Medicinal Plants Used for the Treatment and Management of Bilharziasis and Other Parasitic Infections Affecting Humans in Zimbabwe: A Systematic Review

*Elliot Nyagumbo,Trust Nyirenda, Cephas Mawere, Ian Mutasa, Emmanuel Kademeteme, Alfred M. Mutaramutswa, Donald Kapanga, Godwins Ngorima, Leroy Nhari, Fabian Maunganidze, Michael Bhebhe, William Pote and Lucy Mabaya*

## **Abstract**

The World Health Organization (WHO) estimated that at least 251.4 million people from 78 countries were in need of preventative care for bilharziasis in 2021. Globally, soil-transmitted helminth infections are present in at least 24% of the world's population. Tropical and subtropical areas have a wide distribution of infections with a high prevalence in the sub-Saharan Africa. The aim of this study was to document plants that have been traditionally used in Zimbabwe to manage bilharziasis and other parasitic infections. The literature review was based on published papers and abstracts retrieved from the online databases. Books, book chapters, scientific reports and theses from universities in Zimbabwe that were available online were also used in this review. Plants with the reported traditional usage against bilharziasis and other parasitic infections were recorded from the data retrieved. In total, 68 species were used to treat and manage bilharzia and other parasitic infections. Most of these medicinal plants were used to treat and manage schistosomes (fluke or worm). A total of 76.5% of the medicinal plants reported have been scientifically validated and documented to exhibit anthelmintic activity. In conclusion, Zimbabwe has a plethora of medicinal plants that can be used to manage bilharziasis and other parasitic infections.

**Keywords:** ethnobotanical, bilharzia, schistosomiasis, worms, pharmacological, toxicology, traditional plants, anthelmintic, Zimbabwe

## **1. Introduction**

Schistosomiasis is a neglected parasitic tropical disease caused by blood flukes (trematode worms) of the genus Schistosoma. According to WHO [1] estimates, at least 251.4 million people reported from 78 countries were in need of preventative care for bilharziasis in 2021. Schistosomiasis, a disease caused by *Schistosoma mansoni* (intestinal) and *S. haematobium* (urogenital) species, is mainly concentrated in sub-Saharan Africa, where about 90% of the disease burden exists. The transmission of these species occurs through feces and urine, respectively [2]. Endemic areas where the infection is prevalent are inhabited by over 700 million people, particularly in tropical and subtropical regions. Schistosomiasis is more prevalent in impoverished rural communities, particularly in regions where fishing and agricultural activities are prevalent. These areas are often characterized by poor communities lacking access to potable water and adequate sanitation [3]. Morbidity reduction can therefore be accomplished with the use of preventative therapy, which should be repeated over a number of years in endemic areas with moderate to high transmission [4]. According to WHO [5] the most frequent illnesses worldwide are soil-transmitted helminth (STH) infections, which mostly afflict the poorest and most destitute populations. Where sanitation is inadequate, the soil is polluted with egg-infected human feces and fecal waste [5]. The primary causative species that infect humans are whipworms (*Trichuris trichiura*), hookworms (*Ancylostoma duodenale, Necator americanus* and *Ancylostoma duodenale*) and roundworms (*Ascaris lumbricoides*) [6]. STH infections afflict at least 24% of the world's population, which exceeds 1.5 billion individuals. Infections are widely distributed in tropical and subtropical locations, with the Americas, China, East Asia and sub-Saharan Africa having the highest frequency [5].

Pharmacotherapy is the most effective approach for decreasing the incidence of schistosomiasis infections. The WHO recommends preventive chemotherapy using praziquantel as the strategy for managing schistosomiasis. School-age children (5 to 15 years old) are the target population for this therapy due to their high infection burden and ability to be effectively targeted through schools [7]. Zimbabwe aims to eradicate bilharzia and intestinal worms, by 2030. During a mass treatment campaign carried out from April 3–9, 2022, over 1.8 million children received free oral treatment for schistosomiasis (bilharzia) and soil-transmitted helminthiases (intestinal worms) [8].

