Asia-Pacific Journal of Public Health

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Sentinel Surveillance of Soil-Transmitted Helminthiasis in Selected Local Government

Units in the Philippines
Vicente Y. Belizario, Jr, Winifreda U. de Leon, Yvonne F. Lumampao, Marilyn Benedith M. Anastacio
and Cyndi Mae C. Tai
Asia Pac J Public Health 2009 21: 26 originally published online 13 November 2008
DOI: 10.1177/1010539508327245

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 Asia-Pacific Journal of
Public Health
Volume 21 Number 1

Sentinel Surveillance of January 2009 26-42

© 2009 APJPH
10.1177/1010539508327245
Soil-Transmitted Helminthiasis http://aph.sagepub.com
hosted at

in Selected Local Government http://online.sagepub.com

Units in the Philippines

Vicente Y. Belizario Jr, MD, MTM&H, Winifreda U. de Leon, DAP&E, MPH,
Yvonne F. Lumampao, MD, MPH, Marilyn Benedith M. Anastacio, MD,
Cyndi Mae C. Tai, BSPH

This study describes baseline prevalence and intensity of soil-transmitted helminth infections as
well as baseline anthropometric and school performance data among public elementary school
children in 6 sentinel provinces in the Philippines. Stratified cluster sampling was used to select
6 provinces, where grade 3 elementary school pupils were surveyed. Secondary anthropometric
data and achievement test results of the immediate past academic year were examined. Overall
cumulative prevalence and proportion of heavy intensity infections for the 6 selected provinces
were 54.0% and 23.1%, respectively. These recent findings further support the need for mass
treatment to be given at least twice a year. The findings of the study also demonstrate the rela-
tionship that exists between worm burden and nutritional status. Strategies focusing on mass
treatment integration, environmental sanitation, personal hygiene, and health education should
be developed to control soil-transmitted helminth infections and their detrimental effects.

Keywords: integrated helminth control; nutritional status; Philippines; Schistosoma japon-

icum; soil-transmitted helminthes

S
oil-transmitted helminth (STH) infections, commonly affecting children, are reported
in almost all countries in Asia, including the Philippines. An Integrated Helminth
Control Program is currently being proposed by the Department of Health (DOH) for
implementation as a response to the continuing challenge posed by STH infections. This
program aims to permit coordination of nationwide mass deworming activities from plan-
ning, implementation, integrated delivery schemes, advocacy, networking, health promotion,
monitoring, and evaluation. The DOH National Center for Disease Prevention and Control
(DOH-NCDPC) spearheads the program in collaboration with other government agencies
such as the Department of Education (DepEd), Department of Social Welfare and
Development (DSWD), Department of Interior and Local Governments (DILG), non-
government agencies, academic institutions, and international agencies.

From National Institutes of Health (VYB, MBMA, CMCT) and College of Public Health (WUdL), University of the
Philippines Manila; and Department of Health (YFL), Manila, the Philippines.

Address correspondence to: Vicente Y. Belizario Jr, National Institutes of Health, University of the Philippines Manila, P.
Gil St., Ermita, Manila 1000, the Philippines; e-mail: vbelizar@yahoo.com.

26

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 Sentinel Surveillance of Soil-Transmitted Helminthiasis / Belizario et al 27

Whereas data on the 2004 national STH prevalence study supported by the United
Nations Children’s Fund are available, the DOH implements a few strategies in the area of
worm control such as the Garantisadong Pambata, and the DepEd implements deworming
of school entrants. In addition, mass drug administration (MDA) for lymphatic filariasis
(LF) elimination is being implemented in endemic areas with the administration of alben-
dazole plus diethylcarbamazine (DEC) to individuals aged ≥2 years. Because all these major
interventions, among others, may have had an impact on STH prevalence, a baseline assess-
ment may be useful in tracking down changes in monitoring parameters over time. Baseline
assessment will aid in describing the impact of the integrated helminth control. This study
aimed to describe baseline prevalence and intensity of STH infections among public ele-
mentary school children in 6 selected provinces, and baseline anthropometric and school
performance data as reported by the DepEd school division offices.

Methodology

Study Site and Population

The study used stratified cluster sampling to select provinces in the 3 island groups in the
Philippines. The selected provinces were Bulacan and Camarines Sur in Luzon, Negros
Occidental and Leyte in Visayas, and Compostela Valley and Surigao del Norte in
Mindanao. Provinces selected were representative for the region where they belong and not
the country in general.
Two school districts selected by systematic random sampling represented each province.
Four public elementary schools represented each school district, selected with probability
proportional to the size of grade 3 students. A sample size of 3600 participants, divided into
1200 participants per island group was targeted. The sample size was estimated based on
the data that each of the 3 island groups had at least 50% STH prevalence. This is made on
the basis that 50% STH prevalence is the cut-off point in the determination of high-risk
communities, which require twice a year mass treatment.1

