaciais na identificação das áreas de risco para a esquistossomose mansônica no Município de Lauro de Freitas, Bahia, Brasil. Cad Saúde Pública [Internet]. 2011 May; [cited 2017 Dec 18]; 27(5):899-908. Available from: http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102-311X2011000500008&lng=es&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?script=s... The schistosomiasis is associated with the disease-impoverishment-poverty cycle⁴4 Souza FA, Santos I. Disseminação da Esquistossomose Mansônica na Região de Santa Cruz das Palmeiras-SP. Rev Logos [Internet]. 2008;16:43. Available from: https://drive.google.com/file/d/0B2QbBA2RX3q5VjF0T0Ewb0NaRHc/view
https://drive.google.com/file/d/0B2QbBA2... ^,55 King CH. Parasites and poverty: the case of schistosomiasis. Acta Trop [Internet]. 2010 Feb; [cited 2017 Dec 18]; 113(2):95-104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19962954
https://www.ncbi.nlm.nih.gov/pubmed/1996... and its epidemiological profile is determined by environmental, biological, socio-economic and cultural factors of a society⁶6 Utzinger J, N'goran EK, Caffrey CR, Keiser J. From innovation to application: social-ecological context, diagnostics, drugs and integrated control of schistosomiasis. Acta Trop [Internet]. 2011 Sep; [cited 2017 Dec 18]; 120(Suppl 1):S121-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20831855
https://www.ncbi.nlm.nih.gov/pubmed/2083...

7 Mazigo HD, Nuwaha F, Kinung'hi SM, Morona D, Moira AP, Wilson S, et al. Epidemiology and control of human schistosomiasis in Tanzania. Parasit Vectors [Internet]. 2012 Nov; [cited 2017 Dec 18]; 5(274):1-20. Available from: https://parasitesandvectors.biomedcentral.com/articles/10.1186/1756-3305-5-274
https://parasitesandvectors.biomedcentra... ^-88 Dawaki S, Al-Mekhlafi HM, Ithoi I, Ibrahim J, Abdulsalam AM, Ahmed A, et al. Prevalence and risk factors of schistosomiasis among Hausa Communities in Kano State, Nigeria. Rev Inst Med Trop [Internet]. 2016 Jul; [cited 2017 Dec 18]; 58:1-9. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0036-46652016005000241
http://www.scielo.br/scielo.php?script=s... that interconnected, influence the development and the disease control cycle.

In Brazil, it is estimated that 2.5 to 8 millions of Brazilians are affected by the schistosomiasis mansoni and about 5 millions of persons may be infected, in which the Southeastern and Northeastern are the most affected regions, with the highest prevalence rates in the Northeastern states.¹1 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Coordenação-Geral de Desenvolvimento da Epidemiologia em Serviços. Guia de Vigilância em Saúde. 2ª ed. Atual. Brasília (DF): Ministério da Saúde; 2017. The state of Alagoas, situated in Northeast Brazil, provides favorable conditions for the establishment of the schistosomiasis, in view of its environmental aspects, presence of the transmitter molluscs, strong social inequalities and intensive human contact with water collections (contact standard with water collections). For this reason, approximately 70% of the municipalities in Alagoas are affected by the spread of the disease,⁹9 Couto JLA. Esquistossomose mansoni em duas mesorregiões do Estado de Alagoas. Rev Soc Bras Med Trop [Internet]. 2005 Jul/Aug; [cited 2017 Dec 18]; 38(4):301-4. Available from: http://www.scielo.br/pdf/rsbmt/v38n4/a04v38n4.pdf
http://www.scielo.br/pdf/rsbmt/v38n4/a04... ^,1010 Rocha TJM, Santos MCS, Lima MVM, Calheiros CML, Wanderley FS. Aspectos epidemiológicos e distribuição dos casos de infecção pelo Schistosoma mansoni em municípios do Estado de Alagoas, Brasil. Rev Pan Amaz Saúde [Internet]. 2016 Jun; [cited 2017 Dec 18]; 7(2):27-32. Available from: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S2176-62232016000200027
http://scielo.iec.gov.br/scielo.php?scri... including Marechal Deodoro, situated in the transition of risk to the schistosomiasis and prevalence rate of 7.54% between 2010 and 2016.¹¹11 Ministério da Saúde (BR). Departamento de Informática do SUS. Programa de Controle da Esquistossomose (PCE) [Internet]. [cited 2017 Aug 11]. Available from: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sinan/pce/cnv/pce.def
http://tabnet.datasus.gov.br/cgi/deftoht...

In this municipality, one of the main source of income and generation of jobs is the fishing¹²12 Instituto Brasileiro de Geografia e Estatística (BR). Cidades. [Internet]. [cited 2018 Feb 8]. Available from: https://cidades.ibge.gov.br/brasil/al/marechal-deodoro/panorama
https://cidades.ibge.gov.br/brasil/al/ma... and the fishing workers, by having a greater contact with the water, constitute a group of greater vulnerability, exposition and contamination by S. mansoni, in addition to being a potential source to the spread of the disease. Thus, the aim of this research was to analyze the epidemiological clinical aspects involved in the transmission and manifestation of the disease in a fishing community from endemic area of the schistosomiasis.

