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Acta Tropica 141 (2015) 16–24

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

Parasitological and nutritional status of school-age and preschool-age


children in four villages in Southern Leyte, Philippines: Lessons for
monitoring the outcome of Community-Led Total Sanitation
Vicente Y. Belizario Jr. a,b , Harvy Joy C. Liwanag b,d,∗ , June Rose A. Naig b ,
Paul Lester C. Chua a,b , Manuel I. Madamba c , Roy O. Dahildahil a,b
a
Department of Parasitology, College of Public Health, University of the Philippines Manila, 625 Pedro Gil St., Ermita, Manila 1000, Philippines
b
Neglected Tropical Diseases Study Group, National Institutes of Health, University of the Philippines Manila, 623 Pedro Gil St., Ermita, Manila 1000,
Philippines
c
Plan International—Philippines, 205 Salcedo St., Legaspi Village, Makati City 1229, Metro Manila, Philippines
d
Ateneo School of Medicine and Public Health, Ateneo de Manila University, Ortigas Campus, Pasig City 1605, Metro Manila, Philippines

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

Article history: While preventive chemotherapy remains to be a major strategy for the prevention and control of soil-
Received 26 February 2014 transmitted helminthiases (STH), improvements in water, sanitation, and hygiene (WASH) comprise the
Received in revised form 1 August 2014 long-term strategy to achieve sustained control of STH. This study examined the parasitological and
Accepted 14 September 2014
nutritional status of school-age and preschool-age children in four villages in Southern Leyte, Philippines
Available online 22 September 2014
where two of the villages attained Open-Defecation-Free (ODF) status after introduction of Community-
Led Total Sanitation (CLTS).
Keywords:
A total of 341 children (89.0% of the total eligible population) submitted stool samples which were
Intestinal helminthiasis
School-age population
examined using the Kato-Katz technique. Results showed that 27.9% of the total stool samples exam-
Preschool child ined had at least one type of STH (cumulative prevalence), while 7.9% had moderate-heavy intensity
Sanitation infections. Between the two villages where CLTS was introduced, Buenavista had a significantly higher
Defecation cumulative prevalence of STH at 67.4% (p < 0.001) and prevalence of moderate-heavy intensity STH at
Tropical medicine 23.5% (p = 0.000), while Caubang had a significantly lower cumulative prevalence at 4.9% and preva-
lence of moderate-heavy intensity at 1.8%. On the other hand, the non-CLTS villages of Bitoon and Saub
had similar rates for cumulative prevalence (16.7% and 16.8%, respectively; p = 0.984) and prevalence of
moderate-heavy intensity STH (2.0% and 3.1%, respectively; p = 1.000). The findings may be explained by
factors that include possible reversion to open defecation, non-utilization of sanitary facilities, and mass
drug administration (MDA) coverage, although further studies that can accurately assess the impact of
CLTS are recommended. While this study was descriptive, the data indicate no clear pattern among the
parasitological and nutritional parameters, as well as the presence of CLTS in the village, suggesting the
need to monitor the ODF status of villages on a regular basis even after the end of CLTS activities to ensure
the sustainability of the CLTS approach. In order to achieve effective control of STH, deeper collaboration
between the WASH and STH sectors are recommended where partners can work together in the area of
monitoring and evaluation that may include improved parasitological and nutritional status in high-risk
groups, as well as sustainable behavior change as outcome indicators.
© 2014 Elsevier B.V. All rights reserved.

1. Introduction diseases (NTDs) that continue to cause burden to more than two bil-
lion people worldwide (WHO, 2012). The highest prevalence rates
Soil-transmitted helminthiases (STH) caused by Ascaris lumbri- of STH are observed in low- and middle-income countries where
coides, Trichuris trichiuria, and hookworms are neglected tropical the disease is strongly associated with poverty, poor hygiene, lack of
access to safe and clean water, and inadequate sanitation (Brooker,
2010). Among school-age children (SAC) in the Philippines, sentinel
∗ Corresponding author. Tel.: +63 25264266; fax: +63 25250395. surveillance in selected public elementary schools in 2006 revealed
E-mail addresses: hjcliwanag@post.upm.edu.ph, harvyliwanagmd@gmail.com that cumulative prevalence, or positivity for at least one type of STH,
(H.J.C. Liwanag). was 54.0% (Belizario et al., 2009), which decreased to 44.7% three

http://dx.doi.org/10.1016/j.actatropica.2014.09.008
0001-706X/© 2014 Elsevier B.V. All rights reserved.
V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24 17

