Integration of deworming into an existing immunisation and vitamin A supplementation campaign is a highly effective approach to maximise health benefits with minimal cost in Lao PDR

Article Outline

• Abstract
• 1. Introduction
• 2. Methods
  • 2.1. Costs of the 2007 deworming campaign
  • 2.2. Coverage of the 2007 campaign
  • 2.3. Data on organisation and coverage of the integrated campaign (2009)
  • 2.4. Estimation of the cost of including deworming in the existing vitamin A campaign
  • 2.5. Questionnaire survey with health workers and women of child-bearing age
• 3. Results
  • 3.1. Coverage of the 2007 and 2009 campaigns
  • 3.2. Cost of the 2007 campaign
  • 3.3. Additional cost of adding deworming to the 2009 campaign
    • 3.3.1. Supply (tablet) cost
    • 3.3.2. Additional cost for drug storage and transport
    • 3.3.3. Additional cost of surveillance and monitoring activities
    • 3.3.4. Additional personnel cost
    • 3.3.5. Additional cost for supervision, meetings at different levels and social mobilisation
    • 3.3.6. Additional cost for training
  • 3.4. Challenges experienced by health workers in the integrated campaign
  • 3.5. Acceptance of the integrated campaign by women of child-bearing age
• 4. Discussion
• Authors’ contributions
• Funding
• Conflicts of interest
• Ethical approval
• Acknowledgements
• References
• Copyright

Abstract 

Infection with soil-transmitted helminths (STH) is a major public health problem in many developing countries, with pregnant women and children particularly at risk. Preventive chemotherapy, which is the intervention currently recommended by the WHO against the main helminth infections including those caused by STHs, aims at reducing morbidity through periodical administration of anthelminthic drugs either alone or in combination. The Expanded Programme on Immunization is one of the most widely implemented health programmes in the world and has well established access to children and women. The present study investigated the cost of the provision of anthelminthic drugs during existing immunisation campaigns. In Lao PDR, use of this integrated approach compared with implementation of the vertical deworming campaign alone allowed a reduction of the individual cost of deworming by 10 times (from US$0.23 in the vertical deworming campaign to US$0.03 in the integrated campaign). When drug cost was excluded, the cost of deworming an individual was US$0.007, implying that deworming 100 children would cost less than US$1 if drug donation was in place. The burden posed on health workers by the integration process was perceived as minimal and manageable. Moreover, delivery of anthelminthic drugs during immunisation campaigns enabled campaign teams to observe drug intake directly, which assured safety. These findings prove that integration is an opportunity to maximise health benefits through the delivery of multiple health products and the attainment of high coverage.

Keywords: Deworming, Immunisation, Vaccination, Integrated campaign, Cost effectiveness, Soil-transmitted helminths

Back to Article Outline

1. Introduction 

Soil-transmitted helminths (STH), commonly known as intestinal worms, afflict more than 2.5 billion people worldwide.¹ Infection is caused either through ingestion of eggs in contaminated soil (Ascaris lumbricoides, Trichuris trichiura and the hookworm Ancylostoma duodenale) or through penetration of the skin by larvae in the soil (the hookworms A. duodenale and Necator americanus). STH infections can adversely affect nutritional status, cause anaemia, increase susceptibility to other communicable diseases, worsen iron and vitamin A deficiency, and seriously jeopardise the physical and cognitive growth of children. Pregnant women and children are the groups most at risk of morbidity owing to their increased need for nutrients.²

The health intervention that is currently recommended by the WHO against STHs is preventive chemotherapy (PC), which aims at reducing morbidity through the periodical administration of a tablet of albendazole (ALB) or mebendazole (MBZ).³ PC interventions are highly effective, inexpensive and easy to implement. The World Health Assembly Resolution WHA 54.19 (2001) urged administration of PC to ≥75% of school-age children (SAC) at risk of morbidity due to STH infections by 2010.⁴

The Expanded Programme on Immunization (EPI), targeting primarily mothers and children, is one of the most widely implemented health programmes in the world, with the most well established access to these population groups in a significant number of countries, currently reaching >70% of pre-school age children (pre-SAC) worldwide.⁵ Integration of additional health interventions into immunisation campaigns is increasingly recognised as an opportunity to maximise health benefits by achieving high coverage with multiple interventions.⁶ In 2008, over 100 million pre-SAC received treatment against STH infections through immunisation campaigns throughout the world.⁷

Lao People's Democratic Republic (PDR) is a landlocked country in Southeast Asia where only 60% of the population has access to adequate drinking water sources and 48% has access to sanitation facilities.⁸ A recent national survey has shown that the prevalence of STH infections is 41.6% among pre-SAC (aged 12 months to 5 years) and 62% among SAC (aged 6–11 years).⁹ Among children under 5 years of age in Lao PDR, 48.2% are stunted and 36.4% are underweight for their age.¹⁰ STH infections are recognised as one of the factors contributing to this situation, and consequently the Ministry of Health (MoH) of Lao PDR endorsed the comprehensive National Plan of Action in March 2003 setting the following targets.