METHODS

Epidemiological, cross-sectional, prospective, descriptive study with a quantitative approach, carried out between June 2016 and March 2017, composed of three evaluation steps: parasitological, epidemiological and clinical that occurred simultaneously during the period, where there has been a hierarchy in steps, as a prerequisite for another.

The municipality investigated is Marechal Deodoro (Latitud: 09042' 37", Longitud 35° 53' 42") located by the right edge of Manguaba lagoon, through which is bathed on the extreme northteastern by the Rio dos Remédios and to the south by the Niquim River, to the east by the Atlantic Ocean and it central portion by the Rios Grande and of the Estiva that fed the Mundaú lagoon. It stands at 19 km to the south-west of Maceió (Capital), to a resident population of 45,995 inhabitants, demographic density of 138,62 inhabitants per km² and poverty rate of 64,32%, the economy is based on the productive chain of the chemical and of the plastics production, sugarcane-alcohol companies, shelfish, fishing and tourism.¹²12 Instituto Brasileiro de Geografia e Estatística (BR). Cidades. [Internet]. [cited 2018 Feb 8]. Available from: https://cidades.ibge.gov.br/brasil/al/marechal-deodoro/panorama
https://cidades.ibge.gov.br/brasil/al/ma...

In this study fishing workers (fishers and shelfish) registered and active in the Fishermen Colony São Pedro (Z-6) and its respective family unit. This population was chosen by having greater risk of contracting schistosomiasis and randomly selected, from a listing provided by the Colony, containing identification data and address.

In the parasitology research, fishing workers and their family unit have participated, excluding non-resident families at home and children aged under or equal 2 years old, following the Schistosomiasis Control Program protocol (PCE) in not including in its coproscopy routine, children in this age group. In the epidemiological and clinical research schistosomiasis-positive individuals have participated.

The method used for the parasitological diagnosis was Kato-Katz and the processing of the fecal material and slide analysis were carried out by the PCE technicians. Cases confirmed by laboratorial criterion had slides containing S. mansoni egg(s). The parasite load has been determined by multiplying the number of eggs by the constant 24, (considering that one slide contains 45 g of feces that multiplied by 24, will be a result of approximately 1 g of feces), therefore obtaining eggs for every gram of feces (opg). The individuals we classified¹³13 World Health Organization (WHO). Prevention and control of schistosomiasis and soil-transmitted helminthiasis: Report of a WHO Expert Committee. Geneva: World Health Organization; 2002 [Internet]. Available from: http://www.who.int/iris/handle/10665/42588
http://www.who.int/iris/handle/10665/425... with low (to 100 opg) moderate (101 to 400 opg) and high (higher than 400 opg) parasite load.

In the epidemiological research a form validated by Melo et al.¹⁴14 Melo AGS, Melo CM, Oliveira CCC, Oliveira DS, Santos VB, Jeraldo VLS. Esquistossomose em área de transição urbano-rural: reflexões epidemiológicas. Ciênc Cuid Saúde [Internet]. 2011 Jul/Sep;10(3):506-13. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12479
http://periodicos.uem.br/ojs/index.php/C... was applied, containing the following variables: identification, sociodemographic (ethnicity, nationality, income, schooling, water supply and treatment and waste disposal, destination of the trash and housing type), autochthony and risk behavior of schistosomiasis (labor, household and leisure activities and frequency of contact with hydro solutions).

In the clinical evaluation an individual form elaborated by the authors of this research was used, with the following variables: self-reported gastrointestinal symptomatology, nutritional and pressure assessment (body weight), abdominal physical examination with liver assessment (down to the left costal margin) and spleen (left costal margin) and medicinal therapy of schistosomiasis.

The nutritional assessment through the body weight occurred by the Body Mass Index: Weight (measured by the digital balance with capacity of 150Kg) / Height² (measured with a meter rule). The participants were classified¹⁵15 Ministério da Saúde (BR). Orientações para coleta e análise de dados antropométricos em serviços de saúde: norma técnica do sistema de vigilância alimentar e nutricional-SISVAN. Brasília (DF): Ministério da Saúde; 2011. as low weight (≤ 18.5); eutrophic (≥ 18.5 >25); overweight (≥25<30) and obesity (≥30). In the adolescents aged 10 years old and lower than its classification through the percentile between 5 and 85, being classified into: low weight (>5), eutrophic (≥ 5 <85) and overweight (≥85). For the elderly the classification was: low weight (≤ 22); eutrophic (>22<27), overweight (≥27).

Blood pressure was measured by auscultation, using an aneroid sphygmomanometer tested and calibrated, with width of rubber pouch compatible with the arm circumference. The systolic and diastolic arterial pressure (PAS/PAD) of the participants in the study were classified¹⁶16 Malachias MVB, Souza WKSB, Plavink FL, Rodrigues CIS, Brandão AA, Neves MFT, et al. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol [Internet]. 2016 Sep; [cited 2018 Feb 2018]; 107(3 Supl. 3):1-83. Available from: http://publicacoes.cardiol.br/2014/diretrizes/2016/05_HIPERTENSAO_ARTERIAL.pdf
http://publicacoes.cardiol.br/2014/diret... in: normal (≤120/ ≤80), pre- hypertension (120 - 139/ 80 - 89), hypertension (≥ 140 /100).

