https://orcid.org/0000-0001-9319-0859
Figures
Abstract
Schistosomiasis is a water-based disease transmitted through contact with freshwater contaminated by cercariae from infected snails. Transmission is shaped by access to water, sanitation, and hygiene (WASH) services, human behaviour, and environmental factors. While several systematic reviews have examined WASH-schistosomiasis links, a synthesis of emerging evidence and identification of knowledge gaps across the transmission pathways is needed. This scoping review aimed to map WASH-related risk factors linked to schistosomiasis transmission, to assess alignment with a schistosomiasis-specific conceptual framework, and to characterise methodological features of the evidence base, including diagnostics and WASH measurement. We searched five databases, supplemented by a call for papers, yielding 2915 de-duplicated records; 181 were included (160 observational, 21 interventional studies). We developed a conceptual framework to map WASH-related transmission pathways and identify evidence gaps. Our analysis reveals a growing body of research on WASH access and practices, yet key gaps persist. Observational studies mostly examined domestic, recreational, and occupational water contact, with limited attention to transmission pathways such as agricultural use of faecal waste; most relied on simple access measures, rarely assessing WASH quality, functionality, or sustained use, limiting the ability to translate findings into effective service delivery strategies. Among interventional studies, 43% focussed on water access, 24% implemented integrated WASH and health education, and 19% sanitation, hygiene, and education. Over 90% reported reduced infection, but few assessed sustained uptake or environmental impacts. Limitations include lack of species-specific reporting, inconsistent WASH definitions, and insensitive diagnostics. Future studies would benefit from adopting standardised WASH definitions and transmission-specific frameworks, report outcomes by species and infection intensity, and design interventions with explicit theories of change addressing transmission pathways. Intervention studies should assess fidelity, sustained uptake, and community-level coverage alongside infection outcomes, with follow-up to capture reinfection dynamics, strengthening evidence for integrating WASH with preventive chemotherapy in elimination programmes.
Citation: Braun L, Velleman Y, Straily A, Secor WE (2026) Water, sanitation, and hygiene in schistosomiasis control: A scoping review of evidence gaps across transmission pathways. PLOS Glob Public Health 6(7): e0006916. https://doi.org/10.1371/journal.pgph.0006916
Editor: Nnodimele Onuigbo Atulomah, Babcock University, NIGERIA
Received: March 28, 2026; Accepted: July 6, 2026; Published: July 30, 2026
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All data can be found in the manuscript and supplementary materials.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Schistosomiasis, also known as Bilharzia or Snail Fever, is a parasitic disease caused by Schistosoma spp. Transmission occurs when eggs from infected persons enter freshwater sources through urine (for Schistosoma haematobium) or faeces (for S. mansoni and all other species). If suitable freshwater snail species are present, the parasites develop inside them before being released into the water as larvae (cercariae), which can penetrate human skin during water contact. Once inside the body, the parasites mature and produce eggs, some of which are excreted, continuing the cycle. Schistosomiasis can lead to diarrhoea, haematuria, anaemia, developmental delays, enlargement of liver and spleen, and genital schistosomiasis, often contributing to significant morbidity in endemic regions [1,2].
Schistosomiasis transmission pathways are shaped by the availability, accessibility, affordability, acceptability, and quality of water supply, sanitation and hygiene (WASH) services. Limited access to safe water and inadequate sanitation facilitates the spread of infection, while behaviours such as bathing, swimming, and washing clothes in contaminated water increase exposure risk. Due to its dependence on freshwater bodies and specific snail hosts, schistosomiasis is highly focal in nature.
Previous systematic reviews have examined the relationship between WASH and schistosomiasis. Grimes et al. (2014) found that access to safe water and adequate sanitation were associated with lower odds of both S. mansoni and S. haematobium infections [3]. Similarly, Freeman et al. (2018) identified an association between sanitation and lower odds of both S. mansoni and S. haematobium infections, though this held only when comparing any sanitation with no sanitation, rather than improved versus unimproved sanitation [4]. Water treatment processes have been shown to effectively remove or inactivate schistosome cercariae, yet variations in initial water quality and measurement approaches limit study comparability [5].
