Advances in Parasitology, Volume 115

Russell Stothard
Visit to download the full and correct content document:
https://ebookmass.com/product/advances-in-parasitology-volume-115-russell-stothar
d/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Advances in Parasitology, Volume 117 David Rollinson

https://ebookmass.com/product/advances-in-parasitology-
volume-117-david-rollinson-2/

Advances in Parasitology, Volume 117 David Rollinson

https://ebookmass.com/product/advances-in-parasitology-
volume-117-david-rollinson/

Advances in Protein Chemistry and Structural Biology

Volume 115 - DNA Repair Rossen Donev

https://ebookmass.com/product/advances-in-protein-chemistry-and-
structural-biology-volume-115-dna-repair-rossen-donev/

Advances in Ophthalmology and Optometry, 2022 (Volume

7-1) (Advances, Volume 7-1) Myron Yanoff Md (Editor)

https://ebookmass.com/product/advances-in-ophthalmology-and-
optometry-2022-volume-7-1-advances-volume-7-1-myron-yanoff-md-
editor/
Advances in Ophthalmology and Optometry, 2021 (Volume
6-1) (Advances, Volume 6-1) Myron Yanoff Md (Editor)

https://ebookmass.com/product/advances-in-ophthalmology-and-
optometry-2021-volume-6-1-advances-volume-6-1-myron-yanoff-md-
editor/

Advances in Economic Measurement: A Volume in Honour of

D. S. Prasada Rao Duangkamon Chotikapanich

https://ebookmass.com/product/advances-in-economic-measurement-a-
volume-in-honour-of-d-s-prasada-rao-duangkamon-chotikapanich/

Advances in Cosmetic Surgery (Volume 2) – 2019 2019

Edition Edition Gregory H. Branham

https://ebookmass.com/product/advances-in-cosmetic-surgery-
volume-2-2019-2019-edition-edition-gregory-h-branham/

Understanding Willing Participants: Milgram’s Obedience

Experiments and the Holocaust. Volume 1 Nestar Russell

https://ebookmass.com/product/understanding-willing-participants-
milgrams-obedience-experiments-and-the-holocaust-volume-1-nestar-
russell/

Understanding Willing Participants, Volume 2: Milgram’s

Obedience Experiments and the Holocaust Nestar Russell

https://ebookmass.com/product/understanding-willing-participants-
volume-2-milgrams-obedience-experiments-and-the-holocaust-nestar-
russell/
VOLUME ONE HUNDRED AND FIFTEEN

ADVANCES IN
PARASITOLOGY
 SERIES EDITOR
D. ROLLINSON
Life Sciences Department
The Natural History Museum,
London, United Kingdom
d.rollinson@nhm.ac.uk
EDITORIAL BOARD
T. J. C. ANDERSON
Department of Genetics, Texas
Biomedical Research Institute,
San Antonio, TX, United States
M. G. BASÁÑEZ
Professor of Neglected Tropical
Diseases, Department of Infectious
Disease Epidemiology, Faculty of
Medicine (St Mary’s Campus),
Imperial College London,
London, United Kingdom
D. D. BOWMAN
Director Cornell CVM MPS—Veterinary
Parasitology, Professor of Parasitology,
C4-119 VMC, Dept Micro & Immunol,
CVM Cornell University, Ithaca,
NY, United States
R. B. GASSER
Faculty of Veterinary and Agricultural
Sciences, The University of Melbourne,
Parkville, VIC, Australia
A. L. GRAHAM
Professor of Ecology & Evolutionary Biology,
Co-Director of the Global Health Program,
Princeton University, Princeton,
NJ, United States
J. KEISER
Head, Helminth Drug Development Unit,
Department of Medical Parasitology and
Infection Biology, Swiss Tropical and Public
Health Institute, Basel, Switzerland
J. R. STOTHARD
Department of Tropical
Disease Biology
Liverpool School of Tropical
Medicine, Liverpool, United Kingdom
russell.stothard@lstmed.ac.uk
K. KING
Department of Zoology,
University of Oxford,
Oxford, United Kingdom
M. G. ORTEGA-PIERRES
Professor of the Department of Genetics
and Molecular Biology,
Centro de Investigación y de
Estudios Avanzados IPN,
Mexico City, Mexico
D. L. SMITH
Johns Hopkins Malaria Research
Institute & Department of Epidemiology,
Johns Hopkins Bloomberg School
of Public Health, Baltimore,
MD, United States
R. C. A. THOMPSON
Head, WHO Collaborating Centre
for the Molecular Epidemiology
of Parasitic Infections, Principal
Investigator, Environmental
Biotechnology CRC (EBCRC),
School of Veterinary and Biomedical
Sciences, Murdoch University,
Murdoch, WA, Australia
X.-N. ZHOU
Professor, Director, National Institute of
Parasitic Diseases,
Chinese Center for Disease Control
and Prevention, Shanghai,
People’s Republic of China
VOLUME ONE HUNDRED AND FIFTEEN

ADVANCES IN
PARASITOLOGY
Edited by

DAVID ROLLINSON
Life Sciences Department
The Natural History Museum,
London, United Kingdom

RUSSELL STOTHARD
Department of Tropical
Disease Biology
Liverpool School of Tropical
Medicine, Liverpool, United Kingdom
Academic Press is an imprint of Elsevier
125 London Wall, London EC2Y 5AS, United Kingdom
The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom
50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States
525 B Street, Suite 1650, San Diego, CA 92101, United States

First edition 2022

Copyright © 2022 Elsevier Ltd. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

ISBN: 978-0-323-98871-1
ISSN: 0065-308X

For information on all Academic Press publications

visit our website at https://www.elsevier.com/books-and-journals

Publisher: Zoe Kruze

Acquisitions Editor: Leticia Lima
Developmental Editor: Cindy Angelita Gardose
Production Project Manager: Abdulla Sait
Cover Designer: Mark Rogers
Typeset by STRAIVE, India
Contents

Contributors vii

1. An update on female and male genital schistosomiasis and

a call to integrate efforts to escalate diagnosis, treatment and
awareness in endemic and non-endemic settings: The time is now 1
Amaya L. Bustinduy, Bodo Randriansolo, Amy S. Sturt, Seke A. Kayuni,
Peter D.C. Leustcher, Bonnie L. Webster, Lisette Van Lieshout,
J. Russell Stothard, Hermann Feldmeier, and Margaret Gyapong
1. Introduction 3
2. Pathogenesis and clinical manifestations 9
3. Immunology 12
4. Diagnosis of genital schistosomiasis 13
5. Co-infections and co-morbidities 21
6. Immigrants and returned travellers 24
7. Management of FGS and MGS 25
8. Disability, stigma and community awareness 29
9. Programme integration 30
10. Conclusions and way forward 33
Acknowledgements 33
References 33

2. Vertebrates as uninfected disseminators of helminth

eggs and larvae 45
Neil J. Morley

1. Introduction 46
2. Terminology and definitions of helminth zoochory 48
3. Features of different vertebrates that affect their ability to disseminate
parasites 49
4. Endozoochory 54
5. Ectozoochory 127
6. Long-distance dispersal 138
7. Conclusion 143
References 146

v
vi Contents

3. Anthelmintic resistance in ruminants: challenges and solutions 171

J. Charlier, D.J. Bartley, S. Sotiraki, M. Martinez-Valladares, E. Claerebout,
G. von Samson-Himmelstjerna, S.M. Thamsborg, H. Hoste, E.R. Morgan,
and L. Rinaldi
1. Concerted action for combatting anthelmintic resistance in ruminants 173
2. Prevalence and impact of anthelmintic resistance 175
3. Gastrointestinal nematodes: current and future diagnosis 179
4. Diagnosis of anthelmintic resistance 185
5. Towards a sustainable use of anthelmintics 193
6. Prospects of new anthelmintics 197
7. Complementary control approaches 198
8. Facilitating behavioural change 206
9. Conclusions 210
Acknowledgements 211
References 211
Further reading 226
Contributors

