PREVENTION AND CONTROL

OF SOIL-TRANSMITTED HELMINTHIASIS
WITH FOCUS ON DEWORMING

i
 Deworming Module Project Team
Vicente Y. Belizario, Jr.
Paul Lester C. Chua
Chiqui M. de Veyra
Taggart G. Siao
Jemar Anne V. Sigua

Deworming Module Contributors

Leda M. Hernandez
Winston A. Palasi
Evelyn B. Perez
Ella G. Naliponguit
Stephanie M. Lao
Erwin G. Benedicto
Rhodesia G. Makahilig

Acknowledgements

Department of Education
University of the Philippines Manila - Neglected Tropical Diseases Study Group
World Health Organization
Johnson & Johnson (Philippines), Inc.

Cover photo
School-age children in Western Visayas
after school-based, teacher-assisted
mass drug administration
(UP Manila - NTD Study Group)

ii
 TABLE OF CONTENTS

Glossary ............................................................................................................................ iv
List of abbreviations .......................................................................................................... vi
List of boxes ...................................................................................................................... vii
List of figures .................................................................................................................. viii
List of tables ....................................................................................................................... ix
List of annexes ................................................................................................................... x
Introduction ........................................................................................................................ 1
Neglected tropical diseases and soil-transmitted helminthiasis .................................... 2
Pathology and clinical manifestations ............................................................................. 5
Diagnosis ............................................................................................................................ 6
Treatment ........................................................................................................................... 8
Control and prevention ...................................................................................................... 9
Preventive chemotherapy .............................................................................................. 9
Preventive chemotherapy for soil-transmitted helminthiasis ....................................... 10
Adolescent females, women of child-bearing age, and pregnant women ................... 13
Ancillary benefits and advantages of preventive chemotherapy ................................. 14
Drug resistance in human helminthiasis ..................................................................... 14
Safety and adverse events ......................................................................................... 14
Safety of drug combinations for treatment of helminth infections ................................ 15
Progress of preventive chemotherapy for soil-transmitted helminthiasis .................... 15
Water, sanitation, and hygiene .................................................................................... 16
Health promotion and education ................................................................................. 18
Innovation through integration of deworming with
other health, education, and social development programs .................................... 21
References ........................................................................................................................ 26
Frequently asked questions ............................................................................................. 29

iii
 GLOSSARY

Adverse drug Any noxious, unintended, and undesired effect of a drug which
reaction (ADR) occurs at doses used in humans for prophylaxis, diagnosis, or
therapy.

Adverse event Any untoward medical occurrence that may present during
(AE) treatment with a medicine, but that does not necessarily have a
causal relationship with this treatment.

Anthelminthic A medicine used to expel helminths (worms) in humans. The action

of the medicine kills the worms and facilitates their expulsion from
the human body. The anthelminthics most commonly used to treat
intestinal worm infections in children are the benzimidazoles
(albendazole and mebendazole).

Contraindication Specific situation in which a drug cannot be used because it may be

harmful to the person.

Cumulative The percentage of individuals in a population infected with at least

prevalence (CP) one species of STH.
of soil-transmitted
helminth (STH)
infections

Disability-adjusted The number of years of healthy life lost attributable to a disease (or
life years (DALYs) group of diseases). DALYs are used as a measure of disease
burden and provide a comparative indication of the public health
importance of the disease.

Disease burden The cumulative mortality, morbidity, and disability attributable to a

disease.

Eggs per gram The number of parasite eggs per gram of feces, which provides an
(epg) indirect measure of the intensity of helminth infection.

Endemic area Area in which a disease is intensively transmitted.

Helminthiasis A general term for any form of disease attributable to a helminth

infection.

Helminths A group of parasites commonly referred to as worms. The group

includes the nematodes (roundworms), cestodes (tapeworms), and
trematodes (flukes).

High-risk Community where the CP of STH infections among school-age

community children (SAC) is ≥50%.

Intensity The number of helminths infecting an individual. In the case of STH,

of infection it can be measured directly, by counting expelled worms after
anthelminthic treatment, or indirectly, by counting helminth eggs
excreted in feces (expressed as epg).

Low-risk Community where the CP of STH infections among SAC is ≥20%

community and <50%.

iv
Mass drug The entire population of an area (e.g. state, region, province, district,
administration subdistrict, village) is given anthelminthic drugs at regular intervals,
(MDA) irrespective of the individual infection status.

Morbidity The clinical consequences of infections and diseases that adversely

affect human health.

Morbidity control Limiting the morbidities associated with helminthiasis through

preventive chemotherapy.

Neglected tropical Group of infectious diseases that are considered not to have
diseases (NTDs) received sufficient attention from the donor community and public
health planners.

Open defecation Practice wherein people go out in fields, bushes, forests, open
bodies of water, or other open spaces rather than using the toilet to
defecate.

Preschool-age Children between 12 and 59 months of age.

children (PSAC)

Preventive The use of anthelminthic drugs, either alone or in combination, as a

chemotherapy public health tool against helminth infections. Preventive
chemotherapy can be applied with different modalities: MDA,
targeted chemotherapy, selective chemotherapy.

Sanitation Means of promoting health through prevention of contact with the

hazards of human waste including facilities for the safe disposal of
human excreta.

School-age Children between 5 and 14 years of age.

children (SAC)

Selective After a regular screening exercise in a population group living in an

chemotherapy endemic area, all individuals found (or suspected) to be infected are
given anthelminthic drugs.

Sensitivity Ability of a test to correctly identify affected individuals.

Soil-transmitted Intestinal infections in humans caused by nematodes or

helminth (STH) roundworms. Four species of more common nematodes are
infections collectively referred to as STH: Ascaris lumbricoides (giant
roundworm), Trichuris trichiura (whipworm), and Necator americanus
and Ancylostoma duodenale (hookworms).

Specificity Ability of a test to correctly identify non-affected individuals.

Targeted Specific risk groups in the population, defined by age, sex, or other
chemotherapy social characteristic such as occupation (e.g. SAC, fishermen) are
given anthelminthic drugs at regular intervals, irrespective of the
individual infection status.

Women of Women between 15 and 49 years of age.

childbearing age
(WCBA)

v
 LIST OF ABBREVIATIONS

4Ps Pantawid Pamilyang Pilipino LF Lymphatic filariasis

Program LGU Local government units
ADR Adverse drug reaction MBD Mebendazole
AE Adverse event MDA Mass drug administration
ALB Albendazole MDG Millennium Development Goals
CCT Conditional Cash Transfer MHI Moderate-heavy intensity
CP Cumulative prevalence NSDD National School Deworming Day
DALY Disability-adjusted life years NSDM National School Deworming Month
DEC Diethylcarbamazine NSSP National Sustainable Sanitation
DepEd Department of Education Program
DFS Direct fecal smear NTD Neglected tropical diseases
DOH Department of Health PCR Polymerase chain reaction
DSWD Department of Social Welfare PSAC Preschool-age children
and Development PYR Pyrantel pamoate
EPG Eggs per gram PZQ Praziquantel
FECT Formalin-ether concentration SAC School-age children
technique SCH Schistosomiasis
GP Garantisadong Pambata STH Soil-transmitted helminth
HSCMDA Harmonized Schedule and UNICEF United Nations Children's Fund
Combined Mass Drug Administration UP University of the Philippines
IEC Information, education, WASH Water, sanitation, and hygiene
communication WCBA Women of childbearing age
IHCP Integrated Helminth Control Program WHO World Health Organization
IVM Ivermectin WinS WASH in Schools
LEV Levamisole WOW War on Worms

vi
 LIST OF BOXES

Box 1. The neglected tropical diseases.

Box 2. Good practices for accurate results using the Kato-Katz technique.

Box 3. Highlights of new diagnostic tools for soil-transmitted helminth infections.

Box 4. Preventive chemotherapy is directed against four common forms of

helminthiasis.

Box 5. The recommended dosages of selected benzimidazoles apply to large-scale

treatment programs without diagnosis.

Box 6. Integrating water, sanitation, and hygiene, and deworming through inter-
sectoral collaboration.

Box 7. Poor knowledge, attitudes, and practices related to deworming.

Box 8. What are examples of effective health education?

Box 9. Garantisadong Pambata Program.

Box 10. War on Worms Campaign: A model for effective helminthiasis control.

Box 11. Fit for School: Improving health for better education and child development.

Box 12. The Department of Social Welfare and Development Pantawid Pamilyang
Pilipino Program (4Ps): deworming as conditionality for conditional cash
transfer.

Box 13. Nutrition and deworming: First 1000 Days.

vii
 LIST OF FIGURES

Figure 1. Life cycle of Ascaris lumbricoides and life cycle of Trichuris trichiura.

Figure 2. Life cycle of hookworm.

Figure 3. School-age children from Guimaras Island in 2012.

Figure 4. Preschool-age child from Masbate in 2015.

Figure 5. Heavy intensity Ascaris lumbricoides and Trichuris trichiura co-infection,

heavy intensity A. lumbricoides infection, and hookworm ova.

Figure 6. Albendazole and mebendazole tablets.

Figure 7. Preventive chemotherapy in human helminthiasis.

Figure 8. Launch of the War on Worms Campaign in Pandan, Antique in 2007.

Figure 9. Development of lesson exemplars for helminthiasis control and mass drug
administration which was initiated by Department of Education and supported
by Department of Health in 2016.

Figure 10. School-age children in Calatrava, Negros Occidental after deworming in

2012.

Figure 11. Mass drug administration coverage rates for soil-transmitted helminth
infections in preschool-age children and school-age children from 2011 to
2015.

Figure 12. Water coverage of the Philippines from 1990 to 2015.

Figure 13. Sanitation coverage of the Philippines from 1990 to 2015.

Figure 14. Prevalence and intensity of, and mass drug administration coverage rates
for, soil-transmitted helminth infections among school-age children in
selected sites in Capiz from 2007 to 2015.

Figure 15. Health promotion and education prior to school-based mass deworming in
Biñan, Laguna in 1999.

Figure 16. Video cover and poster for the National School Deworming Month.

viii
 LIST OF TABLES

Table 1. Prevalence and intensity of soil-transmitted helminth infections among

populations at-risk in the Philippines.

Table 2. Three classes of intensity (light, moderate, and heavy) of infection are defined
for each soil-transmitted helminth.

Table 3. Sensitivity estimates for selected diagnostic methods by helminth species.

Table 4. World Health Organization-recommended anthelminthic drugs for use in

preventive chemotherapy.

Table 5. Recommended strategy for soil-transmitted helminth infections in preventive

chemotherapy.

