Cost analysis for "The Magic Glasses Philippines" health education package to prevent intestinal worm infections among Filipino schoolchildren.

Background: Soil-transmitted helminth (STH) infections are a significant public health problem affecting over 900 million people globally. Health education has been shown to complement mass drug administration (MDA) for the control of these intestinal worms. We reported recently results of a cluster randomised control trial (RCT) showing the positive impact of the "The Magic Glasses Philippines (MGP)" health education package in reducing STH infections among schoolchildren in intervention schools with ≤15% STH baseline prevalence in Laguna province, the Philippines. To inform decision making on the economic implications of the MGP, we evaluated the in-trial costs and then quantified the costs of scaling up the intervention both regionally and nationally. Methods: Costs were determined for the MGP RCT conducted in 40 schools in Laguna province. We estimated the total cost and the costs incurred per student for the actual RCT and the total costs for regional and national scale-up in all schools regardless of STH endemicity. The costs associated with the implementation of standard health education (SHE) activities and mass drug administration (MDA) were determined with a public sector perspective. Findings: The cost per participating student in the MGP RCT was Php 58.65 (USD 1.15) but if teachers instead of research staff had been involved, the estimated cost would have been considerably lower at Php 39.45 (USD 0.77). Extrapolating the costs for regional scale-up, the costs per student were estimated to be Php 15.24 (USD 0.30). As it is scaled up at the national level to include more schoolchildren, the estimated cost was increased at Php 17.46 (USD 0.34). In scenario 2 and 3, consistently, labour/salary costs associated with the delivery of the MGP contributed most to overall programme expenditure. Furthermore, the estimated average cost per student for SHE and MDA were Php 117.34 (USD 2.30) and Php 58.17 (USD 1.14), respectively. Using national scale up estimates, the cost of combining the MGP with SHE and MDA was Php 192.97 (USD 3.79). Interpretation: These findings suggest that the integration of MGP into the school curriculum would be an affordable and scalable approach to respond to the continuous burden of STH infection among schoolchildren in the Philippines. Funding: National and Medical Research Council, Australia, and the UBS-Optimus Foundation, Switzerland.

"The Magic Glasses Philippines": a cluster randomised controlled trial of a health education package for the prevention of intestinal worm infections in schoolchildren.

BACKGROUND: Soil-transmitted helminths (STH) cause substantial disease and disability globally. Health education has proven complementary to school-based drug administration programs for STH control. We determined the generalizability of the impact of "The Magic Glasses" health education package for STH prevention in schoolchildren in Laguna province, the Philippines, having previously shown its positive impact in China. METHODS: We conducted a cluster-randomised controlled trial, in schoolchildren, aged 9-10 years, across 40 schools over one year. Schools were randomly assigned either to the "Magic Glasses Philippines" health education intervention package (consisting of a cartoon video, classroom discussions, drawing and essay competition) complementing the standard health education activities of the Philippines Departments of Health and Education, or to a control group, which involved only the standard health education activities. The primary trial outcomes were the proportion of STH infected schoolchildren and their knowledge, attitude and behaviour of STH assessed in both groups at baseline and through two follow-up surveys undertaken immediately prior to the semi-annual national mass administration of albendazole. The outcomes between the study arms were compared using generalized estimating equation models, accounting for clustering at the school level. The trial is registered with Australian New Zealand Clinical Trials Registry number: ACTRN12616000508471. FINDINGS: At follow-up assessments, the mean knowledge and behaviour scores in the intervention group were, respectively, 5·3 (95% confidence interval [CI]:4·2-6·5; p=<0.001) and 1·1 (95% CI: 0·4-1·7; p=0.002) percentage points higher than the control group. There was no overall effect on helminth infections (any STH; adjusted odds ratio [aOR]:1·0; 95% CI: 0·8-1·3; p=0·856), Ascaris lumbricoides; aOR:1·0; 95% CI: 0·7-1·6; p=0·894, or Trichuris trichiura; aOR:1·7; 95% CI: 0·9-1·6; p=0·315) but sub-group analysis showed a 60% reduction in the odds of any STH infection resulting from the "Magic Glasses" intervention in schools with a baseline prevalence ≤15% (aOR: 0·4; 95% CI: 0·2-0·7; p=0·001). INTERPRETATION: The health-education package demonstrated a modest but statistically significant impact on the students' overall STH knowledge and changes in their behaviour but was only effective in preventing STH infections in intervention schools where the baseline prevalence was ≤15%. FUNDING: National Health and Medical Research Council, Australia, and the UBS-Optimus Foundation, Switzerland.