Beyond sanitation and water treatment, human-water contact behaviours are a critical factor in schistosomiasis transmission. A meta-analysis by Reitzug et al. found that individuals in communities with ≥10% prevalence who engaged in water contact had a threefold higher infection risk compared to those who did not [6]. However, no associations were observed between the duration or frequency of exposure and infection risk.
The focus on elimination and background to review
In 2024, schistosomiasis was endemic in 79 countries, with preventive chemotherapy (PC) required in 50 countries [7]. PC with praziquantel, through the World Health Organization (WHO)-managed drug donation programme, has been the primary control strategy for the past two decades. The WHO neglected tropical diseases (NTD) 2021–2030 road map goal is to eliminate schistosomiasis as a public health problem [8], yet over 250 million people, primarily school-aged children, still require preventive chemotherapy [7].
While most control efforts focus on reducing prevalence to below the 10% threshold to reduce the need for mass treatment [9], some countries such as China [10] or St Lucia [11,12] are pursuing transmission elimination through integrated healthcare and environmental interventions. The process for verifying interruption of transmission is under development.
Significant barriers to elimination persist. PC alone is insufficient to break transmission, requiring complementary strategies [8]. Snail control can reduce intermediate host populations but can pose environmental risks, and snails can rapidly recolonise or repopulate through self-fertilisation [13,14]. Similarly, asexual reproduction of schistosomes within snails results in amplification of infectious parasites in water bodies. The percentage of infected snails is often disproportionately small compared to the prevalence of human infection.
Despite evidence from systematic reviews indicating that improved WASH access is associated with reduced schistosomiasis prevalence, simply providing access to water and sanitation infrastructure does not necessarily translate into reduced infection risk, largely due to the persistent interaction between at-risk populations and contaminated surface water. Furthermore, achieving sustained behaviour change to reduce exposure is challenging [15], given the focal nature of schistosomiasis transmission, the long latency between infection and the development of severe morbidity, and the persistence of misconceptions shaped by cultural beliefs and practices.
Efforts to achieve the targets set out in the 2021–2030 WHO NTD road map [8] have renewed attention to the role of WASH in interrupting transmission of schistosomiasis. In 2021, the WHO Department for the Control of Neglected Tropical Diseases convened the Technical Advisory Group (TAG) on Soil-Transmitted Helminthiasis and Schistosomiasis Control and Elimination to provide strategic and technical guidance to countries pursuing elimination goals. A dedicated WASH sub-group was formed to strengthen the evidence base linking WASH interventions to transmission dynamics and to inform policy development and research prioritisation.
The WASH sub-group agreed that the biological and epidemiological connections between WASH conditions and schistosomiasis transmission are well recognised. Rather than re-evaluating the magnitude of associations between WASH indicators and infection outcomes, a scoping review approach [16] was decided to be most appropriate to systematically map how WASH-related exposures have been conceptualised and measured in relation to schistosomiasis transmission pathways, with a focus on alignment between exposure definitions and hypothesised mechanisms of effect.
Although WASH is often discussed jointly for schistosomiasis and STH, important differences in transmission biology warrant separate analyses. A companion scoping review on WASH and STH has been published. We developed a schistosomiasis-specific conceptual framework that captures sanitation services and related behaviours, pathways of faecal contamination of freshwater, the role of water services, and distinct drivers of water contact.
By mapping the breadth and structure of available evidence, this review seeks to clarify where empirical support is strong, where measurement approaches lack conceptual coherence, and where critical gaps remain along the transmission pathway. These insights are intended to guide future research design and strengthen the integration of WASH within schistosomiasis control and elimination strategies.
Methods
The protocol for this scoping review was registered on the Open Science Framework registries website on 4 October 2022 [17], and was conducted in accordance with the PRISMA guidelines. The PRISMA diagram is shown in Fig 1, and a PRISMA checklist is included in the supplementary information (S1 File).
