• View in gallery
    Figure 1.

    Body shape pictogram. Pictogram developed originally by Stunkard and others11 to evaluate body in shape Danish men and women, and subsequently adapted and validated in other populations.10 The optimal sensitivity and specificity for obesity in a Caucasian population uses the sixth figure for both men and women as the cut-off point19; however, the optimal cut-off for overweight was not assessed. To our knowledge, no study to date has evaluated use of this pictogram to categorize body-mass index in sub-Saharan African populations. Reprinted from10 with permission from Elsevier.

  • View in gallery
    Figure 2.

    Dose pole models for praziquantel administration. Original World Health Organization (WHO) pediatric dose pole with height categories and corresponding number of 600 mg tablets to administer (left). Modified dose pole for adults with additional half-tablet categories and new height cut-offs in red (right). The tables below each pole show the percentage of adults who would have received an inadequate dose (< 30 mg/kg), acceptable dose (30–40 mg/kg), optimal dose (40–60 mg/kg), and high dose (> 60 mg/kg) of praziquantel.

  • View in gallery
    Figure 3.

    Dosing range of praziquantel in rural Zimabwean adults. Range of theoretical dose received by rural Zimbabwean adults based on their height category as determined by the original World Health Organization (WHO) dose pole (left), which has three height categories, and the modified dose pole (right), which has five height categories, without body mass index (BMI) correction (upper panels) and with BMI correction (lower panels). The dashed lines indicate the acceptable dose range of praziquantel (30–60 mg/kg).

  • 1.

    World Health Organization, 2006. Preventive Chemotherapy in Human Helminthiasis. Geneva: World Health Organization. Available at: http://www.who.int/schistosomiasis/strategy/en/index.html. Accessed April 16, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Montresor A, Engels D, Chitsulo L, Bundy DA, Brooker S, Savioli L, 2001. Development and validation of a ‘tablet pole’ for the administration of praziquantel in sub-Saharan Africa. Trans R Soc Trop Med Hyg 95: 542544.

    • Search Google Scholar
    • Export Citation
  • 3.

    Montresor A, Odermatt P, Muth S, Iwata F, Raja'a YA, Assis AM, Zulkifli A, Kabatereine NB, Fenwick A, Al-Awaidy S, Allen H, Engels D, Savioli L, 2005. The WHO dose pole for the administration of praziquantel is also accurate in non-African populations. Trans R Soc Trop Med Hyg 99: 7881.

    • Search Google Scholar
    • Export Citation
  • 4.

    World Health Organization, 2011. Report of a meeting to review the results of studies on the treatment of schistosomiasis in preschool-age children. Geneva: World Health Organization. Available at: http://www.who.int/schistosomiasis/archives/en/. Accessed November 10, 2013.

    • Search Google Scholar
    • Export Citation
  • 5.

    Sousa-Figueiredo JC, Betson M, Stothard JR, 2012. Treatment of schistosomiasis in African infants and preschool-aged children: downward extension and biometric optimization of the current praziquantel dose pole. In Health 4: 95102.

    • Search Google Scholar
    • Export Citation
  • 6.

    Downs JA, Mguta C, Kaatano GM, Mitchell KB, Bang H, Simplice H, Kalluvya SE, Changalucha JM, Johnson WD Jr, Fitzgerald DW, 2011. Urogenital schistosomiasis in women of reproductive age in Tanzania's Lake Victoria region. Am J Trop Med Hyg 84: 364369.

    • Search Google Scholar
    • Export Citation
  • 7.

    Kjetland EF, Ndhlovu PD, Gomo E, Mduluza T, Midzi N, Gwanzura L, Midzi N, Mason PR, Friis H, Gundersen SG, 2006. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 20: 593600.

    • Search Google Scholar
    • Export Citation
  • 8.

    Mbabazi PS, Andan O, Fitzgerald DW, Chitsulo L, Engels D, Downs JA, 2011. Examining the relationship between urogenital schistosomiasis and HIV infection. PLoS Negl Trop Dis 5: e1396.

