Integrated Helminth Control Program in the

HIGH BURDEN OF SOIL-TRANSMITTED HELMINTHIASES IN PRESCHOOL-AGE CHILDREN IN MASBATE: A DECADE OF IMPLEMENTATION OF THE INTEGRATED HELMINTH CONTROL PROGRAM IN THE PHILIPPINES

Vicente Y Belizario Jr1, Janice V Ng2, Maria Lourdes E Amarillo3, John Paul Caesar R delos Trinos1, Maureen R Reyes1 and Oscar Fudalan4

1Department of Parasitology, College of Public Health; 2Department of Biology, College of Arts and Sciences; 3Department of Clinical Epidemiology, College of Medicine, University of the Philippines ; 4Action Contre La Faim, Makati, Philippines

Abstract. This study aimed to describe the status of soil-transmitted helminthiases (STH) control in preschool-age children (PSAC) in four municipalities in Masbate Province, Philippines, a decade after the implementation of the Integrated Hel- minth Control Program. This cross sectional study, which included 1,224 PSAC, utilized Kato-Katz technique to determine parasitological status. Secondary data were reviewed to obtain deworming coverage in the selected municipalities. Re- sults showed a prevalence of STH and a prevalence of moderate-heavy intensity STH of 72% and 41%, respectively, while the deworming coverage in the province in 2013 was 71%. None of the municipalities met the global target on prevalence of moderate-heavy intensity STH of below 1, while only met the national target for STH prevalence of below 50%. The deworming coverage in the prov- ince was below the global and national targets of 75% and 85%, respectively. The failure to meet these targets may be related to challenges with coverage of mass drug administration, water, sanitation, and hygiene (WASH), health promotion, and other factors, such as poverty. Recommended strategies to meet global and national targets include increasing access to deworming, improving WASH and health promotion and education, and addressing factors contributing to STH, such as poverty. The War on Worms Campaign, which improved helminth control outcomes in various sites in the country, may be adopted. Keywords: community-led total sanitation, Integrated Helminth Control Program, preschool-age children, preventive chemotherapy, soil-transmitted helminthiases, war on worms, WASH, Philippines

INTRODUCTION

Correspondence: Vicente Y Belizario Jr, Depart- The Integrated Helminth Control ment of Parasitology, College of Public Health, Program (IHCP) implemented by the University of the Philippines Manila, 625 Pedro Philippine Department of Health (DOH) Gil St, Ermita 1000, Manila, Philippines. in 2006 aimed to reduce the prevalence Tel: +632 523 5929 of soil-transmitted helminthiases (STH) E-mail: [email protected] to less than 50% by 2010 and to achieve

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Fig 1–Map of Philippines (left) and Masbate Province (right) showing the municipalities of , Cawayan, Milagros, and Monreal. Map generated using QGIS v2.8. an 85% deworming coverage in children control, especially in poor provinces, such ages 1 to 12 years (DOH, 2006). Prior to as Masbate, is yet to be described. Describ- its implementation, a study showed STH ing such will provide information on the prevalence of 66% among preschool-age effectiveness of the program. Likewise, children (PSAC) in sentinel sites (de Leon it will provide opportunities to improve and Lumampao, 2005, final report submit- program implementation thereby alleviat- ted to UNICEF). The global targets set by ing those infected, especially PSAC, from World Health Organization (WHO), on the burden of STH. the other hand, are to reduce prevalence of This study aimed to describe the moderate-heavy intensity STH to below 1% status of STH control in PSAC in selected and to achieve a 75% deworming coverage municipalities in Masbate Province in at- by 2020 (WHO, 2012). The IHCP and WHO taining global and national targets. adopted various helminth control strate- gies, such as preventive chemotherapy, MATERIALS AND METHODS improvements in water, sanitation and hygiene (WASH), through approaches Study site and population including Community-Led Total Sanita- The study was conducted in four mu- tion (CLTS), and health promotion and nicipalities in Masbate, namely, Aroroy, education. Cawayan, Milagros, and Monreal (Fig Almost a decade after its implementa- 1). The municipalities were selected in tion, however, the status of IHCP in attain- this study based on reported high rates ing the national and global targets on STH of chronic undernutrition, low socioeco-

