Mebendazole and albendazole supported by MOH and WVS Australia ... The main STH control strategy is regular distribution of Albendazole (or Mebendazole).
Fit for School-Cambodia
A Review on Cambodian National Policies for Soil-Transmitted Helminth (STH) and Lymphatic Filariasis (LF): Information on the implementation of the STH Control and LF programme in Cambodia-January 2013 Report Prepared by Sara Canavati
2013
i
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
ii
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Table of Contents LIST OF FIGURES
III
LIST OF TABLES
IV
A REVIEW OF THE REGIONAL ACTION PLAN
1
NATIONAL POLICY ON STH CONTROL IN CAMBODIA
4
Cambodia Demographics in brief
4
Epidemiology of NTDs in Cambodia
6
Partnership development
7
Chemotherapy Strategy in Cambodia
8
MDA Strategy in Cambodia The school kit Preschool children School Children Women of child bearing age: Endemic provinces
9 9 10 11 12 13
STH Deworming Structure in Cambodia
14
A SUMMARY OF CAMBODIA NTD STRATEGY ON STH AND LF
16
At risk groups of each disease
16
Soil Transmitted Helminthiasis (STH) Current endemic situation Current situation of control activities Control strategy
16 16 18 20
NATIONAL POLICY ON LYMPHATIC FILARIASIS IN CAMBODIA Current endemic situation and activities for elimination Coverage and monitoring Stop MDA Survey in 2010 Plans for 2012 and beyond
23 23 25 25 25
OPERATIONAL ASPECTS OF STH AND LF PROGRAMMES IN CAMBODIA
26
ANNEXES
29
Annex 1: Summary of questions in ToR
29
Annex 2: National Centre for Malaria Control, Parasitology and Entomology, Ministry of health, Cambodia—a summary of an updated strategy plan Program Governance Policy for Periodic deworming Treatment Guidelines of Soil Transmitted Helminth (STH) Program Partners STH Control Program Objectives Monitoring STH Prevalence & Intensity STH Control Activities
30 30 30 30 31 31 31 32
iii
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
List of Figures Figure 1:
WHO Western Pacific Region
Figure 2.
Map of the Kingdom on Cambodia
Figure 3.
Cambodia age pyramid
Figure 4.
CNM pilot study to understand the impact of MDA in a district in urban Cambodia
Figure 5.
The school kit distributed by CNM
Figure 6.
STH Deworming Structure in Cambodia
Figure 7a.
Geographical distribution of STH intervention in Cambodia and MDA for the control of STH
Figure 7b.
Geographical location of provinces of HOS intervention and control schools in Cambodia
Figure 8.
Map of Cambodia showing endemic areas of Lymphatic filariasis
iv
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
List of Tables Table 1.
Basic data of Soil-transmitted helminth target groups in Cambodia
Table 2.
National Programme Coverage for Pre-school children
Table 3.
National programme coverage for school children
Table 4.
National programme coverage for women of child bearing age
Table 5.
Monitoring the impact of the national programme over time
Table 6.
Extent of recent mass deworming coverage of different risk groups in Cambodia, 2006 – 2009
Table 7.
Number of the provinces where MDA for STH control is planned
Table 8.
Number of provinces where M & E of STH control is planned
Table 9.
Latest deworming for STH in Cambodia at school level and village level before the HOS took place
Table 10.
Stool survey to follow up the prevalence of helminth infection before conduct MDA with the school age children in 2011.
1
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
A review of the regional action plan Regional Action Plan for Neglected Tropical Diseases in the Western Pacific Region (2012-2016) WPRO1 was developed as a critical step towards securing sustained financial and human resources for NTDs in endemic countries, integrating disease-specific plans, measuring progress and improving coordination.
