Acta Tropica 141 (2015) 385–390

Contents lists available at ScienceDirect

Acta Tropica
journal homepage: www.elsevier.com/locate/actatropica

School-based mass distributions of mebendazole to control

soil-transmitted helminthiasis in the Munshiganj and Lakshmipur
districts of Bangladesh: An evaluation of the treatment monitoring
process and knowledge, attitudes, and practices of the population夽
Israt Hafiz a , Meklit Berhan b , Angela Keller c , Rouseli Haq a , Nicholas Chesnaye c ,
Kim Koporc b , Mujibur Rahman a , Shamsur Rahman a , Els Mathieu c,∗
a
Ministry of Health and Family Welfare (MOH&FW), Bangladesh
b
Children Without Worms, The Task Force for Global Health, Atlanta, GA, USA
c
Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Bangladesh’s national deworming program targets school-age children (SAC) through bi-annual school-
Available online 24 December 2013 based distributions of mebendazole. Qualitative and quantitative methods were applied to identify
challenges related to treatment monitoring within the Munshiganj and Lakshmipur Districts of
Keywords: Bangladesh. Key stakeholder interviews identified several obstacles for successful treatment monitoring
STH within these districts; ambiguity in defining the target population, variances in the methods used for
Bangladesh
compiling and reporting treatment data, and a general lack of financial and human resources. A treat-
Mebendazole
ment coverage cluster survey revealed that bi-annual primary school-based distributions proved to be an
Process evaluation
Mass drug administration
effective strategy in reaching school-attending SAC, with rates between 63.0% and 73.3%. However, the
Treatment coverage survey WHO target of regular treatment of at least 75% of SAC has yet to be reached. Particularly low coverage
was seen amongst non-school attending children (11.4–14.3%), most likely due to the lack of national
policy to effectively target this vulnerable group. Survey findings on water and sanitation coverage were
impressive with the majority of households and schools having access to latrines (98.6–99.3%) and safe
drinking water (98.2–100%). The challenge now for the Bangladeshi control program is to achieve the
WHO target of regular treatment of at least 75% of SAC at risk, irrespective of school-enrollment status.
© 2013 The Authors. Published by Elsevier B.V. All rights reserved.

1. Introduction occurring in poor populations throughout sub-Saharan Africa, East

Globally, an estimated 1.2 billion people are infected with one
or more species of intestinal nematodes, the most common being
Ascaris lumbricoides, Trichuris trichiura, Ancylostoma duodenale, and
Necator americanus. These parasites are the causative agents of
soil-transmitted helminthiasis (de Silva et al., 2003), one of the
most prevalent parasitic infections in the world, the majority
夽 This is an open-access article distributed under the terms of the Creative Com-
mons Attribution-NonCommercial-No Derivative Works License, which permits
non-commercial use, distribution, and reproduction in any medium, provided the
original author and source are credited.
∗ Corresponding author at: Center for Global Health, CDC, Blg 21, 9210.3, 1600
Clifton Road, NE, Atlanta, GA 30329-4018, USA. Tel.: +1 404 6393518.
E-mail addresses: dr.ihafiz2012@gmail.com (I. Hafiz), mberhan@gmail.com
(M. Berhan), angela.j.keller@gmail.com (A. Keller), dr.rouselihaq@gmail.com
(R. Haq), nchesnaye@gmail.com (N. Chesnaye), kkoporc@taskforce.org (K. Koporc),
drmujib.rahman@gmail.com (M. Rahman), mirsamsut@gmail.com (S. Rahman),
emm7@cdc.gov (E. Mathieu).
Asia, China, India and South America (Brooker et al., 2006). Chil-
dren suffer the most intense worm infections, causing significant
harmful effects on both physical health and cognitive development
(Brooker, 2010).
In support of the World Health Assembly resolution 54.19,
which urges member states to achieve “regular treatment of at
least 75% of school-age children at risk of morbidity by soil-
transmitted helminth (STH) infections by 2010”, the World Health
Organization (WHO) recommends regular deworming with broad-
spectrum anthelminthic drugs to reduce the parasite burden to a
level that alleviates morbidity and decreases transmission (WHO,
2006). Mass preventive chemotherapy is currently considered the
cornerstone of STH control, however, as reinfection is common,
additional measures such as access to clean drinking water,
improved sanitation, and health education are crucial to ensure
sustainable control (WHO, 2012).
In Bangladesh, a national parasitological survey revealed that
79.8% of school-age children were infected with one or more
helminth species Ministry of Health and Family Welfare, 2010. To