Provision of PC with ALB or MBZ to:

Every year the MoH in Laos PDR organises CHD, a campaign to reach children aged 12–59 months and WCBA, including pregnant women, with vitamin A and immunisation, and since 2007 provision of anthelminthic drugs to children has been integrated into CHD. For the first time in November 2009, WCBA, including pregnant women, were also offered anthelminthics during CHD.

The 2009 CHD campaign lasted for 1 week, providing 544471 pre-SAC (aged 6–59 months) with vitamin A capsules and 485495 pre-SAC (aged 12–59 months) with MBZ, and vaccinating 205658 pre-SAC (under 5 years of age) with oral polio vaccine (OPV). In addition, 671349 WCBA were immunised with tetanus toxoid (TT) and 654886 were provided with MBZ (Table 1).

Table 1. Comparison between the incremental costs of adding deworming to the integrated national campaign for immunisation and vitamin A supplementation and the financial costs of implementing a national deworming campaign in Lao People's Democratic Republic, targeting 1140381 individuals

Item	Integrated national campaign				National deworming campaign
	Immunisation (OPV, TT, vitamin A)	Cost ($US)	Deworming (added)	Cost ($US)	Deworming	Cost ($US)
Supplies	TT, $0.25×671349 WCBA	167837	MBZ, $0.02×485495 pre-SAC	9710	MBZ, $0.02×485495 pre-SAC	9710
	OPV, $0.16×205658 pre-SAC	32905	MBZ, $0.02×654886 WCBA	13098	MBZ, $0.02×654886 WCBA	13098
	Vitamin A, $0.03×544471 pre-SAC	16334
Drug storage and transport	($100/province×17 provinces)+($50/district×99 districts)+($20/health centre×700 health centres)	20650		No additional costs		17500
Surveillance and monitoring	$5000 (AEFI response)	5000		No additional costs		8750
	$5000 (printing)	5000		No additional costs		8750
Others
Personnel	$56000 (central authority)+$56000 (provincial authority)+$40000 (district authority)	146920		5080		66500
Supervision visits	$15000 (central authority)+($1500/province×17 provinces)+($500/district×99 districts)	90000		No additional costs		35000
Provincial meeting	$2500/province×17 provinces	42500		No additional costs		29750
Administration	$10000 (central authority)	10000		No additional costs		8750
Social mobilisation	$30000 (central authority)+($300/province×17 provinces)+($150/district×99 districts)	49950		No additional costs		21000
Training (1 day)	$500/district×99 districts	46461		3039		43750
Total		633557		30927		262558
Cost/treated individual				0.03		0.23
Cost/treated individual, excluding drug cost				0.007

OPV: oral polio vaccine; TT: tetanus toxoid; WCBA: women of child-bearing age; MBZ: mebendazole; SAC: school-age children; AEFI: advanced events following immunisation.

The present study aimed at generating evidence on the cost effectiveness of the integration of STH deworming into the immunisation and vitamin A supplementation campaign in Lao PDR. The challenges encountered by health workers in integrating multiple health interventions were also investigated and measures to improve the situation were discussed.

Back to Article Outline

2. Methods 

2.1. Costs of the 2007 deworming campaign 

Costs of the vertical national deworming campaign conducted in 2007 were collected retrospectively by checking on the files of the MoH and WHO, which was the main provider of funding for deworming, and by interviews with the MoH's national manager for control of parasitic diseases and with the WHO focal point for control of neglected tropical diseases. To facilitate comparison between the campaigns of 2007 (targeting 650000 individuals) and 2009 (targeting 1140381 individuals), the 2007 costs have been multiplied by a factor of 1.75.

2.2. Coverage of the 2007 campaign 

Data on coverage of the deworming activities were collected by analysing the report for the 2007 campaign.

2.3. Data on organisation and coverage of the integrated campaign (2009) 

The first author interviewed the national EPI manager as well as other staff of the MoH at different administrative levels, and investigated how the integrated campaign was organised and implemented. Data on numbers of children who received the different health products were obtained through registers, which included information generated by forms that were completed in the field.