Despite not achieving complete elimination of bilharzia, Zimbabwe has significantly reduced the burden of the disease through the annual national treatment campaigns. In 2014 a study revealed that the district of Chiredzi in Masvingo province had the highest prevalence of *S. mansoni* at 43.7%, followed by the Hwedza district in Mashonaland East and Nyanga in Manicaland province, with prevalence rates of 32.3 and 31.5%, respectively [9]. Despite the great prevalence of parasitic diseases worldwide and the substantial amount of suffering caused by these parasites, the majority are considered neglected diseases. Only malaria treatment and prevention receive significant financing, but there is an urgent need for more action to be done to alleviate the suffering of the large populations of people who are infected with other parasitic diseases [10]. Similarly, despite those parasitic infections accounting for more than 10% of the world's disease burden, drug discovery efforts for parasitic diseases are limited, with only 1% of new medications addressing parasitic diseases in the last 40 years [6].

The purpose of the study is to find medicinal plant species that are used as an effective treatment against schistosomiasis in Zimbabwe. The study involved the compilation of a list of medicinal plants used in Zimbabwe to treat parasitic infections

in humans. Bilharzia, gastrointestinal worms and helminths, ectoparasites, trichomoniasis, leishmaniasis and trypanosomiasis are among the diseases covered. Due to the broad scope of these topics, veterinary usage and malaria were excluded. This systematic review will create a comprehensive digital database of medicinal plants used in traditional practice which holds the potential to expand treatment options, improve access to healthcare, preserve traditional knowledge and promote sustainable practices in disease management. Moreover, the potential development of drug resistance has sparked an ongoing debate about the future efficacy of praziquantel. The emergence of drug-resistant strains of schistosomes will pose a significant challenge in controlling the disease. Thus, exploring medicinal plants may help to identify novel compounds that can overcome drug resistance and provide alternative treatment options.

## **2. Objectives**

This systematic review was therefore undertaken to:

### **2.1 Inclusion criteria**

Plants used to treat the following parasitic infectious diseases were included in this study

## **2.2 Exclusion criteria**

Plants used to treat the following parasitic infectious diseases were excluded from this study

1.Malaria

2.Veterinary parasites

## **3. Materials and methods**

## **3.1 Research protocol and reporting**

The Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in the reporting of this study (**Figure 1**). The protocol used in this systematic review was as previously reported [14].

## **3.2 Literature search**

Electronic data on the ethnobotany of medicinal plants used in Zimbabwe were retrieved from electronic databases such as Google, Google Scholar, Springer Link, Researchgate, PubMed, Science Direct and JSTOR. The keywords set "medicinal plants AND (antiparasitic OR antihelmintic) AND Zimbabwe" were used. The retrieved articles were downloaded and stored in EndNote X9 (Thomson Reuters, San Francisco, CA and USA). Duplicate articles were then removed from the file. Further, a manual search from the reference lists of screened eligible articles and deposited electronic copies of dissertations and theses in online Universities' repositories and National Herbarium and Botanic Gardens (SRGH) libraries up to 31 December 2020 were done. Other sources utilized in this study included books [15–18], book chapters, scientific reports and theses available at universities [19, 20] and National Herbarium and Botanic Gardens (SRGH) libraries. The authors continuously received notifications of any new "similar reports" meeting the search criteria from Science Direct, Scopus and Google Scholar.

The plant names were verified with http://www.theplantlist.org and https://www. zimbabweflora.co.zw. Plants with the reported traditional usage against bilharziasis and other parasitic infections were identified and compiled from the information collected and gathered. A master list was prepared including all the medicinal plants used in Zimbabwe for the treatment and management of bilharziasis and other parasitic infections (**Table 1**). The above-mentioned databases were also searched for pharmacological and toxicological properties providing scientific evidence of medicinal usage comparable to their ethnomedicinal usage. All the information was summarized in three tables (**Tables 1**–**3**) and five figures (**Figures 2**–**6**). The review excluded medicinal plants for veterinary use and those against malaria to limit the plants to those used in the treatment and management of bilharziasis and other parasitic infections in humans.