0001-706X/$ – see front matter © 2013 The Authors. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.actatropica.2013.12.010
386 I. Hafiz et al. / Acta Tropica 141 (2015) 385–390

control STH morbidity, the Bangladesh Ministry of Health & Family

Welfare (MOH&FW) piloted a school-based mass drug administra-
tion (MDA) of mebendazole in three districts in 2005. The pilot was
successfully implemented, and in 2008, a national control strat-
egy was formulated. At the time of the evaluation (January 2010),
school-based MDAs were implemented bi-annually, targeting all
children between the ages of 6–12. In 2011, the control program
expanded the definition of school-age children to include children
aged 5 years. In October 2012, the definition of school-age children
was expanded again to include children aged 5–14, which is in line
with the WHO definition.
Since 2007, mebendazole has been donated (by Johnson & John-
son through Children Without Worms [CWW]) for bi-annual MDAs.
At the time of the survey donated mebendazole was distributed
in 27 of the 64 districts (website CWW). Donated albendazole (by
GlaxoSmithKline through WHO) is distributed annually to treat
children and adults in 34 districts where lymphatic filariasis is
endemic (WHO, 2011). The remaining districts are treated with
albendazole procured by the government. Pre-school children are
targeted for deworming through the Expanded Program on Immu-
nization in all districts.
Monitoring and evaluation (M&E) activities are essential for
disease control programs, as they provide up-to-date informa-
tion on program performance, as well as opportunities to identify
and resolve issues (Gyorkos, 2003). The percentage of individuals
treated within a target population (treatment coverage), is used
as the primary indicator to monitor and evaluate the performance
of MDAs, as it reflects the performance of most of the program
processes. The monitoring of treatment coverage contributes to
informed programmatic decisions, allows for identification of chal-
lenges encountered during MDAs, as well as geographical areas
where the program is performing poorly. Fig. 1. Munshiganj and Lakshipur study districts, STH treatment evaluation,
An evaluation of the treatment monitoring process was con- Bangladesh, 2010.
ducted in the Munshiganj and Lakshmipur Districts of Bangladesh Source: Google Maps: Bangladesh, 23.402765, 90.439453, Map data 2013 AutoNavi,
(Fig. 1) using a combination of key stakeholder interviews and sur- Retrieved from: http://www.istanbul-city-guide.com/map/country/bangladesh-
map.asp.
veys. The primary objective was to review the performance of the
treatment monitoring process and to identify challenges and solu-
tions. The second objective was to validate reported mebendazole training given by sub-district health staff prior to each MDA,
treatment coverage in school age children, and the third objective where they receive information on the benefits of deworming, how
was to assess water and sanitation conditions in households and to administer the deworming drug, how to respond to (serious)
schools, and assess knowledge, attitudes, and practices (KAP) of adverse reaction, and how to report treatment data. School direc-
the population regarding water purification methods, awareness tors are then responsible for training the teachers in their respective
of the mebendazole distribution, and STH prevention. schools. Health assistants are responsible for distributing meben-
dazole along with the treatment reporting forms to schools prior
2. Methods to the MDA. On the day of the MDA, each health assistant visits
all schools in the assigned working area to supervise the admin-
2.1. Study sites istration of drugs and monitor for adverse events. Treatment data
are collected by teachers and health assistants at the school level
The Munshiganj and Lakshmipur districts were selected to con- and submitted to the sub-district level. Here, the data are com-
duct the key stakeholder interviews and surveys due to country piled and reported to the district level, which in turn compiles and
representative school enrollment rates, good accessibility, and submits data to the central level STH program, where the national
population size. Munshiganj contains a population of roughly 1.4 treatment coverage report is prepared. Districts and sub-districts