2.4. Estimation of the cost of including deworming in the existing vitamin A campaign 

In 2002, the WHO published guidelines for estimating the cost of the introduction of new vaccines into the national immunisation system in order to help public health officials make an informed decision.¹¹ Considering that this concept is similar to that of integrating different health interventions in the routine immunisation system, the said guidelines were adopted to estimate the incremental cost of adding deworming to the existing immunisation and vitamin A campaign.

Both the financial and economic incremental costs of introducing deworming into the immunisation campaign were estimated. Based on the WHO guidelines,¹¹ the inputs to assess the financial costs were identified as follows: (i) supplies; (ii) drug storage and transport; (iii) surveillance and monitoring; and (iv) other costs such as training, stationery and social mobilisation.

The economic cost associated with the introduction of deworming in the existing campaign was defined as in-kind contribution made by the MoH and time spent by health workers. To estimate such economic cost, information on the type of in-kind contribution made by the MoH and by the health workers, the time spent for each contribution and their monetary values were collected during the same interviews.

2.5. Questionnaire survey with health workers and women of child-bearing age 

To investigate the challenges encountered by the implementers of the integrated intervention, questionnaires were delivered to health workers who were distributing drugs and vitamin A in the integrated campaign. The questionnaires were prepared in English and were translated into the local language (Laotian). The first author of the manuscript administered the questionnaires assisted by a translator.

Every day of the campaign, a central team from the MoH and WHO visited different villages to provide supervision and support. The villages to be visited were selected partially at random and partially where problems were reported.

The first author accompanied the central team and interviewed the health workers present on the site as well as a randomly selected sample of WCBA present on the site to receive the service for themselves or their children.

Questionnaires for health workers contained 10 questions specifically investigating difficulties encountered in training, transport of material, and administration of the different health products.

Questionnaires for WCBA contained five questions investigating the services that were received during the integrated campaign and their previous experience in receiving immunisation and deworming services.

Health workers and WCBA selected for administration of the questionnaire were explained the reason for the questionnaire and were investigated only after consent was obtained.

Back to Article Outline

3. Results 

3.1. Coverage of the 2007 and 2009 campaigns 

Estimated coverage of the two campaigns was similar at approximately 84%.

3.2. Cost of the 2007 campaign 

The estimated cost of provision of MBZ through the national deworming campaign implemented in 2007 was US$150000. The cost of covering 1140381 individuals obtained by applying the multiplication factor of 1.75 was estimated at US$262558. Details of the different components are presented in Table 1.

3.3. Additional cost of adding deworming to the 2009 campaign 

The additional cost to integrate deworming into the immunisation campaign was estimated at US$30927, which is equivalent to US$0.03 per dewormed individual. When drug cost was excluded, the cost of deworming an individual was US$0.007.

The cost of MBZ for pre-SAC and WCBA for both the campaigns (2007 and 2009) was estimated at US$22808.

During the CHD organised in November 2009, a number of health products (i.e. OPV, TT, vitamin A and MBZ) were provided in 1 day at each of the campaign sites located at central, provincial and district hospitals, at local health centres as well as at the outreach posts in the 17 provinces of the country. Vaccines were transported from the MoH's premises in Vientiane to provincial offices and subsequently to district offices and health centres with refrigerated containers in order not to spoil the vaccines. Vitamin A capsules and MBZ tablets were transported together by MoH vehicles. Owing to the limited volume of the MBZ, its transport did not require additional facilities (stored at central and peripheral level and vehicles).

The same registers used for vaccination were also used for reporting treatments and potential side effects with anthelminthic drugs. No serious adverse events following administration of MBZ were reported.

The additional time spent for each child dewormed by a health worker was estimated at 1min for pre-SAC and 30s for WCBA. Since 485495 pre-SAC and 654886 WCBA were treated, 13549 additional hours of work were necessary for integrated deworming. This corresponds to 1693 working days with a monetary value of US$5080 (US$3/day).

The same supervision team was used to provide supervision/support activities. No additional meetings were necessary to discuss deworming and no additional social mobilisation was conducted. Therefore, no extra costs were reported in these areas.

The integrated training on vaccination and administration of vitamin A and anthelminthics was provided to health workers between 19 and 26 October 2009. The time dedicated to deworming was approximately 30min during the 1-day seminar. According to the EPI manager, this additional 30min did not generate additional financial costs. The value of this training time was evaluated at US$3039, corresponding to 1/16 of the total cost of training.