Table 6. Management of adverse events.

ix
 LIST OF ANNEXES

Annex 1. Zentel® (albendazole) product information.

Annex 2. Vermox/Antiox® (mebendazole) product information.

Annex 3. Integrated Helminth Control Program: Adverse events following

deworming/severe adverse events reporting form.

Annex 4. Flow of severe adverse event reporting and investigation.

Annex 5. Proper handwashing technique.

x
Introduction

Soil-transmitted helminth (STH) infections, caused by common roundworms, whipworms, and

hookworms, remain as a public health concern in developing countries like the Philippines.
Considered among the neglected tropical diseases (NTDs) or infectious diseases of poverty,
STH infections are related to poor nutritional status and school performance in children, as
well as other states of poor health in at-risk groups that include preschool-age children
(PSAC), school-age children (SAC), and women of childbearing age (WCBA). NTDs are
specifically mentioned as part of the targets of the Sustainable Development Goal 3 of the
United Nations.

To control and prevent STH infections, the World Health Organization (WHO) promotes a
package of interventions that include preventive chemotherapy (targeted mass deworming)
for morbidity control, improvement of water, sanitation, and hygiene (WASH), and health
promotion. To address the high burden of these infections in the Philippines, the Department
of Health (DOH) launched the Integrated Helminth Control Program (IHCP) in 2006 with
strategies consistent with the directions of the global control program. WHO targets STH
elimination as a public health problem by 2020.

A little more than 10 years following the launch of the DOH-IHCP and closer to year 2020,
STH infection rates are markedly lower than baseline figures; however, there remain major
concerns related to WASH that result in high reinfection rates in poverty-stricken areas.
Preventive chemotherapy remains to be optimized to effectively control morbidity especially
in at-risk populations.

This Deworming Module is an evidence-based learning resource that provides valuable

information on STH infections, the parasites and their life cycles, epidemiology, pathology and
clinical manifestations, diagnosis, treatment, prevention, and control. The section on
treatment covers the drugs of choice, their mechanism of action and pharmacology, adverse
events (AE), as well as their use in preventive chemotherapy. This module also provides
examples of innovation through integration, where deworming efforts have been closely linked
with other health, education, and social development programs.

This module provides a guide on the use of deworming drugs for trainors, health workers, and
implementation partners like teachers and possibly child development workers. The intent of
this module is to promote acceptability of deworming on a large scale to result in high mass
deworming coverage rates that would make effective morbidity control possible and attainable.

1
Neglected tropical diseases and soil-transmitted helminthiasis

NTDs are infectious diseases of poverty caused by a diverse group of pathogens, including
viruses, bacteria, and parasites. These diseases prevail in tropical and subtropical areas.
More than a billion people in 149 countries worldwide are affected by NTDs, especially those
who have little access to clean water and sanitation facilities. NTDs, which account for at least
26 million disability-adjusted life years (DALYs) (1), cause chronic disabilities and deformities
that lead to poor growth and development in children and decreased productivity in adults.

Box 1. The neglected tropical diseases. NTDs are viral, bacterial, or parasitic diseases
of poverty. Eleven of these NTDs are caused by parasites. At least eight of which are
known to be endemic in the Philippines.

Disease Causative agent_________

Buruli ulcer Bacteria
Chagas disease Parasite (protozoa)
Dengue and chikungunya* Virus
Dracunculiasis (guinea-worm disease) Parasite (helminth)
Echinococcosis Parasite (helminth)
Foodborne trematodiases* Parasite (helminth)
Human African trypanosomiasis (sleeping sickness) Parasite (protozoa)
Leishmaniasis Parasite (protozoa)
Leprosy (Hansen’s disease)* Bacteria
Lymphatic filariasis* Parasite (helminth)
Onchocerciasis (river blindness) Parasite (helminth)
Rabies* Virus
Schistosomiasis* Parasite (helminth)
Soil-transmitted helminthiasis* Parasite (helminth)
Taeniasis/cysticercosis* Parasite (helminth)
Trachoma Bacteria
Yaws Bacteria
* Endemic in the Philippines

Eleven of the 17 NTDs are caused by protozoan and helminthic parasites that may cause
considerable morbidities in infected individuals. Among these are STH infections, which
remain a major public health concern in the Philippines. These helminth infections are caused
by giant roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), and hookworms
(Necator americanus and Ancylostoma duodenale), which inhabit the intestines and produce
thousands of eggs passed out in feces each day. Roundworm and whipworm eggs develop
further in soil and become infective. These can be ingested through dirty hands or
contaminated food. Hookworm eggs develop further in soil into infective larvae that gain entry
into the human body through skin penetration. The transmission of STH occurs in areas where
open defecation persists.

2
Figure 1. Life cycle of Ascaris lumbricoides (left) and life cycle of Trichuris trichiura
(right) (2, 3). Open defecation plays a crucial role in the transmission of A. lumbricoides and
T. trichiura as eggs that pass out in the feces can contaminate soil and develop into infective
ova.

Figure 2. Life cycle of hookworm (4). Infective hookworm larvae in soil can enter the human
body through skin penetration.

Approximately 1.5 billion people, or 24% of the world’s population, are infected with STH (5).
At-risk populations for these infections include PSAC, SAC, WCBA including pregnant women,
and adults in high-risk occupations such as farmers, miners, or soldiers (6, 7). The highest
burden of helminthiasis is found among children who are in a critical period of growth and
development and are therefore at increased risk of adverse health outcomes caused by STH
(8, 9).

3
Figure 3. School-age children from Guimaras Island in 2012 (UP Manila - NTD Study
Group). The highest burden of intestinal helminthiasis is found among children which may lead
to poor growth and development.

In the Philippines, baseline parasitologic surveys were conducted among PSAC and SAC prior
to the launch of the IHCP of DOH in 2006. A cumulative prevalence of STH infections of
66.4% was found among PSAC in 2004 (10). On the other hand, a cumulative prevalence of
STH infections of 54.0% with a prevalence of heavy intensity infections of 23.1% was found
among SAC in 2006 (11). Follow-up parasitologic surveys conducted in 2009 in PSAC and
SAC revealed prevalence and intensity rates which were significantly lower than baseline (12).

Table 1. Prevalence and intensity of soil-transmitted helminth infections among

populations at-risk in the Philippines (10, 11, 13). Follow-up parasitologic assessments
were conducted in preschool-age children and school-age children in 2009 showing significant
reductions in prevalence and intensity. The Department of Health - Integrated Helminth
Control Program was launched in 2006, and mass drug administration commenced in 2007
(12).
Baseline Follow-up
Cumulative Heavy Cumulative Heavy
At-risk groups
prevalence intensity prevalence intensity
(%) (%) (%) (%)
PSAC (2004) 66.4 1.2 - 13.8 43.7 22.4
SAC (2006) 54.0 23.1 44.7 19.7
WCBA (2011)
Adolescent females 30.4 7.9
Pregnant women 31.5 10.2

4
Pathology and clinical manifestations

Morbidity refers to the detectable and measurable signs and symptoms of a disease. Morbidity
is related to the number of worms harbored by infected individuals. People with light infections
usually have no symptoms. Heavier infections can cause a range of symptoms including
gastrointestinal tract manifestations like abdominal pain and diarrhea, general malaise and
weakness, and impaired cognitive and physical development.

STH infections impair the nutritional status of infected people. The worms feed on host tissues
and blood, which leads to loss of iron and protein. The worms also increase malabsorption of
nutrients. In addition, roundworms may possibly compete for vitamin A in the intestines. Some
STH infections cause loss of appetite, which may result in a reduction of nutritional intake and
physical fitness. In particular, T. trichiura can cause diarrhea and dysentery. Hookworms
cause chronic intestinal blood loss that can result in anemia. The nutritional impairment
resulting from STH infections is recognized to have a significant impact on growth and physical
development.

Evidence indicates that children acquire helminth infections early in life. Early infection in
childhood may cause initial organ damage that may remain subclinical for years and manifest
overtly in adulthood (14-17). Overt morbidities include iron-deficiency anemia, micronutrient
deficiencies, growth retardation, and intestinal obstruction (18).

Figure 4. Preschool-age child from Masbate in 2015 (UP Manila - NTD Study Group). Soil-
transmitted helminth infections impair the nutritional status of children.

Organ pathology specific for each form of helminthiasis may be accompanied by subtle
morbidities that may include impaired cognitive performance, chronic fatigue, and unremitting
pain. These conditions may in turn lead to increased school absenteeism, reduced worker
productivity, lowered self-esteem, and social exclusion (8, 19, 20). There is evidence that
helminthiasis may exacerbate the transmission and/or severity of Human Immunodeficiency
Virus/Acquired Immune Deficiency Syndrome, malaria, and tuberculosis (21-23).

Although the death rate from helminthiasis is low relative to the millions of cases, helminth
infections should not be neglected as they constitute a large burden on human health and
resources (8).

5
Diagnosis

Diagnosis of STH infections is mainly through visualization of parasite ova in stool (24).
Several techniques are useful for demonstrating parasite ova through microscopy. These
include direct fecal smear (DFS), Kato-Katz technique, formalin-ether concentration technique
(FECT), and flotation techniques, such as FLOTAC, mini-FLOTAC, and McMaster egg
counting technique (25). The choice of diagnostic tool is based on the organisms being
recovered and the purpose of diagnosis, whether it is for clinical diagnosis or surveillance (26).

Figure 5. Heavy intensity Ascaris lumbricoides and Trichuris trichiura co-infection

(left), heavy intensity A. lumbricoides infection (center), and hookworm ova (right) (UP
Manila - NTD Study Group). Diagnosis of soil-transmitted helminth infection relies on
visualization of characteristic ova in stool.

In the Philippines, routine stool examination is usually done using DFS. This is the simplest
of the microscopic examination techniques where approximately 2 mg of stool is examined
(24). The DFS is useful for detecting intestinal protozoan infections especially when dealing
with diarrheic stools. Its use in recovery of helminth ova is limited due to the small amount of
stool being examined (27). It is also not recommended for field surveys as it cannot estimate
intensities of infection (26).

For field surveys, WHO recommends the use of the Kato-Katz technique (27) due to its
simplicity and low cost (28, 29). It is a semi-quantitative method that allows the estimation of
the intensity of infection (28, 29), which is measured by the number of eggs per gram of stool.
Intensity of infection is classified as light, moderate, or heavy. Morbidities associated with
STH infections are most commonly associated with infections of heavy intensity (8). The
target for elimination of STH infections as a public health problem is less than 1% prevalence
of moderate-heavy intensity STH (30).