    • Search Google Scholar
    • Export Citation
  • 9.

    World Health Organization, 2002. Report of the WHO Informal Consultation on the Use of Praziquantel during Pregnancy/Lactation and Albendazole/Mebendazole in Children under 24 Months. Geneva: World Health Organziation. Available at: http://apps.who.int/iris/bitstream/10665/68041/1/WHO_CDS_CPE_PVC_2002.4.pdf. Accessed April 16, 2013.

    • Search Google Scholar
    • Export Citation
  • 10.

    Keshtkar AA, Semnani S, Pourshams A, Khademi H, Roshandel G, Boffetta P, Malekzadeh R, 2010. Pictogram use was validated for estimating individual's body mass index. J Clin Epidemiol 63: 655659.

    • Search Google Scholar
    • Export Citation
  • 11.

    Stunkard AJ, Sorensen T, Schulsinger F, 1983. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 60: 115120.

    • Search Google Scholar
    • Export Citation
  • 12.

    World Health Organization, 2012. Schistosomiasis. Fact Sheet No. 115, March 2013. Geneva: World Health Organization. Available at: http://www.who.int/mediacentre/factsheets/fs115/en/. Accessed April 17, 2013.

    • Search Google Scholar
    • Export Citation
  • 13.

    Baalwa J, Byarugaba BB, Kabagambe EK, Otim AM, 2010. Prevalence of overweight and obesity in young adults in Uganda. Afr Health Sci 10: 367373.

    • Search Google Scholar
    • Export Citation
  • 14.

    Shayo GA, Mugusi FM, 2011. Prevalence of obesity and associated risk factors among adults in Kinondoni municipal district, Dar es Salaam Tanzania. BMC Public Health 11: 365.

    • Search Google Scholar
    • Export Citation
  • 15.

    Patt MR, Lane AE, Finney CP, Yanek LR, Becker DM, 2002. Body image assessment: comparison of figure rating scales among urban Black women. Ethn Dis 12: 5462.

    • Search Google Scholar
    • Export Citation
  • 16.

    Jordan I, Hebestreit A, Swai B, Krawinkel MB, 2013. Breast cancer risk among women with long-standing lactation and reproductive parameters at low risk level: a case-control study in northern Tanzania. Breast Cancer Res Treat 142: 133141.

    • Search Google Scholar
    • Export Citation
  • 17.

    Strandgaard H, Johansen MV, Montresor A, Ornbjerg N, 2007. Field testing of the WHO dose pole for administration of praziquantel in the treatment of opisthorchiasis in Lao PDR. Trans R Soc Trop Med Hyg 101: 11201123.

    • Search Google Scholar
    • Export Citation
  • 18.

    Alexander ND, Cousens SN, Yahaya H, Abiose A, Jones BR, 1993. Ivermectin dose assessment without weighing scales. Bull World Health Organ 71: 361366.

    • Search Google Scholar
    • Export Citation
  • 19.

    Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ, 2001. Relating body mass index to figural stimuli: population-based normative data for caucasians. Int J Obes Relat Metab Disord 25: 15171524.

    • Search Google Scholar
    • Export Citation
  • 20.

    Harris CV, Bradlyn AS, Coffman J, Gunel E, Cottrell L, 2008. BMI-based body size guides for women and men: development and validation of a novel pictorial method to assess weight-related concepts. Int J Obes (Lond) 32: 336342.