million, and Lakshmipur a population of 2 million inhabitants. both set their own timeline for receiving treatment data reports.
In addition, both districts have consistently conducted bi-annual The central level requires the district level reports to be submitted
MDAs between 2007 and 2009. For the key stakeholder inter- within one month of the MDA.
views, the sub-districts Gazaria and Screenagar were randomly
selected from Munshiganj district, and the sub-districts Raipur 2.3. Key stakeholder interviews
and Ramgati from Lakshmipur district. The evaluation occurred in
2010, from February 25th to March 4th and again on March 15th Separate semi-structured, open-ended, interview guides were
in Munshigonj district, and from March 7th through the 10th in prepared for teachers and health and education officers from the
Lakshmipur district. sub-district and district levels, as well as for staff members of the
STH control program at the central level. From each sub-district,
2.2. MDA and treatment monitoring two schools were selected by the sub-district health or education
staff for inclusion in the evaluation. In each of the eight participat-
School-based MDAs are implemented bi-annually, targeting ing schools, at least three school staff members were interviewed;
all school-age children. Each school director participates in a the head master/mistress, and at least two teachers. In cases where
 I. Hafiz et al. / Acta Tropica 141 (2015) 385–390
there were more than two teachers available for an interview in
a school, a focus group discussion was held with all the teachers
that wanted to participate. In-depth interviews were conducted
by CWW staff, accompanied by an interpreter, and a staff mem-
ber of the MOH&FW. In several cases, one or two staff from the
sub-district health or education office accompanied the interview
team to the schools and participated in the interviews. Participants
discussed their role and responsibilities regarding treatment data
reporting procedures, perceived challenges in reporting treatment
data, the process of drug administration, and their views on the
dissemination and use of treatment data.
2.4. Household survey
A three-step cluster sampling strategy was applied to select
households to participate in the household survey. First, thirty
unions (the administrative unit under the sub-district) were
selected per district using probability proportional to estimated
size (PPES) sampling from the 2001 population census. Second, one
village per union was sampled using PPES. Third, ten households
were sampled per village using an adaptation of the ‘random walk’
method. A random direction was determined in the center of the
village and all houses were counted until the village boundary was
reached. One of those houses was randomly selected as a starting
house and 9 additional houses were selected using the ‘left-rule’ as
described in detail by Worrell and Mathieu (2012). The survey team
received practical and theoretical training on the sampling strategy,
and was selected from national program staff and university stu-
dents who were not previously involved with the distributions. In
each sampled household, all children under the age of fifteen were
questioned on their mebendazole intake during both MDAs in May
and November of 2009, as well as deworming treatment received
elsewhere (e.g. health center) during 2009. Additional information
was collected on age, gender, and school enrolment status. Par-
ents served as proxy when their children were absent from the
household or in the case that a child was too young to answer for
themselves. In addition, a structured questionnaire was adminis-
tered to one adult in each selected household using open-ended
questions. Information was collected on the household source of
drinking water, methods used to purify drinking water, type of
latrines present, awareness of the MDA, and knowledge regarding
the prevention of STH infections. In addition, parents were asked
whether their children had experienced any side effects after treat-
ment with mebendazole.
2.5. School survey
In each sampled village, data was collected from teachers and
through direct observation of the latrines and water sources, at a
school attended by the majority of children included in the coverage