Figure 1: WHO Western Pacific Region (WPR) The purpose of this regional plan is to address a number of neglected tropical diseases (NTDs) with different control/elimination strategies that requires an integrated regional plan. Regional Action Plan could serve as a roadmap for Member States and partners template for national plans of action monitor programme progress mobilize internal and external funds
1
http://www.wpro.who.int/about/regional_committee/63/documents/RC63_06_Item_11_NTD_FINAL_COMPLETE.pdf
2
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Development of the plan… 2009: Development of 1st version at an Informal Consultation in March in WPRO and review at Programme Managers Meeting in Nov in Papua New Guinea May 2011: Revision at Programme Managers Meeting, Fiji March 2012: Final draft April 2012: Final consultative process with Member States and partners: adoption Sept 2012: Planned to be submitted to and endorsed by Western Pacific Regional Committee Meeting Prioritized NTDs in the Western Pacific Region Lymphatic filariasis (LF) Soil-transmitted helminthes (STH) Schistosomiasis (SCH) Food-borne trematodes (FBT) Trachoma Leprosy Yaws Others: Leishmaniasis Echinococcosis Taeniasis/ cysticercosis Buruli ulcer Scabies Strongyloides Regional NTD Goal (2012-2016) To reduce the health and socio-economic impact due to NTDs, especially among vulnerable groups, and eliminate specific NTDs as public-health problems where feasible, thus contributing to the achievement of the Millennium Development Goals. Regional Goal Indicators - Elimination Elimination of lymphatic filariasis in 10 additional countries and areas by 2016. Elimination of blinding trachoma in 3 countries by 2016.
3
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Elimination of leprosy in Kiribati, the Marshall Islands, and the Federated States of Micronesia by 2016. Elimination of yaws in at least one country by 2016. Regional Goal Indicators – Sustainable Control Reduction in morbidity from soil-transmitted helminth (STH) infections through national deworming coverage of at least 75% of at-risk: Preschool & school-aged children in 12 countries by 2016 Women of childbearing age in 4 countries by 2016 Reduction in morbidity from schistosomiasis through national preventive chemotherapy coverage of at least 75% of the population at risk in 4 countries by 2016 Better assessment of burden of infection based on availability of national mapping data for key foodborne trematodiases by 2016. Regional Objectives Objective 1: Strengthen advocacy and resource mobilization for NTDs. Objective 2: Enhance NTD programme management and intersectoral collaboration, in order to scale up and sustain NTD programmes. Objective 3: Scale up access to NTD prevention and case management interventions. Objective 4: Strengthen integrated NTD monitoring and evaluation (M&E) and surveillance. Objective 5: Strengthen research capacity on NTDs and implement research to fill programmatic knowledge gaps. Main Activities Objective 1.
Advocacy and Resource Mobilization
Objective 2.
Enhance NTD Programme Management
Objective 3.
NTD Prevention and Disease Management
Objective 4.
Strengthen integrated vector management for targeted NTDs
Objective 4/1: Objective 5:
Monitoring and Evaluation / Surveillance
Research to fill Knowledge Gaps
4
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Targets in the regional plan relevant to Cambodia are the elimination of lymphatic filariasis, schistosomiasis, and blinding trachoma by 2016. In terms of soil-transmitted helminthiases, Cambodia has achieved the WHO global target of deworming 75% of school-aged children. National policy on STH control in Cambodia Cambodia Demographics in brief 23 provinces & one capital Population 2011 o
14, 300,000
Growth rate o
+1.54%
Birth rate o
25.40 births/1,000 population
Death rate o
8.07 deaths/1,000 population (2011 est.)
Figure 2. Cambodia Map
5
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Figure 3. Cambodia age pyramid (2005)
Population Country total population 12 – 59 months (pre-school at a village level)* 6 – 14 years old
Number 14, 300,000 1,386,453
2,628,381
(primary school students)* Females 15 – 49 years old 3,455,929 (women of child bearing age) Table 1. Basic data of Soil-transmitted helminth target groups in Cambodia
6
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Epidemiology of NTDs in Cambodia Cambodia is entirely endemic for STH. Lymphatic Filariasis (LF) is transmitted in 4 regions. Schistosomiasis is transmitted in 2 provinces on Mekong River.