Table 2. Three classes of intensity (light, moderate, and heavy) of infection are defined
for each soil-transmitted helminth (9).
Light intensity Moderate intensity Heavy intensity
Parasite
infections (epg) infections (epg) infections (epg)
Ascaris lumbricoides 1 - 4,999 5,000 - 49,999 ≥ 50,000
Trichuris trichiura 1 - 999 1,000 - 9,999 ≥ 10,000
Hookworms 1 - 1,999 2,000 - 3,999 ≥ 4,000

The Kato-Katz technique has limited sensitivity, particularly in detecting light intensity
infections. The sensitivity of Kato-Katz technique is significantly increased when two slides
from one stool sample (two aliquots) are examined, but the prevalence of STH infections may
still be underestimated especially in areas with low intensities of infection (25). In addition,
hookworm eggs tend to clear one hour after processing, thus, prompt reading of slides is
recommended so that hookworm eggs may still be visualized (24).

6
 Box 2. Good practices for accurate results using the Kato-Katz technique (9, 26).

• Quality control. Internal monitoring of working processes and technical

procedures.
• Proper preparation and maintenance of reagents.
• Stool collection procedures. Standard procedures followed, presence of
accurate labels, adequate amount of stool collected.
• Stool processing procedures. Standard procedures followed, good quality of
reagents and materials used.
• Microscopic examination. High level of parasite recognition among laboratory
staff, slides read promptly especially for areas where hookworms are expected.
• Accurate recording and reporting of results.
• Validation. For surveillance, 10% of slide readings validated by a reference
microscopist.
• Training and capacity building. Adequate and regular training programs for
medical technologists.

FLOTAC is the most sensitive method for diagnosis of STH infections, and its sensitivity in
detecting hookworm eggs is also high at 92.4% (25). FLOTAC is ready for use in field surveys
(31), and it may be a viable alternative to the Kato-Katz technique (32). More sensitive
diagnostic techniques are still being developed (33).

Table 3. Sensitivity estimates for selected diagnostic methods by helminth species (25).
Direct microscopy and 1-slide Kato-Katz have lower sensitivity for soil-transmitted helminth
compared with more recently developed techniques such as FLOTAC and mini-FLOTAC.
Ascaris lumbricoides Trichuris trichiura Hookworm
Number of comparisons 63 67 94
Sensitivity Sensitivity Sensitivity
Method 95% CI 95% CI 95% CI
(%) (%) (%)
1-slide Kato-Katz 63.8 59.1-68.6 82.2 80.1-84.5 59.5 56.9-62.2
2-slide Kato-Katz 64.6 59.7-69.8 84.8 82.5-87.1 63.0 59.8-66.4
2-sample Kato-Katz 69.2 63.2-74.6 89.7 86.3-92.6 74.2 70.6-78.1
3-sample Kato-Katz 70.4 64.9-75.6 90.5 87.6-93.1 74.3 70.8-78.2
Direct microscopy 52.1 46.6-57.7 62.8 56.9-68.9 42.8 38.3-48.4
Formol-ether concentration (FEC) 56.9 51.1-63.5 81.2 73.0-89.2 53.0 48.6-57.5
FLOTAC 79.7 72.8-86.0 91.0 88.8-93.5 92.4 87.6-96.2
Mini-FLOTAC 75.5 54.0-95.9 76.2 33.9-99.4 79.2 72.7-85.9
McMaster 61.1 56.3-65.9 81.8 79.6-84.2 58.9 55.7-62.2
Specificity 99.6 97.5 98.0

Box 3. Highlights of new diagnostic tools for soil-transmitted helminth infections

(31).

Coprological methods rely on detection of parasite ova in stool. New methods such as
the FLOTAC and mini-FLOTAC offer better alternatives to the Kato-Katz technique as
the sensitivity of these tests is greater than that of duplicate Kato-Katz technique. These
methods are ready for field deployment.

Molecular diagnosis relies on detection of parasite DNA, such as through the

polymerase chain reaction technique. These methods are generally more sensitive than
coprological techniques, and have very high species specificity. These need further
development to improve field applicability.

7
Treatment

The WHO recommended medicines for STH infections, albendazole (400 mg) and
mebendazole (500 mg), are safe, effective, inexpensive, and easy to administer by non-
medical personnel (e.g. teachers). These drugs have undergone extensive safety testing and
have been used in millions of people in many countries around the world with generally few
and minor side effects. Both albendazole and mebendazole are donated by major industry
partners (GlaxoSmithKline and Johnson & Johnson) to national ministries of health through
WHO for the treatment of all children of school age. (34)

Figure 6. Albendazole and mebendazole tablets (35, Johnson & Johnson, Inc.).

Albendazole is a benzimidazole derivative that interferes with microtubule assembly and

blocks glucose uptake by many intestinal and tissue nematodes as well as some cestodes. It
is poorly absorbed from the gastrointestinal tract and is extensively and rapidly metabolized
in the liver. The absorbed fraction, which has a half-life of about 8 hours, is largely eliminated
in the urine as sulfoxide. (34)

Albendazole is indicated for treatment of ascariasis, trichuriasis, hookworm infection,

strongyloidiasis, enterobiasis, and capillariasis. In children 12-23 months old, a single dose
of 200 mg is recommended. In adults and children two years old and over, a single dose of
400 mg is sufficient for most cases of ascariasis, hookworm infection, enterobiasis, and
moderate intensity trichuriasis. Strongyloidiasis and heavy intensity trichuriasis require a
three-day course of treatment. (36, 37)

Mebendazole is a benzimidazole derivative that blocks glucose uptake by many intestinal and
tissue nematodes as well as some cestodes. The small amounts absorbed after oral intake
are extensively metabolized in the liver to inactive moieties. Its plasma half-life of usually two
to nine hours is considerably lengthened when hepatic function is impaired. It is excreted in
the feces largely unchanged. (34)

Mebendazole is indicated for treatment of ascariasis, trichuriasis, hookworm infection,

enterobiasis, and capillariasis. All doses are suitable for adults and children over one year
old. For ascariasis, a single dose of 500 mg is effective. For hookworm infection and
trichuriasis, a dose of 100 mg given twice daily for three days or a single dose of 500 mg is
effective. For enterobiasis, a single dose of 100 mg, repeated after two to four weeks, is
effective. (36, 37)

For albendazole and mebendazole, known hypersensitivity and pregnancy in the first trimester
are contraindications. AEs are mostly mild and transient. These include gastrointestinal
discomfort and headache. (34)

There is no evidence that the use of antihistamine (e.g. diphenhydramine) provide added
benefit in deworming.

8
Control and prevention

Preventive chemotherapy

Preventive chemotherapy is the use of anthelminthic drugs, either alone or in combination, as

a public health tool against targeted helminth infections. The aim of preventive chemotherapy
is to avert the widespread morbidity that invariably accompanies helminth infections. Early
and regular administration of the anthelminthic drugs recommended by WHO reduces the
occurrence, extent, severity, and long-term consequences of morbidity. In certain
epidemiological conditions, preventive chemotherapy contributes to sustained reduction in
transmission. (38)

Figure 7. Preventive chemotherapy in human helminthiasis (38). The World Health

Organization manual for health professionals and program managers for coordinated use of
anthelminthic drugs in control interventions.

9
 Box 4. Preventive chemotherapy is directed against four common forms
of helminthiasis. (38)

Lymphatic filariasis* – caused by infection with the nematodes Wuchereria bancrofti,

Brugia malayi, and B. timori

Onchocerciasis – caused by infection with the nematode Onchocerca volvulus

Schistosomiasis* – intestinal schistosomiasis caused by infection with the trematodes

Schistosoma mansoni, S. mekongi, S. japonicum, and S. intercalatum; urinary
schistosomiasis caused by infection with S. haematobium

Soil-transmitted helminthiasis* – caused by infection with the nematodes

Ascaris lumbricoides (giant roundworm), Trichuris trichiura (whipworm), Ancylostoma
duodenale and Necator americanus (hookworms)

* Endemic in the Philippines

In practice, preventive chemotherapy requires the delivery of good-quality drugs to as many

people in need as possible at regular intervals throughout their lives. High priority is given to
achieving high, if not full, coverage of targeted at-risk groups. Rather than identifying every
infected individual, large-scale preventive chemotherapy interventions assess entire
communities for endemicity or ongoing transmission of the target helminthic diseases. The
recommended drug or drug combination is then administered to all eligible members of the
endemic communities. (38)

Table 4. World Health Organization-recommended anthelminthic drugs for use in

preventive chemotherapya,b (38).
Disease ALB MBD DEC IVM PZQ LEVc PYRc
Ascariasis ✓ ✓ - (✓) - ✓ ✓
Hookworm disease ✓ ✓ - - - ✓ ✓
Lymphatic filariasis ✓ - ✓ ✓ - - -
Onchocerciasis - - - ✓ - - -
Schistosomiasis - - - - ✓ - -
Trichuriasis ✓ ✓ - (✓) - (✓) d
(✓)d
a
Prescribing information and contraindications are given in the WHO Model Formulary 2004.
b
In this table, ✓ indicates drugs recommended by WHO for treatment of the relevant disease, and (✓) indicates
drugs that are not recommended for treatment but that have a (suboptimal) effect against the disease.
c
At present, LEV and PYR do not have a prominent role in preventive chemotherapy as described in this manual.
However, they remain useful drugs for the treatment of soil-transmitted helminthiasis, and since – unlike ALB and
MBD – they do not belong to the benzimidazole group, they will be expected to contribute to the management of
drug-resistant STH infections should that problem emerge.
d
LEV and PYR have only a limited effect on trichuriasis but, when used in combination with oxantel, PYR has an
efficacy against trichuriasis comparable to that observed with MBD.