survey. A structured questionnaire was used to collect information
on the availability, accessibility, and use of latrines, availability of a
hand washing arrangement, and the source of drinking water. Both
school and household questionnaires were translated to Bengali by
the MOH&FW and back translated to English for validation.
2.6. Data analysis
The STH control program calculated treatment coverage by
dividing the number of school-attending children between 6 and 12
years of age treated with mebendazole, with the number of school
attending children of the same age range in the intervention area.
The WHO defines treatment coverage as the total number of chil-
dren between 5 and 14 years of age treated, irrespective of school
attendance. Both definitions were used to calculate mebendazole
treatment coverage and data was analyzed for these specified age
387
categories of interest. EpiInfo (version 3.5.3) was used for data entry
and SAS (version 9.2) for statistical analysis.
2.7. Ethical considerations
The protocol was evaluated by the CDC Institutional Review
Board and was deemed to be a program evaluation activity not
involving human subjects research. Oral informed consent was
obtained from each subject, or the legal guardian if the participant
was under the age of 18.
3. Results
3.1. Key stakeholder interviews
Interviews were conducted with four staff members of the STH
control program at the central level, as well as with health offi-
cers, education officers, and statisticians and/or other personnel
responsible for data collection at the district and sub-district lev-
els. A total of 35 head masters/mistresses and teachers participated
in the stakeholder interviews and/or focus group discussions, and
on average there were 2–7 teachers per focus group.
3.1.1. Treatment reporting procedures
Although all participants were aware of the reporting structure,
there were some variances in the methods for compiling and sub-
mitting treatment data at the school level. In some schools, teachers
used the attendance sheet to register students who were treated,
and compiled this information into the treatment report at the
end of the MDA. In other schools, teachers verbally informed the
health assistants of the number of students that were treated, and
the health assistants completed the treatment report. In a single
school, it was reported that the treatment forms were completed
to show 100% coverage, even if not all students were treated, as it
was assumed that teachers would treat all students within a few
days following the MDA.
3.1.2. Treatment reporting timelines
Interviews at the district, sub-district, and school levels did not
indicate any challenges in submitting treatment data in a timely
manner. All schools stated that they submitted treatment reports
up to the sub-district level either at the end of the MDA or the fol-
lowing day, which was confirmed by the sub-district level parti-
cipants. Participants from the sub-district level reported compiling
and submitting data up to the district level within 2–7 days after
the MDA, which was confirmed by district level participants. Cen-
tral level participants indicated that they often encounter delays
with the submission of district level reports, as at the time of the
interview (February and March 2010), 12 out of 64 districts had not
yet submitted their treatment reports for the November 2009 MDA.
Contradictorily to the information provided by central level inter-
views, district level interviews indicated that after receiving the
sub-district level treatment data, it generally takes approximately
7 days to compile data and submit the reports to the STH control
program at the central level.
3.1.3. Challenges in meeting the treatment reporting
requirements
Sub-districts reported that they do not receive sufficient treat-
ment reporting forms from the district level. As a result, sub-district
health centers take on the responsibility for providing the remain-
ing forms for distribution to all the schools in their jurisdiction,
which poses a challenge, as the sub-districts have limited funding
to cover expenses for all components of the deworming program.
Moreover, all sub-districts receive the same amount of funding for
388 I. Hafiz et al. / Acta Tropica 141 (2015) 385–390