668 Vol 47 No. 4 July 2016 Integrated Helminth Control Program in the Philippines nomic indicators, and implementation of with the ICFs, were distributed by the CLTS by Action Contre la Faim (ACF), a research staff to the parents of the par- non-government organization working ticipants prior to fieldwork. Each targeted on WASH in Masbate. The study included participant was asked to submit one stool barangays implementing CLTS, as well sample on the scheduled date and time as other barangays selected based on ac- of specimen collection. Submitted stools cessibility, relative distance from the po- were processed using the Kato-Katz blacion (town center), topography, peace technique following the WHO Bench and order situation, and willingness of Aids for Diagnosis of Intestinal Parasites the local government units (LGUs) and (WHO, 1994) and were examined in the community to participate. field laboratory within the day. Processing PSAC residing in the selected ba- and examination of stool samples were rangays and enrolled in day care centers performed by trained research staff and (DCCs) were recruited in the study. Pre- medical technologists from the University requisites to their participation included of the Philippines (UP) Manila. Results of Inform Consent Forms (ICFs) signed by the examination were recorded on Parasi- parents and no history of treatment with tological Results Forms. albendazole or mebendazole within the Intensities of STH were classified as last four months prior to the study. Basic light, moderate, or heavy based on the information of the participants, such as number of helminth eggs per gram (epg) their name, birthdate, age, and sex were following WHO guidelines (WHO, 2012). obtained, verified, and recorded in the For the purpose of this study, moder- Master List by assigned research staff. ate and heavy intensity infections were classified together as moderate-heavy Study design and sampling intensity STH. The study utilized a cross-sectional The accuracy of parasitological assess- design, which involved the assessment ment was maintained through quality as- of parasitological status of PSAC. A total surance measures, which included proper of 39 barangays from the four selected collection of stool specimens, utilization of municipalities were included. Nineteen of fresh reagents, adherence to standard labo- these barangays implement CLTS, seven ratory techniques, meticulous examination of which were already declared as Open of processed specimens, and accurate Defecation Free (ODF) prior to the study. reporting of findings. In cases where medi- The minimum sample size was computed cal technologists were not certain of their at 280 per municipality or 1,120 PSAC from diagnosis, electronic images of the slides the four municipalities using the PASS soft- were taken and referred to the Medical ware (PASS®, NCSS LLC: East Kaysville, Teleparasitology (MTP) System based in UT). From each , 30 participants UP Manila, where diagnostic parasitolo- were targeted for the study. Overall, the gists provided confirmatory diagnoses. To total targeted number of PSAC was 1,170. ensure accuracy of microscopy readings, at Parasitological assessment least 10% of all samples processed using The parasitological assessment was Kato-Katz technique were re-examined by conducted in the selected municipalities a reference microscopist from UP Manila in March 2015. Stool cups with instruc- who was blinded to the results of the initial tions for proper stool collection, along examination.

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Deworming coverage was used. Only authorized members of Deworming coverage rates in PSAC the research team were allowed access to for each selected municipality and for the results. PSAC positive for STH were the province for 2013 were obtained from referred to respective rural health units the Provincial Nutrition Action Office (RHUs) for appropriate management and (PNAO) of Masbate. treatment with anthelminthics. Data processing and analysis RESULTS Data in the forms were validated and double encoded using Microsoft Excel Parasitological assessment 2007 to ensure accuracy. The initial and A total of 1,224 PSAC were included in second encoding were compared and the study, of which 480 were from Aroroy, finalized before data analysis was per- 375 from Cawayan, 231 from Milagros, formed. and 138 from Monreal. Among them, 885 Descriptive statistics, which include were positive for at least one STH, giving cumulative prevalence of STH, prevalence an overall cumulative STH prevalence of moderate-heavy intensity STH, preva- of 72%. The highest prevalence obtained lence of Ascaris, Trichuris, and hookworm were in Aroroy (86%) and Milagros (85%), infections, and prevalence of coinfec- followed by Monreal (73%), and lastly, tions, were calculated. A 95% confidence Cawayan (46%). Cumulative prevalence interval was computed for prevalence across municipalities varied significantly estimates. The mean of these values were (p<0.001). Out of the 39 barangays, 30 had compared using t-test. Statistical analyses cumulative prevalence higher than 50%, were performed using STATA 12 (STATA while three barangays, namely, Poblacion 12®; StataCorp, College Station, TX). De- East and West in Milagros and Poblacion worming coverage rates, STH prevalence, in Monreal, had cumulative prevalence and prevalence of moderate-heavy inten- of 100%. The lowest prevalence was sity STH were compared with global and observed in Tuburan, Cawayan at 18% national targets. (Table 1). Ethical considerations Moderate-heavy intensity STH was The study protocol was reviewed and found in 500 PSAC, giving 41% preva- approved by the UP Manila Research Eth- lence. All four municipalities had preva- ics Board (UPMREB 2015-128-01) to ensure lence of moderate-heavy intensity STH adherence to ethical standards for human higher than 1%, the highest of which subject protection. Groundwork meetings was 58% in Milagros, while the lowest with representatives from DOH and LGUs was 16% in Cawayan. The prevalence of were carried out before project implemen- moderate-heavy intensity STH varied sig- tation. The project was coordinated with nificantly (p<0.001) across municipalities. health and social welfare development There were 36 barangays with prevalence offices at provincial and municipal lev- of moderate-heavy intensity STH higher els. A designated research staff obtained than 1%, while three barangays from informed consent from parents or guard- Cawayan, namely, San Jose, San Vicente, ians using the ICFs during fieldwork. For and Maihao, had no case of moderate- confidentiality of health information, a heavy intensity STH (Table 1). coding scheme for participant’s identity Ascariasis, the most prevalent STH,

