Evaluation of case management in the integrated schistosomiasis-control programme in Mali

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Abstract
Currently, schistosomiasis control in Mali is mainly based on treatment with praziquantel (PZQ). The policy is to ensure (1). the treatment, every 3 years, of school-age children in all areas where the prevalence of haematuria (an indicator of Schistosoma haematobium infection) in this age-group is >30%, and (2). the sound management of all patients presenting with haematuria or (bloody) diarrhoea (an indicator of S. mansoni infection) at health centres. In the present study, the application of case management was evaluated by visiting 60 healthcare facilities in four geographical areas and interviewing the health-workers at these facilities. The presence of S. haematobium and S. mansoni was reported in the coverage areas of 83% and 37%, respectively, of the healthcare facilities investigated. Health-worker knowledge of the main symptoms of schistosome infection was good and patients exhibiting symptoms attributable to schistosome infection were very likely to receive adequate treatment, particularly (at a frequency of about 80%) when they presented with haematuria. At health-centre level, patients were often directly treated with PZQ, whereas health-workers in district hospitals and private clinics requested a diagnostic test prior to any treatment. PZQ was available in most healthcare facilities but not in the private clinics. The mean cost of treatment of a patient with S. haematobium infection (euro; 2.30) was very similar to the corresponding cost for S. mansoni infection (euro; 2.37). The cost of the PZQ represented approximately 50% of the total costs borne by the patients when presenting at health centres. Patients with the symptoms of S. haematobium infection in Mali can expect adequate diagnosis and treatment in agreement with the recommendations of the World Health Organization. Patients presenting with symptoms related to S. mansoni infection are, however, less likely to be correctly diagnosed. The relatively high costs of treatment and the infrequency with which cases of schistosomiasis seek healthcare necessitate policy decisions, to ensure an affordable and more attractive, clinical system of case management.