Baseline Parasitologic Assessment

This study was done prior to the MDA in the LF endemic areas of Camarines Sur, Leyte,
Compostela Valley, and Surigao del Norte. Stool cups were distributed to pupils with appro-
priate collection instructions. Stool samples were sent to the field laboratory for analysis
using Kato-Katz method.2 Processing and initial reading were performed by the DOH
Provincial Health Team (PHT) trained microscopists. Data gathered were used to derive the
cumulative prevalence, prevalence of STH species, and intensities of STH infections
reported as eggs per gram (epg) and classified as light, moderate, or heavy according to the
World Health Organization (WHO) classification.3 Geometric mean egg count (GMEC) was
also computed. For the purposes of this study, moderate to heavy intensities of STH infec-
tions were combined and considered “heavy” for the determination of the overall proportion
of heavy infections. A total of 10% of all negative slides were reexamined blindly by a refer-
ence microscopist from the University of the Philippines Manila to ensure accuracy. Data
were encoded and analyzed using Stata 8.0 software.

Nutritional Status Assessment

Secondary anthropometric data, taken and collated by school nurses during the immediate
past academic year (school year 2005-2006), were requested and retrieved from the School

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28 Asia-Pacific Journal of Public Health / Vol. 21, No. 1, January 2009

Health and Nutrition Center of the DepEd. These anthropometric measurements are clas-
sified by the DepEd and DOH using the International Reference Standard (IRS). The same
method of reporting was used in the study. Furthermore, nutritional status per school dis-
trict was evaluated. The overall weight-for-age/body mass index (BMI) and height-for-age
data per division were also assessed, the sums of which were computed to reflect the over-
all nutritional status of the pupils in the selected provinces.

School Performance Assessment

Achievement tests are given to Filipino school children to evaluate school performance at
the end of each academic year. The National Achievement Test (NAT) is given by the
National Education Testing and Research Center of the DepEd National Office. This mea-
sures the learning outcomes of students in the elementary level as recommended by the
Congressional Commission on Education. The Division Achievement Test (DAT) is given to
students of all levels by the Division Office of the DepEd, the results of which are used in
assessing the performance of schools in a division. The DAT is a nonstandardized examina-
tion administered depending on the policies of the DepEd School Divisions.

Results

Baseline Parasitologic Assessment

A total of 3373 pupils submitted stool samples and 1820 were found positive for STH infec-
tion giving an overall cumulative prevalence of 54.0%. Cumulative prevalence ranged from
33.2% in Compostela Valley to 67.4% in Negros Occidental. In all, 4 of the 6 provinces had
a cumulative prevalence higher than 50%. The rates in Bulacan and Compostela Valley were
lower than 50% (Table 1).
Among the selected school districts, the highest cumulative prevalence was observed in
Hinigaran I in Negros Occidental at 91.6%, whereas the lowest cumulative prevalence of
21.3% was noted in Laak in Compostela Valley. The cumulative prevalence was higher than
50% in half of the school districts surveyed.
The overall proportion of heavy intensity infections was 23.1% with 4 of the 6 provinces,
namely, Camarines Sur, Negros Occidental, Leyte, and Surigao del Norte, having a propor-
tion greater than 10%. Bulacan and Compostela Valley had proportions of heavy intensity
infection less than 10%. Among the 12 school districts, the highest overall proportion of
heavy intensity infection was 64.0% in Hinigaran I in Negros Occidental (Table 1).
Ascaris infections were seen in 38.6% of the pupils examined. Ascariasis prevalence was
highest in Leyte at 51.7% and lowest in Compostela Valley at 21.0%. More than 50% of
pupils examined had moderate to heavy intensities of ascariasis. The overall GMEC for
Ascaris was 22.4 epg. The highest GMEC for Ascaris was seen in Camarines Sur at 59.7 epg,
and was lowest in Bulacan at 2.0 epg (Table 2).
Trichuris infection was seen in 38.5% of the pupils examined. The prevalence of
trichuriasis was highest in Negros Occidental at 59.8%, whereas it was lowest in
Compostela Valley at 14.5%. Moderate to heavy intensities of trichuriasis were seen in
26.5% of the pupils examined. The overall GMEC for Trichuris was 8.5 epg. GMEC for
Trichuris was highest in Negros Occidental at 63.9 epg and lowest in Compostela Valley at
1.1 epg (Table 3).
Hookworm infection was seen in 3.8% of pupils examined. The prevalence of hookworm
infection was highest in Leyte and Compostela Valley at 7.4% and 7.5%, respectively.

