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Greetings!
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 One of
the biggest challenges our program, and other programs like Children Without Worms (CWW) face, is evaluating program
effectiveness. Key to this evaluation is monitoring drug coverage--the percent
of people in a targeted population who ingested the drug or drug combinations.
In this issue, we describe CWW's approach to monitoring drug coverage,
highlighting the new World Health Organization (WHO) guide to monitoring drug
coverage upon which we based much of our approach.
In this issue, we also describe the work of Dr. Jeremiahs Twa-Twa of Uganda's Ministry
of Health. Dr. Twa-Twa manages his country's Child Health Days Plus program,
which delivers critical child health interventions, including bi-annual
deworming. We next place the spotlight on the program in Lao PDR, where
a tight collaboration between the Ministry of Health and the Ministry of
Education has resulted in a highly effective school-based deworming program.
I hope
you are as energized as I am by the successes of our program. I feel so
fortunate to work with such dedicated people in a program that helps so many
children lead healthier, worm-free lives.
Thank you
for taking the time to learn more about Children Without Worms.
Sincerely,
Kim Koporc
Acting Director
Children Without Worms
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| The People Behind CWW: Dr. Jeremiahs Twa-Twa of Uganda
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 As the
Assistant Commissioner of Health Services in the Child Health Division of
Uganda's Ministry of Health (MoH), Dr. Jeremiahs Twa-Twa is responsible for
managing the activities of the Child Health Days Plus program. This program
combines numerous health interventions for Uganda's 14 million preschool and
school age children, and for women of childbearing age. Interventions include
administering immunizations, providing vitamin A supplements, deworming
children, promoting breastfeeding up to 6 months, improving sanitation and
hygiene, and providing insecticide treated bed nets. The "Plus" component
addresses Neglected Tropical Diseases (NTDs), vision screening, and early
infant diagnosis of HIV/AIDS to administer early antiretroviral therapy. By
combining resources targeted toward preschool and school age children, Uganda
provides cost-effective health interventions to both age groups in a single
program.
The MoH selected Dr. Twa-Twa to run the Child Health Days program
because of his vast experience working in public health in a career that spans
30 years. Early on, he worked as a general doctor in local communities, and later, as
a Director of District Health Services. In these positions, he became familiar
with the common health issues like malaria, worms, and other NTDs that people, especially the poor, experience. Dr. Twa-Twa then moved to the MoH headquarters,
where he played a critical role in collecting the surveillance data used to
demonstrate the emerging issue of HIV/AIDS in Uganda. He was then promoted to
Registrar of the Uganda Medical and Dental Practitioners Council, a position he
held for close to five years before accepting his current position in
2004.
For Dr. Twa-Twa, job satisfaction comes from identifying what public health work needs
to be done, developing a plan, and seeing the benefits that occur from
implementing the plan. He is particularly proud of the Child Health Days Plus
bi-annual deworming efforts and its continued progress. He sees the
mebendazole donations from Johnson & Johnson through Children Without Worms (CWW) as key to this
progress. He states that, "The de-worming coverage has progressively improved
from 40 percent when the program started in 2004, to 70 percent in 2008.
Dr. Twa-Twa believes the program succeeds because of the tremendous support from
top MoH leadership. He says, "The Director General of Health services of the
Ministry of Health Dr. Sam Zaramba is very keen about the deworming and
neglected tropical diseases program and about having the program's activities
implemented." He also attributes program success to the commitment by and
effective collaboration with numerous partners, including CWW, the United Nations World Food Program, UNICEF, the World Health Organization (WHO), and USAID's A2Z micronutrient program. But the understated Dr. Twa-Twa is always at work on
behalf of the program. Any given day might find him in meetings with program
stakeholders or others in the health sector, on field visits to distribution
sites, and writing reports and correspondence.
Dr. Twa-Twa notes the challenge of getting the donated mebendazole into Uganda and
out to the point-of-use on time to take full advantage of the bi-annual
mobilization efforts. He also says that collecting data from the deworming
sites is difficult, so assessing and reporting program progress to the MoH,
CWW and other stakeholders is often delayed. Fortunately, a planned MoH
partnership with the School of Public Health and other training institutions
will address this second challenge. The schools will assign students to
districts for 2 to 3 months a year as part of the training program, providing
the much-needed program support at the district level for planning,
implementation, data retrieval, and timely report submission. This arrangement
will also prepare individuals to serve as district health workers in the future.
Although
Dr. Twa-Twa says that the ultimate goal of the deworming efforts is to reach
100 percent of the 14 million children in Uganda, he notes that "Public health
programs take time, and you have to keep them going." He says, "However, we
are moving forward." And with a 30 percent increase in de-worming coverage, Uganda
is clearly poised to reach that ultimate goal in the near future. Dr. Twa-Twa
thanks CWW for joining hands with other development partners and the Ugandan
government to improve the quality of life for Uganda's children.
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| Leveraging Partner and Stakeholder Support for Success
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Lao People's Democratic Republic (PDR), is a landlocked country bordered by
Vietnam to the east and Thailand to the west. According to Dr. Chitsavang
Chanthavisouk, Lao PDR Coordinator for the School Health Program, a 2002
parasitological survey revealed that over 90 percent of school age children in
Laos were infected with soil-transmitted helminthes (STH). The survey results,
coupled with encouragement from the World Health Organization (WHO), persuaded
the Laotian government to establish a deworming program in 2005.
Since the
deworming program started, the 2006 survey showed a reduction in STH infection
prevalence from 90 percent in 2002 to 64 percent. A 2008 survey
indicated a further reduction to 56 percent.