Soil-transmitted helminth infections and nutritional indices among Filipino schoolchildren.

BACKGROUND: Soil-transmitted helminth (STH) infections are still prevalent among schoolchildren in the Philippines. We evaluated the risk factors associated with STH and the relationship between STH and nutritional indices among schoolchildren aged 9-10 years in Laguna province, the Philippines. METHODS: We used the baseline data from 40 schools enrolled in a randomised controlled trial of the Magic Glasses Philippines health education package. Data on demographic and socio-economic variables, and STH related knowledge, attitudes and practices, were obtained through a questionnaire. Stool samples were collected and assessed for STH egg presence using the Kato-Katz technique. Haemoglobin levels and height and weight of study participants were also determined. The generalized estimating equations approach was used to construct logistic regression models to assess STH-associated risk factors, and the association between any STH infection and anaemia, child stunting, wasting and being underweight. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000508471). FINDINGS: Among 1,689 schoolchildren, the prevalence of any STH was 23%. The prevalence of anaemia, stunting, being underweight and wasting was 13%, 20.2%, 19% and 9.5%, respectively. Age, socio-economic status, rural/urban classification of schools and knowledge of STH were significant risk factors for acquiring a STH infection. Moreover, infections with any STH were significantly associated with stunting (P = <0.001) and being underweight (P = <0.003), but not wasting (P = 0.375) or anaemia (P = 0.462) after controlling for confounding covariates. CONCLUSION: The study findings emphasise the need for sustainable deworming in tandem with other measures such as the provision of health education, improvements in sanitation and hygiene, and nutritional programs in order to control STH infections and improve morbidity outcomes in schoolchildren. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12616000508471).

Risk of Transmission and Viral Shedding From the Time of Infection for Respiratory Syncytial Virus in Households.

Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infection worldwide, but reports of temporal changes in the risk of transmission among close contacts has been scarce. This study aimed to examine an association between the viral load trajectory and transmission risk to develop a better control strategy for the disease spread. We conducted a household-based prospective cohort study in Biliran Province, the Philippines, and enrolled 451 participants to observe the development of acute respiratory infection. Including the cases found at the health-care facility, we analyzed the data of viral loads with symptom records obtained from 172 followed participants who had household member positive for RSV with a rapid test during an RSV outbreak in 2018-2019. We developed a model estimating a temporal change in the viral shedding from the infection and evaluated transmission dynamics. We found that most transmission events occurred within approximately 7 days of the household exposure, including potential presymptomatic transmissions. The inferred risk of infection among those younger than 5 years was 3.5 times higher than that of those older than 5 years. This finding suggested that the initial week after the household exposure is particularly important for preventing RSV spread.

Factors affecting mothers' intentions to visit healthcare facilities before hospitalisation of children with pneumonia in Biliran province, Philippines: a qualitative study.

BACKGROUND AND OBJECTIVES: Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers' intention to seek care before the hospitalisation of children with pneumonia. METHODS AND ANALYSIS: A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their socio-demographic information was analysed using descriptive statistics. RESULTS: Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers' intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children's unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers' major concerns about hospitalisation. CONCLUSION: Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers' burden may reduce the hospitalisation delay for children with pneumonia.

Determining the Impact of a School-Based Health Education Package for Prevention of Intestinal Worm Infections in the Philippines: Protocol for a Cluster Randomized Intervention Trial.

