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May 2010 Issue        
In This Issue
A Plan for Long-term Reductions in STH Infection Prevalence
Zerca y Lejos Improves Health in Cameroon with WASHED
Progress Implementing the WASHED Framework in the Lobéké Region of Cameroon
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Kim Koporc CCW Acting Director One of the things I find most exciting and encouraging about my work is the opportunity to collaborate with others. All around the world non-governmental organizations (NGOs), Ministries, private organizations, and others contribute to reducing the impacts of infection by soil-transmitted helminths (STH) through deworming or providing access to potable water and safe and sanitary latrines.
In this newsletter, we focus on the concept of WASHED, a framework Children Without Worms (CWW) developed that takes a more comprehensive approach to reducing STH infection by breaking the cycle of re-infection. You'll learn about the WASHED framework and how this approach so effectively breaks the cycle of STH infection.
We also highlight the WASHED efforts of two NGOs working in Cameroon, one of the first countries to receive mebendazole donated from Johnson & Johnson. First, you'll read about Maria Rebollo, a self-starter who founded the NGO Zerca y Lejos to improve the health of Cameroon's Bulu and Baka communities by delivering essential health services and helping them incorporate WASHED components in their communities. In addition, you will read about the Public-Health-Environment (PHE) Program of the World Wildlife Fund (WWF), which recently added WASHED activities to their traditional wildlife and habitat conservation efforts in the richly biodiverse Jengi region of Cameroon.
The work of WWF is supported by a grant from Johnson & Johnson. Although Zerca y Lejos does not receive financial support from either CWW or Johnson & Johnson, we've featured their work in this newsletter because I am just as excited to tell their story as I am in telling the story of WWF. The work of these organizations inspires me, and I hope their stories will inspire others working to link treatment with prevention for comprehensive STH control. We will continue to feature similar stories in future newsletters.
As always, thank you for your interest in our work, and that of others, to help children around the world live healthier lives free of infection from STH.

Warmest regards,

Kim Koporc
Acting Director
Children Without Worms

 A Plan for Long-term Reductions in STH Infection Prevalence
Potable drinking water in BangledeshChildren Without Worms (CWW) has successfully reduced soil-transmitted helminth (STH) infection prevalence through its preventive chemotherapy program that administers mebendazole donated by Johnson & Johnson to school-age children. But administering medication without changing the environment and modifying behaviors cannot lead to long-term, sustainable reduction in STH prevalence.
CWW developed and advocates for the WASHED framework, which consists of four components--potable water, sanitation, hygiene education and deworming--to achieve sustainable control of neglected tropical diseases (NTDs) by reducing infection and preventing re-infection. This four-part approach echoes a 2003 article in Trends in Parasitology, which states, "approaches that use drug intervention to induce changes in transmission, coupled with improvements in water and sanitation and health education to ensure proper use of these changes, can bring about dramatic reductions in [disease]."[1]
Many who work in STH control understand the need for a more comprehensive approach, but several factors prevent that approach's implementation. Advocacy efforts tend to target only the deworming component of the framework. Government ministries, non-governmental organizations, development agencies and bilateral organizations work independently of each other, which hampers collaboration and coordinated efforts to meet a common goal. And from a practical standpoint, it's easier to count the number of pills administered than to quantify the impact of health education campaigns and latrines.
Studies of the impact of access to potable water, sanitary latrines, and hygiene education on STH infection are limited, but those that are available demonstrate the effectiveness of these three prevention components in reducing infection rates. For example, a set of studies showed that efforts to improve access to water and sanitation facilities alone reduced Ascaris infection rates with a median of 28 percent [2] in one study, and reduced Ascaris and Trichuris infection rates by 30 percent and 50 percent, respectively, in a separate study.[3] Four additional studies indicated that pairing education about hygiene with deworming reduced STH infection rates from 40 percent to 95 percent.[4,5,6] In contrast, with deworming treatment alone, the prevalence reduction rates were only 35 percent to 38 percent.[7] Clearly, an approach that combines all WASHED components could significantly reduce infection rates in a target community compared to applying just one or even two of the components.
School health programs that integrate distribution of mebendazole with hygiene education and access to water and sanitation facilities can provide a foundation for implementing the WASHED framework. However, success requires the collaborative efforts between NGOs implementing programs and Ministries of Health, Education, and Water and Sanitation. CWW is working with recipient countries and local NGOs to link all four components of the WASHED framework.