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 Sentinel Surveillance of Soil-Transmitted Helminthiasis / Belizario et al 29

Table 1. Cumulative Prevalence and Proportion of Heavy-Intensity

Infections in Selected Sentinel Provinces, 2006

Number of Number Proportion

Selected School Pupils of Positives, of Heavy
Provinces Districts Examined n (%) Intensity, n (%)

Bulacan Angat 196 79 (40.3) 12 (6.1)

Norzagaray 270 92 (34.1) 10 (3.7)
Subtotal 466 171 (36.7) 22 (4.7)

Camarines Sur Magarao-Bombon 300 130 (43.3) 52 (17.3)

Sagnay 302 227 (75.2) 136 (45.0)
Subtotal 602 357 (59.3) 188 (31.2)

Negros Occidental La Castellana II 266 116 (43.6) 21 (7.9)

Hinigaran I 261 239 (91.6) 167 (64.0)
Subtotal 527 355 (67.4) 188 (35.7)

Leyte Barugo I 262 198 (75.6) 84 (32.1)

Matalom North 264 134 (50.8) 40 (15.2)
Subtotal 526 332 (63.1) 124 (23.6)

Compostela Valley Compostela 300 135 (45.0) 47 (15.7)

Laak 300 64 (21.3) 6 (2.0)
Subtotal 600 199 (33.2) 53 (8.8)
Surigao del Norte Loreto 327 213 (65.1) 119 (36.4)
Mainit 325 193 (59.4) 84 (25.8)
Subtotal 652 406 (62.3) 203 (31.1)
Total 3373 1820 (54.0) 778 (23.1)

Moderate to heavy intensities of hookworm infections were seen in 11.0%. Proportion of

moderate to heavy intensities of hookworm infections was higher than the overall rate in
Leyte at 23.1%. The overall GMEC for hookworm infection was 0.2 epg. GMEC for hook-
worm was highest in Leyte at 0.6 epg (Table 4).
Other parasites seen in the pupils examined included the following: Heterophyid sp.
(1.7%), Schistosoma japonicum (1.2%), and Enterobius vermicularis (0.4%). Schistosomiasis
was seen in the provinces of Compostela Valley, Surigao del Norte, Negros Occidental, and
Leyte. Heterophydiasis was seen in Compostela Valley and Surigao del Norte (Table 5).

Quality Control
Validation of 10% of all negative slides showed a false negative rate of 13.2%, which means
that about 1 out of 10 negative slides were truly positive. If such a false negative rate is
applied as correction factor, the resulting cumulative prevalence is about 60.0%. In terms of
the ability to identify specific parasite species, the false negative rate was higher for Ascaris
at 7.3% compared with 6.0% for Trichuris. Most slides read as false negative actually had
unfertilized Ascaris eggs and low Trichuris egg counts.

Nutritional Status and School Performance Assessment

Among the 6 provinces, only 5 submitted results on nutritional status. In the areas with data
submitted, 14.8% of the pupils measured had weights/BMI below normal for their age,
whereas 83.2% had weights/BMI normal for their age. Proportion of pupils with below

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 30
Table 2. Ascaris Infection Rate and Intensity of Infection in Selected Sentinel Provinces, 2006

Pupils Ascariasis
Number of Infected Geometric Light Moderate Heavy
Selected School Pupils Mean Egg
Province Districts Examined n Percentage Count n Percentage n Percentage n Percentage

Bulacan Angat 196 50 25.5 2.2 41 82.0 1 2.0 8 16.0

Norzagaray 270 52 19.3 1.8 43 82.7 4 7.7 5 9.6
Subtotal 466 102 21.9 2.0 84 82.4 5 4.9 13 12.7

Camarines Sur Magarao-Bombon 300 89 29.7 12.1 41 46.1 34 38.2 14 15.7

Sagnay 302 190 62.9 278.0 67 35.3 89 46.8 34 17.9
Subtotal 602 279 46.3 59.7 108 38.7 123 44.1 48 17.2

Negros Occidental La Castellana II 266 52 19.5 2.2 42 80.8 6 11.5 4 7.7

Hinigaran I 261 181 69.3 484.4 57 31.5 95 52.5 29 16.0
Subtotal 527 233 44.2 37.5 99 42.5 101 43.3 33 14.2

Leyte Barugo I 262 164 62.6 146.1 91 55.5 69 42.1 4 2.4

Matalom North 264 108 40.9 20.2 73 67.6 32 29.6 3 2.8
Subtotal 526 272 51.7 54.7 164 60.3 101 37.1 7 2.6

Compostela Valley Compostela 300 100 33.3 13.5 56 56.0 33 33.0 11 11.0

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Laak 300 26 8.7 1.0 20 76.9 6 23.1 0 0
Subtotal 600 126 21.0 4.4 76 60.3 39 31.0 11 8.7

