Capacity gaps in health facilities for case management of intestinal schistosomiasis and soil-transmitted helminthiasis in Burundi

Please see Additional file 1 for translation of the abstract into the six official working languages of the United Nations.

Among the neglected tropical diseases (NTD), schistosomiasis and soil-transmitted helminthiasis (STH) are the most common parasitic infections. Both have major implications for health and socioeconomic aspects and are important public health problems in Burundi [1].

From 1950 to the 1960s, population movement from the highlands to the Rusizi plain, deterioration of water and sanitation infrastructures and migration of refugees from neighbouring countries contributed to a serious increase of the disease burden due to Schistosoma mansoni [2–6]. A high prevalence of STH (Ascaris lumbircoides, Trichuris trichuria, and hookworm) in Usumbura in 1935 [7] and in the Central Highlands (around Kitega) in 1936 [8] had already been reported.

In Burundi, STH case management has been integrated into health facilities (HF) across the country for many decades. This is not the case for schistosomiasis, for which any form of control only began in the 1970s. In 1973, a schistosomiasis treatment programme for schools was implemented in the capital city of Bujumbura, and ambulant treatment for positive cases was initiated at the health centres (HC). In both cases, direct smear was used for diagnosis and niridazole for treatment [6, 9]. This resulted in a decrease of the school prevalence of S. mansoni infection from 16% in 1974 to 10% in 1982 [9]. With the availability of new tools for diagnosis (Kato-Katz test) and treatment (praziquantel [PZQ]) [10] of intestinal schistosomiasis, a new national control programme was launched in 1982 for intestinal schistosomiasis and STH control using Kato-Katz as the diagnostic tool and PZQ and mebendazole (MBZ) for intestinal schistosomiasis and STH treatments, respectively [9]. Ten years later, in the primary schools of Bujumbura, the prevalence had decreased from 49.5 to 29.4% for STH and from 23.3 to 6.4% for S. mansoni infection [9].

In 1989, S. mansoni control was integrated into the primary health care (PHC) services of all provinces of Burundi where the disease was endemic (Bujumbura Mairie, Bujumbura Rural, Bubanza, Cibitoke, Bururi, Makamba and Kirundo) [11] (Fig. 1). However, in 1993, the civil war began. Throughout the country, the resulting situation of instability affected all factors of life, including the health sector, and control activities declined considerably [11]. In 2005, S. mansoni and STH were again widespread, with prevalence in some provinces reaching 61 and 60%, respectively [12].

In 2007, a Neglected Tropical Disease Control Programme was implemented in Burundi. The main objectives were to define populations at risk for each NTD and to develop and implement a drug treatment strategy targeting at-risk populations. A nationwide school-based survey in 20 schools confirmed that intestinal schistosomiasis and STH were still endemic in the country, with 24 communes at high risk of these diseases [13]. No urogenital schistosomiasis was found, confirming previous reports [3, 4]. During the same year, a programme of mass drug administration (MDA) with PZQ and albendazole (ALB)/MBZ was initiated. Target groups were school-age children for PZQ and children between 1 and 14 years of age and pregnant women for ALB/MBZ [13]. From 2007 to 2011, the treatment coverage in school-age children at the national level increased from 87.9% in 2008 to 95.9% in 2011 [13].

Data from a countrywide reassessment of S. mansoni infection in Burundi published in 2017 showed a significant decrease in the prevalence from 12.7% in 2007 to 2.2% in 2014 [14] in communes targeted by MDA [14]. For STH, a significant decrease was also registered from 2007 to 2014 [15]. The pooled STH prevalence was 32% in 2007 and 18% in 2014 [15].

In Burundi, STH control is integrated into HF across the country, but schistosomiasis control is not, with only HC involved and only during MDA campaigns. Vertical programmes are difficult to maintain over long periods, especially when they are dependent on external funding [16, 17]. For sustainability reasons, the World Health Organization (WHO) 1993 recommendation on integrating schistosomiasis control into PHC services [18] was reconsidered by others [19] in 2010.

We investigated the capacity of HF to integrate intestinal schistosomiasis case management into their routine activities. In addition, the capacity for current HF-based STH case management was evaluated. To this end, the current knowledge of health staff on the symptoms and the available options for diagnosis and treatment of intestinal schistosomiasis and STH were assessed in endemic areas in Burundi at HF of different levels.