years later (Belizario et al., 2013). Among preschool-age children


(PSAC), sentinel surveillance in 2004 revealed a cumulative preva-
lence of 66.0% (De Leon and Lumampao, 2005), which decreased to
43.7% during follow-up assessment five years later (Belizario et al.,
2013). While reductions in prevalence rates were noted in these
studies, the estimated prevalence of STH in the Philippines in the
SAC and PSAC populations still have not satisfied the targets of <20%
cumulative prevalence and zero heavy intensity STH recommended
by the World Health Organization (WHO) to achieve morbidity
control (WHO, 2011). On the other hand, the National Nutrition
Survey, which is undertaken every five years by the Philippine Food
and Nutrition Research Institute (FNRI) to monitor the population’s
nutrition status, among other parameters, revealed a significant
increase in the proportion of children 0–5 years old who were
underweight (26.2% from 24.6%) and stunted (27.9% from 26.3%)
between 2008 and 2005. A significant increase in the proportion of
children 6–10 years old who were underweight (25.6% from 22.8%)
and stunted (33.1% from 32.0%) was likewise observed in the same Fig. 1. Map of the Philippines showing the location of the four villages included in
survey (FNRI, 2008). this study (modified map from https://maps.google.com/).
Preventive chemotherapy through regular mass drug adminis-
tration (MDA) of anthelminthics to populations at-risk remains to
be a major strategy of STH control programs worldwide (WHO, open defecation that would move villagers to be “disgusted, embar-
2012). However, deworming alone may not be effective in pre- rassed, and ashamed” of open defecation; (c) post-triggering, which
venting re-infections which are associated with poor sanitation involved action planning by the village residents to attain zero open
(Ziegelbauer et al., 2012; Singer and Castro, 2007; Bethony et al., defecation; and (d) scaling-up, which involved the introduction of
2006; Chan et al., 1992). On the one hand, the WHO and NTD CLTS in more villages (Dominguez, 2012).
control programs worldwide have long recognized the importance A key success indicator for CLTS is the number of communi-
of water, sanitation, and hygiene (WASH) as critical components ties that eventually attain ODF status, rather than the number of
on-top of deworming to achieve sustained control of STH. On the latrines built or the amount of investment. However, the experience
other hand, the WASH sector has usually emphasized a rights- in selected African countries has suggested that further research
based approach which focuses more on universal coverage of is needed to examine the link between ODF status and the inci-
WASH services as outcome goals than disease control. Hence, dence of disease, as well as sustained behavior change (Sah and
deeper inter-sectoral collaboration between NTD control programs Negussie, 2009). A recent report in 2013 commissioned by the
and the WASH sector has been advocated to achieve a common United Nations Children’s Fund (UNICEF) describing the experience
long-term vision of disease-free communities (Freeman et al., of 14 Asia Pacific countries, including the Philippines, on CLTS has
2013). In two recent meta-analyses, the Cochrane Collaboration suggested that CLTS monitoring remains to be a significant weak-
reported no evidence for the benefit of routine deworming on nutri- ness and that widespread reversion to open defecation may result
tion, hemoglobin, and school performance (Taylor-Robinson et al., post-CLTS. In the Philippines, where CLTS has mostly been champi-
2012), as well as a small evidence for the benefit of WASH inter- oned by international non-government organizations (NGOs) like
ventions on the length growth of children <5 years old (Dangour Plan International, challenges include the lack of a formal and sus-
et al., 2013), both suggesting the need for further studies. tainable system for monitoring CLTS progress data, as well as the
In the Philippines, Plan International, an international non- lack of a common criteria for validating ODF status (UNICEF, 2013).
government child rights organization, introduced Community-Led Consequently, there remains to be a lack of compelling evidence on
total Sanitation (CLTS) in 381 selected barangays/villages in 28 the contributions of CLTS not only to attaining ODF but also to sus-
municipalities across the country beginning in 2009 (Dominguez, tainable behavior change and improvements in disease prevention
2012). CLTS is described as an integrated approach to sanitation and nutritional status, which may nonetheless be useful in con-
to achieve and sustain Open-Defection-Free (ODF) status through vincing the Philippines and other governments to adopt a national
the facilitation of the community’s analysis of their sanitation pro- policy on CLTS.
file and their practice of defecation and its consequences, which This study determined the prevalence and intensity of STH and
are expected to lead to collective action to become ODF (Kar and described the nutritional status of SAC and PSAC in two villages
Chambers, 2008). Plan International adopted the CLTS approach in Southern Leyte that benefitted from CLTS and subsequently
drawing from its experience of implementing its WASH Program attained ODF status, and in two other villages that did not benefit
in the Philippines during the past decade, such as: (a) provision from CLTS. To our knowledge, this is the first attempt to examine
of subsidy for toilet construction which did not necessarily trans- the cumulative prevalence of STH and nutritional status in children
late to the use of toilet by recipient families; and (b) co-financing after introduction of CLTS using data from the Philippines.
schemes which did not favor poorer beneficiaries who often had
difficulty raising counterpart funding to complete construction of 2. Methodology
their toilets (Dominguez, 2012).
Following the steps outlined by Kar and Chambers (2008), Plan 2.1. Study sites and population
International introduced CLTS in collaboration with local govern-
ment units (LGUs) through the following steps: (a) pre-triggering, This study was conducted in four villages in the province of
which involved groundwork meetings with LGU representatives Southern Leyte in the Eastern Philippines (Fig. 1). Plan Interna-
and stakeholders in the locality to select the villages where CLTS tional introduced CLTS in the villages of Caubang and Buenavista
will be piloted; (b) triggering, which involved sanitation profiling in November 2009 and August 2011, respectively. Initial mobi-
and analysis by the residents through focus group discussions, as lization activities included the orientation and training of an
well as “transect walks” in the village surroundings to map sites of LGU-led provincial Technical Working Group (TWG), composed of
18 V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24

Fig. 2. Diagram showing the timeline of interventions, assessments, and other activities in the four villages (CLTS—Community-Led Total Sanitation; ODF—Open-Defecation-
Free; MDA—Mass Drug Administration; STH—Soil-Transmitted Helminthiases; SAC—School-Age Children; and PSAC—Preschool-Age Children).

