Date Published: November 19, 2015
Publisher: Public Library of Science
Author(s): Lesley J. Drake, Sarman Singh, C. K. Mishra, Amarjeet Sinha, Sanjay Kumar, Rajesh Bhushan, T. Deirdre Hollingsworth, Laura J. Appleby, Rakesh Kumar, Kriti Sharma, Yogita Kumar, Sri Raman, Stalin Chakrabarty, Jimmy H. Kihara, N. K. Gunawardena, Grace Hollister, Vandana Kumar, Anish Ankur, Babul Prasad, Sushma Ramachandran, Alissa Fishbane, Prerna Makkar, Charles H. King. http://doi.org/10.1371/journal.pntd.0004106
Partial Text: Globally, more than 600 million school-age children are at risk of infection with soil-transmitted helminths (STH) and require treatment . These infected children frequently carry the largest burden of disease in a community and are at greater risk of malnutrition and anaemia [2–5], with detrimental effects on educational access and learning as well as mental and physical performance [4,6–10]. Many of these detrimental effects of helminth infection, however, are reversible with antihelminthic drugs [9–11]; thus, the World Health Organization (WHO) advocates reaching a minimum target of regular administration of antihelminthics to at least 75%, and up to 100%, of school-age children at risk of morbidity from STH infection by 2020 [1,12].
Two flagship programmes of the central government, the National Rural Health Mission (NRHM) and the Indian national educational program Sarva Shiksha Abhiyan (SSA) (or Universalization of Elementary Education) ensured that sufficient operational funding was available within the state government to scale up feasible programmes in the areas of health and education. Thus, in 2009, with financial backing from these institutions and endorsement by high-ranking politicians and bureaucrats willing to support evidence-based, cost-effective solutions in health and education, the school-based deworming MDA programme in Bihar was initiated.
The evidence base for the programme was financed, coordinated, and conducted by DtW/PCD and the All India Institute of Medical Sciences (AIIMS), New Delhi. In the absence of any previous data collection on the prevalence or intensity of STH in Bihar, school-based surveys were conducted to determine baseline prevalence levels and geographical distribution of STH in the state. The surveys, largely conducted according to WHO recommendations for epidemiological data collection , were to asses the overall prevalence and intensity of infections, so as to guide the programme design concerning treatment strategy and scale. Surveys were conducted across six diverse districts—Patna, Supaul, Gopalganj, Araria, Muzaffarpur, and Aurangabad—selected based on diversity in land surface temperatures, socioeconomic profiles, and climatic, sanitation, and environmental indicators. For logistical and practical reasons, the surveys were carried out in two phases; the first phase was conducted in May–June 2010 across two districts covering 40 schools and a total of 2,079 school-age children, and the second phase was conducted in January–February 2011, covering 20 schools and 1,159 school-age children. A total of 3,238 school-age children in 60 schools were surveyed.
Nearly 140,000 teachers and 20,000 healthcare staff throughout Bihar were trained to deliver the deworming tablets, monitor the programme, record and handle adverse effects, and help build awareness within the community. A cascaded training system was used to train this number of individuals in a short period of time. Training was rolled out in three phases to coordinate with the deworming and “mop-up” days being conducted across the state. Fig 3A illustrates the timeline of the rollout of planning, training, and deworming activities. For each phase, state-level master training took place over two days, district-level training over one day, and school-level training over half a day. District and school-level training took place after the state-level master training and the week before the school-based deworming and “mop-up” days. The structure of the cascaded training plan is shown in Fig 3B. The cascaded training model consisted of teachers and healthcare staff who attended centralized, state-level training and passed on training knowledge to teachers at the district and subdistrict levels, thereby maximizing resource capacity and increasing the speed of dissemination. Furthermore, such a cascaded training design provided the opportunity for training materials, reporting and monitoring forms, and deworming drugs to be easily and cost-effectively distributed throughout the state.