    • Search Google Scholar
    • Export Citation
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Dosing of Praziquantel by Height in Sub-Saharan African Adults

Chiquita A. Palha De SousaJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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Tracy BrighamJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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Bernard ChasekwaJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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Mduduzi N. N. MbuyaJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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James M. TielschJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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Jean H. HumphreyJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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Andrew J. PrendergastJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Highline Community College, Des Moines, Washington; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe; Department of Global Health, School of Public Health and Health Services, George Washington University, Washington, District of Columbia; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, United Kingdom

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The cornerstone of schistosomiasis control is mass praziquantel treatment in high prevalence areas. Adults are an important target population, given increasing recognition of the burden of male and female genital schistosomiasis. However, use of weighing scales to calculate praziquantel dosing in rural areas can be challenging. For school-age children, the World Health Organization (WHO) has approved a dose pole to simplify praziquantel dosing based on height. We modified the pediatric dose pole by adding two height categories and incorporating a simple overweight/obesity adjustment, for simplified mass treatment of adults in sub-Saharan Africa. Using the rural Zimbabwean Demographic and Health Survey data, we show that the modified dose pole with body mass index adjustment would result in > 98% of adults receiving an acceptable dose (30–60 mg/kg), with only 1.4% and 0.3% receiving an inadequate dose (< 30 mg/kg) or high dose (> 60 mg/kg), respectively. An adult dose pole may provide a more feasible alternative to weighing scales in community-based praziquantel treatment programs.

Introduction

The cornerstone of schistosomiasis control is mass praziquantel treatment in areas of high prevalence. The World Health Organization (WHO) recommends annual treatment of all school-age children and adults considered to be at risk in areas with > 50% prevalence, and treatment every 2 years in areas with 10–50% prevalence.1 Given the challenges of using a weighing scale in rural households, praziquantel dosing for children has been simplified by use of a vertical “dose pole” that uses height as a surrogate for weight to estimate the correct dose of praziquantel for each child.2,3 This dose pole has recently been modified for preschool-age children, a vulnerable target group previously excluded from mass drug administration (MDA) programs.4,5

Adults are generally dosed according to body weight, despite the logistical challenge of accurate weight measurement in rural areas of developing countries. Use of a dose pole, as for children, would simplify mass treatment of adults in rural communities. Including adults in control strategies is important, particularly in the context of morbidity reduction among women who are at risk of female genital schistosomiasis associated with human immunodeficiency virus (HIV) acquisition.68 Males are also an important target group in MDA strategies, given the growing understanding of male genital schistosomiasis.8

We therefore set out to develop and validate a variant of the WHO praziquantel dose pole for the mass treatment of adults. Dosing adults based on height, rather than weight, in the context of the emerging obesity epidemic in developing countries risks underdosing with praziquantel. We therefore also evaluated a simple adjustment for overweight and obesity that could be used in community-based treatment programs.

Materials and Methods

We first modified the WHO pediatric dose pole1 to make it more suitable for adult use. The modified dose pole included two additional height/dose intervals corresponding to the median heights of adults in the original categories to correct for potential underdosing of heavy adults in these groups. The new height cut-offs of 156 cm and 164 cm allow for the dosing of 3.5 tablets and 4.5 tablets, respectively. The theoretical dose administered using each of the two poles was calculated by dividing the dosage corresponding to each adult's height category by his or her respective weight. An optimal dose of praziquantel was defined as 40–60 mg/kg, with an acceptable dose defined as 30–60 mg/kg.2,3,9 We reasoned that adults could easily be classified as overweight or obese by fieldworkers using a pictogram (Figure 1).10,11 Adults with body mass index (BMI) > 25 kg/m2 were estimated to require an additional 25% of the average adult dose (2,400 mg), translating to one extra 600 mg tablet (Montresor A, WHO; personal communication).

Figure 1.
Figure 1.

Body shape pictogram. Pictogram developed originally by Stunkard and others11 to evaluate body in shape Danish men and women, and subsequently adapted and validated in other populations.10 The optimal sensitivity and specificity for obesity in a Caucasian population uses the sixth figure for both men and women as the cut-off point19; however, the optimal cut-off for overweight was not assessed. To our knowledge, no study to date has evaluated use of this pictogram to categorize body-mass index in sub-Saharan African populations. Reprinted from10 with permission from Elsevier.