the implementation of all deworming activities, regardless of their
population size or geographic situation.
Interviews made comparisons with other health programs, such
as the immunization program, which provides stipends for health
assistants. The deworming program does not provide such financial
incentives. Interviewers felt that the lack of remuneration affects
health assistants’ motivation for carrying out tasks related to the
MDA.
At the central level, staff mentioned how inconsistencies in
the approach of setting treatment targets (e.g. the denomina-
tor for treatment coverage calculations) result in difficulties in
determining treatment coverage rates. District and sub-district
level interviewers voiced their confusion on whether or not non-
enrolled school-age children should be included in the target
definition. Some district participants mentioned that when non-
enrolled children are treated, they are included in the total number
of children treated (the numerator), whilst the denominator only
includes school-attending children, leading to coverage rates of
over 100%.
A lack of a national strategy for treating non-enrolled school
age children resulted in various approaches in treating this group.
School staff described how some schools allocate a certain percent-
age (5–10%) of mebendazole to treat non-enrolled children, whilst
others use any leftover drugs, and some choose not to provide treat-
ment at all. A single school mentioned that they ran out of drugs
to treat their enrolled students, because non-enrolled students had
come for the MDA and received treatment.
3.1.4. Dissemination and use of treatment data
Only one of the sub-district interviewers indicated that his staffs
refers to the treatment reports for programmatic purposes, in this
case, for comparing attendance rates and treatment numbers to
develop messages for motivating teachers and communities to
increase MDA attendance. Other respondents did not mention any
use of the data other than reporting it to the above administrative
level.
3.2. Reported coverage
calculating the treatment coverage is the number of school-
attending children between 6 and 12 years.
3.3. Treatment coverage survey
3.3.1. Respondent characteristics
In total, 580 households were surveyed, and 1280 children were
interviewed in both districts. In Munshiganj district, 637 children
were interviewed, with a median age of 7 (range 1–14), of which
53.1% were female. The school attendance rate amongst children
between the ages of 6–12 was 93.2% (95% CI 90.0–96.4). In Laksh-
mipur district, 643 children were interviewed, with a median age of
7 (range 0–14), of which 49.9% were female. The school attendance
rate amongst children between the ages of 6–12 was 86.4% (95% CI
80.8–92.0).
3.3.2. Treatment coverage for children age 6–12 during 2009
The treatment coverage survey revealed that a relatively low
proportion of the school-attending children received mebendazole
during the MDA in May (52.3%, 95% CI 43.6–61.1) and November
(54.3%, 95% CI 44.8–63.8) in Munshiganj district. Almost two thirds
(63.0%, 95% CI 54.0–72.0) of school-attending children in this dis-
trict received mebendazole at least once during a MDA in 2009. In
Lakshmipur district, treatment coverage was slightly higher, with
73.3% (95% CI 66.1–80.5) having received mebendazole at least
once during a MDA in 2009. Treatment coverage during the MDAs
was significantly lower for children not attending school in both
districts, with rates ranging from 14.3% (95% CI 0.0–37.1) to 9.1%
(95% CI 0.0–19.0). Furthermore, 38.7% (95% CI 30.5–47.0) and 26.2%
(95% CI 18.2–34.2) of school-attending children received deworm-
ing treatment elsewhere (i.e. health centers), in Munshiganj and
Lakshmipur respectively. Irrespective of the source of treatment,
approximately 85% of all school-attending children received at least
one deworming treatment during 2009. In addition, results show a
treatment coverage rate of 58.2% (95% CI 51.9–64.4) in Munshiganj,
and 60% (95% CI 52.4–67.6) in Lakshmipur, for pre-school children
between 1 and 5 years of age. Treatment coverage details can be
found in Table 1.