The determination of the clinical schistosomiasis presentation followed the classification of Pessoa and Barros¹⁷17 Pessoa SB, Barros PR. Sobre o diagnóstico da esquistossomose mansônica na infância, pela intradermoreação com antígeno de esquistossomas adultos. Hospital. 1953;43:19-25. adapted by Barbosa¹⁸18 Barbosa FS. Morbidade da esquistossomose. Rev Bras Malariol Doen Trop. 1966;(no.esp):3-159.: Intestinal (liver and spleen not palpable), Hepatointestinal (liver palpable at more than 3 cm from the right costal edge) and Hepatosplenic (spleen not palpable with normal or increased consistency).

The collection of fecal samples was conducted in the households of the participants in the study, during the morning period with a mean time of 2 hours, in collectors previously identified, stored in styrofoam boxes and sent to the Health Surveillance laboratory of the municipality examined. Over the 24-hour period before the feces collection, the individuals were registered by means of a form of daily records for coproscopy, used by the PCE during the coproscopic census.

The epidemiological and clinical data collection occurred in a reserved place at home or in the fishermen colony, with an average duration of 30 to 40 minutes. In order to avoid information bias in epidemiological data collection, the relatives investigated were not interviewed regarding family income and questions related to environment sanitation, whose information was gathered in the interview of the fishing workers (family head).

The population registered and active in the Fishermen Colony São Pedro (Z-6) is composed of 669 fishing workers and 939 relatives. The obtainment of the sample of 275 individuals, between fishermen and shelfish, considered the Barbetta calculation¹⁹19 Barbetta PA, Reis MM, Bornia AC. Estatística para curso de engenharia e informática. 3ª ed. São Paulo: Atlas; 2010. with the addition of 10% for possible losses (n = 669x400/669+400 = 250 + 10%). From the total of the fishing workers, 86.5% (n = 238) and 54.5% (n = 512) of the relatives agreed to cooperate in the study.

The endpoint of the study corresponded to the identification of the individuals infected by the S. mansoni, being this the dependent variable, and of the epidemiological and clinical data, to the dependent variable, and the epidemiological and clinical data, to the independent variable. Eligibility criteria were: to be fishing worker registered in the Fishermen Colony and be developing fishing activities.

The study was approved by the Ethics Research Committee of the Tiradentes University/UNIT: CAAE 557773216.3.0000.5371; Protocol 1.585.464, approved on 09 June 2016. All the participants signed the Consent Form for the research, the respect to the autonomy and anonymity were preserved in all phases.

The statistical observations were conducted using the SPSS version 16.0 statistical software (Statistical Package for the Social Sciences Inc., Chicago, IL, EUA), and adopted a 95% confidence level. The used statistics was descriptive (percentage and average), hazard ratio (Odds Ratio) in order to identify the schistosomiasis occurrence among the assessed and the Pearson chi-squared test, in order to verify the association or not among the analyzed variable. The differences were considered significant when p value was less than 0.05.

RESULTS

Of the 750 individuals that provided fecal material for the stool test (238 fishing workers and 512 relatives), the general prevalence of schistosomiasis was 18%, being 15.9% between the fishing workers (fisherman 13.8% and selfish 2.1%) and 2.1% among the relatives. More than half (57.9%) of these bearers of the infection originate from the rural environment and live in Marechal Deodoro, since his birth.

Approximately 65.8%, of these workers use the hydro collections solely for the labor activity (OR= 0.6 IC 95% = 0.46 - 0.79) and 34.2% associate labor activities and leisure. The fishermen has a relative risk 3.6 times higher of getting infected with the parasite, for displaying high frequency of contact with the hydro collections, behavior strongly associated with the schistosomiais (Table 1).

The socio-demographical characteristics of the individuals parasitized by S. mansoni are described in the Table 2 and Pearson correlation did not indicate statistically significant association among the variables analyzed (p > 0.05).

The cases confirmed of the schistosomiasis infection are autochtony, occurring in the three ethnic groups, in which black and brown individuals had the higher frequencies. Among the fishing workers, the adults (29 to 49 years) and elderly (more than 60 years) were the most affected and, among the relatives inverse condition was found, and adolescents and it was more prevailed between adolescents and young adults (10 to 28 years).

Approximately 51.5% of the fishermen and 20% of the selfish are assisted by the minimum income social program of the federal government "Family Allowance", earning a family income under one minimum wage (R$ 937.00). Regarding the schooling, the schistosomiasis is prevalent in those who cannot read or write (illiterates) and among those who have few years of schooling (incomplete basic school).

Regarding the basic infra structure and habitation conditions, the access to water and energy are derived from the public service. The most fishing (97%) does not carry out any prior treatment of the drinking water, and, among those who use the filtration, there is no habit of changing periodically the filter. The predominant profile of the houses is brick adobe, and the domestic waste are directed into the septic fossa (63.6%), while the remainder is directed into the lagoon Mundaú and rivers that border the residences (Table 2).