D.J. Bartley
Disease Control, Moredun Research Institute, Penicuik, United Kingdom
Amaya L. Bustinduy
Department of Clinical Research, London School of Hygiene & Tropical Medicine,
London, United Kingdom
J. Charlier
Kreavet, Kruibeke, Belgium
E. Claerebout
Ghent University, Faculty of Veterinary Medicine, Laboratory of Parasitology, Merelbeke,
Belgium
Hermann Feldmeier
Charit
e University Medicine Berlin, Institute of Microbiology, Infectious Diseases and
Immunology, Berlin, Germany
Margaret Gyapong
Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
H. Hoste
INRAE, UMR 1225 IHAP INRAE/ENVT, Toulouse University, Toulouse, France
Seke A. Kayuni
Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool,
United Kingdom; MASM Medi Clinics Limited, Blantyre, Malawi
Peter D.C. Leustcher
Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring; Department of
Clinical Medicine, Aalborg University, Aalborg, Denmark
M. Martinez-Valladares
Instituto de Ganaderı́a de Montaña (CSIC-Universidad de León), Departamento de Sanidad
Animal, León, Spain
E.R. Morgan
Institute for Global Food Security, Queen’s University Belfast, Belfast, United Kingdom
Neil J. Morley
School of Biological Sciences, Royal Holloway, University of London, Egham, Surrey,
United Kingdom
Bodo Randriansolo
Association K’OLO VANONA, Antananarivo, Madagascar
L. Rinaldi
University of Naples Federico II, Unit of Parasitology and Parasitic Diseases, Department of
Veterinary Medicine and Animal Production, CREMOPAR, Napoli, Italy

vii
viii Contributors

S. Sotiraki
Veterinary Research Institute, Hellenic Agricultural Organisation ELGO-DIMITRA,
Thessaloniki, Greece
J. Russell Stothard
Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool,
United Kingdom
Amy S. Sturt
Section of Infectious Diseases, Veterans Affairs Palo Alto Health Care System, Palo Alto,
United States
S.M. Thamsborg
Veterinary Parasitology, University of Copenhagen, Frederiksberg C, Denmark
Lisette Van Lieshout
Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
G. von Samson-Himmelstjerna
Institute for Parasitology and Tropical Veterinary Medicine, Veterinary Centre for
Resistance Research, Freie Universit€at Berlin, Berlin, Germany
Bonnie L. Webster
Natural History Museum, London, United Kingdom
 CHAPTER ONE

An update on female and male

genital schistosomiasis and
a call to integrate efforts
to escalate diagnosis, treatment
and awareness in endemic
and non-endemic settings:
The time is now
Amaya L. Bustinduya,∗, Bodo Randriansolob, Amy S. Sturtc,
Seke A. Kayunid,e, Peter D.C. Leustcherf,g, Bonnie L. Websterh,
Lisette Van Lieshouti, J. Russell Stothardd, Hermann Feldmeierj,
and Margaret Gyapongk
a
Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United
Kingdom
b
Association K’OLO VANONA, Antananarivo, Madagascar
c
Section of Infectious Diseases, Veterans Affairs Palo Alto Health Care System, Palo Alto, United States
d
Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
e
MASM Medi Clinics Limited, Blantyre, Malawi
f
Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark
g
Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
h
Natural History Museum, London, United Kingdom
i
Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
j
Charite University Medicine Berlin, Institute of Microbiology, Infectious Diseases and Immunology, Berlin,
Germany
k
Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
∗
Corresponding author: e-mail address: amaya.bustinduy@lshtm.ac.uk

Contents
1. Introduction 3
1.1 Selection criteria 3
1.2 Epidemiology and geographical distribution of genital schistosomiasis 3
1.3 Life cycle and transmission 4
1.4 FGS and MGS in less common Schistosoma species 7
1.5 The importance of different hybrids of S. haematobium group species
(including minor species contributing to FGS/MGS) 8
2. Pathogenesis and clinical manifestations 9
2.1 Female genital schistosomiasis (FGS) 9
2.2 Male genital schistosomiasis (MGS) 11

Advances in Parasitology, Volume 115 Copyright #2022 Elsevier Ltd 1

ISSN 0065-308X All rights reserved.
https://doi.org/10.1016/bs.apar.2021.12.003
2 Amaya L. Bustinduy et al.

3. Immunology 12
3.1 Vaginal environment in FGS 12
3.2 Immune activation during pregnancy 13
4. Diagnosis of genital schistosomiasis 13
4.1 FGS diagnostics 13
4.2 Molecular diagnostics (nucleic acid amplification tests) 17
4.3 MGS diagnostics 19
4.4 Immunopathology in MGS 20
5. Co-infections and co-morbidities 21
5.1 Human immunodeficiency virus (HIV) 21
5.2 Human papillomavirus (HPV) and FGS 22
6. Immigrants and returned travellers 24
7. Management of FGS and MGS 25
7.1 FGS treatment 25
7.2 Treatment of MGS 28
7.3 Pregnancy 28
8. Disability, stigma and community awareness 29
8.1 Case study: Ghana 29
9. Programme integration 30
10. Conclusions and way forward 33
Acknowledgements 33
References 33

Abstract
The last decades have brought important insight and updates in the diagnosis, man-
agement and immunopathology of female genital schistosomiasis (FGS) and male
genital schistosomiasis (MGS). Despite sharing a common parasitic aetiological agent,
FGS and MGS have typically been studied separately. Infection with Schistosoma
haematobium manifests with gender-specific clinical manifestations and consequences
of infection, albeit having a similar pathogenesis within the human genital tract.
Schistosoma haematobium is a known urinary bladder carcinogen, but its potential caus-
ative role in other types of neoplasia, such as cervical cancer, is not fully understood.
Furthermore, the impact of praziquantel treatment on clinical outcomes remains largely
underexplored, as is the interplay of FGS/MGS with relevant reproductive tract infections
such as HIV and Human Papillomavirus. In non-endemic settings, travel and immigrant
health clinics need better guidance to correctly identify and treat FGS and MGS. Our
review outlines the latest advances and remaining knowledge gaps in FGS and MGS
research. We aim to pave a way forward to formulate more effective control measures
and discuss elimination targets. With a growing community awareness in health prac-
titioners, scientists and epidemiologists, alongside the sufferers from these diseases,
we aspire to witness a new generation of young women and men free from the
downstream disabling manifestations of disease.
An update on female and male genital schistosomiasis 3

1. Introduction
As a neglected tropical disease (NTD), interventions against schisto-
somiasis are featured within the recently outlined WHO 2021–30
Roadmap (WHO, 2021a). Preventive chemotherapy against urogenital
and intestinal schistosomiasis-related morbidity is strongly encouraged and
disease-specific control targets are also defined. However, the detection
and management of disease sequelae within the female and male genital
tracts due to urogenital schistosomiasis, remain unaddressed. In this review,
we seek to highlight the importance and often overlooked connections
between female genital schistosomiasis (FGS) and male genital schistosomi-
asis (MGS), addressing disease-specific needs and challenges in endemic and
non-endemic settings, respectively. Our review presents a comprehensive
summary of the recent published evidence about FGS and MGS to ulti-
mately inform policy makers to support integrative approaches for disease
management.

1.1 Selection criteria

References were searched in PubMed and Medline databases using the key
words ‘female genital schistosomiasis’, ‘male genital schistosomiasis’, ‘genital
or urogenital schistosomiasis’, ‘praziquantel’, for the last 10 years (2011–21)
with the terms ‘AND’, ‘OR’. A total of 324 articles were identified.
Abstracts were reviewed for suitability and were included in this review if
they pertained to any discipline related to FGS and MGS. A total of 123 arti-
cles related specifically to FGS published in the last decade were screened
and 85 were reviewed. No clinical trials were identified. For MGS, 56 arti-
cles were retrieved and only 32 were found to be related to the topic. A sea-
rch for articles covering both FGS and MGS retrieved 29 results but only
3 studied both diseases jointly. Historical articles were included where
relevant

1.2 Epidemiology and geographical distribution of genital

schistosomiasis
The global distribution of FGS is estimated to be around 50 million people
limited to S. haematobium endemic areas in sub-Saharan Africa (SSA)
(Christinet et al., 2016). Urinary schistosomiasis (viz. S. haematobium eggs
in urine) and FGS often co-exist, and are commonly referred to as urogenital
schistosomiasis. For example, a Tanzanian study reported concurrent FGS
4 Amaya L. Bustinduy et al.