While the
reduced infection rates indicate program success, there's a second success
story--one that revolves around achieving buy-in from and participation by
multiple groups, including the Lao PDR Ministries of Health and Education (MoH
and MoE), community leaders, parents, and teachers. In particular, the School
Health Task Force (SHTF), a collaboration of the MoH with the MoE, establishes
an approach worth replicating elsewhere. In this collaboration, the MoE coordinates among the
educational administrators to implement the program, and the MoH provides
technical backup, coordinates funding and drug donations, and stores and
transports the drugs.
Dr. Padmasiri
Aratchige, Inter-country Program Officer for Parasitic Diseases Control explained
how these parties joined forces. First, WHO recognized the critical need for
deworming in Lao PDR, providing health experts like Dr. Aratchige and Dr.
Chanthavisouk and identifying ways for the Lao PDR MoH and the MoE to collaborate.
With the backing and official recognition of the Laotian government, the two
Ministries signed a memorandum of understanding to create the SHTF, the document
that defined how the ministries would coordinate the national and
province/district deworming efforts.
Dr.
Aratchige notes that a spirit of volunteerism, part of the Laotian and Buddhist
culture, also contributes to the program's success. The approximately 20 national
and 10 province/district members of the SHTF meet regularly, receiving no
additional payment for holding and attending these meetings. The teachers implementing
the program also put in unpaid time to distribute the deworming medication, attend
trainings and educate the students about the infection cycle and using proper
hygiene. For these teachers, Dr. Aratchige says, the reward is observing "the
children, after the worms are removed, increasing [school] attendance and
improving memory and learning."
Fortunately,
deworming also gained community support. Dr. Aratchige states that the side
effects of the drugs are, "almost nil, so their [the communities'] experience
taking these drugs has been positive, making it far easier to promote the
program." Dr. Aratchige further notes, "The parents [of the school children]
are very happy and come to the school and ask for deworming for the children."
Dr.
Aratchige states that early on the program was challenged by the short-term
commitment of drug donors and the less predictable quality of the drugs. In
2008, Children Without Worms (CWW) began
supporting the Lao PDR deworming program by giving a long-term commitment to donating its high-quality mebendazole. According to
Dr. Aratchige, because of this commitment from CWW, the program can now devote energy to developing a long-term,
self-sustaining strategy for deworming.
Dr. Aratchige says that the program faces
additional challenges, including a lack of financial and human resources to set
up the drug distribution infrastructure, monitor the program effectiveness,
and break the infection cycle with improved sanitation. In spite of these
challenges, he sees the program as highly successful and notes the importance
of continuing to work toward its sustainability.
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| Highlighting Program Effectiveness With Treatment Coverage Metrics |
 Treatment coverage, the
percentage of individuals in a defined population that ingested a specific
administered drug or drug combination, is a critical measurement that disease control programs like Children Without Worms (CWW) can
make to demonstrate program effectiveness. As a program with numerous
stakeholders, including program sponsors, country governments, partners and
volunteers, as well as the people in its target communities, CWW understands the
importance of capturing and reporting this metric.
The Importance of Monitoring Treatment Coverage
Monitoring drug treatment coverage provides numerous benefits to a disease control or Preventive Chemotherapy (PCT) program, providing information that:
- Enables informed decision- and policy-making.
- Reveals problems, like drug distribution issues, so that corrective action can be taken
- Provides evidence to program funders, drug donors, and country governments to justify maintaining the program.
- Increases program compliance by target communities when community members know that many people are being treated.
- Improves morale of program partners and volunteers when they see the positive impact of their efforts.
- Strengthens advocacy for the program because stakeholders know that in-need populations are getting treated.
- Assists in forecasting future drug supply needs.
The CWW Approach to Monitoring Treatment Coverage
CWW tapped into the expertise of the neglected tropical
disease (NTD) groups at both RTI and the World health Organization (WHO) to develop
a well-constructed approach to and guidelines for monitoring treatment
coverage. In this approach, CWW defines treatment coverage as:
Establishing a clear
denominator in the equation--all school-age children (5 to 14 years old) living
in a targeted district--was critical, as this can be easily taken from national
census data and is clearly understood by all program stakeholders. And because
CWW defines the implementation unit as a district, coverage rates can be easily compared across districts. Also,
if a national deworming campaign uses more than one type of benzimidazole or different sources of the same type of benzimidazole, CWW requests
programs use only mebendazole donated by Johnson & Johnson to treat school
age children in targeted districts. This approach ensures that only those who
have ingested mebendazole from Johnson & Johnson are included in the tally
for the numerator and the program can more accurately monitor for adverse
effects and drug efficacy because the drug quality is consistent in a defined
area.
To verify
the accuracy of collected data, CWW is field-testing a survey protocol in
Cambodia and Cameroon. The survey, developed with assistance from the Centers for Disease Control and Prevention (CDC), verifies the reported coverage rate
and also helps determine how accessible mebendazole is to school-age children
not enrolled in school in areas where school attendance is low. The survey tool
additionally assesses knowledge, attitudes, and practices around STH infection
and helps determine the prevalence, accessibility and use of sanitary latrines
and potable water at schools.
Further Guidance on Monitoring Treatment Coverage
CWW's approach and
guidelines for monitoring treatment coverage are complementary to those
published in Monitoring Drug Coverage for Preventive Chemotherapy, a guide developed by the WHO's Department of NTDs that was released in
July of this year. The guide provides best practices and information around
monitoring treatment coverage for PCT programs to control NTDs and is a
recommended source other PCT programs can turn to when they need to monitor treatment
coverage.
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If you are interested in learning more, please visit the Children Without Worms web site or fill out the contact form on our site.
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