Surigao del Norte Loreto 327 159 48.6 92.2 48 30.2 71 44.6 40 25.2
Mainit 325 130 40.0 30.4 56 43.1 45 34.6 29 22.3
Subtotal 652 289 44.3 53.2 104 36.0 116 40.1 69 23.9
Total 3373 1301 38.6 22.4 635 48.8 485 37.3 181 13.9
 Table 3. Trichuris Infection Rate and Intensity of Infection in Selected Sentinel Provinces, 2006

Pupils Trichuriasis
Number Infected Geometric Light Moderate Heavy
Selected School of Pupils Mean Egg
Province Districts Examined n Percentage Count n Percentage n Percentage n Percentage

Bulacan Angat 196 51 26.0 2.3 48 94.1 2 3.9 1 2.0

Norzagaray 270 61 22.6 1.8 60 98.4 1 1.6 0 0.0
Subtotal 466 112 24.0 2.0 108 96.4 3 2.7 1 0.9

Camarines Sur Magarao-Bombon 300 81 27.0 3.3 66 81.5 14 17.3 1 1.2

Sagnay 302 160 53.0 25.6 110 68.7 39 24.4 11 6.9
Subtotal 602 241 40.0 9.7 176 73.0 53 22.0 12 5.0

Negros Occidental La Castellana II 266 89 33.5 5.5 76 85.4 11 12.4 2 2.2

Hinigaran I 261 226 86.6 673.0 82 36.3 107 47.3 37 16.4
Subtotal 527 315 59.8 63.9 158 50.1 118 37.5 39 12.4

Leyte Barugo I 262 166 63.4 32.5 130 78.3 36 21.7 0 0

Matalom North 264 81 30.7 3.6 70 86.4 11 13.6 0 0
Subtotal 526 247 47.0 11.4 200 81.0 47 19.0 0 0

Compostela Valley Compostela 300 65 21.7 2.1 57 87.7 8 12.3 0 0

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Laak 300 22 7.3 0.4 22 100.0 0 0 0 0
Subtotal 600 87 14.5 1.1 79 90.8 8 9.2 0 0

Surigao del Norte Loreto 327 156 47.7 14.4 122 78.2 30 19.2 4 2.6
Mainit 325 142 43.7 10.6 112 78.9 30 21.1 0 0
Subtotal 652 298 45.7 12.4 234 78.5 60 20.1 4 1.4
Total 3373 1,300 38.5 8.5 955 73.5 289 22.2 56 4.3

31
 32
Table 4. Hookworm Infection Rate and Intensity of Infection in Selected Sentinel Provinces, 2006

Pupils Hookworm
Number Infected Geometric Light Moderate Heavy
Selected School of Pupils Mean Egg
Province Districts Examined n Percentage Count n Percentage n Percentage n Percentage

Bulacan Angat 196 9 4.6 0.3 8 88.9 0 0 1 11.1

Norzagaray 270 7 2.6 0.1 7 100.0 0 0 0 0
Subtotal 466 16 3.4 0.2 15 93.7 0 0 1 6.3

Camarines Sur Magarao-Bombon 300 0 0.0 0.0 0 0 0 0 0 0

Sagnay 302 3 1.0 0.1 3 100.0 0 0 0 0
Subtotal 602 3 0.5 0.02 3 100.0 0 0 0 0

Negros Occidental La Castellana II 266 6 2.3 0.1 5 83.3 0 0 1 16.7

Hinigaran I 261 5 1.9 0.1 5 100.0 0 0 0 0
Subtotal 527 11 2.1 0.1 10 90.9 0 0 1 9.1

Leyte Barugo I 262 32 12.2 1.2 23 71.9 5 12.5 4 12.5

Matalom North 264 7 2.7 0.2 6 85.7 1 14.3 0 0
Subtotal 526 39 7.4 0.6 29 74.4 6 12.8 4 10.3

Compostela Valley Compostela 300 16 5.3 0.6 16 100.0 0 0 0 0

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Laak 300 29 9.7 0.1 27 93.1 2 6.9 0 0
Subtotal 600 45 7.5 0.4 43 95.6 2 4.4 0 0

Surigao del Norte Loreto 327 5 1.5 0.1 5 100.0 0 0 0 0

Mainit 325 8 2.5 0.1 8 100.0 0 0 0 0
Subtotal 652 13 2.0 0.1 13 100.0 0 0 0 0
Total 3373 127 3.8 0.2 113 89.0 8 6.3 6 4.7
 Sentinel Surveillance of Soil-Transmitted Helminthiasis / Belizario et al 33

Table 5. Other Parasites Seen According to Species in Selected Sentinel Provinces, 2006

Enterobius Schistosoma
Number vermicularis japonicum Heterophyid sp.
Selected of Pupils
Province Examined N Percentage n Percentage n Percentage