*Medicinal Plants Used for the Treatment and Management of Bilharziasis and Other… DOI: http://dx.doi.org/10.5772/intechopen.113291*

**Figure 1.**

*PRISMA flow diagram showing the search and retrieval steps of the study (adopted from Moher et al. [14]).*

#### **Table 1.**

*Medicinal plants used to treat and manage bilharziasis and other parasitic infections in Zimbabwe: Family and botanical name, local name, part used, mode of preparation, growth form, distribution and ethnomedicinal uses.*

In vitro *experiments were carried-out and reported by Mølgaard et al. [23] demonstrating dose-dependent anthelmintic activity. Anthelmintic activities reported were conducted on a number of biological targets (Figure 6): Cestodes; Earthworms:* Pheretima posthuma, Edrilus euginiae, Eisinia fetida*; Leishmania:* Leishmania donovani*; Nematode:* Ascaris suum, Ascaridia galli, Caenorhabditis elegans, Chabertia ovina, Cooperia spp., Haemonchus contortus, Trichostrongylus spp., Trichostrongylus colubriformis, Teladorsagia circumcincta, Teladorsagia spp; *Protozoa:* Ichthyophthirius multifiliis, Trichomonas vaginalis, T. b. rhodesiense*; Schistosomes:* Schistosoma haematobium*; Trypanosome:* Trypanosoma brucei brucei, Trypanosoma brucei rhodesiense, Trypanosoma cruzi. *More studies should be carried out on more prevalent biological targets such as Schistosomes:* Schistosoma haematobium*. \* signifies the major pharmacological activity attributed by the different plant species of plants which is the anthelmintic activity.*

#### **Table 2.**

*Pharmacological and toxicological evaluation of medicinal plants used to treat and manage bilharziasis and other parasitic infections in Zimbabwe.*

*c No cestodes: schistosomules died.*

*Schistosomules of* Schistosoma mansoni*, Cestodes of* Hymenolepis dimin.

#### **Table 3.**

*Anthelmintic screening of Zimbabwean plants traditionally used against schistosomiasis [23].*

#### **3.3 Screening**

Retrieved articles were first screened based on the titles and abstracts for relevance to the study excluding articles that reported on malaria and on veterinary use of medicinal plants. For example, we excluded articles on bovine mastitis and Oriental medicines, although they appeared in the search results. However, articles that

#### **Figure 2.**

*Growth habit of medicinal plant species used to treat and manage bilharziasis and other parasitic infections in Zimbabwe.*

#### **Figure 3.**

*Parasites managed or treated using medicinal plants in Zimbabwe.*

included both malaria and schistosomiasis were considered. The eligible full articles were then assessed further for inclusion in the study using the inclusion/exclusion criteria.

#### **Figure 4.**

*Mode of preparation of medicinal plant species used to treat and manage bilharziasis and other parasitic infections in Zimbabwe.*

**Figure 5.**

*Plant parts used for medicinal preparations used for the management of bilharziasis and other parasitic infections in Zimbabwe.*

#### **3.4 Inclusion and exclusion criteria**

Full-text articles that at least reported on ethnobotany of Zimbabwean medicinal plants written in English and published in peer-reviewed journals, reports, books,

**Figure 6.**

*Biological targets of tested parasites of medicinal plants reported.*

theses and dissertations dated 31 December 2020 were considered. All publishing years were included without any geographical restrictions. Articles that reported data not relevant to the study or reviews or those not written in English were excluded from the study.

### **3.5 Data extraction**

A data collection tool was designed in Microsoft Excel (Microsoft Corporation, USA) to capture data on different aspects of Zimbabwean medicinal plants. Three reviewers independently extracted relevant data from the included articles regarding the ethnobotany of Zimbabwean medicinal plants. For ethnobotanical data, the diseases or ailments managed, parts used and mode of preparation and administration were captured. The collected data were checked for completeness and processed independently by two other reviewers.

## **4. Results and discussion**

From the several scientific papers reviewed based on ethnobotanical surveys of different areas of Zimbabwe, the results are presented in the following sections.

### **4.1 Literature search and publications**

A total of 750 reports were retrieved out of which 138 met the inclusion criteria and were reviewed. Most of the articles were published in the 2010–2019 decade, indicating a lot of research is being done as compared to the preceding decades. This could be due to: (1) the growing need for more effective and less toxic medicinal products of plant origin, (2) emerging antimicrobial resistance that has rendered most

chemotherapeutic agents less effective, (3) new disease outbreaks like COVID-19 and (4) increase in noncommunicable diseases such as cancers, hypertension, diabetes mellitus and sexual dysfunction that require readily available, affordable, effective and safe therapies.