the provincial rural sanitary inspector, two district rural sanitary Control Program (IHCP) of the Philippine Department of Health
inspectors, four municipal rural inspectors, and a representative (DOH, 2006). On the other hand, MDA for PSAC has been con-
from Plan International. The working group coordinated the imple- ducted bi-annually (every April and October) in the community
mentation of triggering activities with community leaders and setting by local health unit (LHU) midwives since 2011 as part of
volunteers who identified areas of open defecation through tran- Garantisadong Pambata, a DOH program that delivers a package of
sect walks. Key messages delivered by the community leaders and health services for PSAC (DOH, 2010). Reports obtained from DepEd
volunteers to households included: (a) the shame of having open showed that MDA coverage in the elementary schools was 100% in
defecation in the village and the importance of attaining ODF sta- the last round of deworming conducted prior to this study (January
tus in the village; (b) the importance for each household to possess 2013). On the other hand, MDA coverage of PSAC in the villages
its own sanitary toilet; and (c) the need for households to ensure was reported to be 100% in both Bitoon and Saub, 90% in Buenav-
solid waste management and disposal, as well as maintain sanitary ista, and 83% in Caubang during the last round of deworming (April
conditions in animal facilities in the backyard (e.g. pig pens). Dur- 2013) (Table 1). The study population may have also benefitted
ing post-triggering, the TWG conducted home visits, focus group from the National Lymphatic Filariasis (LF) Program which targeted
discussions, and additional transect walks to sustain the campaign those who were ≥2 and <65 years old in endemic provinces through
and monitor progress. Caubang was subsequently declared as an annual community-based mass drug co-administration of diethyl-
ODF village by the TWG in July 2010 after nine months of CLTS carbamazine and albendazole (DOH, 1998). However, the last MDA
activities, while Buenavista was declared as ODF in June 2012 after for LF in Southern Leyte was conducted in February 2008, a few
11 months (Fig. 2). The criteria for declaring ODF status included months before the DOH declared the province as LF-free after seven
the following: (a) no signs of open defecation were observed dur- years of annual MDA.
ing transect walks and household visits; (b) 100% of households
possessed sanitary toilets; (c) enactment of local legislation at the
2.3. Study design and sampling
village level supporting CLTS activities; and (d) implementation of
other local government activities that supported the maintenance
This study followed a descriptive cross-sectional study design.
of ODF status (e.g. village “clean and green” program). CLTS activi-
In August 2013, all SAC (6–15 years old) and PSAC (2–5 years old)
ties ended after certification of ODF status. Likewise, a re-evaluation
enrolled in public elementary schools and day care centers, respec-
of ODF status was not conducted at the time of the parasitological
tively, and residing in the selected villages were recruited as study
and nutritional survey (Fig. 2).
participants to aim for total coverage of the eligible study popula-
On the other hand, the villages of Bitoon and Saub in San Ricardo
tion. Excluded from the study were those who were: (a) outside the
were selected because these villages had existing partnerships with
age bracket; (b) without assent and/or informed consent from their
Plan International but did not benefit from CLTS activities and were
parents; (c) not residing in the selected villages; and/or (d) treated
similar to the two “CLTS villages” in terms of the following: (a)
with albendazole and/or mebendazole within the last six months
number of SAC and PSAC; (b) number of households; (c) presence
prior to stool collection.
of elementary schools and day care centers; (d) sources of liveli-
hood; and (e) security, accessibility, and willingness of community
leaders to collaborate. Apart from the absence of CLTS activities in 2.4. Parasitological assessment
Bitoon and Saub, other sanitation indicators were not considered
in the choice of these villages due to the unavailability of such data. Study participants were given specimen containers with stool
Table 1 provides a summary of selected information about the four collection instructions by DepEd nurses and LHU midwives who
villages. were oriented by the project team. The same health workers col-
lected stool samples from study participants before the conduct of
MDA for STH in the selected villages. Stool samples were processed
2.2. Mass drug administration coverage using the Kato-Katz technique (WHO, 1994) and examined by
trained medical technologists in a field laboratory. Stool samples
In Southern Leyte, MDA of anthelminthics (albendazole, 400 mg, with insufficient amount were processed using the Kato thick
single dose) for SAC has been conducted bi-annually (every January method and examined only for the presence of helminth ova. Inten-
and July) since 2006 in the school setting by Philippine Department sities of infection were categorized as light, moderate, or heavy
of Education (DepEd) nurses based on the Integrated Helminth based on the number of helminth ova present in the stool specimen
V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24 19

Table 1
Selected information on demographics, sanitation, livelihood, and topography in the four villages (2013) (Source: Plan International).

Villages Total MDAb Total MDA Total No. of HH with Presence Main source of Main Topography
no. of coverage no. of coverage population HHd sanitary of hand drinking waterg source of
SACa for SAC (%) PSACc for PSAC toilete (%) washing livelihood
(%) facility in
ES/DCCf

With CLTSh Buenavista 62 100 31 90 634 113 100 Yes Electric-powered Farming Hilly
piped water
system
Caubang 48 100 26 83 325 71 100 Yes Gravity-type Farming Coastal/Plain
piped water and fishing
system

Without Bitoon 50 100 13 100 338 59 88 None Gravity-type Farming Coastal


CLTS piped water and fishing
system
Saub 110 100 43 100 802 183 93 Yes Gravity-type Farming Coastal
piped water and fishing
system

Total 270 100 113 NAi 2099 426 NA NA NA NA NA


a
School-age children (6–15 years old) enrolled in public elementary schools.
b
Mass drug administration (2013).
c
Preschool-age children (2–5 years old) enrolled in day care centers.
d
Households.
e
Pour-flush type toilet.
f
Elementary school/day care center.
g
All spring sources.
h
Community-Led Total Sanitation.
i
Not applicable.

