Dididi project

Why stronger diagnostic capacity belongs on the management agenda of hospitals, clinics and dispensaries.

A patient returns with persistent abdominal discomfort. A child is being assessed for anaemia. A woman seeks care for urinary or genital symptoms. Each presentation enters a familiar clinical pathway, yet a parasitic infection may remain unrecognised. For the facility manager, the question extends beyond identifying the cause: can the service obtain an appropriate specimen, produce a reliable result, communicate it promptly and ensure that the patient receives suitable care?

Helminth infections—diseases caused by parasitic worms—expose weaknesses across this entire pathway. Their importance is particularly clear in endemic settings in sub-Saharan Africa, where DIDIDI focuses its research. However, relevant exposure histories also matter in facilities serving mobile populations and patients who have previously lived in endemic areas.

Scientific evidence explains why these infections can be difficult to detect and why diagnostic approaches must be chosen carefully. The operational implications are equally important: better diagnostic capacity means organising people, equipment, supplies, referral services and information around decisions that improve patient care. The management priorities discussed below are practical implications of that evidence, rather than claims of proven savings for every facility.

A large burden that can remain hidden in routine care

The World Health Organization estimates that soil-transmitted helminth infections affect approximately 1.5 billion people globally. These infections are associated with inadequate sanitation and disproportionately affect disadvantaged communities. The principal intestinal species include Ascaris lumbricoides, Trichuris trichiura and hookworms. Infection intensity influences morbidity, including nutritional impairment and intestinal symptoms; hookworm-associated blood loss can contribute to anaemia. [1]

Schistosomiasis adds a different pattern of disease. Infection follows contact with freshwater containing infective larvae released by snails. Depending on the species and disease progression, patients may develop intestinal, liver, urinary or genital complications. WHO reports that at least 253.7 million people required preventive treatment in 2024. This figure describes a population requiring preventive treatment, rather than a count of confirmed infections. [2]

For managers, the consequence is that helminth-related demand may be distributed across several services rather than concentrated in a designated tropical-disease clinic. Outpatient care, paediatrics, maternity services and specialist referral pathways can all encounter relevant patients. Facility records organised only around presenting symptoms may therefore provide an incomplete picture of the underlying problem.

This is a reason to review local diagnostic pathways, not to assume that every nonspecific symptom is caused by worms. Clinicians need to consider alternative diagnoses and coexisting conditions. Management should ensure that an appropriate helminth investigation is accessible when the clinical assessment and exposure history justify it.

Why diagnostic uncertainty becomes an operational issue

A laboratory test is one step in a sequence. Someone must request it, explain specimen collection, receive and identify the sample, prepare it, perform the analysis, validate the result and return it to the clinical team. A technically sound test cannot support care if any of these steps fails.

Consider a dispensary that sends samples to a district laboratory. Referral may be the right arrangement, but its value depends on transport, specimen requirements, reporting and patient contact. If the result arrives after the patient has left, the service needs a dependable method of communicating it and arranging treatment. Purchasing equipment addresses only part of this problem.

Diagnostic uncertainty can also create additional work. A clinician may request another specimen, arrange a referral or reassess a patient whose symptoms persist. These actions can be appropriate, but managers should establish whether they reflect unavoidable clinical complexity or a correctable weakness in the diagnostic process.

Useful starting questions are concrete: how many requested tests are completed, how often are samples rejected, how long do results take, and who follows up an unresolved case? Tracking these steps can reveal problems that a simple count of tests performed will miss. Any claim that improved testing reduces repeat visits or referral costs should then be evaluated with local data.

Microscopy: valuable capacity with important limitations

Microscopy remains central to many helminth diagnostic services. For intestinal infections, techniques such as Kato–Katz allow parasite eggs to be detected and counted in stool. However, a meta-analysis by Nikolay and colleagues showed that diagnostic sensitivity varies with the method, parasite species and infection intensity. Examining additional samples can improve detection, especially when infections are light. [3]

This creates a practical tension. A more extensive sampling strategy may increase sensitivity while also increasing preparation time, slide-reading workload and the demands placed on patients. Managers and clinical teams need to agree on protocols appropriate to the purpose of testing and the resources available.