## **4.2 Ethnobotanical surveys and distribution of medicinal plants traditionally used to treat and manage bilharziasis and other parasitic infections in Zimbabwe**

Based on soil, rainfall regime and several other factors, Zimbabwe is divided into 5 agro-ecological regions. A total of 43 of the medicinal plants reported in this review are widely distributed throughout the Northern (N), Eastern (E), Central (C), Western (W) and Southern (S) regions of Zimbabwe as represented in **Figure 7**. The remaining plant species were distributed in several regions across the country with n = 9 plant species distributed in 4 regions, n = 8 in 3 regions, n = 2 in 2 regions and n = 1 in 1 region. A total of n = 3 plant species are being cultivated [*Celtis africana, Musa sp., Phaseolus vulgaris*] and n = 1 has been recently introduced *Ricinus communis*. *Warburgia sulcata* had no information on distribution in Zimbabwe (**Table 1**).

The current review indicates that there are at least 68 species of plants belonging to 63 genera in 33 families used to treat and manage bilharziasis and other parasitic infections in Zimbabwe (**Table 1**).

Generally, the family with the highest number of medicinal plants in Zimbabwe was the *Fabaceae* family represented with a total of 17 plants followed by *Combretaceae* (n = 5), *Apocynaceae* (n = 5), *Anacardiaceae* (n = 4), *Rubiaceae* (n = 3), *Euphorbiaceae* (n = 3) *Asteraceae* (n = 3), *Rutaceae* (n = 2) and *Meliaceae* (n = 2). A further 24 more plant families which only had one plant represented were also

**Figure 7.** *General distribution of medicinal plants in different floristic regions of Zimbabwe.*

recorded, giving a total of 33 families. These included *Apiaceae, Asparagaceae, Bignoniaceae, Boraginanceae, Canellaceae, Celastraceae, Dracaenaceae, Ebenaceae, Hydroraceae, Loganiaceae, Lorantaceae, Menispermaceae, Musaceae, Olacaceae, Poaceae, Polygalaceae, Proteaceae, Rhamnaceae, Salicaceae, Sapindaceae, Solanaceae, Ulmaceae, Verbenaceae* and *Vitaceae*.

Hutchings et al. [17] reported similar use of some medicinal plants reported in this study to treat and manage bilharziasis: *Abrus precatorius, Cassia abbreviata, Cissampelos mucronata, Euclea divorum, Faurea saligna, Gymnosporia senegalensis (Maytenus senegalensis), Mondia whitei, Pterocarpus angolensis, Sclerocarya birrea and Ximenia caffra*. Other studies reported similar anthelmintic medicinal plants; *Dicoma anomala* - Intestinal worms [15]; *Pterocarpus angolensis -* General use against intestinal worms, *Sclerocarya birrea* - Intestinal worms [18]; *Securidaca longipedunculata* – Tapeworm, *Vangueria infausta* - Roundworm [238]; *Ximenia caffra* - Intestinal worms [226]. These medicinal plants have been compiled by Cock et al. [10] review of Southern Africa.

## **4.3 Growth habit, parts used and mode of preparation of medicinal plants used to treat and manage bilharziasis and other parasitic infections in Zimbabwe**

According to **Figure 2**, the frequency and type of plants used to treat and manage bilharziasis and other parasitic infections is as follows; tree (n = 23), tree, tree or shrub (n = 18), herb (n = 9), shrub (n = 5), climber, liane (n = 3), herb or shrub (n = 3), climber (n = 3), grass (n = 1), liane (n = 1), root parasite (n = 1) and shrub or climber (n = 1).