following the WHO classification (WHO, 2012). For the purpose of and 12.0 g/dL for 7–15 years old were used to classify hemoglobin
this study, moderate and heavy intensity infections were both clas- levels as below normal (WHO, 1972). Data obtained during nutri-
sified as moderate–heavy intensity infections (Belizario et al., 2009, tional status assessment were compared with the latest available
2011). Data on cumulative prevalence of STH, individual prevalence data from the FNRI (2008 and 2011).
of Ascaris, Trichuris, and hookworm infections, and geometric mean
egg count (GMEC) were obtained. Ten percent (10%) of slides were 2.6. Data encoding and analysis
re-examined blindly by a reference microscopist from the Univer-
sity of the Philippines Manila—National Institutes of Health as part Data were double-encoded on pre-tested Microsoft Excel 2007
of quality control measures. sheets. Statistical analysis was performed using STATA 12. Data on
parasitological and nutritional status were described and examined
using Chi-square test or Fisher’s exact test, whenever appropriate,
2.5. Nutritional assessment
to determine significant differences in parasitological and nutri-
tional parameters between the following groups: (a) SAC and PSAC;
Trained DepEd nurses and LHU midwives performed anthropo-
and (b) among individual villages. Level of significance was set at
metric measurements, namely, height and weight, on participating
0.05.
SAC and PSAC, respectively. Height was measured through a mea-
suring tape attached to a 6 feet × 1 in. × 3 in. wooden plank with a
12-in. plastic ruler (in place of a microtoise), placed on top of the 2.7. Ethical considerations
child’s head and perpendicular to the measuring tape. Reading of
height measurements was taken from the edge of the ruler at eye The study protocol was reviewed and approved by the
level, done twice, and recorded to the nearest 0.1 cm. On the other University of the Philippines Manila—Research Ethics Board (2013-
hand, weight was measured, also twice, and recorded to the near- 249-01). Individual informed consent was obtained from parents or
est 0.1 kg using a bathroom scale placed on a firm level surface and guardians and assent from study participants, whenever applica-
calibrated every 10th child using a standard 5-kg weight. ble, by the trained nurses and midwives. To ensure confidentiality
Nutritional status indicators, i.e., weight-for-age (WFA), height- of health information, codes were used to replace patient identi-
for-age (HFA), and body mass index (BMI)-for-age were derived fiers. A masterlist of names and corresponding codes (encoded in
from the height and weight measurements. WFA was calculated Microsoft Excel 2007) was created and kept as reference. All results
for 2–5 and 6–9 years old, BMI-for-age for 10–15 years old, and of parasitological and nutritional status assessment were written
HFA for 2–5, 6–9, and 10–15 years old following the WHO Growth opposite the codes and kept confidential. Only authorized mem-
Reference (2007) and subsequently classified as below normal, nor- bers of the research team were allowed access to the results. Results
mal, or above normal. WFA is considered inadequate for monitoring of the parasitological assessment were forwarded to the LHU and
growth beyond childhood due to its inability to distinguish between DepEd nurses to facilitate treatment of students positive for STH.
relative height and body mass; hence, BMI-for-age was used for
older school children and adolescents (WHO, 2007). 3. Results
Blood was collected by trained medical technologists through
finger prick using a lancing device. A microcuvette was filled 3.1. Parasitological assessment
with blood sample which was assessed for hemoglobin level using
a portable hemoglobin analyzer (HemoCue® Hb 201+, Angholm, A total of 341 study participants (241 SAC and 100 PSAC),
Sweden). The WHO cut-off values of 11.0 g/dL for 2–6 years old or 89.0% of the total target population, submitted stool samples.
20 V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24

Table 2
Prevalence and intensity of soil-transmitted helminthiases (STH), and individual Ascaris, Trichuris, and hookworm infections and their geometric mean egg count (GMEC) in
the study population in four villages in Southern Leyte, Philippines (2013). (Data for school-age and preschool-age children were combined since the prevalence rates of STH
in each of the two groups were not significantly different.).

Villages with CLTS Villages without CLTS Overall


no. (%)
Buenavista no. (%) Caubang no. (%) Subtotal no. (%) Bitoon no. (%) Saub no. (%) Subtotal no. (%)

Total examined (KKa and KTb ) 89 61 150 54 137 191 341


Total examined (KK only) 81 57 138 51 127 178 316
Positive for STH 60 (67.4) 3 (4.9) 63 (42.0) 9 (16.7) 23 (16.8) 32 (16.8) 95 (27.9)
Moderate-heavy intensity 19 (23.5) 1 (1.8) 20 (14.5) 1 (2.0) 4 (3.1) 5 (2.8) 25 (7.9)
Positive for Ascaris ova 30 (33.7) 3 (4.9) 33 (22.0) 4 (7.4) 17 (12.4) 21 (11.0) 54 (15.8)
Moderate-heavy intensity 17 (21.0) 1 (1.8) 18 (13.0) 1 (2.0) 4 (3.1) 5 (2.8) 23 (7.3)
GMEC (epg)c 19.3 0.4 5.8 0.2 1.2 0.7 1.9
Positive for Trichuris ova 51 (57.3) 0 (0.0) 51 (34.0) 7 (13.0) 10 (7.3) 17 (8.9) 68 (19.9)
Moderate-heavy intensity 5 (6.2) 0 (0.0) 5 (3.6) 0 (0.0) 0 (0.0) 0 (0.0) 5 (1.6)
GMEC (epg) 25.2 0.0 5.8 0.3 0.3 0.3 1.5
Positive for hookworm ova 4 (4.5) 0 (0.0) 4 (2.9) 0 (0.0) 0 (0.0) 0 (0.0) 4 (1.2)
Moderate-heavy intensity 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
GMEC (epg) 0.2 0.0 0.09 0.0 0.0 0.0 0.03
a
Kato-Katz.
b
Kato thick.
c
Eggs per gram.