[1] Horton, J, 2003. Global anthelminthic chemotherapy programs: learning from history. Trends in Parasitology. Vol 19, No 9; 405-409.
[2] Esrey SA, Potash JB, Roberts L, Shiff C, 1991. Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma. Bull World Health Organ 69: 609-21.
[3] Henry FJ, 1981. Environmental sanitation infection and nutritional status of infants in rural St. Lucia, West Indies. Trans R Soc Trop Med Hyg 75: 507-513.
[4] Mascie-Taylor CG, Karim R, Karim E, Akhtar S, Ahmed T, Montanari RM, 2003. The cost-effectiveness of health education in improving knowledge and awareness about intestinal parasites in rural Bangladesh. Econ Hum Biol 1: 321-30.
[5] Gungoren B, Latipov R, Regallet G, Musabaev E, 2007. Effect of hygiene promotion on the risk of reinfection rate of intestinal parasites in children in rural Uzbekistan. Trans R Soc Trop Med Hyg 101: 564-9.
[6] Lin, Li-Ping Chen, Sen-Hai Yu, Jones Jack, 2000. Creating health-promoting schools in rural China: a project started from deworming. Health Promot Int 15: 193-206.
[7] Ritter, M, 2010. Literature Review: Making the Link Between WASHED and STH. Unpublished paper.

 Zerca y Lejos Improves Health in Cameroon with WASHED
Maria Rebollo of Zerca y LejosAs a young child, Maria Rebollo learned about "all the suffering [of Africa] on TV" and "dreamed to go there and do something to help." Years later, as a medical student at the Autonome University in Madrid, Spain, she began fulfilling that dream. She formed Zerca y Lejos (in English, "Near and Far"), a non-governmental organization (NGO) based in Cameroon that addresses health issues of the impoverished. That was 2001, and Maria was only 21 years old.
Now almost 31, Maria serves as President of the NGO, which currently provides a wide range of health programs in Cameroon to the Bulu and Baka communities, two populations that suffer from health issues associated with poverty. Maria also consults with organizations such as the Pan American Health Organization (PAHO), the Inter-American Development Bank (IDB), and the World Health Organization (WHO) to help developing countries create public health programs.
With a limited permanent staff of twenty Cameroonians and volunteers, Zerca y Lejos carries out a broad range of work through its four programs: health, education, infrastructure and basic dwelling, and socio-economic development. The NGO addresses numerous public health issues such as intestinal worm infections and malaria. They provide immunizations and primary health care, perform surgery, and train health workers and partners to improve existing or deliver new health services. Zerca y Lejos has trained hundreds of "health agents" who now promote health in local communities. In addition, the NGO improves access to potable water and sanitation, helping build wells, latrines, drinking fountains, and rainwater catchment tanks.
Over the years, Maria had determined that, "based on the cycle of infection, a more comprehensive approach was needed" to sustainably reduce soil-transmitted helminth (STH) infection. While consulting in Haiti, she had written about this approach in a blog post. Upon invitation from Children Without Worms (CWW), Maria attended the February CWW Technical Assistance Workshop in Kampala, Uganda, and described how Zerca y Lejos applies the WASHED framework through Cameroon's Healthy Schools initiative to break the cycle of STH infection.
Maria believes that "WASHED is the perfect framework to fight against intestinal parasites. Deworming is important to control morbidity and reduce the burden of parasites that perpetuate transmission. But to interrupt transmission you have to... ...attack the real causes of the problem." She also notes that by giving people access to clean water, improved sanitation, and hygiene education, communities can "offer the next generations a community free of worms."
Prior to the mebendazole donations through CWW, the NGO found it difficult to sustain deworming projects because of lack of regular deworming, low coverage, and uncoordinated efforts. Because CWW advocates for the WASHED framework, Cameroon's Ministries of Health, Education, and Infrastructure now demonstrate improved coordination with each other and with Zerca y Lejos to implement the framework, resulting in Cameroon's "sustained national deworming strategy." She notes that Zerca y Lejos's Healthy Schools strategy directly applies the WASHED framework, providing schools with an improved latrine, clean water access, and hand washing stations, and training school teachers to educate on good hygiene. They coordinate these activities with the deworming program conducted by Cameroon's national program against intestinal worms. To ensure they target their efforts effectively, before and two years after implementing the program, the NGO conducts parasitological surveys as well as knowledge, attitude and practice (KAP) surveys.
Maria believes that the work of Zerca y Lejos has been successful; the organization's work continues to grow, with plans to expand into five new communities. Each year, the NGO brings 200 volunteers to the country to work hand-in-hand with the Cameroonians to improve living conditions. To date, thousands of people's living conditions have been improved through the NGO's programs.
For Maria, this success stems from empowering communities. She says, "We didn't come from Europe with projects in mind." Instead, Zerca y Lejos gained support by "living in the community, understanding how they feel, and trying to do the things the community says they want." The NGO also ensures community projects can be sustained by the community by using mostly local materials and depending on community volunteers.
Maria thinks that the WASHED framework must be a top priority for government and development agencies to ensure we leave a legacy that we can be proud of. Maria also believes that "we all have the possibility to make a difference in people's living conditions," and that "children's rights must be a priority for society." For Maria, these beliefs represent a way of life.