Citation: The American Society of Tropical Medicine and Hygiene 90, 4; 10.4269/ajtmh.13-0252

Data from the 2005–06 Zimbabwe Demographic and Health Survey (DHS) were then used as a model for adults in sub-Saharan Africa to validate the modified dose pole compared with the original pediatric dose pole. The proportion of adults who would receive theoretical doses in the following categories was determined: inadequate (< 30 mg/kg), acceptable (30–40 mg/kg), optimal (40–60 mg/kg), and high (> 60 mg/kg). Stata 12.0 (StataCorp LP, College Station, TX) was used to perform χ2 analysis to compare accuracy of the original pediatric dose pole with the modified dose pole in determining the correct dose of praziquantel, with and without BMI correction.

Results

The DHS data comprised 5,614 rural Zimbabwean adults between 15 and 49 years of age. Their mean height was 160 cm (range 131–191) and mean weight 57.2 kg (range 30.0–117.5), with 10.1%, 70.5%, 15.2%, and 4.2% of adults categorized as underweight (BMI < 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥ 30 kg/m2), respectively.

Using the WHO pediatric dose pole to determine the number of tablets administered, 15.0%, 52.9%, 32.0%, and 0.1% of adults would receive an inadequate, acceptable, optimal, or high dose, respectively (Figures 2 and 3). Correcting for BMI by providing an additional 600 mg tablet to all adults classified as overweight or obese, resulted in a significant improvement of this model (P < 0.001, χ2), with 3.8%, 58.4%, 37.7%, and 0.1% receiving an inadequate, acceptable, optimal, or high dose, respectively (Figures 2 and 3).

Figure 2.
Figure 2.

Dose pole models for praziquantel administration. Original World Health Organization (WHO) pediatric dose pole with height categories and corresponding number of 600 mg tablets to administer (left). Modified dose pole for adults with additional half-tablet categories and new height cut-offs in red (right). The tables below each pole show the percentage of adults who would have received an inadequate dose (< 30 mg/kg), acceptable dose (30–40 mg/kg), optimal dose (40–60 mg/kg), and high dose (> 60 mg/kg) of praziquantel.

Citation: The American Society of Tropical Medicine and Hygiene 90, 4; 10.4269/ajtmh.13-0252

Figure 3.
Figure 3.

Dosing range of praziquantel in rural Zimabwean adults. Range of theoretical dose received by rural Zimbabwean adults based on their height category as determined by the original World Health Organization (WHO) dose pole (left), which has three height categories, and the modified dose pole (right), which has five height categories, without body mass index (BMI) correction (upper panels) and with BMI correction (lower panels). The dashed lines indicate the acceptable dose range of praziquantel (30–60 mg/kg).

Citation: The American Society of Tropical Medicine and Hygiene 90, 4; 10.4269/ajtmh.13-0252

Using our modified WHO dose pole to determine the number of tablets administered, 8.7%, 45.3%, 45.7%, and 0.3% of adults would receive an inadequate, acceptable, optimal, or high dose, respectively (Figures 2 and 3). Correcting for BMI by providing an additional 600 mg tablet to all adults classified as overweight or obese, resulted in a significant improvement of this model (P < 0.001, χ2), with 1.4%, 43.3%, 55.0%, and 0.3% receiving an inadequate, acceptable, optimal, or high dose, respectively (Figures 2 and 3). Of note, the new model was significantly better than the original WHO dose pole, both with and without BMI correction (P < 0.001, χ2).

Discussion

Schistosomiasis affects over 240 million people worldwide, especially in developing countries with poor access to clean water and adequate sanitation.12 Although praziquantel is an effective and low-cost medication that is suitable for MDA, only 10% of people in need of treatment in 2011 had access to it.12 The development of the WHO pediatric dose pole has helped to address this treatment gap by facilitating dosing by height instead of weight; however, its use is limited to treating school-age children in endemic areas. More recently, a dose pole modification was proposed that includes new height categories corresponding to dosing for preschool-age children, an important target population previously excluded from MDA programs.4,5

We propose here an additional modification to the original dose pole to provide a more accurate means of calculating the dose of praziquantel by height for adults in rural areas of endemicity. Adding two height categories to the original pole enables dosing of half-tablets, reducing the proportion of adults receiving inadequate praziquantel doses (from 15% to 8.7%), and increasing the proportion receiving optimal dosing (from 32% to 46%); very few adults (< 1%) with either pole received too high a dose (> 60 mg/kg). Using the modified pole, without correction for BMI, 91% of adults received an acceptable (30–60 mg/kg) dose of praziquantel.