BACKGROUND: Repeated mass drug administration (MDA) of antihelminthics to at-risk populations is still the main strategy for the control of soil-transmitted helminth (STH) infections. However, MDA, as a stand-alone intervention, does not prevent reinfection. Accordingly, complementary measures to prevent STH reinfection, such as health education and improved sanitation, as part of an integrated control approach, are required to augment the effectiveness of MDA for optimal efficiency and sustainability. OBJECTIVE: The aim of this study is to determine the impact and generalizability of a school-based health education package entitled The Magic Glasses for STH prevention in the Philippines. METHODS: We conducted a cluster randomized controlled intervention trial, involving 2020 schoolchildren aged 9-10 years, in 40 schools in Laguna Province, Philippines, to evaluate the impact of the school-based health education package for the prevention of STHs. The trial was conducted over the course of 1 year (June 2016 to July 2017). A total of 20 schools were randomly assigned to the intervention arm, in which The Magic Glasses Philippines health education package was delivered with the standard health education activities endorsed by the Philippines Department of Health (DOH) and the Department of Education (DepEd). The other 20 schools comprised the control arm of the study, where the DOH/DepEd's standard health education activities were done. At baseline, parasitological assessments and a knowledge, attitude, and practice survey were carried out in all schools. In addition, height, weight, and hemoglobin levels were obtained from each child (after parental consent), and their school attendance and academic performance in English and mathematics were accessed from the school records. The baseline and 2 follow-up surveys were completed using the same study measurements and quality-control assessments. RESULTS: Key results from this cluster randomized intervention trial will shed light on the impact that The Magic Glasses health education package will have against STH infections in schoolchildren in the province of Laguna, located on the Island of Luzon, in the Calabarzon Region of the Philippines. CONCLUSIONS: The results of the trial will be used to assess the generalizability of the impact of The Magic Glasses health education package in different epidemiological and cultural settings, providing evidence for translation of this health education package into public health policy and practice in the Asian region and beyond. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number ACTRN12616000508471; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368849. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18419.

Transmission of Respiratory Syncytial Virus Among Children Under 5 Years in Households of Rural Communities, the Philippines.

BACKGROUND: To develop a more effective vaccination strategy for reducing the impact of respiratory syncytial virus (RSV) infection, especially in young infants (<6 months old), it is necessary to understand the transmission dynamics of RSV. METHODS: We conducted a community-based prospective cohort study from 2014 to 2016 in Biliran Province, the Philippines, on children <5 years old. We collected nasopharyngeal swabs from symptomatic children with acute respiratory infection (ARI) during household visits and at health facilities. In households (n = 181) with RSV-positive ARI cases (RSV-ARI), we also identified ARI episodes among other children <5 years old in the same household. In addition, we determined the serial interval to estimate the basic reproduction number (R 0), the average number of secondary cases generated by a single primary case. RESULTS: In the 181 households analyzed, we found 212 RSV-ARI in 152 households with a single case and 29 households with multiple cases, which included 29 1st RSV-ARI and 31 2nd RSV-ARI. We also found possible index cases among children <5 years old in the same household for 29.0% (18 of 62) of young infants with RSV-ARI. The estimated mean serial interval was 3.2 days, and R 0 was estimated to be 0.92-1.33 for RSV-A and 1.04-1.76 for RSV-B, which varied between different times (2014 and 2015) and places. CONCLUSIONS: Young infants are likely to acquire RSV infection from older children in the same household. Therefore, vaccination targeting older children might protect infants from RSV infection.

Association Between Preceding Viral Respiratory Infection and Subsequent Respiratory Illnesses Among Children: A Prospective Cohort Study in the Philippines.

Background: Acute respiratory infection (ARI) is of great concern in public health. It remains unclear whether viral infections can affect the host's susceptibility to subsequent ARIs. Methods: A prospective cohort study on ARIs of children below 5 years old was conducted in the Philippines from 2014 to 2016. The respiratory symptoms were recorded daily, and nasopharyngeal swabs were collected at both household and health facilities. The specimens were tested for respiratory viruses. We then determined whether viral etiology was associated with the severity of the present ARI and whether previous viral infections was associated with subsequent ARIs. Results: A total of 3851 children and 16337 ARI episodes were enrolled and recorded, respectively. Samples were collected from 24% of all ARI episodes; collection rate at the healthcare facilities was 95%. Enterovirus D68, rhinovirus species C, and respiratory syncytial virus were significantly associated with severe ARIs. The risk for subsequent ARIs was significantly enhanced after infections with adenovirus, influenza A virus, parainfluenza virus type 4, and rhinovirus species C. Conclusions: This study revealed that viral etiology plays a significant role in the severity of the present ARI and that viral infection affects the host's susceptibility to subsequent ARIs.

Father's roles and perspectives on healthcare seeking for children with pneumonia: findings of a qualitative study in a rural community of the Philippines.