The presence of a microscope is therefore an incomplete measure of capacity. A service also needs competent staff, suitable preparation materials, maintained equipment and quality assurance. Managers should ask whether coverage remains adequate during leave, staff turnover or competing laboratory demand, and whether staff can obtain expert support for uncertain findings.

Timing can matter as well: hookworm eggs can deteriorate in Kato–Katz preparations, making preparation and reading schedules relevant to detection. [3] An apparently convenient arrangement that batches specimens or delays slide examination should be assessed against the requirements of the actual technique.

A negative result must be interpreted in context. It may reduce the likelihood of infection without excluding it. Facilities need a documented route for clinicians to seek advice, request additional investigation or refer a patient when suspicion remains high. This prevents the laboratory report from becoming the endpoint of an unresolved clinical assessment.

One diagnostic pathway cannot cover every helminth infection

“Helminth testing” is not a single interchangeable service. The relevant specimen, method and interpretation depend on the parasite and the clinical question. A facility offering routine stool microscopy may still need additional arrangements for urinary schistosomiasis or strongyloidiasis.

Schistosomiasis illustrates this diversity. Egg detection, antibody tests, antigen detection and molecular methods have different applications and limitations. Antibodies may reflect previous exposure, while antigen detection can provide evidence of active infection. Performance also varies across species and settings. A review by Ally and colleagues highlights the need to match diagnostic tools to their intended use, including clinical detection and elimination programmes. [4]

For managers, this translates into a tiered service model. Some investigations can be performed locally; others require a district or reference laboratory. The referral agreement should specify accepted specimens, transport conditions, expected turnaround and how difficult results will be discussed.

The test menu should also be clear to clinicians. A request labelled “stool test” does not communicate which organisms or methods are covered. Explicit descriptions of available investigations help avoid assumptions about what a negative report means and allow staff to explain the next step to patients.

Strongyloidiasis makes diagnostic preparedness a patient-safety priority

Strongyloides stercoralis requires particular attention because its autoinfection cycle can sustain infection for many years. Immunosuppression can trigger severe hyperinfection or disseminated disease. Low larval output limits stool detection, and serological sensitivity can be reduced in immunocompromised patients. [5]

Evidence-based guidelines for non-endemic countries recommend screening people with relevant exposure risk before immunosuppression where possible. These recommendations are especially pertinent to hospitals providing services in which corticosteroids or other immunosuppressive treatments are used. Their application should follow local clinical guidance and specialist assessment. [6]

The management task is to make an agreed pathway usable: identify where exposure history is recorded, which team orders the investigation, how specialist testing is accessed and who reviews the result. Urgent clinical situations need a clear escalation route rather than dependence on an informal contact who may be unavailable.

This example shows why helminth diagnostic capacity cannot be judged solely by average outpatient demand. A relatively infrequent investigation may be important at a critical decision point. Facilities should consider the consequences of a missed diagnosis alongside test volume when deciding which capabilities to provide directly and which to secure through referral.

Preventive treatment and individual diagnosis serve different purposes

Large-scale preventive chemotherapy is an established component of helminth control. WHO’s schistosomiasis guideline addresses population treatment alongside measures to reduce transmission, including water, sanitation and hygiene interventions. [7] Such programmes can reduce morbidity, but they do not answer every question arising during individual patient care.

A patient with persistent symptoms, an atypical presentation or a relevant treatment risk may need targeted investigation. Similarly, a facility needs a plan for patients whose clinical course does not match expectations after treatment. Population-level eligibility for treatment and an individual clinical diagnosis are related but distinct decisions.

Treatment is also species-dependent. A systematic review and network meta-analysis found important differences in the efficacy of commonly used medicines against Ascaris, Trichuris and hookworm. [8] Managers should therefore support pathways that connect diagnostic findings with appropriate clinical review and access to the necessary medicines.

The operational objective is coherence. Outreach programmes, dispensaries and hospitals should be able to exchange relevant information about prior treatment and unresolved symptoms, while preserving patient confidentiality. Better connections between these services can help clinicians decide when further investigation is warranted.