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Table 1 Cumulative prevalence and moderate-heavy intensity STH in PSAC in selected municipalities and barangays in Masbate, March 2015. Municipality/Barangays PSAC Cumulative prevalence Prevalence of moderate- examined heavy intensity STH n n (%) n (%)

Aroroy Poblacion 39 33 (85) 19 (49) Ambolong 45 36 (80) 26 (58) Baga Uma 46 44 (96) 32 (7) Syndicate 37 31 (84) 13 (35) Bangon 26 25 (96) 17 (65) Talabaan 21 18 (86) 11 (52) Don Pabloa 46 44 (96) 27 (59) Matalang talanga 31 22 (71) 10 (32) Tinago 21 18 (86) 10 (48) Cabangcalana 40 32 (80) 19 (48) Malubi 41 36 (88) 23 (56) Taliba 53 47 (89) 27 (51) Jaboyoan 34 28 (82) 14 (41) Subtotal 480 414 (86) 248 (52) Cawayan Naro 30 27 (90) 20 (67) Mahayahay 34 28 (82) 9 (27) Tabernaa 32 13 (41) 4 (13) Palo Bandera 25 9 (36) 1 (4) San Jose 34 7 (21) 0 - Tuburan 34 6 (18) 2 (6) Madbad 18 4 (22) 2 (11) San Vicente 23 5 (22) 0 - Poblacion 42 23 (55) 10 (24) Divisoria 44 20 (46) 6 (14) Behia 25 19 (76) 5 (20) Maihao 34 12 (35) 0 - Subtotal 375 173 (46) 59 (16) Milagros Calasuche 26 23 (89) 15 (58) Poblacion Easta 24 24 (100) 23 (96) Poblacion West 25 25 (100) 21 (84) 25 12 (48) 5 (20) Tawad 21 18 (86) 10 (48) Capaculan 26 25 (96) 18 (69) Paraiso 26 18 (69) 12 (46) Bangad 29 24 (83) 9 (31) Subtotal 231 197 (85) 133 (58) Monreal Poblacion 29 29 (100) 23 (79) Famosa 22 20 (91) 11 (50) 37 19 (51) 10 (27) Real 29 16 (55) 8 (27) Cantornaa 21 17 (81) 8 (38) Subtotal 138 101 (73) 60 (43) Total 1,224 885 (72.3) 500 (40.8) 95% CI (69.8-74.8) 95% CI (38.1-43) Cumulative prevalence across municipalities; Pearson chi2=194.3565; p=<0.001. Moderate-heavy intensity STH across municipalities; Pearson chi2=148.2878; p =<0.001. aODF barangays.

