The effects of selected neglected tropical diseases on economic performance at the macrolevel in Africa

BACKGROUND

Neglected tropical diseases (NTDs) such as leprosy, lymphatic filariasis (LF), schistosomiasis and onchocerciasis are endemic in several African countries. These diseases can lead to severe pain and permanent disability, which can negatively affect the economic productivity of the affected person(s), and hence resulting into low economic performance at the macrolevel. Nonetheless, empirical evidence of the effects of these NTDs on economic performance at the macrolevel is sparse. This study therefore investigates the effects of the above-mentioned NTDs on economic performance at the macrolevel in Africa.

METHODS

The study employs a panel design with data comprising 24 to 45 African countries depending on the NTD in question, over the period, 2002 to 2019. Gross domestic product (GDP) is used as the proxy for economic performance (Dependent variable) and the prevalence of the above-mentioned NTDs are used as the main independent variables. The random effects (RE), fixed effects (FE) and the instrumental variable fixed effects (IVFE) panel data regressions are used as estimation techniques.

RESULTS

We find that, an increase in the prevalence of the selected NTDs is associated with a fall in economic performance in the selected African countries, irrespective of the estimation technique used. Specifically, using the IVFE regression estimates, we find that a percentage increase in the prevalence of leprosy, LF, schistosomiasis and onchocerciasis is associated with a reduction in economic performance by 0.43%, 0.24%, 0.28% and 0.36% respectively, at either 1% or 5% level of significance.

CONCLUSION

The findings highlight the need to increase attention and bolster integrated efforts or measures towards tackling these diseases in order to curb their deleterious effects on economic performance. Such measures can include effective mass drug administration (MDA), enhancing access to basic drinking water and sanitation among others.

The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation

BACKGROUND

Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge.

METHODS

We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit.

RESULTS

Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment.

INTERPRETATION

Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.

Cost of interventions to control schistosomiasis: A systematic review of the literature

BACKGROUND

Schistosomiasis, a disease caused by blood flukes of the genus Schistosoma, belongs to the neglected tropical diseases. Left untreated, schistosomiasis can lead to severe health problems and even death. An estimated 800 million people are at risk of schistosomiasis and 250 million people are infected. The global strategy to control and eliminate schistosomiasis emphasizes large-scale preventive chemotherapy with praziquantel targeting school-age children. Other tools are available, such as information, education, and communication (IEC), improved access to water, sanitation, and hygiene (WASH), and snail control. Despite available evidence of the effectiveness of these control measures, analyses estimating the most cost-effective control or elimination strategies are scarce, inaccurate, and lack standardization. We systematically reviewed the literature on costs related to public health interventions against schistosomiasis to strengthen the current evidence-base.

METHODOLOGY

In adherence to the PRISMA guidelines, we systematically searched three readily available electronic databases (i.e., PubMed, WHOLIS, and ISI Web of Science) from inception to April 2019 with no language restrictions. Relevant documents were screened, duplicates eliminated, specific rules on studies to consider were defined, and the eligible studies fully reviewed. Costs of schistosomiasis interventions were classified in three groups: (i) preventive chemotherapy; (ii) preventive chemotherapy plus an individual diagnostic test to identify at-risk population; and (iii) test-and-treat interventions.

PRINCIPAL FINDINGS

Fifteen articles met our inclusion criteria. In general, it was hard to compare the reported costs from the different studies due to different approaches used to estimate and classify the costs of the intervention assessed. Costs varied considerably from one study to another, ranging from US$ 0.06 to US$ 4.46 per person treated. The difference between financial and opportunity costs only played a minimal role in the explanation of the costs' variation, even if delivery costs were two times higher in the analyses including economic costs. Most of the studies identified in our systematic review focused on sub-Saharan African countries.

CONCLUSIONS/SIGNIFICANCE

The degree of transparency of most of the costing studies of schistosomiasis interventions found in the current review was limited. Hence, there is a pressing need for strategies to improve the quality of cost analyses, and higher reporting standards and transparency that should be fostered by peer-review journal policies. Cost information on these interventions is crucial to inform resource allocation decisions and those regarding the affordability of scaling-up interventions.

Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study

BACKGROUND

Neglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control.

METHODS

We built on extended cost-effectiveness analysis (ECEA) methods to assess the health gains (e.g. infections, disability-adjusted life years or DALYs averted), household financial gains (out-of-pocket expenditures averted), and education gains (cases of school absenteeism averted) for five NTD interventions that the government of Madagascar aims to roll out nationally. The five NTDs considered were schistosomiasis, lymphatic filariasis, and three soil-transmitted helminthiases (Ascaris lumbricoides, Trichuris trichiura, and hookworm infections).

RESULTS

The estimated incremental cost-effectiveness for the roll-out of preventive chemotherapy for all NTDs jointly was USD125 per DALY averted (95% uncertainty range: 65-231), and its benefit-cost ratio could vary between 5 and 31. Our analysis estimated that, per dollar spent, schistosomiasis preventive chemotherapy, in particular, could avert a large number of infections (176,000 infections averted per $100,000 spent), DALYs (2,000 averted per $100,000 spent), and cases of school absenteeism (27,000 school years gained per $100,000 spent).

CONCLUSION

This analysis incorporates financial and education gains into the economic evaluation of health interventions, and therefore provides information about the efficiency of attainment of three Sustainable Development Goals (SDGs). Our findings reveal how the national scale-up of NTD control in Madagascar can help address health (SDG3), economic (SDG1), and education (SDG4) goals. This study further highlights the potentially large societal benefits of investing in NTD control in low-resource settings.

Equity and efficiency in the scaled-up implementation of integrated neglected tropical disease control: the health economics protocol of the COUNTDOWN multicountry observational study in Ghana, Cameroon and Liberia

INTRODUCTION

Worldwide, millions of individuals are affected by neglected tropical diseases (NTDs). They are frequently the poorest and most marginalised members of society. Their living conditions, among other things, make them susceptible to such diseases. Historically, several large-scale treatment programmes providing mass drug administrations (MDAs) were carried out per single disease but over the last decade there has been an increasing trend towards co-implementation of MDA activities given the resources used for such programmes are often the same. The COUNTDOWN multicountry studies focus on scaled-up implementation of integrated control strategies against four diseases: lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis. The objective of the COUNTDOWN economic study is to assess the multicountry implementation of control interventions in terms of equity, impact and efficiency.

METHODS

The health economic study uses different analytical methods to assess the relationship between NTDs and poverty and the cost-effectiveness of different large-scale intervention options. Regression analysis will be used to study the determinants of NTD occurrence, the impact of NTDs on poverty, factors that hinder access to MDAs and the effect of NTDs on quality-of-life of those affected, including disability. Cost-effectiveness analyses of various integration methods will be performed using health economic modelling to estimate the cost and programme impact of different integration options. Here, cost-effectiveness ratios will be calculated, including multivariate sensitivity analyses, using Bayesian analysis.

ETHICS AND DISSEMINATION

Ethics approval has been received both at the Liverpool School of Tropical Medicine and in all participating countries. Results of the various substudies will be presented for publication in peer-reviewed journals.

STUDY DATES

1 July 2016 to 30 June-October 2019.

[Disease burden of patients with advanced schistosomiasis in Jiangsu Province]

OBJECTIVE

To understand the disease burden of patients with advanced schistosomiasis in Jiangsu Province.

METHODS

Totally 450 patients with advanced schistosomiasis from southern, northern and central Jiangsu were chosen by the stratified sampling method, and surveyed by the self-designed economic burden questionnaire in 2015. The economic burden of the patients was analyzed by the descriptive analysis method, and its determinants were explored by the multiple linear regression analysis.