Extensive experience of the use of anthelminthic drugs has shown excellent safety records,
regardless of infection status. Safety is key to large-scale interventions, particularly when
individual laboratory diagnosis may be impossible to implement. (38)

Preventive chemotherapy for soil-transmitted helminthiasis

In STH infections, preventive chemotherapy involves targeted administration of albendazole

or mebendazole. The aim of preventive chemotherapy in STH infections is morbidity control,
where periodic treatment of at-risk populations will reduce the intensity of infection and protect

10
infected individuals from morbidity. The frequency of intervention is determined by the levels
of prevalence and intensity of infection among SAC. (38)

WHO recommends periodic deworming without previous individual diagnosis to all at-risk
people living in endemic areas. Treatment should be given once a year when the baseline
prevalence of STH infections in the community is over 20%, and twice a year when the
prevalence of STH infections in the community is over 50%. This intervention reduces
morbidity by reducing the worm burden. (38)

Eligible populations include PSAC, SAC, WCBA (including pregnant women in their second
and third trimesters, as well as lactating women), and adults at certain high risk occupations
(e.g. farmers, soldiers, etc.). Ineligible populations include children in the first year of life and
pregnant women in the first trimester of pregnancy. (38)

Table 5. Recommended strategy for soil-transmitted helminth infections in preventive

chemotherapya (38).
Prevalence of any
Category Action to be taken
STH among SAC
High-risk ≥50% Treat all SAC Also treat:
community (enrolled and not • PSAC
enrolled twice each • WCBA, including
year)b pregnant women in
the 2nd and 3rd
trimesters and
lactating women
• Adults at certain
high risk
occupations
Low-risk ≥20% and <50% Treat all SAC Also treat:
community (enrolled and not • PSAC
enrolled once each • WCBA, including
year) pregnant women in
the 2nd and 3rd
trimesters and
lactating women
• Adults at certain
high risk
occupations
a
When prevalence of any STH infection is less than 20%, large-scale preventive chemotherapy interventions are
not recommended. Affected individuals should be dealt with on a case-by-case basis.
b
If resources are available, a third drug distribution intervention might be added. In this case the appropriate
frequency of treatment would be every 4 months.

The global target is to eliminate morbidity due to STH infections in children by 2020. This will
be obtained by regularly treating at least 75% of the children in endemic areas. (6)

11
 Box 5. The recommended dosages of selected benzimidazoles apply to large-
scale treatment programs without diagnosis (36-38).

Preschool-age children (ages 12 to 59 months)

Albendazole 200 mg for children ages 12 to 23 months
400 mg for children ages 2 to 5 years
Mebendazole 500 mg for children ages >1 year

School-age children (ages 5 to 14 years) and adults (ages ≥15 years)

Albendazole 400 mg
Mebendazole 500 mg

In the Philippines, preventive chemotherapy is a major strategy in the DOH-IHCP, which was
launched in 2006 in response to the high burden of STH infections (39). Bi-annual mass
deworming is scheduled every January and July for PSAC (as part of Garantisadong
Pambata) and SAC for morbidity control (39, 40). DOH has set a target coverage rate of 85%
(39). For SAC, school-based deworming using albendazole or mebendazole among five to
18 years of age is implemented in collaboration with the Department of Education (DepEd)
(41). Deworming in SAC is also one of the requirements in the Conditional Cash Transfer
Program administered by the Department of Social Welfare and Development (42).

Figure 8. Launch of the War on Worms Campaign in Pandan, Antique in 2007 (Philippine
Star). The leadership of Department of Health and local government units is key to successful
implementation of the DOH-Integrated Helminth Control Program.

In 2016, the DOH-IHCP expanded the coverage of biannual deworming to include children
and adolescents, ages one to 18 years old (39). To synchronize deworming initiatives, the
DOH and DepEd launched the National School Deworming Month (43). The Harmonized
Schedule and Combined Mass Drug Administration launched in the same year prescribed
harmonized schedules for the three NTD programs requiring preventive chemotherapy,
specifically targeting STH infections and schistosomiasis in January and STH infections and
lymphatic filariasis in July. With a harmonized schedule of MDA, the DOH recommends
combined administration of anthelminthic drugs (albendazole or mebendazole + praziquantel
in January; albendazole + diethylcarbamazine in July in LF endemic areas) which has been
shown to be safe and efficient (38, 41, 44).

12
Figure 9. Development of lesson exemplars for helminthiasis control and mass drug
administration which was initiated by Department of Education and supported by
Department of Health in 2016 (UP Manila - NTD Study Group). The leadership of DepEd is
essential in implementation of STH control efforts in the school setting.

Adolescent females, women of childbearing age, and pregnant women

Despite excellent empirical safety profiles, none of the anthelminthic drugs used in preventive
chemotherapy is licensed for use in the first trimester of pregnancy. While women have the
right to refuse or delay treatment if they are unsure about pregnancy, the control program must
ensure that treatment is subsequently available to women who choose to exercise this right.
(45)

In areas where STH infections and schistosomiasis are endemic, risk-benefit analyses have
revealed that the health advantages of treating WCBA and pregnant women far outweigh the
risks to their health and to the health of their babies (45). Several studies have failed to find
a statistically significant difference in the occurrence of congenital abnormalities in babies born
to women treated with single dose albendazole or mebendazole during pregnancy and those
born to untreated women (46-50).

The benefits of treating pregnant women include reduced maternal anemia (49, 50) and
improved infant birth weight and survival (51). The proven benefits of antenatal deworming in
the absence of any evidence indicative of drug teratogenicity or embryotoxicity in humans
provide compelling evidence to support the treatment of women with albendazole or
mebendazole for STH infections after the first trimester of pregnancy (46-53).

The exclusion of drug combinations involving diethylcarbamazine in relation to pregnancy is a

necessary precaution in the absence of definitive safety information. In preventive
chemotherapy interventions against lymphatic filariasis, current guidelines indicate that
pregnant women are ineligible for treatment with the drug combination diethylcarbamazine +
albendazole. (54, 55)

For STH infections, albendazole or mebendazole may be offered to pregnant women in the
second and third trimesters of pregnancy. The same may be offered to lactating women as
part of preventive chemotherapy in areas where the prevalence of any STH infection exceeds
20%. Every effort must be made to avoid excluding from treatment eligible adolescents and
WCBA. For identification of women who are pregnant and for definition of the stage of
pregnancy, the date of a woman’s last menstrual period has been proven to be reliable (38,
54, 55).

13
Ancillary benefits and advantages of preventive chemotherapy

Preventive chemotherapy targeting lymphatic filariasis, schistosomiasis, and STH infections

not only reduces the morbidity caused by these diseases but also yields a number of ancillary
benefits and advantages. Epidemiological evidence strongly suggests that the establishment
of HIV infection and acceleration to AIDS will be reduced when schistosomiasis and STH
infections are treated (22, 23, 56). Treatment of STH infections will help lessen the burden of
malaria (21, 57), and may help lessen the burden of tuberculosis (22). Community compliance
within other health-care programs and school attendance can improve (58-60).

Drug resistance in human helminthiasis

While there is still little or no evidence of the emergence of drug resistance in human
helminthiasis, the problem is entrenched in helminths that infect livestock. Drug resistance
should be suspected if high-coverage, high-frequency anthelminthic treatment is found to have
less than the expected effect on the targeted helminths. Hookworms are known to be at higher
risk than other helminths for developing drug resistance. Long-term preventive chemotherapy
must be accompanied by collection of baseline data on drug efficacy at the beginning of the
intervention, followed by regular monitoring. (61, 62)

Safety and adverse events

Millions of doses of anthelminthics have been used since registration of these drugs for human
treatment was approved. Each drug has an excellent safety record. AEs are mostly mild and
transient, and serious AEs are extremely infrequent. (63)

Figure 10. School-age children in Calatrava, Negros Occidental after deworming in 2012
(UP Manila - NTD Study Group). Anthelminthics are safe, and adverse events are usually mild
and transient.

In preventive chemotherapy in the community setting, both infected and uninfected people are
treated. Temporary minor reactions following treatment occur mainly in infected people and
usually result from the body’s response to the dying worms. Heavily infected people are more

14
likely to experience such reactions (64, 65). Generally, the number of people reporting AEs is
highest at the first round of treatment and tends to decrease during subsequent rounds (66).

Seriously ill individuals, such as people unable to engage in the normal activities of daily living
without assistance because of illness, should be excluded from large-scale anthelminthic
treatment interventions. Program managers must ensure that people who are about to receive
drugs are adequately informed about what possible AEs may occur following treatment and
what they should do in the event of such a reaction. People who have previously suffered one
of the rare serious AEs caused by reaction to the drugs (e.g. Stevens-Johnson syndrome)
should be excluded from treatment. Program managers must ensure that care and support
are available for individuals who experience AEs. Proper training of medical or community
health personnel must be offered. Any serious AE should be carefully recorded and reported
to the relevant authorities. (38)

Adverse drug reaction (ADR) is any noxious, unintended, and undesired effect of a drug which
occurs at doses used in humans for prophylaxis, diagnosis, or therapy. ADR is different from
AE, which is an untoward and unexpected experience by a patient following the use of a
medicinal product but does not necessarily have a causal relationship with the treatment. All
AEs and problems regarding the products (i.e. counterfeiting, product defect, therapeutic
ineffectiveness, and other problems) shall be reported to the National Pharmacovigilance
Center or other Pharmacovigilance units using the approved forms, network and systems.

Table 6. Management of adverse events. Adverse events following deworming are usually
mild and transient.
Adverse event Management
Hypersensitivity or allergic reaction Antihistamine
Moderate to severe abdominal pain Antispasmodic
Diarrhea Oral rehydrating solution

Tablets, especially scored tablets, should be broken into smaller pieces or crushed for
administration to young children, while older children should be encouraged to chew tablets
of albendazole or mebendazole. Forcing very small children to swallow large tablets may
cause choking or asphyxiation. Program managers should be aware of any other public health
intervention that involves distributing drugs in the same area and of its timing. This is to
minimize the risk of targeted people suffering from AEs due to interactions between drugs
distributed by different programs. (38)

Safety of drug combinations for treatment of helminth infections

A number of studies have investigated the safety of drug combinations in the treatment of
helminth infections. Albendazole and praziquantel can be safely co-administered for STH
infections and schistosomiasis (67). Mebendazole and praziquantel have been widely co-
administered in many countries and reported to be safe (67-69). Albendazole plus
diethylcarbamazine is also a safe combination in the treatment of lymphatic filariasis (70-72).

Progress of preventive chemotherapy for soil-transmitted helminthiasis

Over the past 10 years, significant progress has been made in controlling these infections. In
2010, about 314 million PSAC and SAC (representing 31% of all children in the world at risk
of STH infections) were dewormed. Despite this result in coverage, the target of reaching
75% of SAC by 2010 was not reached. However, in the past few years a number of partners
have focused efforts on control, and the private sector has donated large amounts of
medicines for control of these infections. WHO considers these unique opportunities as a
positive indicator that 75% coverage will be reached in all countries by 2020 (73).

15
 100
90
DOH-IHCP Target
80
WHO Target
70
60
50
40
30
20
10
0
2011
2011a 2012
2011b 2012a 20132013b 2014a
2012b 2013a 2014 20152015b
2014b 2015a

PSAC MDA coverage SAC MDA coverage

Figure 11. Mass drug administration coverage rates for soil-transmitted helminth
infections in preschool-age children and school-age children from 2011 to 2015
(Department of Health). MDA coverage rates in PSAC were reported to have reached both
the global and national targets for morbidity control in 2014 but did not meet the targets in
2015. While MDA coverage rates in SAC from 2011 to 2014 did not meet both the global and
national targets, the global target was reached after the launch of the National School
Deworming Day/National School Deworming Month in 2015.

