The influence of sampling effort and the performance of the Kato-Katz technique in diagnosing <i>Schistosoma mansoni</i> and hookworm co-infections in rural Côte d'Ivoire

The Klato-Katz method is widely used for diagnosing helminth infections in epidemiological surveys, but is known to have a low sensitivity. In the case of Schistosoma mansoni, statistical methods have been developed to compensate for the poor sensitivity, but the same is not true of any other helminth parasite, or infections with multiple-helminth species. We screened 101 schoolchildren from a rural area of Côte d'Ivoire over 5 consecutive days and made 5 Kato-Katz readings from each stool specimen. We estimated single and dual-species infections with S. mansoni and hookworm based on raw egg count data and after developing a latent-class model. The cumulative prevalence of co-infections was estimated at 9.9% after reading slides on the first day, and 57.0% after reading all 25 slides per person. The latent class model yielded a co-infection prevalence estimate of 79.6%, with marginal prevalence estimates for hookworm and S. mansoni infections of 83.9% and 91.6% respectively. The sensitivities of a single Kato-Katz thick smear for detection of S. mansoni alone, hookworms alone, or S. mansoni plus hookworms were 22.4%, 8.0% and 17.7%, respectively. In the current setting this could be attributable to low infection intensities of both parasites, combined with intra-specimen and day-to-day variation in egg output. If confirmed in other settings, these findings have implications for estimating the prevalence of multiple species helminth infections, and hence the design and implementation of efficacious and cost-effective control programmes.