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5 (1.0) 3 (1.0) 0 - 18 (2.0) 10 (2.0) infection Positive for (0.9) (1.5) (0.5) (0.5) - (%) 7 2 2 0 95% CI n 11 Ascaris-Trichuris (%) hookworm coinfections n (13.3-17.4) 23 (6.0) 96 (20.0) 55 (24.0) 14 (16.0) 188 (15.4) intensity 95% CI Moderate-heavy (%) -hookworm 0 - 1 (0.3) 0 - 0 - 1 (0.1) n coinfections

(51.2-56.8) Trichuris (%) n Positive for trichuriasis 55 (40.0) (31.0) 117 661 (54.0) 332 (69.0) 157 (68.0) 95% CI (%) 3 (0.6) 0 - 1 (0.4) 0 - 4 (0.3) -hookworm n (%) n coinfections (34.9-40.4) Ascaris Table 2 Table 3 Table 54 (14.0) 53 (38.0) 461 (37.8) 227 (47.0) 127 (55.0) March 2015. March Moderate-heavy 95% CI

Positive for ascariasis (%) n 61 (16) 42 (30) (56.2-61.7) 254 (53) 132 (57) 489 (40) coinfections (%) 88 (64.0) n Ascaris-Trichuris (31.0) 117 722 (59.0) 343 (72.0) 174 (75.0) 95% CI

) hookworm n n 480 375 231 138 intensity

1,224 examined 480 375 231 138 1,224 PSAC Rates of coinfection of STH in PSAC in selected municipalities in Masbate, March 2015. March Masbate, in municipalities selected in PSAC in STH of coinfection of Rates examined (

Municipality Aroroy Cawayan Milagros Monreal Total Municipality PSAC Aroroy Cawayan Milagros Monreal Total Ascariasis, trichuriasis, and hookworm infection prevalence and intensity in PSAC in selected municipalities in Masbate, Masbate, in municipalities selected in PSAC in intensity and prevalence infection hookworm and trichuriasis, Ascariasis, There was no case of moderate-heavy hookworm infection. There a

672 Vol 47 No. 4 July 2016 Integrated Helminth Control Program in the Philippines was observed in 722 (59%) of PSAC, while targets for deworming coverage. moderate-heavy ascariasis was found in 461 (38%) of PSAC. Trichuriasis was ob- DISCUSSION served in 661 (54%) of the PSAC, while moderate-heavy trichuriasis was found The study described the status of in 188 (15%) of the PSAC. Hookworm STH control in PSAC in selected munici- infection was observed only in 18 (2%) palities in Masbate in attaining global and of the PSAC. None of the municipalities national targets. The overall cumulative had a case of moderate-heavy hookworm STH prevalence, as well as the prevalence infection (Table 2). of moderate-heavy intensity STH, in the four municipalities did not meet both the Coinfections were prevalent with global and national targets for STH mor- Ascaris-Trichuris coinfection being most bidity. The results also revealed that only common with 489 cases (40%), followed Cawayan met the IHCP target for STH by Ascaris-hookworm with four cases prevalence, while none of the selected (0.3%), and Trichuris-hookworm with municipalities met the global target for one case (0.1%). Triple STH coinfection prevalence of moderate-heavy intensity was found in 11 PSAC (0.9%). Most cases STH. When the data is disaggregated of coinfections were observed in Aroroy into barangays, most of the barangays (Table 3). likewise failed to meet the national and Among the four municipalities, only global targets. Three barangays had 100% Cawayan (46%) met the national target STH prevalence. It must be noted that of reducing STH prevalence to less than the IHCP targets were intended to have 50%. The municipalities of Aroroy (86%), been attained in 2010, five years prior Milagros (85%), and Monreal (73%) had to the conduct of the study. Aside from higher STH prevalence than the national failing to meet the global and national baseline data. None of the municipalities targets, the cumulative STH prevalence attained the global target of reducing in PSAC observed was also higher than prevalence of moderate-heavy STH to that of a survey conducted before the <1%. implementation of the IHCP, which was Quality control only 66% (de Leon and Lumampao, 2005; final report submitted to UNICEF) Validation of the slides examined by and a sentinel survey conducted in 2009 field microscopists showed an overall sen- wherein prevalence was at 44% (Belizario sitivity and specificity of 93.8% and 86.8%, et al, 2013a). The failure to meet both the respectively. The sensitivity and specific- national and global targets may suggest a ity are 98.4% and 89.3% for Ascaris and need to enhance the STH prevention and 88.1% and 83.1% for Trichuris, respectively. control strategies, which include increas- Deworming coverage ing access to preventive chemotherapy, The deworming coverage for PSAC improving WASH, and intensifying health in the selected municipalities in 2013 promotion and education. was 66% for Aroroy, 106% for Cawayan, Ascariasis was the most prevalent 67% for Milagros, and 87% for Monreal. STH, followed by trichuriasis. Low hook- The deworming coverage in the province worm infection prevalence may indicate (71%) was below the global and national lack of exposure or limitation of Kato-Katz