According to **Figure 3**, the parasites managed or treated are schistosomes (fluke or worm) 79%, unspecified parasitic worms 11%, hookworm 5%, tapeworm 4% and roundworm 1%. Midzi et al. [9] carried out a nationwide survey in Zimbabwe in 2010 and 2011 to map schistosomiasis and STH. The survey was conducted among primary school children. The study reported a high national prevalence of schistosomiasis (22.7%) and STH (5.5%). The common schistosome was *Schistosoma haematobium* with a prevalence of 18.0% while that of *Schistosoma mansoni* was 7.2%. The most common STH were hookworms (*Ascaris lumbricoides* and *Trichuris trichiura*) with a prevalence of 3.2% followed by *A. lumbricoides* and *T. trichiura* with prevalence of 2.5 and 0.1%, respectively [9]. Mutsaka-Makuvaza et al. [239] recorded a 13.3% prevalence in Madziwa, Shamva District among preschool-aged children. Therefore, there has been high use of medicinal plants to treat schistosomiasis due to its high prevalence in Zimbabwe.

The most frequently used mode of preparation was infusion 46% followed by decoction 22%, soup 19% and powder 13% (**Figure 4**). Methods of preparation of plant medicines seem to vary according to the area and subculture of the people in that region. Plant materials may be used as fresh or dry. However, the review observed a high usage of fresh material. Preparation of decoctions is carried out by boiling the plant material in water to such an extent that the volume of water is reduced to half. An infusion is a less concentrated version of a decoction and usually prepared by adding the plant material to water. There is a predominant use of decoctions and infusions which when both combined contribute to 68% of the gross mode of preparation. This may be attributed to the quick, low cost and easy to administer properties of these methods. Unfortunately, some of the ethomedicinal papers did not highlight the mode of preparation of the medicinal plants used [21, 22, 25, 26, 28].

The plant parts that are frequently used to treat and manage bilharziasis and other parasitic infections are shown in **Figure 5**. It appears the roots (46%) are the main target plant parts used. The use of the roots, bark and / or stem are the least environmentally sustainable part of the plant as its collection may lead to death of the plant however, they are the most preferred source of medicine. A number of papers did not highlight the plant parts used: [21, 22, 25, 26, 28].

## **4.4 Pharmacological properties of medicinal plants traditionally used to treat and manage bilharziasis and other parasitic infections in Zimbabwe**

Some of the plant species have demonstrated a wide range of medicinal uses across different clinical conditions and therefore utilizing scientific methods to fully understand their pharmacological consequences could be vital. We have summarized the results of the pharmacological properties of 61 (89.7%) of the plant species (**Table 2**). The activities that were reported to be key in the treatment of bilharzia and parasitic infections were mainly dominated by the anthelmintic/antiparasitic properties. A medicinal plant with anthelmintic activity is responsible for treating and managing infections caused by a broad range of parasites (trematodes, worms, cestodes and nematodes) [240] (**Table 3**). Other complementary pharmacological properties include antioxidant, antibacterial and antifungal activities responsible for managing and treating parasitic infections (**Table 2**).

## **4.5 Toxicological evaluation of medicinal plants used to treat and manage bilharziasis and other parasitic infections in Zimbabwe**

Out of the medicinal plants listed in **Table 1**, a total of 47 species (69.1%) have been subjected to toxicological evaluation studies, while the remaining 21 species (30.9%) lacked documented studies in this regard (**Table 2**). According to Kumari and Kotecha [241] ensuring the safety of herbal medicines is crucial in herbal research due to the potential for adverse effects and interactions. Of the 47 plants with toxicological profiles, the toxicological activities of the extracts were evaluated in several ways, including their effects on liver chang cells, cytotoxic activities on human monocyte cells, genotoxicity and anticancer properties among others. According to Kumari and Kotecha [241] toxicity assessment of herbal medicines involves various techniques, including *in vivo, in vitro* and cell line studies, as well as modern methods like microarray analysis. The BSLT and rodent acute toxicity experiments were the most common methods used to assess the toxicity of the 47 plants with available toxicological profiles (**Table 2**). Munodawafa et al. [100] reported that the BSLT and rodent acute toxicity tests were the most common methods used to assess the toxicity of herbal extracts. This is probably because the tests are relatively reliable, accurate, simple and cost-effective.