diagnosed by histopathology in 62% of 543 women with urinary schistoso-

miasis (Poggensee et al., 1998). Overall, there are fewer studies evaluating
FGS compared with the broader disease definition of urogenital schistoso-
miasis, including urine-based diagnostics with and without genital involve-
ment. Thus, accurate geographical estimates for FGS are lacking and remain
an extrapolation from the broader disease manifestations. Estimates for
MGS are scarce and also rely on extrapolation of a wider range of clinical
manifestations attributed to S. haematobium (Kayuni et al., 2019a).
Genital schistosomiasis is an inflammatory parasitic disease caused when
eggs from the waterborne blood fluke S. haematobium, are lodged within the
reproductive organs. Genital schistosomiasis affects both females and males
(Colley et al., 2014; Kjetland et al., 2012; Yu et al., 2013). FGS and MGS are
not yet included in the global burden of disease estimates of 1.44 million
disability-adjusted life years (DALYs) attributed to schistosomiasis, despite
the well-known disabling morbidities associated with FGS (DALYs and
Collaborators, 2018). Control efforts for schistosomiasis, noting urogenital
and intestinal manifestations, broadly focus on decreasing heavy intensity
infections leading to severe morbidity in school-aged children in the urinary
tract, and in the liver and spleen, respectively (Savioli et al., 2017; WHO,
2020). This approach neglects to recognize manifestations related to genital
disease that are often difficult to quantify such as infertility, ectopic pregnan-
cies, sexual dysfunction and menstrual disorders (Bustinduy et al., 2017;
Helling-Giese et al., 1996a; Kjetland et al., 2008; Stothard et al., 2020b).
WHO has recognized the hidden manifestations of FGS as a public health
problem whereas MGS remains unacknowledged, not only by its sufferers
but also overlooked in health statistics captured across the continent of
Africa and other schistosome endemic locations (WHO, 2020). Fig. 1 shows
the limited number of countries with reported FGS and MGS studies.
The recognition of gender differences is necessary, as they may impact
exposure, transmission, manifestation and treatment for genital schistosomi-
asis (Ozano et al., 2020). Importantly, there are several differences in disease
awareness and social stigma for each disease manifestation (Mazigo
et al., 2021).

1.3 Life cycle and transmission

The life cycle of the waterborne Schistosoma species is complex but can be
highly efficient when certain temperature and humidity environmental
conditions are met; this can result in universal exposure and infection in
An update on female and male genital schistosomiasis 5

Fig. 1 Countries with FGS (A) and MGS (B) case reports and studies in S. haematobium
endemic areas in sub-Saharan Africa published to date. Panel (A) is adapted from
Sturt, A.S., Webb, E.L., Francis, S.C., Hayes, R.J., Bustinduy, A., 2020a. Beyond the barrier:
female genital schistosomiasis as a potential risk factor for HIV-1 acquisition. Acta
Trop. 209, 105524 and Panel (B) is adapted from Kayuni, S., Lampiao, F., Makaula, P.,
Juziwelo, L., Lacourse, E.J., Reinhard-Rupp, J., Leutscher, P.D.C., Stothard, J.R., 2019b. A sys-
tematic review with epidemiological update of male genital schistosomiasis (MGS): a call for
integrated case management across the health system in sub-Saharan Africa Parasite
Epidemiol. Control 4, e00077.

communities that have unsafe water contact (Satayathum et al., 2006). In

Africa, two main Schistosoma species infect humans, S. haematobium and
S. mansoni (Lai et al., 2015). While cross-specific worm pairings occur
within a co-infected host, it is likely that successful mating between these
two species is very rare although such mixed worm pairs may lead to ectopic
egg deposition (e.g. S. mansoni eggs in urine) and associated pathology
(Stothard et al., 2020a) (Fig. 2).
Schistososoma mansoni primarily causes hepatosplenic and intestinal
disease, while S. haematobium is strongly associated with urogenital manifes-
tations. In mixed heavy infections, S. mansoni eggs can be excreted in the
urine (mansonuria), contributing to urinary tract disease. This is most likely
resultant from mixed worm pairings between S. haematobium and S. mansoni,
with S. mansoni females being carried by S. haematobium males to the uro-
genital system (Doehring et al., 1986). Schistosoma haematobium infections
are endemic in Africa, the Middle East, and now also in Corsica (France)
(WHO, 2020), while S. mansoni is distributed in Africa, the Middle East
and also the Americas (Colley et al., 2014). While co-infection with both
6 Amaya L. Bustinduy et al.

Fig. 2 The life cycle of S. haematobium. Adapted from Countdown (https://countdown.

lstmed.ac.uk).

parasites is common, its epidemiological occurrence is only rarely reported,

even by WHO. In 2012, for example, 163 million men and women in Africa
were infected with either of these two Schistosoma species with about a quar-
ter having dual infections. Some 57 million (35%) are school aged children
(Lai et al., 2015). Much of the pathological description of S. haematobium’s
related disease has focused on urinary abnormalities, ignoring the less obvi-
ous genital complications of the disease (Bustinduy et al., 2021).
FGS is defined by the detection of parasite eggs or DNA in genital tissue
or in secretions. Schistosoma eggs (also referred to as ova) are immunogenic,
and once tissue-entrapped they invoke granulomatous inflammation. The
accumulation of eggs in genital tissues over time results in subsequent mor-
bidity and organ dysfunction (Kjetland et al., 2014). Worm migration pat-
terns of adult schistosomes and the accessibility of genital organs via the
pelvic venous plexus explain why genital manifestations are so common
in S. haematobium infections and their disease sequelae more noticeable in
sexually active adults. Signs and symptoms therefore overlap with many sex-
ually transmitted infections (Poggensee et al., 2000). Depending on where
An update on female and male genital schistosomiasis 7

Fig. 3 Schistosoma haematobium egg deposition in the female and male genital tracts
causing female and male genital schistosomiasis. Graphic components courtesy of
https://smart.servier.com/.

eggs are released, clinical pathology develops in the vulva and vagina, cervix,
uterus, fallopian tubes and the ovaries (Kjetland et al., 2012) (Fig. 3). All gen-
ital organs may be affected simultaneously, and their dynamics change
through time concurrent with administration with praziquantel, the only
available deworming medication that is active against Schistosoma spp.
(WHO, 2020).
Male genital schistosomiasis (MGS) is a specific chronic manifestation of
schistosomiasis, associated with presence of Schistosoma eggs and pathologies in
male genital fluids and organs of men inhabiting or visiting schistosomiasis-
endemic areas. Of the 54 countries in Africa, only 20 of them have formally
reported FGS and 17 countries have MGS reported cases in the literature
(Kayuni et al., 2019b; Sturt et al., 2020a).

1.4 FGS and MGS in less common Schistosoma species

Although uncommon, genital manifestations of the disease are not always
directly related to infections with S. haematobium alone. In a Tanzanian
study, 5% (19/359) of women who underwent gynaecological exam had
S. mansoni eggs detected in cervical tissue and 52.6% (10/19) had both
S. haematobium and S. mansoni eggs present in genital samples (Poggensee
et al., 2001a). In S. mansoni endemic areas in Brazil there are reported
FGS cases affecting the fallopian tubes (Faria et al., 2010) and presenting
as ovarian tumours (Cavalcanti et al., 2011; Feldmeier et al., 1998).
There are several reports of MGS caused by species other than
8 Amaya L. Bustinduy et al.

S. haematobium; for example, a case of testicular schistosomiasis leading to

secondary infertility was reported in a S. mansoni endemic area in Nigeria
(Adisa et al., 2012) and prostate involvement reported in a patient with
Schistosoma japonicum living by the Yangtze river in China (Yu et al., 2013).