Grey: areas where STH are transmitted (all Cambodia) Yellow: districts with additional LF transmission Red: districts where Schisto is transmitted Orange: districts where in addition to SCH, LF and STH are also transmitted Reasons for high transmission: Hot & humid climate Lack of sanitation Hygiene behavior
7
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Partnership development 1995: A pilot project for schistosomiasis and soil-transmitted helminth with MSF& Swiss TPH 1997: Impact of the project was reported to MoH and MoH set up the national programme at CNM. The program was presented in coordination committee meeting (COCOM) at MoH (IO, NGOs, governors) 1998: A pilot project of school based deworming program started in Mean Chey district, Phnom Penh. Information was disseminated through COCOM, CNM and MSF 2000: STH control started in 8 provinces through partners (MSF, WV, SERVANTS, Marinoll, YWAM, Red Cross, WFP, GTZ, SMHF) 2002: Partners meeting started for expansion of school based deworming program - CNM, MoEYS, MoRD, MEDICAM (association of health NGOs) GTZ, UNICEF, WFP, and WHO 2002: Presentation at MEDICAM meeting 2002: School Teachers Training Started by CNM with MoEYS and MoRD with assistance of Government of Japan, UNICEF and WHO local NGOs were invited to join to the training and to support the programme 2003: Task Force for Helminth Control 2004: National Policy and Guideline for Helminth Control An example of impact of control of STH in an urban area The graph below shows the impact of STH prevalence of control on among school children in Meanchey district, Phnom Penh (urban area) and not surprisingly the prevalence decreased from 46% to 2% due to intensive MDA efforts during seven conscuitive years.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Impact of Control on STH prevalence of school children in Meanchey district, Phnom Penh (urban area)
Prevalence %
8
50 45 40 35 30 25 20 15 10 5 0 1998
1999
2000
A. lumbricoides
2001
Hookworms
2002
H. nana
2003
2004
T. Trichuiria
Figure 4. CNM pilot study to understand the impact of MDA in a district in urban Cambodia
Chemotherapy Strategy in Cambodia Targeted treatment based on: Infection rates Transmission Feasibility Strategies School-based Outreach services Community-based
9
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
MDA Strategy in Cambodia The targets of the STH control program are: pre- school children school age children women of child bearing age (WCBA)
Treatment of all individuals in the at-risk-age groups in the endemic provinces The school kit
Figure 5. The school kit distributed by CNM
10
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Preschool children
100 90
(Piggyback with Vitamin A distribution campaign)
80
Criteria for mass deworming for preschool children 70
o
Countrywide
o
Children aged 12-59 months
60
o
Consent from parents
50
Frequency: twice a year 40
Distribution method o
Integrated with vitamin A distribution program
30
o
Gathering people at the community
20
Distributors o
10
Staff working at HC level
0 Geographical Treatment coverage coverage 2010
MEB
2010
2011
2012
No of Pre-SAC at risk
1,320,000
1,386,453
N/A
No of Pre-SAC targeted
1,320,000
1,386,453
1,386,453
No of Pre-SAC treated
1,218,360
1,125,349
1,310,349
Geographic Coverage
100%
100%
100%
92.30%
81.16%
95%
(24 Provinces) Programme Coverage (Over pop. at risk) Table 2. National Programme Coverage for Pre-school children
2011
11
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
School Children 100
(Through school deworming programme), aim is to reach all primary school children in the entire country (resource
90
constraints limit current coverage to selected schools).
80
School-based approach
70
Criteria
60
o
Countrywide
50
Frequency: twice a year
40
Mechanism
30
o
HCs sent drugs to the schools
o
School teachers distributed to school children
20
Additional approach
10
o
Health education done by school teachers
o
IEC materials distributed to the schools
0 Geographical coverage 2010
MEB
2010
2011
2011
2012
No of SAC at risk
2,640,000
2,628,381
1,386,453
No of SAC targeted
2,640,000
2,628,381
1,386,453
No of SAC treated
2,563,440
2,378,094
1,116,963
Geographic coverage
97.10%
100%
100%
Programme coverage
95.80%
90.47%
80.56%
(over pop. At risk) Table 3. National programme coverage for school children
Treatment coverage
12
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Women of child bearing age:
100
Currently only antenatal (administered during or after 2nd
90
trimester and lactating women (6 weeks following delivery)
80
are targeted for deworming at ANC & PN clinics
70
Criteria
60
o
Countrywide 50
Frequency o
Twice a year (after first trimester one tablet & after delivery one tablet)
40 30
Distribution method o
Maternal health service at HC
Distributor
20 10
o
HC and RH staff
0 Geographical coverage 2010
Treatment coverage 2011
MEB
2010
2011
WCBA at risk
3,900,000
3,455,929
290,000
380,560
WCBA treated
277,820
302,164
Geographic coverage
100% (24/24)
100% (24/24)
7.12%
8.74%
WCBA targeted (Antenatal & lactating women)
Programme coverage (Over population at risk)
Table 4. National programme coverage for women of child bearing age
13
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Endemic provinces All 24 with endemicity level > 20% for any STH (for operational reasons all of them are also considered for two rounds of deworming, or as having prev. >50%.