Given the emerging obesity epidemic in countries undergoing the nutrition transition,13,14 it is important that a modified dose pole can accommodate supplementary dosing for overweight and obese adults. A simple pictogram, such as that developed originally in Denmark by Stunkard and others,11 but validated10,15 or modified16 for other populations, would enable fieldworkers to visually assess body shape and increase the dose of praziquantel in those judged to be overweight or obese. With BMI correction, we found that both dose poles allowed improved dosing compared with no BMI correction. However, the modified pole with BMI correction performed better than the original WHO pediatric dose pole in this population of rural Zimbabwean adults. Overall, > 98% of adults would have received an acceptable dose in the 30–60 mg/kg range using the modified pole; the proportion of adults receiving an inadequate dose was reduced to 1.4%, whereas the proportion receiving a high dose remained very low (0.3%).

Underdosing is of particular concern in schistosomiasis control programs because it may lead to partial or inadequate treatment. Modifying the pediatric dose pole for adult use and applying a BMI correction led to very few adults receiving an inadequate dose. The number of adults who would receive a high dose (> 60 mg/kg) with this new strategy remained low (3 adults/1,000); even at this dose, praziquantel is generally well tolerated because daily doses of 100 mg/kg are safely administered for 10 days for the treatment of neurocysticercosis. However, there are potential side-effects at high dose, including abdominal pain, nausea, fatigue, dizziness, and headache, in addition to the unnecessary increased costs to MDA programs associated with overdosing of praziquantel.

Previous field-testing of the WHO dose pole for administering praziquantel to treat opisthorchiasis in a village in Lao People's Democratic Republic (PDR) with a high proportion (19.4%) of overweight adults, concluded that the dose pole performed poorly when compared with digital scales as the gold standard.17 A similar limitation in determining the dose of ivermectin among a population in northern Nigeria that included a high proportion of overweight individuals has been reported.18 From the rural Zimbabwean DHS data used in our study, the percentage of overweight (15.2%) and obese (4.2%) adults is lower than in these previous studies; there is therefore a need to validate this modified dose pole in settings with a different prevalence of overweight. We propose that a pictogram,10,11 instead of a subjective visual assessment, should be used to identify adults who require an additional 600 mg tablet for overweight or obesity. A pictogram has the advantage of being feasible for use in communities with low literacy and avoids the need for complex dose corrections by fieldworkers. The cut-off point providing the best sensitivity and specificity for obesity has been defined in Caucasian populations using this pictogram (Figure 1)19; however, to our knowledge, this analysis has not been undertaken in African populations, and the optimal cut-off for overweight has not been evaluated in any population. Modified figure-rating scales using photographs of Caucasian volunteers provide overweight and obese categorization20; however, we are not aware of a scale using photographs of black Africans. Therefore, further work may be required to develop a field tool that optimally identifies adults requiring additional praziquantel dosing in developing countries.

There are potential disadvantages to introducing a new dose pole for adults. Currently, paper copies of the pediatric dose pole are included in boxes of praziquantel donated for MDA programs; introducing additional poles would increase printing costs and may cause confusion to fieldworkers. Additionally, dose poles were introduced to minimize the need to divide praziquantel tablets, which complicates dosing and can lead to wastage. However, given the recent development of a preschool-age dosing pole,5 policymakers may wish to consider redesigning these materials so that all three poles could be included in MDA boxes, together with a simple pictogram on the adult pole to facilitate dosing of overweight and obese adults. Although dividing tablets is more complicated, we show here that use of half-tablets would increase the number of adults receiving an optimal dose of praziquantel. Furthermore, the preschool-age pole requires division of tablets, therefore a similar change in adult dosing may be feasible.