1.5 The importance of different hybrids of S. haematobium

group species (including minor species contributing
to FGS/MGS)
There are currently 23 Schistosoma species, 13 of which are found in
sub-Saharan Africa, which are split into three species groups.
S. haematobium resides within the S. haematobium species group, which con-
sists of nine closely related species all of which share the characteristic of ter-
minal spined ova. Apart from S. haematobium two other species within this
group are considered to be human pathogens S. guineensis and S. intercalatum,
both of which cause intestinal schistosomiasis in specific foci in central
African regions. Other species within the group are considered pathogens
of mammalian livestock and/or wildlife. Of note is the occurrence of
S. haematobium hybrids; S. haematobium-guineensis, S. haematobium-bovis,
S. haematobium-curassoni, S. haematobium-mattheei, the latter three involve
livestock Schistosoma species and raise concerns over zoonoses and animal
reservoir hosts. Mixed species combinations are likely to result in ectopic
egg excretion and/or deposition, though there is still much to learn about
these hybrid forms, together with their potential impact on schistosomiasis
control. This has been observed for co-infections between S. haematobium
and S. mansoni where the species are urogenital and intestinal forms,
respectively.
Schistosoma intercalatum and Schistosoma guineensis have not been specifi-
cally reported to be involved FGS or MGS, either alone or in combination
with an underlying S. haematobium. However, this association has never
actually been investigated. This absence, together with that of any morbidity
impact of S. haematobium hybrid forms is more likely to represent a deficit in
application of precise species-specific diagnostic methods per se rather than
these species’ inability to colonize veins surrounding the genitalia and
deposit eggs therein.
The same molecular genetic markers that have been used to characterize
these species and hybrid forms collected from their human hosts, could be
applied for a more in-depth analysis of clinical materials associated with FGS
and MGS. This could involve the evaluation of ejaculate or cervicovaginal
samples with molecular diagnostics, to gauge the extent to which existing
An update on female and male genital schistosomiasis 9

S. haematobium-hybrids contribute to genital schistosomiasis. A further

research need is an improved understanding of not just the epidemiology
of S. haematobium-hybrids, but also their role in inflammation, and
organ-specific responses, including FGS and MGS (Baay et al., 2004;
Kayuni et al., 2019a; Leutscher et al., 2009).

2. Pathogenesis and clinical manifestations

2.1 Female genital schistosomiasis (FGS)
FGS was specifically recognized in the medical literature over 100 years ago
(Madden, 1899), but it is still often incorrectly reported and seldom treated.
This is partly due to overlapping symptoms with sexually transmitted infections
(Christinet et al., 2016; Kjetland et al., 2012). As a neglected gynaecological
condition in SSA, FGS is not frequently considered in clinical practice, with
both patients and practitioners alike unaware of the disease and its downstream
sexual and reproductive health consequences (Ngwenya, 2016).
The pathogenesis of FGS is the result of a complex inflammatory
immune response driven by the antigens released from both viable eggs,
which have been entrapped in genital tissue, and adult worms located in
small veins of the pelvis (Fig. 3). Inflammation occurs in all strata of the gen-
ital tissue including the small blood vessels ( Jourdan et al., 2011a, 2013).
Schistosomiasis related inflammation extends beyond egg-deposition site
eventually affecting entire organs (Ramarokoto et al., 2014; Schanz et al.,
2010). Lesions in the vulva, vagina and the cervix are easiest to detect
and can be identified with a colposcope (Yirenya-Tawiah et al., 2011).
Deeper lesions in the uterus, the Fallopian tubes and the ovaries are challeng-
ing to assess (Andrianjafitrimo et al., 2019) but the ensuing pathology is asso-
ciated with chronic morbidity and can sometimes be life-threatening
(Kjetland et al., 2010; Norseth et al., 2014; Schanz et al., 2010; Swai
et al., 2006) and often negatively impacts women’s reproductive health
(Laroche et al., 2016; Laxman et al., 2008).
Studies in Niger, Malawi and Zimbabwe have found that up to 75% of
women with urinary schistosomiasis also have S. haematobium eggs distrib-
uted in the genital tissues (Kjetland et al., 1996, 2005; Poggensee et al., 1998;
Renaud et al., 1989). However, just as importantly, at least 20% of women
with Schistosoma genital involvement did not have eggs present in the urine
(Poggensee et al., 1998). These data highlight the non-linear relationship
between egg detection by different diagnostic methods and established
genital morbidity.
10 Amaya L. Bustinduy et al.

Vulvar or vaginal ulcerations and papillomata have been associated with

FGS (Goldsmith et al., 1993; Laven et al., 1998; Yirenya-Tawiah et al.,
2011). These may lead to stigmatization if the findings are misinterpreted
as being caused by a sexually transmitted infection (Goldsmith et al.,
1993). Consequences of FGS may include post-coital pain and bleeding
which are not uniquely identifiable as associated with schistosomiasis. Of
special concern, women with FGS in rural Zimbabwean had a twofold
greater odds of prevalent HIV infection (Kjetland et al., 2006).
Recent population-based and ecological studies have linked FGS with
female infertility and sub-fecundity in endemic communities (Kjetland
et al., 2010; Miller-Fellows et al., 2017; Woodall and Kramer, 2018).
More recently, the Bilharzia and HIV (BILHIV) study in Zambia (Sturt
et al., 2020b), found a twofold increase in delayed conception in women
with FGS as diagnosed by DNA-based detection methods (Mills, 2021).
FGS occurs in women of all age groups, including young girls, and is
associated with important, frequently debilitating and stigmatizing morbid-
ity. Women with FGS report spontaneous or post-coital bleeding, vaginal
discharge, pain during sexual intercourse, pelvic pain, irregular menstruation
and infertility (Kjetland et al., 2008, 2010). Across studies in Zambia and
Zimbabwe, a higher proportion of young women were found to have more
detectable Schistosoma DNA in their genital tract than older women
(Kjetland et al., 2009; Sturt et al., 2020b). Additionally, young girls with uri-
nary S. haematobium may present with gynaecological symptoms prior to
their sexual debut, in particular bloody or foul-smelling vaginal discharge
(Hegertun et al., 2013). These symptoms are frequently attributed to STIs
by health care providers, contributing to the associated stigma. As a conse-
quence, many women are not encouraged to pursue medical help at health
centers and are seeking help from traditional healers (Madagascar KAP study,
Randriansolo, B, personal communication). Vagino-vesical fistulae in
women are unlikely to heal if concomitant schistosomiasis is left untreated
(Richter et al., 2008).

2.1.1 Pregnancy and placental involvement

The placenta may also be involved during chronic Schistosoma infection,
however foetal outcomes of prematurity or lower birth weight are primarily
due to the effect of schistosomiasis on the mother, in conjunction with pro-
tein loss and anaemia (Schleenvoigt et al., 2014). Maternal iron deficiency
An update on female and male genital schistosomiasis 11

during pregnancy is also associated with iron deficiency among infants

(Abioye et al., 2019; Friedman et al., 2007; Mombo-Ngoma et al., 2017;
Siegrist and Siegrist-Obimpeh, 1992). Importantly, the effect of underlying
FGS on pregnancy outcomes has not been explored.