Year
2005
2006
2007
2008 2009
2010
2011
1-
0.8-
Soil-transmitted helminthiasis
Prevalence of any STH in SAC (range)
1-
0-
1-
27.4% 39.8% 38.4%
9.6-
5-
21%
30%
0%
0%
31.1% 38.7%
Proportion of heavy intensity infection among SAC –
1%
0%
0%
Ascaris/Trichuris/hookworms Table 5. Monitoring the impact of the national programme over time
0%
0%
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
14
STH Deworming Structure in Cambodia
J&J; MOH; GSK; KAHP Mebendazole 500mg & Albendazole 400mg CNM & SHD
WHO UNICEF WFP World Vision Other NGOs
CMS/MOH PHD & PED (24)
OD Pharmacy
SHD: school health department 78 ODs & 185 DHEs
PED: provincial education department
HC®
School*
980 HCs
Outreach (@ a village level)
HC
School
6,664 schools
Outreach (@ a village level)
HC
School
Outreach (@ a village level) 10
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
15
The medication administered for mass deworming is different at different levels of society Community level Mebendazole and albendazole supported by MOH and WVS Australia School level Mebendazole from J&J Frequency of administration of medication Pre-school children and school age children Twice a year for pre-school children and school age children Women of child bearing age Once a year for women of child bearing age (WCBA) Agency/Person responsible to administer medication to children Community level Health Centre (HC) through outreach activity during campaign in the months of May and November (integrated with Vitamin A administration) School level At school level medicine is administered through the school teacher
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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A summary of Cambodia NTD Strategy on STH and LF At risk groups of each disease STH: pre-school children, schoolchildren and women of child bearing age (WCBA). Integration of STH Control in public health activities
Measles immunization campaign (National Immunization program)
Vitamin A distribution for children (National Nutrition program)
Women in Reproductive Age (Mother and Child programme)
School Health (MoEYS)
Insecticide-treated Bed net distribution
LF: the entire population in 6 endemic districts
Soil Transmitted Helminthiasis (STH) Helminthiasis in Cambodia: THE GLOBAL TARGET To regularly treat at least 75% of all school-aged children at risk of illness from schistosomiasis and soil transmitted helminths by 2010.2 Cambodia was the first country to achieve the above target Current endemic situation Cambodia is highly endemic throughout the country for Soil Transmitted Helminthiasis (STH) due to humid climatic conditions favorable for transmission, lack of proper sanitation and presence of certain unhygienic practices such as the use of human excreta as fertilizer in agriculture. The baseline prevalence by 2002 for roundworm ranged from 40 - 63%, whipworm 15-60% and hookworm 20-83%, mix worm infections is 60-70%.3,4
2
World Health Assembly Resolution WHA54.19 (22 May 2001) Centre for Parasitology, Entomology and Malariology (CNM). National data at CNM, Ministry of Health, Cambodia. Dec 2010. 3
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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The total population at risk of STH morbidity in Cambodia is estimated at arround 8.4 million individuals. They are comprised of three distinct risk groups that are most prone to associated health impacts such as anaemia, malnutrition and vitamin A malabsorption; preschool children (pre-SAC), school-age children (SAC) and women of child-bearing age (WCBA) in all parts of the country Figure 7a shows the HOS targeted provinces and figure 7b shows STH-endemic provinces by integrated interventions in Cambodia, where children and women need to be periodically treated.
Figure 7a. Geographical location of provinces of HOS intervention and control schools in Cambodia
4
Sinuon M, Tsuyuoka R, Socheat D, Montresor A, Palmer K. Financial costs of deworming children in all primary schools in Cambodia (2005) Transactions of the Royal Society of Tropical Medicine and Hygiene, 99, 664-668.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
18
Figure 7b. Geographical distribution of STH intervention in Cambodia and MDA for the control of STH:
In red provinces where all school children are treated twice/year and pregnant and lactating women are regularly dewormed In yellow provinces where in addition the entire population is treated with albendazole + DEC for the control of LF.