RESULTS

A total of 450 subjects were surveyed and 434 valid questionnaires were recovered with the recovery rate of 96.44%. The per capita economic burden of advanced schistosomiasis patients was 10 217 Yuan in Jiangsu Province in 2015, including 7 221 Yuan in direct economic burden and 2 996 Yuan in indirect economic burden. The average lost labor force time was 140 days for the patients, and was 23 days for the family. The multiple linear regression analysis showed that the marital status, hospitalization health service utilization, and self-reported health score impacted on the disease economic burden.

CONCLUSIONS

The disease burden of patients with advanced schistosomiasis in Jiangsu Province is heavy.

[Study on effect of clinical pathway implementation in advanced schistosomiasis with ascites]

OBJECTIVE

To evaluate the effect of clinical pathway (CP) on the implementation of advanced schistosomiasis patients with ascites.

METHODS

Totally 1 129 cases of advanced schistosomiasis patients with ascites but without other complications were selected randomly from the Performance Evaluation and Management System for Medical Treatment of Advanced Schistosomiasis Patients in Hubei Province from year 2011 to 2013. Among the patients, 754 cases were treated by CP (CP group), and 375 cases were treated with traditional methods (NCP group), and the hospitalization days, hospitalization expenses, medicine proportions, treatment outcomes and degrees of satisfaction and health knowledge rates of the two groups were compared. Meanwhile, the variation of CP was calculated.

RESULTS

The average length of hospital days of the CP group and NCP group were (13.85 ± 5.60) d and (17.92 ± 5.80) d, respectively, and the average hospitalization costs of the two groups were (4 699.14 ± 1 520.59) Yuan and (5 692.01 ± 1 616.66) Yuan, respectively, both the differences were statistically significant (both P ＜ 0.05). Also the hospitalization cost structures of the two groups were remarkably different, the composition ratios of the inspection fee and accommodation fee in the CP group were lower than those in the NCP group, but the constituent ratios of the examination fee, diagnosis and treatment fee, drug charges and other expenses were higher than those in the NCP group (all P < 0.05). The awareness rate of health knowledge in the CP group was higher than that in the NCP group (P < 0.05), but there were no statistically significant differences in the treatment outcome and the degree of satisfaction between the two groups (both P > 0.05). The variation rate of CP was 9.02% (68/754).

CONCLUSIONS

The implementation of CP can decrease the days of hospital stay and medical expenses, improve the awareness rate on health knowledge of the patients. The CP treatment with low variation rate is applicable to advanced schistosomiasis patients with ascites but without complications.

Building a global schistosomiasis alliance: an opportunity to join forces to fight inequality and rural poverty

Schistosomiasis, one of the 17 neglected tropical diseases listed by the World Health Organization, presents a substantial public health and economic burden. Of the 261 million people requiring preventive chemotherapy for schistosomiasis in 2013, 92% of them lived in sub-Saharan Africa and only 12.7% received preventive chemotherapy. Moreover, in 2010, the WHO reported that schistosomiasis mortality could be as high as 280 000 per year in Africa alone.In May 2012 delegates to the sixty-fifth World Health Assembly adopted resolution WHA65.21 that called for the elimination of schistosomiasis, and foresees the regular treatment of at least 75% of school age children in at-risk areas. The resolution urged member states to intensify schistosomiasis control programmes and to initiate elimination campaigns where possible.Despite this, in June 2015, schistosomiasis was indicated to have the lowest level of preventive chemotherapy implementation in the spectrum of neglected tropical diseases. It was also highlighted as the disease most lacking in progress. This is perhaps unsurprising, given that it was also the only NTD with access to drug donations but without a coalition of stakeholders that collaborates to boost commitment and implementation.As a consequence, and to ensure that the WHO NTDs Roadmap Targets of 2012 and World Health Assembly Resolution WHA65.21 are met, the Global Schistosomiasis Alliance (GSA) has been set up. Diverse and representative, the GSA aims to be a partnership of endemic countries, academic and research institutions, international development agencies and foundations, international organizations, non-governmental development organizations, private sector companies and advocacy and resource mobilisation partners. Ultimately, the GSA calls for a partnership to work for the benefit of endemic countries by addressing health inequity and rural poverty.

Benchmarking the Cost per Person of Mass Treatment for Selected Neglected Tropical Diseases: An Approach Based on Literature Review and Meta-regression with Web-Based Software Application

Background

Advocacy around mass treatment for the elimination of selected Neglected Tropical Diseases (NTDs) has typically put the cost per person treated at less than US$ 0.50. Whilst useful for advocacy, the focus on a single number misrepresents the complexity of delivering “free” donated medicines to about a billion people across the world. We perform a literature review and meta-regression of the cost per person per round of mass treatment against NTDs. We develop a web-based software application (https://healthy.shinyapps.io/benchmark/) to calculate setting-specific unit costs against which programme budgets and expenditures or results-based pay-outs can be benchmarked.

Methods

We reviewed costing studies of mass treatment for the control, elimination or eradication of lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, onchocerciasis, trachoma and yaws. These are the main 6 NTDs for which mass treatment is recommended. We extracted financial and economic unit costs, adjusted to a standard definition and base year. We regressed unit costs on the number of people treated and other explanatory variables. Regression results were used to “predict” country-specific unit cost benchmarks.

Results

We reviewed 56 costing studies and included in the meta-regression 34 studies from 23 countries and 91 sites. Unit costs were found to be very sensitive to economies of scale, and the decision of whether or not to use local volunteers. Financial unit costs are expected to be less than 2015 US$ 0.50 in most countries for programmes that treat 100 thousand people or more. However, for smaller programmes, including those in the “last mile”, or those that cannot rely on local volunteers, both economic and financial unit costs are expected to be higher.

Discussion

The available evidence confirms that mass treatment offers a low cost public health intervention on the path towards universal health coverage. However, more costing studies focussed on elimination are needed. Unit cost benchmarks can help in monitoring value for money in programme plans, budgets and accounts, or in setting a reasonable pay-out for results-based financing mechanisms.

Advocacy around mass treatment for the elimination of selected Neglected Tropical Diseases (NTDs) has typically put the cost per person treated at less than US$ 0.50. Whilst useful for advocacy, the focus on a single number misrepresents the complexity of delivering “free” donated medicines to about a billion people across the world. Given the increasing focus of the NTD community on value for money and, in the context of universal health coverage, of the global health community on outreach beyond health facilities, there was a need for greater nuance. We performed the most comprehensive literature review and first regression analysis of differences between settings in the cost per person treated against six NTDs (excluding the cost of individual medicines). We considered more than ten possible drivers of cost. We found, for example, that the unit cost of treatment depends very much on the number of people treated (economies of scale). We then developed a web-based software application (https://healthy.shinyapps.io/benchmark/) that can be used to predict setting-specific unit costs against which programme budgets and expenditures or results-based pay-outs can be benchmarked.

[Schistosomiasis monitoring and its cost in population in Danyang City, 2010-2014]

OBJECTIVE

To explore the monitoring method of the infection source of schistosomiasis in the population of the schistosomiasis transmission-interrupted area with Oncomelania hupensis snails.

METHODS

The changes of schistosomiasis among the population were investigated by using the active and passive monitoring methods in Danyang City from 2010 to 2014, and the cost-effectiveness of the two monitoring methods was evaluated.

RESULTS

Totally 49,277 persons were detected for schistosomiasis by dipstick dye immunoassay (DDIA) from 2010 to 2014 and 608 cases were positive, and the positive rate was 1.23%. There were no positive persons by etiology detections. The positive rates of active and passive monitoring methods were 1.61% and 1.13%, respectively and there was a significant difference between them (χ² = 15.982, P < 0.05). The average cost per positive case of the active monitoring was higher than that of the passive monitoring without considering the costs of the mobilization and labor.

