Deworming school children in Ethiopia: The importance of a comprehensive approach

Introduction: A quarter of the world’s population, most commonly in developing countries like Ethiopia, are infected with intestinal parasites. School age children are the most affected segment of the population. The World Health Organization (WHO) recommends periodic deworming of all at-risk people living in endemic areas. Methods: In 2009, Ben Gurion University, in partnership with the NALA Foundation and in collaboration with the Organization for Social Services and AIDS (OSSA), an Ethiopian non-governmental organization, and the health and education bureau of Tigray Regional State, launched a deworming project for school children in Mekele City, Ethiopia. During its four years of implementation (2009-2012), we evaluated the effi cacy of this intervention in controlling helminthic infection in participating schools. The program entailed a comprehensive approach, combining intensive health education with water sanitation and mass drug administration and with preand post-intervention stool surveys, during each year of the intervention. Results: A total of 23,214 students were dewormed in four annual deworming campaigns. The results of the sequential stool surveys demonstrated a signifi cant and consistent decrease in the prevalence of both schistosomiasis and soil-transmitted helminthes infection in all the school children who participated in the project, and was sustained throughout the intervention period, decreasing from 52.8% at the beginning to 6.4% at the end. Conclusions: Results suggest that a comprehensive program, which combines mass drug administration with health education and water sanitation, can lead to sustained control of helminthic infections in school children living in highly endemic areas for these infections. Though continued evaluation of this program is warranted to determine how long and permanent such a control can last, deworming programs of this type are likely to prove useful throughout Ethiopia and other developing countries where these infections are highly common and where their long-lasting control is greatly needed. Research Article Deworming school children in Ethiopia: The importance of a comprehensive approach Jemal Ali1,7, Allison Polland2, David Adlerstein3, Yirga G Gziabher4, Galia Sabar5, Yonat Liss6 and Zvi Bentwich1,6* 1Department of Microbiology, Immunology and Genetics, Ben-Gurion University of the Negev, Center for Emerging Tropical Diseases and AIDS (CEMTA), Beer Sheba, Israel 2Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA 3Department of Family Medicine, Saints Mary and Elizabeth Medical Center, Chicago, IL, USA 4Organization of Social Services for AIDS (OSSA), Mekele City, Ethiopia 5African Studies, Tel Aviv University, Tel Aviv, Israel 6NALA Foundation, Tel Aviv, Israel 7Department of Microbiology Immunology and Parasitology, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia Received: 19 April, 2019 Accepted: 09 July, 2019 Published: 10 July, 2019 *Corresponding author: Zvi Bentwich, NALA Foundation, Tel Aviv, Israel, E-mail: https://www.peertechz.com


Introduction
More than 1.5 billion people, or 24% of the world's population, most commonly in developing countries, are infected with soil-transmitted helminthes (STH) [1] and more than 207 million people, 85% of whom live in Africa, are infected with schistosoma [2]. These worm infections are widespread in most developing countries, like Ethiopia, with extremely high prevalence among school children. Risk factors for these infections include poor hygiene, lack of sanitation and low socioeconomic status. Sanitation coverage varies widely in developing countries. In most of the developing countries, less than half the population uses improved sanitation facilities, with the countries with the lowest coverage concentrated in sub-Saharan Africa and southern Asia [3]. blood in the stool, with complications of chronic infection [5].
The impact of helminthic infections extends far beyond these obvious health effects to include economic and social effects resulting from lost school attendance and effective work time [7,11]. Treatment of these infections by MDA, at a cost of three cents (for STH) to fi fty cents (for Schistosoma) (in US dollars) per individual, is an extremely cost-effective and attractive way to control these infections [7].
The World Health Organization (WHO) recommends treating all school children at regular intervals with deworming drugs in areas where helminth infection is common. The WHO states this will improve nutritional status, hemoglobin, and cognition and thus improve health, intellect, and school attendance [12].
For worm infections, morbidity can be signifi cantly reduced through repeated and regular treatment with single-dose MDA delivered through school health programs. The drugs are safe, inexpensive, and simple to administer, and are thus ideally suited for mass administration [13]. However, the rates of reinfection in countries where the infrastructure, sanitation and hygiene have not been improved, are extremely high, raising serious questions about the effi cacy of MDA alone.
A number of recent studies have suggested that health education and provision of hygiene and sanitation facilities may impact the prevalence of helminth infections and reinfection [14][15][16][17][18]. Based on our primary experience, we concluded that a more comprehensive approach is needed to achieve behavioral change in school children and reach these goals. Therefore, we developed a program for deworming school children that combines intensive health education, water sanitation, and hygiene with community and parental involvement and commitment, in addition to MDA. We implemented this program in Mekele City, Ethiopia during four years (2009-2012) with the aim of achieving longer lasting control of these infections and a decrease in the rate of reinfection.  During the four years of the program, there were 68 governmental and private elementary and junior high schools in the city, attended by 45,307 students. A total of 38 schools, including roughly half the students in Mekele City (23,214), were involved in the intervention. Schools were selected based on previous studies in the area and existing reports from the city health bureau and in consultation with regional and zonal health bureaus. Priority was given to those schools with a high prevalence of helminth infections, but schools with low prevalence were also included to decrease possible bias of the study. The target age group was 5-15 years and all students present at school during the MDA took the deworming tablets.

Study site and study population
A total of 1,871 randomly selected students participated in the four annual stool surveys. From the start, the intervention was planned as a multistage deworming program. The comprehensive program entailed training of health-care workers, health education, drug distribution, and improvement of water supply and sanitation. The protocol used on the deworming campaign was based on the WHO guidelines for deworming school children [20] and modifi ed in accordance with resource availability.

Data collection and analysis
Data were collected in a standard record format prepared for the deworming program records. They were entered in Excel format and then converted to SPSS version 16 statistical package. The prevalence of the parasitic infection at the baseline and in subsequent stages was compared.

Results
At baseline and in all the stages of the survey, different parasite species were found. Schistosoma mansoni was the most prevalent parasitic infection across all surveys and Ascaris lumbricoides was the leading STH infection (Table 1)

Conclusions
The results reported here clearly demonstrate a marked and  [19,25] further suggest that the decreased prevalence of these infections persisted long after the conclusion of our intervention. This success, which in some locations was truly dramatic, is likely, though not proven, to be accounted for by the comprehensive approach used in our program, which combined MDA with intensive health education and also addressed water and sanitation issues.

Limitations and future studies
The study is not without limitations. First, this was part of a programmatic implementation of deworming in which  in Ethiopia, as well as elsewhere, in areas with high prevalence of these infections.