Reference Manual for Administration of Deworming to Preschool-Age Children in Vitamin A Distribution Projects
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A TechnicalVitamin Document Angels1 Our vision is to be a leading partner for the alleviation of essential micronutrient deficiency among underserved and at-risk infants and young children.
Our mission is to help at-risk populations in need — specifically pregnant women, new mothers, and children under five — gain access to lifesaving and life changing vitamins and minerals.
2 Preface
This manual is intended for healthcare providers and aims to This manual is designed for personnel responsible for managing promote the deworming of preschool-age children (PSAC) where and delivering health care services who seek to incorporate the vitamin A distribution campaigns are conducted.1 distribution of deworming into regular activities associated with community or facility-based health care. It has been produced in In this manual, preschool-age children are defined as all such a way that each section may be removed for individual use children who are at least 1 year and are not yet 5 years of age. and may be reproduced in whole or in part according to user Attention is focused on this group because while school-age needs, as long as this is not for commercial purposes. children who (classified from the age of 5 years onwards) are In initiatives for either MDA or targeted distribution of deworming normally dewormed through school health programs, preschool- tablets, it is likely that those who distribute deworming will age children are often not reached by deworming interventions. encounter young children who require treatment for more serious In recognition of the constant demands made on health planners worm infections. The information contained in this Reference to prioritize health interventions, often with limited financial and Manual is NOT intended as a guide to the diagnosis and human resources, this manual describes some of the advantages treatment of these or other conditions. A young child should of combining two programs that are often delivered separately: be referred to a qualified health care practitioner for evaluation vitamin A distribution and deworming. for conditions that might require treatment with deworming Vitamin Angels is a leading partner in the efforts to eliminate the medications. death and disease associated with micronutrient deficiencies, Vitamin Angels gratefully acknowledges the use and adaptation especially vitamin A deficiency among neonates, infants, and of materials from the World Health Organization (WHO), the children. We mobilize and deploy private-sector resources to Pan American Health Organization (PAHO), and the increase the availability, access and use of micronutrients – Micronutrient Initiative (MI) for inclusion in this Reference especially vitamin A – by at-risk infants and children in need. Manual. These sources are: Vitamin A supplements may be provided alone or in combination 1. World Health Organization (2004). How to add deworming with the deworming agent, albendazole, as recommended by the to vitamin A distribution. World Health Organization (WHO) to reduce the burden of intestinal worms that consume micronutrients that would 2. World Health Organization (February 2007). Action against otherwise be available to the growing preschool-age child. worms, Issue 8.
An estimated 272.2 million preschool-age children under five 3. Pan American Health Organization (2001). Providing vitamin A years of age suffer from worm infections caused by soil- supplements through immunization and other health contacts transmitted helminths (STH), which is a major underlying cause for children 6–59 months and women up to 6 weeks of child morbidity. Vitamin Angels works to support preventive postpartum: A guide for health workers, Second edition. “mass drug administration (MDA)” or “targeted distribution” 4. Micronutrient Initiative (2007). Vitamin A in child health weeks: of deworming in countries defined by the WHO as being endemic A toolkit for planning, implementing, and monitoring. for STH. This manual provides information that is essential to think about when planning and implementing effective MDA or targeted 5. World Health Organization (2017). Guideline: Preventive distribution of deworming to PSAC. The focus of this manual is chemotherapy to control soil-transmitted helminth infections in to provide guidelines and technical information to aid in at-risk population groups. establishing MDA projects for preschool-aged children, including those that are paired with vitamin A supplementation for preschool-age children.
3 Contents
Deworming Basics 1 An Introduction to Deworming...... 5 2 How to Prevent STH Infections...... 8 3 When Preschool-Age Children Should be Dewormed...... 10
How to Administer Deworming to Children Ages 12-59 Months 4 How to Administer Deworming Tablets...... 13 5 Giving Deworming to Children Ages 12–59 Months...... 17
Storage and Organizing a Distribution 6 How to Ship, Transport and Store Deworming Tablets...... 19 7 Organizing Mass Distribution of Deworming Tablets ...... 22 8 Training and Public Awareness...... 25 9 Requirements for Distribution Points...... 28 10 Arranging Your Work Station...... 30 11 Recordkeeping...... 32
Appendices 45 Appendix A: VAS and Deworming Priority Countries...... 37 Appendix B: FAQs...... 42 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming...... 47 Appendix D: How to Give Vitamin A to Children...... 53 Appendix E: Guide for Vitamin A Supplementation Supervisors...... 55 Appendix F: How to Give Deworming with Universal Distribution of Vitamin A...... 57 Appendix G: Daily Tally Sheet...... 59 Appendix H: Distribution Register...... 60 Appendix I: Child Health Card Sample...... 61
References 62
Notes 64
4 1 An Introduction to Deworming
About this Chapter
Soil-transmitted helminths (STH), commonly called intestinal worms, include roundworms, hookworms, and whipworms. STH are a serious public health problem and impair the health of preschool-age children 12-59 months of age. Deworming eliminates these parasites from the body, improving the nutritional status of young children.
This chapter explains what STH are and how they are transmitted. Next, it explains who is most at risk for STH infections and why it is so effective to deliver deworming to preschool-age children. In addition, it looks at the effects of not treating STH and the benefits of deworming.
Finally, the chapter tells us the importance of combining vitamin A supplementation with deworming and how both programs can benefit by delivering multiple health services.
What are Soil-Transmitted Sources of STH Who Needs Deworming Helminths (STH)1 Transmission2 and Why
Soil-transmitted helminths (STH), more STH are transmitted by eggs excreted in Globally—millions of children are commonly known as intestinal worms, human feces that contaminate the soil and infected with worms represent a serious public health problem water in areas that lack adequate sanitation. Estimates show that 272.2 million preschool- wherever the climate is warm and humid and Humans are infected through: age (1-4 years) children in 101 countries or inadequate sanitation and unhygienic • ingestion of infective eggs (Ascaris territories required preventive chemotherapy conditions are common. The term STH lumbricoides and Trichuris trichiura) from (PC) for STH in 2017 worldwide; this means typically includes three types of worms, contaminated hands, food, or utensils; that they live in areas where the prevalence of which impair the health of preschool-age STH is estimated to be >20%. Of those children 12-59 months of age (at least 1 • penetration of the skin by infective larvae countries, 55 reported PC data to WHO in year and less than 5 years old): contaminating the soil (hookworm) 2017. The number of children requiring PC • Roundworms (Ascaris lumbricoides), There is no direct person-to-person and treated was 188 million, corresponding transmission of worms, or infection from fresh to a global coverage of 69%.4 • Hookworms (Ancylostoma duodenale and feces, because eggs passed in feces need Necator americanus), about 3 weeks to mature in the soil before • Whipworms (Trichuris trichiura). they become infective. Since these parasites do not multiply in the human host, reinfection Other parasitic worms, such as occurs only as a result of contact with schistosomes, are not discussed here infective stages in the environment. 3 because their treatment requires different drugs.
5 An Introduction to Deworming
Left: Child with distended abdomen due to large bolus of A. lumbricoides adult worms in small intestines / Parasites Without Borders
Right: Adult ascaris recovered from child at left after treatment with mebendazole. Similar results can be seen for treatment with albendazole / Parasites Without Borders
Deworming Protects Our STH Infections and Health Conditions or Illness Health in Several Ways Morbidity that Prevent Deworming
Worm-free children have a better Morbidity is directly related to worm burden: Do not give the deworming tablets to children nutritional status, grow faster and learn the greater the number of worms in the who are ill on treatment day.16 A child should 5 better infected child, the greater will be the severity be excluded from deworming if they are of the disease. In the case of hookworm, for observed to have fever or difficulty breathing, Treating children of any age for worms is one example, the amount of blood lost in the or if the mother or caregiver, when of the simplest and most cost-effective feces (as an indicator of morbidity) increases questioned, reports that they currently have interventions for improving their health. with the number of worms (measured in (i.e., that day): fever, vomiting, severe diarrhea The evidence demonstrating how worm terms of eggs per gram of feces).14 or difficulty breathing.17 This is not because of infections damage a child’s health is clear: any danger of adverse effects, but to prevent Children under 5 years of age are particularly worm infections are associated with a the potential misperception that the susceptible to the detrimental effects of significant loss of micronutrients.6 deworming medicine caused the illness. intestinal worms because of their smaller, Roundworms are the most prevalent STH These children should be given the rapidly growing bodies. So, even at low infection in preschool-age children and cause deworming medicine later, when they are intensities of infection, intestinal worms can significant vitamin A malabsorption,7 which well again.18 compromise healthy growth and development can aggravate undernutrition and anemia and in young children.12 Reasons for delivering contribute to retarded growth.8 A child’s deworming tablets with physical fitness and appetite are negatively Overall, in areas endemic for soil-transmitted vitamin A supplements20 affected9 and his or her cognitive helminths, it is considered essential to performance at school is compromised.10,11 treat all preschool and school-age children The constant and life-long immune activation for the purpose of reducing the worm burden due to worm infections can reduce the body’s in those who are moderately to heavily ability to resist other infections.12 infected.15 Hookworm / CDC Photo Preschool-age children are extremely vulnerable to the deficiencies induced by worm infections: they are rapidly developing, both physically and mentally, and they need the micronutrients that are lost through worm infections. By decreasing the worm burden, periodic drug treatment – deworming – reduces morbidity and rapidly improves health.13 An added bonus of deworming is that a dewormed child may respond better to vaccinations.12 Roundworm / CDC Photo Whipworm / Parasites Without Borders 6 An Introduction to Deworming
Reasons for Delivering Deworming Tablets with Vitamin Points to Remember A Supplements 19 • Soil-transmitted helminths (STH) are Programs to deliver vitamin A supplements and deworming programs share several intestinal worms, which includes features: they target children of similar age, are delivered periodically, and, when given roundworms, hookworms, and together, can provide added health impact. These features make it logical to deliver both whipworms. interventions at the same time. One of the clearest advantages of combining these • STH are a serious public health interventions is simply the coverage opportunity offered by vitamin A programs: Over 167 problem and impair the health of million children are reached every year by vitamin A supplementation programs in young children. countries across the world. Vitamin A supplementation thus represents a unique opportunity to provide deworming at the same time and at very low cost.20 The reasons • Transmission of STH happens when for delivering together are listed next. eggs are excreted in feces and contaminate soil and water in areas 1. Vitamin A-deficient children are at risk for worms that lack adequate sanitation. Vitamin A deficiency and worms are often found in the same child, especially in low-resource communities with poor sanitation and hygiene. Children living in these • Intestinal worms are spread through environments are at increased risk for both vitamin A deficiency and for worm contact with contaminated soil and infections. Delivering deworming tablets and vitamin A supplements to the same water. children at the same time provides added health benefits at little extra cost, particularly • Untreated, intestinal worms can for remote communities that are difficult to reach. compromise health, growth, and 2. Simple delivery – simple training development in young children. The drugs used for deworming are regarded as so safe that nonmedical staff, such as • Regular deworming can improve the 18 village health workers or teachers, can be trained to deliver them. This means that the nutritional status of preschool-age deworming training is so simple that it can easily be added onto the training for vitamin children. A distribution programs. Both vitamin A and deworming can be given on the same schedule of every 4 to 6 months. The main difference is the target age group: (a) • A child should be excluded from Vitamin A supplements are given starting at 6 months of age while (b) Deworming deworming if they are observed to tablets are given starting at 1 year of age. have fever or difficulty breathing, or if the mother or caregiver, when 3. Worm-free children have a better vitamin A status questioned, reports that they Research has shown that there is a clinical link between worm infection and reduced currently have (i.e., that day): fever, vitamin A levels. Roundworms live in the gut and need vitamin A to grow. They vomiting, severe diarrhea or difficulty compete with the child for vitamins, and worms appear to be more efficient at breathing. absorbing vitamin A than their host. Where vitamin A-rich foods are already low in the diet, roundworm infections can tip the balance towards vitamin A deficiency.7 In Nepal, • There are many benefits to delivering where vitamin A deficiency and STH infections are both high, the intensity of deworming with vitamin A roundworm infection in children with xerophthalmia was found to be three times that supplementation. found in an uninfected control group.21 Chronic roundworm infection leads to malabsorption of vitamin A which leads to vitamin A deficiency in the child.22,23 • Vitamin A-deficient children are at risk for worms.
4. Deworming is popular and can increase vitamin A supplementation coverage • Deworming training can be easily Deworming is an extremely popular intervention with communities, and with parents in added to vitamin A training sessions. particular. This is partly because it has an immediate and highly visible effect: the worms – especially roundworms, which are the most prevalent STH in preschool-age • Worm-free children have a better children – are expelled and can be seen in the feces. Children feel better in just a few vitamin A status. days. The popularity of this intervention and its visible effects increase a community’s • Deworming is popular and can trust in health personnel. increase vitamin A supplementation 5. Delivering multiple health benefits can increase campaign coverage coverage. Offering multiple health benefits can boost attendance at health campaigns. Offering • Delivering multiple health benefits vitamin A supplements during immunization campaigns can increase the number of can increase campaign coverage. mothers bringing their children for services,24 and offering deworming along with vitamin A also boosts coverage.
7 2 How to Prevent STH Worm Infections
About this Chapter
We can learn about how to prevent STH worm infections in children by looking first at how worms are transmitted.
This chapter outlines the ways in which children get worms through ingestion of eggs found on unwashed food or hands and through penetration of the skin by larva that contaminate soil or water.
It then reviews ways to interfere with the transmission cycle of worms through treatment, health education, and sanitation. Finally, this chapter presents actions that can be taken to prevent STH infections in children, including washing hands, drinking clean water, and taking deworming 1-2 times per year.
How Children Get Worms1 How to Prevent STH Worm Infections
Worms are transmitted by eggs excreted in Three components of a control program can interfere with the transmission cycle of human feces, which contaminate the soil or worms’ infections: water sources in areas that lack adequate sanitation. Humans are infected through:
• Ingestion of infective eggs or larvae on contaminated food or hands
• Penetration of the skin by infective larvae that contaminate the soil or fresh water
Children most often get worms by:
• Swallowing worm eggs found on unwashed hands, fruit, vegetables, Treatment Sanitation and contaminated water
• Playing in contaminated soil (near where people have not used a toilet but have used bushes instead)
• Walking barefoot
• Eating beef or pork that has not been properly cooked
• Swimming/walking in contaminated rivers, dams, and puddles/rice fields
Health Education 8 How to Prevent STH Worm Infections
Children and adults can avoid STH worm infections if they:
USE TOILETS
• Always use a latrine / toilet when you need to urinate / defecate, do not use bushes/fields, or ponds/rivers/puddles Points to Remember • Keep latrines and the area around the toilets clean • Wash hands with soap/ash after going to the latrine or cleaning child feces • Worms are transmitted by eggs excreted in human feces, which contaminate the soil or water sources in areas that lack adequate WASH HANDS sanitation.
