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A population-based approach was used to investigate morbidity from Schistosoma mansoni in a rural community in eastern Puerto Rico that was representative of remaining endemic foci on the island. In 1974 the prevalence of infection 855 of 1,056 inhabitants was 32.7% and the geometric mean egg output was 17.6 eggs per gram. A standardized medical history was obtained, and physical and laboratory examinations were performed on 737 (70%) of the community residents. Quantitative S. mansoni egg counts were performed on 1 gram of feces with a modified Ritchie formol-ether concentration technique; other intestinal parasites were recorded on a semi-quantitative basis. Interviews and physical examinations were conducted "blind" to minimize observer bias, and statistical analysis was done on data from 149 infected subjects and 149 noninfected controls matched by age and sex. For subjects under 20 years of age the frequency of hookworm infection and trichuriasis and absolute eosinophilia was significantly higher in the infected group, but no difference was found in the frequency of signs and symptoms of schistosomiasis. For the subjects 20 years and over, the symptom "blood in the stool" was reported more frequently in the infected group, but hematocrit level did not differ between infected and noninfected controls. Although palpable livers were noted more frequently in infected (8) than in noninfected (1) subjects 20 years and over, further evaluation of these subjects cast doubt upon a causal role for S. mansoni. These data indicate that morbidity from S. mansoni infection in the community is low, a finding consistent with the apparent decline in S. mansoni morbidity in Puerto Rico during recent decades and the relatively low intensity of infection in this community. Nevertheless, because of the sporadic occurrence of S. mansoni-induced disease on the island, and because heavily infected subjects are clearly at greater risk of disease, we are recommending treatment for community residents with high egg output.

The Boqueron Schistosomiasis Project is a prospective community-based study of Schistosoma mansoni infection after the interruption of transmission by nonchemotherapeutic control measures. The study methods and the parasitologic results of the first five annual stool surveys are described in this report. In the first year, 1972, among 904 inhabitants (88% of the total population) the prevalence of infection was 40%, and the geometric mean intensity of infection among positives was 16.1 eggs per gram (epg). Snail control was begun in early 1973 with molluscicides and habitat modification. Intensive monitoring every 2 weeks revealed only 63 noninfected Biomphalaria glabrata in the community during the subsequent 4 years. The incidence of new infectins among people negative in all previous surveys dropped from 17% in 1972 to 1% in 1974 and has remained negligible since then. Among young children and newborn, only four new infections (all less than 5 epg) were found after the first control year. Despite this low rate of transmission, prevalence only decreased from 37% to 34%, and the population geometric mean fecal egg output has not substantially changed in a cohort of 528 individuals examined in each of the six annual surveys. Possible reasons for the minimal change in parasitologic status are discussed and include water contact behavior outside the community and changes in laboratory techniques. Data from the first 5 years of the study suggest that in a population where mean intensity of infection with S. mansoni is low, further decreases in prevalence and intensity of infection occur slowly. The implications for control programs based on nonchemotherapeutic measures are discussed.