3.4. Challenges experienced by health workers in the integrated campaign 

Thirty health workers were interviewed in seven areas in four provinces [one urban province (Vientiane, capital city) and three rural provinces (Khammouane, Savannakhet and Xieng Khouang)].

Four health workers (13%), all from the rural province of Khammouane, reported difficulty in transport of drugs and materials, whilst six (20%) reported a complication in providing the multiple health products and this complication resulted in a longer waiting time for the people attending the CHD. In addition, 28 individuals received training on the integration of deworming and vaccination, of which only 1 (4%) reported difficulties in understanding the concept and technical aspects of the integration; 2 persons did not receive training prior to the campaign. There were also concerns expressed by some senior MoH officials about the safety of giving anthelminthics to WCBA, especially pregnant women. WHO documents were referred to prove the safety of the drug administration after the first trimester.¹²

3.5. Acceptance of the integrated campaign by women of child-bearing age 

The authors interviewed 109 WCBA in the four areas visited. Of 109 WCBA, 105 received ALB in the integrated campaign in 2009, 71 of whom ingested a deworming tablet for the first time in their life. Those who had ingested deworming tablets before either purchased them themselves or received them from the local health centres or schools. Also, of the 109 WCBA interviewed, the number who were immunised with TT was 108 in the integrated campaign in 2009 and 86 before the integration. WCBA reported satisfaction with the deworming campaign and appreciation of the simultaneous delivery of multiple interventions. None expressed complaints or concerns. No reports of adverse events attributed to MBZ were reported in the provinces visited during the study, and very few were reported nationwide.

Back to Article Outline

4. Discussion 

The present paper compares the estimated costs of providing MBZ to pre-SAC and WCBA through an integrated intervention delivering a number of health products and through a vertical campaign exclusively dedicated to STH deworming in Lao PDR.

The study indicated that integration of anthelminthic distribution into the existing immunisation and vitamin A supplementation campaign enabled deworming an individual with as little as US$0.03. This is 10 times lower than the cost of deworming an individual through implementation of the national campaign dedicated to deworming (US$0.23). When drug cost was excluded, the cost of deworming an individual was US$0.007 which implies that deworming 100 children would cost less than US$1 if drug donation was in place. The factors that made the cost containment possible were two-fold. The first was the shared use of the campaign venues and the meeting opportunities as well as the simultaneous mobilisation of communities, health workers and social mobilisation teams. The second was the non-remuneration of health workers for the additional time dedicated to deworming training and activities in the context of the integrated campaign, which was equivalent to a monetary value of US$8119.

Despite the concern that the integration of multiple health interventions might have overburdened the health workers in the field and also posed them logistical challenges in co-ordination, drug administration and social mobilisation as suggested by Wallace et al.,⁶ 20% of the staff reported difficulties in logistics, drug administration and the integrated training; however, all were able to treat all of the children and WCBA attending the CHD even if with some increased waiting time. In particular, logistical difficulties were reported only from one rural province. Such difficulties are, in our opinion, well manageable through the development of a simple but comprehensive technical manual and the organisation of training sessions on integrated logistics, social mobilisation and provision of health products for programme managers and health workers.

The advantage of the integration of deworming into ongoing public health interventions such as immunisation campaigns is not limited to cost containment on the deworming side. The results of questionnaire survey with WCBA implied that the integrated campaign introduced deworming to those who had never received such service. The present study also indicated the increased number of participants (WCBA) to the integrated campaign to receive vaccination and deworming together compared with when vaccination and deworming were done separately. Anthelminthic treatment was demonstrated to be very popular and well received because it often brings about immediate visible effects to the recipients or their relatives in the form of expelled intestinal worms in the faeces. This study confirmed that, as already shown in other populations,¹³ satisfaction of target individuals is higher when multiple health services are provided at the same time. Packaging of anthelminthic distribution and vaccination not only allows deworming to achieve a higher coverage through the use of the extensive communication and distribution channels that are well established by the EPI, but also allows the immunisation campaigns to reach a higher number of people who are attracted by the addition of deworming. Integration with the campaign also allows direct observation of clients actually consuming deworming tablets. The Integrated Family Planning, Nutrition and Parasite Control Project in Bangladesh, for example, has utilised administration of deworming treatment as a tool for field workers to gain the respect, confidence and acceptance of community members prior to implementation of other integrated components such as vaccination, child health care and oral rehydration therapy.¹⁴ Moreover, the delivery of anthelminthics during the immunisation campaigns enabled the campaign teams to observe drug intake by the clients directly, which assured safety as this was the first time ever that MBZ was delivered at mass scale to WCBA in Laos.