The parasitic load observed in this study, irrespectively of the labor category regarding the fishing, was 1 to 13 eggs per blades (X = 3.45 ± 3.28), while the mean of eggs per gram of feces was 82.1 ± 79.2. The results of the clinical evaluation (Table 3) showed that the bearers of S. mansoni had light to moderate infection, in which the low parasitic load is the predominant (until 100 opg) among fishermen (78.8%), selfish (80%) and relatives (72.7%), without significant differences (p > 0.05).

At physical abdomen examination, the liver was impalpable in the selfish (100%) and in the relatives (100%), although palpable in 9.1% of the fishermen, with normal consistence and of smooth surface, while the spleen was impalpable in the individuals examined. Regarding the clinical presentation of schistosomiasis, the intestinal form prevailed in the evaluated, and the hepatointestinal form affected a small number of fishermen (9.1%), without statistically significant association with the labor activity. In this study, cases of hepatosplenic form were not observed (Table 3).

Abdominal pain and diarrhea were the most referred digestive symptoms. The pain was showed with different variations, of light to moderate intensity, being, sometimes, felt with predominance of the colic-type (Table 4).

The diarrhea was present with light to moderate intensity, however the light is the most prevalent between the selfish and the relatives and, the moderate, among the fishermen. Small amounts of blood around the feces (rectal bleeding) was a little mentioned clinical by the evaluated and of rare occurrence. There was no reports of dark and fetid feces (melena).

Regarding the classification of pressure levels, the hypertension was more frequent among the fishermen (45.5%), while the condition of pre-hypertensive prevailed in the selfish (80%) and the normotensive in the relatives (63.6%). Regarding the classification of the nutritional condition, 36.4% of the fishermen showed overweight, 40% of the selfish obesity and 45.5% of the relatives, the thinness (Table 5).

DISCUSSION

The municipality study object is endemic for schistosomiais, as it presents environmental scenario favorable to infection of the host mollusc Biomphalaria glabrata and the human infection, by cercariae of S. mansoni. The positive cases analyzed are authocthonous, indicating that the exposition occurred in the investigation location. These individuals, due to not exhibit the clinical manifestation of the disease in the acute phase,²⁰20 Vitorino RR, Souza FPC, Costa AP, Faria Júnior FC, Santana LA, Gomes AP. Esquistossomose mansônica: diagnóstico, tratamento, epidemiologia, profilaxia e controle. Rev Bras Clin Med [Internet] 2012 Jan/Feb; [cited 2017 Dec 18]; 10(1):39-45. Available from: http://files.bvs.br/upload/S/1679-1010/2012/v10n1/a2676.pdf
http://files.bvs.br/upload/S/1679-1010/2... evolve to the chronic forms of the disease, configuring in a challenge for the public health and parasitic infection control.

The fishing environment gathered desirable characteristics for S. mansoni contamination, due to have inefficiency of basic sanitation and represent the final disposition of the domestic effluents, constituting spaces of occupational risks,²¹21 Pena PGL, Gomez CM. Saúde dos pescadores artesanais e desafios para a Vigilância em Saúde do Trabalhador. Ciênc Saúde Coletiva [Internet]. 2014 Dec; [cited 2018 Jan 2018]; 19(12):4689-98. Available from: http://www.scielo.br/scielo.php?pid=S1413-81232014001204689&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... by the exposition to transmissible infections, such as the schistosomiasis.