CONCLUSION

In the schistosomiasis transmission-interrupted area with snails, the active and passive monitoring methods need to be combined in the future.

[Measures and effectiveness of comprehensive schistosomiasis control along Xinglong River in Qianjiang City]

OBJECTIVE

To evaluate the effect of comprehensive control of schistosomiasis along the Xinglong River in Qianjiang City, so as to provide the evidence for improving schistosomiasis control.

METHODS

The comprehensive control measures including infection source control and Oncomelania hupensis snail eradication were surveyed along the Xinglong River in Qianjiang City.

RESULTS

The prevalence of schistosomiasis was under control, that was the human and cattle infection rates decreased by 53.77% and 100% respectively, the snail area decreased by 26.9%, the mean density of living snails decreased by 25.5%, and no infected snails was found.

CONCLUSIONS

The comprehensive control measures along the Xinglong River are effective, and the management and surveillance of snail environments still should be strengthened.

[Cost-effectiveness evaluation on comprehensive control measures carrying out in schistosomiasis endemic areas with regard to different layers of administrative villages stratified by infection situation of human and domestic animals. II Correlation analysis of costs and inputs with changes of schistosomiasis endemic situation in inner embankment of marshland and lake regions from 2006 to 2013]

OBJECTIVE

To investigate the correlations between inputs and costs and endemic situation of schistosomiasis in inner embankment, so as tb provide the references for the strategy optimization of schistosomiasis control.

METHODS

Jiangling County was selected as the study field. The correlatibn and regression analyses were applied to analyze the endemic situation of schistosomiasis in Jiangling County from 2006 to 2013. The methods of two-stages least squares and path analysis were applied to analyze the impacts between costs and inputs and endemic situation of schistosomiasis.

RESULTS

The adjusted infection rate of population, number of bovines and Oncomelania hupensis snail areas reduced by 77.42%, 76.34% and 19.43%, respectively in Jiangling County from 2006 to 2013. The correlations between the infection rate of snails and the population positive rates of blood and fecal exams, and the infection rate of bovines were significant (all P < 0.05); and there was a significant linear regression between the infection rates of snails and bovines (P < 0.05). There were statistically significant regressions between inputs at different levels and the population positive rates of blood and fecal exams, and the infection rates of bovines and snails, as well as between the costs and the population positive rate of fecal exams and the infection rates of bovines and snails (all P < 0.05), whereas there was no statistically significant regression between the costs and the population positive rate by blood exams (P > 0.05). The inputs at county level had an impact on the population positive rate of blood exams; the costs of comprehensive treatment had an impact on the population positive rate of fecal exams; the costs of human labor and measures for exams and treatments had an impact on the infeiction rate of bovines; the inputs at national level and the costs of measures for exams and treatments had an impact on the infection rate of snails (all P < 0.05).

CONCLUSION

The inputs and costs of schistosomiasis control were related to the epidemic situation of schistosomiasis in Jiangling County from 2006 to 2013; therefore, it is necessary to develop a comprehensive surveillance system as substitute for the current indexes on schistosomiasis control.

[Surveillance and risk assessment system of schistosomiasis in Jiangsu Province. II. Surveillance pattern and effect of Oncomelania hupensis snail status in Dongtai City, Jiangsu Province]

OBJECTIVE

To explore the method of Oncomelania hupensis snail surveillance in transmission-interrupted regions of schistosomiasis, so as to provide a new pattern for the surveillance of snail status in the transmission-interrupted areas.

METHODS

In Dongtai County, north of Jiangsu Province where the transmission of schistosomiasis was interrupted, the surveillance of snail status was performed by means of the village-level general survey, village-level sampling survey, snail survey in key settings of township and county, and snail reporting by residents. In addition, quality-control snail sites were set up for quality control. The effectiveness and cost of the four methods of snail surveillance was compared.

RESULTS

A total of 163 079 settings and 22 785.62 hm2 were surveyed in Dongtai County from 2008 to 2013, and 89 residual snail breeding sites were found, with a snail area of 1.48 hm2. The patterns of village-level general survey, village-level sampling survey, and snail survey in key settings of township and county were employed for investigation of 94 550, 45 033 and 23 496 settings, consisting of 57.98%, 27.61% and 14.41% of total settings, and 2, 0 and 6 settings were found with snails, with 0.021/thousand, 0, and 0.255/thousand detection rates of settings with snail breading sites, respectively. The pattern of snail survey in key settings of township and county was more effective than that of village-level survey to detect-snail breeding sites (χ2 = 19.158, P = 0). The recovery rate of quality-control snail breeding sites was 52.56%, 38.27% and 73.62% for the three patterns of snail survey, respectively, and the pattern of snail survey in key settings of township and county showed a higher quality for snail survey than that of village-level survey (χ2 = 111.597 and 85.991, both P = 0). During the period from 2008 to 2013, 289 person-times reported 279 suspected snail habitats and 1 501 living snails, and no Oncomelania snails were found. During the 6-year period, there were 1617.5, 964.7 and 527.7 thousand RMB invested for village-level general survey, village-level sampling survey, and snail survey in key settings of township and county, and the cost of snail survey per hm2 was 129.88, 133.6 and 162.57 RMB/hm2, respectively. The cost of village-level general survey and snail survey in key settings of township and county to detect a snail-breeding site was 808 800 and 88 000 RMB, respectively (t = 12.850, P = 0.000), and the cost of snail survey in key settings of township and county was 10.88% of that of village-level general survey.

CONCLUSION

The snail survey in key settings of township and county is a highly effective and high-quality method for snail surveillance, which miay serve as a prior way for the surveillance of snail status in the transmission-interrupted areas of schistosomiasis.

[Research on competency building standards of institutions of schistosomiasis prevention and control in Hubei Province. II. Investigation of human resources]

OBJECTIVE

To understand the human resources of the grassroots institutions of schistosomiasis control and prevention, so as to provide the evidence for formulating the standards of institutional capacity-building.

METHODS

By using the combination of quantitative and qualitative methods, the hierarchy of schistosomiasis control institution workers, structural features of workers, and benefits of workers were investigated and the results were analyzed statistically after the 2004 reform.

RESULTS

The constituent ratios of personnel ≤ 30 years old, 30 to 45 years old, and ≥ 45 years old were 6.8%, 64.0% and 29.2% respectively, with an average age of 43.1 years. For education levels, 61.35% of the personnel had secondary or high school levels. At the city level, the structural proportion of the senior professional; medium professional and primary professional titles was 1.4 : 5.6 : 3.0, and at the county level, the proportion was 0.5 : 6.1 : 3.4. There was 14 200 yuan per capita at the township schistosomiasis control institutions.

CONCLUSION

The technology of the personnel in schistosomiasis institutions of Hubei Province is weak, the average age of personnel is old, and the salary is low.

[Evaluation on effect of treatment and assistance to advanced schistosomiasis patients in Hunan Province from 2004 to 2013]

OBJECTIVE

To comprehensively evaluate the effect of the program of treatment and assistance to advanced schistosomiasis patients in Hunan Province from 2004 to 2013.

METHODS

The fund investment of the program, the profits of hospitals and the improvement of the patients' health were investigated by data collection and questionnaire survey. The evaluation index system of treatment and assistance to advanced schistosomiasis in Hunan Province was constructed by the Delphi method and analytic hierarchy process, and the program was assessed comprehensively.

