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The objectives of this study were 1) to provide more accurate estimates of the relationship between Schistosoma japonicum infection and both protein energy malnutrition (PEM) and anemia through better adjustment for potential confounders such as socioeconomic status (SES) and geo-helminth infections and 2) to assess the role of occult blood loss in mediating S. japonicum–associated anemia. We examined cross-sectionally 729 individuals (86.7% S. japonicum–infected and 13.3% S. japonicum–uninfected) aged 7–30 years in Leyte, The Philippines. The main outcome measures were height-for-age Z-score (HAZ), body-mass-index Z-score (BMIZ), triceps skinfold Z-score, hemoglobin, and fecal occult blood loss. Multivariate models were created to assess the relationship between S. japonicum infection and nutritional status after adjusting for age, gender, other helminths, and SES. After controlling for confounders, intensity of S. japonicum infection was inversely related to hemoglobin in all age groups (P < 0.0001) and HAZ among children 
12 years (P = 0.03), but not to BMIZ (P = 0.52) or triceps skinfold Z-score (P = 0.11). Individuals with high-intensity S. japonicum infection were 3.5 times more likely to have occult blood in the stool. Adjustment for occult blood did not attenuate the relationship between S. japonicum and hemoglobin, suggesting other mechanisms are involved. Adjustment for SES allows more accurate assessment of the relationship between S. japonicum and both PEM and anemia. Exploration of the mechanisms of S. japonicum–associated anemia suggests that processes other than extracorporeal blood loss, such as anemia or inflammation, may be involved.
Received April 14, 2004. Accepted for publication August 13, 2004.
Acknowledgments: The authors thank our field staff for their diligence and energy: Blanca Jarilla, Mario Jiz, Archie Pablo, Raquel Pacheco, Patrick Sebial, Mary Paz Urbina, and Jemaima Yu. The authors thank the study participants from Macanip, Buri, and Pitogo in Leyte, The Philippines.
Financial support: This work was funded by NIH RO1AI48123 and K23AI52125.
* These authors contributed equally to this work.
Authors’ addresses: Jennifer F. Friedman, Hemal K. Kanzaria, Gretchen C. Langdon, Haiwei Wu, Stephen T. McGarvey, and Jonathan D. Kurtis. International Health Institute, Brown University, Box G-B495, Providence, RI 02912. E-mails: jennifer_friedman{at}brown.edu, hemal.kanzaria{at}alumni.brown.edu, haiwei_wu{at}brown.edu, gretchen_langdon{at}brown.edu, stephen_mcgarvey{at}brown.edu, and jonathan_kurtis{at}brown.edu.;Luz P. Acosta, Daria L. Manalo, and Remigio M. Olveda, Research Institute of Tropical Medicine, FICC, Alabang, Muntinlupa City 1770, Metro Manila, The Philippines, E-mails: lacosta{at}ritm.gov.ph and dmanalo{at}ritm.gov.ph.
Reprint requests: Jennifer F. Friedman, Brown University, International Health Institute, Box G-B495, Providence, RI 02912, E-mail: Jennifer_Friedman{at}Brown.edu.
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