INTEGRATED HELMINTH CONTROL PROGRAM IN THE PHILIPPINES 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 Manila; 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 Cawayan 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 Vol 47 No. 4 July 2016 667 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH Fig 1–Map of Philippines (left) and Masbate Province (right) showing the municipalities of Aroroy, 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 barangay, 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. Vol 47 No. 4 July 2016 669 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH 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.