OBJECTIVES: Pneumonia remains a primary cause of death for under-five children. It is possible to reduce the mortality impact from childhood pneumonia if caregivers recognise the danger signs of pneumonia and obtain appropriate healthcare. Among caregivers, research on fathers' healthcare-seeking behaviours and perceptions are limited, whereas research on mothers is available. This study aims to reveal fathers' roles and perspectives with respect to the selection of care and treatment for children with pneumonia in a remote island of the Philippines. DESIGN: A qualitative research was carried out using semistructured interviews. SETTING AND PARTICIPANTS: The interviews were conducted with 12 fathers whose children had pneumonia-like episodes in the 6 months prior to the interview. Data analysis was performed using the concept analysis method to identify codes which were merged into subcategories and categories. Finally, the themes were identified. RESULTS: Three themes were identified as part of fathers' roles, and two were identified as fathers' perspectives on various treatment options. Fathers took care of their sick children by not entrusting care only to mothers because they considered this as part of their role. Notably, fathers considered that arranging money for the child's treatment was a matter of prime importance. They selected a particular treatment based on their experiences and beliefs, including herbal medicine, home treatment, and visiting traditional healers and health facilities. Their decision was influenced by not only their perception of the severity of illness but also cultural beliefs on the cause of illness. Visiting health facilities, particularly during hospital admissions, causes significant financial burden for the family which was the main concern of fathers. CONCLUSION: It is crucial to consider the cultural background and also imperative to address issues related to medical cost and the credibility of health facilities to improve fathers' healthcare-seeking behaviour.

Status of soil-transmitted helminth infections in schoolchildren in Laguna Province, the Philippines: Determined by parasitological and molecular diagnostic techniques.

BACKGROUND: Soil-transmitted helminths (STH) are the most common parasitic infections in impoverished communities, particularly among children. Current STH control is through school-based mass drug administration (MDA), which in the Philippines is done twice annually. As expected, MDA has decreased the intensity and prevalence of STH over time. As a result, the common Kato Katz (KK) thick smear method of detecting STH is less effective because it lacks sensitivity in low intensity infections, making it difficult to measure the impact of deworming programs. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study was carried out over a four-week period from October 27, 2014 until November 20, 2014 in Laguna province, the Philippines. Stool samples were collected from 263 schoolchildren, to determine the prevalence of STH and compare diagnostic accuracy of multiplex quantitative polymerase chain reaction (qPCR) with the KK. A large discrepancy in the prevalence between the two techniques was noted for the detection of at least one type of STH infection (33.8% by KK vs. 78.3% by qPCR), Ascaris lumbricoides (20.5% by KK vs. 60.8% by qPCR) and Trichuris trichiura (23.6% by KK vs. 38.8% by qPCR). Considering the combined results of both methods, the prevalence of at least one type of helminth infection, A. lumbricoides, and T. trichiura were 83.3%, 67.7%, and 53.6%, respectively. Sensitivity of the qPCR for detecting at least one type of STH infection, A. lumbricoides, and T. trichiura were 94.1%, 89.9%, and 72.3% respectively; whereas KK sensitivity was 40.6%, 30.3%, and 44.0%, respectively. The qPCR method also detected infections with Ancylostoma spp. (4.6%), Necator americanus (2.3%), and Strongyloides stercoralis (0.8%) that were missed by KK. CONCLUSION/SIGNIFICANCE: qPCR may provide new and important diagnostic information to improve assessment of the effectiveness and impact of integrated control strategies particularly in areas where large-scale STH control has led to low prevalence and/or intensity of infection.

Seasonality of Influenza and Respiratory Syncytial Viruses and the Effect of Climate Factors in Subtropical-Tropical Asia Using Influenza-Like Illness Surveillance Data, 2010 -2012.