Current situation of control activities The main STH control strategy is regular distribution of Albendazole (or Mebendazole) to the three groups at risk. MoH/CNM has been collaborating in planning, piloting and scaling up of activities for the control of NTD with WHO, various other developmental partners and INGOs over 7 years. The collaborative efforts have facilitated Cambodia to conduct one of the largest deworming programmes in the region at very low cost.6 Table 1 presents the extent of recent mass deworming coverage of different risk groups in Cambodia from 2007 to 2009.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
19
Population group
2007
2008
2009
Remarks
Preschool children For operational reasons, total Population at risk
1,324,650
1,386,592
1,124,668
preschool population is considered eligible for deworming
Population targeted
1,324,650
1,339,571
1,124,668
1,226,530
1,146,205
966,960
(90%)
(85.6%)
(86%)
90%
82.7%
86%
Geographic coverage (of
24/24
23/24
24/24
endemic provinces)
(100%)
(96%)
(100%)
Population treated & program coverage (%) National coverage of population at risk
School aged children Population at risk
2,574,197
2,481,699
2,811,671
Population targeted
2,574,197
2,481,699
2,811,671 2,520,114
Population treated & program coverage (%)
National coverage of population at risk Geographic coverage (of endemic provinces)
2,377,493
2,429,114 (90%)
(92.4%)
(97.9%)
92.4%
97.9%
90%
24/24
24/24
24/24
(100%)
(100%)
(100%)
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
20
Population group
2007
2008
2009
Remarks
Women of Child Bearing Age Population at risk
3,685,000
3,800,000
3,900,000
Antenatal
Antenatal
Antenatal
& lactating
& lactating
& lactating
women
women
(375,000)
(414,000)
290,461
314,640
(77.4%)
(76%)
6.14%
7.6%
8.6%
Geographic coverage (of
24/24
24/24
24/24
endemic provinces)
(100%)
(100%)
(100%)
Population targeted
women (360,000)
The estimated number of AN and lactating women is 2.8% of the total population
226,333 Population treated & program coverage (%)
National coverage of population at risk
(62.8%)
Table 6. Extent of recent mass deworming coverage of different risk groups in Cambodia, 2006 – 2009 (Source: CNM – MoH, Cambodia) * All provinces in Cambodia has STH endemicity >50% and require 2 deworming rounds per year but no second round has been planned for those areas as yet.
As shown in the above table the WCBA are the high risk group that is least covered in Cambodia. Control strategy The main strategy to control STH is preventive chemotherapy, consisting of regular treatment of the population at-risk with antihelminthics and drugs - alone or in combination according to the disease targeted. Drugs are made available to target population, free of charge, through large-scale drug distribution interventions. Several drug donation programmes are in place. For instance Johnson&Johnson donated about 5 million mebendazole, Glaxosmithkline donated albendazole 800,000, and KAHP donated 150,000 tablets of praziquantel and 200,000 albendazole annually.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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This reduced the burden of control activities of the national program. Cambodia has demonstrated its ability to integrate drug distribution with the existing structures (e.g. school system, vitamin A distribution activities, women union) and personnel (teachers, village health workers) further reducing cost of logistics. Treatment activities are also often combined with health education messages. However, the national programme activities are largely dependent on availability of external financial resources while government commitments are mainly in kind with
financial
commitments
to
purchase
deworming
drugs
for
preschoolers
and
pregnant/lactating women. For deworming of Pre-SAC an outreach strategy has been successfully used and this structure can be expanded to reach WCBA. These outreach activities are also supplemented with Village Health Volunteer and Village Malaria Worker through their routine activities to enhance the coverage by treating those who missed in the outreach campaign. The main challenge in Cambodia is (1) to maintain the high level of coverage with albendazole or mebendazole in SAC, Pre-SAC in all areas that had high prevalence of STH and (2) to allow progressive scaling up of the coverage in WCBA, to cover all at risk at least once per year integrating with existing campaigns. The specific activities will include:
TOT and training for district personnel in the provinces where mass drug administration (MDA) is newly implemented for a new target group for the first time;
Refresher training on STH including training of teachers, who are drug distributors, on newly developed school health which includes an extensive sector on helminthiasis
Distribution, monitoring and evaluation costs for the school deworming programme;
Drug procurement and distribution costs to cover pre-SAC during vitamin A campaign;
Drug procurement and distribution cost to expand from coverage of pregnant and lactating women to coverage of all WCBA;
Conducting health education campaigns to impart hygienic behavior
Maintaining linkages and holding forums to share/disseminate information
Conducting parasitological evaluation surveys, 1 survey for each risk group, every 3 years after intervention.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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Target Group
2012
2013
2014
2015
SAC
24
24
24
24
pre-SAC
24
24
24
24
WCBA
12
24
24
24
Table 7. Number of the provinces where MDA for STH control is planned
Target Group Pre-SAC
Indicator
2012
STH prevalence
6**
2013
2014
2015 6
and Intensity SAC
school attendance,
STH prevalence
6
and intensity
WBCA
KAP
Anaemia
STH prevalence
6
and Intensity
KAP
Table 8. Number of provinces where M & E of STH control is planned* * M&E activities will be carried out in sentinel sites of each planned province. ** Two provinces each from three ecological areas (costal, plain and hilly) to represent these areas
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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National Policy on Lymphatic Filariasis in Cambodia Target of the Lymphatic Filariasis control program All population living in endemic areas Medication given for mass deworming (MDA) Diethycarbamacine (DEC) + Albendazole at both community and school levels. Frequency of administration of medication Once a year for five consecutive years. Agency/person to administer the medication to the children Provincial level staff (PHD) administers the medication under close supervision of National programme at both community and school levels.