2.2 Male genital schistosomiasis (MGS)

The first case of MGS was reported in 1911 (Madden, 1911). This was
followed by several case reports, post-mortem and histopathological research
studies in the subsequent decades (Corachan et al., 1994; Gelfand et al., 1970;
Leutscher et al., 2000). Like FGS, MGS is underreported and often not rec-
ognized by medical providers in endemic areas. Schistosome eggs passing
through or being entrapped in the tissues of prostate, seminal vesicles, vas
deferens, epididymis and testis, trigger immune reactions and granulomata
formation (Kayuni et al., 2019b). In addition to granulomatous inflammation,
post-mortem and histopathological studies have shown egg-induced lesions
such as fibrosis and calcifications which can also be detected on radiological
examinations (Al-Saeed et al., 2003; Ramarakoto et al., 2008; Vilana
et al., 1997).
In MGS, changes of sperm consistency or blood in semen
(haematospermia) are often presenting symptoms (Corachan et al.,
1994). A particular observation in retuning travellers, haematospermia can
present in the early stages of MGS (Barlow and Meleney, 1949; Feldmeier
et al., 1999; Schwartz et al., 2002) and in some instances at a young age
(Rambau et al., 2011). Symptoms associated with semen quality and outflow
include, coital or ejaculatory pain, abnormal ejaculates, and occasional spe-
rmaturia (presence of spermatozoa in urine). Additionally, orchitis, prostatitis,
dyspareunia, and hydrocele are also associated with MGS. Other potential
symptoms include pelvic pain, erectile and ejaculatory dysfunction or para-
phimosis. To date, the epidemiology, diagnostic testing, specific clinical man-
ifestations and case management of MGS are not well or widely described.
There are little data regarding the current burden of and morbidity among
local inhabitants in endemic areas of SSA.
The aetiology of symptom underreporting in MGS is likely multi-
factorial including stigma associated with genital tract infections and the
potential impact on fertility-despite the quality of the semen being
preserved (Leutscher et al., 2009). Studies in Madagascar and Malawi have
demonstrated resolution of symptoms after anti-schistosomal therapy
Another random document with
no related content on Scribd:
jurisdiction.
GEN. ALEXANDROV: That is not quite so. I did not wish to
touch on this question, but I must revert to it now as you have
somewhat minimized your part in this matter.
SAUCKEL: I request permission to reply to the word “minimize.”
The distribution and direction of manpower in the Reich was my
principal task. It included, with the German workers, 30 million
persons. I do not wish to minimize this task, for I did my best to
introduce order into this mass of workers, as dictated by my sense of
duty. I do not wish to minimize anything. It was my task and my duty
towards my people.
GEN. ALEXANDROV: We need not argue on this subject. It
would be much simpler to consult the document. An order by Göring
will be handed to you in a moment.
SAUCKEL: I wish—I must apologize to you if you have
misunderstood me. I—I have no intention of arguing. I am only
asking for permission to clarify my conception of duty with regard to
this task, for it was the most personal task I had.
GEN. ALEXANDROV: That is quite apparent in this order by
Göring of 27 March 1942. It is Document Exhibit Number USSR-365.
It will be handed to you in a minute. I will read a brief excerpt from it,
showing the powers you were endowed with.
THE PRESIDENT: What is the number of it?
GEN. ALEXANDROV: It is Exhibit Number USSR-365.
THE PRESIDENT: Has it got a PS number?
GEN. ALEXANDROV: No. This is a Soviet exhibit.
[Turning to the defendant.] Please read Subparagraph 4 which
clearly states:
“The Plenipotentiary General for the Allocation of Labor for
the execution of his tasks is given authority through power
assigned to me by the Führer to issue instructions to the
highest authorities of the Reich and to their subordinate
offices, as well as to the offices of the Party and to its
organizations and affiliated organizations, to the Reich
 Protector, the Governor General, the military commanders,
and the heads of civil administration.”
That is what we read in Subparagraph 4 of this order. I believe,
therefore, that on the strength of this order you were appointed
Plenipotentiary General, with extraordinary powers, for the Allocation
of Labor. Is that correct or not?
SAUCKEL: That is correct. I should like to add that this authority
was limited to my own special sphere, and I take the liberty of
reading the following sentence: “Orders and directives of
fundamental importance are to be submitted to me in advance.”
Also I might point out that a restriction was imposed on my
deputies later in the autumn. There is a witness who can make a
statement to that effect.
GEN. ALEXANDROV: I am not talking about your deputies. Your
powers are only too clearly defined in Subparagraph 4 of Göring’s
order.
Now, will you enumerate which of the defendants, at the same
time as yourself, directly and in his own sphere of action participated
in the execution of measures for the mass deportation into slavery of
the population of the occupied territories and their employment in
Germany. Name them in succession. Did Defendant Göring
participate in all these crimes, as your immediate chief and leader?
SAUCKEL: I want to point out most emphatically that I could not
possibly have been aware that entire populations had been carried
off by means of lawful recruitment and service engagements based
on legal decrees. I deny this. I had nothing to do with measures
concerning prisoners, et cetera, but...
THE PRESIDENT: The question was, did the Defendant Göring
participate with you in the bringing of foreign workers into Germany?
You do not seem to me really to be answering it at all.
SAUCKEL: I was directly subordinate to the Reich Marshal of
the Greater German Reich in the question of the introduction of
foreign manpower.
THE PRESIDENT: Then why do you not say so?
 GEN. ALEXANDROV: So the Defendant Göring participated in
the execution of these criminal measures?
THE PRESIDENT: General Alexandrov, when you want to ask a
question of that sort I think it would be much better that you should
not allege the fact that it is a crime. If you want to know whether the
Defendant Göring took part with this defendant in the work that he
was doing you can refer to that without calling it a crime; and then he
perhaps will answer you more easily.
GEN. ALEXANDROV: Yes, My Lord.
[Turning to the defendant.] Did the Defendant Von Ribbentrop
participate in carrying out these measures on diplomatic lines, and
did he sanction the violation of international treaties and conventions
where the utilization of foreign workers and prisoners of war in the
German industries was concerned?
THE PRESIDENT: Well, there again, these defendants are
saying that there was no violation of international law; so the
question you should put to him is: Did Von Ribbentrop participate
with him in these measures as far as diplomacy was concerned?
GEN. ALEXANDROV: I am now asking what was the connection
between the Defendant Von Ribbentrop and the allocation of labor,
and I would like to receive an answer to this question from the
Defendant Sauckel.
SAUCKEL: The part played by Defendant Ribbentrop consisted
in holding conferences with foreign statesmen or foreign government
offices in the occupied territories as well as in neutral and friendly
foreign countries; and he considered it highly important that these
conferences should be conducted in a correct manner and that the
aim should be to obtain the best possible conditions for foreign
workers.
GEN. ALEXANDROV: I will question you about that a little later,
when the question arises concerning the employment of prisoners of
war in the German industries.
Please tell me now, what was the attitude of the Defendant
Kaltenbrunner regarding these measures?
SAUCKEL: In this connection I met the Defendant
Kaltenbrunner on one single occasion during a conference—the date
of which I cannot at present remember—at the Reich Chancellery
with Minister Lammers. I believe it was in 1944. Apart from that, I
had no interview of any kind with Kaltenbrunner, nor did I reach any
agreements with him on questions concerning the employment of
labor.
GEN. ALEXANDROV: Yet the Defendant Kaltenbrunner placed
police forces at your disposal for carrying out the recruitment of
labor, did he not?
SAUCKEL: I have repeatedly emphasized the fact that the
recruitment of workers was no concern of the Police. I must ask my
defense counsel to submit the relevant regulations, of which there
are numerous specimens available. They prove quite clearly and
unequivocally and irrefutably the division of tasks between the Police
and my department.
GEN. ALEXANDROV: Did the Police participate in the execution
of these measures or did it not? I am not reproaching you now.
SAUCKEL: In my opinion the Police participated only in cases
where the execution of administrative duties was rendered
impossible in partisan areas. In White Ruthenia alone 1,500 local
mayors were murdered by the partisans. This is seen from the
document.
GEN. ALEXANDROV: But was recruitment, even in normal
circumstances, not carried out by police methods? Did you know
nothing at all about that?
SAUCKEL: I will tell you exactly what I know about it. There
were in the occupied territories of Europe about 1,500 districts—here
I mean areas or departments, the Feldkommandanturen, which we in
German administration would describe as being the size of a Kreis
(district)—and these 1,500 districts contained 1,500 administrative
centers staffed partly by local and partly by German personnel. In
addition to this personnel, in the territories of the Soviet Union alone,
1,000 Russian workers who were previously employed in Germany
were acting as recruiting officers. Now if each of these administrative
centers, which would correspond to a German Landkreis and have a
population of 40,000 to 70,000 inhabitants, selected in a proper way,
examined, and tested five persons daily, that alone would amount to
2 million people a year; a perfectly clear method of administration,
such as I ordered, organized, and carried out to the best of my
administrative possibilities.
GEN. ALEXANDROV: You are giving needlessly detailed
explanations in reply to these questions, and under such conditions
the interrogation is being greatly prolonged. I consider it necessary
that you answer briefly. You are perfectly able to do this, for I am
putting the questions to you clearly.