• Wash hands with soap/ash before and after • Children most often get worms by: eating food and when cooking - swallowing eggs on unwashed hands, fruits, and vegetables, CUT NAILS ONCE A WEEK and contaminated water, - playing in contaminated soil, • Keep fingernails clean and short - walking barefoot, - eating food that is not properly WEAR SHOES WHEN OUTSIDE cooked, and
• Always wear shoes when walking outside - being exposed to contaminated and wash feet every day fresh water sources
• Treatment, health education, and USE CLEAN WATER sanitation can interfere with the transmission cycle of STH infections. • Drink clean water or boil the water • Keep food and household water safe and • To prevent STH infections, always: away from flies and dirt - wash hands with soap and water before eating and preparing food WASH FRUITS AND VEGETABLES and after using the latrine, - drink clean water, • Always wash fruit and vegetables thoroughly in clean water and then cook to get rid of eggs or larvae - wash fruit and vegetables in clean water before eating and cook meat properly, DO NOT SWIM IN RIVERS - wear shoes, - use a latrine, and • Avoid swimming/walking in contaminated rivers, dams or puddles/rice fields - take deworming tablets 1-2 times a year • Avoid using river water for drinking or cooking
TAKE DEWORMING TABLETS 1-2 TIMES A YEAR
• Encourage family and friends to treat worm infection and prevent reinfection
9 When Preschool-Age Children 3 Should be Dewormed 1
About this Chapter
Deworming is important for the health of preschool-age children. This chapter explains how the prevalence of STH infections in school-age children serves as an indicator for mass drug administration that guides policy for the whole population in a country.
Chapter 3 also shows how to calculate the correct dose of albendazole and mebendazole according to a child’s age. This includes the safest method of crushing the tablet before administering the dose to preschool-age children.
This chapter describes that deworming is extremely safe and how the drugs work to eliminate worms. It details the effectiveness of deworming and how often preschool-age children should receive it as a preventive measure against STH infection.
Finally, the chapter points out potential side effects of deworming and the appropriate actions to alleviate any adverse effects that may occur.
Using STH Prevalence as a Guide2
The prevalence of infection with soil- While deworming drugs are known to be beneficial to infected children and will not transmitted helminths (STH) in school-age harm an uninfected child, the need for treatment should always be based on epidemiological evidence. children serves as an indicator that guides policy for the whole population. If the prevalence is ≥20%, all children (preschool Table 1. Cut-offs for action for preschool and school-age children.a,1,3 and school-age) should be treated once a year; if it is ≥50%, then treatment should be Prevalence in Category Action to be Taken twice a year (Table 1). School-Age Children The frequency of deworming should be Treat all schoolchildren (enrolled and non-enrolled) and based on epidemiological evidence of STH High ≥50% preschool-age children twice a yearb infection. This does not require a lengthy and costly assessment. WHO recommends Treat all schoolchildren (enrolled and non-enrolled) and Low ≥20% - ≤50% preschool-age children once a year a survey approach1 that is rapid and inexpensive. Deworming project managers a. When prevalence of any STH infection is less than 20%, large-scale preventive chemotherapy interventions may want to refer to the This Wormy World are not recommended. Affected individuals should be dealt with on a case-by-case basis. website to see what existing data on b. If resources are available and the prevalence is towards the higher end of the interval, a third drug distribution intervention might be added. In this case, the appropriate frequency of treatment would be prevalence suggest for any given area. every 4 months.
10 When Preschool-Age Children Should be Dewormed
Deworming Drugs and Doses4 Drug Safety Minimizing the impact of adverse events following STH deworming treatment9 In 2002, a WHO Informal Consultation Deworming drugs are extremely safe8 concluded that albendazole and An adverse event is any untoward medical Deworming drugs reach and kill the mebendazole are safe for administration to occurrence that may present during parasites in the digestive tract and, because children aged 12 months and older.5 There treatment with a medicine but that does not they are poorly absorbed, cause no are no data on the use of these drugs in necessarily have a causal relationship with significant side effects. Minor side-effects children under 12 months of age. Children this treatment. For example, if a child falls such as nausea and abdominal discomfort under 12 months of age should not be and cuts their arm at a distribution, that are uncommon (occurring in 1–5% of treated (unless indicated by a physician in a would be an adverse event that is not individuals, according to different studies), clinical setting). WHO recommends four related to the deworming medicine. transient, and well tolerated by children. drugs for the treatment of infection with However, if a child experiences nausea, soil-transmitted helminths; all these drugs Mild abdominal pain, nausea, vomiting, vomiting, headache, diarrhea, or fatigue after have excellent therapeutic efficacy. Two, headache, diarrhea, and fatigue are the most taking deworming, these are adverse events albendazole and mebendazole, are more frequently reported adverse effects and do not that could be a result of the deworming appropriate for use in large scale campaigns normally require medical treatment.9 medicine. because there is no need to weigh the Occasionally, in heavily infected children An adverse drug reaction is a response to a children6 and are the only deworming worms exit through the mouth and nose; medicine which is noxious and unintended treatments addressed in this manual. these can be pulled out or spit out. and which occurs at doses normally used in Albendazole and mebendazole tablets are Deworming drugs can be given to children humans.10 These definitions indicate that chewable and normally fruit or mint flavored, beginning at the age of 1 year8 there are events that are caused by the action of the medicine – the adverse drug which means it is easy to persuade children According to a recent WHO consultation, reactions – as well as events that are not to take them. The tablets can be broken and deworming is safe and, in highly endemic caused by the medicine and can simply be crushed in one of 3 ways: (a) in a folded areas, recommended from the age of 1 coincidental (that is, just temporally paper using a glass pop bottle, (b) with a year.5 Children less than 1 year of age are associated with the use of a medicine). mortar and pestle, or (c) between two not usually infected with STH and spoons. When cups and clean water are deworming is not recommended.b The deworming drugs used for preschool- available, the crushed tablets can be given age children are effective, have an excellent with a glass of water for children who have Similarly, deworming is seldom recommended safety record and are approved for use in difficulties in chewing and swallowing the more than twice per year, even in areas of preschool-age children. The cumulative tablets.7 intense STH transmission. However, if experience of deworming millions of children treatment occurs at more frequent intervals (for worldwide shows that these drugs cause example, if a child has recently been treated at only rare, mild and transient adverse events a health clinic and then receives another tablet or adverse drug reactions, with durations during a mass campaign), adverse effects are lasting less than 48 hours. 11, 12 unlikely, since for other diseases, higher daily doses of albendazole are recommended for Adverse drug reactions are generally 30 days or longer. reactions to degeneration of the worms that have been killed. Most of the adverse Table 2. Druga dosage for albendazole and mebendazole. reactions or side-effects observed in school programs occur during the first rounds of Dose by Age implementation of the intervention; that is, at Drugs a time when children have the most worms. Comment 12-23 Months 24-59 Months Mild abdominal pain, nausea, vomiting, headache, diarrhea, and fatigue are the most frequently reported adverse effects and Albendazole ½ tablet 1 tablet These 2 drugs are easy 400 mg tablet do not normally require medical treatment. to administer because there is no need to weigh However, it is important to address adverse Mebendazole 1 tablet the children. events in advance by communicating clearly 500 mg tablet with community leaders: in some instances, a. For treatment of all children under 5 years of age, chewable tablets must be used. rumors about the drug’s lack of safety have b. If a child younger than 1 year is treated by accident, no harm will be caused as albendazole and mebendazole have been used for treatment for this age group, without reported side-effects. 11 When Preschool-Age Children Should be Dewormed
resulted in a large number of children • Take immediate action in case of even or mebendazole at the same time as drugs complaining of nonspecific symptoms minor adverse events: nausea, vomiting, for other parasitic diseases, (i.e., and in a high number of referrals to the headache, diarrhea, and fatigue can be ivermectin for river blindness or lymphatic health units, not to mention disruption easily managed with inexpensive remedies filariasis and praziquantel for of health programs. (such as resting in a quiet room for a few schistosomiasis) – since adverse drug hours, and, in the case of vomiting or reactions are generally a reaction to the Briefly, the principal measures for minimizing diarrhea, providing water mixed with oral degeneration of the killed parasites. the impact of adverse events and adverse rehydration salts/ORS or its equivalent). Administering the drugs on separate drug reactions during anthelminthic occasions avoids the simultaneous killing deworming treatment are the following:9 • In the first year of intervention, when of large numbers of different parasites and infection intensities are highest, avoid triple • Communicate clearly to the community thus reduces the probability of adverse therapy – the administration of albendazole leaders and caregivers the reasons for the reactions. deworming intervention and information on the known adverse effects. Respond to questions and clarify doubts. Stress that:
- adverse events will be minor and transient while preventive deworming is highly beneficial;
- an adverse event may occur at the same time as, or immediately after, the treatment, but this is not sufficient to attribute the cause to the drug administration;
Points to Remember
• The prevalence of STH infections in • Children who are 12-59 months old (1 • It is important to address adverse school-age children determines how year up to 5 years) get one whole tablet events in advance by communicating often all children, including preschool- (500 mg) of mebendazole. clearly with community leaders and age children, should receive deworming. • Deworming drugs are extremely safe. caregivers. • Children can start receiving deworming • Adverse drug reactions are generally a • Take action in case of adverse events, at 12 months (1 year) of age. reaction to the degeneration of the killed such as managing them with • Albendazole and mebendazole are worms. inexpensive remedies, time for rest, and providing water mixed with oral appropriate drugs to use for large scale • Since deworming drugs are not easily deworming campaigns since there is no rehydration salts for vomiting or absorbed into the system, there are few diarrhea. need to weigh the children and they are side effects, only about 1-5% of very safe. individuals experience them. • Avoid treating multiple parasitic diseases at the same time. • Albendazole and mebendazole are • Side effects may include mild abdominal flavored, chewable tablets that can be Administering the drugs on separate pain, nausea, vomiting, headache, occasions avoids the simultaneous crushed and given to young children diarrhea, and fatigue. with a glass of water. killing of large numbers of different • Occasionally, in heavily infected children parasites and thus reduces the • Children who are 12-23 months (1 year worms exit through the mouth and probability of adverse reactions. up to 2 years) old get a ½ tablet (200 nose; these can be pulled out or mg) of albendazole and children who spit out. are 24-59 months (2 years up to 5 years) old get a whole tablet (400 mg).
12 4 How to Administer Deworming Tablets About this Chapter
It is simple to administer deworming – with minimal training, non-medical personnel can easily and safely give the drugs and provide education on the benefits of deworming.
This chapter outlines the process for administering deworming to preschool- age children. It shows health care providers how to crush the deworming tablets and safely administer the powder to young children. It also explains how to calculate the correct doses for different age groups.
This chapter also gives advice on essential hygiene and infection prevention measures. It includes a practical analysis of risks, good practice, and precautions in both community-based settings and out-patient health care clinics for managers who are thinking about holding a mass drug administration program.
In addition, the chapter presents details of respiratory hygiene and cough etiquette to control the spread of pathogens from infected individuals. Advice is provided for health workers, children, caregivers, volunteers, and visitors, as well as for the managers of deworming programs. Finally, the chapter advises on hand hygiene and appropriate hand sanitizer and indications for use.
Only Limited Training is How to Administer Deworming Tablets to Preschool-Age Needed for Distributors1 Children Ages 12-59 Months of Age (1 year up to 5 years)3
Administering deworming drugs is simple. 1. Use age of a child to determine the dose of albendazole or mebendazole needed With only a few hours of training, non-medical personnel such as village health volunteers or teachers can easily and safely give the drugs Dose and Tablet Crushing by Age and provide clear simple education on the benefits of deworming.2 This makes it easy to Tablets may be given combine deworming training with the training Tablets must be crushed without crushing for vitamin A distribution. Drugs
12-23 months 24-35 months 36-59 months
Albendazole 400 mg tablet ½ tablet 1 tablet 1 tablet
Mebendazole 500 mg tablet 1 tablet 1 tablet
13 How to Administer Deworming Tablets
Crushing a Tablet 2. Crushed Tablets: Tablets must be Infection Prevention crushed for children ages 1 year up Without proper precautions, deworming may to 3 years (12-35 months) risk the spread of infectious diseases, a. Albendazole: Children 12-23 months especially among young children. should receive ½ tablet; Children 24-35 Distribution programs should be designed to months should receive 1 tablet. minimize this risk and prevent the transmission of infections and diseases. Mebendazole: Children 12-35 months should receive 1 tablet. Distribution of deworming usually takes Place albendazole tablet inside a place in one of two settings: a health care b. Put either ½ or 1 tablet of albendazole or folded piece of paper, then crush with facility, such as an out-patient health clinic, 1 tablet of mebendazole inside a folded a glass bottle. or a community setting, such as a school, small piece of clean paper. Using a glass community center or local gathering place. bottle, crush the tablet into a fine powder. (Alternately, use a mortar and pestle to Giving Albendazole crush the tablet or crush the tablet Risks between two spoons). The health-care setting may present a c. Sit the child on the mother’s lap. greater risk of infection than the community d. Ensure that child is calm. setting. This is because: e. Administer the mixture gently. To assure • Many people seeking health care infection prevention, use the folded paper services are already sick. as a funnel and pour the powder directly • Invasive procedures are routinely • Use folded piece of paper to slowly into the child’s mouth, without touching performed in health care facilities. pour the crushed tablet into the the child. These can increase the risk of exposure child’s mouth. f. If clean water is available, provide each to micro-organisms. • Never force a child to take child with a small amount of water to help • Service providers and other staff are deworming, do not hold a child’s in swallowing the powder. constantly exposed to potentially nose to force them to swallow, and g. Ask if the child has chewed and infectious materials, as a part of their do not give it to a child who is swallowed all of the albendazole or work. Without proper precautions, they crying. mebendazole and is comfortable. can inadvertently spread infectious germs to the people with whom they h. Dispose of used paper in an appropriate have contact. container. ! For all Children • Services are sometimes provided to 3. Whole Tablets: Tablets can be Receiving Deworming many clients in a limited physical given whole, without crushing, to space. They often take place over a children ages 3 years up to 5 years Tablets short period of time. This can lead to (36-59 months) increased exposure of all clients. • Do NOT force a child to swallow a. Albendazole: Children 36-59 months the powder or tablet should receive 1 tablet. Mebendazole: Children 36-59 months • Do NOT hold the child’s nose to make him/her swallow should receive 1 tablet. b. Make sure the child is calm • DO let the child go home untreated if administration is unsuccessful; c. Give 1 albendazole or mebendazole he/she will be treated during the tablet to the caretaker to give to the next round child to chew • Do NOT send deworming tablets d. Make sure that the child has chewed and home with a caregiver to give swallowed the tablet and is comfortable to the child later; he/she will be treated during the next round
14 How to Administer Deworming Tablets
Good Practice and Hand Hygiene7 Precautions
Infection prevention practices should be Hand hygiene is one of the most important measures for the prevention and control adapted and applied routinely wherever of the spread of disease. It is a major component of the Standard Precautions that are there is a deworming distribution program.4 noted previously. Main points include: This protects clients, such as infants and • The preferred means to ensure routine hand hygiene, if your hands are not young children receiving deworming, health visibly soiled, is an alcohol-based hand rub. If an alcohol-based hand rub is not care workers, and other staff and volunteers. available, wash your hands with soap and water. Use a single-use towel to dry If you are thinking about holding a your hands. deworming distribution program, you need • If your hands are visibly dirty or soiled with blood or other body fluids, if you to consider how to address the underlying think that broken skin might have been exposed to potentially infectious need that is implied by generally accepted or material, or you have used the toilet, your hands should be washed thoroughly 5 “standard” precautions. These include: with soap and water. • Hand washing and antisepsis The alcohol-based hand rubs with the highest level of antimicrobial (hand hygiene) efficacy usually contain 75 to 85% ethanol, isopropanol, or n-propanol • Using personal protective equipment – or a combination of these products. WHO-recommended formulations (such as gloves, masks, goggles, aprons, contain either 75% v/v isopropanol or 80% v/v ethanol.8 gowns, shoes and hair covers) when you handle blood, body substances, 9 excretions and secretions Indications for Hand Hygiene
• Appropriate handling of patient care You need to perform hand hygiene: equipment and soiled linen • Before and/or after touching each child or caregiver. If a child is sick, you MUST • Prevention of injuries by needles and clean your hands after dosing the child. other sharp items • After you come into contact with body fluids or excretions and mucous • Environmental cleaning and the membranes. management of spills • After you come into contact with inanimate surfaces and objects (including • The appropriate handling of waste. medical equipment) anywhere near each child or caregiver.