INTRODUCTION: The seasonality of influenza and respiratory syncytial virus (RSV) is well known, and many analyses have been conducted in temperate countries; however, this is still not well understood in tropical countries. Previous studies suggest that climate factors are involved in the seasonality of these viruses. However, the extent of the effect of each climate variable is yet to be defined. MATERIALS AND METHODS: We investigated the pattern of seasonality and the effect of climate variables on influenza and RSV at three sites of different latitudes: the Eastern Visayas region and Baguio City in the Philippines, and Okinawa Prefecture in Japan. Wavelet analysis and the dynamic linear regression model were applied. Climate variables used in the analysis included mean temperature, relative and specific humidity, precipitation, and number of rainy days. The Akaike Information Criterion estimated in each model was used to test the improvement of fit in comparison with the baseline model. RESULTS: At all three study sites, annual seasonal peaks were observed in influenza A and RSV; peaks were unclear for influenza B. Ranges of climate variables at the two Philippine sites were narrower and mean variables were significantly different among the three sites. Whereas all climate variables except the number of rainy days improved model fit to the local trend model, their contributions were modest. Mean temperature and specific humidity were positively associated with influenza and RSV at the Philippine sites and negatively associated with influenza A in Okinawa. Precipitation also improved model fit for influenza and RSV at both Philippine sites, except for the influenza A model in the Eastern Visayas. CONCLUSIONS: Annual seasonal peaks were observed for influenza A and RSV but were less clear for influenza B at all three study sites. Including additional data from subsequent more years would help to ascertain these findings. Annual amplitude and variation in climate variables are more important than their absolute values for determining their effect on the seasonality of influenza and RSV.

Incidence and Risk Factors of Childhood Pneumonia-Like Episodes in Biliran Island, Philippines--A Community-Based Study.

Pneumonia is a leading cause of deaths in infants and young children in developing countries, including the Philippines. However, data at the community level remains limited. Our study aimed to estimate incidence and mortality rates and to evaluate risk factors and health-seeking behavior for childhood pneumonia. A household level interview survey was conducted in Biliran Island, the Philippines. Caregivers were interviewed using a semi-structured questionnaire to check if children had symptoms suggesting pneumonia-like episodes from June 2011 to May 2012. Of 3,327 households visited in total, 3,302 (99.2%) agreed to participate, and 5,249 children less than 5 years of age were included in the study. Incidence rates of pneumonia-like episodes, severe pneumonia-like episodes, and pneumonia-associated mortality were 105, 61, and 0.9 per 1,000 person-years, respectively. History of asthma [hazard ratio (HR): 5.85, 95% confidence interval (CI): 4.83-7.08], low socioeconomic status (SES) (HR: 1.11, 95% CI: 1.02-1.20), and long travel time to the healthcare facility estimated by cost distance analysis (HR: 1.32, 95% CI: 1.09-1.61) were significantly associated with the occurrence of pneumonia-like episodes by the Cox proportional hazards model. For severe pneumonia-like episodes, a history of asthma (HR: 8.39, 95% CI: 6.54-10.77) and low SES (HR: 1.30, 95% CI: 1.17-1.45) were significant risk factors. Children who had a long travel time to the hospital were less likely to seek hospital care (Odds ratio: 0.32, 95% CI: 0.19-0.54) when they experienced severe pneumonia-like episodes. Incidence of pediatric pneumonia-like episodes was associated with a history of asthma, SES, and the travel time to healthcare facilities. Travel time was also identified as a strong indicator for health-seeking behavior. Improved access to healthcare facilities is important for early and effective management. Further studies are warranted to understand the causal relationship between asthma and pneumonia.

Estimating influenza outpatients' and inpatients' incidences from 2009 to 2011 in a tropical urban setting in the Philippines.

OBJECTIVES: Although the public health significance of influenza in regions with a temperate climate has been widely recognized, information on influenza burden in tropical countries, including the Philippines, remains limited. We aimed to estimate influenza incidence rates for both outpatients and inpatients then characterized their demographic features. DESIGN: An enhanced surveillance was performed from January 2009 to December 2011 in an urbanized highland city. The influenza-like illness (ILI) surveillance involved all city health centers and an outpatient department of a tertiary government hospital. The severe acute respiratory infection (sARI) surveillance was also conducted with one government and four private hospitals since April 2009. Nasal and/or oropharyngeal swabs were collected and tested for influenza A, influenza B, and respiratory syncytial virus. RESULTS AND CONCLUSIONS: We obtained 5915 specimens from 13 002 ILI cases and 2656 specimens from 10 726 sARI cases throughout the study period. We observed year-round influenza activity with two possible peaks each year. The overall influenza detection rate was 23% in the ILI surveillance and 9% in the sARI surveillance. The mean annual outpatient incidence rate of influenza was 5·4 per 1000 individuals [95% confidence interval (CI), 1·83-12·7], and the mean annual incidence of influenza-associated sARI was 1·0 per 1000 individuals (95% CI, 0·03-5·57). The highest incidence rates were observed among children aged <5 years, particularly those aged 6-23 months. Influenza posed a certain disease burden among inpatients and outpatients, particularly children aged <5 years, in an urbanized tropical city of the Philippines.