RESULTS

The evaluation index system including 6 primary indices and 33 secondary indices was established. Among all the primary indices, the score of the treatment and assistance (22.25) was the highest, and that of the satisfaction assessment (8.15) was the lowest, and the score of the comprehensive assessment was 87.06. The average cure rate of the patients was 13.08% from 2004 to 2013. More than 60% of the patients' disease condition got better, and nearly 70% of the patients' psychological condition improved, and more than 70% of patients' self-help ability and social contact improved, as well as family happiness increased. In addition, the annual average cost for caretakers decreased by 2000 Yuan, and the profits of all the fixed-point hospitals for treatment and assistance increased.

CONCLUSION

The effectiveness and efficiency of the treatment and assistance to advanced schistosomiasis patients in Hunan Province is obvious, and the government should continuously invest in the program.

[Application of health education path in advanced schistosomiasis patients with splenomegaly in perioperative period]

OBJECTIVE

To evaluate the effect of health education path on advanced schistosomiasis patients with splenomegaly in perioperative period.

METHODS

A total of 60 advanced schistosomiasis patients with splenomegaly in perioperative period were randomly divided into an observation group and a control group (30 cases each group). The patients in the observation group were intervened by the nursing and health education from admission to discharge according to the standardized process of health education path, while those in the control group were implemented with the conventional health education. Then the satisfaction of nursing work, hospital stays, hospitalization expenses and mastery of health knowledge of the patients in the two groups were investigated and the results were compared.

RESULTS

The satisfaction rates of nursing work of patients in the observation group and the control group were 90% and 60%, respectively, the difference between them was statistically significant (χ2 = 7.57, P < 0.05). The average hospitals stays of the above two groups were 14.0 ± 3.5 d and 19.0 ± 6.8 d (t = 2.85, P < 0.01), respectively, and the average hospitalization expenses were (1.5 ± 0.5) thousand Yuan and (2.2 ± 0.7) thousand Yuan (t = 24.57, P < 0.01), respectively, both of the differences were statistically significant. On the 10th day after surgery, the mastery rates of the health knowledge of the two groups were 96.7% and 50.0%, respectively, the difference was statistically significant (χ2 = 16.86, P < 0.001).

CONCLUSIONS

The implementation of the health education path can promote the rehabilitation of advanced schistosomiasis patients with splenomegaly, and increase the satisfaction as well as improve the mastery of the health knowledge of the patients. Meanwhile, it also can cut down the hospital stays and save the hospitalization expenses.

[Performance of detection and treatment in schistosomiasis in Hubei Province, 2011]

OBJECTIVE

To evaluate the performance of schistosomiasis detection and treatment program in Hubei Province in 2011, so as to enhance the benefit and management of the program.

METHODS

In 63 schistosomiasis epidemic counties of Hubei Province, there were 3 types of endemic situation, that was endemic controlled, transmission controlled, and transmission interrupted. Six counties (districts) in each type were selected by the stratified random sampling method. The data including schistosomiasis detection and treatment, fund utilization and others were collected and analyzed statistically in 2011.

RESULTS

The completion rate of schistosomiasis detection task was 103.9% and the completion rate of chemotherapy task 106.9%. The total fund was 73.815 million Yuan. The detection cost accounted for 12.0% while the chemotherapy cost accounted for 4.9%. The detection cost per capita was 9.03 Yuan and the treatment cost per capita was 10.35 Yuan. The cost effectiveness ratio was 1:6.1 and the net cost effectiveness ratio was 1:5.1.

CONCLUSION

The social-economic benefits in schistosomiasis control and treatment are obvious. However, the resource allocation still needs to be optimized.

[Application of clinical nursing path in standard management of advanced schistosomiasis patients with splenomegaly]

OBJECTIVE

To study the feasibility and effect of clinical nursing path in the standard management of advanced schistosomiasis patients with splenomegaly.

METHODS

A total of 64 advanced schistosomiasis patients with splenomegaly were randomly divided into a routine nursing group (control group) and a clinical nursing pathway group (CNP group), and the postoperative situation, average hospitalization days, cost of hospitalization and the satisfaction of the patients of the 2 groups were compared.

RESULTS

The complications, average hospitalization days, costs of hospitalization in the CNP group were significantly decreased compared with those in the control group, and satisfaction rate of the patients in the CNP group increased from 81.25% to 100%.

CONCLUSION

The implementation of CNP effectively reduces the length of hospitalization, costs and complications, and improves the satisfaction of the patients.

[Effect and cost-benefit of Oncomelania snail control by plowing and planting in Jiaobei Beach of Zhenjiang City]

OBJECTIVE

To evaluate the effect and cost-benefit of Oncomelania snail control by plowing and planting in Jiaobei Beach of Zhenjiang City.

METHODS

In 2009, the measures of building low dike and plowing and planting were implemented in the experimental area of the east part of Jiaobei Beach, while in the control area of the west part of the beach, the molluscacide (niclosamide) was used to control snails. Then, the snail control effects and the cost-benefits of the two groups were compared.

RESULTS

In the experimental area, the density of living snails decreased by 99.75% in the year when the measures were implemented, and no living snails were found from the second year. Though that the density of living snails in the control area decreased by 70% around, it aroused again in the second year. The net cost-benefit ratios of the experimental area and the control area were 2.18 and -0.92, respectively.

CONCLUSION

Building low dike and plowing and planting in the beaches along the middle and lower reaches of the Yangtze River can effectively control snails, meanwhile, it is economic.

[Cost-effectiveness of schistosomiasis monitoring in Rugao City from 2001 to 2010]

OBJECTIVE

To understand the cost-effectiveness of schistosomiasis monitoring in Rugao City, a schistosomiasis transmission interrupted area, so as to provide the evidence for improving schistosomiasis control.

METHODS

According to the national and Jiangsu provincial working scheme of schistosomiasis monitoring and consolidation, the data of schistosomiasis monitoring were collected and the cost-effectiveness was analyzed in Rugao City from 2001 to 2010.

RESULTS

During 10 years, the financial input for Oncomelania snail survey was 11.694 8 million Yuan, accounting for 92.9% of the total monitoring cost. In 6 years, a few remaining snails with low density and small area were detected, and per 100 m2 snail area spent 76 788 Yuan averagely. Totally 23 694 people were investigated with serological tests and 15 persons were positive, but no person was positive in feces tests, and the accumulative total cost was 410 350 Yuan. The average cost for detection of 1 person was 17.32 Yuan. Totally 454 heads of cattle were investigated but there was no positive, and the accumulative total cost was 18 716 Yuan and the average cost of detection of 1 case was 41.22 Yuan. The health education during the 10 years spent 172 500 Yuan, only accounting for 1.4% of the total monitoring funds. The awareness rate of schistosomiasis control knowledge and the health behavior formation rate increased year by year, and they were increased by 2.48 times and 2.71 times respectively from 2001 to 2010.

CONCLUSIONS

In schistosomiasis transmission interrupted areas and areas with Oncomelania snails but without schistosomiasis, the monitoring index and monitoring method need to be studied and adjusted. Health education has a good cost-effectiveness.

[Performance evaluation of rural latrine renovation in key schistosomiasis control areas, Jiangsu Province]

OBJECTIVE

To evaluate the hygienic, environmental, social and economic benefits achieved by rural latrine renovation in key schistosomiasis control areas, Jiangsu Province.

METHODS

Eights villages (evaluation villages) that finished and the three villages (control villages) that did not finish the latrine renovation work were sampled and investigated through field visits, questionnaire, referring to information and so on, to collect relevant data, and human waste samples were detected for laboratory indicators in hygiene and environment, in key schistosomiasis control areas in three counties (cities, districts), Jiangsu Province.