The fishing activity can be used as an indicator to increase the prevalence of infection.²²22 Silva CO, Santos LX, Silva VA. Geografia de saúde: Diagnóstico da esquistossomose no sítio Jiboia em São José da Laje-AL. Rev Okara [Internet]. 2015;9(1):50-71. Available from: file:///C:/Users/susana/Downloads/22575-50063-1-PB.pdf The male fishing workers were the most affected, corroborating the recognized high frequency of the schistosomiasis infection among the men,²³23 Palmeira DCC, Carvalho AG, Rodrigues K, Couto JLA. Prevalência da infecção pelo Schistosoma mansoni em dois municípios do Estado de Alagoas. Rev Soc Bras Med Trop [Internet]. 2010 Jun; [cited 2018 Jan 18]; 43(3):313-7. Available from: http://www.scielo.br/scielo.php?pid=S0037-86822010000300020&script=sci_abstract&tlng=pt
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25 Tukahebwa EM, Magnussen P, Madsen H, Kabatereine N, Nuwaha F, Wilson B, et al. A very high infection intensity of Schistosoma mansoni in a Ugandan Lake Victoria Fishing Community is required for association with highly prevalent organ related morbidity. PLoS Negl Trop Dis [Internet]. 2013 Jul; [cited 2018 Jan 18]; 7(7):e2268. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23936559
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26 Taman A, El-tantawy N, Besheer T, Taman S, Helal R. Schistosoma mansoni infection in a fishermen community, the Lake Manzala region-Egypt. Asian Pac J Trop Dis [Internet]. 2014 Dec; [cited 2018 Jan 18]; 4(6):463-8. Available from: https://www.sciencedirect.com/science/article/pii/S2222180814606071
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27 Gomes ACL, Galindo JM, Lima NN, Silva EVG. Prevalência e carga parasitária da esquistossomose mansônica antes e depois do tratamento coletivo em Jaboatão dos Guararapes, Pernambuco. Epidemiol Serv Saúde [Internet]. 2016 Jun; [cited 2018 Feb 7]; 25(2):243-50. Available from: http://www.scielo.br/scielo.php?pid=S2237-96222016000200243&script=sci_abstract&tlng=pt
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28 Santos AS, Santos MB, Santos PGR, Barreto AS, Araújo KCGM. Análise espacial e características epidemiológicas dos casos de esquistossomose mansônica no município de Simão Dias, nordeste do Brasil. Rev Patol Trop [Internet]. 2016 Jan/Mar; [cited 2018 Feb 8]; 45(1):99-114. Available from: https://revistas.ufg.br/iptsp/article/view/39978/20709
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29 Lima CWR, Oliveira NMC, Silva SVD, Duarte MEL, Barbosa APF. Ectopic forms of schistosomiasis mansoni in the second macroregion of Alagoas: case series report and review of the literature. Rev Soc Bras Med Trop [Internet]. 2017 Nov/Dec; [cited 2018 Feb 8]; 50(6):812-8. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0037-86822017000600812
http://www.scielo.br/scielo.php?script=s... ^-3030 Rodrigues Júnior CA, Dias FCF, Rosa RTS, Cardoso CRL, Veloso FPFS, Mariano SMB, et al. Esquistossomose na região norte do Brasil. Rev Patol Tocantis [Internet]. 2017 Jun; [cited 2018 Feb 8]; 4(2):58-61. Available from: https://sistemas.uft.edu.br/periodicos/index.php/patologia/article/view/3757/9745
https://sistemas.uft.edu.br/periodicos/i... since in this occupation there is a gender influence³¹31 Rollemberg CV, Silva MM, Rollemberg KC, Amorim FR, Lessa NM, Santos MD, et al. Predicting frequency distribution and influence of sociodemographic and behavioral risk factors of Schistosoma mansoni infection and analysis of co-infection with intestinal parasites. Geospat Health [Internet]. 2015 May; [cited 2018 Feb 8]; 10(1):303. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26054512
https://www.ncbi.nlm.nih.gov/pubmed/2605... ^,3232 Donohue RE, Mashoto KO, Mubyazi GM, Madon S, Malecela MN, Michael E. Biosocial Determinants of Persistent Schistosomiasis among Schoolchildren in Tanzania despite Repeated Treatment. Trop Med Infect Dis [Internet]. 2017 Dec; [cited 2018 Feb 8]; 2(4):1-25. Available from: https://search.informit.com.au/documentSummary;dn=313417967569645;res=IELHEA
https://search.informit.com.au/documentS... due to the social division of labor: fishermen are more exposed because develop activities with parts of its body in the water, different from the work conditions in the selfish, in which the selfish reception and processing reduce the water contact and exposition.

The fishing work division and the risk of S. mansoni infection is documented by several authors,³³33 Pinot de Moira A, Fulford AJ, Kabatereine NB, Kazibwe F, Ouma JH, Dunne DW, et al. Microgeographical and tribal variations in water contact and Schistosoma mansoni exposure within a Ugandan fishing community. Trop Med Int Health [Internet]. 2007 Jun; [cited 2018 Fev 8]; 12(6):724-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17550469
https://www.ncbi.nlm.nih.gov/pubmed/1755... which observed that the prevalence of infection is more increased among the fisherman, specially, those who fished on foot compared with those who practiced the boat fishing, in which are present the women, who were less affected by this helminthiasis.

Increased occurrences of this parasitosis in adults were also observed in a community where the fishing activity is predominant.²⁶26 Taman A, El-tantawy N, Besheer T, Taman S, Helal R. Schistosoma mansoni infection in a fishermen community, the Lake Manzala region-Egypt. Asian Pac J Trop Dis [Internet]. 2014 Dec; [cited 2018 Jan 18]; 4(6):463-8. Available from: https://www.sciencedirect.com/science/article/pii/S2222180814606071
https://www.sciencedirect.com/science/ar... In the relatives the disease occurrence between adolescents and young adults is justified by the behavioral aspect of the age (swimming/ fishing), and similar trends were observed in a municipality rich in water sources and endemic for the schistosomiasis.²⁸28 Santos AS, Santos MB, Santos PGR, Barreto AS, Araújo KCGM. Análise espacial e características epidemiológicas dos casos de esquistossomose mansônica no município de Simão Dias, nordeste do Brasil. Rev Patol Trop [Internet]. 2016 Jan/Mar; [cited 2018 Feb 8]; 45(1):99-114. Available from: https://revistas.ufg.br/iptsp/article/view/39978/20709
https://revistas.ufg.br/iptsp/article/vi... Specifically in this study, the prevalence among the adolescents can be attributed to the follow-up in the fishing activity of the relatives. The family occupation can interfere in the epidemiology of this parasitosis.³⁴34 Coulibaly JT, N'Gbesso YK, N'Guessan NA, Winkler MS, Utzinger J, N'Goran EK. Epidemiology of schistosomiasis in two high-risk communities of South Côute d'ivoire with particular emphasis on pre-school-aged children. Am J Trop Med Hyg [Internet]. 2013 Jan; [cited 2018 Fev 8]; 89(1):32-41. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748484/
https://www.ncbi.nlm.nih.gov/pmc/article...