Overall cumulative prevalence and prevalence of moderate–heavy population (35 children who participated in nutritional assessment
intensity STH were 27.9% and 7.9%, respectively. In SAC, cumu- did not submit stool samples). Study participants were grouped
lative prevalence and prevalence of moderate-heavy intensity during nutritional assessment following the WHO Growth Ref-
STH were 28.6% and 6.2%, respectively. Prevalence of STH among erence (2007). Among children 2–5 years old, 28.8% had below
6–9 years old was 28.8% while prevalence among 10–15 years normal WFA (underweight) while 31.5% had below normal HFA
old was 28.7%, suggesting that the prevalence rates of STH (stunted). Among children 6–9 years old, 32.4% had below normal
between younger and older SAC are not significantly different. In WFA (underweight) while 26.9% had below normal HFA (stunted).
PSAC, cumulative prevalence and prevalence of moderate-heavy Among children 10–15 years old, 15.0% had below normal BMI-for-
intensity STH were 26.0% and 12.2%, respectively. There was age (wasted) while 45.0% had below normal HFA (stunted). On the
no significant difference between SAC and PSAC in cumulative other hand, the prevalence rates of below normal hemoglobin lev-
prevalence (p = 0.622) and in the prevalence of moderate-heavy els (anemic) among 2–5 and 6–15 years old were 33.3% and 35.8%,
intensity STH (p = 0.073) (Table 4). Disaggregating the data accord- respectively (Table 3).
ing to sex also showed no significant difference between males Disaggregating the data according to sex showed a significantly
and females (SAC and PSAC combined) in cumulative preva- higher prevalence of below normal BMI-for-age or wasting in males
lence (p = 0.760) and prevalence of moderate-heavy intensity STH than in females among children 10–15 years old (p = 0.013). Disag-
(p = 0.799). Overall, Trichuris infection was the most common gregating the data according to each village revealed no wasting
STH (19.9%) followed by Ascaris infection (15.8%) and hook- in Buenavista. On the other hand, Bitoon had a significantly higher
worm infections (1.2%). However, prevalence of moderate-heavy prevalence of below normal HFA or stunting among 2–15 years old
intensity infection was higher in Ascaris infection (7.3%) than when compared to Saub (p = 0.036) (Table 4). Fig. 4 provides a pic-
in Trichuris infection (1.6%), although GMEC for each infection ture of the prevalence of below normal anthropometric parameters
were similar (1.9 epg and 1.5 epg, respectively) (Table 2). The and hemoglobin levels in each village.
most common co-infection overall was with Ascaris and Trichuris
(7.5%).
100
Between the two CLTS villages, Buenavista had a signifi-
cantly higher cumulative prevalence of STH at 67.4% (p < 0.001) 90

and prevalence of moderate-heavy intensity at 23.5% (p = 0.000), 80


while Caubang both had a significantly lower cumulative preva-
70
lence at 4.9% and prevalence of moderate–heavy intensity at
Prevalence (%)

Negative
1.8% (Table 2; Fig. 3). Between the non-CLTS villages, Bitoon 60
and Saub had similar rates for cumulative prevalence (p = 0.984) Light Intensity
50
and prevalence of moderate-heavy intensity STH (p = 1.000).
Moderate-Heavy
Buenavista had a significantly higher cumulative prevalence 40
Intensity
and prevalence of moderate-heavy intensity STH than both 30
Bitoon (p < 0.001 and p = 0.000, respectively) and Saub (p < 0.001
20
and p = 0.000, respectively). In contrast, Caubang had a signifi-
cantly lower cumulative prevalence of STH when compared to 10
Saub (p = 0.023) but not when compared to Bitoon (p = 0.064)
0
(Table 4). Buenavista Caubang Bitoon Saub

Fig. 3. Cumulative prevalence and prevalence of light and moderate-heavy intensity


3.2. Nutritional assessment soil-transmitted helminthiases in the study population in Buenavista and Caubang
(CLTS villages) and in Bitoon and Saub (non-CLTS villages) in Southern Leyte,
Philippines (2013). (Data for school-age and preschool-age children were combined
Data on anthropometric parameters and hemoglobin levels since the prevalence rates of STH in each of the two groups were not significantly
were obtained from 376 SAC and PSAC, or 98.2% of the total eligible different.).
V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24 21

Table 3
Nutritional status parameters based on anthropometric and hemoglobin level measurements in the study population in four villages in Southern Leyte, Philippines (2013).

Parameters CLTS villages Non-CLTS villages Overall


no. (%)
Buenavista no. (%) Caubang no. (%) Subtotal no. (%) Bitoon no. (%) Saub no. (%) Subtotal no. (%)

No. examined (2–5 years old)a 30 26 56 13 42 55 111

Weight-for-age
Below normal (underweight) 11 (36.7) 6 (23.1) 17 (30.4) 2 (15.4) 13 (31.0) 15 (27.3) 32 (28.8)
Normal 19 (63.3) 20 (76.9) 39 (69.6) 10 (76.9) 29 (69.0) 39 (70.9) 78 (70.3)
Above normal 0 (0.0) 0 (0.0) 0 (0.0) 1 (7.7) 0 (0.0) 1 (1.8) 1 (0.9)