RESULTS

A total of 11 villages and 220 households were investigated. In the evaluation villages, the owning rate and quality conformity rate of three-format sanitary latrines were 98.6% and 98.8%, respectively. The human schistosome infection rate, intestinal parasite infection rate, the incidence of intestinal infectious diseases, and related medical costs decreased by 100%, 44.5%, 34.2% and 82.8%, respectively, compared with those before latrine renovation. In laboratory testing, the removal rates of fecal coliform values, CODcr, BOD5 and ammonia nitrogen in the third cell of household latrine were 99.99%, 68.50%, 63.17% and 52.30%, respectively, compared to those in the first cell. The village appearance had changed fundamentally, the villagers were satisfied with the latrine renovation, and their health knowledge and health behavior improved significantly.

CONCLUSIONS

Rural latrine renovation in key schistosomiasis control areas has got great achievements in hygienic, environmental, social and economic benefits. It plays an important role in the promotion of schistosomiasis control, economic development and social harmony.

[Exploration of model of Oncomelania snail survey post-transmission control in Jiangdu City]

OBJECTIVE

To explore the model of Oncomelania snail survey in inland areas, so as to reduce the burden of farmers as well as to improve the quality of snail survey.

METHODS

A database of environment in snail survey was established, and specialized personnel were organized at town level. The general survey combined with survey in turn was used.

RESULTS

After the improvement of the survey model, the personnel numbers and amounts of labor used, especially the cost afforded at village level decreased significantly, without any influence on the quality of snail survey.

CONCLUSIONS

The improvement of snail survey model can enhance the efficiency and quality of survey, and can reduce the burden of farmers, but careful organization, strengthened management, and standardized operations are needed in the procedure.

[Snail control effect and eco-economical benefit of forest for snail control and schistosomiasis prevention in mountainous regions]

OBJECTIVE

To evaluate the snail control effect and eco-economical benefit of the forest for snail control and schistosomiasis prevention in mountainous regions.

METHODS

From 2006 to 2010, the retrospective survey, field inspection and family interview were adopted to collect the data of snail status, and the economic income and ecological environment of local region in rice paddy, seedling bed, irrigation channel and kaleyard channel in Sanying Village, Eryuan County, Yunnan Province, where the Flourishing Forest and Controlling Snails Project was implemented.

RESULTS

After the implementation of the project, compared to 2006, the snail areas in rice paddy, seedling bed, irrigation channel and kaleyard channel in 2010 reduced by 70.5%, 91.0%, 49.7%, and 58.8%, respectively; the occurrence rates of frames with living snails dropped by 81.6%, 97.2%, 84.4% and 87.9%, respectively; and the average densities of living snails dropped by 79.0%, 97.8%, 86.0% and 93.6%, respectively. The economic income of farmers and ecological environment improved obviously.

CONCLUSIONS

The forest for snail control and schistosomiasis prevention in mountainous areas not only has an obvious effect on snail control, but also can yield significant economic and ecological benefits.

[Selection of government instruments in schistosomiasis control services]

From the perspective of public administration and epidemiology, on the combination of the governance cases in the central and local government of China, the author explores ten modes of the provision of public goods and services in schistosomiasis control services, discusses seven main government instruments, and points out its pluralism, complexity and the slight changes of government' s preference. This paper also explores the approach to help the relevant government make schistosomiasis control work more practicable in field.

[Technology of preventing Oncomelania snail diffusion in east route of South-to-North Water Diversion Project. I. Field test of blocking diffusion of Oncomelania snails with blocking network via collecting water from middle layer]

OBJECTIVE

To evaluate the effectiveness of blocking diffusion of Oncomelania snails with the blocking network via collecting water from middle layer.

METHODS

According to the principle of the installation preventing snails via collecting water from middle layer without snails, the blocking network was manufactured. The field test of the blocking diffusion of snails with the blocking network was carried out in the electric pumping station and the irrigation located in the area with snails. The snails stained were put into the water inlet of the pump when the pump was actuating, and the snails pumped were observed during the test period. The cost of the test was also calculated.

RESULTS

The rate of blocking diffusion of snails with the blocking network was 100%, and the direct costs were only 11 030 CNY.

CONCLUSIONS

The blocking network via collecting water from middle layer has good effect for prevention of snail dispersal. It is simple for manutacturing and installation, and suitable for emergency blocking diffusion of snails in the east route of South-to-North Water Diversion Project and the electric pumping station with snails.

[Effect of jian-gan-le on advanced schistosomiasis]

A total of 80 cases of advanced schistosomiasis were selected and divided into an experiment group and a control group, 40 cases each group, by the random sampling method. The patients in the experiment group were administered with Jian-gan-le, and the patients in the control group received compound purple granules. In the experiment group, the curative rate was 25.0%, the improving rate was 70.0%, the inefficacy rate was 5%, and the efficiency rate was 95.0%. In the control group, the curative rate was 12.5%, the improving rate was 75%, the inefficacy rate was 12.5%. There was no statistic difference between the 2 groups (P all > 0.05). The expense was cheaper in the experiment group than in the control group.

[Effect of project of afforestation for schistosomiasis prevention on snail control in marshland and lake regions]

OBJECTIVE

To evaluate the effect of the project of afforestation for schistosomiasis prevention on Oncomelania hupensis control.

METHODS

The situation of afforestation for schistosomiasis prevention in the field and the snail distribution in marshland regions were surveyed with the systematic sampling method in the spring, 2009. The database of snail distribution was established and the status of afforestation was investigated, and the effect of the project on snail control was evaluated.

RESULTS

The rates of frames with living snails in the environment with plantations and the environment without a plantation were 14.9% and 19.7%, respectively, and there was a significant difference (Chi2 = 2 267, P < 0.01). The rate of frames with living snails in agroforestry model was lower than that in other models except for fishery-husbandry-forestry model. The average densities of living snails in the environment with plantations and the environment without a plantation were 0.552 snails/0.1 m2 and 0. 989 snails/0.1 m2, respectively. The average densities of living snails in the cultivating group and un-cultivating group were 0.354 snails/0.1 m2 and 0.653 snails/0.1 m2, respectively. The rate of frames with living snails and the average density of living snails were the lowest in the environment of long-term afforestation.

CONCLUSIONS

The project of afforestation for schistosomiasis prevention has a good effect on snail control in Anhui Province. Long-term afforestation could stably maintain the effect on snail control.

[Cost-effectiveness and cost-benefit analysis on the integrated schistosomiasis control strategies with emphasis on infection source in Poyang Lake region]

OBJECTIVE

To evaluate the cost-effectiveness and cost-benefit on the integrated schistosomiasis control strategies with emphasis on infection source, and provide scientific basis for the improvement of schistosomiasis control strategy.

METHODS

Aiguo and Xinhe villages in Jinxian County were selected as intervention group where the new comprehensive strategy was implemented, while Ximiao and Zuxi villages in Xinzi County served as control where routine control program was implemented. New strategy of interventions included removing cattle from snail-infested grasslands and providing farmers with farm machinery, improving sanitation by supplying tap water and building lavatories and methane gas tanks, and implementing an intensive health education program. Routine interventions were carried out in the control villages including diagnosis and treatment for human and cattle, health education, and focal mollusciciding. Data were collected from retrospective investigation and field survey for the analysis and comparison of cost-effectiveness and cost-benefit between intervention and control groups.

RESULTS

The control effect of the intervention group was better than that of the control. The cost for 1% decrease of infection rate per 100 people, 100 cattle, and 100 snails in intervention group was 480.01, 6 851.24, and 683.63 Yuan, respectively, which were about 2.70, 4.37 and 20.25 times as those in the control respectively. The total cost/benefit ratio (BCR) was lower than 1 (0.94 in intervention group and 0.08 in the control). But the total benefit of intervention group was higher than that of the control from 2005 to 2008. The forecasting analysis indicated that the total BCR in intervention group would be 1.13 at the 4th year and all cost could be recalled. Sensitivity analysis revealed that the BCR in intervention group changed in the range around 1.0 and that of the control ranged blow 0.5. The cost-benefit of intervention group was evidently higher than that of the control.