The schistosomiasis was more prevalent between blacks and browns, this trend was found in individuals infected with S. mansoni.¹⁴14 Melo AGS, Melo CM, Oliveira CCC, Oliveira DS, Santos VB, Jeraldo VLS. Esquistossomose em área de transição urbano-rural: reflexões epidemiológicas. Ciênc Cuid Saúde [Internet]. 2011 Jul/Sep;10(3):506-13. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12479
http://periodicos.uem.br/ojs/index.php/C... ^,2828 Santos AS, Santos MB, Santos PGR, Barreto AS, Araújo KCGM. Análise espacial e características epidemiológicas dos casos de esquistossomose mansônica no município de Simão Dias, nordeste do Brasil. Rev Patol Trop [Internet]. 2016 Jan/Mar; [cited 2018 Feb 8]; 45(1):99-114. Available from: https://revistas.ufg.br/iptsp/article/view/39978/20709
https://revistas.ufg.br/iptsp/article/vi... The key element for the occurrence of this infection is not the ethnicity but the socio-economic factor: individuals of this ethnical group m more devoid of income and years of study and reside in places with environmental insalubrity. The deficiency of basic sanitation and the risk of infection have been documented by several authors³⁵35 Enk MJ, Amaral GL, Costa Silva MF, Silveira-Lemos D, Teixeira-Carvalho A, Martins-Filho AO, et al. Rural tourism: a risk factor for schistosomiasis transmission in Brazil. Mem Inst Oswaldo Cruz [Internet]. 2010 Jul; [cited 2018 Feb 8]; 105(4):537-40. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0074-02762010000400032
http://www.scielo.br/scielo.php?script=s...

36 Gomes ECS, Leal-Neto OB, Albuquerque J, Silva HP, Barbosa CS. Schistosomiasis transmission and environmental change: a spatio-temporal analysis in Porto de Galinhas, Pernambuco - Brazil. Int J Health Geogr [Internet]. 2012; [cited 2018 Feb 8]; 11(51):1-11. Available from: https://ij-healthgeographics.biomedcentral.com/track/pdf/10.1186/1476-072X-11-51
https://ij-healthgeographics.biomedcentr...

37 Adenowo AF, Oyinloye BE, Ogunyinka BI, Kappo AP. Impacto of humam schistosomiasis in Sub-Sarah Africa. Braz J Infect Dis [Internet]. 2015 Mar/Apr; [cited 2018 Feb 8]; 19(2):196-205. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25636189
https://www.ncbi.nlm.nih.gov/pubmed/2563... ^-3838 Worku L, Demekech D, Endris M, Tesfa H, Aemero M. Schistosoma mansoni Infection and Associated Determinant Factors among School Children in Sanja Town, Northwest Ethiopia. J Parasitol Res [Internet]. 2014; [cited 2018 Feb 8]; 2014:792536. Available from: https://www.hindawi.com/journals/jpr/2014/792536/cta/
https://www.hindawi.com/journals/jpr/201... as well as the adequate sanitation and lesser chances of acquiring the infection by this parasite.³⁹39 Grimes JET, Croll D, Harrisso WE, Utizinger J, Freeman MC, Templetom MR. The Relationship between Water, Sanitation and Schistosomiasis: A Systematic Review and Meta-analysis. PLoS Negl Trop Dis [Internet]. 2014 Dec; [cited 2018 Feb 8]; 8(12):e3296. Available from: http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003296
http://journals.plos.org/plosntds/articl...

The relation between low level of schooling and schistosomiasis are reported in several studies.³3 Cardim LL, Ferraudo AS, Pacheco STA, Reis RB, Silva MMN, Carneiro DDMT, et al. Análises espaciais na identificação das áreas de risco para a esquistossomose mansônica no Município de Lauro de Freitas, Bahia, Brasil. Cad Saúde Pública [Internet]. 2011 May; [cited 2017 Dec 18]; 27(5):899-908. Available from: http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102-311X2011000500008&lng=es&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?script=s... ^,2222 Silva CO, Santos LX, Silva VA. Geografia de saúde: Diagnóstico da esquistossomose no sítio Jiboia em São José da Laje-AL. Rev Okara [Internet]. 2015;9(1):50-71. Available from: file:///C:/Users/susana/Downloads/22575-50063-1-PB.pdf^,4040 Neresb RC, Araújo EM, Rocha WJFS, Lacerda RS. Caracterização epidemiológica dos casos de esquistossomose no município de Feira de Santana, Bahia. Rev Baiana Saúde Pública. [Internet]. 2011 Jan/Jun; [cited 2018 Feb 8]; 35(Supl.1):28-37. Available from: http://files.bvs.br/upload/S/0100-0233/2011/v35nSupl1/a2296.pdf
http://files.bvs.br/upload/S/0100-0233/2... The instruction level is an important factor in the control of this parasitosis, because the access to information promotes the empowerment of the population, adherence to health care, behavioral change and consequent reduction of the prevalence rates. On the other hand, individuals less educated are less prone to orientations for prevention of the disease and health promotion, thus, the education and the health embrace the health-falling ill-healing process, impede the occurrence or complications of the disease.⁴¹41 Salci MA, Maceno P, Rozza SG, Silva DMGV, Boehs AE, Heidemann ITSB. Educação em saúde e suas perspectivas teóricas: algumas reflexões. Texto Contexto Enferm [Internet] 2013 Jan/Mar; [cited 2018 Feb 8]; 22(1):224-30. Available from: http://www.scielo.br/pdf/tce/v22n1/pt_27
http://www.scielo.br/pdf/tce/v22n1/pt_27...