Bulacan 466 1 0.2 0 0 0 0

Camarines Sur 602 3 0.5 0 0 0 0
Negros Occidental 527 0 0 3 0 0 0
Leyte 526 0 0 3 0.6 0 0
Compostela Valley 600 6 1.0 11 1.8 51 8.5
Surigao del Norte 652 4 0.6 24 3.7 7 1.1
Total 3373 14 0.4 41 1.2 58 1.7

normal weight-for-age/BMI measurements was highest in the provinces of Leyte at 21.5%

and Surigao del Norte at 21.4%, whereas Bulacan had the lowest at 7.1% (Table 6).
Approximately 19.0% of the pupils measured had below normal height-for-age or were
stunted, whereas 78.8% had normal height-for-age. Among the provinces with data, Leyte
had the highest proportion of stunted pupils at 42.8%, whereas Bulacan had the lowest pro-
portion of stunted pupils at 7.2% (Table 7).
Only 4 of the 6 provinces submitted NAT results. All district level and division level data
on average marks per subject (MPS) from the 4 provinces were below the competence level
of 75%, except for the school district of Loreto in Surigao del Norte, which had an average
MPS of 76.40% (Table 8).
Only 1 of the 6 provinces submitted DAT results. Negros Occidental had average MPS
(58.19%) below the competence level of 75%, although at the school district level, Hinigaran
I reported an average MPS (77.28%) above the competence level of 75% (Table 9).
Due to a calamity, Camarines Sur was unable to submit data on the nutritional status
and school performance. Bulacan was unable to submit data on school performance before
the completion of this final report. Data on the DAT results of Surigao del Norte and Leyte
were not available because the school division offices do not administer the said test.
Compostela Valley did not conduct the DAT in the previous school year.

Discussion

Baseline Parasitologic Assessment

Overall cumulative prevalence and overall proportion of heavy-intensity STH infections
revealed that the 6 selected provinces are high-risk communities (Figure 1). These may sug-
gest a lack of effective control of STH infections in spite of the many initiatives of the health
and education sectors. There may be a need to reexamine existing helminth control strate-
gies and indicators of success, such as coverage of treatment, coverage and utilization of
sanitary toilets, and personal hygiene.
The MDA strategy for LF elimination started in some endemic provinces in 2001. In
the nationwide parasitologic study done in 2004, Region V and most of the regions in
Mindanao had higher than 50% STH cumulative prevalence.4 After 2 years, the cumulative
prevalence of the LF endemic provinces of Camarines Sur, Leyte, and Surigao del Norte
were still higher than 50%. On the other hand, Compostela Valley, another endemic area,
has a figure much lower than 50%, which may indicate effectiveness of albendazole admin-
istered with DEC for LF, among others things. The province of Negros Occidental, not

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 34
Table 6. Weight-for-Age/Body Mass Index of Pupils in Selected Provinces and School Districts, School Year 2005-2006a

Weight-for-Age/Body Mass Index

Number Below Normal Normal Above Normal

of Pupils
Province School Districts Measured n Percentage n Percentage n Percentage

Bulacan Angat 5716 512 9.0 5099 89.2 105 1.8

Norzagaray 15 927 644 4.0 15 151 95.2 132 0.8
Overall for the province 250 999 17 803 7.1 229 520 91.4 3676 1.5

Camarines Sur Magarao-Bombon

Sagnay Data not available
Overall for the province

Negros Occidental La Castellana II 4096 1139 27.8 2874 70.2 83 2.0

Hinigaran I 6272 1938 30.9 3995 63.7 339 5.4
Overall for the province 216 118 37 994 17.6 169 631 78.5 8493 3.9

Leyte Barugo I 2998 765 25.5 2150 71.7 83 2.8

Matalom North 2442 288 11.8 2143 87.8 11 0.4
Overall for the province 209 690 45 012 21.5 162 090 77.3 2588 1.2

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Compostela Valley Compostela 10 502 1376 13.1 8966 85.4 160 1.5
Laak 10 461 1450 13.9 8912 85.2 99 0.9
Overall for the province 99 873 11 415 11.4 87 442 87.6 1016 1.0

Surigao del Norte Loreto 1317 336 25.5 899 68.3 82 6.2
Mainit 4093 847 20.7 3233 79.0 13 0.3
Overall for the province 37 701 8063 21.4 29 168 77.4 470 1.2
Overall for the 5 provinces 814 381 120 287 14.8 677 851 83.2 16 243 2.0
a
Adapted from Department of Education (2006).
 Table 7. Height-for-Age Status of Pupils in Selected Provinces and School Districts, School Year 2005-2006a

Height-for-Age

Number Below Normal Normal Above Normal

of Pupils
Province School Districts Measured n Percentage n Percentage n Percentage

Bulacan Angat 3810 310 8.1 3461 90.8 39 1.1

Norzagaray 11526 545 4.7 10908 94.6 73 0.7
Overall for the province 179121 12914 7.2 163702 91.4 2505 1.4