SAUCKEL: I am trying to answer as briefly as possible. I regret
that a specialized field is always difficult to understand and calls for
explanations; I found it very difficult myself.
GEN. ALEXANDROV: Please answer: What part did the
Defendant Kaltenbrunner play in the execution of measures on the
allocation of labor? Did he participate in this or did he not?
SAUCKEL: I have already given you that answer.
GEN. ALEXANDROV: I did not understand you. Did he
participate or did he not?
THE PRESIDENT: I beg your pardon. He said that he only met
Kaltenbrunner on one occasion and that the task of the recruitment
of labor was not one for Police. That is what he said.
GEN. ALEXANDROV: It is not necessary to multiply the number
of meetings in order for Kaltenbrunner to have participated in the
execution of these measures. He did not have to meet Defendant
Sauckel frequently.
THE PRESIDENT: General Alexandrov, I do not want you to
argue with me. I have told you what his answer was. It seemed to be
an answer to your question.
GEN. ALEXANDROV: I am not arguing. I am merely explaining
the reason for this question.
[Turning to the defendant.] As far as the participation of
Defendant Rosenberg is concerned, I shall not ask you any
questions, as Defendant Rosenberg gave sufficiently clear answers
when questioned by my American colleague, Prosecutor Dodd. Now
tell me, what part did Defendant Frick play in the execution of these
measures?
 SAUCKEL: Defendant Frick, as Reich Minister of the Interior—I
do not know how long he remained in office—scarcely participated at
all. As far as I can remember I had discussions with his Reich
Ministry of the Interior concerning the most necessary laws to be
promulgated within Germany for German workers and the validity of
those laws. Apart from that, he had no further part in this task; his
work was quite different.
GEN. ALEXANDROV: We are discussing the question of foreign
manpower. It was not merely by accident that you mentioned, in a
letter to Lammers written after a meeting at Hitler’s headquarters on
the 4 January 1944, that the Ministry of the Interior was among the
government offices detailed to operate with you. That is why I ask
you, what part did Defendant Frick play in the execution of these
measures for the recruitment of labor? You yourself asked for the co-
operation of the Ministry of the Interior. Then how was this co-
operation to be expressed?
SAUCKEL: To my very great personal sorrow Frick was at that
time no longer Reich Minister of the Interior, but Himmler—if I
remember correctly.
GEN. ALEXANDROV: What co-operation did you expect from
the Ministry of the Interior?
SAUCKEL: It is, I believe only natural that in every form of
government the internal and the general administration should be
kept informed of events occurring and should participate as well, and
so important a sphere as the employment of human beings calls for
many ordinances. I could not possibly issue legal decrees, nor had I
authority to do so. I had to submit them to the Ministerial Council for
the Defense of the Reich. I could only issue technical directions, and
that is quite a different thing altogether.
GEN. ALEXANDROV: Were Defendant Funk, as Minister of
Economics, and Defendant Speer, as Minister for Armaments, the
principal intermediaries between the industrialists and yourself as
suppliers of manpower? Is that correct?
SAUCKEL: The end of your sentence contains a very erroneous
conclusion. They were not middlemen between myself and the
industries, but the industries were responsible to the Ministry for
Armaments. Of course there were personal instructions issued about
this in the course of years. I did not negotiate with the industries. The
industries asked for workers and they got them, as did the
agricultural industries.
GEN. ALEXANDROV: Please tell me, what part did the
Defendants Funk and Speer play in the execution of these
measures? I do not want any long drawn-out explanations. Answer
me briefly.
SAUCKEL: Those two ministers were heads of the various
business enterprises inside German economy which came within the
jurisdiction of their ministries. They received their workers, and that
was the end of my task.
GEN. ALEXANDROV: Did the Defendants Frank, Seyss-Inquart,
and Neurath participate in the execution of these measures for the
allocation of labor in such territories as were under their jurisdiction?
I mean the territories of Poland, Bohemia and Moravia, and Holland.
Is that correct?
SAUCKEL: These gentlemen, within the framework of their
duties inside their own territories, supported me in issuing decrees
and laws, and they themselves attached great importance to the
proper and humane drafting of these laws and decrees.
GEN. ALEXANDROV: What was the part played by Defendant
Fritzsche?
SAUCKEL: That I cannot tell you. I only met Dr. Fritzsche in
Germany on one occasion—and that a very brief one—in, I believe,
1945, the beginning of 1945. I never spoke to him at all about my
work, nor do I know whether he had anything to do with it. I can only
state that I made repeated applications to the Reich Ministry for
Propaganda to have my instructions and directives—as contained in
the document books submitted by my defense counsel—widely
circulated, particularly to the industries and other circles which
received these workers.
GEN. ALEXANDROV: But one defendant is left—Bormann—
and he is missing. What part did he play? He placed at your disposal
the entire Party machinery of the NSDAP, did he not?
 SAUCKEL: No, he did not. He placed the Gauleiter at my
disposal. The instructions which I issued to the Gauleiter and the
letters which I addressed to them—three of which are available here,
and there never were many more of them—were to the effect that I
was entitled to call on the Party for assistance in insuring the
welfare, feeding, and clothing of the workers, and to see that they
received everything that was humanly necessary and all we could
possibly supply in view of existing wartime conditions. That was the
role played by the Party, to the extent that it was asked to do so for
me. Thus it was a form of control for the benefit of the foreign and
German workers employed in Germany. Otherwise the Party had
nothing to do with it. Incidentally, I did not much like interference on
the part of outside offices.
GEN. ALEXANDROV: That is incorrect. I would remind you of
your program for the allocation of labor which was issued in 1942.
This is Document Number USSR-365 which states that the Gauleiter
are appointed as your plenipotentiaries where the question of
manpower is concerned, and that they will utilize this manpower.
SAUCKEL: Where does it say that? I could not appoint my
plenipotentiaries myself.
GEN. ALEXANDROV: You will be shown the document in one
moment. I do not quote the paragraph, I merely mention the
contents, the gist of the paragraph, where it states that the Gauleiter
will use the Party organizations in the districts subordinate to them. I
therefore assume that the Party machinery as a whole participated in
the execution of these measures.
SAUCKEL: It does not say so at all, Mr. Prosecutor.
GEN. ALEXANDROV: Have you found it: “The plenipotentiaries
... make use of their...”?
SAUCKEL: Yes, and I did this only for the purpose I have
described. Will you be good enough to read on?
GEN. ALEXANDROV: Read it yourself.
SAUCKEL: Thank you.
 “The leaders of the highest departments of the state and of
economy which are competent in their respective Gaue
shall advise and instruct the Gauleiter on all important
questions dealing with the allocation of labor.”
That means within the scope of their spheres of duty; and then
the latter are specified:
“The president of the Regional Labor Office”—that is not a
Party but a government department—“the Trustee for
Labor”—not a Party but a government department—“the
Regional Peasant Leader”—not a Party but a government
department—“the Gau Economic Adviser”—now, that is a
Party department...
THE PRESIDENT: Please observe the light, to be sure the
interpreters are getting it.
SAUCKEL: I apologize, Your Lordship.
“...the Gau representative of the Labor Front”—a
department of the Labor Front—“the Regional Leaders of
the Women’s League...”
GEN. ALEXANDROV: Everything is perfectly clear, you need
not enumerate. I should like to draw your attention to Subparagraph
VI. It clearly states that the Gauleiter, functioning as plenipotentiaries
for the allocation of labor, will, in their own Gaue, make use of the
Party organizations under them. Is it written there?
SAUCKEL: Yes.
GEN. ALEXANDROV: It next enumerates the methods by which
this task was executed, also through what institutions and what
authorities. I conclude from this subparagraph, which states that they
will utilize the Party institutions under their control, that the entire
organization of the NSDAP participated in the execution of these
measures, and I wish you to answer “yes” or “no.”
SAUCKEL: No.
GEN. ALEXANDROV: There is no more to say.
 SAUCKEL: No. May I supplement this reply of “no.” You, in your
first reply, told me that my description was not quite correct. My
description is absolutely correct, that the Party was employed to deal
with the welfare of German and foreign workers and to see to it that
they were properly cared for and supplied. The Party organizations
here mentioned were only entrusted with this kind of task, and could
have had no other; and I, a former workman myself, was eager that
these workers, both German and foreign, should be cared for as well
as wartime conditions allowed. Hence this employment of Party
organizations and no others. Therefore, my reply was absolutely
correct.
GEN. ALEXANDROV: Did the district leaders of the Hitler Youth
also participate in the execution of these measures?
SAUCKEL: The district leaders of the Hitler Youth participated in
order to protect and care for the young people as expressly required
by Reichsleiter Schirach and later by Reich Youth Leader Axmann.
Protection had to be provided for the young people against any
danger. The Hitler Youth did this, including young people employed
from foreign countries. I must expressly emphasize this.
GEN. ALEXANDROV: Did you personally approve of the policy
of the Hitlerite Government with regard to the deportation into
slavery of the population of the occupied territories in order to insure
the waging of a war of aggression? Did you approve of that policy?
SAUCKEL: I am forced to consider your question in the light of
an accusation.
I personally have said over and over again that I had nothing to
do with either foreign or domestic politics; nor was I a soldier, I