Current endemic situation and activities for elimination
Lymphatic Filariasis (LF) caused by Wucheraria bancrofti is endemic in 4 provinces. Cambodia is committed to eliminate it on par with the Global Programme to Eliminate Lymphatic Filariasis. 5,6 Mapping of endemic areas with ICT testing as well microfilaria blood film examinations were completed in 2004. As many as 18 districts in four provinces, namely, Rattanakiri, Stung Treng, Preah Vihear and Siem Reap were identified as the areas with on-going transmission. Figure 4 shows the endemic areas of filariasis. The population at risk in the endemic districts is around 475,000. With a well written national strategic plan for the elimination of LF the national programme was got underway in 2005. Five rounds of MDA have been completed by 2009. Stop-MDA surveys conducted in 2010 showed that transmission of LF has been reduced below critical levels to enable stopping of MDA. The national LF elimination programme is now transiting into post intervention surveillance phase. 1-
5
Centre for Parasitology, Entomology and Malariology (CNM). National data at CNM, Ministry of Health, Cambodia. Dec 2010. 2- 6 Ottesen EA et al. The global programme to eliminate lymphatic filariasis: health impact after 8 years. PLoS Neglected Tropical Diseases, 2008, 2(10):e317 (also available at http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000317
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
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Figure 8. Map of Cambodia showing endemic areas of Lymphatic filariasis
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
25
Coverage and monitoring The coverage assessment surveys verified the estimated figure to range between 79 – 90% in different IUs. Overall, it has been a satisfactory level of preventive chemotherapy coverage of the population at risk since 2005. Further, MF surveys carried out in sentinel sites indicate 100% reduction rate of microfilareamia in all IUs after two rounds of MDA. 7 Stop MDA Survey in 2010 Stop MDA surveys were conducted in all IUs in 2010 using ICT survey sampling 900 in each IU. It showed that transmission of LF has been reduced (0.1 – 0.6%) below critical levels in each IU. Thus further MDA will not be required. Disability alleviation Currently, the case load of affected persons, as detected by the programme is not high with about 50 cases of lymphoedema and hydrocele. All these patients are above the age of 50 years and no new clinical cases among young people have been detected for several years. The majority of these patients are under care of general health care system. At the beginning of the program the doctors in the endemic areas have been trained in the disability alleviation of LF cases. Plans for 2012 and beyond Cambodia could now passage to post intervention surveillance. The Post-MDA Surveillance 1 should be conducted in 2012 and Post-MDA Surveillance II in 2015. These should be conducted according to the new guidelines from WHO. Preparation of the verification dossier could be targeted for 2015/2016. Research should be conducted to identify any pockets of systematically excluded populations from MDA e.g. prison inmates, forest workers. Xenomonitoring should also be conducted to complement the post-MDA surveillance.
7
Annual Report for the National Programme to Eliminate Lymphatic Filariasis, Ministry of Health, Cambodia. 2008.