In order to sufficiently sensitize and educate the community about the deworming programme, both in terms of why the government was initiating it as well as the outcomes and potential side effects, materials specific to India and the context of Bihar were developed in the local language (Hindi). Key government partners SHSB and BEPC and Bihar’s Public Relations Department (PRD), together with DtW/PCD, were responsible for developing and dissemination of the press and community sensitization materials. Fig 4 presents an example of a poster that was produced for this purpose. In the weeks leading up to school-based deworming, the programme was communicated throughout the community, particularly to children, parents, teachers, community leaders, and local officials. Communication strategies included newspaper appeals by the government to the public, radio jingles, street plays, school plays, and prabhat pheris (morning processions of children through their neighborhoods shouting deworming slogans). In addition there was extensive press coverage, including radio broadcasts, press conferences, and media interviews of the various government officials from both the Ministry of Education and Ministry of Health. Wherever possible, the message of deworming was associated with a “Right to Education” (RTE) message, as part of an extensive state campaign. This linking of the two campaigns leveraged additional resources for sensitization and ensured sustainability and acceptability of the programme because of the continuation of an existing message of RTE, as well as preexisting local involvement in the messaging.
Dates for deworming days were advertised across the state. These deworming days were rolled out in three phases between February and April of 2011 (Fig 4), targeting over 21 million school-age children and reaching over 17 million children both enrolled and non-enrolled. As the programme predated the global drug donation of albendazole and mebendazole , enough low-cost, quality-assured drugs were procured to treat the estimated 21 million school-age children in Bihar, plus an additional 20% added to this number of tablets in order to treat out-of-school and pre-school children who were encouraged to attend deworming and “mop-up” days.
At the same time as baseline surveys were being conducted, India was due to commence lymphatic filariasis (LF) treatment within Bihar state as part of the annual National Filaria Control Programme (NFCP). The control strategy consists of coadministration of diethylcarbamazine citrate (DEC) with albendazole. The administration of albendazole, one of the two drugs which are used for treating STH, could have resulted in duplication of efforts if the school-based deworming programme was not coordinated with the NFCP. Thus, because of the high prevalence of STH infections in Bihar (Fig 2) and the WHO-recommended treatment strategy of biannual treatment in areas where prevalence is ≥50% , the SSHCC in Bihar endeavored to maximize the impact of the existing NFCP programme and ensure at least annual deworming to all at-risk children by implementing the school-based deworming programme at a six-month staggered interval with the NFCP programme.
Monitoring and evaluation was conducted at every level of training and programme implementation in Bihar. Side effects were monitored and recorded, and an adverse event protocol developed by SHSB had been distributed prior to the deworming days to all health facilities to advise on appropriate management. Any adverse effects were to be treated by the health department of Bihar.
The strong evidence base that had been developed as part of the programme bolstered high-level advocacy and support for the programme. Indeed, a preliminary analysis of cost sharing between development partners and the state government suggested that support provided by the development partners catalyzed investment of at least three times the initial investment value in additional operational financing from the government—US$500,000 invested by DtW/PCD (with funding from The World Bank and Global Network for Neglected Tropical Diseases) and at least US$1.56 million (calculated on a best-effort basis) invested by the Government of Bihar.
In 2011, Bihar state successfully implemented its first ever state-wide deworming programme. Treating over 17 million of the 21 million targeted school-age children in over 67,000 schools across Bihar and within a year of programme conceptualization, the programme constitutes the largest school-based deworming exercise ever completed globally. Rolled out across the state in just over three months, the programme reached over 80% coverage, and exceeded WHO recommended targets [13,27].
Large-scale, evidence-based programmes operating from a school-based platform have been shown to be an efficient way to reach large numbers of school-age children with safe and effective drugs, increasing programme impact [15,33,34]. Leveraging teachers as a human resource in addition to healthcare staff provides a cost-effective method for programme delivery. In efforts to control STH infections and reach WHO targets of treating 75% of school-age children by 2020 [12,35], widespread coverage of deworming programmes in different settings will be required.