Minyoo: Deworming reduced absenteeism, increased school performance

Minyoo (worms) have been a public health threat for Kenya’s children for many decades, with the worst hit being pupils in primary schools who carry the disease burden.

The attendant absenteeism results in poor academic performance besides diseases affecting their nutrition intake.

In rural areas, most play barefoot or with shoes oblivious playgrounds could have soil-transmitted schistosomiasis and helminthes commonly caused by roundworms, hookworms and whipworms.

But programs to eliminate them faced myriad challenges including negative perceptions: some parents believed deworming brought devil-worshipping, or was a form of birth control, whole some pupils had low tolerance to medicines. 

“At first when we began, 10 years back, so many children vomited worms, had diarrhoea with worms and some worms coming through the mouth,” says Agneta Juma, the in-charge, of Health Programmes at St Mary’s Primary School in Busia, recalls adding that in the early days' misconception almost derailed the program.

“People alleged that deworming programmes were bringing devil-worshipping and some resisted but we sensitized parents that the drugs had a good impact,” says Juma.

Worse still, pupils did not tolerate praziquantel, one of the medicines against schistosomiasis (bilharzia), but with continued sensitization, they embraced deworming.

“They used to have stomach problems, and miss school,” says Moses Ouma, a parent at Rabuor Primary School in Kisumu County.  “Taking them to the hospital was an expense but nowadays, the illnesses are not related to water like bilharzia.”

Ouma’s daughter managed to join Ng’iya Girls, a national school. 

Dorcas Opiyo, the last born of six girls has never missed any deworming exercise since she joined Rabuor Primary.

The KCPE candidate takes deworming medication and “I didn’t experience stomach pains. I felt so good and sometimes I liked to eat many fruits.”

Deworming meant more time in school without any sickness interrupting learning for most. For some like Adrian Wilson, 12, deworming affected food rations as “the food I ate before and after deworming reduced a little bit.”

Rabuor area in Kadibo sub-county is prone to flooding which increases the risk of bilharzia caused by parasitic worms that thrive in freshwater contaminated by human faeces.

But since deworming started “the rate of infection of the worms has gone down, we do not experience a lot of absenteeism,” says Dick Awuonda, the Head Teacher at Rabuor Primary, adding that enrolment improved from 640 to 1,154 pupils.

Regular attendance, adds Awuonda, has also improved school performance from a previous mean score of 239 to 280.

In 2012, the Ministries of Health and Education entered a five-year Programme Implementation and Partnership Framework Agreement with Evidence Action to scale deworming in all high-risk counties.

Ujiplus project field officers distribute porridge to pupils at Bondo Township Primary in Mbita Sub-county, Homa Bay County on July 8, 2021. Ujiplus is a porridge made of flour combining nutrition, deworming and treatment of bacterial and fungal infections. [James Omoro, Standard]

The aim was to reach about 6.7 million children aged between two to 14  for soil-transmitted helminthes and schistosomiasis.

According to the World Health Organisation (WHO), soil-transmitted helminthes, commonly caused by roundworms, hookworms and whipworms, are parasitic worms transmitted by eggs present in human faeces that contaminate the soil in areas with poor sanitation.

Experts say, pupils aged between five and 15 bear the biggest brunt of the worm burden; harbouring 70 to 80 per cent of the disease burden which affects them nutritionally and physically.

Dr Charles Mwandawiro, a Senior Principal Research Scientist, KEMRI, explains that areas with dense populations and intense agricultural activity have a high prevalence of  worms but the country's “worm burden is mostly found in Western Kenya, Luo Nyanza, some parts Rift Valley and the Coast,”

He adds: “Other areas like North-Eastern or Northern Kenya are too dry for worms to survive,” says Dr Mwandawiro who is also the officer in charge of monitoring and evaluation of the deworming programme.

The National School-Based Deworming Programme has been a success in counties with high worm burdens like Busia County in Western Kenya.

Julian Anyango a 42-year-old mother of seven and a parent at St. Mary’s Nambale Primary School in Busia, has seen five of her seven children transit successfully to secondary school.

“When a child is dewormed, their health improves. They are attentive in class and hardly miss school because of ill health,” she says adding that two of her children are in university while three are in secondary school, a success she attributes to the deworming programme.

Chrispin Owaga, the Kenya Country Director of Evidence Action, the main organisation supporting school deworming, says the program also has economic benefits as “recent research indicate adults who received two or three rounds of deworming get higher incomes up to 13 per cent more than the ones who did not.”