The flow diagram structure is from the PRISMA guideline [18].
Search strategy
The search strategy includes database searches, a call for papers, and results from a previous review [3]. We searched five databases (Medline, Embase, Cochrane, Global Health, and Scopus) using the search terms in the supplementary information (S1 Table). The search strategy was informed by a conceptual framework (Fig 2) setting out all likely transmission pathways related to WASH practices and infrastructure. Searches were conducted in English in September 2022 and updated in May 2025. Additionally, a call for papers was shared in March 2022 through various networks and channels, including the NTD NGO network membership list, the Sustainable Sanitation Alliance (SuSanA) Forum, the WHO PHE newsletter and through social media. The reference lists of included studies and identified relevant systematic reviews were hand-searched for additional relevant studies.
The literature search focused on studies published on or after 1 January 2014 to capture studies published since the last comprehensive systematic review and meta-analysis by Grimes et al [3]. All included studies, as well as studies excluded by the authors for not providing sufficient data for the meta-analysis despite being on schistosomiasis and WASH, were screened based on the inclusion criteria of this review.
Screening and data extraction
Search results were de-duplicated in the reference management system Endnote [19] and uploaded to Rayyan, a systematic literature review application [20]. Titles and abstracts were double screened, split equally among four reviewers (YV, ES, AS, LB). Disagreements were resolved through discussion among reviewers. Full texts of articles meeting the inclusion criteria were retrieved and double screened by two reviewers, with the list of articles and decisions noted in Microsoft Excel. A pre-specified data extraction sheet was used to extract data from included studies (including those from Grimes et al [3]), listing study metadata (author, year, title, country, study design, diagnostic method, setting (urban/rural), number, age and details of participants, study aims) and data items (variables) of interest. Given that schistosomiasis and STH are often studied simultaneously, the search, abstract review and full text review were conducted jointly for schistosomiasis and STH. The two diseases were then separated at the data extraction phase.
Inclusion criteria
Studies with an abstract in English, French and Spanish published in peer-reviewed journals were considered. Both observational and intervention studies were included if they quantified WASH-related exposure and schistosomiasis infection (prevalence or intensity of infection). There were no limits to diagnostic methods used. Studies that reported genus-level as opposed to species-level infection, as well as studies combining infection measures for schistosomiasis with STH infections (e.g., prevalence of any intestinal helminth), were excluded. Studies linking WASH to parts of the lifecycle besides human infection (e.g., snail infection, presence of cercariae in water) were also excluded.
Results
The review identified a total of 4615 records via the database search, 32 via the call for papers, and 759 from the review by Grimes et al [3] (Fig 1). Following de-duplication, 2728 titles and abstracts identified via databases were screened, and 667 by full text. Most studies were excluded as they only reported STH infections, did not disaggregate results from STH infections or by Schistosoma species, or combined multiple WASH variables (e.g., “access to safe water and sanitation”). A total of 115 studies were included in this review from the database search. Of the 32 studies identified through the call for papers, 2 are included, with most being excluded as they focused on STH infections. Of the 759 identified from the previous review, 64 studies are included. Overall, 181 studies are included in this review - 115 from the literature search, 2 from the call for papers and 64 from the previous review. Of these, 21 studies are intervention trials and 160 are observational studies.
Observational studies
Among observational studies (160/181), 75% (n = 120/160) were conducted in Africa, 16% (n = 25) in South America, and 9% (n = 15) in Asia (S2 Table and S3 Table). Ethiopia (n = 29/160) was the country where most studies were conducted, followed by Nigeria (27/160) and Brazil (25/160). In Asia, most studies were conducted in Yemen (n = 6). 65% of observational studies (105/160) were conducted in rural settings, 12% in peri-urban or urban settings (16/160) and 15% in both rural and urban (24/160), with 8% not indicating setting type (13/160). On average, studies included 1604 participants, and in total, 258,225 participants. Half of the studies included only young and school-aged children (81/160) (<19 years old), with most focussing on the 6–15-year age range. A total of 46% of studies focussed on adults and children (74/160), and 3% (n = 5) included only adults. More than half of observational studies reported S. mansoni infections (88/160), followed by S. haematobium (56/160), with 5% of studies reporting both S. mansoni and S. haematobium (8/160). Only seven studies on S. japonicum and two studies on S. mekongi were included. Supplementary Information (S2 Table and S3 Table) report the extracted data and citation for each observational study. Most observational studies evaluated both intensity of infection and prevalence, but only 12% (19/160) analysed the relationship between intensity (i.e., egg output) and WASH-related factors.