Water, sanitation, and hygiene

Effective prevention and control of STH infections require improvements in water access,
sanitation, and hygiene practices. The use of improved sanitary facilities prevents open
defecation, while proper hand washing deters ingestion of eggs from dirty hands. Careful
washing, peeling, and cooking of vegetables are also needed to remove attached eggs. In
addition, the use of footwear prevents skin penetration of hookworm larvae.

In the Philippines, notable increase in sanitation has been documented. Percentage of use of
improved sanitation facilities increased from 57% in 1990 to 74% in 2015 (74). About 7% of
the population, mostly from rural settings, were estimated to practice open defecation due to
lack of any sanitation facility in 2015 (74). In resource-poor settings, provision of adequate
sanitation remains a challenge.

16
 MDG target
≥92% water
coverage

Figure 12. Water coverage of the Philippines from 1990 to 2015. According to the Joint
Monitoring Programme of World Health Organization and United Nations Children’s Fund, the
Philippines achieved the Millennium Development Goals target for water access (74).

MDG target
≥78.5%
sanitation
coverage

Figure 13. Sanitation coverage of the Philippines from 1990 to 2015. Despite non-
attainment of Millennium Development Goals target for sanitation, the Joint Monitoring
Programme recognized the good progress in the use of improved sanitation facilities in the
country (74).

Most of the local sanitation efforts has been supply-driven. However, adopting the use of
improved sanitation facilities requires a behavioral change approach more than just provision
of toilets and other hardware. To fill this gap, the Philippine National Sustainable Sanitation
Program (NSSP) was adopted by the DOH to assist local sanitation planners and stakeholders
to promote sustainable sanitation for all (74). The NSSP targets universal access to safe and
adequate sanitary facilities and reduction of STH infections attributable to poor sanitary
conditions by 2028 (75).

In school settings, the DepEd implements the WASH in Schools (WinS) Program. This
program aims to promote hygiene and sanitation practices among school children and
promote a clean environment in and around schools (76). The main strategies involved are
provision and maintenance of water and sanitary facilities, daily supervised hand washing,

17
and daily tooth brushing. With deworming in the school setting, this program contributes to
the control and prevention of STH infections (77).

Figure 14. Prevalence and intensity of, and mass drug administration coverage rates
for, soil-transmitted helminth infections in school-age children in selected sites in
Capiz from 2007 to 2015 (UP Manila - NTD Study Group). Despite twice yearly deworming
with generally high coverage, further reductions in moderate-heavy intensity infections were
not observed in 2009 to 2013 possibly due to continuing challenges related to poor sanitation
and hygiene.

Box 6. Integrating water, sanitation, and hygiene, and deworming through inter-
sectoral collaboration (77).

Successful collaboration between the WASH and health sectors depend on commitment
toward a shared vision as well as measurable benefits toward each sector’s principal
goals and measurements of success. In order to sustain collaboration, benefits for both
sectors must be clearly articulated.

Opportunities may include:

1. Joint advocacy – harmonizing messages of both sectors to stakeholders and
target population for efficiency
2. Monitoring – identifying areas that are at greatest need of interventions through
use of multiple indicators and mapping
3. Working group – conducting an inventory of existing materials and gaps, as well
as creating advocacy action plan
4. Capacity building – increase human resources capacity for advocacy of improved
WASH services alongside neglected tropical disease control

Health promotion and education

Health and hygiene promotion reduces transmission and reinfection by encouraging healthy
behaviors. Through health promotion strategies, the level of overall health knowledge and
acceptability of deworming interventions can be significantly increased (77). Key to these
strategies is the behavioral change aspect motivating at-risk individuals including their parents
or guardians to accept selective and targeted treatment, and to improve their sanitation and
hygiene practices (78).

18
 Box 7. Poor knowledge, attitudes, and practices related to deworming.

In Capiz, some parents associated soil-transmitted helminth infections with polluted air
and living in urban environment. They also believed that deworming should only be
done once in a lifetime (79). Most of teachers surveyed in Capiz believed that
reinfection of STH is impossible or unlikely (79). Attitudes toward deworming were also
an issue as some parents and teachers surveyed from Guimaras refuse to allow children
to be dewormed (80). In Baguio and Cavite, 60% of surveyed pregnant women would
refuse to take deworming after their first trimester as they believed deworming will cause
both maternal and fetal harm (81).

To achieve health literacy, effective health promotion strategies equip target individuals the
knowledge, skills, and information to make healthy choices. Such strategies may package the
practical and basic information about STH infections, such as transmission cycle, morbidities,
disease burden, preventive chemotherapy, safety of drugs and drug combinations, and
benefits of deworming. They may also include specific behaviors related to transmission of
STH infections that need to be modified or avoided, such as unhygienic practices and refusal
to submit to treatment.

Figure 15. Health promotion and education prior to school-based mass deworming in
Biñan, Laguna in 1999 (UP Manila - NTD Study Group). School children themselves can
contribute to information, education, and communication campaigns in the school setting.

An example of a health promotion strategy is the information, education, and communication

(IEC) campaign, which aims to increase awareness as well as change attitudes and behaviors
(81). IEC campaign is the sharing of information and ideas using culturally sensitive and
acceptable channels, messages, and methods. Effective IEC makes use of a full range of
approaches and activities, such as radio and TV broadcast, press releases, promotional
materials, orientations, and counselling (81). IEC campaigns could make use of popular social
media platforms like Facebook, YouTube, Twitter, and Instagram as part of social preparation.

In the context of deworming, the timing of IEC campaigns is essential to maximize health
promotion efforts. Providing an IEC campaign prior to the scheduled deworming provides an
opportunity to increase awareness about an upcoming event and can maximize participation.
Continuing the IEC efforts during and post-deworming is also beneficial to allay fears and
concerns on drug AEs, as well as prevent reinfection through improved sanitation and hygiene.

19
 Box 8. What are examples of effective health education?

In Peru, post-deworming hygiene education was found to reduce intensity of STH among
school children by 58% in comparison with the control group (82).

In China, an educational package was developed to partner with deworming. It was

composed of a 12-minute cartoon video (The Magic Glasses), classroom discussions,
posters, and pamphlets. This package was further reinforced by including drawing and
essay-writing competitions among children. The intervention group was found to have
decreased intensity of STH by 50% compared with the control group (83).

(The video can be accessed at https://www.youtube.com/watch?v=7C-O5M3YnRE.)

To sustain the interest and support of the stakeholders and communities, social mobilization,
a complex process of mobilizing stakeholders, healthcare providers, and communities to
influence behavior change, should be established (84). This allows continued interaction
among them that may ultimately influence the change of behavior needed by the community
(79). Investing in social mobilization is critical to reach and sustain high deworming coverage
as well as to demonstrate hygienic behaviors (84).

20
 (b)

Figure 16. Video cover (a) and poster (b) for the National School Deworming Month.
Advocacy and promotional efforts resulted to a nationwide deworming coverage of 83% in
January 2016.

Innovations through integration of deworming with other health, education, and social
development programs

Further cost reductions and improved efficiency can be achieved by integrating deworming
efforts with other interventions and programs. The most productive form of integration is to
use existing government structures and personnel to the greatest extent possible. Integration
can be done in several areas: drug administration, health education, orientation and training,
data collection, and monitoring and evaluation. Examples of innovative strategies through
integration are: Garantisadong Pambata Program, War on Worms Campaign, Fit for School,
Pantawid Pamilyang Pilipino Program, and Intervention Package for First 1000 Days.

21
Box 9. Garantisadong Pambata Program.

Community-based delivery of vitamin A and iron supplementation, immunization,

deworming, oral health promotion, good nutrition promotion, and child rearing practices
are included as part of the package of interventions in the Garantisadong Pambata
Program. Deworming covers children ages 1-14 years old. (40)

22
Box 10. War on Worms Campaign: A model for effective helminthiasis control.

In support of the Department of Health-Integrated Helminth Control Program, the

University of the Philippines Manila developed the War on Worms Campaign. The
campaign involves multiple components and ties up with DOH’s deworming efforts for
school-age children. These components are advocacy, capacity building, social
mobilization, monitoring and evaluation, as well as multisectoral collaboration. This
campaign had also featured school teachers assisting health workers in the mass
administration of deworming tablets. (85-87)

23
Box 11. Fit for School: Improving health for better education and child
development.

The Fit for School approach applies school-based management to support the
implementation of daily handwashing and tooth brushing and regular deworming to
address high-impact diseases. Combined with improved access to clean water, washing
facilities, appropriate sanitation, oral health, and deworming, key determinants of health
are addressed in a single intervention package. (88)

24
Box 12. The Department of Social Welfare and Development Pantawid Pamilyang
Pilipino Program (4Ps): deworming as conditionality for conditional cash transfer.

Pantawid Pamilyang Pilipino Program (4Ps) is a poverty reduction strategy that provides
cash grants to extremely poor households to allow the members of the families to meet
certain human development goals. The focus is on building human capital of poorest
families (health/nutrition and education) given the observation that low schooling, ill
health and high malnutrition are strongly associated with the poverty cycle in the
Philippines. Provision of cash grants to poor households is based on beneficiaries’
compliance with the conditions set forth by the program that include biannual deworming
of their school-age children. (42)

Box 13. Nutrition and deworming: First 1000 Days.

The first 1000 days of life starting from conception and before the second birthday of the
child is the period when growth faltering happens. Studies have shown a link between
undernutrition, especially stunting, in the first years of life. Therefore, the First 1000
Days is a golden window of opportunity for a comprehensive package of nutrition and
related interventions to achieve significant changes in reduction in child stunting,
underweight and wasting, at the same time contribute to complete child development.
Acknowledging the nutritional deficits caused by intestinal helminth infections, the
Department of Health integrated the deworming component of Garantisadong Pambata
with the National Nutrition Council’s First 1000 Days health promotional services. (89)

25
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Frequently asked questions

What are soil-transmitted helminth (STH) infections?

STH infections are common infections caused by nematodes or roundworms, Ascaris
lumbricoides (giant roundworm), Trichuris trichiura (whipworm), and Necator americanus and
Ancylostoma duodenale (hookworms). These infections are acquired by ingestion of infective
Ascaris and Trichuris eggs or penetration of infective hookworm larvae. Helminth eggs are
passed out on soil by infected individuals due to open defecation. Eggs either develop further
to become embryonated that makes them infective to humans or hatch to become infective
larvae.