Camarines Sur Magarao-Bombon

Sagnay Data not available
Overall for the province

Negros Occidental La Castellana II 1715 251 14.6 1452 84.7 12 0.7

Hinigaran I 3308 860 26.0 2415 73.0 33 1.0
Overall for the province 216 115 45 795 21.2 163 901 75.8 6419 3.0

Leyte Barugo I 1789 490 27.4 1296 72.4 3 0.2

Matalom North 893 292 32.7 601 67.3 0 0.0
Overall for the province 71 028 30 413 42.8 39 746 56.0 869 1.2

Compostela Valley Compostela 7174 1076 15.0 5984 83.4 114 1.6

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Laak 5598 1329 23.7 4241 75.8 28 0.5
Overall for the province 57 501 10 219 17.8 46 033 80.0 1249 2.2

Surigao del Norte Loreto 1317 161 12.2 1156 87.8 0 0.0
Mainit 2881 1050 36.4 1831 63.6 0 0.0
Overall for the province 22 078 4487 20.3 17 009 77.0 582 2.7

Overall for the 5 provinces 545 843 103 828 19.0 430 391 78.8 11 624 2.1
a
Adapted from Department of Education (2006).

35
 36
Table 8. National Achievement Test Results of Selected Provinces and School Districts, School Year 2005-2006a
Province School Districts Math English Science Filipino Hekasi Average

Bulacan Angat
Norzagaray Data not available
Overall for the province

Camarines Sur Magarao-Bombon

Sagnay Data not available
Overall for the province

Negros Occidental La Castellana II 42.36 48.20 44.37 56.20 55.34 49.29

Hinigaran I 55.13 55.06 49.51 60.98 61.47 56.43
Overall for the province 43.46 46.73 41.44 55.22 50.77 47.52

Leyte Barugo I 73.89 75.29 66.23 74.57 76.79 73.75

Matalom North 67.17 53.78 46.87 55.86 55.21 55.78
Overall for the province 65.12 63.11 52.56 64.23 64.04 61.81

Compostella Valley Compostela 53.93 58.65 51.09 59.88 59.11 56.53

Laak 47.46 45.54 44.18 54.33 53.35 49.28

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Overall for the province 56.15 55.81 51.01 60.25 61.73 56.99

Surigao del Norte Loreto 82.83 77.32 70.53 77.28 74.53 76.40
Mainit 85.70 86.97 60.25 68.78 71.42 66.63
Overall for the province 72.49 70.63 62.20 70.60 75.60 70.30
a
Adapted from Department of Education (2006).
 Table 9. Division Achievement Test Results of Selected Provinces and School Districts, School Year 2005-2006a

Province School District Math English Science Filipino Hekasi Average

Bulacan Angat Data not available

Norzagaray
Overall

Camarines Sur Magarao-Bombon Data not available

Sagnay
Overall

Negros Occidental La Castellana II 52.22 57.39 45.38 46.14 58.81 52.00

Hinigaran I 79.71 75.03 76.02 78.48 77.14 77.28
Overall 46.39 58.50 53.67 67.33 64.84 58.19

Leyte Barugo I Data not available

Matalom North
Overall

Compostella Valley Compostela Data not available

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Laak
Overall

Surigao del Norte Loreto Data not available

Mainit
Overall
a
Adapted from Department of Education (2006).

37
38 Asia-Pacific Journal of Public Health / Vol. 21, No. 1, January 2009

Proportion
No. of pupils No. of
Provinces School districts of heavy
examined positives (%)
intensity (%)
Angat 196 79 (40.3) 12 (6.1)
Bulacan Norzagaray 270 92 (34.1) 10 (3.7)
Subtotal 466 171 (36.7) 22 (4.7)
Magarao-Bombon 300 130 (43.3) 52 (17.3)
Camarines Sur Sagnay 302 227 (75.2) 136 (45.0)
Subtotal 602 357 (59.3) 188 (31.2)
La Castellana II 266 116 (43.6) 21 (7.9)
Negros Occidental Hinigaran I 261 239 (91.6) 167 (64.0)
Subtotal 527 355 (67.4) 188 (35.7)
Barugo I 262 198 (75.6) 84 (32.1)
Leyte Matalom North 264 134 (50.8) 40 (15.2)
Subtotal 526 332 (63.1) 124 (23.6)
Compostela 300 135 (45.0) 47 (15.7)
Compostela Valley Laak 300 64 (21.3) 6 (2.0)
Subtotal 600 199 (33.2) 53 (8.8)
Loreto 327 213 (65.1) 119 (36.4)
Surigao del Norte Mainit 325 193 (59.4) 84 (25.8)
Subtotal 652 406 (62.3) 203 (31.1)
Total 3,373 1,820 (54.0) 778 (23.1)

Figure 1. Map of the Philippines with cumulative prevalence and proportion of heavy intensity soil-transmitted
helminth (STH) infections in the selected sentinel provinces, 2006.