Faecal contamination and sanitation pathways were examined across included studies, with sanitation access (n = 54) and open defecation or urination (n = 42) being the most frequently analysed risk factors (Fig 3). Overall, the association of access to sanitation facilities and schistosomiasis infection was assessed in 30–35% of studies for all species except S. mekongi (Fig 4). Additional sanitation-related variables included animal presence, anal cleansing and use of faecal waste in agriculture, which all remained rarely studied across all species. Definitions of sanitation facilities varied greatly across studies (e.g., “latrine,” “toilet,” “latrine with slab connected to septic tank”), and most studies only reported on household-level access rather than sanitation facilities in schools or workplaces where people may spend significant time.
Diagram showing the number of studies reporting schistosomiasis transmission routes from parasite egg contamination sources (left) through surface water (centre) to human water contact exposures (right). Box heights are proportional to the frequency of study reporting for each pathway. “Other water contact” includes unspecified reason for surface water contact.
Circle numbers and size correspond to the number of studies.
Water contact exposure routes were extensively documented across studies (Fig 3). Drinking water access was the most frequently analysed pathway (n = 95), with 50% of S. haematobium and S. mansoni studies analysing this risk factor (Fig 4), reflecting the water-based nature of schistosomiasis transmission. However, water sources were defined with varying specificity (e.g., “safe water source” vs. “household water”), and comparisons typically contrasted household- or community-level improved sources (e.g., borehole, piped water) with surface water (e.g., rivers, lakes), making it difficult to determine schistosomiasis risk. Additionally, most studies only assessed primary or drinking water sources, omitting potential contact with alternative unsafe water sources. Recreational water contact (n = 85), bathing (n = 70), occupational water contact (e.g., fishing, rice farming, irrigation, animal/tool washing (n = 67)), and laundry activities (n = 64) were also frequently studied (Fig 3). Transportation by crossing streams or entering canoes and boats was included in 26 studies focussed on either S. mansoni or S. haematobium. Water collection (n = 33), unspecified water contact activities (n = 21), and water treatment (n = 7) were less frequently examined. S. japonicum studies primarily reported on domestic and occupational water activities, while the two included S. mekongi studies analysed occupational and recreational water contact. Overall, water sources and contact activities were often defined with limited specificity, making it difficult to assess schistosomiasis risk consistently across studies.
Interventional studies
In total, 21 interventional studies were included in this review (Table 1), conducted between 1961–2017. Four studies were implemented in China, two each in Kenya, South Africa, Tanzania, Sudan and Brazil, and one each in St Lucia, Lao, Côte d’Ivoire, Ghana, Nigeria, Ethiopia and Zimbabwe. All but one study in China [21] were conducted in rural settings. All studies published after 1976 provided treatment with praziquantel as part of the intervention. Interventions focussed on improving safe access to water made of 43% of studies (9/21) and included water supply for domestic and recreational activities. Integrated interventions including WASH and health education were implemented in 5 studies (24%). Four studies, all from China, implemented One Health measures alongside integrated WASH and health education interventions, aiming to interrupt disease transmission by mechanising agriculture and restricting and treating livestock to prevent environmental contamination, engineering safe water and sanitation infrastructure, and providing health education. Three studies focussed on sanitation, hygiene and education. Interventions were implemented across domestic, school and occupational settings, e.g., agricultural fields. Study duration ranged between 9 months and 12 years, with more than 90% of studies (19/21) reporting a reduction in prevalence or intensity of infection following the intervention, compared to baseline or a control.