What are the major risk factors that promote STH infections?
A number of factors promote STH infections. Open defecation allows eggs to embryonate or
hatch in soil to become infective to humans. Poor personal hygiene practices, specifically
non-practice of hand washing before eating, and non-use of footwear or walking barefoot
allowing entry of the infective stages (eggs of roundworm and whipworm, larvae of hookworm)
of the parasites to the human body.

Who are the at-risk populations for STH infections?

Preschool-age children (PSAC) and school-age children (SAC), women of childbearing age
(WCBA), and adults in certain high-risk occupations, such as farmers, miners, or soldiers, are
among the at-risk populations for STH infections.

What are the clinical manifestations of STH infections?

People with light infections usually have no symptoms. Heavier infections can result in a range
of clinical manifestations including gastrointestinal tract manifestations like abdominal pain
and diarrhea, general malaise and weakness, and impaired cognitive and physical
development. STH infections may also cause loss of appetite, which may result in a reduction
of nutritional intake and physical fitness. Whipworms can cause diarrhea and dysentery.
Hookworms cause chronic intestinal blood loss that can result in anemia.

What are the complications of untreated STH infections?

The nutritional impairment resulting from STH infections is recognized to have a significant
impact on growth and development. Overt morbidities include iron-deficiency anemia,
micronutrient deficiencies, growth retardation, and intestinal obstruction. Organ pathology for
each form of helminthiasis may be accompanied by subtle morbidities that may include
impaired cognitive performance, chronic fatigue, and unremitting pain. These conditions may
in turn lead to increased school absenteeism, reduced worker productivity, lowered self -
esteem, and social exclusion. There is evidence that helminthiasis may exacerbate the
transmission and/or severity of HIV/AIDS, malaria, and tuberculosis.

How are STH infections diagnosed?

STH infections are diagnosed through visualization of characteristic helminth ova through
microscopic examination of stool specimens. While routine stool examination through direct
fecal smear or wet mount can demonstrate helminth ova, the sensitivity of this commonly used
technique is lower compared with other recommended techniques. The WHO recommends
the use of Kato-Katz technique, a semi-quantitative method for demonstration of helminth ova,
which allows examination of a greater amount of stool, resulting in a higher sensitivity and an
estimation of intensity of infection, which is an indicator of worm burden. More recently
developed laboratory methods like the FLOTAC and Mini-FLOTAC provide higher levels of
sensitivity than that of duplicate Kato Katz technique.

29
What is the importance of knowing the intensity of STH infections?
STH egg counts are an indicator of worm burden. The presence of more eggs indicates more
worms, and the presence of more worms means greater morbidity. The WHO has set a goal
of having less than 1% moderate to heavy intensity of STH infections in PSAC and SAC by
2020.

What are the drugs of choice for STH infections according to WHO?
Albendazole and mebendazole are safe, effective, inexpensive, and easy to administer by
non-medical personnel (e.g. teachers or child development workers). These drugs have
undergone extensive safety testing and have been used in millions of people in many countries
around the world over the last several years. Both albendazole and mebendazole are donated
by major industry partners (GlaxoSmithKline and Johnson & Johnson) to national ministries of
health through WHO for the treatment of all children of school-age. Albendazole has also
been extensively used by the Global Program for the Elimination of Lymphatic Filariasis.

What is the mechanism of action of deworming drugs?

Albendazole interferes with microtubule assembly and blocks glucose uptake by many
intestinal and tissue nematodes (roundworms) as well as some cestodes (tapeworms). It is
poorly absorbed from the gastrointestinal tract and is extensively metabolized in the liver.
Mebendazole blocks glucose uptake by many intestinal and tissue nematodes, as well as
some cestodes. The small amounts absorbed after oral intake are extensively metabolized in
the liver.

What are the side effects of deworming drugs?

For albendazole and mebendazole, adverse events (side effects) include gastrointestinal
discomfort and headache. Adverse events are mostly mild and transient. Temporary minor
reactions following treatment occur mainly in infected people and usually result from the body’s
response to the dying worms. Heavily infected people are more likely to experience such
reactions. Serious adverse events are extremely infrequent.

Is there a need for the use of antihistamine (e.g. diphenhydramine) in deworming?

There is no evidence that the use of antihistamine provides added benefit in deworming.

What is preventive chemotherapy?

Preventive chemotherapy is the use of anthelminthic drugs, either alone or in combination, as
a public health tool against targeted helminth infections. The aim of preventive chemotherapy
is to avert the widespread morbidity that invariably accompanies helminth infections. Early
and regular administration of anthelminthic drugs recommended by WHO reduces the
occurrence, extent, severity, and long-term consequences of morbidity. In certain
epidemiologic conditions, preventive chemotherapy contributes to sustained reduction in
transmission. Preventive chemotherapy directed against STH infections entails administration
of either albendazole or mebendazole on a mass scale to identified at-risk groups like PSAC
and SAC at a prescribed frequency (i.e. once-a-year or twice-a-year) without the need for the
use of diagnostic tests.

What are the targeted at-risk groups for preventive chemotherapy in the Philippines?
In the Philippines, the targeted at-risk groups for preventive chemotherapy for STH infections
include PSAC and SAC, as well as WCBA.

What is the targeted coverage of preventive chemotherapy for STH infections?

WHO recommends a target coverage of 75% for PSAC and SAC, while the DOH recommends
a target coverage of 85%.

30
What are the reasons for low coverage of preventive chemotherapy?
Lack of information and misinformation are major obstacles to attaining high coverage rates.
These are addressed by effective information, education, and communication campaigns.

Is it safe to deworm pregnant and lactating women?

Studies have failed to find a statistically significant difference in the occurrence of congenital
abnormalities in babies born to women treated with single dose albendazole or mebendazole
during pregnancy and those born to untreated women. According to WHO, albendazole or
mebendazole for STH infections may be offered to pregnant women in the second or third
trimesters of pregnancy. The same may be offered to lactating women in areas where the
prevalence of STH infection exceeds 20%.

What are the benefits of deworming pregnant women?

The benefits of treating pregnant women include reduced maternal anemia and improved
infant birth weight and survival. The proven benefits of antenatal deworming in the absence
of any evidence indicative of drug teratogenicity or embryotoxicity in humans provide
compelling evidence to support the treatment of women with albendazole or mebendazole for
STH infections after the first trimester of pregnancy.

Is it safe to co-administer anthelminthic drugs?

Albendazole and praziquantel can be safely co-administered for STH infections and
schistosomiasis. Mebendazole and praziquantel have been co-administered in many
countries and reported to be safe. Albendazole and diethylcarbamazine is also a safe
combination in the treatment of lymphatic filariasis.

What goal or indicator for success has been set by WHO for year 2020?
The goal is to reach <1% moderate to heavy intensity STH infections in PSAC and SAC by
2020. Such is the indicator for elimination of STH infections as a public health problem.

How are STH infections best prevented?

Effective prevention and control of STH infections require improvement in water access,
sanitation, and hygiene practices. The use of improved sanitary facilities prevents open
defecation, while proper hand washing deters ingestion of eggs from dirty hands. The use of
footwear prevents skin penetration by hookworm larvae. Health and hygiene promotion
reduces transmission and reinfection by encouraging healthy behaviors. Through health
promotion strategies that involve information, education, and communication campaigns, the
level of overall health knowledge and acceptability of deworming interventions can be
significantly increased.

31
 ANNEX 1. ZENTEL® (ALBENDAZOLE) PRODUCT INFORMATION.

Description Albendazole rapidly undergoes extensive first-

ZENTEL contains albendazole, which is methyl pass metabolism in the liver, and is generally not
[5-(propylthio)-1H-benzimidazol-2-yl] carbamate. detected in plasma. Albendazole sulphoxide is
It is a member of the benzimidazole group of the primary metabolite, which is thought to be
anthelmintic agents. the active moiety in effectiveness against
systemic tissue infections. The plasma half life
of albendazole sulphoxide is 8½ hours.
Albendazole sulphoxide and its metabolites
appear to be principally eliminated in bile, with
only a small proportion appearing in the urine.

Indications
Single dose or short term courses of ZENTEL are
indicated in the treatment of single or mixed
Albendazole is a white to off-white, odourless or infestations of intestinal and tissue parasites, in
almost odourless powder, which is practically adults and children over 2 years of age.
insoluble in water and slightly soluble in
methanol, chloroform, ethyl acetate and Clinical studies have shown ZENTEL to be
acetonitrile. Its molecular weight is 265.33. effective in the treatment of infections caused by:

Pharmacology Enterobius vermicularis (pinworm/

ZENTEL (albendazole) is a broad-spectrum threadworm), Ascaris lumbricoides
anthelmintic, which is highly effective against a (roundworm), Ancylostoma duodenale and
wide range of intestinal helminths. ZENTEL is Necator americanus (hookworms), Trichuris
also effective against tissue helminth infections, trichiura (whipworm), Strongyloides
such as cutaneous larva migrans (see stercoralis, animal hookworm larvae causing
INDICATIONS). cutaneous larva migrans, and the liver flukes
Opisthorchis viverrini and Clonorchis
Albendazole therapy has also been used in the sinensis.
high dose, long term treatment of tissue helminth
infections including hydatid cysts and ZENTEL is also indicated for the treatment of
cysticercosis. Hymenolepis nana and Taenia spp. (tapeworm)
infections, when other susceptible helminths
The antihelminthic action of albendazole is species are present. Treatment courses should
thought to be mainly intra-intestinal. However, at be extended to 3 days (see WARNINGS AND
higher albendazole doses, sufficient is absorbed PRECAUTIONS).
and metabolised to the active sulphoxide
metabolite, to have a therapeutic effect against Contraindications
tissue parasites. ZENTEL should not be administered during
pregnancy or in women thought to be pregnant.
Albendazole exhibits larvicidal, ovicidal and ZENTEL has been shown to be teratogenic and
vermicidal activity, and is thought to act via embryotoxic in rats and rabbits. Women of
inhibition of tubulin polymerization. This causes childbearing age should be advised to take
a cascade of metabolic disruption, including effective precautions against conception during
energy depletion, which immobilizes and then and within one month of completion of treatment
kills the susceptible helminth. with ZENTEL (see Use in Pregnancy, Category
D).
Pharmacokinetics
In man, the full extent of albendazole absorption ZENTEL is contraindicated in persons who are
following oral administration has not been known to be hypersensitive to albendazole, other
established. However, it is known that benzimidazole derivatives, or any component of
albendazole is poorly absorbed with most of an the tablets.
oral dose remaining in the gastrointestinal tract.
The poor absorption is believed to be due to the
low aqueous solubility of albendazole.
Absorption is significantly enhanced
(approximately 5 fold) if albendazole is
administered with a fatty meal.