Vol 47 No. 4 July 2016 673 Southeast Asian J Trop Med Public Health technique in demonstrating hookworm the major strategy for morbidity control eggs. Information on prevalent STH may of STH (WHO, 2012). In the Philippines, help determine morbidity and thus the deworming in PSAC (1-5 years old) is interventions needed, such as micronu- done biannually through the Garantisa- trient supplementation. While STH, in dong Pambata (GP) program (DOH, 2006). general, contributes to malnutrition and Deworming tablets are also made avail- poor cognitive performance, each type of able in health centers to children aged STH causes specific morbidities, such as 1-14 years old through the Expanded GP low serum vitamin A (retinol) levels, in- Program (DOH, 2010a). testinal obstruction, and erratic migration The reported mass drug administra- for ascariasis (de Silva et al, 2010), anemia, tion (MDA) coverage rate in the province rectal prolapse, and Trichuris Dysentery in 2013 was below both the global and Syndrome for trichuriasis (Robertson national targets. The two municipalities et al, 1992; Noorizan and Mahendra Raj, with the highest STH prevalence rates 2001) and anemia for hookworm infection and prevalence of moderate-heavy STH (Stoltzfus et al, 1997; Albonico et al, 2008). (Aroroy and Milagros) had the lowest Cases of coinfections were observed deworming coverage rates. Challenges with Ascaris-Trichuris coinfection being contributing to low MDA coverage most common due to their similar oro- include misconceptions of parents on fecal route of transmission (Ezeamama deworming and poor delivery channels et al, 2005). Available evidence suggests for MDA (Krentel et al, 2013). Increasing that parasitic coinfections or polypara- the knowledge on benefits of deworming sitism may result to increased morbidity makes MDA more acceptable which may due to the possible synergistic effects of likewise help increase the coverage rates individual parasites. Coinfections may, (Amarillo et al, 2008). MDA delivery in likewise, increase susceptibility of indi- Day Care Centers (DCC) may be explored viduals to other infections (Pullan and to help increase treatment coverage for Brooker, 2008). Moreover, PSAC with STH PSAC (Belizario et al, 2014). The use of coinfection are likely to suffer from physi- existing infrastructure and manpower cal, social, and cognitive developmental allows for a more cost effective service constraints (Tchuem Tchuente et al, 2003), delivery (Crompton and Nesheim, 2002). considering that they are in a period of MDA, however, will still be a challenge rapid growth and development. for PSAC who are not enrolled in DCCs. Determinants of STH include chal- While the MDA coverage rate in the lenges in the conduct of preventive province did not meet the global and na- chemotherapy, poor WASH and health tional targets, it is higher than the national promotion and education, and poverty MDA coverage in the same year (19%) (Ulukanligil and Seyrek, 2003; DOH, 2006; (WHO, 2015). The relatively high cover- Ostan et al, 2007). Focusing on these deter- age rates, compared with the national minants is crucial in improving helminth average, were inconsistent with the high control and reducing the burden of STH. prevalence of moderate-heavy intensity Preventive chemotherapy, the use STH observed. Reinfection, which occurs of anthelminthics regardless of infection rapidly especially for Ascaris and Trichuris status in high-risk groups, remains to be infection (Jia et al, 2012), may contribute to

