Immediate Impact: Health/Deworming Project for Primary School-Aged Students

Poor health is a major obstacle to providing quality education.  Kilifi shares problems endemic to the developing world—too little to eat, too little medical care, and too few jobs.  The mortality rate in Kilifi for children under 5 is 12.5%; undernourishment, exacerbated by human parasites, is persistent (51% of children in Kilifi are underweight); and Malaria alone kills 30,000 children across Kenya each year while HIV/AIDS has left 1.3 million children orphaned.  Kilifi has some of Kenya’s highest infection rates and most abject poverty. 

Primary school in Kenya is free and compulsory for all students, yet the quality of education provided does not meet the needs of the population.  Specifically, the poor health of the students is a significant obstacle leading to chronic absenteeism and poor learning performance. However, there are very inexpensive and easy-to-administer treatments for some of the main causes: de-worming pills combat a number of parasites affecting almost the entire school-aged population (infection rates run from 85-90%). Significant improvements in educational metrics have been observed within weeks of employing these treatments. 

The treatment planned follows World Health Organization guidelines - that schools with geohelminth (hookworm) prevalence over 50 percent should be mass treated with a medication called albendazole every six months, and schools with schistosomiasis prevalence over 30 percent should be mass treated with praziquantel annually. The medication has been used all over the world on numerous occasions, and is considered very safe - the worst side effects are upset stomachs. The treatment is shown to kill 99% of parasites in the body. The medication and any possible side effects will be explained to the parents of these students, after which medication will be administered in school, under the guidance of medical professionals.

To reduce incidence of reoccurrence, the program also implements, according to WHO guidelines, an education component cover basics such as washing of hands and not swimming in rivers that may be infected. The WHO provides education materials that will be adapted for use in Kilifi primary schools.  We would hope to model this part of the project after a similar initiaitve undertaken in Kilifi several years ago by the Kilifi District Hospital and AMREF. 

Measuring Success

The immediate-impact/health program for primary students will be based off of a program implemented by a Dutch organization ICS Africa and the Kenyan Ministry of Health. For a $0.49 per child per year intervention, organizers saw positive results across the board—even for children (22% of the total population) who were absent on the treatment day. Absenteeism decreased by 25%, and the effective amount of schooling increased by 0.14 years. Overall, the de-worming project cost only $3.50 per additional year of school participation. Since that study (2003), costs for the medication have decreased—the estimated costs today for these drugs are 29¢ per child per year.

Updates

• July 28:  The project was discussed formally with the top Ministry of Health official in Kilifi while the visiting US project participants (Michael, Marc, Gary) were there.  The ministry is very enthused about the prospect of re-establishing the deworming program.  In the 90s, the MoH did do deworming in primary schools with the support of AMREF, until AMREF's funding evaporated.  The plan as it stands now is to have the staff of the MoH administer the pills (praziquantel for Schisto and albendazole for hookworm) in the primary school.  Schisto meds should be administered once per year and hookworm twice per year, and there's not a risk of interaction, so the meds can be administered concurrently.  The budget will cover four years of treatment.
  
  MoH medical staff who will be administering the drugs will also be providing some low-level training to teachers the first time out;  while Kenyan regulations require physical oversight of administration by MoH staff, the teachers can assist in the next administration period, reducing number of staffers needed, and thus the staff.  Much of our discussion was geared towards how to spread educational messages.  An educational component is considered a must.  Having a "schisto/hookworm day" was also an idea that interested MoH administrators
  
  The plan now is that, once more details are ironed out, funding would go through Kilifi Rotary Club, who would oversea its proper dispersal.  We did not discuss a timeframe in any serious detail.
  
  
• August 21:  The final budget for this phase of the deworming has been submitted.  If Rotary International matching grants come through, we'll be able to treat 2 zones in Kilifi District, for a total of about 26,000 kids over four years.

More Information

The World Health Organization has a great collection of resources. See http://www.who.int/wormcontrol/en/. It includes articles about parasite mitigation, educational materials, and scientific research.

Also, these scholarly articles offer some insight and many specifically discuss de-worming in Kenya (regions outside Kilifi):

• Satayathum SA, Muchiri EM, Ouma JH, Whalen CC, King CH. 2006. "Factors affecting infection or reinfection with Schistosoma haematobium in coastal Kenya: survival analysis during a nine-year, school-based treatment program." Am J Trop Med Hyg, 75(1), 83-92.
  
• G. R. Olds, C. King, J. Hewlett, R. Olveda, G. Wu, J. Ouma, P. Peters, S. McGarvey, O. Odhiambo, D. Koech, C. Y. Liu, G. Aligui, G. Gachihi,1 Y. Kombe, I. Parraga, B. Ramirez, C. Whalen, R. J. Horton, and P. Reeve. 1999.  "Double-Blind Placebo-Controlled Study of Concurrent Administration of Albendazole and Praziquantel in Schoolchildren with Schistosomiasis and Geohelminths." The Journal of Infectious Diseases, 179, 996-1003.
  
• Muchiri EM, Ouma JH, King CH. 1996. "Dynamics and control of Schistosoma haematobium transmission in Kenya: an overview of the Msambweni Project."  Am J Trop Med Hyg, 55(5 Suppl), 127-34.
  
• Miguel, Edward, and Michael Kremer. 2004. “Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities,” Econometrica, LXXII (2004), 159-217.
• Kremer, Michael. 2004. “The Role of Randomized Evaluations in Making Progress Towards Universal Basic and Secondary Education,” American Academy of Arts and Sciences Working Paper (Cambridge, Massachusetts: American Academy of Arts and Sciences).
• Partnership for Child Development (PCD). 1999. “The Cost of Large-Scale School Health Programmes which Deliver Anthelmintics in Ghana and Tanzania,” Acta Tropica, 73, 183-204.