CONCLUSIONS

The integrated control strategy focusing on infection source control brings about triplex benefits in schistosomiasis control, social development (and ecological protection) and economic efficacy, and shows better effects and benefits than the conventional control strategy.

Improving control of African schistosomiasis: towards effective use of rapid diagnostic tests within an appropriate disease surveillance model

Contemporary control of schistosomiasis is typically reliant upon large-scale administration of praziquantel (PZQ) to school age children. Whilst PZQ treatment of each child is inexpensive, the direct and indirect costs of preventive chemotherapy for the whole school population are more substantive and, at the national level where many schools are targeted, maximising cost effectiveness and the health impact are essential requirements for ensuring longer-term sustainability (i.e. >5 years). To this end, the WHO has issued a set of treatment guidelines, inclusive of re-treatment schedules, such that, where possible, treatment decisions by school are based upon local disease prevalence as determined by parasitological and/or questionnaire methods. As each diagnostic method has known shortcomings, presumptive treatment of at-risk schools may initially be preferred, especially if the existing infrastructure for disease surveillance is poor. It is against this background of school-based preventive chemotherapy that a rapid diagnostic test (RDT) for schistosomiasis is most urgently needed, not only to improve initial disease surveillance but also to focus drug delivery better through time. In this paper, the development, evaluation and application of selected diagnostic tests are reviewed to identify barriers that impede progress, foremost of which is that a new disease surveillance and evaluation model is required where the in-country price of each RDT ideally needs to be less than US$1 to be cost effective both in the short- and long-term perspective.

[Evaluation indices of social burden caused by advanced schistosomiasis]

OBJECTIVE

To study the evaluation indices and their weights of social burden caused by advanced schistosomiasis so as to provide scientific basis for control of the disease.

METHODS

Primary indices of social burden evaluation for advanced schistosomiasis were summarized based on literature review. Secondary indices were put forward by a brainstorming process of experts. After the first round Delphi method, the secondary indices that needed were chosen, and the importance of primary indices was prioritized. Through the second and third round Delphi method, the weight of each secondary index was obtained.

RESULTS

Four primary indices and 16 secondary indices consisted the index system of social burden induced by the disease. According to the significance, the 4 primary indices were arranged as social economy, government image, public psychology and social security. The weight of "funding for schistosomiasis control from central and local governments" in "social economic" stood the largest (14.063), while that of "equity to patients" in "government image", the smallest (3.125).

CONCLUSION

The study covers all major aspects and their significance in social burden of advanced schistosomiasis, and an evaluation index system has been established for field validation.

Willingness to pay for praziquantel treatment in a hyperendemic community of Ogun State, Nigeria

BACKGROUND

Schistosomiasis is highly endemic in Nigeria. However, very little is known about the usage and social marketing of praziquantel in the control of schistosomiasis in endemic communities and on the persons willingness to pay for the drug to support its extensive use and thus aid control efforts in Nigeria.

OBJECTIVE

The study examined the willingness of people in a hyperendemic community, to pay for treatment with praziquantel before and after provision of the drug, with a view to assess the feasibility of achieving widespread coverage.

METHODS

Data were collected through focus group discussions among household heads and other adult family members and through the use of a questionnaire to survey household heads in Imala-Odo, a community hyperendemic for schistosomiasis, in southwest Nigeria. The main outcome measure was the respondents' willingness to pay for schistosomiasis treatment.

RESULTS

The results showed that in contrast to the 92.3% of respondents who expressed willingness to buy the drug in the preintervention study, only 46.5% actually purchased the drug during intervention for the treatment of their infected household members. The respondents' level of education, occupation, and income influenced their willingness to pay (P<.05). Statistical tests showed that those willing to pay for treatment had a higher income score than those unwilling to do so. Most respondents preferred their community head and reliable persons chosen by the community as convenient outlets for drug distribution. The number of household members respondents were willing to treat increased from 4 to 6 at N320.00 (US $2.52) in the preintervention and postintervention phases, respectively. Gender factor was found to influence the respondents' perceived average treatment cost; the females wanted N300.00 (US $2.36) against N100.00 (US $0.79) among the males.

CONCLUSION

Efforts need to be made and sustained to ensure that all families can afford to praziquantel drug to achieve the ultimate goal of controlling the infection in endemic communities of Nigeria.

Reassessment of the cost of chronic helmintic infection: a meta-analysis of disability-related outcomes in endemic schistosomiasis

BACKGROUND

Schistosomiasis is one of the world's most prevalent infections, yet its effect on the global burden of disease is controversial. Published disability-adjusted life-year (DALY) estimates suggest that the average effect of schistosome infection is quite small, although this is disputed. To develop an evidenced-based reassessment of schistosomiasis-related disability, we did a systematic review of data on disability-associated outcomes for all forms of schistosomiasis.

METHODS

We did structured searches using EMBASE, PUBMED, and Cochrane electronic databases. Published bibliographies were manually searched, and unpublished studies were obtained by contacting research groups. Reports were reviewed and abstracted independently by two trained readers. All randomised and observational studies of schistosomiasis morbidity were eligible for inclusion. We calculated pooled estimates of reported disability-related effects using weighted odds ratios for categorical outcomes and standardised mean differences for continuous data.

FINDINGS

482 published or unpublished reports (March, 1921, to July, 2002) were screened. Of 135 selected for inclusion, 51 provided data for performance-related symptoms, whereas 109 reported observed measures of disability-linked morbidities. Schistosomiasis was significantly associated with anaemia, chronic pain, diarrhoea, exercise intolerance, and undernutrition.

INTERPRETATION

By contrast with WHO estimates of 0.5% disability weight assigned to schistosomiasis, 2-15% disability seems evident in different functional domains of a person with schistosomiasis. This raised estimate, if confirmed in formal patient-preference studies, indicates a need to reassess our priorities for treating this silent pandemic of schistosomiasis.

Schistosomiasis control in Ghana: case management and means for diagnosis and treatment within the health system

An essential component of integrated schistosomiasis control as promoted by WHO is adequate clinical care for patients presenting at health care facilities. We evaluated the functioning of the Ghanaian health system for diagnosis and treatment of schistosomiasis by interviewing health workers from 70 health care facilities in 4 geographical areas in April and May 2000. Results from presentation of 4 hypothetical cases and a subsequent interview demonstrated that patients presenting with symptoms related to schistosomiasis have a small chance of receiving adequate treatment: often health workers do not recognize the symptoms, especially those of Schistosoma mansoni; patients are frequently referred for a diagnostic test or treatment with a large risk of non-compliance; and praziquantel was not available in 78% of the health care facilities with reported schistosomiasis in their coverage area. The overall cost of treatment is considerable: [symbol: see text] 2.13 for S. haematobium and [symbol: see text] 1.81 for S. mansoni patients, with drug costs contributing approximately 40% of the total cost. To better meet WHO recommendations for passive case detection as part of integrated schistosomiasis control, the Ghanaian health system needs to emphasize training of health workers in schistosomiasis case recognition and case management and increase the availability of praziquantel. Experience from other West African countries indicate that this is feasible.

Achievement of the World Bank loan project on schistosomiasis control (1992-2000) in Hubei province and the challenge in the future

Since the World Bank provided a loan for control of schistosomiasis in China, started from 1992, with the objective of a reduction of prevalence and intensity of the infection both in humans and animals by 40%, through mass chemotherapy in areas of high prevalence, and selective chemotherapy in areas with medium and low endemicity together with focal mollusciciding, the objective of morbidity control of the project has been reached in Hubei Province.