known to be endemic for LF, had 67.4% infection rate. This area deserves support for imple-
mentation of a mass treatment strategy for intestinal helminth control because it is not get-
ting enough allocation of albendazole.
Communities are classified based on parasitologic survey results. This will determine
the frequency of chemotherapy in the target population and the urgency for health educa-
tion and sanitation control measures.3 Category I communities have cumulative prevalence
≥70% and/or an overall proportion of heavy intensity infection exceeding 10%.5 The
provinces of Camarines Sur, Negros Occidental, Leyte, and Surigao del Norte fall under this
category. Mass treatment with single dose twice a year albendazole 400 mg or mebendazole
500 mg tablets under this category is generally given once a year. However, those who may
suffer from greater morbidity, with particular reference to women of child-bearing age,
preschool children, and school-age children, are given treatment 2 to 3 times a year. The
classification also implies that the sanitary conditions in the communities are extremely
poor. Sustained periodic treatment will result in reduction of the number of heavy intensity
infections and will help control STH infection morbidity. The prevalence of STH infections
in these communities may not be easily brought down to near zero values unless there are
major improvements in environmental conditions and/or human behavior.3
Bulacan and Compostela Valley provinces fall under category III. In this category, the
communities have cumulative prevalence of less than 50% and overall proportion of heavy
intensity infections of less than 10%.5 The standards of sanitation in the communities also need
improvement. The recommended interventions include proper management and treatment of

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 Sentinel Surveillance of Soil-Transmitted Helminthiasis / Belizario et al 39

only those with STH infections, and mass treatment is not advocated.5 However, local condi-
tions in the Philippines pose great challenges in the implementation of stool examinations cov-
ering a huge number of individuals and treating only those with STH infections. A more feasible
and cost-effective approach may be to administer mass treatment once a year to pupils in the
school setting.1,6
Overall hookworm infection rate was only 3.8%. The low hookworm infection rate in
most of the provinces may mean that urbanization and health education, focusing on the
use of footwear, may have made an impact. This observation could also be attributed to the
limitations of the Kato-Katz technique. The Kato-Katz smears may rapidly deteriorate in dry
climates, affecting slide egg counts especially those reexamined after prolonged storage.7
Also, hookworm eggs tend to dissolve after the preparation of the slide smears.8,9
S. japonicum and heterophyid sp. were the other significant parasites noted on para-
sitologic examination. Infections caused by these parasites may also reduce productivity and
quality of life of affected individuals. Aside from the Philippines, schistosomiasis still poses
as a public health problem in China, Cambodia, and Laos.10 Schistosomiasis has long been
endemic in Compostela Valley, Surigao del Norte, and Leyte,11 whereas Negros Occidental
has only been recently identified as an endemic area specifically in the municipality of
Calatrava (Belizario and de Leon, unpublished report). This is the first report of schistoso-
miasis in the municipalities of La Castellana II and Hinigaran I. Further studies looking into
clinical, epidemiological, and sociobehavioral aspects of schistosomiasis in these new areas
are recommended to formulate a rational approach for control and prevention.
Reexamination of 10% of the negative slides revealed an overall false negative rate of
13.2%. Accurate identification of the parasites seen in field surveys remains dependent on
the expertise of the microscopist. The relatively fair performance as shown by the relatively
low false negative rate may have reflected the trainings and seminars that the field micro-
scopists have received, thus, emphasizing the need for continued training of the laboratory
staff in diagnosis of STH infections.
The high prevalence of STH infections may be attributed to poverty, poor environmen-
tal hygiene, and impoverished health services.12 Mass treatment with single dose twice a
year albendazole 400 mg or mebendazole 500 mg tablets are used for preventive chemother-
apy for STH infections.5 However, this intervention strategy will be more effective and the
subsequent rounds of treatment would be accepted in the communities, if proper informa-
tion about the aims and objectives of the program are disseminated in the concerned areas.1
Coverage is an important factor considered during mass treatment administration.
Although 75% coverage rate is recommended by WHO experts, a higher coverage rate will
translate to higher possibility of eliminating more worms thereby resulting in a higher reduc-
tion in morbidity.5 Whether the recommended target coverage will work in the Philippine
setting or not may be established by future studies.