Epidemiological characterization of influenza A(H1N1)pdm09 cases from 2009 to 2010 in Baguio City, the Philippines.

BACKGROUND: Baguio City, Philippines experienced its first influenza A(H1N1)pdm09 [A(H1)pdm09] case in May 2009. In spite of numerous reports describing the epidemiological and clinical features of A(H1)pdm09 cases, there are no studies about A(H1)pdm09 epidemiology in the Philippines, where year-round influenza activity was observed. OBJECTIVES: We aimed to investigate the epidemiological and clinical features of A(H1)pdm09 in pandemic and post-pandemic periods. METHODS: Data were collected under enhanced surveillance of influenza-like illness (ILI) and severe acute respiratory infection (SARI) from January 2009 to December 2010. RT-PCR was used to detect A(H1)pdm09, following the protocol of the United States Centers for Disease Control and Prevention. The reproduction number was computed as a simple exponential growth rate. Differences in proportional and categorical data were examined using chi-square test or Fishers' exact test. RESULTS AND CONCLUSIONS: The outbreak was observed from week 25 to 35 in 2009 and from week 24 to 37 in 2010. The highest proportion of cases was among children aged 5-14 years. The number of ILI outpatients was 2.3-fold higher in 2009 than in 2010, while the number of inpatients was 1.8-fold higher in 2009. No significant difference in gender was observed during the two periods. The clinical condition of all patients was generally mild and self-limiting, with only 2 mortalities among inpatients in 2009. The basic reproduction number was estimated as 1.16 in 2009 and 1.05 in 2010 in the assumption of mean generation time as 2.6 days. School children played a significant role in facilitating influenza transmission.

Is mass treatment the appropriate schistosomiasis elimination strategy?

OBJECTIVE: In the year 2000, the Philippines' Department of Health adopted mass chemotherapy using praziquantel to eliminate schistosomiasis. Mass treatment was offered to an eligible population of 30 187 residents of 50 villages in Western Samar, the Philippines, in 2004 as part of an ongoing epidemiological study, Schistosomiasis Transmission and Ecology in the Philippines (STEP), aimed at measuring the effect of irrigation on infection with schistosomiasis. This paper describes the mass-treatment activities and factors associated with participation. METHODS: Advocacy, information dissemination and social mobilization activities were conducted before mass chemotherapy. Village leaders were primarily responsible for community mobilization. Mass treatment was offered in village meeting halls and schools. Participation proportions were estimated based on the 2002-2003 census. Community involvement was measured using a participation index. A Bayesian hierarchical logistic regression model was fitted to estimate the association between sociodemographic factors and residents coming to the treatment site. FINDINGS: A village-level average of 53.1% of residents (range: 21.1-85.3) came to the treatment site, leading to a mass-treatment coverage with an average of 48.3% (range: 15.8-80.7). At the individual level, participation proportions were higher among males, preschool and school-age children, non-STEP participants and among those who provided a stool sample. At the village-level, better community involvement was associated with increased participation whereas a larger census was associated with decreased participation. CONCLUSION: The conduct of mass treatment in the 50 villages resulted in far lower participation than expected. This raises concern for the ongoing mass-treatment initiatives now taking place in developing countries.

Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance.

The usefulness of rapid diagnostic tests (RDT) in malaria case management depends on the accuracy of the diagnoses they provide. Despite their apparent simplicity, previous studies indicate that RDT accuracy is highly user-dependent. As malaria RDTs will frequently be used in remote areas with little supervision or support, minimising mistakes is crucial. This paper describes the development of new instructions (job aids) to improve health worker performance, based on observations of common errors made by remote health workers and villagers in preparing and interpreting RDTs, in the Philippines and Laos. Initial preparation using the instructions provided by the manufacturer was poor, but improved significantly with the job aids (e.g. correct use both of the dipstick and cassette increased in the Philippines by 17%). However, mistakes in preparation remained commonplace, especially for dipstick RDTs, as did mistakes in interpretation of results. A short orientation on correct use and interpretation further improved accuracy, from 70% to 80%. The results indicate that apparently simple diagnostic tests can be poorly performed and interpreted, but provision of clear, simple instructions can reduce these errors. Preparation of appropriate instructions and training as well as monitoring of user behaviour are an essential part of rapid test implementation.

