Three annual cross-sectional community-based Knowledge, Attitudes and Practices (KAP) and prevalence surveys for urogenital schistosomiasis infection in two rural communities within Mangochi and Nsanje Districts, southern Malawi.

In 2022 the World Health Organization (WHO) issued guidelines with key interventions to control and eliminate schistosomiasis in endemic countries. In Malawi, whilst praziquantel Mass Drug Administration (MDA) campaigns have been ongoing for over a decade, implementation of other interventions have not been formally assessed. To help formulation of an integrated country-specific control strategy, we assessed the Knowledge, Attitudes and Practices (KAP) and infection prevalences in two representative rural communities in Mangochi and Nsanje Districts. Longitudinal cross-sectional community-based questionnaire surveys were undertaken with participants aged from 6 to 45 years in 2022 and later repeated in 2023 and in 2024. Participants (including children aged 2 to 5 years) provided urine samples for parasitological tests. Comparative analysis involved calculation of percentages, tabulations, frequencies, and a logistic regression (logit) model to assess the effect of education level, gender, age, and study area on general and correct knowledge of schistosomiasis. A total of 1964 participants took part in the KAP surveys in 2022, and 1789 and 1908 participants were followed up in 2023 and 2024 respectively, while for the parasitological surveys, 2,319 participants took part in 2022, and 2,006 and 2,014 participants were followed up in 2023 and 2024 surveys respectively. In total, 53.2 % were from Mangochi, 55.5 % were females, 62.1 % were School-Aged Children (SAC) and 37.9 % were adults with their mean ages at 11 and 28 years, respectively. Overall, 65.5 % of respondents demonstrated satisfactory (≥50.0 % - ≤70.0 %) knowledge of schistosomiasis while only 5.1 % correctly mentioned freshwater snails as intermediate hosts. In 2022, prevalence of urogenital schistosomiasis by urine microscopy was 43.6 %, which despite annual MDA increased to 44.1 % in 2023, then after biannual MDA decreased to 27.0 % in 2024. In 2022, 10.5 % of all participants had heavy-intensity infections which increased to 11.4 % in 2023 before decreasing to 7.7 % in 2024. The majority (91.3 %) used a borehole or piped source of drinking water and used a latrine to urinate or defecate (93.8 %) although many (59.6 %) reported to have visited a freshwater body more than once in a day. Since MDA has taken place over several years in these areas and only had insufficient local impact, we strongly encourage addition of complementary methods to bolster its impact. It is therefore essential to engage individuals and communities, improving their understanding of disease and behaviour change to more effectively control and potentially eliminate schistosomiasis.