Nutritional Status and School Performance Assessment

Related With STH Infections
The proportion of pupils who were underweight (14.8%) and/or stunted (19.0%) for the
selected provinces in this study were found to be lower than the national figures for children
in the age group of 6 to 10 years reported in 2003, which were 26.7% and 36.5%, respec-
tively.13 Various factors may account for the undernutrition observed in school-age children.
Inadequate food intake due to poor eating habits and practices may lead to undernourishment.
Intestinal parasitism is also implicated as one of the leading reasons for undernutrition.14
Bulacan, which had the lowest proportion of underweight and/or stunted pupils, also had the
lowest proportion of heavy intensity of STH infections. The province of Compostela Valley had the

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40 Asia-Pacific Journal of Public Health / Vol. 21, No. 1, January 2009

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B CS NO L CV SN

B - Bulacan
negative STH infection
CS - Camarines Sur
light intensity STH infection
NO - Negros Occidental
moderate to heavy intensity STH infection
L - Leyte
below normal weight/BMI
CV - Compostela Valley
below normal height
SN - Surigao del Norte

Figure 2. Summary of the proportion of intensity of soil-transmitted helminth (STH) infections and nutritional
status by province, 2006.

second lowest proportion of underweight and/or stunted pupils. In the school district level, Laak
had one of the lowest proportions of underweight pupils, as well as the lowest cumulative preva-
lence of STH infections and the lowest proportion of pupils heavily infected with STH.
Negros Occidental had the lowest NAT average MPS. The school districts of Hinigaran
I and La Castellana II, both from the said province, had the highest proportion of under-
weight pupils. Hinigaran I also had the highest cumulative prevalence of STH infections
and the highest proportion of pupils heavily infected.
Leyte had the highest proportion of underweight and/or stunted pupils, whereas Surigao
del Norte had the second highest proportion of underweight pupils. Both provinces had
cumulative prevalence levels of STH infections that were greater than 50%. The NAT aver-
age MPS of Surigao del Norte and Leyte were below the competence level of 75%. These
findings demonstrate the relationship that exists between STH infection and nutritional sta-
tus. Furthermore, these results may reflect the impact of subtle morbidities of STH infec-
tions, such as poor nutritional status and poor school performance, which may later lead to
diminished productivity and quality of life (Figures 2 and 3).5,15,16
A limitation of the study was that data on the nutritional status and school performance
of the pupils were secondary. School nurses in the various areas were tasked to measure the
weights and heights of the pupils, which may have entailed interobserver variability and
instrument-to-instrument variability, unless careful standardization of techniques and
instruments had been done. There was general difficulty in retrieving secondary data from
the DepEd. A database system that collects, processes, and provides data on the health sta-
tus and school performance of pupils useful for policy and planning is highly recommended.
Economic progress and development of an efficient public health system can create sus-
tainable control of helminth infections as evidenced by Japan and Korea. The key elements
for a successful implementation of helminth control at the local level are identifying prior-
ities, building capacities, and availability of financial support and partnership with stake-
holders. Also, a strong political commitment on the part of the government is needed to
achieve effective control of helminth infections in the Philippines and in other countries in
the Asia Pacific Region.17

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 Sentinel Surveillance of Soil-Transmitted Helminthiasis / Belizario et al 41

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B1 B2 CS1 CS2 NO1 NO2 L1 L2 CV1 CV2 SN1 SN2

negative STH infection

B1 - Angat light intensity STH infection
moderate to heavy intensity STH infection
B2 - Norzagaray below normal weight/BMI
CS1 - Magarao-Bombon below normal height

CS2 - Sagnay
NO1 - La Castellana II
NO2 - Hinigaran I
L1 - Barugo I
L2 - Matalom North
CV1 - Compostela
CV2 - Laak
SN1 - Loreto
SN2 - Mainit

Figure 3. Summary of the proportion of intensity of soil-transmitted helminth (STH) infections and nutritional
status assessment by school district, 2006.

A multifaceted social mobilization campaign against STH infections encompassing dif-

ferent types of media and components of the society should be organized. School-based
strategies are strongly recommended to address the high prevalence of parasitic infections
and malnutrition. Also, monitoring will ensure that programs are run effectively and effi-
ciently by health and school authorities and that maximal benefit is attained by infected
individuals, their families, and their communities.18 The complementary roles played by
the Local Government Unit, the DepEd, and the community will be most crucial in the
successful implementation of the Integrated Helminth Control Program.

Acknowledgments

This project would not have been successful without the invaluable support and assistance
of the officials and staff of the UNICEF, the DOH Central Office, and the DOH Center for
Health Development STH Coordinators and Provincial Health Team of Regions III, V, VI,
VIII, XI, and Caraga Region, and the DepEd Central Office and the DepEd for Regions III,
V, VI, VIII, XI, and Caraga Region.
The research team would also like to acknowledge the effort of the principals/school
heads, school nurses, and school teachers of the following school districts included in the
study: Angat and Norzargaray in Bulacan, Magarao-Bombon and Sagnay in Camarines Sur, La

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42 Asia-Pacific Journal of Public Health / Vol. 21, No. 1, January 2009

Castellana II and Hinigaran I in Negros Occidental, Barugo I and Matalom North in Leyte,
Compostela and Laak in Compostela Valley, and Loreto and Mainit in Surigao del Norte.

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