meant to say. I received a task and I received orders. As a German, I
tried to carry out that task correctly for the sake of my people and its
government and to carry it out to the best of my ability, for it was
made perfectly clear to me that the fate of my people depended on
the accomplishment of this task. I worked with this in mind, and I
admit that I did my utmost to accomplish that task in the manner
which I have pointed out here. I conceived this to be my duty and
must acknowledge this fact here.
 GEN. ALEXANDROV: In order to define your personal attitude
to these crimes, I would like to remind you of a few of your own
statements. These are taken from Document Number USSR-365.
This document is a program for the utilization of labor in 1942, Page
9. You will now be shown the passage which I am about to quote: “I
beg you to believe me, as an old and fanatical National Socialist
Gauleiter...” Is it written there?
SAUCKEL: That is written there.
GEN. ALEXANDROV: Now we will go on to Document Number
566-PS. It is your telegram to Hitler dated 20 April 1943 which you
sent during your flight to Riga. This telegram will now be handed to
you and you will be shown the excerpt which I am about to read:
“I shall devote my entire strength with fanatical
determination to the accomplishment of my task, and to
justify your confidence.”
Is that correct?
SAUCKEL: It is correct. I saw in Hitler, whom at that time I
revered, a man who was the leader of the German people, who had
been chosen by the German people; and I, as a German citizen and
a member of a German government department, considered it my
duty to justify by my work in my own sphere the confidence placed in
me by the head of the State. I might say regarding this telegram...
GEN. ALEXANDROV: No explanations are needed about this
telegram. I am not interested in your attitude towards Hitler. I am only
interested in your personal attitude to those measures for
compulsory labor which were carried out by you. It is essential to
keep all questions within these limits. Now follows Document
Number 1292-PS. This is a record of the meeting at Hitler’s
headquarters on 4 January 1944...
SAUCKEL: I request the permission of the Tribunal to add a few
words to your last statement, Mr. Prosecutor. I was unable to see a
criminal in Hitler at that time, and I never felt he was one; but I did
feel obliged to do my duty, nothing else. As a human being and as
the result of my upbringing I would never have supported crime.
 THE PRESIDENT: What was your question, General? Simply
whether this was a telegram sent to Hitler?
GEN. ALEXANDROV: I asked about the telegram, from which I
have read one sentence into the record, in order to obtain a
confirmation from the Defendant Sauckel that this telegram had been
sent. I was not interested in anything else.
[Turning to the defendant.] The next document is 1292-PS.
Have you got this document?
SAUCKEL: No.
GEN. ALEXANDROV: You have already been shown the
passage I am about to read. Your statement reads as follows: “GBA
Sauckel declared that with fanatical determination he would attempt
to secure this manpower.”
You were, at that time, speaking of the mobilization of 4 million
workers. It says further: “He would do everything in his power to
obtain the manpower desired for 1944.”
Did you say that? Is the statement correctly rendered in the
minutes of the report?
SAUCKEL: I did say that, and I ask to be allowed to add the
following to my affirmative reply. I knew that the German people, and
they were my people, were in dire—may I add an explanation to my
clear reply, stating why I answered as I did? I am entitled to do so.
GEN. ALEXANDROV: Defendant Sauckel, you accompany
every answer you give with lengthy supplementary explanations. You
are merely delaying the interrogation. I am quite satisfied with your
reply; what you have told me is perfectly sufficient.
THE PRESIDENT: General, he has given a perfectly clear
answer that he did say it, and I think he is entitled to give some word
of explanation. It is perfectly true that his explanations are intolerably
long, but he is entitled to give some explanation.
GEN. ALEXANDROV: Mr. President, if every answer is to be
accompanied by such extensive explanations...
THE PRESIDENT: General Alexandrov, I have said that he is
entitled to give some explanation.
[Turning to the defendant.] Now then; please make it short.
 SAUCKEL: I knew that the German people were engaged in
their most bitter struggle. It was my duty to carry on with my task with
all my strength—that is what I meant by “fanatical.” I further
explained, in another sentence, that I could not accomplish my task
that year. As far as I was able to accomplish it in 1944 two-thirds
were German workers, not mainly aliens but more than two-thirds
Germans; and I was trying my utmost to put all German women to
work, as far as they were capable of working, and in 1944 there were
over 2 million of them.
GEN. ALEXANDROV: In April 1943 in order to accelerate the
deportation of manpower to Germany from the occupied territories
you visited Rovno, Kiev, Dniepropetrovsk, Zaporozhe, Simferopol,
Minsk, and Riga. In June of the same year you visited Prague, Kiev,
Kraków, Zaporozhe, and Melitopol. Is that correct?
SAUCKEL: That is true, and during those journeys I personally
satisfied myself that my departments were working properly. That
was the object of my journey.
GEN. ALEXANDROV: Thus you personally organized the
deportation into slavery of the peaceful population of the occupied
territories. Is that correct too?
SAUCKEL: I must protest against that statement in the most
vehement and passionate way. I did not do that.
GEN. ALEXANDROV: Then why did you go to all these towns
and inhabited places? Did you not do so in order to enforce the
deportation of the people in the occupied territories?
SAUCKEL: I visited these areas to satisfy myself personally as
to how my offices in these cities—I should not say “my,” but the labor
offices of the local administrations—were working; whether they
were conscientiously carrying out their obligations towards the
workers; whether they were attending to medical examinations, card
indexing, et cetera, according to my instructions. That is why I went
to those towns. I negotiated with the chiefs in the matter of quotas,
that is quite true, since it was my task to recruit workers and to check
the quotas, but during my visits to these cities I inspected the offices
personally to satisfy myself that they were functioning properly.
 GEN. ALEXANDROV: And also to insure the speedy deportation
of compulsory labor to Germany? Is that correct?
SAUCKEL: To employ the best possible methods for the
purpose in view. That is indisputably stated in my orders, and the
manifesto which has been submitted to the Tribunal was written on
this very journey which you have just mentioned.
GEN. ALEXANDROV: You specially visited these cities in order
to improve the methods of compulsory recruitment? Have I
understood you correctly?
SAUCKEL: I went to these towns to see for myself whether the
methods were correct or not, and to discuss them with the
departments. That is true, for it was not necessary for me to visit
Kharkov, Kiev, or any other town to discuss my task in terms of
figures. For that I would only have to talk to the reporter for the East,
whose office was in Berlin, or with the Reich Commissioner—whom I
did not contact as he was sometimes in Rovno.
GEN. ALEXANDROV: In your statements to your defense
counsel you declared that no cases of criminal or illegal methods of
compulsory recruitment had ever come to your knowledge. Then
what was the reason for such extensive trips to the occupied
territories? Does it mean that some indication had already reached
you that large-scale, illegal practices were taking place in the
process of labor recruitment? Was that the reason for your journeys?
You visited over 10 cities.
SAUCKEL: May I inform you, Mr. Prosecutor, while we are on
this subject, that my defense counsel has already asked me that
question and that I answered it with “yes,” and that, generally
speaking, whenever complaints reached me I discussed them with
Rosenberg, and that wherever a wrong could be righted it was
righted. Please hear my defense counsel and my witnesses in this
connection...
GEN. ALEXANDROV: The witnesses will be called on the
decision of the Tribunal. I should now like to ascertain that you took
those trips in order to improve methods of recruitment. I have come
to the logical conclusion that in all these towns, prior to your arrival, a
certain lawlessness had prevailed and crimes had been committed
during the recruiting of manpower. That is what I am speaking about.
And now will you give me a definite answer as to why you visited
these places?
SAUCKEL: I have already answered that question in every
respect. However, I would add that I assume that you, Mr.
Prosecutor, have yourself had sufficient administrative experience to
realize that in every department, anywhere in every country of the
world, it is a matter of course that administrative orders should be
checked. One does not need to know that mistakes are made in
human life and in every human organization; a control must be
exercised all the same.
GEN. ALEXANDROV: If you deny that you went there in order to
improve conditions and to suppress the crimes perpetrated in the
course of labor recruitment, then you must have gone there to
accelerate the deportation of manpower into Germany. It is one thing
or the other. Choose for yourself.
SAUCKEL: No, I must emphatically deny that. I undertook these
journeys in order to satisfy myself, within the scope of my duties,
how this task was being carried out, and to stop defects which were
reported to me, as for instance—as I once told my defense counsel
during my interrogation—I had also been asked to do so by Field
Marshal Kluge. But I also wanted to look into matters carefully and
myself give appropriate admonitions and instructions to the
departments. My best evidence of this is the manifesto produced
during this journey.
THE PRESIDENT: General Alexandrov, can you tell the Tribunal
how much longer you will be?
GEN. ALEXANDROV: I am afraid to make an exact statement,
but I should imagine about 2 more hours.
THE PRESIDENT: You are not losing sight of the fact, are you,
that we have already had a thorough cross-examination by the
French Prosecutor?
GEN. ALEXANDROV: Mr. President...
THE PRESIDENT: The Tribunal hopes that you will try to make
your cross-examination as short as possible, and the Tribunal will
adjourn now.
 [A recess was taken.]

