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Introduction

The National Bilharzia (Schistosomiasis) Worm Control Program (NBWCP) has a Parasitic Worm Laboratory that was officially opened in 1981 funded by USAID and the Government of Swaziland. The NBWCP was established after a national population schistosomiasis survey in which showed a prevalence rate of 34%. The programme management and budget was combined with National Malaria Control Program (NMCP). The National Schistosomiasis Control Program was established in 1982 known as the Bilharzia Control Unit with the only mandate to control Bilharzia. In 1997 recurrent budget was separated from NMCP and only the personnel cost that is still united. Schistosomiasis is one of the neglected tropical diseases (NTD) that disable millions of people globally and thousands in the country.

In 2005, the programme had expanded its mandate to a dual approach of morbidity control with provision of mass preventive chemotherapy (de-worming) using the antihelminthic tablets praziquantel 600mg and Albendazole 400mg for schistosomiasis and soil - transmitted helminthiasis (STH) control respectively through repeated routine or regular control-dose treatment with inexpensive, single-dose and highly effective drugs, so safe can be given to all age groups at risk.

The de-worming exercise meet the millennium development goals that are similar to vision 2022 of: 1) Eradicate extreme poverty and hunger, 2) Achieve universal primary education, 3) Promote gender equality and empower women, 4) Reduce child mortality, 5) Improve maternal health, 6) Combat HIV/AIDS, malaria and other diseases, 7) Develop a global partnership for development.

Components

NBWCP consist of five key components:

1.    Programme Management
2.    Service delivery
3.    Bilharzia and STH surveillance and control
4.    De-worming tablets procurement and distribution
5.    Advocacy, communication and social mobilization

Goal
To improve provision of and increase access to essential, affordable and quality de-worming services in order to reduce the burden of diseases, morbidity and mortality and improve the health status of the population exposed to Bilharzia and STH infections.

The aim of mass preventive chemotherapy programme may be two-fold:

  • To control locally prevalent parasitic worm infection.
  • To promote integration of the primary health program at the community level and the development of community cooperation in health matters.

Objectives
1. To ensure provision of routine mass preventive chemotherapy of Albendazole 400mg de-worming control-dose for STH infection to the high-risk groups namely:

  • Under-five years – Every six months intervals as from 12months old.
  • Pregnant women after the first trimester – first dose during the 2nd trimester and second dose during the 3rd trimester.
  • School-aged children aged 6 to 19 years – depending to the ecological zone location of the school. To attain at least 75% to 100% de-worming campaign coverage per round by 2015.

2. To ensure 100% population access to essential drugs against schistosomiasis and soil-transmitted Helminth (STH) infection in all primary health care services in endemic areas for the treatment dose of clinical cases and for routine control-dose to groups at high-risk of morbidity.

3. To periodically conduct assessment so as to verify reduction of the prevalence of re-infection to all the age-groups at risk receiving the routine control dose at least by 10%.

4. To provide intensive Bilharzia disease surveillance in primary schools amongst the target age-group of 6-14years children to reduce the morbidity of Bilharzia infection.

5. To improve advocacy and IEC at all level about importance of routine de-worming.

Strategies
De-worming is defined as the extraction mechanism caused by the removal of worms that are embedded or rooted in the walls of the inner lining of the intestines. The worms leave open bleeding sores and lesion in the guts which may eventually be mixed with gastric juices and causes minor stomach discomfort sometimes accompanied with mild diarrhea that subsides in few hours or days known as side-effects.


The programme

1. Presently the NBWCP follows the Government three year rolling strategic plan with the budgetary items which serves as the only funding source that is sometimes boosted by UN resources through UNICEF. The programme has adopted all UN strategies to facilitate its contribution towards the achievement of the new public health approach -routine de-worming.

2.  To achieve a wide routine de-worming coverage of the age groups at risk, interventions are directed to the two structures at community level:

  • At the Health Facility level de-worming:

a) Integration with immunization visits for the under-5 years children
b) Integration with Ante-Natal care for pregnant women

  • At the School Facility level de-worming is piggy-backed onto teaching network.

3.In the national Helminth control program, individual case diagnosis is replaced by age-groups at risk baseline assessment of worm infection and the results of microscopically examination of faeces, urine, duodenal contents can be analyzed and provide relevant parameters to guide decision making process, this parameter can then be used as a basis for selection  of the relevant WHO recommended     treatment strategy for STH and Bilharzia infections control in preventive     chemotherapy that specify category and action to be taken as per the WHO Expert Committee resolution WHA54.19 for the implementation of mass preventive chemotherapy or de-worming program. Relevant parameters to guide decision making process for the control of helminthiasis are:

  • The prevalence of infections – gives information on the number of infected persons in a population.
  • The intensity of infections – gives information on the severity of the infection.

