Although the general impact of schistosome infection has been well reviewed in recent years, there is no special attention paid to advanced hepatosplenic disease due to schistosomiasis in the GBD study 
. As a late-stage of chronic schistosomiasis, the harms of advanced schistosomiasis are more extensive, intensive and fatal with a protracted course 
. Undoubtedly, the language gap is an important issue explaining the limited application of the Chinese literature in the updating of the schistosomiasis burden in the GBD study 
. Moreover, only few studies attempted to assess the patient's disability in terms of overall quality of life 
. In our preceding investigations, we concluded that the DW of chronic schistosomiasis japonica (early stage) is considerably higher than that put forth by expert opinion, which fed into the original GBD study in the 1990s 
. The current study clearly shows that advanced schistosomiasis japonica is associated with poor self-reported quality of life, high morbidity, and heavy disability.
As a whole, the overall DW of advanced schistosomiasis japonica is 0.447, 2.34 times higher than that of chronic cases and 4.30 times higher than that of the advanced hepatic disease due to schistosomiasis (DW
0.104) used in the GBD 2004 update, which could be classified as ‘moderate and severe’ disability in the disability classes for the GBD study (see ) 
. The multivariate regression models indicate that DW is positively associated with psychological abnormality, ascites, impaired work capacity, and co-infection by active hepatitis B virus (HBeAg positive), whereas splenectomy is a protective factor for quality of life (see and ).
Abdominal ultrasonography is considered as a specific and sensitive examination for diagnosis of advanced schistosomiasis 
. In this study, although 88.8% (191/215) of cases had been subjected to etiologic and symptomatic treatment, more than half (61.1%; 121/198) were detected with hepatic fibrosis of grade III characterized by ‘fish-scale’, ‘turtle-back’, or ‘map-like’ pathognomonic pattern of ultrasonography in parenchyma of the liver, obviously different from post-hepatitis cirrhosis 
. The enlargement of portal vein is a typical indicator of portal hypertension, which implies the risk of upper gastrointestinal hemorrhage 
. Referring to normal values obtained from the general population, the mean of inner diameter of the major portal vein was 3.9 mm larger than that of the normal value 
. Anemia is a common outcome of Schistosoma
infection and is further aggravated by the emergence of hypersplenism in the advanced stage 
. It is showed that the mean hemoglobin of advanced cases is far less than that of the normal population (see ).
The EQ-5D is a valid generic questionnaire that is frequently used for describing and measuring health-related quality of life 
. Our study showed that the impairment rates of advanced cases in each of six health dimensions of EQ-5D+C questionnaire are all significantly higher than those of early-stage chronic cases we had assessed (all P
<0.001) (see and ) 
. Moderate or extreme problems were reported by 55.8% (787/1410) of the chronic cases and by 96.3% (207/215) of the advanced cases. Severe impairments in each of health dimensions contributed considerably to the severe disabilities seen in advanced cases. Activity restriction such as impairment of mobility or self-care is a severe disability, especially for people living in remote areas who are primarily engaged in agriculture. Some characteristics of advanced schistosomiasis – such as long duration, frequent relapse of ascites, impaired work capacity, and worsening family economic status – could induce severe psychological problems 
. Our study shows that the reported rates of pain or discomfort, or anxiety or depression among advanced schistosomiasis japonica cases are very high, reaching 90.7% and 80.9%, respectively, which explains most of the variation of DW in model 1. Impaired usual activities or work capacity were reported in 87.9% or 92.1% of the patients, which could be explained as the combined effect of anemia, ascites, impaired liver function, splenomegaly, and other complications.
Ascites means a serious impairment and disability affecting a person's ability to work or take part in family and community activities. In the current study, it has been shown that the DW of ascites is 0.135 higher than that of megalosplenia. Compared with megalosplenia type cases, those suffering from ascites manifest themselves with lower quality of life, longer duration of disability, higher reoccurring rates, worse treatment outcomes, and greater overall family burden 
. In P.R. China, splenectomy, either with or without portosystemic anastomosis, is a general surgical intervention for the treatment of portal hypertension due to hepatosplenic schistosomiasis, which would help to reduce the risk of upper gastrointestinal hemorrhage, cure refractory ascites, recover work capacity, and remove hypersplenism 
P.R. China is one of the most highly endemic areas for chronic HBV infection in the world 
. Superimposed HBV infection has been suggested to play a role in the development of the more severe form of liver disease among cases with schistosomiasis 
. There is a general agreement that the association of HBV and S. japonicum
infection are associated with higher morbidity and mortality compared with either infection alone 
. In this study, 32.8% of advanced cases were found to be positive for HBsAg and HbeAg. Positivity was positively related with DW in advanced schistosomiasis, revealing that there is an active interaction between HBV and schistosome infection.
The current investigation suffers from several limitations that are offered for consideration. First, co-morbidity was inevitably included in this disability assessment. Although hepatitis with clinical features was excluded after a physical examination, four of 198 cases were detected to be HBeAg positive and kept in the statistical analysis. However, given this small number, it is unlikely that exclusion of these four cases would have substantially changed the overall DW of advanced schistosomiasis japonica. Second, a control group (absence of advanced schistosomiasis japonica, matched for age and sex) was not available. The quality of life has been defined as a person's subjective sense of wellbeing, derived from current experience of life as a whole. The use of a VAS, as an approach of psychometrics, allows visualizing, and hence estimating the gap between the ‘real’ health and an ideal, hypothetical stage of health (best imaginable) of the respondents. Hence, the respondent becomes the control of him- or herself 
. Additionally, it is not always easy to obtain representative population samples of health states associated with a given sequelae, particularly those with a low population prevalence 
. We had tried to focus our attention on advanced schistosomiasis japonica, and avoided administering a similar questionnaire twice on the chronic cases (early stage). However, in a subsequent study, the current results obtained from patients with advanced schistosomiasis japonica could be readily compared with those obtained from chronic cases reported in our previous work 
or from other inpatients without schistosomiasis. Third, the general health condition of people is likely to deteriorate as they become older. It should be noted, however that this effect could be offset by a lower health expectation of the elderly 
We conclude that uncertainty remains while assessing DWs, particularly for burden estimates due to neglected tropical diseases 
. There is a pressing need to incorporate new findings from studies as the one reported here into the current revisions and updates of the GBD study 
. Re-evaluation and recalibration of health burden of helminthic parasite infection would highlight the strong potential of integrated parasite control that are likely to go hand-in-hand with efforts for poverty alleviation 
. We therefore believe that the results presented here provide valuable data for a revision of the local, regional, and global burden of schistosomiasis, as well as for evidence-based decision making in P.R. China's national schistosomiasis control program.