Before deworming distribution programs are Before you handle vitamin A supplements or deworming medication, you need to introduced at health care centers, the centers perform hand hygiene using an alcohol-based hand rub. Alternately, you should wash should already rigorously employ standard your hands with either plain or antimicrobial soap and clean water. infection prevention practices. This is especially important if the facility is not easily Soap and alcohol-based hand rub should not be used at the same time. able to separate people receiving deworming from sick patients who are coming there for treatment.6
Further Reading For a more in-depth discussion about these issues, see EngenderHealth (2001), Infection prevention: A reference booklet for health care providers.
15 How to Administer Deworming Tablets
Respiratory Hygiene/Cough Etiquette10 Points to Remember
To avoid transmission to unprotected The managers of a deworming distribution contacts, it is essential to control the spread program should promote respiratory • Make sure you follow the steps for of pathogens from infected individuals. For hygiene/cough etiquette, as follows: correctly administering deworming tablets to young children. diseases transmitted through large droplets • Promote the use of respiratory hygiene/ and/or very small, airborne droplets, all • More detailed steps can be found in cough etiquette by all health care the Vitamin Angels’ VAS+D Visual individuals with respiratory symptoms should workers, children, and family members Checklist. apply respiratory hygiene/cough etiquette. with acute febrile respiratory illness. • Remember that there are different People with signs or symptoms of a respiratory • Educate health care workers, children, doses for children from 12-23 months infection, including health workers, children, and 24-59 months. caregivers, and visitors on the caregivers, volunteers and visitors: importance of containing respiratory • Always check the expiration date on • Should cover their mouth and nose aerosols and secretions. This is because the bottle, as you should not administer deworming that is out when they cough or sneeze. they help prevent the transmission of of date. respiratory diseases. • Should use tissues, handkerchiefs, cloth • Do NOT force a child to swallow the masks or medical masks, if available, as • Consider providing resources for hand powder or tablet. a source control. These materials hygiene, such as dispensers of alcohol- • Do NOT hold the child’s nose to capture respiratory secretions and must based hand rubs and hand-washing make him/her swallow. be disposed of in a waste container. supplies, and resources for respiratory • DO let the child go home untreated hygiene, such as tissues. Places where • Should use a medical mask if they are if administration is unsuccessful; he/ people gather, such as waiting rooms, she will be treated during the next coughing or sneezing, provided a mask should be made a priority. round. can be tolerated. • Do NOT send deworming tablets • Must perform hand hygiene. home with a caregiver to give to the child later; he/she will be treated during the next round. Covering Your Nose and Mouth when Coughing or Sneezing • Always wash your hands with an alcohol-based rub before and/or after touching each child or caregiver. • If alcohol-based rub is not available, use soap and clean water. • Clean your hands before handling deworming tablets. • Wear gloves, masks, goggles or other protection when you handle blood, body substances, excretions and secretions. • Cover your mouth and nose when • If you have to cough or • For prolonged coughing • If you do not have a clean you cough or sneeze. sneeze, cover your mouth or sneezing, please wear tissue, turn your face into • Ask your deworming distribution with a clean tissue. a face mask. your shoulder or the bend program manager if there is anything of your elbow to cough that you are not sure about. or sneeze.
16 Giving Deworming to Children 5 Ages 12–59 Months
About this Chapter
This chapter examines important aspects to providing deworming to children ages 12- 59 months. It points out the risk of choking and the importance of crushing deworming tablets for the safe administration of deworming to young children. It also notes the importance of staff and volunteers knowing what to do in case a child does choke when receiving deworming.
The chapter also looks at six recommendations when giving deworming to preschool- age children. The main concern is the safety of the children and ensuring that those administering deworming are trained to crush the deworming tablets to minimize risk of choking.
The chapter emphasizes that children should never be forced to take deworming. It talks about the importance of training and continued supervision of healthcare providers, and that they should always crush the deworming tablets and give water, if needed.
Finally, it outlines the best order of health services in order to diminish issues with children being upset.
Giving Deworming to Children 12-59 Months Old Six Recommendations when Deworming Young Children3 While the drugs themselves are extremely campaign which is treating millions, it is safe, their administration must also be safe.1 significant.2 It is strongly recommended that the following In one study on the safety of deworming, six points are taken into consideration if researchers measured problems encountered The approach of health staff is the deworming tablets are to be included in when deworming was administered to most important determinant affecting large-scale campaigns. children. “Problems” in swallowing the tablet the number of children having were graded from minor to serious, and problems. 1. Assess the need for treatment contributing factors included crying, spitting, choking, and vomiting. Problems could have If the staff delivering the tablets do not know • Before any preschool-age program is been caused by multiple factors. If the health what to do if a child chokes, that child can launched, a rapid assessment of worm staff were patient, and were able to resolve the potentially die. See recommendations below infection levels in school-age children more minor problems (e.g., crying, spitting), a for this training. Formulations of deworming must indicate that treatment is justified. child could be classified as having a problem(s) drugs that do not require chewing are being This information can usually be obtained and yet still be “successfully treated on site.”2 investigated. Until then, in using chewable from the Ministry of Health. The website tablets, WHO makes the six “this wormy world” also provides maps of The proportion of children who choked was recommendations in the next section.2 STH prevalence. 1–3%. This may sound relatively low, but in a
17 Giving Deworming to Children Ages 12–59 Months
! Points to Remember Safety First 4. Crush tablets and use water • Only chewable deworming tablets should • Deworming is very safe, and the Program managers must guarantee be given to children under 5 years of age. administration of it should also be adequate training for the drug safe. distributors to ensure that they • Tablets which taste good should be • There is a risk of children choking on have the time to crush the tablets chosen. before administering them safely the deworming tablet, so extra care to children • For children under 3 years of age, tablets should be taken to minimize this risk should be broken and crushed in one of as much as possible. three ways: (a) in a folded paper using a • Health staff can take measures to 2. Never force a child glass bottle, (b) with a mortar and pestle, reduce problems with swallowing the tablet. • NEVER force a child to take the or (c) between two spoons. When cups deworming tablet. Gently coax the child to and clean water are available, the crushed • It is very important that health staff know what to do if a child chokes. swallow the crushed tablet or offer it as a tablets can be given with a glass of water sweet. If the child is still uncooperative, let for children that have difficulties in • Safety should always come first. 4 the child pass without treatment; he or chewing and swallowing the tablets. • Proper training of health staff and she will have another chance to be crushing of deworming tablets treated at the next round. increases safety. 5. Administer deworming treatment under • 6 recommendations are provided for supervision the administration of deworming: 3. Provide training for all products • During large-scale campaigns, deworming o Assess the need for deworming • All service providers and volunteers must should be administered on site where o Never force a child to take be trained in how to safely administer supervision and assistance can be given if deworming a child needs help. vitamin A capsules and deworming o Provide training and supervision tablets. to health staff
• Supervision should be routinely 6. Set up the health post correctly o Always crush deworming and conducted. use water to help children • The order in which products are delivered swallow it • Training must be repeated regularly. is important. In an integrated campaign, o Always administer deworming Cascade training is known to become the recommended sequence is shown under supervision less effective the further down the line it below. The measles injection (or any other o Set up the health post so that goes. The most remote post is, therefore, injectable) is given last because it is most children will not be upset or more likely to be unsupervised, further likely to result in a screaming child, which crying when they receive from help if it is needed, and have fewer rapidly results in a room full of upset deworming well-trained staff. children.The approach of the health staff • Training must include how to handle is the most critical determinant affecting reluctant children and those having the number of children having problems. difficulties in swallowing the tablet.
• Training must include the simple steps that can be taken to save a child’s life if he/she chokes on either the deworming tablet or the vitamin A 1 2 3 4 5 capsule if it slips into the child’s mouth Register Vitamin Deworming Measles/ Insecticide- (see Appendix C). child A injectable treated bednet
18 How to Ship, Transport, and Store 6 Deworming Tablets
About this Chapter
This chapter explains how deworming tablets are packaged, shipped, transported and stored long term, so that they do not lose their potency.
It looks at how the shipment process works from start to finish, and provides advice for consignees and shipping agents in terms of packing and temporary storage, as well as how to work with customs.
It also gives details of the different forms that deworming can take. It explains how they must be stored long term, in warehouses and at point of distribution. It also looks at how to maintain packaging, and how and when packaging can be opened.
In addition, Chapter 6 looks at how deworming tablets must be stored once their packaging or containers have been opened.
General Guidance1,2
Deworming tablets are more stable than vaccines. They do not need a cold chain3 and do not need to be stored in a refrigerator. Their potency is, however, reduced by air and sunlight.
Deworming tablets should:
• be kept out of direct sunlight
• be kept cool
• be kept dry
• not be frozen
• be kept away from insects and pests
• be kept away from toxic chemicals, and
• be kept off of the ground
19 How to Ship, Transport and Store Deworming Tablets
International and Onward Shipping and Warehousing
The deworming tablets provided by Vitamin Consignees should, however, take At the same time, it is essential to: Angels are high-quality chewable tablets, possession of the bulk shipments as soon • minimize exposure to light and heat manufactured consistent with best practices, as is practical. and are packed at a factory. The way in • prevent freezing, and When possible, arrangements should be which they are prepared for international made to clear the deworming tablets from • maintain dry conditions. shipment is based on manufacturer customs before they arrive. Vitamin Angels specifications. These specifications follow provides the relevant documentation to international best practices. As a result, the Packaging Requirements consignees, who are then responsible for packaging must be maintained intact at all making the necessary arrangements for points during the international shipment • Bulk shipments should be kept in their deworming tablets to be released from process. packaging for as long as possible. customs. Once the deworming shipments arrive at the • The packaging should only be broken Once bulk-packaged deworming tablets port of entry, the shipping agents must if it is necessary to inspect quantities have reached the destination country, its continue to follow the shipper’s instructions. or to verify labelling. onward shipment should be completed as These apply to both packaging and quickly as possible. The original packaging • The seal of any individual container temporary storage. must be maintained as much as possible. containing deworming must never be broken until it is time to dispense it.
Storing Tablets4 Storing Syrup Local Point-of-Distribution Storage4 Deworming tablets normally come in the form In some, very limited circumstances, of a chewable tablet. Each tablet contains deworming is prepared by the manufacturer • Deworming can be stored locally in a 400mg of albendazole, which can be divided as syrup and packed in sealed bottles. Each secured room or cabinet. This keeps into two doses of 200mg for young children. bottle contains many doses. bottles out of direct sunlight, and Tablets are transported in bulk, sealed, ensures that they are cool, dry, and not When deworming is provided as syrup opaque bottles, each of which contains 100, subject to freezing. packaged in bottles, it requires a larger 500 or 1,000 tablets. storage space. How big this is depends on • Make sure that bottles are secure from Sometimes deworming tablets need to be the volume of syrup in each bottle. insects and pests. temporarily warehoused in bulk. When this Individual bottles of deworming tablets and • Do not store deworming in the same happens, each consignment of 10,000 tablets syrup must not be opened at either central or place as poisonous or toxic substances (which is enough to meet the needs of 5,000 regional warehouses. They must be kept or in the same places as chemicals, children for one year) requires approximately intact until they are received at the point of such as kerosene or petrol. one cubic meter of space. distribution and administration. • If an unopened bottle is properly It should be stored: stored, deworming tablets in either • in a dry, cool area Monitoring Expiry Dates capsule or syrup form will retain their potency for at least two years. They • at temperatures above freezing The people who manage the supply and should be kept unopened and must be • out of direct sunlight distribution of deworming must ensure stored in a sealed bottle. that they monitor expiry dates. This • away from insects and pests ensures that the syrup and/or tablets are • away from toxic chemicals, and used before the expiry date on the label, • off the ground or before the use-by date written on the bottle by the health care provider.
20 How to Ship, Transport, and Store Deworming Tablets
Using Chewable Tablets Points to Remember
Once the seal on a bottle is opened, individual deworming tablets must be used • Deworming tablets are more stable than • Deworming is normally provided as within one year. vaccines; however, they are affected by tablets. However, it occasionally takes air and sunlight. the form of syrup. As soon as you have opened a bottle of • When deworming is being shipped from tablets, write the date on the label so that the manufacturer to your country, the • It is very important to store both forms of you will know when to stop using it. packaging must be maintained at all deworming correctly. They must be times. stored in opaque containers. In addition, they must not be exposed to excessive • Once the deworming has arrived in your light or heat, they must be kept dry, and country, the shipping agents must they must be kept out of direct sunlight. Storing Opened Containers follow the shipper’s instructions very They should also be kept free from and Bottles carefully. This is also important when insects or pests and should not be the tablets are in temporary storage. exposed to poisons or chemicals. • Deworming tablets need to be cleared • As soon as you have opened a • Once a bottle has been opened, through customs as quickly as possible. bottle of tablets, or a glass bottle of individual deworming tablets should be Vitamin Angels provides the used within one year. deworming syrup, write the date on documentation you need to do this. the label. You will then know when • Writing the date on the deworming bottle • You need to follow packaging to stop using it. label immediately after opening it for the requirements very carefully. In particular, first time will help you remember the • Always check the expiry date printed you need to keep bulk shipments in their date by which the tablets or syrup on the label. 2,5 packaging as long as possible. You ought to be used. should only break the packaging if the • All deworming tablets should be quantities or labeling need to be stored in opaque bottles. This inspected or verified. protects them against the light.2
21 Organizing Mass Distribution 7 of Deworming
About this Chapter Chapter 7 looks at how deworming tablets are distributed in countries which are experiencing endemic infections of soil transmitted helminths (STH). It examines the range of opportunities for deworming distribution inside and outside of government-run health programs.
The chapter shows how deworming distribution can be integrated into existing health service interventions. These include facility-based health care centers, maternal and child survival services, postnatal care services and specially-organized programs and events. It advises health workers on what to ask caregivers of infants and young children.
It also looks at why child health weeks and days, micronutrient days, community-based outreach approaches and regular deworming programs are set up, who they help, and what they achieve.
Finally, Chapter 7 provides a reading list of manuals that suggest ways to organize deworming around health activities or regular vitamin A supplementation.
