A large-scale school based deworming programme in Bihar State, India – recipe for success Laura Appleby Imperial College, London

Soil-transmitted Helminths Ascaris lumbricoides, Trichuris trichiura and the hookworms, Necator americanus and Ancylostoma duodenale Most commonly treated with Mebendazole and Albendazole: MDA administration via preventative chemotherapy

Infection in Children Infection Loss of nutrients and malabsorption of micronutrients Anaemia (hookworm), stunting and poor growth measures Poor school attendance Poor concentration while at school, and decrease in cognitive capacity Long term and irreversible measures of morbidity if infection continues untreated Affects community development Treatment Greater availability of consumed nutrients Decreased anaemia (in the case of hookworm) Increased cognitive development Decreased school absenteeism Better concentration in schools Better health through red. Morbidity May lead to improved development indicators for community

School based deworming Age (years) Mean no of worms Age-infection profile for STH infections

Situational Analysis of Bihar Rural population, employed in agriculture Poor state: low levels of sanitation and high levels of poverty: 75% do not have access to a latrine Per capita income is 30% of India’s average Diarrhoea, dysentery, skin diseases, measles and parasitic infection common in the region 26% of population aged 5-14 In 2009 the Principal Secretary for Health in Bihar approached DtW and PCD for technical support in initiating a school based deworming exercise.

Partnership, advocacy, coordination & commitment Community/ Schools/ Teachers Dept. of HRD/DoH& FW/SHSB State School Health Coordination Committee

Survey and Mapping Programme Design & Evaluation Surveys for baseline prevalence took place in 6 districts in Bihar 50 schools selected, children per school were asked to provide a stool sample Diagnostics took place locally where logistically possible, or in district laboratory when required GIS coordinates of schools combined with prevalence data and environmental factors

Prevalence maps

STH prevalence in Bihar PrevalenceControl ≥50%treat all school-aged children twice a year. ≥20% & ≤50%risk areas treat all school- aged children once a year WHO Treatment categories for STH infection: Source: Extrapolation of results from worm prevalence surveys conducted by London School of Hygiene and Tropical Medicine MDA for all schools via school based deworming

Core components of implementation of the school-based deworming programme Drugs: Single-dose of chewable Albendazole tablet 400 mg

Core components of implementation of the school-based deworming programme Drugs: Single-dose of chewable Albendazole tablet 400 mg Cascade Trainings: ~140,000 teachers trained for administering deworming tablet ~20,000 healthcare staff were trained to provide support to teachers.

Core components of implementation of the school-based deworming programme Drugs: Single-dose of chewable Albendazole tablet 400 mg Cascade Trainings: ~140,000 teachers trained for administering deworming tablet ~20,000 healthcare staff were trained to provide support to teachers. Community Sensitisation: press conference, newspaper appeals, radio jingles, posters, banners

Core components of implementation of the school-based deworming programme Drugs: Single-dose of chewable Albendazole tablet 400 mg Cascade Trainings: ~140,000 teachers trained for administering deworming tablet ~20,000 healthcare staff were trained to provide support to teachers. Community Sensitisation: press conference, newspaper appeals, radio jingles, posters, banners

Core components of implementation of the school-based deworming programme Drugs: Single-dose of chewable Albendazole tablet 400 mg Cascade Trainings: ~140,000 teachers trained for administering deworming tablet ~20,000 healthcare staff were trained to provide support to teachers. Community Sensitisation: press conference, newspaper appeals, radio jingles, posters, banners Monitoring: Internal DoH&FW, DoHRD, PCD, and DtW independently monitor ~5% of schools on deworming and mop-up days across all 38 districts adverse effects were all reported and treated by health department of Bihar

Programme Roll-Out District Children Covered (millions) Time line DecJanFebMarApril Planning Master-training District level activity De-worming and mop-up days Phase 1 Phase 2 Phase 3

Bihar has successfully implemented the largest school-based mass deworming programme globally Cost-effectively treated over 17 million school-age children (18 rupees /child) State-wide coverage across all 38 districts Coverage of children through network of over 67,000 government schools First-ever programme implemented in just 3 months from February – April 2011 Total number of School-age Children in Bihar (Source: BEPC; ) 20,800,000 (20.8 million) Total School-age Children Dewormed (Source: District-level data, 2011) 17,044,840 (17.04 million)

Reasons behind the success Identifying need Cross sector collaboration Co-ordination with other programmes –LF programme, means children can be treated twice a year between two groups, for no extra cost Using existing structures: schools Local governmental support: drug procurement, deliver, training, community sensitization and reporting Sensitization of community - awareness

Bihar state-wide deworming programme Large population with low standard of basic health care High prevalence of STH Unfamiliarity with large scale deworming programme Untrained personnel Existing NTD programme underway Challenges School based targeting Survey of schools in the state for prevalence maps Sensitization of communities & Training of personnel Coordination between stakeholders Actions 17million children treated for STH infection Bihar has planned and executed two additional rounds of deworming State School Health Committee is still in existence with an active role in school health activities Outcomes

Bihar state-wide deworming programme Large population with low standard of basic health care High prevalence of STH Unfamiliarity with large scale deworming programme Untrained personnel Existing NTD programme underway Challenges School based targeting Survey of schools in the state for prevalence maps Sensitization of communities & Training of personnel Coordination between stakeholders Actions 17million children treated for STH infection Bihar has planned and executed two additional rounds of deworming State School Health Committee is still in existence with an active role in school health activities Outcomes Large population with low standard of basic health care High prevalence of STH Unfamiliarity with large scale deworming programme Untrained personnel Existing NTD programme underway Challenges

Bihar state-wide deworming programme Large population with low standard of basic health care High prevalence of STH Unfamiliarity with large scale deworming programme Untrained personnel Existing NTD programme underway Challenges School based targeting Survey of schools in the state for prevalence maps Sensitization of communities & Training of personnel Coordination between stakeholders Actions 17million children treated for STH infection Bihar has planned and executed two additional rounds of deworming State School Health Committee is still in existence with an active role in school health activities Outcomes Large population with low standard of basic health care High prevalence of STH Unfamiliarity with large scale deworming programme Untrained personnel Existing NTD programme underway Challenges School based targeting Survey of schools in the state for prevalence maps Sensitization of communities & Training of personnel Coordination between stakeholders Actions

Acknowledgements Prerna Makkar Ruth Dixon Rakesh Kumar Kriti Sharma Yogita Kumar Late Sri Raman Stalin Chakrabarty Alissa Fishbane Grace Hollister Sarman Singh & all technicians Government of Bihar C.K. Mishra Sanjay Kumar Rajesh Bhushan Jimmy H Kihara Lesley Drake Esther Havens.

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