4.  Use of special health campaign - Mass health campaigns also offers the opportunity to reach thousands of people very effectively. These include national immunization days, vitamin A supplementation Programmes, feeding Programmes, and water and sanitation initiatives.

5.  Use of existing health services to provide the de-worming control-dose in endemic areas – a lot of infections are reported to subside after de-worming as the removal of worms from the guts clears the path-way for the three vital food groups essential nutrients to reach the body cells and tissues for restoration of any opportunistic infection that may not necessarily be related to parasites but may be of viral, bacterial and or fungal origin.
6. The approach is now radically different. It is now clear that instead of reducing the number of people with worms, reducing the number of worms in each person is vitally more important for that person’s health. This approach implicitly recognizes that re-infection will occur until effective clean water and sanitation facilities are installed. While these are hugely important, they take time. If on the other hand one regularly treats high-risk groups the infection is never allowed to develop into critically debilitating disease. Nor does it so severely affect all aspects of a child’s development that he does not have the chance of becoming a healthier adult.

7. A combined control strategy for both schistosomiasis and the common STH is logical:

  • They both thrive where poverty, malnutrition, inadequate sanitation and minimal health care and awareness exist.
  • The high-risk groups for the two infections largely overlap.
  • These groups can easily be reached through the same existing channels.
  • For both infections the first goal is to control diseases in well person rather than treat disease in sick person and prevent re-infection.
  • The claim that therapy is irrelevant because children become re-infected collapses in the face of remarkable improvement in health achieved after de-worming.

8. Involving non-medical people as de-worming requires no specialized training, no injections, and no complicated drug regiments. The drugs are single dose, safe and easy to administer. What this means is that non medical people, for example school teachers, can be given a basic training which allows them to distribute the drugs. There are two immediate advantages to such an approach. First it takes some of the pressure off from already overloaded and short-staffed qualified double staff nurses. Secondly, teachers are often respected and trusted members in the community making them extremely well-placed to carry out such activities in the school level.

Major Achievements
(a)    Total Laboratory Confirmed Attendant cases from the population of suspected cases for Urinary Bilharzia per year as from 1999 to 2010.

Year

Bilharzia Suspected cases attended

Positive Cases

Negative Cases

Bilharzia suspects Prevalence Rate for the population

Screened

1999

2033

1644

389

81%

2000

1825

1418

408

78%

2001

2066

1363

705

66%

2002

1950

1531

419

79%

2003

1825

1116

709

61%

2004

2742

1658

1084

60%

2005

2616

1634

982

62%

2006

2354

1794

560

76%

2007

2042

1800

243

88%

2008

3400

2890

510

85%

2009

3470

2893

577

83%

2010

1674

1120

554

67%

(b) Total Primary school children aged 6 to 15 years screened for Urinary Bilharzia per year
As from 1999 to 2010.

 

 

Year

Suspected Children

Positive Cases

Negative Cases

Suspects Prevalence Rate for children

1999

205

128

77

62%

2000

3686

2415

1271

66%

2001

8914

5805

3109

65%

2002

7240

5298

1942 

73%

2003

5269

3847

1422

73%

2004

1765

1259

506

71%

2005

5759

3853

1906

67%

2006

6860

4137

2723

60%

2007

5740

3873

1867

67%

2008

6530

4114

2416

63%

2009

4151

3290

861

79%

2010

3388

2234

1154

66%


(c)      Total routine de-worming of School- Aged Children per year as from 2005
- for the routine control of Bilharzia worm from Lowveld (L), middleveld (M), Highveld (H) and STH control in high-prevalent (hp) areas only and national (all) school de-worming campaign rounds.

Year

De-worming Round

Month of De-worming campaign

Number of Children De-wormed

De-worming Coverage

2005

1st - all

October

221 591

75%

2006

2nd - hp

May

206 694

98%

2nd - all

September

248 949,

82%

2007

3rd - hp

April

204 470,

99%

3rd - all

September

250 927

84%

L - Bilharzia

September

121 000

97%

2008

4th - hp

April

204 462

98%

4th - all

September

250 920

83%

M - Bilharzia

September

105 132

98%

2009

 

5th - hp

May

203 4560

82%

5th - all

September

151 676

51%

5th - Bilharzia

September

60 792

252/120 000

51%

0.2%-side-effects

2010

Suspended

Suspended

Suspended

Suspended

(d) Total number of antihelminthic drugs used for de-worming in the laboratory in the     year 2010.
Praziquantel 600mg -3 935 tablets
Albendazole 400mg – 27 656 tablets
Piperazine Citrate – 17 x 2.5litres

(e) Total praziquantel 600mg drugs distributed to health facilities for the treatment of Bilharzia clinical cases in 2010 is 16500.

 

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Programme Manager

Precious Dlamini
Telephone number -    +268 2505

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