Distribution Projects and Initiatives
Traditionally, deworming tablets are national health system, and are not being A range of opportunities is available for distributed as part of a variety of health reached by traditional distribution systems. deworming in the context of health programs. system-related initiatives. These include, for Above all, every health system which As a result, other methods are being used to example, maternal and child health (MCH) operates in a country which is endemic for increase deworming coverage, while still services at health centers and community STH should take the opportunity to increase coordinating with the national and district outreach services. Some of these are run as its coverage of deworming. This can be done level health system. One such innovative part of a ministry or department of health by adding deworming services to all of the method for increasing coverage is to use program, often with the support of a ministry basic health services. This is possible both local networks of indigenous non- or department of education. when distribution takes place within a health governmental organizations (NGOs) to care facility and when it takes place through Deworming distribution initiatives offered access hard-to-reach populations. Another community health outreach services. through the national health system are nearing method is to engage large, community- their maximum potential for reach. However, based microfinance associations to manage large numbers of young children still do not deworming distributions within their have access to deworming through the geographic area.
22 Organizing Mass Distribution of Deworming
Integration into Health Service Interventions Meeting Caregivers and Children Deworming distributions can be integrated into any number of existing health service interventions. These include:1,2 • Interventions that are part of the regular services at facility-based health care • All health workers should centers, such as: always ask a child’s caregiver if their child needs his or her next 1,3 (a) Expanded programs for immunization (EPI) activities dose of deworming. (b) Integrated management of childhood illness (IMCI) • You should also check the (c) Maternal and child health (MCH) services child’s immunization or health card to find out when the child (d) Maternal and child survival services last took a deworming tablet. (e) Other postnatal care services • Each time you come into • During specially planned child health weeks (CHW) or immunization contact with a mother or young days or weeks child, you can use this as an • During specially organized micronutrient distribution events opportunity to check and treat children with intestinal worms. • Through community-based outreach and distribution, and • During regularly scheduled vitamin A supplementation programs
23 Organizing Mass Distribution of Deworming
Child Health Weeks or Days Community-Based Points to Remember Outreach Approaches Child Health Weeks (CHW) are regular events. They deliver an integrated package This approach is usually administered • Traditionally, deworming tablets are of preventive services that are known to be through the government health distributed as part of a variety of highly cost-effective for improving child infrastructure. health system-related initiatives. health and survival. CHWs are run alongside • It is based upon massive social • However, large numbers of infants routine services at health facilities. mobilization. and children do not have access to the formal health system, and are not • CHWs aim to reach all children under the • Deworming tablets are distributed to being reached by traditional age of five years at least once every six the district health office, then to health distribution systems. months. posts, and finally through village • As a result, large-scale • CHWs take place during a limited time workers. demonstration projects, which use period, such as a day, week or month. One example of this approach comes from innovative distribution schemes, are being undertaken to distribute • The package of essential preventive Nepal. A program was set up which asked deworming. health services depends on what people female community health volunteers to in the area need. distribute products on the same four days • Every health system that operates in every year. Two days were set up for the first a country which is endemic for STH • The package of services could include distribution and two for the second. should take the opportunity to deworming, vitamin A supplementation, increase its coverage of deworming. insecticide-treated bed nets (ITNs) or • A range of opportunities is available other services. Regular Deworming Programs for deworming distribution in the context of health programs. About two thirds of the countries which • Deworming distribution can be Micronutrient Days experience vitamin A deficiency are also integrated into any number of classified by the World Health Organization In many countries, deworming has been existing health service interventions, distributed successfully during National (WHO) as being endemic with soil- from regular services at facility- Immunization Days. These provide one transmitted helminths (STH or “worms”). based health care centers to deworming tablet and one vitamin A • STH compete for available maternal and child services, child health weeks, or days, micronutrient supplement per year. Consequently, micronutrients ingested by infants days, community-based outreach Micronutrient Days were developed to and children. approaches, and regular vitamin A provide the second distribution in a year. • The distribution schedule for both supplementation programs, among • Typically, specific dates during the year deworming tablets and vitamin A others. are identified. are similar. • Whenever a health worker meets a child or its caregiver, it is an • These dates are the focus for distributing • This means that STH treatment offers a opportunity to check up on the deworming, vitamin A supplements and perfect opportunity to provide vitamin A child’s deworming status. other micronutrients such as iron or folic supplements in countries with regular acid tablets. deworming programs. • You can read manuals by WHO/ UNICEF and the Micronutrient Initiative if you want to find out more about organizing deworming Further Reading programs or about integrating regular deworming with vitamin A For more information about when and how to integrate regular deworming with supplementation. vitamin A supplementation, you can read the WHO/UNICEF manual: How to add deworming to vitamin A distribution (2004). To find out more about how to organize vitamin A supplementation programs around other health activities, you can read the Micronutrient Initiative’s manual: Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring (2007).
24 8 Training and Public Awareness
About this Chapter
Chapter 8 provides key points about training and public awareness communications. The chapter also suggests where operations managers can find out more about these topics. It explains why training about deworming is important for health providers and community leaders. It suggests what this training should include. It also suggests what you need to do when you are planning a training program. Next, it provides questions for health workers to use when they are role-playing.
This chapter then looks at areas to focus on during training. It points to the basic facts that the training should provide. It also explains how to develop the skills of the people who provide the deworming tablets.
It also explains why public awareness campaigns are a relatively inexpensive way to promote deworming. It tells why a well-conceived public awareness strategy helps preserve children’s health. It suggests key messages to share with caregivers.
Finally, Chapter 8 looks at how to promote deworming distribution. It shows how to do this in urban settings, towns and villages, and rural or hard-to-reach settings. It also suggests when it is appropriate to use printed materials or newspapers to create demand for deworming.
General Vitamin Angels Deworming Learning Courses
Deworming can be distributed at one or Vitamin Angels’Deworming Learning Package These Deworming Learning Courses provide many locations. Wherever it is distributed, the standardizes and addresses healthcare participants with standardized, step-by-step operations manager must make sure that workers’ deworming distribution training instruction and the opportunity to practice training or refresher training takes place. This needs. It also includes training on how to practical deworming service delivery skills ensures that the deworming is distributed deliver vitamin A at the same time as including entrance and exit counseling, properly. deworming. These interactive learning eligibility determination and distribution. courses aim to ensure that participants are The operations manager must also make Vitamin Angels field partners can request a current on deworming best practices and that people aware of every distribution program training by contacting a Vitamin Angels they have the technical background information that is taking place and provide key information Program Manager. Also, Vitamin Angels will and practical skills needed to plan, facilitate, about each deworming distribution. contact our field partners about trainings that deliver, monitor, and evaluate an effective are planned in their area. deworming distribution project.
25 Training and Public Awareness
Training1 Public Awareness 2
Many health providers and/or community Training should take place before you run the Periodic deworming is a relatively inexpensive leaders do not know about deworming. Even deworming distribution program. This is way to promote active participation by if they do, they may not know about its because each team, in every location, needs caregivers. This is because you only need to important role in preserving and improving time to complete the training and promote deworming twice every year. child health. They therefore need to preparations that are needed for a A well-conceived public awareness undertake the appropriate training. This distribution event. strategy helps preserve children’s health. should address the benefits, safety and side During the training, the health workers should Over time, it will create demand throughout effects of deworming, as well as all aspects follow the steps in the Vitamin Angels’ visual the community for both initial and ongoing of organizing and implementing distribution. checklist, a 39-step job aid that reminds deworming distribution programs. When you set up your training program, you service providers of the important steps in need to ask 3 key questions: service delivery. Some key steps include: Key Messages • Is this is the first time that deworming • practice telling the caregiver that the distribution is being undertaken? child is receiving deworming In order to promote deworming • Is this is a routine activity? • practice telling the caregiver how their distribution in communities, minimal child will benefit by taking deworming information containing key messages • Are you using the same staff or are you should be provided. This should taking on new staff? • discuss safety and side effects happen about a month before the Training can be quite intensive at the start of • practice providing deworming to a distribution. Information should be a new program. However, with time, your pretend child, including using eligibility given to all caregivers, and should deworming distribution program will become criteria for screening and using include:3 more routine. infection prevention practices • the dates of the deworming After a while, you may find that you only • remind the caregiver when to return for distribution program need to arrange refresher training, or even the next dose of deworming. • where and when to go (times and just-in-time, on-the-job training. locations for the nearest services) • what services will be given 1 Training Focus • instructions to bring all children aged 12–59 months (along with Training should focus on: their child health cards) 1. Providing information on basic facts about deworming and its benefits • the health benefits of the services, Health workers need to know the benefits associated with deworming tablets. including that it is important for the They also need to know other basic facts about deworming (see Appendix B). health of every child
2. Developing and standardizing the service providers’ skills
Health workers need to be competent in the proper administration of deworming Job Aid: Visual Checklist tablets. Among other elements, this includes: for Giving Vitamin A and • knowing the proper dosage Deworming Together • screening for eligibility and ineligibility indicators An example of Vitamin Angels “Job •crushing tablets, and Aid” or visual checklist can be found in • tallying and recordkeeping. Appendix C. This includes a picture version of the 39 key steps in giving Do not simply rely on lectures. Training which gives workers an opportunity to solve vitamin A and deworming to young problems in a simulation of the distribution event is more effective. children. It helps to train and remind Demonstration with practice works best. For example, workers should be asked to service providers of the important demonstrate how to use a 200mg half-tablet for a child from 12-23 months of age. steps in service delivery.
26 Training and Public Awareness
Promoting Distribution Using Printed Materials and There are many ways of communicating to the In towns and villages: Newspapers 4 community: • use “town criers” with microphones • It is up to each manager to prioritize • use meetings led by community leaders • Experience suggests that using print which methods work best in their or women’s organizations materials (such as posters, banners or community. billboards) and newspapers is not an In rural and hard-to-reach settings: • Using more than one method will effective way to create a demand for increase the chances of your messages • use interpersonal communication; this is deworming. reaching the target group. particularly important in hard-to-reach, • According to one report, print rural settings Evaluations of vitamin A and polio materials and newspapers could, eradication programs consistently find that it • involve trusted leaders; this is strongly however, be useful to address specific is best to use a number of different recommended. advocacy needs. approaches to spread the word about distributions. These depend on whether you are dealing with people in urban Further Reading environments, towns and villages, or rural settings.3 If you would like to find out more about training and public awareness, the In urban settings: following resources are helpful: • Vitamin Angels: Deworming: Facilitator’s Guide • use the radio and television • Vitamin Angels: Deworming: Learner’s Guide • communicate via religious organizations • MOST/USAID: Twice-yearly vitamin A supplementation: A guide for program (mosques, churches) and their leaders managers, 2001 • The Micronutrient Initiative: Vitamin A in child health weeks: A toolkit for (priests, imams) planning, implementing, and monitoring, 2007
Points to Remember
• Deworming can be distributed at one or • Training should focus on providing • Caregivers and children must be given more locations. information on basic facts about key messages about where and when deworming distribution is taking place, • Training or refresher training should deworming and its benefits and side what to bring, what will happen, and always take place before the effects. why it is important. distribution program is set up; it is • It is also the best time to develop the important to allow enough time for this. skills of the people who provide • There are many ways to promote these events, from using the radio or “town • Many health providers and community deworming. criers” to using trusted community leaders do not know the importance of • Do not simply rely on lectures; it is more leaders. The message used depends deworming. effective to provide training which gives on whether the event is taking place in workers an opportunity to solve problems • They need to be trained about an urban setting, a town or village in a simulation of the distribution event. deworming, as well as about how to setting, or in a rural or hard-to-reach organize and implement its distribution. • Demonstration with practice works best. setting. • Three key questions need to be asked • It is important to make people aware of • It’s important to use the method that every time training takes place. deworming distribution events. Doing works best for your particular • Training is a good opportunity to this is relatively inexpensive because it community. only needs to happen twice a year. practice what to say to the caregivers • Printed materials and newspapers are when the children they are responsible • In order to promote deworming not the best method in any of these for are being given deworming. distribution in communities, minimal environments; however, they could be information containing key messages useful if you need to address advocacy should be provided about a month needs. before the project takes place.
27 9 Requirements for Distribution Points
About this Chapter Chapter 9 lists the supplies you need to provide at a deworming distribution location. The chapter explains why you need supplies. It also shows how to calculate the number of deworming tablets, training materials, educational materials, tablet crushing tool, plastic bags or boxes, child health cards, and tally sheets you need.
The chapter lists the specific physical facilities and processes that need to be set up at every location were deworming distribution is to occur. It also explains what each process involves.
Equipment required
Supplies and easy access to clean water, for It is important to have the correct supplies at infection prevention practices. each deworming distribution location. In • Small squares of clean, blank white particular, each location should have: paper folded in half into triangles. These slips of paper are used when crushing • Enough deworming tablets for each the tablets. child expected to attend. • A plastic bag or box where used paper • Child health cards for every child can be thrown away. expected to attend for use if a caregiver • Tally sheets for each person supplying does not have them. These are used to deworming (see example on page 59). record deworming doses (see example on page 61). • Training materials for health workers and volunteers. • 1 clean, empty glass bottle or other crushing implement for each person • Educational materials for caregivers distributing the deworming. • Vitamin Angels “Visual Checklist” to • Alcohol-based hand sanitizer, or soap serve as a job aid (pages 47-52).
Tally Sheets
The deworming program should have enough tally sheets to cover the number of children expected to attend.
• One tally sheet usually covers 100 children in the 6–59 months age group.
• The number of tally sheets that are needed is equal to the expected number of children in this age group, divided by 100, plus an additional 10% as a back-up.
For further information, see the example of a tally sheet on page 59.
28 Requirements for Distribution Points
Physical Facilities and Points to Remember Processes
It is also important to set up various physical • Make sure you have the correct supplies facilities and processes wherever deworming at each deworming distribution • You need enough educational distribution is taking place. These include: location. materials for all the caregivers you • An adequate storage area for all • You need one deworming tablet and expect to attend. deworming supplies. This ensures that child health card for every child you • You need to provide adequate storage the deworming tablets are stored in a expect to attend. for all of the deworming supplies. It secure, dry, cool place, away from • You need alcohol-based hand sanitizer, should be secure, cool, dry and away direct sunlight and off the ground. or soap and easy access to clean from direct sunlight and off the ground. water, for infection prevention • You need to set up a method of • A method for disposing of used practices. disposing of used crushing papers. crushing papers. • You need a glass bottle, some clean • You need to create a simple training • A simple program for training those squares of white paper, and a plastic program, including how to administer administering deworming. This includes bag or box for every person distributing deworming, and how to recognize and instruction on how to administer deworming. refer sick children. deworming, and how to recognize and • You need 1 tally sheet for every 100 • You need a systematic method for refer sick children. children you expect to attend, plus an telling all caregivers when to bring their extra 10% as back-up. • A systematically applied method that lets children back for their next dose of every infant or child’s caregiver know • You need training materials for health deworming. when to bring them back for their next workers and volunteers. dose of deworming.
29 10 Arranging Your Work Station
About this Chapter
Chapter 10 suggests how you can arrange your work station so that you can administer deworming tablets. Its advice can also be used when you are providing vitamin A supplements and immunizations.