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
26
Operational aspects of STH and LF programmes in Cambodia The medications for both programs, STH and LF come from the MoH and donor agencies: GSK for albendazole for LF, J&J for Mebendazole; World Vision Australia8 for albendazole and praziquantel medications. The latest deworming dates for STH in Cambodia at school level and village level before the HOS took place is as listed in the table below:
8
World Vision Australia began supporting the national programme in 2012
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
27
Last deworming in the school9 June 2012 June 2012 June 2012 June 2012 July 2012 June 2012 N/A June 2012 June 2012 June 2012 June 2012
School Principal School Principal School Principal School Principal School Principal School Principal School Principal School Principal School Principal School Principal School Principal
CONTROL
January 2012
School Principal
50.94%
INTERVENTION INTERVENTION CONTROL CONTROL
Not administered July 2012 June 2012 June 2012
School Principal School Principal School Principal School Principal
February 2012 PSAC % coverage =
May 2012
School Principal
May 2012
School Principal
January 2012 June 2011
School Principal School Principal
School
Type
Svay Kal Primary School Kampong Thom Krong Chi Meak Primary School Anuwat Hun Sen Acha Leak Anuwat Kampong Chhnang Longvek Samrong Primary School Salalek 5 Primary School Kampot Krong Eng Meas Tany Mouy Makara Primary School Ang Phnom Toch Primary School Anuwat Takeo Sok An Mongkul Mean Leak Takeo Krong Primary School Angroka Primary School Neak Ouknha Moha Pheakdey Hun Neang Boeung Trabek Khang Tboung Neak Ouknha Moha Pheakdey Hun Neang Toul Toppong 2 Chey Chum Neas Primary School Chao Ponheahok
INTERVENTION INTERVENTION CONTROL CONTROL INTERVENTION INTERVENTION CONTROL CONTROL INTERVENTION INTERVENTION CONTROL
Area Kampong Thom
Kampong Chhnang
Kampot
Takeo
INTERVENTION INTERVENTION CONTROL CONTROL
PP
Source
Last deworming in the community February 2012 PSAC % coverage = 53.30% February 2012 PSAC % coverage =
For years 2011-2012, schools did not record exact dates.
CNM, MoH
CNM, MoH
50.94% February 2012 PSAC % coverage =
CNM, MoH
CNM, MoH
90.98% February 2012 PSAC % coverage = 55.60%
Table 9. Latest deworming for STH in Cambodia at school level and village level before the HOS took place
9
Source
CNM, MoH
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
28
The below table10 shows the latest data on prevalence of STH infection before conducting MDA with school aged children (ages 6-12) in selected provinces. The data is gathered at a provincial level and no data is available at a school level at the national programme in Camboida.
Enterobius
Hymenolepis
vermicuralis
nana
n and (%)
n and (%)
3 (0.13)
3 (0.13)
4 (0.18)
3 (0.13)
11 (2.09)
12 (2.29)
3(0.57)
0
0
0
109 (9.62)
1 (0.08)
0
2 (0.17)
0
0
186 (15.12)
1(0.08)
3 (0.24)
3 (0.24)
0
Koh Kong (266)
1 (0.37)
22 (8.27)
8 (3.00)
0
0
0
Kg. Speu (269)
1 (0.37)
27 (10.03)
3 (1.11)
0
3 (1.11)
0
Sihanoukvill (208)
18 (8.65)
28 (13.46)
4 (1.92)
0
2 (0.96)
0
Stung Treng ( 3185)
0
432 (13.56)
0
0
0
5 (0.16)
Ratanakiri (417)
0
22 (5.28)
14 (3.36)
1 (0.24)
2 (0.48)
0
22 (10.68)
14 (6.80)
1 (0.48)
0
0
4 (1.90)
18 (8.57)
11 (5.23)
0
3 (1.42)
0
0
37 (7.17)
12 (2.33)
0
18 (3.49)
0
28 (0.39)
1435 (19.75)
83 (1.15)
11 (0.15)
37 (0.50)
8 (0.11)
T. trichiura
Hookworm
A.lumbricoides
n and (%)
n and (%)
n and (%)
Kratie (2287)
1 (0.04)
521 (22.78)
Kg.Cham (524)
3 (0.57)
Prey Veng (1133) Mondulkiri (1230)
Name of the Province and (N)
Pursat (206) Pailin (210) B. Bang (516) Total (7,266)
Schisto n and (%)
Table 10. Stool survey to follow up the prevalence of helminthic infection before conduct MDA with the school age children in 2011. 10
The blue highlighted rows represent the provinces neighboring the HOS provinces.