GEN. ALEXANDROV: Defendant Sauckel, tell us what attitude

you, as Plenipotentiary General, adopted toward the employment of
Soviet prisoners of war in the German industries?
SAUCKEL: I must reply to your question by saying that I had no
collaborators in the employment of prisoners of war, for I did not
employ prisoners of war.
GEN. ALEXANDROV: And you never saw to their mobilization;
you never registered them?
SAUCKEL: As the authorized mediating agency I had to have
the administrative measures carried out through the labor offices, or
the Gau labor offices, which served as intermediaries between the
factories and the Stalags or the generals in charge of prisoner-of-war
affairs, who in their turn supplied prisoners of war for the industries.
GEN. ALEXANDROV: And what were these organizations?
What kind of organizations were they?
SAUCKEL: They were either the generals in charge of prisoner-
of-war establishments in the military administrative districts, or the
organizations of the industries, or the factories themselves. These
worked through the respective ministries, such as the Reich Ministry
of Food and Agriculture, in which case the majority of the prisoners
were billeted with farmers for work on the land or in war industries.
GEN. ALEXANDROV: In other words, you had nothing to do
with it? I would remind you...
SAUCKEL: I had to include the labor offices and the Gau labor
offices to the extent that they had undertaken to act officially as
intermediaries, but only if they did not act directly between the
factories and the Stalags.
GEN. ALEXANDROV: I shall now quote an excerpt from your
report to Hitler on 27 July 1942. It is Document Number 1296-PS. In
this report, Part III, there is a particular section. It is entitled...
SAUCKEL: II or III, please?
GEN. ALEX ANDROV: III. It is entitled: “Employment of Soviet
Russian Prisoners of War.” You write there:
 “In addition to the employment of civilian manpower, I have
increased the employment of Soviet prisoners of war,
according to plan, in co-operation with the Prisoners of War
Organization of the OKW.”
And further on.
“I particularly stress the importance of a further increased
and expedited deportation of the maximum number of
prisoners of war possible from the front to work within the
Reich.”
Is this correct?
SAUCKEL: That is correct, and it corresponds exactly to what I
have stated before.
GEN. ALEXANDROV: It does not altogether correspond.
SAUCKEL: But it does.
GEN. ALEXANDROV: You mentioned that you did not have
anything to do with the employment of prisoners of war in the
German industries and now, in your report, you give perfectly
different data. So I am asking you, in connection with what I have
read into the record: Did you not plan in advance the employment of
Soviet prisoners of war as workers in the industries? That was
provided for in your plans and your report covers that. Was that so,
or was it not?
SAUCKEL: I must point out one fundamental error on your part.
Labor procurement, the whole world over, whether operated by the
state or by private individuals, is not an organization or institution
which exploits workers, but rather which procures workers. I must
establish this fundamental error. It was my duty to provide the
necessary connection, so that prisoners of war in Stalags in the
occupied territories—let us say in the Government General—could
be registered by local generals in charge of prisoner-of-war
establishments, for work contemplated in Germany in certain
agricultural or other sectors, and then allotted accordingly.
Employment of labor in factories was not under my supervision and
had nothing to do with me.
 GEN. ALEXANDROV: In other words, you participated in
supplying Soviet prisoners of war for utilization in German industry.
Is that correct?
SAUCKEL: That is not correct, according to my use of the
German language, as I understand you. Rather, to act as agent is
quite a different thing from utilization; concerning this, other
gentlemen would have to comment. I can only speak as far as
agency is concerned. In Germany this was managed by the State. In
other countries it is managed privately. That is the difference, but I
have never exploited anybody. As Plenipotentiary General for the
Allocation of Labor I did not employ a single worker.
GEN. ALEXANDROV: Did you know that the Soviet prisoners of
war were being employed in the armament industries in Germany?
SAUCKEL: It was known to me that Soviet prisoners of war
were being employed in the German war industry for this industry
was vast and widespread, and covered the most varied branches.
GEN. ALEXANDROV: Were you acquainted, in particular, with
the directive of Defendant Keitel regarding the employment of Soviet
prisoners of war in the mining industry? This directive is dated 8
January 1943. Do you know anything at all about this directive?
SAUCKEL: I cannot recollect it in detail. I have not got it. Will
you be good enough to put it before me?
[The document was handed to the defendant.]
GEN. ALEXANDROV: Have you read it?
SAUCKEL: I have read it.
GEN. ALEXANDROV: It clearly mentions the employment of
Soviet prisoners of war in the mining industry for military purposes. Is
that correct?
SAUCKEL: It refers to the employment of prisoners of war in the
mining industry in Germany.
GEN. ALEXANDROV: For what purpose? It is clearly stated in
this document.
SAUCKEL: For employment in the mining industry.
GEN. ALEXANDROV: But for what purpose? What purpose was
it to serve? It is clearly stated here.
 SAUCKEL: For work, I presume.
GEN. ALEXANDROV: In the interest of the war?
SAUCKEL: Well, as a matter of fact, the German mining
industry did not only work in the interest of the war; Germany also
supplied quite a lot of coal to neutral countries. It varied according to
circumstances.
GEN. ALEXANDROV: Follow this document; read it with me:
“For the execution of the expanded iron and steel program
the Führer ordered on 7 July the absolute guarantee...”
SAUCKEL: I have not been given the part you are reading.
GEN. ALEXANDROV: “For the execution of the expanded
iron and steel program the Führer ordered on 7 July the
absolute guarantee of the coal and means of production
needed. For this purpose he has also ordered that the
necessary manpower be supplied by prisoners of war.”
Now, have you found the place?
SAUCKEL: Yes, I have read it.
GEN. ALEXANDROV: Thus the Soviet prisoners of war were to
be employed in the mining industry for the purposes of the war. Is
that right? The fact is definitely established by this document.
SAUCKEL: Yes; it says so—I might remark that this document is
not addressed to me.
GEN. ALEXANDROV: I asked you whether you knew of this
document. You said “yes,” did you not?
SAUCKEL: I am not acquainted with it—no; I do not know it
now. I did not know it previously as it was not addressed to me.
GEN. ALEXANDROV: You said that, broadly speaking, you did
know about this directive and you asked me to allow you to acquaint
yourself with it in detail. This is how it was translated to me.
SAUCKEL: No; I told you—and I should like to emphasize this—
that I did not remember; I only asked that this document might
perhaps be placed before me. The document is not addressed to
me. The office to which it is addressed is clearly indicated and
according to that it never came into my hands nor reached my office.
 GEN. ALEXANDROV: In order that you may fully understand
this question, I shall give you Exhibit USA-206. That is your directive
of the 22 August 1942 with regard to supplying manpower by means
of importation from the occupied territories. Do you know about this
directive?
THE PRESIDENT: What is the PS number?
GEN. ALEXANDROV: One minute, please. Unfortunately I have
no information about the PS number. All I have is the USA Exhibit
Number, which is 206. Defendant Sauckel...
THE PRESIDENT: Have the United States prosecutors got the
corresponding number to USA-206?
MR. DODD: I could have it in a few minutes, Mr. President. I do
not have it right at my fingertips, but I will obtain it.
THE PRESIDENT: Right; thank you.
GEN. ALEXANDROV: Defendant Sauckel, Subparagraph. 8 of
this order states: “This order applies also to prisoners of war.” Does it
contain a reference of this description?
SAUCKEL: Yes.
GEN. ALEXANDROV: Therefore, you yourself did not
differentiate between prisoners of war and the civilian population as
far as their utilization in the German war industries was concerned.
Do you admit that?
SAUCKEL: Yes, and I have already replied to my defense
counsel, I think it was yesterday, that a catalog was given to me and
the Ministry of Labor in general showing how prisoners of war might
be employed. But this Paragraph 8 has nothing to do with this
document, for that was an agreement or an order which did not
come to me and was also not addressed to me.
GEN. ALEXANDROV: Mr. President, Exhibit USA-206 bears the
following number: 3044-PS.
[Turning to the defendant.] In addition to those statements to
your defense counsel which you have just mentioned, you also
declared that, although employing prisoners of war in the German
war industries, the requirements of the Geneva and Hague