Height-for-age
Below normal (stunted) 14 (46.7) 8 (30.8) 22 (39.3) 4 (30.8) 9 (21.4) 13 (23.6) 35 (31.5)
Normal 16 (53.3) 18 (69.2) 34 (60.7) 7 (53.8) 17 (40.5) 24 (43.6) 58 (52.3)
Above normal 0 (0.0) 0 (0.0) 0 (0.0) 2 (15.4) 16 (38.1) 18 (32.7) 18 (16.2)
No. examined (6–9 years old) 35 30 65 25 55 80 145

Weight-for-age
Below normal (underweight) 7 (20.0) 13 (43.3) 20 (30.8) 9 (36.0) 18 (32.7) 27 (33.8) 47 (32.4)
Normal 27 (77.1) 17 (56.7) 44 (67.7) 16 (64.0) 37 (67.3) 53 (66.3) 97 (66.9)
Above normal 1 (2.9) 0 (0.0) 1 (1.5) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.7)

Height-for-age
Below normal (stunted) 8 (22.9) 9 (30.0) 17 (26.2) 6 (24.0) 16 (29.1) 22 (27.5) 39 (26.9)
Normal 27 (77.1) 21 (70.0) 48 (73.8) 11 (44.0) 31 (56.4) 42 (52.5) 90 (62.1)
Above normal 0 (0.0) 0 (0.0) 0 (0.0) 8 (32.0) 8 (14.5) 16 (20.0) 16 (11.0)
No. examined (10–15 years old) 25 15 40 25 55 80 120

BMI-for-age
Below normal (wasted) 0 (0.0) 1 (6.7) 1 (2.5) 6 (24.0) 11 (20.0) 17 (21.3) 18 (15.0)
Normal 23 (92.0) 13 (86.7) 36 (90.0) 19 (76.0) 44 (80.0) 63 (78.8) 99 (82.5)
Above normal 2 (8.0) 1 (6.7) 3 (7.5) 0 (0.0) 0 (0.0) 0 (0.0) 3 (2.5)

Height-for-age
Below normal (stunted) 10 (40.0) 6 (40.0) 16 (40.0) 16 (64.0) 22 (40.0) 38 (47.5) 54 (45.0)
Normal 15 (60.0) 9 (60.0) 24 (60.0) 9 (36.0) 33 (60.0) 42 (52.5) 66 (55.0)
Above normal 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
No. examined (2–5 years old)b 30 26 56 13 42 55 111

Hemoglobin status
Below normal (anemic) 12 (40.0) 8 (30.8) 20 (35.7) 5 (38.5) 12 (28.6) 17 (30.9) 37 (33.3)
Normal 18 (60.0) 18 (69.2) 36 (64.3) 8 (61.5) 30 (71.4) 38 (69.1) 74 (66.7)
No. examined (6–9 years old) 35 30 65 25 55 80 145

Hemoglobin status
Below normal (anemic) 1 (2.9) 2 (6.7) 3 (4.6) 1 (4.0) 7 (12.7) 8 (10.0) 11 (7.6)
Normal 34 (97.1) 28 (93.3) 62 (95.4) 24 (96.0) 48 (87.3) 72 (90.0) 134 (92.4)
No. examined (10–15 years old) 25 15 40 25 55 80 120

Hemoglobin status
Below normal (anemic) 1 (4.0) 0 (0.0) 1 (2.5) 4 (16.0) 4 (7.3) 8 (10.0) 9 (7.5)
Normal 12 (48.0) 0 (0.0) 12 (30.0) 21 (84.0) 51 (92.7) 72 (90.0) 84 (70.0)
a
Age grouping and classification for anthropometric measurements based on the WHO Growth Reference (2007).
b
Age grouping for hemoglobin level determination based on a WHO technical report on nutritional anemia (1972).

100 4. Discussion
Below Normal WFA
90 or Underweight (2-9
years old) This study was conducted to determine the parasitological and
80
Below Normal BMI- nutritional status of SAC and PSAC in two villages which benefit-
for-age or Wasted
70
(10-15 years old) ted from CLTS activities and subsequently attained ODF status, and
Prevalence (%)

60 in two other villages without CLTS in Southern Leyte, Philippines.


Below Normal HFA or
Stunted (2-15 years The overall cumulative prevalence of STH in the study population
50 old)
(27.9%) exceeded the WHO target of <20% for morbidity control
40 Below Normal (WHO, 2011). While the overall cumulative prevalence of STH may
Hemoglobin Level or
30 Anemic (2-15 years be lower than the estimated prevalence rates in SAC (44.7%) and
old) PSAC (43.7%) in the Philippines based on the last sentinel surveil-
20
lance (Belizario et al., 2013), the failure to meet the WHO target may
10
suggest a need to enhance STH prevention and control strategies,
0 including sustaining school-based MDA and improving sanitation
Buenavista Caubang Bitoon Saub
following the Water, Sanitation, Hygiene Education, and Deworm-
Fig. 4. Prevalence of below normal anthropometric and hemoglobin level measure- ing (WASHED) framework (CWW, 2013). On the other hand, data
ments in the study population in Buenavista and Caubang (CLTS villages) and in on prevalence of STH at the village level provide an opportunity for
Bitoon and Saub (non-CLTS villages) in Southern Leyte, Philippines (2013). [WFA is making progress in individual villages. For instance, the low preva-
considered inadequate for monitoring growth beyond childhood due to its inability lence rates for moderate-heavy intensity STH in Caubang, Bitoon,
to distinguish between relative height and body mass; hence, BMI-for-age was used
for older school children and adolescents (WHO, 2007).]
and Saub (1.8%, 2.0%, and 3.1%, respectively) suggest that these
22
Table 4
Significant differences (indicated by p-values in italics) in parasitological and nutritional parameters across different groups of data in the study population in Southern Leyte, Philippines as measured by Chi-square and Fisher’s
exact tests (2013).