32
Precautions intracranial pressure and focal signs as a result
of an inflammatory reaction caused by death of
Use in systemic helminth infections (longer the parasite within the brain. Symptoms may
duration of treatment at higher doses) occur soon after treatment, appropriate steroid
Mild to moderate elevations of liver enzymes and anticonvulsant therapy should be started
have been reported with albendazole. In immediately.
prolonged higher dose albendazole therapy for
hydatid disease there have been rare reports of There is a risk that treatment of Taenia solium
severe hepatic abnormalities associated with infections may be complicated by cysticercosis,
jaundice and histological hepatocelluler damage, and appropriate measures should be taken to
which may be irreversible. Enzyme abnormalities minimise this possibility.
usually normalise on discontinuation of
treatment. Confirmation of eradication of many intestinal and
tissue parasites is necessary after treatment.
Patients with abnormal liver function test results (see DOSAGE AND ADMINISTRATION)
(transaminases) prior to commencing
albendazole therapy should be carefully Use in impaired renal or hepatic function
evaluated and therapy should be discontinued if The use of ZENTEL in patients with impaired
liver enzymes are significantly increased (greater renal or hepatic function has not been studied.
than twice the upper limit of normal) or full blood However, caution should be used in patients with
count decreased by a clinically significant level pre-existing liver disease, since ZENTEL is
(see Adverse Reactions). Albendazole treatment metabolised by the liver and has been associated
may be restarted when liver enzymes have with idiosyncratic hepatotoxicity.
returned to normal limits, but patients should be
carefully monitored for a recurrence. Use in children
There is limited experience with ZENTEL in
Case reports of hepatitis have also been received children under 2 years of age, therefore use in
(see Adverse Reactions). Liver function tests this age group is not recommended.
should be obtained before the start of each
treatment cycle and at least every two weeks Carcinogenicity and mutagenicity
during treatment. No evidence of carcinogenic activity was
observed in mice given albendazole in the diet at
Albendazole has been shown to cause bone doses up to 400mg/kg/day for 25 months. In rats,
marrow suppression and therefore blood counts dietary administration of doses of 3.5, 7 and
should be performed at the start and every two 20mg/kg/day did not affect the total incidence of
weeks during each 28 day cycle. Patients with adrenocortical tumours (adenoma plus
liver disease, including hepatic echinococcosis, carcinoma), however, in females there was an
appear to be more susceptible to bone marrow increased incidence of adrenocortical
suppression leading to pancytopenia, aplastic carcinomas.
anaemia, agranulocytosis and leukopenia and
therefore warrant closer monitoring of blood Mutagenicity tests with bacterial cells and an
counts. Albendazole should be discontinued if assay of chromosomal damage in vivo have
clinically significant decreases in blood cell shown no clear evidence that albendazole has
counts occur. genotoxic activity. A cell transformation assay
showed a slight dose-related increase in the
Symptoms associated with an inflammatory transformation rate of cultured mouse cells in the
reaction following death of the parasite may occur presence of metabolic activation.
in patients receiving albendazole treatment for
neurocysticercosis (e.g. seizures, raised Use in pregnancy (Category D)
intracranial pressure, focal signs). These should See CONTRAINDICATIONS. ZENTEL is
be treated with appropriate steroid and contraindicated during pregnancy, and for one
anticonvulsant therapy. Oral or intravenous month prior to conception. In order to avoid
corticosteroids are recommended to prevent administering albendazole during early
cerebral hypertensive episodes during the first pregnancy, women of child bearing age should
week of treatment. initiate treatment during the first week of
Pre-existing neurocysticercosis may also be menstruation or after a negative pregnancy test.
uncovered in patients treated with albendazole
for other conditions, particularly in areas with high The use of ZENTEL in human pregnancy has not
taenosis infection. Patients may experience been studied, but in animal studies it is
neurological symptoms e.g. seizures, increased teratogenic in more than one species. In animal

33
studies oral treatment with maternotoxic doses of enzymes were reported in studies with
albendazole (30mg/kg/day) during the period of laboratory monitoring, however no definite
organogenesis was associated with multiple relationship to the drug was shown.
malformations in rats and ectrodactyly in rabbits.
In one study in rats, an oral dose (10mg/kg/day) Hypersensitvity reactions including rash, pruritis
similar to the human therapeutic dose was not and urticaria have been reported very rarely.
maternotoxic, but was associated with
microphthalmia and microfetalis. The latter During prolonged higher dose albendazole
occurred alone and together with multiple therapy of hydatid disease there have also been
malformations including cranioschisis, talipes reports of severe hepatic abnormalities, including
and renal agenesis. There is no information on jaundice and hepatocellular damage which may
the possible effect of albendazole on the human be irreversible.
foetus.
Post-marketing data
Use in lactation During post-marketing surveillance, the following
Adequate human and animal data on use during reactions have been reported additionally in
lactation are not available. Therefore breast temporal association with ZENTEL.
feeding should be discontinued during and for a
minimum of 5 days after treatment. Use in intestinal infections and Cutaneous
larva migrans (short duration treatment at
Interactions lower dose):
Cimetidine, praziquantel and dexamethasone • Headache has been reported
have been reported to increase the plasma levels uncommonly (≥ 0.1% and <1%) in
of the albendazole active metabolite. treatment with albendazole.
• Erythema multiforme and Stevens-
Ritonavir, phenytoin, carbamazepine and Johnson syndrome have been reported
phenobarbital may have the potential to reduce very rarely (<0.01%).
plasma concentrations of the active metabolite of
albendazole; albendazole sulfoxide. The clinical Use in systemic helminth infections (longer
relevance of this is unknown, but may result in duration of treatment at higher doses):
decreased efficacy, especially in the treatment of • Headache has been reported very
systemic helminth infections. Patients should be commonly (≥10%).
monitored for efficacy and may require alternative • Reversible alopecia (thinning of hair, and
dose regimens or therapies. moderate hair loss) and fever have been
reported commonly (≥1% and <10%).
Adverse reactions • Hepatitis has been uncommonly
The following adverse events were observed associated with albendazole treatment.
during clinical studies. It should however be • Blood disorders such as pancytopenia,
noted that causality has not necessarily been aplastic anaemia and agranulocytosis
established for these events. have been associated very rarely with
albendazole treatment. Patients with
Common (≥1%) liver disease, including hepatic
Abdominal pain was the most frequently echinococcosis, appear to be more
reported symptom (1%) during short term susceptible to bone marrow suppression
dosing, however this frequency was not (see Precautions).
significantly different from that in placebo- • There have been very rare cases of
treated patients. Erythema multiforme and Stevens-
Johnson syndrome.
Uncommon (>0.1% and <1%)
Diarrhoea, nausea, vomiting, dizziness, Dosage and administration
itchiness and/or skin rashes were reported. ZENTEL 200mg chewable tablets may be
There was no significant difference in the crushed, chewed, or swallowed whole.
percentage of patients experiencing
diarrhoea, compared to placebo-treated
patients.
Adults and children (over two years):
Rare (< 0.1%)
• Enterobius vermicularis, Ascaris
Rarely reported events included bone pain, lumbricoides, Ancylostoma duodenale,
proteinuria, and low red cell count. Necator americanus and Trichuris
Leucopenia and transiently raised hepatic
trichiura: 400mg (two ZENTEL 200mg

34
 tablets) as a single dose, taken on an should be re-examined 1 month after
empty stomach. treatment to confirm fluke eradication.
• Suspected or confirmed Strongyloides
stercoralis infestation: ZENTEL 400mg Overdosage
once daily, taken on an empty stomach Further management should be as clinically
for three consecutive days. Patients indicated or contact the Poisons Information
should then be appropriately followed Centre (telephone 131126) for advice on
for at least 2 weeks to confirm cure. overdose management.
• Cutaneous larva migrans: 400mg once
daily, taken with food for one to three Storage
days has been reported to be effective. ZENTEL tablets should be stored below 30°C.
• Suspected or confirmed Taenia spp. or
Hymenolepis nana infestation, when Presentation
other susceptible helminths species are ZENTEL - chewable tablets containing 200mg
present: ZENTEL 400mg once daily, albendazole white to off-white, circular, biconvex,
taken on an empty stomach for three bevel edged film coated tablet, with a pentagonal
consecutive days. If the patient is not pyramid on each face, blisters or bottles of 6
cured after three weeks, a second tablets.
course of ZENTEL treatment is
indicated. In cases of proven H. nana Name and address of sponsor
infestation, retreatment in 10-21 days is GlaxoSmithKline
recommended. (see WARNINGS AND Level 4
PRECAUTIONS) 436 Johnston Street
• Mixed worm infestations including Abbotsford, 3067
Opisthorchis viverrini and Clonorchis Australia
sinensis: 400mg twice a day, taken with
food for three days is effective. Patients Version 3.0
Date of TGA Approval: 25 January 2011

35
 ANNEX 2. VERMOX/ANTIOX® (MEBENDAZOLE) PRODUCT INFORMATION.

Qualitative and quantitative composition described in patients who were treated with
Each tablet contains 500 mg mebendazole. mebendazole at standard dosages for indicated
conditions (See Postmarketing Experience).
Pharmaceutical form These events, along with glomerulonephritis,
VERMOX® 500 mg tablet: white to faintly cream- have also been reported with dosages
colored, circular, flat, beveledged tablet. substantially above those recommended and
with treatment for prolonged periods of time.
Clinical particulars
Results from a case-control study investigating
Therapeutic indications an outbreak of Stevens-Johnson syndrome/toxic
VERMOX® 500 mg is indicated for the mass epidermal necrolysis (SJS/TEN) suggested a
treatment of single or mixed gastrointestinal possible relationship between SJS/TEN and the
infestations by Enterobius vermicularis concomitant use of mebendazole and
(pinworm); Trichuris trichiura (whipworm); metronidazole. Further data suggesting such a
Ascaris lumbricoides (large roundworm); drug-drug interaction are not available.
Ancylostoma duodenale, Necator americanus Therefore, concomitant use of mebendazole and
(hookworm). metronidazole should be avoided.