What digital microscopy and AI can contribute

Digital microscopy creates opportunities to capture slide images, support remote review and assist parasite detection using artificial intelligence. For facilities with limited specialist coverage, these approaches could extend access to expertise. Their value must nevertheless be demonstrated within the full diagnostic workflow.

A 2024 study by Lundin and colleagues evaluated digital mobile microscopy and deep learning using samples collected from schoolchildren in rural Kenya and processed in a local primary healthcare laboratory. The system identified additional parasite eggs in some samples classified as negative by manual microscopy, with digital review confirming those findings. The study supports further evaluation of this approach in resource-limited settings. [9]

A subsequent Kenyan study compared manual microscopy, autonomous AI and expert-verified AI. Performance differed between these approaches, with expert verification improving sensitivity for the species assessed in analysable smears. [10] The distinction matters for procurement: an assisted service with human review is a different operating model from autonomous reporting.

These studies establish diagnostic promise, rather than a universal business case. School-survey findings may not transfer directly to every hospital population or routine service. Managers should examine sample-quality exclusions, reference standards, parasite-specific performance and the work required to resolve uncertain findings before adopting a system.

Better diagnostics must fit the facility’s working conditions

The strongest technology proposal starts with a defined service problem. A hospital seeking more reliable detection of light infections may have different requirements from a dispensary seeking shorter turnaround or a district network seeking remote expert support.

Before purchasing or piloting a tool, managers should define who will use it, which patients it will serve and which decision its result will support. They should then assess the complete process: collection, preparation, analysis, verification, reporting and clinical action. A faster analysis step has limited benefit if the rest of the pathway remains slow.

Practical evaluation should include the following questions:

Performance: Does accuracy remain acceptable for the relevant species, infection intensities and local specimens?
Staffing: What training, hands-on time and expert review are required during routine operation?
Reliability: Can the service function with local power, connectivity, temperature and maintenance constraints?
Supplies: Are consumables consistently available, and is there a workable response to shortages?
Reporting: Can results reach the responsible clinician and be linked to the correct patient?
Continuity: What happens when equipment fails or the usual operator is absent?

These are operational design questions, not secondary implementation details. A pilot should include ordinary users and realistic workloads so that managers can see whether the proposed service remains workable beyond a supervised research session.

Evaluate total cost and clinical usefulness together

The purchase price of a diagnostic device is only one budget component. Facilities should account for sample preparation, consumables, staff time, training, maintenance, quality assurance, software, connectivity and referral support where applicable.

A low-cost test that often produces an unusable result may consume substantial resources. Conversely, a more expensive approach may provide worthwhile clinical benefit without generating immediate cash savings. Cost-effectiveness and affordability are separate questions: a beneficial service still needs a sustainable operating budget.

Managers can make evaluations more informative by defining a small set of measures before implementation. These might include time from request to communicated result, the proportion of specimens yielding a reportable result, hands-on staff time and the proportion of patients with an actionable result who receive documented follow-up.

The denominator matters. Measuring only successfully analysed samples can conceal collection failures, rejected specimens and patients lost before reporting. Comparing performance across the full pathway gives a more realistic picture of service value. Claims about reduced visits, admissions or referrals require additional evidence and should not be inferred from diagnostic accuracy alone.

Make diagnostic information useful beyond the individual encounter

An individual result supports care; aggregated results can also inform service planning. Repeated detection in a particular catchment area may justify discussion with public-health teams, review of outreach priorities or closer attention to demand for relevant tests.

However, facility data are shaped by access to care, clinician requests and test sensitivity. A low recorded case count may reflect limited testing rather than low infection prevalence. Managers should interpret positivity alongside testing volume, changes in methods and the population being investigated.

Digital reporting can make this information easier to retrieve, but it should reduce duplicate entry and assign responsibility for reviewing the data. A dashboard is useful when its information prompts an appropriate decision: adjusting laboratory capacity, investigating a cluster or coordinating with district health authorities.