Groups compared No. of Parasitological parameters Nutritional parameters


positive for
p-value No. of moderate-heavy p-value No. of p-value No. of wasted p-value No. of stunted p-value No. of anemic p-value
STHa and
intensity STH and underweight (10–15 years (2–15 years old) (2–15 years old)
prevalence
prevalence (2–9 years old) old) and and prevalence and prevalence
and prevalence prevalence

SACb 69 (28.6) 0.622c 14 0.073c NAd NA NA NA NA NA NA NA


(6.2)

V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24


PSACe 26 (26.0) 11 NA NA NA NA
(11.0)

Buenavista (CLTSf Village) 60 (67.4) <0.001c 19 0.000g 18 (27.7) 0.458c 0 (0.0) 0.375g 22 0.838c 14 (15.6) 0.607c
(23.5) (33.8)

Caubang (CLTS Village) 3 (4.9) 1 19 (33.9) 1 (6.7) 17 10 (14.1)


(1.8) (30.4)

Bitoon (non-CLTS Village) 9 (16.7) 0.984c 1 1.000g 11 (28.9) 0.734c 6 (24.0) 0.770g 10 0.036c 10 (15.9) 0.313c
(2.0) (26.3)

Saub (non-CLTS Village) 23 (16.8) 4 31 (32.0) 11 (20.0) 25 23 (15.1)


(3.1) (25.8)

Buenavista and Bitoon <0.001c 0.000g 0.891c 0.022g 0.316c 0.101c


Buenavista and Saub <0.001c 0.000g 0.562c 0.014g 0.249c 0.379c
Caubang and Bitoon 0.064g 1.000g 0.611c 0.224g 0.259c 0.281c
Caubang and Saub 0.023g 1.000g 0.802c 0.439g 0.412c 0.801c
a
Soil-transmitted helminthiases.
b
School-age children (6–15 years old).
c
Chi-square test.
d
Fisher’s exact test.
e
Preschool-age children (2–5 years old).
f
Not applicable.
g
Community-Led Total Sanitation.
V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24 23

villages may be nearing the target of reducing moderate-heavy generate more evidence that can truly demonstrate improvements.
intensity to ≤1%, defined by the WHO as elimination of STH as a For instance, it was interesting to note that the highest prevalence
public health problem in school children (WHO, 2012). rates of STH were seen in Buenavista, a CLTS village which also had
A meta-analysis by Ziegelbauer et al. (2012) has concluded that zero prevalence of wasting. While this study was descriptive, the
availability and access to sanitation facilities is associated with a data indicate no clear pattern among the parasitological and nutri-
reduction in prevalence of STH due to a lower risk for STH trans- tional parameters, as well as the presence of CLTS in each village,
mission and re-infections. While this assumption is inconsistent which resonates with the recommendations of the Cochrane stud-
with the cumulative prevalence of STH observed in Buenavista, ies to generate robust evidence that can demonstrate association
the data is limited in its ability to make an accurate assessment among these factors clearly. Nonetheless, there is an opportunity to
of improvements in parasitological status in relation to CLTS due to initiate important interventions (e.g. feeding programs in the ele-
the absence of baseline parasitological information that could have mentary schools/day care centers) to address the malnutrition in
served as a point of comparison. Inclusion of the sanitation profile selected villages, especially targeting the specific age and/or gender
in the criteria used to select villages would have likewise allowed a groups where prevalence rates of below normal anthropometric
better comparison of CLTS outcomes between villages. Since toilet and hemoglobin measurements were higher than national figures.
possession may not necessarily indicate utilization, further stud- Since this study was conceptualized, designed, and conducted
ies that examine the actual use of sanitary facilities, including the after the completion of CLTS activities in Buenavista and Caubang,
practice of hand washing with soap after defection, in the villages the findings also highlight the need for a deeper collaboration
that benefit from CLTS activities may provide an explanation for between the development organizations and LGUs that implement
the high cumulative prevalence of STH observed in Buenavista. WASH interventions on the one hand, and research/academic orga-
Consideration of how long villages are able to sustain their ODF nizations in the NTD sector that can provide technical support for
status is necessary in order to understand whether or not effective program monitoring and evaluation on the other hand. For exam-
prevention and control may have also been achieved, considering ple, the data obtained in the non-CLTS villages of Bitoon and Saub
that a sustained ODF status may be related to a lower risk for STH provide new baseline information and an opportunity to pursue
transmission and re-infection since the viability of helminth ova follow-up studies that may be able to assess impact accurately
in the soil is estimated to last from a few months up to two years should Plan International and the LGUs consider introducing CLTS
(Anderson, 1982; Anderson and May, 1991). There is a need, there- in these villages.
fore, for LGUs and organizations that promote the CLTS approach to
validate the ODF status of villages on a regular basis even long after 5. Conclusion
the suspension of CLTS activities, which also provides an oppor-
tunity to monitor sustained behavior change. This strategy may In summary, this study has described and compared the para-
help address the challenges in CLTS monitoring as well as rever- sitological and nutritional status of SAC and PSAC between selected
sion to open defecation post-CLTS which has been observed in the CLTS and non-CLTS villages in Southern Leyte, Philippines. The
Philippines and other Asia Pacific countries as noted in the UNICEF findings on parasitological and nutritional status in a village
report in 2013. like Buenavista, which are inconsistent with results that may be
The reported high MDA coverage rates of SAC and PSAC in the expected in a village that previously attained ODF status, may sug-
elementary school setting and community setting, respectively, gest the need for some degree of validation of the reported ODF
most of which have satisfied the ≥75% MDA coverage target of status and for LGUs to exercise caution in certifying communities
the WHO (WHO, 2012), are likewise inconsistent with the high as ODF and in reporting such certifications as success indicators.
prevalence of STH observed in a village like Buenavista. There may Several non-government organizations in the WASH sector world-
also be a need for some degree of validation of the excellent MDA wide have developed different protocols for defining, declaring, and
coverage rates reported in the elementary schools. For example, a certifying ODF status in communities, yet no protocol has been rec-
study by Amarillo et al. (2008) to validate coverage for community- ognized as the global standard. The WASH and NTD sectors alike
based MDA for LF in the province of Agusan del Sur in the southern may be in a strategic position to develop a standard protocol, which
Philippines through face-to-face interviews with community resi- may be adopted by LGUs in a country like the Philippines where it
dents concluded that MDA coverage was actually only 60% instead can be part of a clear policy on monitoring and evaluation of ODF
of the reported 92%. within the framework of sustainable sanitation programs.
The lack of baseline data on anthropometric and hemoglobin In order to sustain effective control of STH and other NTDs
level measurements also limits the ability of this study to assess beyond MDA alone, community interventions such as CLTS should
impact on nutritional status, although comparison with national also be enhanced in a manner where the WASH sector would be
figures indicates a higher prevalence of below normal WFA or able to demonstrate impact in terms of improved parasitological
underweight in 2–5 years old (28.8%), below normal BMI-for-age and nutritional status in high-risk groups, as well as sustainable
or wasting (15.0%) and below normal HFA or stunting (45.0%) in behavior change. Monitoring of ODF status after CLTS may be
10–15 years old, and below normal hemoglobin levels or anemia strengthened through the formulation of clear policies by LGUs
in 2–5 (33.3%) and 6–15 years old (35.8%) in the study population working with WASH organizations to institutionalize a sustainable
when compared with the latest data from the Philippines’ National system for monitoring and evaluation of CLTS outcome indicators,
Nutrition Survey [20.2% underweight in 0–5 years old; 9.8% wasted as part of ensuring the sustainability of the CLTS approach in the
and 26.7% stunted in 10–19 years old (FNRI, 2011); and 20.8% and Philippines and in other Asia Pacific countries.
19.2–20.4% anemic in 1–5 years old and 6–12 years old, respectively
(FNRI, 2008)]. Funding
Data on anthropometrics and hemoglobin levels would have
been affected by several factors as the reasons for nutritional sta- This work was supported by Plan International—Philippines.
tus of children are multi-factorial. It must be noted that neither
meta-analyses by the Cochrane Collaboration on deworming and Role of funding source
nutritional status, as well as WASH interventions and nutritional
status discounted the potential benefits of deworming or WASH The co-authors from Plan International—Philippines were
on children’s nutritional status, but only suggested the need to involved in the development of the study design, data collection
24 V.Y. Belizario Jr. et al. / Acta Tropica 141 (2015) 16–24