674 Vol 47 No. 4 July 2016 Integrated Helminth Control Program in the Philippines the high prevalence of moderate-heavy in- The DOH, through Administrative tensity STH observed. Reinfection alone, Order 2010-0021 which declared sustain- however, may not suffice to explain the able sanitation as a national policy and inconsistency since it only often results program priority, envisions that by 2016, to light intensity infections especially if 60% of all barangays are ODF and inci- the children are regularly dewormed. The dence of STH caused by poor sanitary con- high prevalence of moderate-heavy inten- ditions are reduced by 60%. These will be sity STH may indicate that the children achieved through strategies highlighted are not being dewormed regularly. Thus, in the National Sustainable Sanitation another explanation for the inconsistency Plan (NSSP), which include strengthening is the possible lapses in the reporting of of sanitation governance and regulatory deworming coverage. A previous study mechanism, improving service delivery conducted in the Philippines revealed through capacity development, form- that the estimated deworming coverage ing strategic alliances of multisectoral obtained through individual interviews stakeholders, financing and adequate was 32% lower than the reported cover- infrastructure investments, and promot- age. This may be explained by assuming ing sanitation during emergency response that the number of people given the drugs (DOH, 2010b). CLTS, a strategy where is equal to the number of people who communities are facilitated to conduct actually took the drugs (Amarillo et al, their own appraisal and analysis of open 2008). Thus, direct observation of intake of defecation and to take action to become anthelmintics is recommended to improve ODF, may be important in attaining sus- reporting of actual deworming coverage. tainable sanitation (Institute of Develop- Strategies aimed at enhancement, ment Studies, 2011). promotion, and monitoring of WASH are The high STH prevalence rates in crucial for STH prevention and control some barangays where CLTS is imple- (WHO, 2012). Providing access to latrines, mented may be related with the parasi- alone, will not suffice to improve WASH tological assessment conducted less than since this does not guarantee utilization a year after the implementation of CLTS (Institute of Development Studies, 2011; in June 2014. Helminth eggs, particularly Belizario et al, 2014). Active participation Ascaris ova, can survive for two years of the community is crucial in improving (Belizario et al, 2015) up to 10 years WASH. A study in East Java found out (Khuroo, 1996). Improvements in WASH that externally provided subsidies (eg, must be sustained for several years be- provision of free latrines) were associated fore reductions in burden of STH may with lack of ODF outcomes. Conversely, be observed. Follow-up parasitological internally provided subsidies were assessments may be needed to measure instrumental in attaining ODF (World the CLTS outcomes in these communities. Bank Water and Sanitation Program, Conversely, the high STH burden in ODF 2011). Thus, facilitating behavior change barangays were comparable to a previous through strategies aimed at encouraging study where high STH prevalence (67.4%) people to utilize their toilets and provid- was observed in an ODF declared village ing access to cheap sanitary toilets may be (Belizario et al, 2014). Both were inconsis- more feasible and effective in improving tent with a meta-analysis (Zielgelbauer WASH and attaining ODF. et al, 2012), which concluded that avail-

Vol 47 No. 4 July 2016 675 Southeast Asian J Trop Med Public Health ability and access to sanitation facilities nicipality (Philippine Statistics Authority, are associated with reduction in STH n.d.) due in part to the mining activities, prevalence due to reduced risk of STH has the highest burden of STH. This may transmission and re-infections (Anderson indicate that the wealth generated in the and May, 1991). As STH persist in areas municipality does not necessarily benefit where challenges in WASH exist (Strunz the poorest people, especially in terms of et al, 2014), there may be a need to review public health. Thus, strategies aimed at the process of certifying ODF status in the promoting inclusive socio-economic de- province. velopment must be improved to achieve Monitoring and evaluation of para- better health outcomes, especially in ad- sitological status in the community is dressing STH. important to assess the effectiveness The results of this study reflect the of existing helminth control programs. continuing challenges in the selected A parasitological assessment may be municipalities especially in the delivery conducted every two years as recom- of health services. Various components, mended by WHO (WHO, 2011). Aside which include advocacy, capacity build- from parasitological status, monitoring ing, social mobilization, multisectoral and evaluation of the different indicators collaboration, and monitoring and evalu- for the success of WASH programs, such ation, are crucial in the success of public as attainment of ODF status, may also be health intervention in a decentralized included. health system where health service de- Aside from poor sanitation, the high livery is entrusted to LGUs. The War on STH prevalence may also be due to poor Worms Campaign, which utilized these hygienic practices, such as poor practice components, has attained improved of hand washing which may be common health outcomes, such as higher deworm- among children (Vivas et al, 2010). Health ing coverage and reduced prevalence and promotion and hygiene education reduce intensity of STH in Western and transmission and reinfection when com- del Norte (Belizario et al, 2013b). bined with behavioral change. Aware- The good practices on helminth control ness of the community on the preventive in sites where WOW was implemented measures and the morbidity caused by may be adopted in the province in order STH may help improve their health status. to improve delivery of health services, Poverty is among the social determi- particularly deworming. Aside from nants of NTD identified by WHO (WHO, Western Visayas and , 2010). NTDs, such as STH, are more preva- good practices in Compostela Valley and lent in impoverished areas. Thus, poverty del Norte, provinces that had may be a factor contributing to the high significant reductions in both prevalence STH prevalence in the province consid- of STH and of moderate-heavy intensity ering that Masbate has one of the lowest STH three years after baseline (Belizario HDI in the country (HDN, 2013). It must et al, 2013a), may also be adopted. be noted, however, that socio-economic Lastly, various opportunities exist development must be inclusive in order which could be leveraged to improve hel- to benefit those at-risk for STH. In this minth control not only in Masbate but also study, Aroroy, which is a first class mu- to other provinces. The inclusion of WASH