29
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Annexes Annex 1: Summary of questions in ToR 1. Describe the national or if different provincial or city policy on STH control: a. Who are the targets of the STH control program? i. Pre- school children ii. School age children iii. Women of Child bearing age (WCBA) b. What medication is given for mass deworming? i. Community level Mebendazole and albendazole supported by MOH and WVS Australia ii. School level Mebendazole from J&J c. How many times a year is the medication given? Twice a year for pre-school children and school age children and once a year for WCBA. d. Who gives the medication to the children? i. Community level Health Centre through outreach activity during campaign in May and November (integrated with Vitamin A) ii. School level Distribution is done through school teacher 2. Describe the national or if different provincial or city policy on Lymphatic Filariasis control: a. Who are the targets of the Lymphatic Filariasis control program? All population living in endemic areas b. What medication is given for mass deworming? Diethycarbamacine (DEC) + Albendazole i. Community level ii. School level c. How many times a year is the medication given? Once a year for five years d. Who gives the medication to the children? i. Community level ii. School level Provincial level under supervision of National program 3. Where are medications for both programs coming from? a. MoH Yes b. MoE No c. Donors, if so which donor agencies GSK (albendazole for LF) J&J (Mebendazole) World Vision Australia (Albendazole and Praziquantel)
30
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Annex 2: National Centre for Malaria Control, Parasitology and Entomology, Ministry of health, Cambodia—a summary of an updated strategy plan Program Governance 1995: Pilot schistosomiasis control project started 1997: National helminth control programme established, and STH control integrated in. 1998: Baseline survey of STH in 12 provinces 1998: Lymphatic Filariasis assessment started 2002: School Based Deworming Program started 2003: National Task force established, National Policy and Guideline formulated and approved by Minister of Health
– –
Helminthiases Prevention and Control National program for LF elimination
Policy for Periodic deworming (School Age Children, Pre-school children and Women of Child Bearing Age) All primary school children should receive one dose (unique dose) of deworming tablets two times a year: in January and June from the school teachers in all primary schools in the country with the support of HealthCentres/Health Posts. All children from 1 to 5 years-old who come to Health Centre/Health Post should receive one dose (unique dose) of deworming tablet. All children from 1 to 5 years-old in all villages should receive one dose (unique dose) of deworming tablets two times a year: in May and in November through outreach activity during the vitamin A distribution. Deworming should be provided to pregnant women after the first trimester Deworming should be provided to lactating women Other women of child bearing age: Should be considered Treatment Guidelines of Soil Transmitted Helminth (STH)
•
School-Age Children: Regular treatment twice a year with a single dose of Mebendazole 500mg
2. Pre-School Children: 12-23 months children : with a single dose of Mebendazole 250 mg (Half tablet of 500 mg Mebendazole)
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Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
Over 2 years children : with a single dose of Mebendazole 500 mg. 3. Women of Reproductive Age: a single dose of Mebendazole 500mg. Except pregnant women during the first trimester. Program Partners National Helminth Program/Ministry of Health (MoH)
-
Develop Planning
-
Implementation
-
Monitoring & Evaluation
-
Integrated and strengthen collaboration with other program (Vit. A, EPI…)
School Health Department (SHD)/Ministry of Education Youth and Sport (MEYS) Develop the teacher guide of STH for primary school and integrated into National Curriculum. Promote school health by focusing on health education, health-examination service, hygiene and sanitation, and learning environment in all public and private education institutions in formal and non formal education. Provide Deworming tablet at school to children by teachers in collboration with HCs Ministry of Rural Development: Water supply and build latrines at community NGOs WHO: Technical & financial support J &J: Mebendazole donation Wold Vision Australia: Albendazole donation CWW: Technical support & facilitate HKI Cambodia: facilitate to develop teacher guide of STH for primary schools STH Control Program Objectives To improve the health status of the children by deworming (soil transmitted helminth) To improve the skill on hygiene and sanitation of community through Health Education to prevent the transmission of STH. To reduce environmental contamination and risk of infection for other people Monitoring STH Prevalence & Intensity STH nationwide data was not collected for the last five years. Plan in Q4, 2012 to conduct Nationwide survey to reassess the prevalence and intensity of STH in the country following several years of successful MDA with school age children. The survey will be follow the protocol of WHO
32
Information on the implementation of the Soil-Transmitted Helminth Control and Lymphatic Filariasis program in Cambodia
STH Control Activities Promote water supply at school Developed curriculum and materials on hygiene and sanitation at schools Establish Washing hand place at school Collaboration with private sector (provide hygiene materials eg. soap, toothpaste). Fit for School project (Wash hand, Toothbrush, Deworming) Non enrolled school age children by health center staff during outreach services. STH Treatment Data