Is equity being sacrificed? Willingness and ability to pay for schistosomiasis control in China

Decentralization of the health care system in China has led to an increasing need for income generation at all operational levels, both for curative services and for public health programmes. In general, people have accepted the costs of curative services, although the impact of charges on health-seeking behaviour has yet to be assessed. Public health programmes present particular problems in terms of revenue generation, however, because of the less direct impact of these activities on individual health and well-being. In this paper, we report the results of a cross-sectional study of willingness and ability to pay for schistosomiasis control. Questionnaires were administered to household heads of six representative villages in the Dongting Lake Region of Hunan Province, China. A total of 628 valid questionnaires were analyzed. The yearly mean household expenditure on schistosomiasis diagnosis and treatment was RMB 59.50 +/- 146.04 Yuan (US$1 = 8 RMB Yuan), accounting for 0.94% of the total yearly household income. Most household heads (514, 82%) thought schistosomiasis was the greatest health threat in their communities, but only 30.9% of them were willing to pay for screening, diagnosis and treatment of the infection. On the other hand, 72.3% of the respondents were willing to undertake volunteer work for control.

Pattern and cost of medical care for workers with schistosomiasis

This study describes the pattern of medical care provided to workers with schistosomiasis, estimate the total medical cost and to identify the proportional rates of sickness retirement attributed to schistosomiasis. The observational approach was adopted for this study 170 schistosomiasis workers and a similar number of controls were included in this study. An interviewing schedule and a special format were designed for collecting personal, medical and early retirement data. The results revealed that the mean total cost in the outpatient clinics was significantly higher for schistosomiasis workers than their controls (320.2 " 330.11 versus 210.8 " 260.01 L.E). The hospital cost was also higher for schistosomiasis workers compared with their controls (265.9 " 674.47 vs 195.8 " 629.72 L.E) but this differencewas not statistically significant. More than 80% of the total hospital cost was spent on bed cost. The average operative cost/worker was significantly higher among the schistosomiasis workers than the control workers (7.08 " 22.07 vs 2.35 " 5.2 L.E). The total medical cost (outpatient and hospital) was significantly higher for workers with schistosomiasis compared with their controls (586.02" 845.77 vs 406.57 " 694.34). The total number of workers who retired because of sickness disability other than schistosomiasis increased from 1994 to 1998 with a ratio of 2.54 while those who retired because of schistosomiasis and its complications increased with a ratio of 3.64.

The cost of large-scale school health programmes which deliver anthelmintics to children in Ghana and Tanzania. The Partnership for Child Development

It has been argued that the delivery of anthelmintics to school-children through existing education infrastructure can be one of the most cost-effective approaches to controlling parasitic worm infection. This paper examines the actual costs of a combination of mass and selective treatment for schistosomiasis using praziquantel and mass treatment for intestinal nematodes using albendazole, as an integral part of school health programmes reaching 80442 pupils in 577 schools in Volta Region, Ghana, and reaching 109099 pupils in 350 schools in Tanga Region, Tanzania. The analysis shows that financial delivery costs per child treated using praziquantel, which involved a dose related to body mass and a prior screening at the school level, were US$ 0.67 in Ghana and US$ 0.21 in Tanzania, while the delivery costs for albendazole, which was given as a fixed dose to all children, were US$ 0.04 in Ghana and US$ 0.03 in Tanzania. The higher unit costs in Ghana reflect the epidemiology of infection; overall, fixed costs were similar in both countries, but fewer children required treatment in Ghana. Analysis of economic costs-which includes the cost of unpaid days of labour--indicates that the financial costs are increased in Ghana by 78% and in Tanzania by 44%. It is these additional costs which are avoided by integration into an existing infrastructure. It is concluded that: the base cost of delivering a universal, standard, school-based health intervention can be as low as US$ 0.03 per child treated; that even a slight increase in the complexity of delivery can have a significant impact on the cost of intervention; and that the use of the education infrastructure does indeed offer significant savings in delivery costs.

Different approaches to modelling the cost-effectiveness of schistosomiasis control

This paper reviews three different approaches to modelling the cost-effectiveness of schistosomiasis control. Although these approaches vary in their assessment of costs, the major focus of the paper is on the evaluation of effectiveness. The first model presented is a static economic model which assesses effectiveness in terms of the proportion of cases cured. This model is important in highlighting that the optimal choice of chemotherapy regime depends critically on the level of budget constraint, the unit costs of screening and treatment, the rates of compliance with screening and chemotherapy and the prevalence of infection. The limitations of this approach is that it models the cost-effectiveness of only one cycle of treatment, and effectiveness reflects only the immediate impact of treatment. The second model presented is a prevalence-based dynamic model which links prevalence rates from one year to the next, and assesses effectiveness as the proportion of cases prevented. This model was important as it introduced the concept of measuring the long-term impact of control by using a transmission model which can assess reduction in infection through time, but is limited to assessing the impact only on the prevalence of infection. The third approach presented is a theoretical framework which describes the dynamic relationships between infection and morbidity, and which assesses effectiveness in terms of case-years prevented of infection and morbidity. The use of this model in assessing the cost-effectiveness of age-targeted treatment in controlling Schistosoma mansoni is explored in detail, with respect to varying frequencies of treatment and the interaction between drug price and drug efficacy.

Field activity cost estimates for the first 3 years of the World Bank Loan Project for schistosomiasis control in China

The World Bank Loan Project for schistosomiasis in China commenced field activities in 1992. In this paper, we describe disease control strategies for levels of different endemicity, and estimate unit costs and total expenditure of screening, treatment (cattle and humans) and snail control for 8 provinces where Schistosoma japonicum infection is endemic. Overall, we estimate that more than 21 million US dollars were spent on field activities during the first three years of the project. Mollusciciding (43% of the total expenditure) and screening (28% of the total) are estimated to have the most expensive field activities. However, despite the expense of screening, a simple model predicts that selective chemotherapy could have been cheaper than mass chemotherapy in areas where infection prevalence was higher than 15%, which was the threshold for mass chemotherapy intervention. It is concluded that considerable cost savings could be made in the future by narrowing the scope of snail control activities, redefining the threshold infection prevalence for mass chemotherapy, defining smaller administrative units, and developing rapid assessment tools.

Economic evaluation in schistosomiasis: valuation of health states preferences. A research note

Poor countries can ill-afford ineffective health care. An effective disease intervention is one which produces a net improvement in beneficiaries' quality of life and/or increases life expectancy. Unlike developed countries, very little research has been done in developing countries on the measures of the ultimate output of health care. The objectives of this study were to: (i) apply the existing health-related quality of life (HRQoL) methods in eliciting health state valuations from farmers, teachers and health professionals living and working in the schistosomiasis endemic Mwea Irrigation Scheme in Kenya; (ii) determine whether there is significant difference between average health states valuations from the three main groups of people at risk of schistosomiasis infection; and (iii) assess the relative effect of different respondent characteristics and health states prognosis on valuations. The instrument consists of seven health state descriptions-each defined along six functional dimensions: self-care, mobility, livelihood activities, energy, social participation and pain. Cardinal health state values were measured using a visual-analogue-scale (VAS). Values were elicited from three random samples of farming general public, medical professionals and teachers. The Kruskal-Wallis one-way ANOVA test showed that there is significant difference in the average health state values (for mild, moderate, severe, very severe and comatose states) obtained from the three samples. Generally, except for the valuation of the immediately following state, the other explanatory variables are not statistically significant determinants of valuations for the mild, moderate, severe and very severe states. The results suggest that VAS valuations are primarily affected by prognosis. There is urgent need for more representative and systematic HRQoL studies to test the relevance of the Western-based generic instruments in African countries contexts, with a view to developing more appropriate tool(s) if necessary.