676 Vol 47 No. 4 July 2016 Integrated Helminth Control Program in the Philippines and NTDs in the Sustainable Develop- age children through preventive chemo- ment Goals will provide much needed therapy. PLOS Negl Trop Dis 2008; 2: e126. focus and resources aimed at addressing Amarillo MLE, Belizario VY, Sadiang-Abay STH for the next 15 years. Likewise, the JT, Sison SAM, Dayag AMS. Factors as- sustained economic growth in the country sociated with the acceptance of mass and the increase in the budget of DOH will drug administration for the elimination provide resources to address STH. of lymphatic filariasis in del Sur, Philippines. Parasit Vectors 2008; I: 14. In conclusion, the results of the para- Anderson RM, May RM. Infectious diseases sitological assessment in selected munici- of humans. Oxford: Oxford University palities of Masbate revealed high infection Press, 1991. rates and intensity of STH which failed to Azene G, Guyatt H, Brooker S, Hall A, Bundy meet the IHCP and WHO reduction tar- DAP. The cost of large-scale school health gets, despite the implementation of IHCP programmes which deliver anthelmintics for 10 years. Improving helminth control to children in Ghana and Tanzania. Acta outcomes warrants increasing access to Trop 1999; 73: 183-204. preventive chemotherapy, improving Belizario VY, de Leon WU. Medical parasitol- WASH, intensifying health promotion ogy in the Philippines. City: Uni- and education, as well as addressing other versity of the Philippines Press, 2015: 131. factors contributing to STH, such as lack Belizario VY, Liwanag HJ, Naig JR, Chua of inclusive socio-economic development. PL, Madamba MI, Dahildahil RO. Parasi- Good practices in WOW sites, such as tological and nutritional status of school- Western Visayas and Davao del Norte, as age and preschool-age children in four well as in provinces, such as Compostela villages in Southern , Philippines: Valley and where there lessons for monitoring the outcome of had been significant reductions in both community-led total sanitation. Acta Trop STH prevalence and intensity, may be 2014 Sep; 141: 16-24. adopted in the province. Belizario VY, Marfori JR, Chua PC, Naig JR, Erfe J. School-based combined mass drug administration for soil-transmitted hel- ACKNOWLEDGEMENTS minthiases and schistosomiasis among The authors would like to extend school-age children: lessons from two co- their sincerest gratitude to their partners endemic areas in the Philippines. Asia Pac in the conduct of study, which include J Public Health 2015; 5: 358-62. the ACF, the provincial government of Belizario VY, Totañes FI, de Leon WU, Ciro Masbate, especially the Provincial Health RN, Lumampao YF. Sentinel surveil- Office and Provincial Social Welfare and lance of soil-transmitted helminthiasis in Development Office and the municipal preschool-aged and school-aged children in selected local government units in the governments, especially the Rural Health Philippines: follow-up assessment. Asia Units of Aroroy, Cawayan, Milagros, and Pac J Public Health 2013a; 27: 1604-15. Cawayan. Belizario VY Jr, Tuliao AH, Totanes FGT, Asuncion CL. Optimizing school-based REFERENCES intestinal helminth control interventions Albonico M, Allen H, Chitsulo L, Engels D, in the Philippines. J Pediatr Infect Dis Soc Gabrielli AF, Savioli L. Controlling soil- PhiIip 2013b; 14: 2-13. transmitted helminthiasis in pre-school- Crompton DW, Nesheim MC. Nutritional

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