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.
Children Without Worms
| A Plan for Long-term Reductions in STH Infection Prevalence
|Children 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]."
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  in one study,
and reduced Ascaris and Trichuris infection rates by 30 percent and 50 percent,
respectively, in a separate study.
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. 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.
J, 2003. Global anthelminthic chemotherapy programs: learning from history.
Trends in Parasitology. Vol 19, No 9; 405-409.
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.
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.
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.
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.
 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.
 Ritter, M, 2010. Literature Review: Making the Link Between WASHED and STH. Unpublished paper.
| Zerca y Lejos Improves Health in Cameroon with WASHED
|As 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
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
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
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
Region of Cameroon|
|Children 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.