In conclusion, the present study demonstrates the higher cost effectiveness of integration of deworming into an existing immunisation and vitamin A supplementation campaign compared with the vertical implementation of an intervention exclusively delivering anthelminthic drugs. According to the WHO and UNICEF immunisation summary,⁵ EPI has already achieved ≥75% national coverage in >90% of the 130 STH-endemic countries in the world as of July 2010. Strengthened co-ordination and integration between EPI and STH deworming activities therefore has a high potential to increase the national coverage of deworming for pre-SAC and WCBA as well as to further increase the number of people reached by EPI.

Back to Article Outline

Authors’ contributions 

All authors conceived and designed the study; GB conducted the questionnaire survey; GB, PEA, KEF, AX, KP, KS, CC and SP collected the budget data; GB and AY carried out data analysis; GB, AY, AFG, CP and AM interpreted the results of the analysis; GB and AY prepared the draft manuscript. All authors critically reviewed the manuscript and gave final approval of the version to be published. AM is guarantor of the paper.

Back to Article Outline

Funding 

None.

Back to Article Outline

Conflicts of interest 

None declared.

Back to Article Outline

Ethical approval 

Not required; the study was carried out as part of the vaccination campaign. Informed consent was obtained by all the interviewees prior to the questionnaire survey.

Back to Article Outline

Acknowledgements 

The authors are indebted to all the participants as well as the health workers of the vaccination campaign who kindly co-operated with the questionnaire survey and provided their valuable opinions.

Back to Article Outline

References 

1. de Silva NR, Brooker S, Hotez PJ, Montresor A, Engels D, Savioli L. Soil-transmitted helminth infections: updating the global picture. Trends Parasitol. 2003;19:547–551
   • View In Article
   • MEDLINE
   • CrossRef
2. Crompton DWT, Nesheim MC. Nutritional impact of intestinal helminthiasis during the human life cycle. Annu Rev Nutr. 2002;22:35–59
   • View In Article
   • MEDLINE
   • CrossRef
3. WHO . Preventive chemotherapy in human helminthiasis. Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers. Geneva: World Health Organization; 2006;
   • View In Article
4. WHA . Schistosomiasis and soil-transmitted helminth infection. Resolution 19 of the 54th World Health Assembly (WHA 54. 19). Geneva: World Health Organization; 2001;
   • View In Article
5. WHO/UNICEF . Immunization summary—a statistical reference containing data through 2008. Geneva: United Nations Children's Fund and World Health Organization; 2010;
   • View In Article
6. Wallace A, Dietz V, Cairns KL. Integration of immunization services with other health interventions in the developing world: what works and why? Systematic literature review. Trop Med Int Health. 2009;14:11–19
   • View In Article
   • CrossRef
7. WHO . Soil-transmitted helminthiases: estimates of the number of children needing preventive chemotherapy and number treated, 2009. Wkly Epidemiol Rec. 2011;25:257–268
   • View In Article
8. WHO/UNICEF . Progress on sanitation and drinking-water: 2010 update. Geneva: World Health Organization and United Nations Children's Fund; 2010;
   • View In Article
9. Phommasack B, Saklokham K, Chanthavisouk C, Nakhonesid-Fish V, Strandgaard H, Montresor A, et al. Coverage and costs of a school deworming programme in 2007 targeting all primary schools in Lao PDR. Trans R Soc Trop Med Hyg. 2008;102:1201–1206
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (434 KB)
   • CrossRef
10. Phimmasone K, Douangpoutha I, Fauveau V, Pholsena P. Nutritional status of children in the Lao PDR. J Trop Pediatr. 1996;42:5–11
    • View In Article
    • MEDLINE
    • CrossRef
11. WHO . Guidelines for estimating costs of introducing new vaccines into the national immunization system. Geneva: World Health Organization; 2002;
    • View In Article
12. WHO . Report of the informal consultation on hookworm infection and anaemia in girls and women. Geneva: World Health Organization; 1995;WHO/CDS/SIP/96.1
    • View In Article
13. Ching P, Birmingham M, Goodman T, Sutter R, Loevinsohn B. Childhood mortality impact and costs of integrating vitamin A supplementation into immunization campaigns. Am J Public Health. 2000;90:1526–1529
    • View In Article
    • MEDLINE
    • CrossRef
14. Ahmad S. Maternal and child health: effective entry points for family planning. JOICFP Rev. 1985;10:1–3
    • View In Article