In patients living in heavily endemic areas, Interaction with other medicinal products
regular treatment with VERMOX® 500 mg (3-4 and other forms of interaction
times a year) will substantially reduce the overall Concomitant treatment with cimetidine may
wormload and keep it well below the level of inhibit the metabolism of mebendazole in the
clinical significance. liver, resulting in increased plasma
concentrations of the drug especially during
Posology and method of administration prolonged treatment. In the latter case,
determination of plasma concentrations are
Adults and children recommended in order to allow dose
• 1 single tablet of VERMOX® 500 mg. adjustments.
• No special procedures, such as diet or
use of laxatives, are required. Concomitant use of mebendazole and
• NOTE: VERMOX® (PANTELMIN) oral metronidazole should be avoided (see Special
suspension containing 20 mg warnings and special precautions for use).
mebendazole per ml should be
considered for patients such as young Pregnancy and lactation
children who are unable to swallow the Mebendazole has shown embryotoxic and
500 mg tablet. teratogenic activity in rats and in mice at single
oral doses. No harmful effects on reproduction
Contraindications were noted in other animal species tested. (See
VERMOX® 500 mg tablets should not be used in Preclinical Safety Data)
children below the age of 1 year. In addition,
VERMOX® 500 mg is contraindicated in persons The possible risks associated with prescribing
with a known hypersensitivity to the drug or its VERMOX® 500 mg during pregnancy, particularly
components. during the first trimester, should be weighed
against the expected therapeutic benefits.
Special warnings and special precautions for
use Mebendazole is only absorbed to a small extent.
Convulsions in children, including in infants It is not known whether mebendazole is excreted
below one year of age have been reported rarely in human breast milk. Therefore, caution should
during post-marketing experience with be exercised when VERMOX® 500 mg is
VERMOX®. VERMOX® 500 mg should not be administered to nursing women.
used and VERMOX®100 mg or VERMOX® oral
suspension should only be given to very young Effects on ability to drive and use machines
children if their worm infestation interferes signifi VERMOX® does not affect the mental alertness
cantly with their nutritional status and physical or driving ability.
development.

There have been rare reports of reversible liver

function disturbances, hepatitis and neutropoenia

36
Undesirable effects Table 2. Adverse Drug Reactions Identified
Throughout this section adverse reactions are During Postmarketing Experience with
reported. Adverse reactions are adverse events VERMOX® by Frequency Category Estimated
that were considered to be reasonably from Spontaneous Reporting Rates
associated with the use of VERMOX® based on
the comprehensive assessment of the available System/Organ Class
adverse event information. A causal relationship Frequency Category Adverse Reaction
with VERMOX® cannot be reliably established in
individual cases. Further, because clinical trials Blood and Lymphatic
System Disorders
are conducted under widely varying conditions, Very Rare Neutropoenia
adverse reaction rates observed in the clinical
trials of a drug cannot be directly compared to Immune System
rates in the clinical trials of another drug and may Disorders
not reflect the rates observed in clinical practice. Very Rare Hypersensitivity including
anaphylactic reaction and
Clinical trial data anaphylactoid reaction
The safety of VERMOX® was evaluated in 6276
Nervous System
subjects who participated in 39 clinical trials for
Disorders
the treatment of single or mixed parasitic Very Rare Convulsions, Dizziness
infestations of the gastrointestinal tract. In these
39 clinical trials, no adverse drug reactions Gastrointestinal
(ADRs) occurred in ≥1% of VERMOX®-treated Disorders
subjects. ADRS occurring in <1% of VERM OX®- Very Rare Abdominal pain
treated subjects are shown in Table 1.
Hepatobiliary Disorders
Table 1. Adverse Drug Reactions Reported by Very Rare Hepatitis, Abnormal liver
<1% of VERMOX®- Treated Subjects in 39 function tests
Clinical Trials Skin and Subcutaneous
Tissue Disorders
System/Organ Class Adverse Reaction Very Rare Toxic epidermal
necrolysis, Stevens-
Gastrointestinal Abdominal Discomfort, Johnson syndrome,
Disorders Diarrhoea, Flatulence Exanthema, Angioedema,
Skin and Subcutaneous Rash Urticaria, Alopecia
Disorders
Overdose
Post-marketing experience In patients treated at dosages substantially
Adverse drug reactions first identified during higher than recommended or for prolonged
postmarketing experience with VERMOX® periods of time, the following adverse reactions
(mebendazole) are included in Table 2. In the have been reported rarely: alopecia, reversible
table the frequency categories are provided liver function disturbances, hepatitis,
according to the following convention: agranulocytosis, neutropoenia, and
glomerulonephritis. With the exception of
Very common (≥1/10) agranulocytosis and glomerulonephritis, these
Common (≥1/100, < 1/10) also have been reported in patients who were
Uncommon (≥1/1000, < 1/100) treated with mebendazole at standard dosages.
Rare (≥1/10000, < 1/1000) (See Postmarketing Experience.)
Very rare (< 1/10000) including isolated
reports. Symptoms
In the event of accidental overdose, abdominal
In Table 2, ADRs are presented by frequency cramps, nausea, vomiting and diarrhea may
category based on spontaneous reporting rates. occur.

Treatment
There is no specific antidote. Within the first hour
after ingestion, gastric lavage may be performed.
Activated charcoal may be given if considered
appropriate.

37
Pharmacological properties Steady-state pharmacokinetics
During chronic dosing (e.g. 40 mg/kg/day for 3-
Pharmacodynamic properties 21 months), plasma concentrations of
In therapeutic indications (See section mebendazole and its major metabolites increase,
Therapeutic indications) mebendazole acts resulting in approximately 3-fold higher exposure
locally in the lumen of the gut by interfering with at steady-state compared to single dosing.
cellular tubulin formation in the intestines of
worms. Mebendazole binds specifically to tubulin Preclinical safety data
and causes ultrastructural degenerative changes The single-dose toxicity evaluations in multiple
in the intestine. As a result, the glucose uptake species revealed that mebendazole was well
and the digestive functions of the worm are tolerated and has a large margin of safety.
disrupted to such an extent that an autolytic Repeated-dose, oral, chronic toxicity results in
process occurs. rats, at toxic dose levels of 40 mg/kg and above,
showed altered liver weights with some slight
Pharmacokinetic properties centrilobular swelling and hepatocellular
vacuolation, and altered testicular weights with
Absorption some tubular degeneration, desquamation and
Following oral administration, approximately 20% marked inhibition of spermatogenic activity. No
of the dose reaches the systemic circulation, due carcinogenic effects were observed in the mouse
to incomplete absorption and to extensive pre- or rat. No mutagenic activity was shown in in vitro
systemic metabolism (first-pass effect). gene-mutagenicity studies. In vivo tests revealed
Maximum plasma concentrations are generally no structural chromosome damaging activity.
seen 2 to 4 hours after administration. Dosing Micronucleus test results have shown aneugenic
with a high fat meal leads to a modest increase in effects in mammalian somatic cells above a
the bioavailability of mebendazole. threshold plasma concentration of 115 ng/mL. At
maternal toxic doses, embryotoxic and
Distribution teratogenic activity has been shown in pregnant
The plasma protein binding of mebendazole is 90 rats at a single dose of 10 mg/kg and above.
to 95%. The volume of distribution is 1 to 2 L/kg, Teratogenic and fetotoxic effects have also been
indicating that mebendazole penetrates areas observed in mice at maternally toxic doses of 10
outside the vascular space. This is supported by mg/kg and higher. No harmful effects on
data in patients on chronic mebendazole therapy reproduction were noted in other animal species
(e.g. 40 mg/kg/day for 3-21 months) that show tested.
drug levels in tissue.
Pharmaceutical particulars
Metabolism
Orally administered mebendazole is extensively List of excipients
metabolized primarily by the liver. Plasma The inactive ingredients of the tablets are lactose
concentrations of its major metabolites (amino momohydrate, methylcellulose, sodium starch
and hydroxylated amino forms of mebendazole) glycolate, microcrystalline cellulose, maize
are substantially higher than those of starch, magnesiumstearate, and colloidal
mebendazole. Impaired hepatic function, anhydrous silica. Incompatibilities None known.
impaired metabolism, or impaired biliary
elimination may lead to higher plasma levels of Shelf life
mebendazole. Observe expiry date on the outer pack.

Elimination Special precautions for storage

Mebendazole, the conjugated forms of Store between 15° and 30° C.
mebendazole, and its metabolites likely undergo Keep out of reach of children.
some degree of enterohepatic recirculation and
are excreted in the urine and bile. The apparent Nature and contents of container
elimination half-life after an oral dose ranges from Vermox® 500 mg is supplied in packs
3 to 6 hours in most patients. containing one tablet.

38
 ANNEX 3. INTEGRATED HELMINTH CONTROL PROGRAM
Adverse Events Following Deworming/ Severe Adverse Events

REPORTING FORM

To be filled in by the Physician/Midwife/Barangay Health Worker/ Teacher or Parents as

needed during every mass deworming campaign

Region: Province: Municipality:

Service outlet: (Please check and indicate name of RHU, school , daycare

Barangay Health Station/

RHU:

School:

Day care
center:

Day of deworming: Time of

deworming:

Name of Age Complete Chief Action taken Remarks

Patient address complaint
and time of
onset of
symptoms

Accomplished by: __________________________________

(Print name and signature)

Date:_______________________

39
ANNEX 4. FLOW OF SEVERE ADVERSE EVENT REPORTING AND INVESTIGATION

DOH/FDA/DepEd

- Recommend appropriate action

RESU/Regional Coordinator/DepEd School

Governance and Operations Division

- Confirms and validate investigation findings

- Assist in investigation if needed
- Recommends appropriate action

Municipal/Provincial/City Health Office/DepEd

Division Office

- Conducts and confirms initial investigation

using adverse reaction reporting form and
submits to next level
- Recommends appropriate action

Health Worker/Parent/Teacher

- Reports any SAE in the area to higher level

40
 ANNEX 5. PROPER HANDWASHING TECHNIQUE

Proper handwashing requires soap and only a small amount of water. Running water from a
tap is not necessary; a small basin of water or “tippy tap”— cans or plastic bottles that release
just enough water for a clean hand wash each time they are tipped — is sufficient. Steps are:
1. Cover wet hands with soap
2. Scrub all surfaces, including palms, back, between the fingers, and especially under
fingernails for about 20 seconds
3. An easy way to gauge 20 seconds is to find a familiar song, such as “Happy
Birthday”
4. Rinse well with running water rather than still water
5. Dry on a clean cloth or by waving in the air

The two primary times to wash hands are after contact with feces or using the toilet and before
contact with food (preparing food, eating, and feeding a child).

Source of photo: Monse B, Naliponguit E, Benzian H, Palenstein Helderman W. Fit for

School Inc. (2010) Manual for teachers for the implementation of essential health care
program in schools. Fit for School Inc., Cagayan de Oro, Philippines

Source of text: FHI 360 for the Global Public-Private Partnership for Handwashing with
Soap. (2016) Global Handwashing Day Planner’s Guide.
http://globalhandwashing.org/resources/ghd-planners-guide/

41