Most observation and intervention studies (69%) used only one diagnostic method to detect schistosomiasis, whereas 30% used two methods or more, and 1% did not specify (Table 2). Duplicate Kato-Katz (i.e., reading two slides from one stool sample) was the most frequently used diagnostic method for detecting S. mansoni (55%), whereas more than duplicate Kato-Katz slides for S. japonicum (71%). For S. haematobium, urine filtration (69%) was most frequently used. Other methods included concentration of eggs followed by microscopy, point-of-care urine circulating cathodic antigen (POC-CCA) assay, assessment of macro-and micro-haematuria, and miracidial hatching. Overall, 11% (11/103) of studies using Kato-Katz did not specify how many slides were analysed per sample.
Discussion
This scoping review synthesises the evidence available on the link between WASH exposures and schistosomiasis transmission in humans. Of the 181 studies identified, 160 were observational and 21 were intervention studies. Most observational studies examined domestic, recreational and occupational water contact measures. However, several transmission pathways remain under-examined, including anal cleansing and agricultural use of faecal waste. Although studies on these pathways were screened, they addressed environmental contamination (e.g., snail infection) rather than human infection. While some studies measured WASH facility characteristics (e.g., physical condition, cleanliness, usability for all ages) and their usage, few examined how sustained access and maintenance over time influence infection patterns. This reflects reliance on crude binary (yes/no) access measures, which can misclassify exposure and thereby obscure the relationship between WASH access and quality, and schistosomiasis risk.
Most reviewed studies, both included and excluded, employed a cross-sectional design primarily focused on measuring schistosome infection, either by prevalence or intensity, accompanied by an analysis of WASH-related risk factors. A significant limitation affecting study quality was the frequent absence of a conceptual transmission framework during the study design phase. This oversight led to the exclusion of important exposure pathways such as the near-complete absence of animal reservoir considerations in S. japonicum and S. haematobium studies, despite the established role of domestic livestock (cattle, water buffalo) in maintaining transmission for these species. This will likely become increasingly important as endemic areas approach elimination and animal reservoirs sustain residual transmission. Other issues included the incorporation of WASH factors unlikely to directly influence infection risk (e.g., consumption of raw vegetables or shoe wearing) and the failure to address all plausible sources of exposure. Together, these issues may obscure the true impact of interventions, either by diluting observed effects or by leaving some transmission pathways unaddressed.
There was considerable variation in the terminology used to describe WASH services. For sanitation, terms ranged from general mentions of latrines, without specification of latrine location or technology, to a specific latrine type and sanitation service. For water, the location of water points, distance to households or quantity of available water was often omitted, which may affect use for bathing or laundry. These gaps likely reflect practical challenges in measuring WASH infrastructure and behaviours, variability in household practices, and the infrequent application of transmission-focused conceptual frameworks (as discussed above). Incorporating both observed and self-reported measures of water quantity and use can strengthen assessments by reducing biases inherent in self-report alone. Standardising infrastructure and service definitions, as proposed by the WHO/UNICEF Joint Monitoring Programme [41], and using observations could improve the consistency and reliability of future study protocols.
A total of 180/580 (31%) of studies were excluded at full-text review because of the failure to differentiate between Schistosoma spp., other helminth species, or intestinal protozoa in the analysis, despite often disaggregating prevalence and intensity data by species. This lack of species-specific reporting hinders the ability to accurately interpret the relationship between risk factors and infection. It also highlights that schistosomiasis and STH are still grouped together, despite very different life cycles (e.g., water-contact vs ingestion). This sets up failure in selecting appropriate WASH interventions that attempt to reduce helminth infections. For this reason, Bradley et al. [42] categorised water-related diseases by transmission route. Diseases associated with exposure to surface water and transmission via an aquatic intermediate host (i.e., schistosomiasis) have distinct suggested WASH interventions compared to other WASH-related, such as water-borne or water-washed, diseases. While treatment for helminth infections is often delivered through integrated drug administration campaigns that co-administer praziquantel for schistosomiasis alongside anthelminthic drugs for STH for logistical reasons, WASH interventions should be studied and developed specific to the helminth infection and species.