The low parasite load and the light intensity of infection, predominant among the investigated, are common characteristics found in endemic for the schistosomiasis, arisen from the successive reinfections and treatments with the Praziquantel, drug that has the capacity to reduce the parasite load and the production of eggs of S. mansoni.⁴²42 Ross AG, Bartley PB, Sleigh AC, Olds GR, Li Y, Willams GM, Mcmanus DP. Schistosomiasis. N Engl J Med [Internet]. 2002 Apr; [cited 2018 Feb 8]; 346(16):1212-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11961151
https://www.ncbi.nlm.nih.gov/pubmed/1196... Such individuals, are in general asymptomatic and can be held responsible by the maintenance of the outbreaks of the disease.²⁷27 Gomes ACL, Galindo JM, Lima NN, Silva EVG. Prevalência e carga parasitária da esquistossomose mansônica antes e depois do tratamento coletivo em Jaboatão dos Guararapes, Pernambuco. Epidemiol Serv Saúde [Internet]. 2016 Jun; [cited 2018 Feb 7]; 25(2):243-50. Available from: http://www.scielo.br/scielo.php?pid=S2237-96222016000200243&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S223...

The more accentuated intestinal disturbances, as abdominal pain and dirrhea may suggest the chronic form of schistosomiasis,²⁰20 Vitorino RR, Souza FPC, Costa AP, Faria Júnior FC, Santana LA, Gomes AP. Esquistossomose mansônica: diagnóstico, tratamento, epidemiologia, profilaxia e controle. Rev Bras Clin Med [Internet] 2012 Jan/Feb; [cited 2017 Dec 18]; 10(1):39-45. Available from: http://files.bvs.br/upload/S/1679-1010/2012/v10n1/a2676.pdf
http://files.bvs.br/upload/S/1679-1010/2... ^,4343 Souza FPC, Vitorino RR, Costa AP, Faria-Junior FC, Santana LA, Gomes AP. Esquistossomose mansônica: aspectos gerais, imunologia, patogênese e história natural. Rev Bras Clin Med [Internet] 2011 Jul/Aug; [cited 2018 Feb 8]; 9(4):300-7. Available from: http://files.bvs.br/upload/S/1679-1010/2011/v9n4/a2190.pdf
http://files.bvs.br/upload/S/1679-1010/2... ^,4444 Elbaz T, Esmat G. Hepatic and intestinal schistosomiasis: review. J Adv Res [Internet]. 2013 Sep; [cited 2017 Dec 18]: 4(5):445-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25685451
https://www.ncbi.nlm.nih.gov/pubmed/2568... specifically of type intestinal⁵5 King CH. Parasites and poverty: the case of schistosomiasis. Acta Trop [Internet]. 2010 Feb; [cited 2017 Dec 18]; 113(2):95-104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19962954
https://www.ncbi.nlm.nih.gov/pubmed/1996... and, the presence of blood feces and melena, can be associated with hepatointestinal or hepatosplenic forms of the disease.⁴⁴44 Elbaz T, Esmat G. Hepatic and intestinal schistosomiasis: review. J Adv Res [Internet]. 2013 Sep; [cited 2017 Dec 18]: 4(5):445-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25685451
https://www.ncbi.nlm.nih.gov/pubmed/2568... ^,4545 Olveda DU, Olveda RM, Mcmanus DP, Cai P, Chau TNP, Lam AK, et al. The chronic enteropathogenic disease schistosomiasis. Int J Infect Dis [Internet] 2014 Nov; [cited 2018 Feb 8]; 28:193-203. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25250908
https://www.ncbi.nlm.nih.gov/pubmed/2525... These events, with the exception of melena, were symptons commonly found in fishermen and his relatives infected with S. mansoni.²⁶26 Taman A, El-tantawy N, Besheer T, Taman S, Helal R. Schistosoma mansoni infection in a fishermen community, the Lake Manzala region-Egypt. Asian Pac J Trop Dis [Internet]. 2014 Dec; [cited 2018 Jan 18]; 4(6):463-8. Available from: https://www.sciencedirect.com/science/article/pii/S2222180814606071
https://www.sciencedirect.com/science/ar...