Environmental surveillance offers another potential source of information. Its interpretation must remain distinct from individual diagnosis: detecting parasite material in wastewater or other community samples does not identify which person is infected. Linking these data streams requires validation and clearly defined public-health uses.

DIDIDI: connecting diagnostic innovation with service needs

DIDIDI is developing low-cost digital diagnostics and connected data systems for soil-transmitted helminths and schistosomiasis in underserved rural settings in sub-Saharan Africa. Its planned work includes individual diagnostic tools, community-level environmental testing, health-information integration and investigation of climate–health relationships. [11]

For healthcare managers, the relevant feature is the project’s emphasis on field evaluation, usability and health economics alongside technical development. Work in Uganda and Kenya is intended to assess whether innovations can support frontline services and wider health-system decisions. These are research objectives; clinical benefits, operating requirements and economic value must be established through evaluation. [11]

Facilities have an important role in this process. They can explain where existing pathways break down, help define acceptable turnaround and workload, and identify the support needed for sustained use. Their participation helps ensure that diagnostic innovation addresses problems encountered during routine care.

Put helminth diagnostics on the service-improvement agenda

For hospital, clinic and dispensary managers, helminth infections deserve attention because they connect clinical uncertainty with the organisation of everyday services. The response begins with a practical review of local exposure risks, available tests, laboratory coverage, referral arrangements and patient follow-up.

Better capacity may mean improving an existing microscopy service, securing specialist testing, introducing an evaluated digital tool or redesigning how results reach patients. The appropriate investment depends on the facility’s needs and evidence from its operating environment.

The goal is a dependable diagnostic pathway: an appropriate investigation, a result whose limitations are understood, and a clear route to clinical action. Building that pathway makes an overlooked infection more visible—and makes healthcare services better equipped to respond.

References

World Health Organization. Soil-transmitted helminth infections. Fact sheet, 18 January 2023. WHO.
World Health Organization. Schistosomiasis. Fact sheet, 23 February 2026. WHO.
Nikolay B, Brooker SJ, Pullan RL. Sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard. International Journal for Parasitology. 2014;44(11):765–774. PubMed.
Ally O, Kanoi BN, Ochola L, et al. Schistosomiasis diagnosis: Challenges and opportunities for elimination. PLOS Neglected Tropical Diseases. 2024;18(7):e0012282. doi.org/10.1371/journal.pntd.0012282.
Buonfrate D, Bradbury RS, Watts MR, Bisoffi Z. Human strongyloidiasis: complexities and pathways forward. Clinical Microbiology Reviews. 2023;36(4):e00033-23. doi.org/10.1128/cmr.00033-23.
Requena-Méndez A, Buonfrate D, Gomez-Junyent J, Zammarchi L, Bisoffi Z, Muñoz J. Evidence-Based Guidelines for Screening and Management of Strongyloidiasis in Non-Endemic Countries. American Journal of Tropical Medicine and Hygiene. 2017;97(3):645–652. PubMed.
World Health Organization. WHO guideline on control and elimination of human schistosomiasis. Geneva: WHO; 2022. WHO guideline.
Moser W, Schindler C, Keiser J. Efficacy of recommended drugs against soil transmitted helminths: systematic review and network meta-analysis. BMJ. 2017;358:j4307. doi.org/10.1136/bmj.j4307.
Lundin J, Suutala A, Holmström O, et al. Diagnosis of soil-transmitted helminth infections with digital mobile microscopy and artificial intelligence in a resource-limited setting. PLOS Neglected Tropical Diseases. 2024;18(4):e0012041. doi.org/10.1371/journal.pntd.0012041.
von Bahr J, Suutala A, Kucukel H, et al. AI-supported versus manual microscopy of Kato-Katz smears for diagnosis of soil-transmitted helminth infections in a primary healthcare setting. Scientific Reports. 2025;15:20332. doi.org/10.1038/s41598-025-07309-7.
DIDIDI consortium. Project description. Official project website. DIDIDI.

Sources accessed on 13 October 2026. References 1, 2 and 7 provide WHO estimates and guidance; references 3–6 and 8–10 are peer-reviewed scientific publications; reference 11 describes DIDIDI’s research objectives.