In conclusion, we have modified the WHO praziquantel dose pole for adult use and added an overweight/obesity adjustment to provide a more feasible alternative to weighing scales in estimating appropriate doses for adults during praziquantel MDA programs in developing countries. We show that the modified pole with BMI correction would reduce inadequate dosing and increase optimal dosing of praziquantel in rural Zimbabwean adults, compared with the current pole. Given the large burden of disease among adults, simplifying mass treatment for school-age and preschool-age children, may be an important step in improving control of schistosomiasis.

  • 1.

    World Health Organization, 2006. Preventive Chemotherapy in Human Helminthiasis. Geneva: World Health Organization. Available at: http://www.who.int/schistosomiasis/strategy/en/index.html. Accessed April 16, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    Montresor A, Engels D, Chitsulo L, Bundy DA, Brooker S, Savioli L, 2001. Development and validation of a ‘tablet pole’ for the administration of praziquantel in sub-Saharan Africa. Trans R Soc Trop Med Hyg 95: 542544.

    • Search Google Scholar
    • Export Citation
  • 3.

    Montresor A, Odermatt P, Muth S, Iwata F, Raja'a YA, Assis AM, Zulkifli A, Kabatereine NB, Fenwick A, Al-Awaidy S, Allen H, Engels D, Savioli L, 2005. The WHO dose pole for the administration of praziquantel is also accurate in non-African populations. Trans R Soc Trop Med Hyg 99: 7881.

    • Search Google Scholar
    • Export Citation
  • 4.

    World Health Organization, 2011. Report of a meeting to review the results of studies on the treatment of schistosomiasis in preschool-age children. Geneva: World Health Organization. Available at: http://www.who.int/schistosomiasis/archives/en/. Accessed November 10, 2013.

    • Search Google Scholar
    • Export Citation
  • 5.

    Sousa-Figueiredo JC, Betson M, Stothard JR, 2012. Treatment of schistosomiasis in African infants and preschool-aged children: downward extension and biometric optimization of the current praziquantel dose pole. In Health 4: 95102.

    • Search Google Scholar
    • Export Citation
  • 6.

    Downs JA, Mguta C, Kaatano GM, Mitchell KB, Bang H, Simplice H, Kalluvya SE, Changalucha JM, Johnson WD Jr, Fitzgerald DW, 2011. Urogenital schistosomiasis in women of reproductive age in Tanzania's Lake Victoria region. Am J Trop Med Hyg 84: 364369.

    • Search Google Scholar
    • Export Citation
  • 7.

    Kjetland EF, Ndhlovu PD, Gomo E, Mduluza T, Midzi N, Gwanzura L, Midzi N, Mason PR, Friis H, Gundersen SG, 2006. Association between genital schistosomiasis and HIV in rural Zimbabwean women. AIDS 20: 593600.

    • Search Google Scholar
    • Export Citation
  • 8.

    Mbabazi PS, Andan O, Fitzgerald DW, Chitsulo L, Engels D, Downs JA, 2011. Examining the relationship between urogenital schistosomiasis and HIV infection. PLoS Negl Trop Dis 5: e1396.

    • Search Google Scholar
    • Export Citation
  • 9.

    World Health Organization, 2002. Report of the WHO Informal Consultation on the Use of Praziquantel during Pregnancy/Lactation and Albendazole/Mebendazole in Children under 24 Months. Geneva: World Health Organziation. Available at: http://apps.who.int/iris/bitstream/10665/68041/1/WHO_CDS_CPE_PVC_2002.4.pdf. Accessed April 16, 2013.

    • Search Google Scholar
    • Export Citation
  • 10.

    Keshtkar AA, Semnani S, Pourshams A, Khademi H, Roshandel G, Boffetta P, Malekzadeh R, 2010. Pictogram use was validated for estimating individual's body mass index. J Clin Epidemiol 63: 655659.

