Implications for selecting persistent hot spots of schistosomiasis from community-and school-based surveys in Blue Nile, North Kordofan, and Sennar States, Sudan

In several schistosomiasis-endemic countries, the prevalence has remained high in some areas owing to reinfection despite repeated mass drug administration (MDA) interven-tions; these areas are referred to as persistent hot spots. Identifying hotspots is critical for interrupting transmission. This study aimed to determine an effective means of identifying persistent hot spots. First, we investigated the differences between Schistosoma haematobium and Schistosoma mansoni prevalence among school-aged children (SAC) estimated by a community-based survey, for which local key informants purposively se-lected communities, and a randomly sampled school-based survey. A total of 6,225 in-dividuals residing in 60 villages in 8 districts of North Kordofan, Blue Nile, or Sennar States, Sudan participated in a community-based survey in March 2018. Additionally, the data of 3,959 students attending 71 schools in the same 8 districts were extracted from a nationwide school-based survey conducted in January 2017. The community-based survey identified 3 districts wherein the prevalence of S. haematobium or S. man-soni infection among SAC was significantly higher than that determined by the randomly sampled school survey (e.g., S. haematobium in the Sennar district: 10.8% vs. 1.1%, P < 0.001). At the state level, the prevalence of schistosomiasis among SAC, as determined by the community-based survey, was consistently significantly higher than that determined by the school-based survey. Purposeful selection of villages or schools based on a history of MDA, latrine coverage, open defecation, and the prevalence of bloody urine improved the ability for identifying persistent hot spots.