This chapter includes a detailed chart. This focuses on how to ensure a smooth flow of caregivers and children who are coming to your work station to receive health care. Topics it covers include crowd control and health education. The chapter also shows how to operate the registration, vitamin A
How to Arrange a Work Station to Ensure a Smooth Points to Remember Flow of Clients 1,2,3,4
• You can provide deworming and Training on how to set up a well-organized • Someone designated to control the immunizations alongside vitamin A work station is vital. Those that maintain a waiting crowd who allows only a small supplementation. sense of order will operate more smoothly. If number of mothers and children to there is a problem, the staff in an orderly enter the room at one time. • Carefully arranging the layout of your work station will also have the space to The following page shows one way of workstation helps ensure that you respond in time. Work stations should organizing the flow of children and have a smooth flow of clients, ensure that they have: caretakers who are attending a vitamin A including caregivers and children. • Arranged that vitamin A is given first, supplementation and deworming event. • Following these suggestions for then deworming is given. Vaccines and In addition to covering vitamin A crowd control, registration, vitamin A injections should be given last, after supplementation and deworming, this chart supplementation and deworming, vitamin A and deworming. can be used as an example workstation for immunization, tallying and health the provision of immunizations. • Sufficient space between the table education will also help you organize where the measles injection is given your supplementation, deworming and the table where the vitamin A and and immunization days as efficiently deworming are administered. Flow of Children Through a as possible. Well Set-Up Work Station If you are giving vitamin A • Giving children vitamin A and 1. Register child supplements, deworming, and deworming before you immunize immunizations on the same day, 2. Give vitamin A + deworming them helps ensure they are not upset vitamin A should be given first so or crying when they try to swallow 3. Give injectable (e.g., measles vaccine) the child is not upset and crying the vitamin A drops from the capsule when trying to swallow drops of 4. Record each treatment on a tally sheet or crushed deworming tablets. vitamin A. Deworming should be 5. Provide health education given after vitamin A and before immunizations
30 Arranging Your Work Station
Registration Team 1 1. Check that the child is in the target age group. 2. Give the caregiver one health card for each child. 3. Write the child’s age on the back of the card. 3 2
Vitamin A and Deworming Team 2 1. Check the age of the child and give them a deworming tablet– either with or without vitamin A depending on the protocol. 4 1 2. Record the dose given on the child health card. COUNSELING PRESERVICE Immunization Team 3 1. Vaccinate the child. 2. Ensure that safety procedures are followed. 3. Monitor reactions and respond to them as required. 5
Tally Team 4 Use every child’s health card to record each treatment received on EXIT / ENTER the tally sheet. 1. By age group, tally the number Crowd Control Team of vitamin A doses given. 2. By age group, tally the number • Help set up the post every day. of deworming doses given. • Keep order in the waiting zones. 3. By age group, tally the number of immunization doses given. • Let the people who are waiting know if there are any delays. • Keep the flow of people moving. • Mobilize the community. Health Education 5 1. Instruct the child’s caregiver Preservice Counseling when to return for their child’s next dose of deworming. Before delivering deworming to a child, a health worker should tell caregivers: 2. Provide them with a paper • that their child will receive deworming reminder of the next dosing date. • the dosing schedule and benefits of deworming 3. Review possible side effects of deworming with caregiver. • safety and side effects associated with deworming
31 11 Recordkeeping 1
About this Chapter
Chapter 11 explains why it is important to keep records. It recommends how and where to record information about deworming distributions.
The chapter also explains how to record information about deworming distributions. It explains the different types of forms you can use. It also features a sample form for you to use or adapt. In addition, it explains what information you need to include on the form and why it is important.
This chapter includes a sample immunization/child health card. The card has space to include details about deworming distribution.
The chapter also includes advice on how to fill in a card that does not have any space for deworming distribution information. It suggests alternate ways to add this information. The chapter then discusses tally sheets. It explains why they are needed, when they should be used, and how they should be filled in.
Introduction Recording Information
Recordkeeping is an important part of any Cards Without Space for Deworming information form. Another option is to write health service activity. It is a good idea to Data this in the space which is used to record include a record of deworming information about vaccinations. Some forms at your deworming distribution administration as part of your existing record site do not provide any space where you can • Write “ALB” on the form followed by systems. Examples of these include enter information about deworming the date immunization records, growth charts, health distribution to a specific child. center records, and home-based health Doing this indicates that deworming records. When this happens, you should: information has been recorded on the form. Write the date in a way that is easy to Remember that existing health records may • Include exactly the same critical understand. Make sure it is written in a way or may not have a specific place for entering information that is included in the forms that is used by everyone in your country. information about administration of that have a space for deworming data. deworming tablets. They also may or may You can use the form on page 61 to For example, you can write: not have a specific place for entering remind you what you need to include. information about associated follow-up • Choose an appropriate place ALB June 6, 2017 appointments. For example, you could write this information in one of the corners of the
32 Recordkeeping
An example of a form is provided below. Cards with Space for Deworming Data Critical Information You can record information which relates to The form you are using at your deworming to Record the administration of deworming to a specific distribution site may provide some space individual on: where you can write down information about It is essential that you include the deworming distribution to a specific child. • an immunization card following information on the form: This information is critical. • a health card • Child information:
• other forms that anticipate the This includes the name of the child; distribution of deworming. whether the child is female or male; the child’s birth date (if available) or age; the name of the child’s caregiver; and the child’s address.
• Vitamin A information:
This includes the date and dose of the vitamin A. For instance, you could write: November 5, 2017; vitamin A capsule; 200,000 IU.
• Deworming information:
This relates to the deworming agent which is being administered, as appropriate. You need to write down if a deworming agent such as albendazole has been given at the same time as the vitamin A. You also need to write down the date and dose of the deworming agent. For example, you could write: November 5, 2017; Albendazole; 400 mg.
• Next appointment information:
You need to write down the date when this child is due to receive their next dose of deworming. If they are due to be given vitamin A, this should go here too.
33 Recordkeeping
Tally Sheets Filling in Tally Sheets Information for Onsite Supervisors You will often need to record data on a tally Make sure you enter information that helps sheet. Sometimes tally sheets are needed others to identify where the deworming has If you are an onsite supervisor, you need to for your supervisors. They might also be been distributed. You need to put this review each tally sheet with the health needed for local health authorities. It is information at the top of the sheet. Make worker before either of you leave the important to complete them correctly and sure you put the date of the event there, too. distribution site. on time. Whenever you dose a child with a deworming You must deliver the tally sheet to the local tablet, place a “tick” ✔ in the appropriate health authorities as instructed. However, Using Tally Sheets area. This should be in the place marking the you should also prepare a summary sheet correct dose and age group for the child. for the health authority sponsoring the When deworming distribution is recorded on distribution. This is for the authority’s records You also need to place a separate “tick” ✔ an immunization or heath card, the local and future use. It should include information whenever you dose someone with vitamin A. health authority often requires summary data about the total number of people who to be tabulated. This includes information At the end of the day, add up all the ticks for received deworming tablets at that specific about the individuals to whom deworming each age group. Write the total number of site. has been distributed. This information must ticks for each of the groups separately in the The tally sheet also has information be recorded. space provided in the summary section. You regarding deworming tablet supplies. Be can then give your completed tally sheet to When you complete a tally sheet, you need sure to include the information about your supervisor. An example of a tally sheet to remember that: number of tablets received, number of can be found on page 59 of this manual. • A tally sheet is a quick and simple tablets used, and tablets remaining in stock. You also need to complete the child health report of coverage. It is for your This is helpful to have for use in tracking card or the immunization card. You need to: supervisor and for other higher-level inventory. authorities, where required. • include information about the specific Make a note in the appropriate boxes of: individual who received a deworming • Generally, tally sheets are marked with • any adverse effects that were observed tablet. information once someone has been • action taken given a dose of deworming. • mark the tally sheet at the same time. • the outcome. • The tally sheet is the first level of data • do this immediately after giving the collection. As a result, it is very dose of deworming. Use a separate page if needed. important that it is completed If you do not do this immediately, you may accurately and on time. forget to do it. Information for Offsite • You need a fresh supply of new tally Supervisors sheets for each day that you are distributing deworming. Make sure you • Tally sheets can be used to help use a separate tally sheet each day. prepare a report to the person responsible for the distribution • You can find an example of a tally program. sheet for vitamin A and deworming on page 59. • Tally sheets can be useful for reviewing the amount of deworming tablet stock • You can also design tally sheets to levels available and determining the record other forms of distribution. amount of deworming to re-order for Immunizations and bed net distribution future deworming distributions. are examples of this.
34 Recordkeeping
Points to Remember
• Recordkeeping is an important part of • If your cards do not have a set space for • If you are an onsite supervisor, you need any health service activity. deworming data, you can write a capital to review each tally sheet with the • You should include a record of ALB on the form if you are using health worker before you leave the deworming administration as part of albendazole and insert the data in one distribution site. your existing record systems. of the corners. • Onsite supervisors must deliver the tally • You can record deworming on health • Make sure that whatever you write can sheet to the local health authorities. cards, immunization cards or other be understood by anyone in your country. They should also prepare a summary forms. • You often need to use tally sheets, and sheet for the health authority sponsoring the distribution. • You must record information about to give these to your supervisors or every child who receives deworming. health authorities. They need to be filled • Offsite supervisors can use tally sheets This must include information about the in correctly, and on time. to prepare a report for the person child; about the dose of deworming; • The sample tally sheet on page 59 responsible for the distributions. about any vitamin A that is given; and shows you what information you need • Offsite supervisors can also use tally about their next appointment. to record. sheets to review the amount of • The sample immunization/child health • You need to fill in a tally sheet whenever deworming tablets stock levels available card that includes deworming you dose someone with vitamin A or a and determine the amount of distribution is on page 61; this shows deworming talblet. deworming to re-order for future what information you need to record. deworming distribution under • When you are filling in tally sheets, you their authority. also need to complete immunization and child health cards. It is very important to fill these in immediately, so you do not forget.
35 APPENDICES A B C D E F G H I
36 Appendix A: VAS Priority Countries – page 1
VITAMIN A SUPPLEMENTATION and DEWORMING (VAS+D) Vitamin Angels--List for Prioritizing Our Projects for Support
Vitamin Angels supports VAS projects in countries that are categorized by WHO as experiencing moderate to severe VAD. We support albendazole for STH (only where/when product supplies are available in countries listed as experiencing endemic conditions as determined by WHO)
When to begin vitamin A supplementation WHO/UNICEF recommendation:
=> All infants and children 6 - 59 months of age should receive supplementation if they reside in a community in which VAD is classified as being of “public health significance” => “Public health significance” means 15% or more of children sampled have serum retinol levels < .7 umol/L; OR where U5MR is > 50 per 1000 live births => WHO/UNICEF further define “Public health significance” for purposes of programmatic prioritization; universal VAS is recommended for use in both categories: -Countries experiencing “severe VAD” means > 20% of preschool-age children have serum retinol < .7 umol/L. -Countries experiencing “moderate VAD” means ≥ 10% and ≤ 20% of preschool-age children have serum retinol < .7 umol/L.