Progress Implementing the WASHED Framework in the Lobéké Region of Cameroon
Sanitary Latrine Jengi Region, CameroonChildren Without Worms (CWW) advocates for a comprehensive approach to soil-transmitted helminths (STH) control by promoting the WASHED framework, which includes potable water, sanitation, hygiene education, and deworming. In the Lobéké area of Cameroon, CWW is collaborating with the Population-Health-Environment (PHE) Program of the World Wildlife Fund (WWF), a program that applies all four components of the WASHED framework to reduce the cycle of STH re-infection.
The Southeast area of Cameroon, home to the Baka hunter-gatherer communities and Bantu people, boasts incredible biodiversity, including lowland gorillas and the forest elephant. Logging, poaching, and slash and burn fires in the late 1980s and early 1990s threatened to upset the balance between people and the natural environment. In 1995, WWF launched the Jengi project, working with the Cameroon Ministry of Environment and Forest to establish the Lobéké, Boumba-Bek, and Nki National Parks to conserve this rich land and the natural resources the local populations relied upon for their livelihoods.
The Jengi project, one of WWF's model projects, promotes sustainable management of the region's forest and wildlife in an approach that includes partnerships with local communities and the private sector. The project began by inventorying the diverse flora and fauna and studying the region's socio-economic aspects. According to Louis Defo, Collaborative Management Advisor of WWF's work in Southeast Cameroon, the project "supported the Cameroonian government in managing the national parks, battling against poaching, creating community hunting zones and forests, and monitoring biological and socio-economic activity."
Louis notes that WWF extended Jengi project objectives through its PHE Program, which tackles "health issues such as AIDS, STDs, malaria, neonatal tetanus, zoonosis, and water-borne illnesses." He states, "The program also promotes family planning, vaccinations against infant diseases, good hygiene and overall health." Adding the PHE program and engaging the local populations to participate in its health-related activities also establishes goodwill among the local population for the WWF's conservation and natural resource management program. 
In particular, the PHE program provides education to promote hygiene, access to potable water and improved sanitary latrines, and assistance to local Ministry of Health workers in deworming school-age children with mebendazole donated by Johnson & Johnson-all components of the WASHED framework. By promoting all WASHED components, the project will break the cycle of re-infection by reducing exposure to the parasites' eggs.
According to Louis, "More than 90 percent of the households in the project area do not have latrines; instead, they go to the toilet in nature." As a result, the project team placed latrine construction as the highest priority activity. From 2008 to 2009, WWF collaborated with a Catholic hospital to help 130 households build latrines. Then in 2009, with the support of CWW and Johnson & Johnson, WWF began building latrines at primary schools that were selected according to need, number of students, commitment from school authorities, and location.
Louis also points out that in the project area "the water sources for the households were dirty, and a good part of the population did not respect basic hygiene principles." He believes these factors contribute greatly to the high prevalence of STH infections, which are evident from the "registered visits to doctors and high levels of school absenteeism."
To combat the hygiene and sanitation issues, WWF staff members held meetings in villages around Lobéké National Park to increase hygiene and sanitation awareness. They designed and printed 500 posters to distribute in schools that promote good hygiene and sanitation practices. In addition, they trained numerous primary school teachers to educate the community on conservation, waterborne diseases, diseases of poor hygiene, water treatment methods, and good hygiene and sanitation practices.
To help improve access to potable water, the program worked with a divisional delegate for the Ministry of Energy and Water to select 10 villages for improving water sources. A rural water systems specialist will oversee the work of these water source improvement projects.
The team also monitored distribution of deworming medication to both preschool- and school-aged children at all 28 Lobéké area schools, as well as vitamin A to children aged 1 to 5 years at a nursery school. In addition, they collected data on health indicators in 11 villages, which, Louis notes, "the WWF will use to establish a baseline for the PHE monitoring system so that the team can monitor the project impact."
The PHE project team plans to continue its current WASHED efforts. Louis finds the project especially rewarding because of the continued "requests coming from the villages and schools" for the improvement projects, and the "enthusiasm the village chiefs have for them." He observes that as the local people understand how their environment impacts their health, they become more committed to sustaining the project's activities. With commitment and support from the very people impacted by the projects, CWW and WWF anticipate significantly reducing STH infection rates and other water-borne illnesses in the Lobéké area and improving the health and quality of life for the region's people.

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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