Despite developments in diagnostic methods and evidence of the low sensitivity of single Kato-Katz in low intensity infections [43,44], 14% of the studies published in the last 20 years still used single Kato-Katz or did not specify how many stool slides were analysed per sample. This likely resulted in under-reporting of infections, which would affect the accuracy of the reports.
Limitations
Studies may have been missed due to language restrictions, especially for studies on S. japonicum, and the choice of databases. We only included peer-review sources, and therefore did not include grey literature and pre-prints, so may have missed some evidence. This review also did not assess the quality or risk of bias of the included studies. Scoping reviews typically do not include a formal assessment of the quality or risk of bias, which means that findings may include evidence of varying quality without differentiation. This review only included studies linking WASH to human infection, not other parts of the lifecycle. Therefore, studies exploring how much WASH activities contribute to environmental contamination (e.g., snail infection, presence of cercariae in water), were excluded. This is the case for studies reporting links between hygienic bathing or anal cleansing and snail infections, not parasitological surveys in humans (e.g., [45,46]).
Considerations for future research
Further research is needed to better understand the extent to which coverage and use of specific WASH components influence schistosomiasis transmission (Box 1). There are several ways in which study design and reporting could be strengthened to enhance both interpretability and comparability across settings. This would facilitate more robust cross-study comparisons, systematic reviews, and meta-analyses, thereby increasing the overall impact and policy relevance of WASH–schistosomiasis research. Suggested considerations for any future WASH-SCH studies include:
Conclusion
This scoping review highlights important gaps and opportunities in the evidence base linking WASH and schistosomiasis transmission. Empirical support is strongest for water contact and sanitation access, where a substantial body of observational research exists. However, critical transmission pathways, such as anal cleansing, agricultural use of faecal waste, and animal reservoirs in S. haematobium, remain unexamined. The frequent absence of conceptual frameworks of transmission has led to the inclusion of irrelevant WASH variables and the omission of key factors. The lack of standardised WASH definitions, inconsistent species-specific reporting, and underuse of sensitive diagnostics further limit comparability across studies and the strength of current evidence.
To improve the design and implementation of future WASH research for schistosomiasis, we recommend adopting standardised protocols and definitions, species-specific reporting, and conceptual frameworks grounded in transmission dynamics. Intervention studies would benefit from clear theories of change, longer follow-up periods, assessment of intervention fidelity and uptake, and attention to both individual- and community-level exposures. Addressing these research gaps and improving methodological rigor will be essential to optimise WASH interventions as part of integrated schistosomiasis control and elimination strategies.
Supporting information
S2 Table. Included observational studies with references.
https://doi.org/10.1371/journal.pgph.0006916.s003
(DOCX)
S3 Table. Additional data extracted from observational studies.
https://doi.org/10.1371/journal.pgph.0006916.s004
(XLSX)
Acknowledgments
The authors acknowledge the members of the WHO-led Technical Advisory Group on schistosomiasis and soil-transmitted helminths, and in particular: World Health Organization secretariat: Amadou Garba, Antonio Montresor, Denise Mupfasoni, Sophie Boisson, Bruce Gordon, Jonathan King. Other members of the WASH sub-group: Sarity Dodson, FHF/NNN; Paul Emerson, TFGH/ITI; Anouk Gouvras, GSA; Sultani Matendechero, MoH Kenya; Jean Bosco Mbonigaba, MoH Rwanda; Moussa 601 Sacko, NIPH Mali; May Sule, Cranfield University; Russell Stothard, LSTM. Additional thanks: Fiona Fleming, Unlimit Health; Oliver Cumming, LSHTM; Pay Dreschel, CGIAR; Kate Medlicott, World Health Organization.
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