Munshiganj district reported a treatment coverage rate of 69%

after the May 2009 MDA, and 70.7% after the November 2009 MDA. 3.3.3. Treatment coverage for children age 5–14 during 2009
Lakshmipur district reported higher treatment coverage rates of The WHO defines the treatment coverage denominator as the
83.4% after the May 2009 MDA, and 97.4% after the November total number of children between 5 and 14 years of age, irrespec-
2009 MDA (Table 1). The denominator used by the MoH&FW for tive of school attendance. Calculating treatment coverage using the
WHO definition reveals coverage rates of 46.2% (95% CI 38.6–53.8)
and 47.1% (95% CI 38.8–55.4) in Munshiganj district, and 51.4% (95%
Table 1 CI 59.6–43.1) and 54.7% (95% CI 45.4–64.0) in Lakshmipur, for the
Comparison of STH household survey coverage with STH reported coverage (Min- May and November MDAs respectively. Irrespective of the source
istry of Health & Family Welfare), in Munshiganj and Lakshmipur districts, STH
treatment evaluation, Bangladesh, 2010.
of treatment, 79.6% (95% CI 74.5–84.7) of all children in Munshiganj
district received at least one deworming treatment during 2009, for
Treatment coverage 2009 Munshiganj Lakshmipur Lakshmipur, this was 77.3% (95% CI 68.5–86.2). Details can be found
% (95% C.I.) % (95% C.I.)
in Table 1.
School attending children age 6–12 (MoH age target)
Treated during May MDA 52.3 (43.6–61.1) 63.9 (56.3–71.5)
MOH&FW reported coverage* 69.0 83.4 3.4. Household survey
Treated during November MDA 54.3 (44.8–63.8) 68.3 (60.1–76.4)
MOH&FW reported coverage 70.7 97.4
A total of 580 households were interviewed in both districts.
At least one treatment during MDA 63.0 (54.0–72.0) 73.3 (66.1–80.5)
Treated elsewhere 38.7 (30.5–47.0) 26.2 (18.2–34.2) The main source of drinking water for nearly all households came
At least one treatment in 2009 85.1 (793.7–90.4) 85.5 (79.6–91.4) from a tube well (n = 565, 97.4%). The main types of latrines used
Non school attending children age 6–12 by households were a ring slab latrine (63.6–68.7%) and a flush
Treated during May MDA 9.5 (0.0–30.1) 11.4 (0.1–22.6) toilet (29.6–27.3%). Furthermore, almost two thirds of the house-
Treated during November MDA 14.3 (0.0–37.1) 9.1 (0.0–19.0)
All children age 6–14 (WHO age target)
holds were aware of the MDA at school, with the majority of
Treated during May MDA) 46.2 (41.0–51.4) 51.4 (46.2–56.5) households having heard about it through a teacher (46.0–61.5%).
Treated during November MDA 47.1 (41.9–52.3) (45.4–64.0) Regarding STH prevention, general hygiene was a well-known
At least one treatment in 2009 76.4 (67.8–84.9) 79.1 (73.8–84.1) method for preventing infection. In addition, 16 (1.25%) children
Pre-school children age 1–5 58.2 (51.9–64.4) 60.0 (52.4–67.6)
reported adverse experiences after treatment with mebendazole,
 I. Hafiz et al. / Acta Tropica 141 (2015) 385–390 389

Table 2 Table 3
KAP survey results for households in Munshiganj and Lakshmipur districts, STH Access to drinking water and sanitation facilities in schools in Munshiganj and
treatment evaluation, Bangladesh, 2010. Lakshmipur districts, STH treatment evaluation, Bangladesh, 2010.

Household survey Munshiganj (n = 280) Lakshmipur (n = 300) School survey Munshiganj (n = 28) Lakshmipur (n = 30)
N (%) N (%) N (%) N (%)

Drinking water source* Type of latrinea

Tube Well 275 (98.2) 290 (96.7) Flush toilet 21 (75.0) 22 (73.3)
Surface Water 5 (1.8) 0 (0.0) Ring slab latrine 6 (21.4) 9 (30.0)
Tap Water 1 (0.4) 10 (3.3) Other 1 (3.6) 3 (10.0)