and interpretation, finalization of the report, and the decision to Children Without Worms. A Comprehensive Strategy for STH Control.
submit the paper for publication. www.childrenwithoutworms.org (accessed 31.07.13).
Dangour, A.D., Watson, L., Cumming, O., Boisson, S., Che, Y., Velleman, Y.,
Cavill, S., Allen, E., Uauy, R., 2013. Interventions to improve water qual-
Acknowledgments ity and supply, sanitation and hygiene practices, and their effects on
the nutritional status of children. Cochrane Database Systematic Rev. (8),
http://dx.doi.org/10.1002/14651858.CD009382.pub2 (Art. No. CD009382).
The project team would like to extend its gratitude to Dong De Leon, W., Lumampao, Y., 2005. Nationwide Survey of Intestinal Parasitosis in
Waña, Edgar Viterbo, Cecile Cornejo, Totch dela Cruz, Erwin Yam- Pre-School Children: Final Report Submitted to Unicef. UNICEF, Manila.
suan, Lutchie Canon, and the Plan International staff of Southern Department of Health, 1998. National Filariasis Elimination Program. Administrative
Order No. 25-A s. DOH, Manila.
Leyte Program Unit for coordinating and facilitating project imple- Department of Health, Integrated Helminth Control Program, 2006. Mass Treatment
mentation; the Provincial Health Office of Southern Leyte and the Guide, Conceptual Framework and 2006–2010 Strategic Plan. DOH, Manila.
medical technologists and midwives of the Local Health Units of Department of Health, 2010. Garantisadong Pambata. Administrative Order 36 s.
DOH, Manila.
Pintuyan and San Ricardo for assisting in microscopy and field data Dominguez, G., 2012. Community Led and Sustained Sanitation. A Documentation
collection; and the nurses of the Department of Education Division of Good Practice in Plan Philippines. Plan Philippines, Manila.
Office of Southern Leyte for assisting in field data collection. The Food and Nutrition Research Institute, 2008. 7th National Nutrition Survey. Depart-
ment of Science and Technology, Manila.
team also acknowledges Prof. Lourdes Amarillo for her inputs to
Food and Nutrition Research Institute, 2011. Updating of Nutritional Status of
the interpretation of results. Filipino Children and Other Population Groups. Department of Science and Tech-
nology, Manila.
Freeman, M.C., Ogden, S., Jacobson, J., Abbott, D., Addiss, D.G., Astrat, A.G., et al., 2013.
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