When to phase out vitamin A supplementation WHO/UNICEF recommendation:
=> VAD Prevalence as determined by both clinical and biochemical measures is below minimum public health significance levels for an extended period of time => Concurrently, U5MR is in long term decline Prevalence cut-offs to define vitamin A deficiency (VAD) in a population and its level of public health significance (Biochemical) Public health importance Serum or plasma retinol <0.70 μmol/l in (degree of severity) preschool-age children or pregnant women (prevalence in population) Severe (73 Countries) ≥20% Moderate (49 Countries) ≥10% – <20% Mild (32 Countries) ≥ 2% – <10% None (39 Countries) No public health problem assumed NS ( 3 Countries) Not Specified 122 countries are classified as having a moderate to severe public health problem based on biochemical VAD in preschool-age children. VAD Estimated Combined Soil-transmitted VAS VAS population WHO Lancet & helminthiasis Coverage Coverage Population w/ VAD VAD as a WHO Data (*If (Ascariasis, Rate (6-59 Rate (6-59 Country under 5 (number of public health no Lancet trichuriasis, months) months) (*Yellow highlight = (number of children) problem Data hookworm disease) 2008 Full 2014 Full Country with Moderate or children) (000) (122) available, Drug(s) used: coverage coverage Severe VAD) (000) (2016) (2009) 2009 using WHO) ALB or MBD (%) (%) Under 5 mortality rate 2016 Infant mortality rate (under 1) 2016 1960 1980 2000 2010 2016 Rank 1960 1980 2000 2010 2016 Rank Afghanistan 3,109 Severe Severe 5,233 ✓ = endemic 96 95 360 280 257 149 70 25 245 185 165 103 53 20 Albania 177 47 Moderate Moderate No info -- – 151 72 25 18 14 114 105 55 22 16 12 113 Algeria 4,699 505 Moderate Moderate ✓ = endemic -- – 261 134 44 36 25 78 166 94 37 31 22 75 Andorra 3 N/A None None No info -- – - 4 4 3 179 - - 3 3 2 185 Angola 1,982 Severe Severe 5,277 ✓ = endemic 82 6 345 265 260 161 83 17 208 158 154 98 55 16 Antigua and Barbuda 1 Mild Mild 8 ✓=endemic 90w – - - 15 8 9 133 - - 13 7 5 152 Argentina 3,736 478 Moderate Moderate No info -- – 73 41 19 14 11 126 61 36 17 12 10 126 Armenia 202 1 None Moderate No info -- – - 76 36 20 13 118 - 62 32 18 12 113 Australia 1,551 N/A None None No info -- – 24 13 6 5 4 164 20 11 5 4 3 168 Austria 412 N/A None None No info -- – 43 17 6 4 4 164 37 14 5 4 3 168 Azerbaijan 891 176 Severe Moderate No info -- 58 - 123 93 46 31 68 - 95 77 39 27 65 Bahamas N/A None Mild 28 ✓=endemic -- – 68 35 19 16 11 126 51 28 15 14 9 129 Bahrain 107 N/A None Mild Not prevalent -- – 150 30 12 10 8 142 94 23 10 9 7 139 Bangladesh 4,112 Severe Severe 15,236 ✓ = endemic 97 0 248 205 92 48 34 62 149 129 66 38 28 62 Barbados 1 Mild Mild 17 ✓=endemic -- – 90 29 13 20 12 123 74 22 12 17 11 120 Belarus 579 79 Moderate Moderate No info -- – - 26 17 6 4 164 - 22 15 4 3 168 Belgium 643 N/A None None No info -- – 35 15 6 4 4 164 31 12 5 4 3 168 Belize 40 4 Moderate Mild ✓ = endemic -- – - 71 23 17 15 106 - 54 20 14 13 107 Benin 1,052 Severe Severe 1,775 ✓ = endemic 52 99 296 214 160 115 98 7 176 127 95 73 63 12 Bhutan 13 Severe Severe 70 ✓ = endemic -- – 300 227 100 56 32 66 175 135 77 44 27 65 Bolivia 271 Severe Moderate 1,189 ✓ = endemic 45 – 255 175 84 54 37 58 152 115 63 42 30 58 Bosnia and Herzegovina 157 26 Moderate Moderate No info -- – 160 39 17 8 6 153 105 31 14 8 5 152 Botswana 57 Severe Severe 259 ✓ = endemic -- 70 173 84 101 48 41 56 118 62 74 36 33 54 Brazil 2,405 Moderate Moderate 14,919 ✓ = endemic -- – 176 91 30 19 15 106 115 70 27 17 14 99 Brunei Darussalam 34 N/A None None Not prevalent -- – 87 22 9 7 10 131 63 19 8 6 9 129 Bulgaria 324 62 Moderate Moderate No info -- – 70 24 16 13 8 142 49 20 14 11 7 139 Burkina Faso 1,415 Severe Severe 3,221 ✓ = endemic 100 98 308 241 194 176 85 16 183 143 116 93 53 20 Burundi 408 Severe Severe 1,901 ✓ = endemic 80 69 238 191 181 142 72 23 141 114 109 88 48 30 Cabo Verde 1 Mild Severe 55 ✓=endemic -- – - 80 42 36 21 85 - 61 31 29 18 85 Cambodia 377 Severe Moderate 1,761 ✓ = endemic 88 71 - 153 104 51 31 68 - 104 78 43 26 68 Cameroon 1,106 Severe Severe 3,804 ✓ = endemic -- 96 255 173 151 136 80 19 151 105 88 84 53 20
37 Appendix A: VAS Priority Countries – page 2
(*Yellow highlight = Country with Moderate or Severe VAD) ALB MBD 1960 1980 2000 2010 2016 1960 1980 2000 2010 2016 – 157 157 ✓ 3 1 ✓ 2 4 – 142 139 ✓ – 131 129 ✓ – 106 107 ✓ 22 16 ✓ 40 44 ✓ – 142 139 ✓ – 133 133 ✓ 10 9 – 157 157 ✓ – 153 157 – 179 185 – 179 168 ✓ 88 94 ✓ 8 5 – 164 157 ✓ – 31 18 ✓ – 62 57 ✓ – 68 68 ✓ – 85 85 ✓ – 81 81 ✓ – 106 107 ✓ – 11 9 ✓ 51 54 – 179 185 ✓ 35 39 ✓ – 82 81 – 192 185 – 164 168 ✓ – 48 50 ✓ 29 35 – 126 126 – 164 168 ✓ 34 39 – 164 168 ✓ – 100 99 ✓ 72 72 ✓ – 14 14 ✓ 15 14 ✓ – 66 65 ✓ 27 25 – – – – – – – ✓ – 92 93 – 157 157 – 192 185 ✓ 53 49 ✓ 76 75
✓ – 106 107 ✓ – 68 68 – 164 168 – 164 168 – 179 168 ✓ – 106 107 – 179 185 – 95 94 – 126 126 ✓ 47 48 ✓ – 40 35 – 142 139
38 Appendix A: VAS Priority Countries – page 3
(*Yellow highlight = Country with Moderate or Severe VAD) – ✓ – – ✓ ✓ – – – – – – – – ✓ ✓ ✓ – ✓ – ✓ – – ✓ – ✓ ✓ – ✓ – ✓ – – – – ✓ ✓ ✓ – ✓ – ✓ – – ✓ ✓ ✓ ✓ – – – ✓ ✓ – ✓ – ✓ – ✓ – ✓ – ✓ – – – – – – – ✓ ✓ – ✓ – ✓ – ✓ – – ✓ – – ✓ –
39 Appendix A: VAS Priority Countries – page 4
(*Yellow highlight = Country with Moderate or Severe VAD) ✓ – ✓ – – – ✓ – ✓ ✓ – – ✓ ✓ – ✓ ✓ – ✓ – – – ✓ – ✓ – – ✓ – ✓ – ✓ – ✓ – – – – ✓ ✓ – – – – – ✓ – ✓ – ✓ ✓ ✓ – ✓
40 Appendix A: VAS Priority Countries – page 5
Estimated Population population under 5 w/ VAD (number of (number of children) children) VAS VAS SUMMARY (000) (000) Coverage Coverage INDICATORS (2016) (2009) 2008 2014 Under 5 mortality rate Infant mortality rate (under 1) 1960 1980 2000 2010 2016 1960 1980 2000 2010 2016 Sub-Saharan Africa 167,977 163,267 73 74 277 200 170 121 78 161 117 101 76 53 Eastern and Southern Africa 83,757 75,181 73 62 252 179 145 98 61 150 109 91 63 43 West and Central Africa 84,220 82,032 73 83 300 220 193 143 95 171 125 111 88 63 Middle East and North Africa 49,143 53,283 – – 248 133 55 41 24 157 91 42 31 20 South Asia 169,895 173,210 65 62 238 163 96 67 48 157 111 70 52 39 East Asia and Pacific 156,758 146,650 89 86 - 74 40 24 16 - 53 32 19 14 Latin America and Caribbean 53,227 53,155 – – 154 84 35 23 18 103 63 29 18 15 CEE/CIS - 30,726 – – - 70 39 23 14 - 56 33 19 13 Least developed countries 142,971 139,575 85 67 276 207 154 110 68 168 128 98 71 48 World 674,314 668,970 71 69 184 115 80 57 41 120 77 55 40 31
Column References Population under 5 (number of children) (000) The State of the World's Children Reports. UNICEF. 2017. https://www.unicef.org/sowc/ (2015)
Estimated population w/ VAD (number of children) Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency (2009). (000) (2009)
WHO (122) countries are classified as having a moderate to severe public health problem based on biochemical VAD in preschool-age children. From VAD as a public health problem (122) Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency. (2009). 2009
Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled VAD Data from Lancet 2013 analysis of population-based surveys. Stevens GA, Bennett JE,
Soil-transmitted helminthiasis (Ascariasis, trichuriasis, hookworm disease) WHO (2006)--Preventive chemotherapy in human helminthiasis: coordinated use of anthelminthic drugs in control interventions : a manual for health Drug(s) used: professionals and programme managers. Pages 6, 36-39. ALB or MBD
VAS Coverage Rate (6-59 months) 2008, 2013, The State of the World's Children Reports. UNICEF. https://www.unicef.org/sowc/ 2014
Under 5 mortality rate The State of the World's Children Reports. UNICEF. https://www.unicef.org/sowc/
Infant mortality rate (under 1) The State of the World's Children Reports. UNICEF. https://www.unicef.org/sowc/
Countries/Territories WHO VAD as a Not listed above STH Prevalence public health problem 2009 Puerto Rico ✓ Endemic No Information Tokelau ✓ Endemic No Information American Samoa ✓ Endemic No Information French Polynesia ✓ Endemic No Information New Caledonia ✓ Endemic No Information Wallis and Futuna ✓ Endemic No Information
41 Appendix B: FAQ – page 1
Frequently Asked Questions (FAQs) about Vitamin A Supplementation (VAS)
1. What should I do if a child is crying? Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying. Make sure the child is calm to prevent choking. To calm a child, the caregiver may walk around until the child stops crying. If the child does not stop crying, instruct the caregiver to bring the child to the next distribution.
2. Can we give vitamin A supplements to caregivers (i.e., parents or guardians) to deliver to children at home? Vitamin A used in universal distribution projects must be delivered by trained healthcare workers/volunteers, and capsules must not be given to caregivers to deliver at home. Never send vitamin A home with a caregiver to give to a child later.
See the Vitamin Angels Reference Manual for Administration of Vitamin A Supplements in Universal Distribution Projects (i.e., the VAS Reference Manual) for more information on how to treat sick children who arrive at a universal distribution event and will need additional medical treatment, including additional vitamin A supplementation (VAS).
In all circumstances, sick infants and children should be referred immediately to a health provider for further evaluation and treatment directly after dosing with vitamin A unless dosing is specifically contraindicated (i.e., a child is in respiratory distress). Instruct the caregiver to bring the child to the next distribution.
3. Can you give vitamin A to children 5 years of age and older if they are vitamin A deficient? Why not?
Research does not support universal distribution of vitamin A supplementation (VAS) to children 5 years of age and older. Although VAS would not harm children over 5, there is currently no documentation that the average child over 5 would receive any benefit from it. Caregivers (i.e., parents or guardians) who bring children age 5 years and older to distribution events should be educated on vitamin A rich foods and good nutrition practices. Vitamin Angels’ VAS is intended to prevent vitamin A deficiency (VAD) in children under 5 years of age. In some very limited instances, if the grantee organization encounters a child over 5 years of age who has clinical signs of VAD (e.g., xerophthalmia), then, as outlined in Chapter 14 of the Vitamin Angels Reference Manual for Administration of Vitamin A Supplements in Universal Distribution Projects (i.e., the VAS Reference Manual), the decision of whether or not to treat the child with vitamin A should be made on a case-by-case basis as recommended by a healthcare professional.
4. Why does the eligibility criteria check that the child has not received vitamin A in the past 1 month, but the recommended dosing is every 4-6 months? According to the WHO,2 the minimum interval between doses of vitamin A is one month. The maximum interval between doses is 6 months. For example, if a child has not received vitamin A in 2 months, it is better to dose the child than to skip the dose and have the child wait 8 months (i.e. 2 months + 6 months) for the next dose. For more information, please see the Vitamin Angels Reference Manual for Administration of Vitamin A Supplements in Universal Distribution Projects (i.e. the VAS Reference Manual).
For more information contact: [email protected]
42 Appendix B: FAQ – page 2
5. Can vitamin A supplementation be delivered to postpartum mothers? Universal distribution of vitamin A supplementation (VAS) in postpartum women is NOT recommended as a public health intervention for the prevention of maternal and infant morbidity and mortality (strong recommendation by WHO). Postpartum women should continue to receive adequate nutrition.1
6. What if my government recommends vitamin A supplementation for children over 5 years of age, or for women postpartum? Vitamin A supplementation (VAS) granted by Vitamin Angels is not intended for children over 5 years of age or for postpartum mothers, even if a government recommendation states otherwise. Vitamin Angels’ VAS should be used for children 6-59 months of age only. In some very limited instances, Vitamin Angels may approve distribution of VAS to children over 5 years of age or postpartum women; however, before considering this, Vitamin Angels must be given a copy of the official government policy for VAS, including the policy to deliver VAS to these specific populations. Additionally, these groups would only be considered by Vitamin Angels if they are a minor part (less than 5%) of a larger project that focuses on universal distribution of VAS to infants/children 6 to 59 months of age.
7. What happens if I open a vitamin A bottle and do not use the capsules within 1 year, will they go bad or be dangerous to use? If capsules remain unused 1 year after opening the bottle, they will deliver less vitamin A, but will not go bad or pose a danger if consumed. It is important to check your vitamin A stock before a distribution, and use those capsules from bottles that have already been opened and bottles with the shortest expiration date first, before using other vitamin A with a longer shelf life expectation.
8. Sometimes my distribution area gets very hot, what should I do about storage? Vitamin A capsules are tested in conditions of high heat and high humidity, and are able to deliver the expected amount of vitamin A for a period of at least 3 years. Adequate storage area for all vitamin A supplies should be available to ensure that vitamin A can be stored in a secure, dry cool place and away from direct sunlight; these conditions will help to keep the vitamin A at its highest potency. Even in hot distribution areas, vitamin A capsules can be protected by keeping them in their original bottles, with the lids tightly closed, and out of direct sunlight.
9. Can we store the vitamin A in the refrigerator? We don’t have any data to show that refrigeration harms the vitamin A. Refrigeration does make the capsules hard, so before using them the health worker will need to take them out of the cold storage well in advance to let them soften enough to squeeze. If the capsule is too hard, they are hard to cut and also too much vitamin A oil stays inside and the child does not get the full dose.
10. If a child gets side effects from vitamin A such as headache, nausea or vomiting – should the childreceive a dose 6 months later? WHO documents that the side effects are transient, and the child is fine to get their next age-appropriate does 6 months later.
For more information contact: [email protected]
43 Appendix B: FAQ – page 3
11. If a child experiences some side effects after receiving vitamin A supplementation, will they experience side effects the next time they come for VAS? There is a possibility that a child will experience side effects more than once, but there is no data showing that this will happen.
12. If a child is an orphan and/or did not breastfeed, do you advise we give them more vitamin A? No; the WHO recommendations for vitamin A supplementation are based on a child’s age, and it does not provide a recommendation based on breastfeeding status.
13. What does the vitamin A in capsule form taste like? Vitamin A is in oil form, and has a light vanilla flavor.
14. Should we deliver vitamin A supplementation to adults? Research does not support universal distribution of high-dose vitamin A supplementation (VAS) to adults as a preventive intervention, in general. Because of this, VA does not intend its products to be used for treatment; rather, they should be used for prevention. Explanations and exceptions to this regarding women are next.
• Women up to 6 weeks after delivery: Universal distribution of VAS in postpartum women is NOT recommended as a public health intervention for the prevention of maternal and infant morbidity and mortality (strong recommendation by WHO). Postpartum women should continue to receive adequate nutrition.
• Pregnant women and women of child-bearing age: Pregnant women or women of childbearing age who may be in the early stages of pregnancy with or without knowing it, should NOT be given high dose VAS (over 10,000 IU). A high dose of vitamin A early in pregnancy may damage the unborn child.
• Treating women with eye conditions: For treatment information see the Reference Manual for Administration of Vitamin A Supplements in Universal Distribution Projects (i.e., the VAS Reference Manual)
1. WHO. Guideline: Vitamin A supplementation in postpartum women. World Health Organization, 2011. 2. WHO. Distribution of vitamin A during national immunization days: WHO/EPI/ GEN/98.06, 1998:9.
For more information contact: [email protected]
44 Appendix B: FAQ – page 4
Frequently Asked Questions (FAQs) about Deworming
1. What should I do if a child is crying? Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying. Make sure the child is calm to prevent choking. To calm a child, the caregiver may walk around until the child stops crying. If the child does not stop crying, instruct the caregiver to bring the child to the next distribution.
2. Can we give deworming tablets to caregivers to deliver to the children at home? Deworming used in universal distribution projects should be delivered by trained healthcare workers/volunteers, and tablets must not be given to caregivers to deliver at home. Never send deworming home with the caregiver to give to the child later.
3. Can we give a whole, uncrushed deworming tablet to a child to chew? No! To decrease risk of choking, ALWAYS crush deworming tablets for ALL children under 5 years. You can crush deworming tablets using a glass bottle and a clean piece of paper, spoons, or a mortar and pestle.
4. How fine does the tablet need to be crushed? The tablet needs to be crushed sufficiently, so a child who cannot chew can safely swallow the crushedpieces and powder without a risk of choking.
5. What do I do if a child starts to choke while taking deworming? If a child begins to choke while taking deworming, please follow the instructions on the back of the VAS+D Visual Checklist and in the Deworming Reference Manual on “What to Do if a Child Chokes”.
6. What do I do with the other half of the tablet when giving a half tablet of albendazole to children ages 12-24 months? If using a half tablet, store the other half to use for another child.
7. Why is it recommended to give deworming only one to two times per year? The WHO recommends that deworming (albendazole or mebendazole) be given once or twice per year to preschool- age children, depending on the prevalence of STH infections in a country. Most countries have a policy in place that is consistent with the WHO recommendations and fits nicely with the schedule for vitamin A supplementation.
For more information contact: [email protected]
45 Appendix B: FAQ – page 5
8. Why does a fever prevent a child from getting deworming? If a child has a fever, severe diarrhea, or is vomiting, it will not harm a child to receive deworming; however, it is recommended that children with these health concerns not be given deworming, as it may cause a negative response to future deworming if these symptoms continue in the child and then become associated with the deworming.