We aimed to assess the capacity of HF to integrate intestinal schistosomiasis case management into routine activities. We also evaluated the capacity for current STH case management, which has been integrated into the HF for many decades. We found the following: (i) Few staff members had received higher education, and even less had received training on intestinal schistosomiasis case management. The level of knowledge of the main symptoms of intestinal schistosomiasis was low and was related to the level of education. (ii) Clinical guidelines and laboratory protocols were available in only one third of the HF. (iii) In HF with laboratory facilities, only direct smear was used to diagnose intestinal schistosomiasis. (iv) PZQ was not available in any of the HF. (v) Consultation and diagnosis (based on direct smear) were relatively expensive, considering the socioeconomic conditions of Burundians. The results for STH were similar, except that (i) the level of knowledge of main symptoms was considerably higher, (ii) clinical guidelines were available in a higher proportion of the HF (61.5%), and (iii) ALB/MBZ was available in all HF.

The number of HF staff with higher education was very low in our study. This problem is not specific to Burundi. It is a reality in low-income countries [23] that only few HF are managed by medical doctors. For example, in Kenya [24], clinical officers in DH were reported to perform medical tasks that are typically assigned to medical doctors, including medical surgery.

Even though in-job training cannot replace prior education [25], it can bring added value in strengthening the capacity of HF for the prevention and control of infectious diseases [19, 26–32]. In Mali [33] and Senegal [34], training on schistosomiasis case management was provided as part of an intervention project on curative health care, and knowledge of health care providers about the symptoms of S. mansoni infections was high (69–94%) after the training. This is not the case in Burundi, where the percentage of staff that received specific training on intestinal schistosomiasis diagnosis and treatment was very low.

Previous studies have shown that inadequate supply [35] and expired medicines and other materials [30, 35], plus shortages of essential drugs, are access barriers to health services, especially in rural areas [30]. The drug supply problems identified in this study have been observed in other countries as well, such as Ethiopia [25], Uganda and Tanzania [29]. Studies in Ghana [36] and Senegal [34] reported PZQ to be out of stock in 22.5 and 25% of HF, respectively, obliging patients to be referred to other HF or to seek treatment elsewhere. In Burundi, PZQ was unavailable at any HF, causing a major constraint for integration of schistosomiasis case management into HF [37]. Similarly, the lack of adequate diagnostic tests has also been observed in other countries [33, 36] and can seriously hamper intestinal schistosomiasis and STH detection and management in HF. The WHO recommends using Kato-Katz testing for the diagnosis of intestinal schistosomiasis [18] and STH, which is more sensitive than direct smear and still relatively cheap [18]. Recent research has reported the circulating cathodic antigen test in urine as a more sensitive test [14, 38, 39] for intestinal schistosomiasis, in addition to being easy to use. However, it is more expensive than the Kato-Katz test [40].

In Burundi, the average per capita daily income is below the poverty level (1USD): 0.64 USD per day and 0.41 USD per day in urban and rural areas, respectively [21]. Our results show that the costs of consultation and diagnosis for intestinal schistosomiasis/STH range from 0.32 to 8.41 USD, depending on the HF type and level. Hence, many Burundians cannot access care without sacrificing other needs. At present, only pregnant women and children under five years of age do not pay for health care in public or confessional HF. To remove the financial barrier to health care, this should be extended to other vulnerable groups as well.

This study highlighted the lack of capacity in Burundian HF for integrating intestinal schistosomiasis case management into their routine activities. For STH, the capacity for HF-based case management was better, but it still needs improvement. Especially at the HC level, which is the first point of contact with the community, there is an urgent need for the government to address these capacity gaps in order to provide adequate diagnosis and treatment for intestinal schistosomiasis and STH for everybody at all times. At present, treatment of intestinal schistosomiasis is limited to MDA for school-age children [13], and PZQ is not available outside of the yearly campaigns or for other target groups, jeopardizing accessibility and equity of services [19]. In addition, diagnosis in HF of both intestinal schistosomiasis and STH is currently based on direct smears in the context of poor knowledge of symptoms among care providers and, thus, is sub-optimal. As a consequence, many cases are not diagnosed and/or not treated, causing the spread of these infections and potential severe complications in the long term. HF capacity strengthening for case management is an essential, albeit not the only, requirement for sustainable control of intestinal schistosomiasis and STH in Burundi and elsewhere.