Water purification Handwashing arrangement

Nothing 272 (97.0) 285 (95.0) Yes 23 (82.1) 26 (86.7)
Other 7 (2.5) 7 (2.3) Tubewell 11 (39.3) 19 (63.3)
Boil water 1 (0.5) 8 (3.0) By the latrine 7 (25.0) 3 (10.0)
Pond/river 2 (7.1) 3 (10.0)
Type of latrine
Other 2 (7.1) 1 (3.3)
Ring slab latrine 178 (63.6) 206 (68.7)
Unknown 1 (3.6) 0 (0.0)
Flush toilet 83 (29.6) 82 (27.3)
Ventilated latrine 15 (5.4) 10 (3.3) Drinking water sourcea
Field 4 (1.4) 2 (0.7) Tubewell 22 (78.6) 26 (86.7)
a
Other 6 (21.4) 4 (13.3)
STH prevention knowledge
Tap 1 (3.6) 0 (0)
Cleanliness 136 (48.6) 133 (44.3)
a
Washing hands 91 (32.5) 103 (34.3) Multiple answers possible.
Taking drugs 76 (27.1) 63 (21.0)
Unknown 59 (21.1) 77 (25.7)
Other 23 (8.2) 29 (9.7) activities, as this is the primary indicator used for evaluating the
a performance of the STH program. In addition, the use of outdated
Knowledge of deworming day
Aware of the deworming day 189 (67.5) 192 (64.0) census population figures to calculate coverage rates may lead to
School teacherb 87 (46.0) 118 (61.5) over- or under- estimation of the true treatment coverage, further
Mikingb 66 (34.9) 23 (12.0) decreasing the quality of treatment monitoring data (Cakir et al.,
Health workerb 51 (27.0) 54 (28.1)
2008; Mathieu et al., 2003; Zuber et al., 2003).
TVb 29 (15.3) 28 (14.6)
Otherb 11 (5.8) 8 (4.2)
To avoid over- or under-estimation of treatment coverage, and
Leaflet/posterb 2 (1.1) 0 (0.0) to increase the quality of the monitoring data, it is important to
a adhere to the WHO target population definition when calculating
Multiple answers possible.
b
As a percentage of those aware of the deworming day. coverage, therefore including all children between the age of 5 and
14 years in the denominator, irrespective of their school enroll-
ment status (WHO, 2006). Consequently, as of October 2012, the
half of which were gastrointestinal complaints (n = 8). Detailed Bangladeshi MOH&FW has changed their policy to adopt the WHO
results can be found in Table 2. definition.
Several other issues related to the treatment monitoring process
3.5. School survey were identified during the evaluation. First, variances were identi-
fied in the methods used for compiling and reporting treatment
A total of 58 schools were surveyed, 28 in Munshigonj and 30 data at the school level. These methods should be standardized
in Lakshmipur. All of the schools had some type of latrine, most in order to decrease variability between measurements, and avoid
of which were flush toilets (75.0–73.3%). The majority of students complications during aggregation of data at higher levels. To further
were able to use the latrines during school hours (86.7–96.4%). Fur- improve data quality at the school level, it is important that only
thermore, most schools had hand-washing facilities available for pupils treated under direct observation are registered as treated.
their students (82.1–86.7%), and a tube well was the most com- Second, a general lack of financial and human resources avail-
monly used source of drinking water at school (78.6–86.7%). Details able to the control program was identified as an obstacle for
can be found in Table 3. successful treatment monitoring, as is the case for many disease
control programs in developing countries. Scarcity of resources
4. Discussion calls for an effective allocation of that which is available to the
program. Resource allocation should be based on population size
Monitoring treatment coverage provides key information for and geographical situation (i.e. certain sub-districts may require
assessing the performance of STH control programs. The cur- additional resources to distribute mebendazole to remote areas).
rent evaluation combines qualitative and quantitative methods to Furthermore, in comparison with other public health programs
identify challenges in the Munshiganj and Lakshmipur districts in Bangladesh, the deworming program does not provide finan-
related to the treatment monitoring process within the Bangladeshi cial incentives for health workers. Interviewers felt that the lack
mebendazole distribution program. A fundamental issue identified of remuneration affects their motivation for carrying out tasks
during interviews by those involved in the treatment monitoring related to the MDA. The current survey demonstrates the use
system on all levels was the ambiguity of the target population def- of a robust and inexpensive methodology to validate reported
inition, which consequently leads to variations in the calculation of treatment rates in school age children after a school-based dis-
treatment coverage. It was unclear, due to a lack of national policy tribution of mebendazole. Reported treatment coverage rates
for treating non-enrolled school-age children, whether or not to were significantly higher than the surveyed coverage rates in
target this group for treatment, and whether or not to include this both districts, thus overestimating the true treatment coverage.