9. What is recommended if the child spits out the deworming? If a child spits out the deworming, they should be told to come back in a month when they will be eligible to receive deworming again. Remember, it’s important NEVER to force a child to take the deworming tablet. If a child is uncooperative, let the child pass without treatment; he or she will have another chance to be treated at the next round.
10. Should deworming be given with food and/or water? After giving deworming to a child, you may give them water to drink, especially if the child seems to be experiencing difficulty swallowing. Giving water after every deworming is not necessary. Always use clean drinking water in a clean cup. Make sure the child is sitting straight up and not tilting their head backwards.
Please visit our website at: www.vitaminangels.org for updates and more information about vitamin A and deworming for children under 5 years.
For more information contact: [email protected]
46 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 1
Job Aid Visual Checklist for Giving Vitamin A and Deworming Together
Instructions: This visual checklist is a picture version of the performance checklist for Vitamin A Supplementation and Deworming (VAS+D). Each of the 39 steps in the performance checklist Supplies for VAS+D appear here in image form. The purpose of this visual checklist is to help you when you are delivering distribution: VAS+D and when you are coaching others to provide VAS+D, as approved by your organization. £ VAS+D visual checklists £ As you practice and become skilled at providing VAS+D, you should use a ballpoint pen and make 100,000 IU blue vitamin A £ notes on this visual checklist to remind you of important points. 200,000 IU red vitamin A £ Deworming tablets Here are the general steps for using the visual checklist when coaching others to provide VAS+D: £ Alcohol-based hand sanitizer £ 1. Explain: Use this visual checklist to explain each of the steps in VAS+D service delivery (using Clean scissors the performance checklist to provide more detailed information). £ Serviettes/napkins £ Small, clean, white paper • First, show and explain the three parts of the checklist. £ Glass bottle to crush tablet • Then, while everyone points to step 1, ask “What do you see in the picture?”. £ Plastic bag for trash • Next, have one person read the words for step 1 aloud. Take turns doing this for all 39 steps. £ Ballpoint pens 2. Demonstrate: Perform all 39 steps in VAS+D service delivery using this visual checklist. £ Tally sheet £ Distribution register 3. Coach: Ask the service providers to use their copies of the visual checklist to practice giving VAS+D (usually in pairs) while you observe and provide feedback. 4. Feedback: Give each service provider feedback on steps they are doing well and steps that they need to practice more. Have one or more copies of this visual checklist available when VAS+D services are being given. You and the other service providers can refer to the checklist as needed to help ensure that correct and safe services are being provided. For more information on VAS+D service delivery including a copy of the performance checklist, a video on how to provide VAS+D, and other materials, go to the Vitamin Angels’ website at www.vitaminangels.org.
What To Do if a Child Chokes
Staff administering tablets to small children should be trained in what to do if a child chokes. They should also have the authority and respect of the health post staff to act if necessary.
For Very Small Children For Older Children
• Lay the child’s chest on your If the problem is not resolved: • Lay the child on his/her If the problem is not resolved: thigh, then lean the child’s • Lay the child on your thigh abdomen on your thigh, then • Hold the child from behind in head down. facing upwards (child on its lean the child’s head down. a standing position with your • Thump on the middle part back). • Thump on the middle part of hands below the child’s arms just below the rib cage. of the child’s back 5 times • Press on the thoracic area of the child’s back 5 times using using your palm. the child 5 times using your 2 your palm. • Press the child’s body upwards. fingers. • Repeat if necessary. • Repeat if necessary.
English - Oct. 2017
Vitamin Angels gratefully acknowledges the adaptation © 2016 Vitamin Angels. Some Rights Reserved. of materials from UNICEF, WHO, the Micronutrient Use is encouraged with acknowledgement of Initiative, and EngenderHealth for use in this checklist. Vitamin Angels as the source included on all materials.
47 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 2
Name: Part 1 Community Education
Deworming 6-11 Months 12-23 Months 24-59 Months (6 months up to 1 year) (1 year up to 2 years) (2 years up to 5 years)
Vitamin A
1 Welcome children 2 Vitamin A and deworming 3 Explain age to dose relationship and caregivers given today
4 Give every 4 to 6 months 5 Benefits of vitamin A and deworming together:
to
Strong Healthy eyes Free of worms for better nutrition
6 Side effects that may occur: 7 Rare side effects: only 5 out of 100 children
Nausea Vomiting Headache Loss of Appetite 8 Side effects last a maximum of 2 days
9 For symptoms beyond 2 days, or if other symptoms develop, get medical help
1 2 3
Swelling of the Mild Abdominal Pain Diarrhea Fatigue Fontanel (soft spot on head)
10 Other effects of deworming: Worms may be in the stool or in 11 Very safe; even with 12 Ask for questions very rare cases exit nose or mouth – these can be pulled out vaccines or spit out ?
48 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 3
Part 2a Eligibility Criteria to Qualify
13 Ask for child’s name and health card – use to verify name, age, and last dose
14 Check for eligibility. Child is not eligible for a service unless they meet all criteria listed below that service. Never send vitamin A or deworming home with a caregiver to give to the child later
Qualify for Vitamin A Qualify for Deworming
6-59 Months 12-59 Months (6 months up to 5 years) (1 year up to 5 years)
Ask: How old is your child? Ask: How old is your child? Check: Age is 6-59 months Check: Age is 12-59 months
1 2 3 1 2 3
456 7 8 9 10 456 7 8 9 10
11 12 13 14 15 16 17 11 12 13 14 15 16 17
18 19 20 21 22 23 24 18 19 20 21 22 23 24
25 26 27 28 29 30 31 25 26 27 28 29 30 31
Show vitamin A capsules to caregiver Show deworming tablets to caregiver Ask: When did child last receive vitamin A? Ask: When did child last receive deworming? Check: No vitamin A in past 1 month Check: No deworming in past 1 month
Ask caregiver if child has any of the following today. Ask caregiver if child has any of the following today. If so, do not give service and refer child for medical help. If so, do not give service and refer child for medical help.
For vitamin A – OBSERVE and make sure there is NO: For deworming – OBSERVE and make sure there is NO:
Severe Vomiting Fever Severe Difficulty Today Today Diarrhea Breathing Today Severe Difficulty Today Breathing Today Critical steps for = service providers
49 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 4
Part 2b Giving Vitamin A
15 Clean your hands 19 Cut off capsule tip
16 To prevent choking, ask and make sure 20 Do not touch child; give vitamin A the child is calm. Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying.
6-11 Months 12-59 Months (6 months up to 1 year) (1 year up to 5 years)
21 Discard capsule in waste container
100,000 IU 200,000 IU
17 Choose dose by age 22 Ask if child has swallowed oil and is okay
18 Caregiver holds head and helps 23 Wipe oil off hands and scissors child open mouth
50 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 5
Part 2c Giving Deworming
12-23 Months 24-59 Months (1 year up to 2 years) (2 years up to 5 years)
CRUSHED CRUSHED
200 mg 400 mg
24 Choose dose by age. If using a half tablet, 27 Caregiver holds head and helps child open store the other half to use for another child. mouth. Do not touch child, use folded paper to slowly pour powder into child’s mouth.
25 Crush tablet into fine powder with a glass bottle. ALWAYS crush deworming tablets for 28 Discard paper in waste container ALL children under 5 years.
26 To prevent choking, ask and make sure the child is 29 Ask if child chewed and is okay calm. Never force a child to take deworming, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying.
OPTIONAL: After giving deworming to a child, you may give Alternate Crushing Methods them water to drink, especially if the child seems to be experiencing difficulty swallowing. Giving water after every deworming is not necessary. Always use clean drinking or water in a clean cup. Make sure the child is sitting straight up and not tilting their head backwards.
Crush with spoons Crush with mortar and pestle
If giving Mebendazole substitute this step for step 24 above
12-59 Months CRUSHED
a If a child is experiencing b Never force a child to difficulty swallowing, you drink water and do 500 mg may give the child a cup not pour water into a with clean drinking water. child’s mouth. 24 Same dose for ALL children under 5 years
51 Appendix C: Visual Checklist: Job Aid for Giving Vitamin A and Deworming – page 6
Part 3 Recordkeeping and Exit Counseling
Return in 4 to 6 months
to
30 Record doses given on register 31 Write return date for child and 32 Very safe; even with and health card tell caregiver when to return vaccines
33 Side effects that may occur: 34 Rare side effects: only 5 out of 100 children
Nausea Vomiting Headache Loss of Appetite 35 Side effects last a maximum of 2 days
36 For symptoms beyond 2 days, or if other symptoms develop, get medical help
1 2 3 Swelling of the Mild Abdominal Pain Diarrhea Fatigue Fontanel (soft spot on head)
37 Other effects of deworming: Worms may be in the stool or in very rare cases exit nose or mouth – these can be pulled out or spit out
38 Benefits of vitamin A and deworming together: 39 Ask for questions
Strong Healthy Eyes Free of worms for ? better nutrition
52 Appendix D: How to Give Vitamin A to Children – page 1
How to Give Vitamin A to Children 6-59 Months
In countries experiencing vitamin A deficiency, providing supplemental nutrition in the form of a vitamin A capsule every 4 to 6 months is vital for good infant and child health, growth, and development; this is accepted as an essential part of child survival programs. One capsule of vitamin A given two times a year to children 6 to 59 months of age can reduce mortality by 24%.
Vitamin A supplementation can help to protect infant and child health because it:
• Increases child survival
• Supports a healthy immune system
• Reduces new cases or incidences of diarrhea and measles
• Protects eyes and eyesight and prevents anemia
• Promotes physical growth
Recommendations:
• During the first six months of life, infants should be exclusively breastfed.
• Children 6 months and older should eat a nutritious diet that includes a variety of brightly colored fruits and vegetables, animal products such as dairy and meat, nuts, oils, and legumes.
• Infants 6 to 11 months of age should receive one 100,000 IU dose of vitamin A.
• Children 12 to 59 months of age should receive one 200,000 IU dose of vitamin A two times each year.
• Infants and children who have received vitamin A supplementation within the past 1 month (4 weeks) will not get any additional benefits from a second dose of vitamin A given in the same month, and it should not be given.
For more information, contact: [email protected]
53 Appendix D: How to Give Vitamin A to Children – page 2
Giving Vitamin A to Children 6-59 Months
Vitamin A 100,000 IU : Infants 6 -11 Months Vitamin A 200,000 IU : Children 12- 59 Months 6-11 MONTHS
Blue Crawling 12-59 MONTHS Red Walking capsule capsule 1 Age appropriate Dose Every 4-6 Months
Infection Prevention To minimize the spread of infection from Healthcare provider’s one child to another, always ensure that hands are cleaned using an hands are clean when giving vitamin A alcohol-based hand sanitizer or to infants and children. soap and clean water
Capsule Cutting With the capsule’s narrow Cut off the narrow tip of the tip pointing up, use clean capsule using clean scissors scissors to cut off the tip of the capsule.
While the caregiver supports the child’s head and ensures that their mouth is open, squeeze vitamin A oil into the child’s mouth without touching the child.
Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying.
! • Except if the child has a respiratory infection and is unable to breathe, there are no conditions or illnesses that prevent a child age 6 – 59 months from being given VAS. If a child is suffering from respiratory distress, they should be referred for immediate medical attention. • Never send vitamin A home with a caregiver to give to the child later. • Infants and children who have received vitamin A supplementation within the past 1 month (4 weeks) will not get any additional benefits from a second dose of vitamin A given in the same month, and it should not be given.
For more information, contact: [email protected]
54 Appendix E: Guide for Vitamin A Supplementation Supervisors – page 1
Guide for Vitamin A Supplementation (VAS) Distribution Supervisors
Healthcare Provider Training Before providing vitamin A to infants and children, all healthcare providers should be trained. Distribution supervisors should train all workers involved in vitamin A supplementation (VAS) delivery using the steps and sequence provided below, to ensure health service standardization. Vitamin A Introduction and Entrance Counseling • Caregiver and child are greeted/welcomed by health worker • Information is communicated about VAS, including recommended dosing schedule and how VAS will be administered • VAS safety, side effects, and appropriate responses are communicated • Caregiver questions on VAS are requested and answered accurately Vitamin A Eligibility Screening • Child’s name is requested and received • VAS eligibility is determined using the 3 criteria (age, respiratory health, and VAS history) and responded to appropriately • Age-appropriate dose is selected and communicated to the caregiver • Never send vitamin A home with a caregiver to give to the child later Infection Prevention • Hands are washed or sanitized periodically, including before and after giving vitamin A to a sick child Vitamin A Dosing • Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying. • Caregiver is asked to support the child’s head and ensure that their mouth is open • Clean scissors are used to cut off the narrow tip of the vitamin A capsule • Without touching the child, healthcare provider squeezes all liquid vitamin A into the child’s mouth • Healthcare provider has checked that the child has swallowed the vitamin A dose and is comfortable • Vitamin A capsule is disposed of in a plastic bag and oil is removed from hands and scissors Recordkeeping • Age-appropriate vitamin A dose given to the child is recorded on child health card, tally sheet and/or distribution register Exit Counseling • VAS side effects and appropriate responses are communicated to the caregiver • Caregiver questions on VAS are requested and answered accurately • Information about upcoming VAS events, including next dosing date, is shared with caregiver • Caregiver and child are thanked for their attendance
See Vitamin Angels’ Visual Checklist (Job Aid) for more detailed step-by-step instructions.
For more information, contact: [email protected]
55 Appendix E: Guide for Vitamin A Supplementation Supervisors – page 2
Giving Vitamin A to Children 6-59 Months
Vitamin A 100,000 IU : Infants 6 -11 Months Vitamin A 200,000 IU : Children 12- 59 Months 6-11 MONTHS
Blue Crawling 12-59 MONTHS Red Walking capsule capsule 1 Age appropriate Dose Every 4-6 Months
Infection Prevention To minimize the spread of infection from Healthcare provider’s one child to another, always ensure that hands are cleaned using an hands are clean when giving vitamin A alcohol-based hand sanitizer or to infants and children. soap and clean water
Capsule Cutting With the capsule’s narrow Cut off the narrow tip of the tip pointing up, use clean capsule using clean scissors scissors to cut off the tip of the capsule.
While the caregiver supports the child’s head and ensures that their mouth is open, squeeze vitamin A oil into the child’s mouth without touching the child.
Never force a child to take vitamin A, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying.
! • Except if the child has a respiratory infection and is unable to breathe, there are no conditions or illnesses that prevent a child age 6 – 59 months from being given VAS. If a child is suffering from respiratory distress, they should be referred for immediate medical attention. • Never send vitamin A home with a caregiver to give to the child later. • Infants and children who have received vitamin A supplementation within the past 1 month (4 weeks) will not get any additional benefits from a second dose of vitamin A given in the same month, and it should not be given.
For more information, contact: [email protected]
56 Appendix F: How to Give Deworming with Universal Distribution of Vitamin A – page 1
How to Give Deworming to Children 12-59 Months as Part of Universal Distribution of Vitamin A
Many countries with vitamin A deficiency are also endemic with soil-transmitted helminths (STH) or “intestinal worms”--this contributes to child undernutrition. Providing deworming to children together with vitamin A is a simple, effective way to improve a child’s vitamin A status and overall health.