The description of the abdominal sharp pain, attributed to the "worm pinching the abdome", have been reported by other investigators.¹⁴14 Melo AGS, Melo CM, Oliveira CCC, Oliveira DS, Santos VB, Jeraldo VLS. Esquistossomose em área de transição urbano-rural: reflexões epidemiológicas. Ciênc Cuid Saúde [Internet]. 2011 Jul/Sep;10(3):506-13. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12479
http://periodicos.uem.br/ojs/index.php/C... This sensorial perception of pain reveals the interpretative model of the disease, especially of the parasite in the human organism, under a popular conception, linked to sociocultural conditions, in the time and space established, where the (re) significations of the health-disease are built and shared.⁴⁶46 Alves PC, Souza IM, Moura MA, Cunha LA. A experiência da esquistossomose e os desafios da mobilização comunitária. Cad Saúde Pública [Internet] 1998; [cited 2018 Feb 8]; 14(Suppl. 2):S79-90. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X1998000600007
http://www.scielo.br/scielo.php?script=s...

The alterations of the pressure levels and of the weight in the individuals in this research are not attributed to the infection of S. mansoni, although the malnutrition has, as one of its causes the schistosomiasis, by causing alterations in the digestion and absorption of nutrients, with negative consequences for the organism over the long term,⁴⁷47 Mcgarvey ST. Schistosomiasis: Impact on childhood and adolescent growth, malnutrition, and morbidity. Semin Pediatr Infect Dis [Internet]. 2000 Oct; [cited 2018 Feb 8]; 11(4):269-74. Available from: https://www.sciencedirect.com/science/article/pii/S1045187000700082
https://www.sciencedirect.com/science/ar... ^,4848 Mekonnen Z, Meka S, Zeynudim A, Suleman S. Schistosoma mansoni infection and undernutrition among school age children in Fincha'a sugar estate, rural part of West Ethiopia. BMC Res Notes [Internet]. 2014; [cited 2018 Feb 8]; 7:763. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25348748
https://www.ncbi.nlm.nih.gov/pubmed/2534... specially in children, enabling outbreaks of other infections and debilitating the organism.

The adherence rate to the drug treatment in this research was satisfactory, above the rate advised by the (80%) Ministry of Health even having initially aversion to the use of the Praziquantel drug due to its side effects (headache, vomiting, diarrhea, fever, muscular and articular pain, among others), condition also reported in fishermen population resident in endemic areas for the schistosomiasis in the African continent.⁴⁹49 Pearson G. Low prevalence of intestinal schistosomiasis among fisherfolk living along the river Nile in north-western Uganda: a biosocial investigation. J Biosoc Sci [Internet] 2016 Sep; [cited 2018 Jun 8]; 48(Supp1):S74-91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27428067
https://www.ncbi.nlm.nih.gov/pubmed/2742... The reluctance to the use of Praziquantel may be related to the sharing, in the community under study in Alagoas, of the sensations and experiences lived by individuals who adhered and were in drug treatment, provoking in those who did not adhere to the chemotherapy a ripple effect of fear to the anti-parasite drug.

The limitation of this study refers to the low sensibility of the diagnosis method and to the need for complementary exams, such as, the imaging method, in order to define with greater precision, the chronic stage of schistosomiasis. These aspects do not interfere in its relevance and scientificity, with the possibility of being used as a basis for the epidemiological and clinical research of the disease in other endemic localities.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

The unfavorable scenario of the municipality under study, with precariousness of basic sanitation, education, housing and income, reiterates that the disease prevail under conditions of socio-economic vulnerability. These conditions should be considered in the dynamics of the transmission of disease, since the organization of the geographic space and its presentation are determinants and conditionings for the maintenance, propagation and transmission of schistosomiasis.

The labor environment of the fishing workers is favorable to the contamination by S. mansoni and other pathogenic microorganisms causing waterborne diseases. The behavior and the frequency of contact of the fishermen with the water, due to the labor activity or of the leisure, lead him to greater exposition to the parasite. However, both the fishermen and the selfish are population of risk for the schistosomiasis, and as such, should be always investigated and monitored, by be considered signaling factors for the disease.

The authocthony of the cases confirmed constitutes an alert so that the control measures can be performed, in order to reduce the risk, the prevalence and the infection transmission dos. Therefore, it is necessary to set up effective public health policies, housing and infrastructure, to enable the population of this municipality to achieve dignified and appropriate life conditions for his survival, determinants for the control and the reduction of the schistosomiasis prevalence.

The empowerment of the population about the disease contributes to the adherence to the health protection measures and interfere in the health-disease-healing process. The fear with regard to the Praziquantel use should be addressed by the health professionals, through myths and trues about its adverse effects, providing safety to the drug treatment.

From the epidemiological perspective, the predominance of the intestinal clinical form can be attributed to the actions of the PCE of the municipality of Marechal Deodoro, with weekly routine of coproscopy, early diagnosis and timely intervention, referring the positive cases to the Basic Unit of Health for the effective treatment. Despite the actions instituted by the PCE it is essential that partnerships between the health surveillance and the municipality basic health care be strengthened for effective management of the schistosomiasis.

REFERENCES

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