group in the denominator for treatment coverage calculations. High surveyed coverage rates show that Bangladesh’s national
A clearly defined target population is vital to the M&E process of school-based deworming program has been successful in reaching
control programs (Gyorkos, 2003; WHO, 2010). The use of varying school-attending children aged 6–12 in the two surveyed districts,
target definitions contributes to variances and inaccuracies in cal- and that the existing school infrastructure serves as an effec-
culating treatment coverage, which has a negative effect on M&E tive platform for the delivery of drugs to this high-risk group.
390 I. Hafiz et al. / Acta Tropica 141 (2015) 385–390
However, the WHO target of treatment of at least 75% of school-
age children has not yet been reached in either of the surveyed
districts.
Although various (ad hoc) approaches were identified at the
school level for treating non-enrolled children, treatment coverage
in this group remains particularly low due to the lack of a national
policy to effectively target these children. Our results also confirm
the limitation of school-based programs in missing these already
disadvantaged children, thus exacerbating existing inequities, as
these children are often the most disadvantaged children of the
community (i.e. street children, disabled, living in slums), who are
unable to attend school due to various socio-economical reasons
(Husein et al., 1996; Olsen, 2003). Moreover, this group of children
is particularly at risk of STH infection, with several studies show-
ing higher prevalence rates and intensities of infection (Talaat et al.,
1999; Useh and Ejezie, 1999). The challenge now for the Bangladesh
control program is to achieve the WHO target of regular treatment
of at least 75% of SAC at risk, irrespective of school-enrollment
status. As a consequence, a strategy for encouraging non-school
attending SAC to attend school-based deworming distributions is
now under development.
Survey findings on water and sanitation coverage in the two
districts were impressive. Following the UNICEF/WHO ranking clas-
sification of drinking water and sanitation facilities, the majority
of households and schools had latrines which are classified as
improved sanitation facilities, and the main source of drinking
water for the majority of households and schools was a tube well,
which is considered a safe drinking water source (WHO/UNICEF,
2008). This possibly explains the finding that most households did
nothing to purify their drinking water.
Although treatment through MDA is considered the cornerstone
of STH control, as it is highly effective in reducing STH morbidity,
it does not prevent re-infection. It has been well established that
in order to provide long-lasting interruption of STH transmission,
it is essential to include measures to promote hygiene education,
and to improve access to clean drinking water and sanitation facil-
ities. The promotion of these measures have emerged as one of the
most cost-effective possible interventions in not only preventing
re-infection with STH after mass treatment, but also affecting trans-
mission of several other diseases in developing countries (Bartram
and Cairncross, 2010).
One of the potential limitations of this study is that recall bias,
particularly in young children, is a possible concern for the accuracy
of the observed affect.
Significant progress toward meeting the WHO STH treatment
target has been made in Bangladesh as also indicated by our survey.
Notably, most households and schools have access to latrines and
“improved drinking water sources. Bangladesh has also been suc-
cessful in treating school-attending SAC. Areas for continued effort
include adopting a national standard target definition to be imple-
mented within the Bangladeshi mebendazole distribution program
since a clearly defined target population is vital to STH treatment
monitoring. Additionally, continued efforts must focus on increas-
ing the low treatment coverage among non-school attending SAC.
Based on this survey, we recommend that the non-school attend-
ing SAC population must be reached for Bangladesh (1) to narrow
the inequity gap in STH treatment between children of the lowest
and highest wealth quintile; and (2) to successfully reach the WHO
STH treatment target of at least 75% of SAC.
Acknowledgements
The authors wish to thank the survey staff, program staff of the
Filariasis Elimination and STH Control Program, and the Directorate
General of Health Services under the Ministry of Health and Family
Welfare of Bangladesh for their support.
Disclaimer: The findings and conclusions in this report are the
findings and conclusions of the authors and do not necessarily rep-
resent the views of the Centers for Disease Control and Prevention
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