Cross-sectional associations between intensity of animal and human infection with Schistosoma japonicum in Western Samar province, Philippines.

OBJECTIVE: To estimate the association between the intensity of animal infection with Schistosoma japonicum and human infection in Western Samar province, the Philippines. METHODS: We conducted an observational cross-sectional study of 1425 households in 50 villages. Stool samples were collected on each of 1-3 days from 5623 humans, 1275 cats, 1189 dogs, 1899 pigs, 663 rats and 873 water buffalo. Intensity of infection with S. japonicum was measured by the number of eggs per gram (EPG). Egg counts were done using the Kato-Katz method. We used a Bayesian hierarchical cumulative logit model, with adjustments for age, sex, occupation and measurement error. FINDINGS: The adjusted proportions of humans lightly infected (classified as 1-100 EPG) was 17.7% (95% Bayesian credible interval = 15.3-20.2%); the proportion classified as at least moderately infected (>100 EPG) was 3.2% (2.2-4.6%). The crude parasitological results for animals indicated that 37 cats (2.9%), 228 dogs (19.2%), 39 pigs (2.1%), 199 rats (30.0%) and 28 water buffalo (3.2%) were infected. In univariate analyses the odds ratios corresponding to a unit increase in the mean number of EPG at the village-level in dogs was 1.05 (1.01-1.09), in cats 1.35 (1.02-1.78), in pigs 1.16 (0.24- 5.18) and in rats 1.00 (1.00-1.01). Mean EPG values in cats, dogs, pigs and rats were correlated with one another. This confounding made interpreting the odds ratios difficult, but the odds ratios for dogs and cats were more consistent. CONCLUSION: S. japonicum is endemic in areas of the Philippines despite implementation of control programmes. This may be due to the association of infections in dogs and cats with human infections. Infection control in dogs and cats is challenging, and there is a need to develop new methods to control transmission across all species.

A cross-sectional study of the prevalence of intensity of infection with Schistosoma japonicum in 50 irrigated and rain-fed villages in Samar Province, the Philippines.

BACKGROUND: Few studies have described heterogeneity in Schistosoma japonicum infection intensity, and none were done in Philippines. The purpose of this report is to describe the village-to-village variation in the prevalence of two levels of infection intensity across 50 villages of Samar Province, the Philippines. METHODS: This cross-sectional study was conducted in 25 rain-fed and 25 irrigated villages endemic for S. japonicum between August 2003 and November 2004. Villages were selected based on irrigation and farming criteria. A maximum of 35 eligible households were selected per village. Each participant was asked to provide stool samples on three consecutive days. All those who provided at least one stool sample were included in the analysis. A Bayesian three category outcome hierarchical cumulative logit regression model with adjustment for age, sex, occupation and measurement error of the Kato-Katz technique was used for analysis. RESULTS: A total of 1427 households and 6917 individuals agreed to participate in the study. A total of 5624 (81.3%) participants provided at least one stool sample. The prevalences of those lightly and at least moderately infected varied from 0% (95% Bayesian credible interval (BCI): 0%-3.1%) to 45.2% (95% BCI: 36.5%-53.9%) and 0% to 23.0% (95% BCI: 16.4%-31.2%) from village-to-village, respectively. Using the 0-7 year old group as a reference category, the highest odds ratio (OR) among males and females were that of being aged 17-40-year old (OR = 8.76; 95% BCI: 6.03-12.47) and 11-16-year old (OR = 8.59; 95% BCI: 4.74-14.28), respectively. People who did not work on a rice farm had a lower prevalence of infection than those working full time on a rice farm. The OR for irrigated villages compared to rain-fed villages was 1.41 (95% BCI: 0.50-3.21). DISCUSSION: We found very important village-to-village variation in prevalence of infection intensity. This variation is probably due to village-level variables other than that explained by a crude classification of villages into the irrigated and non-irrigated categories. We are planning to capture this spatial heterogeneity by updating our initial transmission dynamics model with the data reported here combined with 1-year post-treatment follow-up of study participants.