Though the programme is managed at the national level it is implemented locally by trained county, sub-county, and division or ward personnel, including teachers who are trained in a cascaded format, explains Nelson Andanje, the Busia County Health Promotion Officer.

“Each class teacher is given a sheet to mark when administering the medicine. We mark ‘x’ for the one who refuses,” says Agneta, adding that sick pupils “are not to give the drug since a parent may think it is the drug that has caused the illness.”

Pupils who develop complications rest under a tree for observation and no child, she says, is forced to take the medicine when they decline.

 “At one time, parasitic infections were at position three as a top cause of disease in the county but now it is position eight, a drastic reduction,” says Jonathan Ino, the Busia Chief officer in charge of Health and Sanitation, attributing the reduction to increased awareness that has seen communities deworm at least twice a year, while others do it every three months.

Ino says though Covid-19 partially disrupted the program, it was a blessing in disguise as regular hand washing and strict sanitation accelerated the decline of the worm burden.

Busia for example, was declared an open defecation-free county in 2015 and has been observing water, sanitation and hygiene standards “through ensuring a good supply of safe and treated water at household level and point of consumption,” adds Ino.

Dr Mwandawiro adds that adequate education also helps in observing hygienic conditions and which goes a long way in eliminating the worms.

Indeed, Dr Christine Wambugu,  Head of the Division of Adolescent and School Health at the Ministry of Health offers that “the school health policy has eight thematic areas and deworming comes under communicable and non-communicable disease control within the school environment.”

She adds that deworming is not a singular intervention but “goes hand in hand with water sanitation and hygiene within the school to prevent re-infection.”

Sarah Ayumba the Nambale sub-county Director of Education in Busia says the county has dewormed 95 per cent of children in public and private schools including “all the ECDE centres within the sub-county.” 

Kenya’s Vision 2030, the country’s economic blueprint singled out deworming as one of the high-impact interventions under the social pillar and “it has increased cognitive ability of the learners and has impacted positively in the outcome of their learning areas,” says Nereah Olik, the Director of Primary Education who has worked been in the program since 2009.

Dr Julius Jwan, the Principal Secretary, Early Learning & Basic Education, says deworming also “reduces the cost of healthcare as parents and government will spend money on treatment” besides wasting productive time for parents.

Dr Jwan says research shows without deworming absenteeism increases by 25 per cent, affecting overall performance.

Dr Patrick Amoth, the Acting Director-General for Health adds that elimination worms “micronutrient and nutrient absorption is increased, therefore increasing the overall nutrition situation of the child.”

Kenya has 47 counties and 295 sub-counties and there is a lot to be done to ensure 100 per cent coverage and to meet the WHO threshold of under two per cent prevalence of worms across the country.

Chrispin Owaga, Kenya Country Director, Evidence Action said the school deworming programme “has been able to surpass the WHO 75 per cent threshold of school-age children treated.”

Dr Mwandawiro reckons that to increase coverage, both the school and community-based approaches need to be merged as “the school-based approach alone cannot bring us to elimination stage” and the coverage should include children out of school, pre-school age children and mothers of reproductive age.

Deworming school-going children differ from one county to another thus affecting the rate of reduction mostly due to differing lifestyles, latrine usage, access to water, attitudes towards hygiene conditions and beliefs which results in drug resistance.

“When we started, a county like Narok was at 50 per cent prevalence rate,” recalls Dr Mwandawiro. “It has only come down in 2018 to 40 per cent while Taita Taveta is now below one per cent and has been excluded from the annual treatment of children but then surveillance has to be done.”

Some counties were left out, like Nairobi “because it was found to have no worms,” says Dr Mwandawiro. “Recent research shows we have worms in Nairobi, especially in slums like Kibera, Korgocho and others.”

This means there is a need for remapping to include previously excluded areas and Susan Mochache, the Health PS, says besides donor support,  the government is allocating resources to the deworming programme including “procuring dewormers from local manufacturers.”

Kenya’s Ministry of Health allocated Sh70 million to the school deworming Program this year and which comes to less than half a dollar a child or Sh50 per year.

To track the success of the programme, Dr Andrew Mulwa, Head Directorate of Medical Services – Preventive & Promotive Health, argues for the need to “have aligned data collection systems through the NEMIS and the National Health Information systems (KDHIS) so that both sets of data speak to each other so that we do not have to rely on partners or other players to get data for planning.”