Deworming through mass drug administration (MDA) can help: • Prevent or eliminate intestinal worms that rob the body of essential nutrients Recommendations: • ALWAYS crush deworming tablets for ALL children under 5 years • Never send deworming home with a caregiver to give to the child later • OPTIONAL: After giving deworming to a child, you may give them water to drink, especially if the child seems to be experiencing difficulty swallowing. Giving water after every deworming is not necessary. Always use clean drinking water in a clean cup. Make sure the child is sitting straight up and not tilting their head backwards. • If mebendazole is used, provide clean drinking water for children
Deworming Dosing Instructions
Albendazole (400 mg)
12 - 23 Months 24 - 59 Months How often Infants younger than 1 year (0-11 months) 200 mg 400 mg 12-23 MONTHS CRUSHED CRUSHED 24-59 MONTHS Give children ages 1 year up to Give children ages 2 years up to 5 years 2 years (12-23 months) a half tablet of (24-59 months) a whole tablet of GIVE ALBENDAZOLE albendazole - store the other half to use albendazole. EVERY 4-6 MONTHS for another child.
Give to children 1 year up to 5 years (12-59 months) of age. It is safe and effective Do not give to infants to give deworming in younger than 1 year combination with vitamin A every 4-6 months. (0-11 months) of age
Place albendazole tablet inside a folded Use folded piece of paper to slowly piece of paper, then crush with a glass pour the crushed tablet into the bottle. child’s mouth. Never force a child to take deworming, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying. For more information contact: [email protected]
57 Appendix F: How to Give Deworming with Universal Distribution of Vitamin A – page 2
Deworming Dosing Instructions Deworming Dosing Instructions Mebendazole (500 mg)
Infants younger 12-59 Months How often than 1 year (0-11 months)
500 mg 12-59 MONTHS
CRUSHED GIVE MEBENDAZOLE EVERY 4-6 MONTHS Give children ages 1 year to 5 years (12-59 months) a whole tablet of mebendazole.
Give to children 1 year up to 5 years (12-59 months) of age. Do not give to infants It is safe and effective to give deworming in combination younger than 1 year with vitamin A every 4-6 (0-11 months) of age. months.
Place mebendazole tablet inside a Use folded piece of paper to slowly folded piece of paper, then crush with a pour the crushed tablet into the glass bottle. child’s mouth. Never force a child to take deworming, do not hold a child’s nose to force them to swallow, and do not give it to a child who is crying.
Use of Vitamin Angels’ Deworming Tablets: Vitamin Angels provides donations of deworming tablets to be used only for children ages 12-59 months. WHO and UNICEF recommend that deworming be given together with vitamin A 200,000 IU supplementation.
Storage: Store in a COOL, DRY place. Keep bottle tightly closed.
!
Never send deworming home with a caregiver to give it to the child later. WARNING: This product should be administered by trained healthcare providers. Do not take this product without direct supervision by qualified healthcare personnel.
STORE THIS PRODUCT OUT OF REACH OF CHILDREN.
For more information contact: [email protected]
58 Appendix G: Daily Tally Sheet
n
e r d
hil C
l
Months Tota tablet
www.vitaminangels.org 59
1
–
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m 24 mg,
Remarks o c t 400 u and O Months
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Months Stock tablet
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23
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# Summary
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Total
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– (red
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ite HEALTH S tion REGION/PROVINCE: Months a Doses
200,000 # ed at
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# INSTRUCTIONS USE EXAMPLE
59 Appendix H: Distribution Register
s Jan-10 Mar-11 tablet 9 h Nov-12 t 5 Deworm- ing whole ing whole - n 4 o 5 m
Jan-11 Mar-11 A 200K A Vitamin Vitamin Nov-12
s Jan-10 Sep-10 tablet 3 h Nov-11 t 5 Deworm- ing whole ing whole - n www.vitaminangels.org 8 o 4 m
Jul-10 Sep-10 A 200K A Vitamin Vitamin Nov-11 s h t for Children 6-59 Months
s n Jan-10 Mar-10 7 tablet h
t May-11 4 o Deworm- ing whole ing whole - n 2 o 4 M m
9
Jan-10 Mar-10 A 200K A Vitamin Vitamin
5 May-11 - 6
s Jul-09 s Sep-09 tablet 1 h
e Oct-10 t 4 Deworm- ing whole ing whole - n g 6 o 3 A m
n Jul-09 Sep-09 A 200K A
Vitamin Vitamin Oct-10 e Vitamin A Supplementation and Supplementation Deworming A Vitamin r d l i
s Jan-09 Mar-09 tablet h 5 h May-10 t 3 Deworm- ing whole ing whole - n C 0 o
3 r m o f Jan-09 Mar-09
A 200K A Vitamin Vitamin May-10 g n i
Jul-08 s Sep-08 m tablet 9 h Nov-09 t r 2 Deworm- ing whole ing whole - n 4 o o 2 m w
e Jul-08 Sep-08 A 200K A Vitamin Vitamin Nov-09 2016 Distribution Register: D
d
n s
tablet Jan-08 Mar-08 3 ing 1/2 h May-09 t 2 Deworm- a - n ) 8 o 1 m S A Jan-08 Mar-08 A 200K A Vitamin Vitamin May-09 V (
s n h t
o Jul-07 n tablet
i Sep-07 ing 1/2 Nov-08 o t Deworm- m a
t 7 1 n -
2 Jul-07 e Sep-07 1 Nov-08 200,000 200,000 IU (200K) IU Vitamin A A Vitamin m
e s l h 1 t p 1 n - o p 6
Jan-07 Mar-07 May-08 m Vitamin A A Vitamin u 100,000 IU100,000 S
e A t
a n d i h t m r i
a 3/8/2006
t 14/7/2006 27/7/2007 B i V d l i h C
f DATE: o
e DISTRICT m a
Sample Child #1 Child Sample #2 Child Sample #3 Child Sample N HEALTH CENTER: REGION/PROVINCE NAME OF RECORDKEEPER:
60 Appendix I: Child Health Card Sample
Sample Child Health Card Sample Child Health/Immunization Card, Including Vitamin A and Albendazole Child/ Family Information
Name of Child (family, given) Sex/Gender (mark one) Female Male Birthdate of Child Day: Month: Year: Name of Mother (family, given)
Name of Father (family, given)
Address of Residence Vitamin A Albendazole 400mg Next Distribution Date Age of Child Date Distributed DDateate D Distributedistributed (dd/mm/yy) (dd/mm/yy) (dd/(dd/mm/yymm/yy) ) 0-5 Months DO NOT GIVE DO NOT GIVE 6-11 Months 100,000 IU: DO NOT GIVE 12-17 Months 200,000 IU: 1/2 Tablet: 18-23 Months 200,000 IU: 1/2 Tablet: 24-29 Months 200,000 IU: 1 Tablet: 30-35 Months 200,000 IU: 1 Tablet: 36-41 Months 200,000 IU: 1 Tablet: 42-47 Months 200,000 IU: 1 Tablet: 48-53 Months 200,000 IU: 1 Tablet: 54-59 Months 200,000 IU: 1 Tablet:
Date Distributed Next Distribution Date Vaccine (dd/mm/yy) (dd/mm/yy) BCG DTP1 DTP2 DTP3 OPV0 OPV1 OPV2 OPV3 MEASLES HepB0 HepB1 HepB2 HepB3 Date Distributed Next Distribution Date Other Services Provided (dd/mm/yy) (dd/mm/yy) Insecticide Treated Bed Net
61
References
Preface Chapter 3
1. World Health Organization (WHO). How to add deworming to vitamin A distribution, 1. WHO. Action against worms, February 2007, Issue 8, p. 2. 2004: 6. 2. WHO. Guideline: preventive chemotherapy to control soil-transmitted helminth infections in at-risk population groups, 2017: 3. 3. WHO. Preventive chemotherapy in human helminthiasis. Coordinated use of Chapter 1 anthelminthic drugs in control interventions: A manual for health professionals and programme managers, 2006.
1. WHO. How to add deworming to vitamin A distribution, 2004: 7. 4. WHO. Prevention and control of schistosomiasis and soil-transmitted helminthiasis. Report of a WHO Expert Committee, 2002 (WHO Technical Report Series No. 912). 2. WHO. Helminth control in school-age children: A guide for managers of control programmes, 2nd Ed., 2011: 4-6. 5. WHO. Report of the WHO Informal Consultation on the use of praziquantel during pregnancy/lactation and albendazole/mebendazole in children under 24 months. 3. WHO. Guideline: preventive chemotherapy to control soil-transmitted helminth Geneva, 8–9 April 2002. infections in at-risk population groups, 2017: 9. 6. WHO. Action against worms, February 2007, Issue 8, p. 3. 4. WHO. Weekly epidemiological record, No. 50, 2018, 93, 681-692. 7. WHO. How to add deworming to vitamin A distribution, 2004: 13. 5. WHO. How to add deworming to vitamin A distribution, 2004: 8. 8. WHO. How to add deworming to vitamin A distribution, 2004: 12. 6. Stoltzfus R et al. Hemoquant determination of hookworm-related blood loss and its role in iron deficiency in African children. American Journal of Tropical Medicine and 9. WHO. Helminth control in school-age children: A guide for managers of control Hygiene, 1996, 55:339–404. programmes, 2nd Ed., 2011: 32. 7. Mahalanabis D et al. Vitamin A absorption in ascariasis. American Journal of Clinical 10. WHO. The importance of pharmacovigilance, 2002: 42. Nutrition, 1976, 29:1372–1375. 11. Loukas A, Hotez P (2006). Chemotherapy of helminth infections. In: Brunton LL et 8. Awasthi S, Pande VK. Six-monthly deworming in infants to study effects on growth. al., eds. Goodman and Gilman’s The pharmacological basis of therapeutics, 11th Indian Journal of Pediatrics, 2001, 68:823–827. ed. New York, McGraw-Hill. 9. Stephenson LS et al. Physical fitness, growth and appetite of Kenyan school boys 12. WHO. Guideline: preventive chemotherapy to control soil-transmitted helminth with hookworm, Trichuris trichiura and Ascaris lumbricoides infections are improved infections in at-risk population groups, 2017: 12. four months after a single dose of albendazole. Journal of Nutrition, 1993, 123:1036–1046. 10. Kvalsvig JD et al. The effects of parasite infections on cognitive processes in children. Annals of Tropical Medicine and Parasitology, 1991, 85:551–568. Chapter 4 11. WHO. Prevention and control of schistosomiasis and soil-transmitted helminthiasis: 1. WHO. How to add deworming to vitamin A distribution, 2004: 12. Report of a WHO Expert Committee, 2002: 8. 2. WHO. Prevention and control of schistosomiasis and soil-transmitted helminthiasis: 12. WHO. Action against worms, February 2007, Issue 8, p. 1. Report of a WHO Expert Committee, 2002: 18. 13. WHO. Helminth control in school-age children: A guide for managers of control 3. WHO. Action against worms, February 2007, Issue 8, p. 6-8. programmes, 2nd Ed., 201: 9. 4. WHO. Infection prevention and control of epidemic- and pandemic-prone acute 14. WHO. Helminth control in school-age children: A guide for managers of control respiratory diseases in health care: WHO Interim Guidelines. June 2007:10–11. programmes, 2nd Ed., 2011: 6. 5. WHO. Practical Guidelines for Infection Control in Health Care Facilities. 2004:10– 15. WHO. Guideline: preventive chemotherapy to control soil-transmitted helminth 15. infections in at-risk population groups, 201: 21. 6. EngenderHealth. Infection prevention: A reference booklet for health care providers, 16. WHO. Helminth control in school-age children: A guide for managers of control 2001:1–6 programmes, 2nd Ed., 2011: 32. 7. WHO. Infection prevention and control of epidemic- and pandemic-prone acute 17. A. Montresor (WHO), personal email communication, April 23, 2014. respiratory diseases in health care: WHO Interim Guidelines. June 2007:53– 54. 18. WHO. Prevention and control of schistosomiasis and soil-transmitted helminthiasis: 8. WHO. Guidelines on hand hygiene in health care: A summary. 2009: 29. Report of a WHO Expert Committee, 2002: 18. 9. WHO. Guidelines on hand hygiene in health care: A summary. 2009:12. 19. WHO. How to add deworming to vitamin A distribution, 2004: 9-11. 10. WHO. Infection prevention and control of epidemic- and pandemic-prone acute 20. Nossal GJ. The Global Alliance for Vaccines and Immunization – a millennial respiratory diseases in health care: WHO Interim Guidelines. June 2007:54– 55. challenge. Nature Immunology, 2000, 1:5–8. 21. Curtale F et al. Intestinal helminths and xerophthalmia in Nepal: a case–control study. Journal of Tropical Paediatrics, 1995,41: 334–337. Chapter 5 22. Sivakumar B, Reddy V. Absorption of vitamin A in children with ascariasis. Journal of Tropical Medicine and Hygiene, 1975, 78:114–115. 1. WHO. Action against worms, February 2007, Issue 8, p. 4. 23. De Silva NR. Impact of mass chemotherapy on the morbidity due to soil-transmitted 2. WHO. Action against worms, February 2007, Issue 8, p. 5. nematodes. Acta Tropica, 2003, 86:197–214. 3. WHO. Action against worms, February 2007, Issue 8, p. 6-8. 24. Ching P et al. Childhood mortality impact and cost of integrating vitamin A supplementation into immunization campaigns. American Journal of Public Health, 4. WHO. How to add deworming to vitamin A distribution, 2004: 13. 2000, 90:1526–1529.
Chapter 2
1. Republic of Kenya. National Worm Control in school-age children: Handout for Teachers.
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Chapter 6
1. WHO. How to add deworming to vitamin A distribution, 2004: 15. 2. WHO. Distribution of Vitamin A during national immunization days: WHO/EPI/ GEN/98.06. 1998:14. 3. WHO. School deworming at a glance, March 2003: 1. 4. WHO. Helminth control in school-age children: A guide for managers of control programmes, 2nd Ed., 2011: 27-28.
Chapter 7
1. MOST/USAID. Vitamin A facts for health workers. 2001: 7. 2. Pan American Health Organization. Providing vitamin A supplements through immunization and other health contacts for children 6–59 months and women up to 6 weeks postpartum: A guide for health workers, 2nd edition, 2001: 30 3. WHO. Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving polio eradication, 1998: 1996 revision.
Chapter 8
1. MOST/USAID. Twice-yearly vitamin A supplementation: A guide for program managers. 2001:13–16. 2. MOST/USAID. Twice-yearly vitamin A supplementation: A guide for program managers. 2001:17–19. 3. Micronutrient Initiative. Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring. 2007:52. 4. Waisbord S. Assessment of communication programmes in support of polio eradication: Global trends and case studies, The Change Project, AED. April 2004:6.
Chapter 10
1. Pan American Health Organization. Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women up to 6 weeks postpartum: A guide for health workers, 2nd edition. 2001:24. 2. WHO. Distribution of Vitamin A during national immunization days: WHO/EPI/ GEN/98.06, p. 33. 3. Micronutrient Initiative. Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, 2007: 61. 4. WHO. Action against worms, February 2007, Issue 8, p. 8.
Chapter 11
1. Pan American Health Organization. Providing vitamin A supplements through immunization and other health contacts for children 6–59 months and women up to 6 weeks postpartum: A guide for health workers, 2nd edition. 2001:26-27.
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