A large-scale school based deworming programme in

Bihar State, India– recipe for success

Laura ApplebyImperial College, London

Soil-transmitted HelminthsAscaris 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 ChildrenInfection

• 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)

Mea

n no

of

wor

ms

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 MappingProgramme Design & Evaluation

• Surveys for baseline prevalence took place in 6 districts in Bihar• 50 schools selected, 50-100 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

Prevalence Control

≥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

DistrictChildren Covered (millions)

Time line

Dec Jan Feb Mar April

5

12

21

3.5

7.5

10

Planning

Master-training

District level activity

De-worming and mop-up days

Phase 1Phase 2Phase 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; 2010-11)

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

Challenges

• 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

Actions• School based targeting• Survey of schools in the state for prevalence

maps• Sensitization of communities & Training of

personnel• Coordination between stakeholders

Outcomes• 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

Bihar state-wide deworming programme

Challenges

• 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

Actions• School based targeting• Survey of schools in the state for prevalence

maps• Sensitization of communities & Training of

personnel• Coordination between stakeholders

Outcomes• 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

• 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

Challenges

• 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

Actions• School based targeting• Survey of schools in the state for prevalence

maps• Sensitization of communities & Training of

personnel• Coordination between stakeholders

Outcomes• 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

• 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 MakkarRuth DixonRakesh KumarKriti SharmaYogita KumarLate Sri RamanStalin ChakrabartyAlissa FishbaneGrace Hollister

Sarman Singh & all technicians

Government of Bihar

C.K. MishraSanjay Kumar Rajesh Bhushan

Jimmy H Kihara

Lesley Drake

Esther Havens.

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