Financing changes of schistosomiasis control programmes in China 1980-1995: a case study in Songzi county

To assess the financing changes of schistosomiasis control programmes in China and estimate the impact of these changes on patients' treatment-seeking behaviour and control of schistosomiasis, a survey was conducted in five schistosomiasis-endemic areas of the lake regions, Hubei province, in 1996. This paper reports financing changes and their impact on the incidence and prevalence of schistosomiasis from one of the five areas as a case study. By examining the surveillance and financial data from 1980 to 1995, and through focus group discussions we found that the schistosomiasis control programmes in People's Republic of China have gone through dramatic financing changes from 1980 to 1995, when the transitions of China's social, economic, and political systems happened. The proportions of funding to schistosomiasis control programmes from high level governmental agencies, county budgets, and services revenue changed from 60%, 23%, and 17%, respectively, in 1980-1987 to 0.7%, 22.3%, and 72% in 1995. The percentages of expenditure of schistosomiasis control activities, salaries and bonuses, and other activities unrelated to schistosomiasis control, were 53.5%, 14.4, and 17.2% in 1980. These percentages changed to 7.7%, 33.3%, and 53.3%, respectively, in 1995. The preponderant role of the state in organizing, financing, and delivery of the services was replaced with the new system which is more influenced by the market economy. The incidence and the prevalence of schistosomiasis in the study area have increased year by year from 1980 to 1990, although there has been a tendency to decrease after 1991 but not to the low pre1980 levels. The collapse of the community-based medical system in rural areas and the dramatic financing changes of schistosomiasis control programmes have created major difficulties for schistosomiasis control in China.

Eradication of schistosomiasis in Guangxi, China. Part 2: Political economy, management strategy and costs, 1953-92

Reported are the results of a study of the political economy, management, and costs of the successful Guangxi schistosomiasis eradication programme, spanning 40 years from 1953 to 1992. For this purpose we analysed all government data and memoranda on the policy, management, technical support, finance, and the control strategy of the programme. We also interviewed many local staff involved in the programme over the 40-year period and obtained cost data from annual county-level records on seven major categories of variable costs. Schistosomiasis control in Guangxi began with one of the first examples of community participation and rapid assessment in public health history--the use of pre-franked envelopes to return disease questionnaires and suspect snails from rural areas. This approach quickly and accurately delineated the endemic area. This was Mao Zedong's "mass line", incorporating ideas and knowledge from peasants directly into services run for and by them, here the schistosomiasis control programme. Recognition by China's leaders that schistosomiasis was a great economic burden, steadfast prioritizing of the programme over 40 years, local innovative scientific study, agricultural and environmental focus on eradicating the snail hosts and boosting rural production, and mass community education and support were all key factors in the final success. Local leaders motivated programme staff and everyone involved knew the objectives. The programme was always multisectoral, with policy developed centrally, and strategy and collaboration encouraged and rewarded at the grass-roots. These features explain how a very poor autonomous region such as Guangxi finally eradicated schistosomiasis, spending less than US$ 0.50 per protected citizen per year; it is remarkable that the disease and snails were initially found across a large area of complex environments and modern drugs such as praziquantel were not available for most of the 40-year period. The lessons from Guangxi can be adapted elsewhere and should encourage other areas to control endemic schistosomiasis using methods devised to suit the local culture and geography.

Human behaviour, cost-effectiveness analysis and research and development priorities: the case of a schistosomiasis vaccine

Cost-effectiveness analysis has been widely used in the health sector to guide decisions about where scarce resources aimed at disease prevention or control should be invested. It has rarely been used to guide decisions about what type of health research should be funded. In addition, the validity of the behavioural assumptions underlying the economic analysis is rarely considered explicitly. This paper explores the use of cost-effectiveness analysis to set priorities for research using the development of a schistosomiasis vaccine as an example. It then explicitly considers behavioural factors which might affect the accuracy of the calculations. A 'product profile' for the new technology is derived which can be used by developers as a target to aim at. To ensure that the vaccine would be more cost-effective than the currently preferred option for the control of schistosomiasis, chemotherapy based on praziquantel, researchers need a vaccine which has sufficient duration of protection to be delivered as part of the regular childhood immunization programme me. The cost of adding it to existing vaccination schedules should not be more than US$4.30 per child in excess of the cost of one round of chemotherapy. It should, ideally, have an efficacy over 80%. These results, however, depend on a number of cultural and behavioural factors which are often ignored in cost-effectiveness studies. For example, low rates of school attendance would increase the cost of contacting children for a chemotherapy programme and increase the relative attractiveness of a vaccine. For chemotherapy to be effective, children also need to comply each year for a number of years. Falling rates of compliance over time would reduce the effectiveness of chemotherapy and increase the attractiveness of a vaccine. But on the other hand, even though a vaccine may still be more cost-effective than chemotherapy at relatively low levels of vaccine efficacy, if mothers perceived the vaccine to be ineffective and refused to bring their children for vaccination, the success of the entire childhood immunization programme could be threatened.

Different approaches to modeling the cost-effectiveness of schistosomiasis control

The limited economic resources available for health care in developing countries necessitates the involvement of cost analysis in the planning of any control intervention. A number of studies have undertaken cost-effectiveness analysis of schistosomiasis control, and the methodologies utilized in both cost and effectiveness evaluation are discussed. In attempting to relate cost to effectiveness, most studies have utilized static models expressing effectiveness in terms of coverage (drug delivery) or cure rate (infection prevalence reduction). These immediate output measures do not consider the long-term impact of control nor the effect on disease. An alternative approach is to use a model of the transmission dynamics of the parasite to permit evaluation of the long-term impact of control. An example of a population dynamic approach to cost-effectiveness analysis that can assess the impact of treatment on infection and disease due to the intestinal nematodes is presented to illustrate the potential of this approach in modeling the cost-effectiveness of schistosomiasis control.

Community-based approach to schistosomiasis control

With few exceptions, efforts to control schistosomiasis have relied upon ongoing community cooperation with "outsiders' rather than creating within the community the capacity and means for carrying out ongoing disease control measures with minimal external support. Offered as a useful model is a program in Kaele subdivision, Extreme North Province, Cameroon designed to establish and integrate within the primary health care (PHC) system the control of urinary schistosomiasis, hyperendemic in the region. At the community level, and with minimal dependence upon external resources, culturally appropriate and effective health education was instituted, the capacity to diagnose and treat schistosomiasis was created, diagnosis and drug therapy (praziquantel) was made available conveniently and at low cost, and, on a very limited basis, snails were controlled. Efforts were made to build upon and strengthen existing community structures and institutions rather than create new ones. The impact of the interventions was measured in terms of changes in knowledge and behavior, prevalence and intensity of infection, utilization of health services, and the ability to finance the control activities within the context of a generalized cost recovery system. Program successes and failures are discussed, as well as lessons learned and their implications.

Controlling schistosomiasis: the cost-effectiveness of alternative delivery strategies

Sustainable schistosomiasis control cannot be based on large-scale vertical treatment strategies in most endemic countries, yet little is known about the costs and effectiveness of more affordable options. This paper presents calculations of the cost-effectiveness of two forms of chemotherapy targeted at school-children and compares them with chemotherapy integrated into the routine activities of the primary health care system. The focus is on Schistosoma haematobium. Economic and epidemiological data are taken from the Kilombero District of Tanzania. The paper also develops a framework for possible use by programme managers to evaluate similar options in different epidemiological settings. The results suggest that all three options are more affordable and sustainable than the vertical strategies for which cost data are available in the literature. Passive testing and treatment through primary health facilities proved the most effective and cost-effective option given the screening and compliance rates observed in the Kilombero District.