    • Search Google Scholar
    • Export Citation
  • 11.

    Stunkard AJ, Sorensen T, Schulsinger F, 1983. Use of the Danish Adoption Register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis 60: 115120.

    • Search Google Scholar
    • Export Citation
  • 12.

    World Health Organization, 2012. Schistosomiasis. Fact Sheet No. 115, March 2013. Geneva: World Health Organization. Available at: http://www.who.int/mediacentre/factsheets/fs115/en/. Accessed April 17, 2013.

    • Search Google Scholar
    • Export Citation
  • 13.

    Baalwa J, Byarugaba BB, Kabagambe EK, Otim AM, 2010. Prevalence of overweight and obesity in young adults in Uganda. Afr Health Sci 10: 367373.

    • Search Google Scholar
    • Export Citation
  • 14.

    Shayo GA, Mugusi FM, 2011. Prevalence of obesity and associated risk factors among adults in Kinondoni municipal district, Dar es Salaam Tanzania. BMC Public Health 11: 365.

    • Search Google Scholar
    • Export Citation
  • 15.

    Patt MR, Lane AE, Finney CP, Yanek LR, Becker DM, 2002. Body image assessment: comparison of figure rating scales among urban Black women. Ethn Dis 12: 5462.

    • Search Google Scholar
    • Export Citation
  • 16.

    Jordan I, Hebestreit A, Swai B, Krawinkel MB, 2013. Breast cancer risk among women with long-standing lactation and reproductive parameters at low risk level: a case-control study in northern Tanzania. Breast Cancer Res Treat 142: 133141.

    • Search Google Scholar
    • Export Citation
  • 17.

    Strandgaard H, Johansen MV, Montresor A, Ornbjerg N, 2007. Field testing of the WHO dose pole for administration of praziquantel in the treatment of opisthorchiasis in Lao PDR. Trans R Soc Trop Med Hyg 101: 11201123.

    • Search Google Scholar
    • Export Citation
  • 18.

    Alexander ND, Cousens SN, Yahaya H, Abiose A, Jones BR, 1993. Ivermectin dose assessment without weighing scales. Bull World Health Organ 71: 361366.

    • Search Google Scholar
    • Export Citation
  • 19.

    Bulik CM, Wade TD, Heath AC, Martin NG, Stunkard AJ, Eaves LJ, 2001. Relating body mass index to figural stimuli: population-based normative data for caucasians. Int J Obes Relat Metab Disord 25: 15171524.

    • Search Google Scholar
    • Export Citation
  • 20.

    Harris CV, Bradlyn AS, Coffman J, Gunel E, Cottrell L, 2008. BMI-based body size guides for women and men: development and validation of a novel pictorial method to assess weight-related concepts. Int J Obes (Lond) 32: 336342.

    • Search Google Scholar
    • Export Citation

Author Notes

* Address correspondence to Andrew J. Prendergast, Centre for Paediatrics, Blizard Institute, Newark Street, London E1 2AT. E-mail: a.prendergast@qmul.ac.uk

Financial support: AJP is funded by the Wellcome Trust [093768/Z/10/Z].

Authors' addresses: Chiquita A. Palha De Sousa, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: cpalhadesousa@gmail.com. Tracy Brigham, Highline Community College, Nutrition, Des Moines, WA, E-mail: tbrigham@highline.edu. Bernard Chasekwa, Zvitambo Institute for Maternal Child Health Research, IT and Statistics, Harare, Zimbabwe, E-mail: bchasekwa@zvitambo.co.zw. Mduduzi N. N. Mbuya, Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe, E-mail: mmbuya@zvitambo.co.zw. James M. Tielsch, George Washington University, School of Public Health and Health Services, Washington, DC, E-mail: jtielsch@email.gwu.edu. Jean H. Humphrey, Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, E-mail: jhumphrey@zvitambo.co.zw. Andrew J. Prendergast, Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, UK, E-mail: a.prendergast@qmul.ac.uk.

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