Munodawafa et al. [100] and Erhabor et al. [242] classified BSLT toxicity by determining the lethal concentration [LC50] of medicinal plant extracts that resulted in 50% mortality in brine shrimps, and the lethal dose [LD50] causing 50% mortality in mice/ rats for rodent acute toxicity studies. In the classification of BSLT toxicity, high toxicity was assigned to [LC50] values below 249 μg/mL, moderate toxicity encompassed the range of 250–499 μg/mL, concentrations between 500 and 999 μg/mL were regarded as weak or low in toxicity and values exceeding 1000 μg/mL were considered safe Bussmann et al. [243] and Erhabor et al. [242]. In the rodent acute toxicity tests

conducted by Malebo et al. [121], substances with [LD50] values below 50 mg/kg body weight were classified as highly toxic, those within the range of 50–300 mg/kg body weight were considered toxic, 300–1000 mg/kg body weight fell under the category of moderately toxic, 1000–2000 mg/kg body weight were mildly toxic and 2000 up to 5000 mg/kg body weight were classified as non-toxic. Among the 47 plants used for the treatment and management of bilharziasis and other parasitic infections in Zimbabwe, 30 plants (63.8%) were deemed safe/non-toxic, 6 plants (12.8%) exhibited weak or low toxicity or mild toxicity, 5 plants (10.6%) showed moderate toxicity, 1 plant (2.1%) was classified as toxic and 5 plants (10.6%) were highly toxic (**Table 4**).

*In vitro* investigations play a crucial role in the initial screening of compounds; however, these studies do not yield insights regarding the bioavailability, toxicity and *in vivo* efficacy of the tested extract/compound. Consequently, it is imperative to conduct future *in vivo* studies utilizing appropriate animal models to comprehensively

#### **Table 4.**

*Toxicological evaluation of medicinal plants used to treat and manage bilharziasis and other parasitic infections in Zimbabwe.*

comprehend the pharmacokinetics and pharmacodynamics of the tested extract/compound. The majority of *in vivo* studies fail to provide evidence concerning the toxicity and mechanism of action of medicinal plants/compounds, thereby highlighting the neglected nature of this aspect. Researchers are strongly encouraged to assess the toxicity levels and pharmacological actions of the tested plant/compound.

## **Conflict of interest**

The authors declare no conflict of interest.

## **Author details**

Elliot Nyagumbo<sup>1</sup> \*, Trust Nyirenda<sup>2</sup> , Cephas Mawere<sup>3</sup> , Ian Mutasa<sup>4</sup> , Emmanuel Kademeteme<sup>4</sup> , Alfred M. Mutaramutswa<sup>1</sup> , Donald Kapanga<sup>1</sup> , Godwins Ngorima<sup>1</sup> , Leroy Nhari<sup>1</sup> , Fabian Maunganidze<sup>1</sup> , Michael Bhebhe<sup>1</sup> , William Pote<sup>4</sup> and Lucy Mabaya<sup>1</sup>

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**Chapter 7**

*Novel Nanomaterials*

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**140**


*Article* **Hybrid Rocket Underwater Propulsion: A Preliminary Assessment**

#### **Heejang Moon 1,\*, Seongjoo Han 1, Youngjun You 2 and Minchan Kwon 2**

Received: 28 January 2019; Accepted: 22 February 2019; Published: 6 March 2019

**Abstract:** This paper presents an attempt to use the hybrid rocket for marine applications with a 500 N class hybrid motor. A 5-port high density polyethylene (HDPE) fuel grain was used as a test-bed for the preliminary assessment of the underwater boosting device. A rupture disc preset to burst at a given pressure was attached to the nozzle exit to prevent water intrusion where a careful hot-firing sequence was unconditionally required to avoid the wet environment within the chamber. The average thrust level around 450 N was delivered by both a ground test and an underwater test using a water-proof load cell. However, it was found that instantaneous underwater thrusts were prone to vibration, which was due in part to the wake structure downstream of the nozzle exit. Distinctive ignition curves depending on the rupture disc bursting pressure and oxidizer mass flow rate were also investigated. To assess the soft-start capability of the hybrid motor, the minimum power thrust, viewed as the idle test case, was evaluated by modulating the flow controlling valve. It was found that an optimum valve angle, delivering 16.3% of the full throttle test case, sustained the minimum thrust level. This preliminary study suggests that the throttable hybrid propulsion system can be a justifiable candidate for a short-duration, high-speed marine boosting system as an alternative to the solid underwater propulsion system.

**Keywords:** hybrid rocket; marine propulsion; rupture disc; idling operation; underwater environment