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Session 2: 10:15 am – 10:45 am
Deworming
Improving Health and Increasing Attendance
Karthik Muralidharan & L.V. Subramanyam
Intestinal worms are extremely prevalent in India, causing
malnutrition, anemia, and stunted growth, and contributing to student
absenteeism. Numerous treatments for worms are available, and
schools are an efficient means to deliver these medications. Children
treated with in-school deworming programs are observed to gain
weight and attend school more frequently.
Researchers:
Edward Miguel (UCB), Michael Kremer (Harvard)
Field Partners: International Christelijk Steunfonds Africa (ICS) in
Kenya; Government of Andhra Pradesh for scale-up discussed below.


Policy Issue
70% of children under 5-years old suffer from iron deficiency anemia. Intestinal worms also cause Intestinal helminths—including hookworm, persistent diarrhea, leading to dehydration, roundworm, schistosomiasis and whipworm— malnutrition and weight loss. Micronutrient infect more than one in four people worldwide and deficiencies are believed to cost India US$2.5 are particularly prevalent among school-aged billion annually, and child malnutrition is children in developing countries. Children infected responsible for 22% of the country’s burden of with intestinal worms suffer from malnourishment, loss of appetite, iron deficiency anemia (IDA), Vitamin A deficiency, stunted physical growth and Evaluations and Evidence
reduced ability to learn. As a result, worms are believed to have a negative impact on education, The impacts of worms on health are well known. A hindering child development as well as school randomized study in Lucknow in the 1990s found attendance. The losses in schooling which result that more than a third of preschool children were from these health problems are evident later in life: infected with soil-transmitted helminths (STH). non-randomized studies have shown that children Children who were administered the deworming chronically infected with worms are 13% less likely drug Albendazole biannually for 2 years exhibited a to be literate and earn 43% less as adults. 35% greater weight gain, equivalent to an extra 1 kg on average, compared to untreated children in Worms are widespread in India, with infection rates The impact of worms on school attendance was less ranging from 5% in some states to as high as 90% well established before 2001, when Kremer and in regions of other states depending on regional Miguel found health and attendance gains from ecology. It is estimated that only 7-10% of infected deworming school-aged children in a randomized school children are currently treated with study in Kenya. Deworming increased school deworming medicines. Worms require vitamin A to participation by at least 7 percentage points - survive, and can rob their hosts of this essential equivalent to a 25% reduction in student absence nutrient. According to a World Bank report, 57% of rates. Moreover, the entire community and those preschool children in India have Vitamin A living up to 6 km away from the treatment schools deficiency, which can cause eye damage and a benefited from “spillovers” of the deworming higher risk of dying from measles or malaria. treatment, as deworming reduces transmission of Worms also cause chronic intestinal blood loss that can result in iron deficiency anemia and cause weakness, stunted physical growth and a In 2004, a randomized study in the slums of Delhi compromised immune system. In India, more than found that 69% of the children in the sample were anemic and 30% suffered from intestinal worm based on high baseline worm loads. Studies in India infections. Preschool children provided with a indicate prevalence rates ranging from 5% - 90%. package supplement consisting of iron, Vitamin A At high prevalence rates, the benefits from and deworming drugs gained roughly 0.5 kg more deworming are very substantial, but even at low than comparison children. Further, average pre- prevalence rates, the costs are low enough and school participation rates increased sharply by 5.8 administration simple enough to warrant a percentage points among treated children, reducing programmatic approach to deworming through preschool absence by roughly 6 percentage points schools. For instance, China has supported (from a base absence rate of ~30%). Given the low universal deworming even at infection rates of 5%. cost of the intervention and the positive externalities, school-based deworming is a highly The suggested policy action for India is therefore to cost-effective way to improve school attendance, conduct simple, regular surveys on worm load in school children and based on these measured worm loads, to conduct school-based deworming Retrospective studies of the American South have programs since deworming has been found to be shown that the long-run gains to deworming are most effective and efficient when administered also quite substantial. Bleakley (2007) uses long- through schools. School-age children typically have run data from over a century ago and shows that the heaviest intensity of worm infection, in part hookworm eradication increased school attendance, because transmission often happens when children literacy, and ultimately long-run labor market are playing in soil or water contaminated with fecal returns to schooling. Groups with higher initial matter. Schools offer a readily available, extensive, levels of hookworm infection (who therefore and sustained infrastructure with a skilled benefited more from the eradication efforts) went workforce that is already in close contact with the on to earn substantially higher incomes as adults. deworming is feasible in India, considering 98% of The combination of rigorous evidence from children now have access to a primary school randomized evaluations as well as historical within 1 km of their home, and several school-evidence based on long-term data suggests that based initiatives have already been undertaken deworming may be able to improve child health and education outcomes in a highly cost-effective There are a number of drug manufacturers in India that locally produce deworming drugs including Mebendazole, Albendazole and Praziquantel. The cost of deworming using existing government infrastructure is less than 50 cents (approximately Rs. 23) a year, per child. The major component of this cost is the initial training of school staff in administering the deworming medicines and the production of educational materials. It is also important to ensure alignment with other programs such as the National Filaria Control Program, since these programs also treat children with similar medication. In Andhra Pradesh, the state government in coordination with J-PAL’s partner organization— Information campaign on school-based Deworm the World (DtW)—has launched a school- based mass deworming program. The program will cover approximately one crore (10 million) school Scale-Ups
children aged 6-14 years, and is being initially Evidence from other contexts suggests that Mahbubnagar, Nalgonda, Nellore, Prakasam and deworming could be a highly promising and cost- Vizianagaram), before being extended to other effective intervention, but some of these results are parts of the state. The program is being run in Pradesh has entered into a Memorandum of collaboration between the Department of Health, Understanding (MoU) to conduct large-scale Medical and Family Welfare (DoHFW), the randomized evaluations of several educational Department of School Education (DoSE), and the programs. The evaluation of school-based health Department of Sarva Shiksha Abhiyan (DoSSA). programs is being carried out under the auspices of This partnership structure, in coordination with this MoU. The programmatic roll out of deworming partners including DtW and the World Bank, has will be phased to cover 23 districts over the next been critical in creating a solid foundation for the three to four years depending on worm load scale-up of a sustainable school health program to prevalence, intensity and other factors, with the improve children’s health and education. evaluation districts being covered in the last phase (since the evaluation districts have both treatment and comparison schools). Thus, the AP deworming program represents a good case study of a marriage between programmatic roll out (in some districts) and rigorous randomized evaluations (in other districts) in an Indian context. Operational lessons with regard to scale-up can be learned from the program roll out, while the impact of the program can be measured through the randomized evaluation. A similar approach may also make sense for other programs in other contexts, since most new programs need to be phased in for administrative School girls stand in line to take deworming medication in Nalgonda district, Andhra Once this partnership was in place, DtW helped train medical laboratory technicians drawn from various districts through a one day training Shally Awasthi, Richard Peto, Vinod Kumar Pande, demonstration of how to process stool samples to and Robert H. Fletcher: “Effectiveness and cost- create worm prevalence surveys. The treatment was effectiveness of albendazole in improving administered by school teachers who were trained nutritional status of pre-school children in urban in advance, and local communities were properly slums.” Indian Pediatrics, January 2000; 37:19-29 sensitized. The treatment was simple and safe: a single dose of mebendazole administered once or Hoyt Bleakley: “Disease and Development: twice a year, depending on prevalence estimates. Evidence from Hookworm Eradication in the The success of the first phase of the Andhra American South.” The Quarterly Journal of Pradesh School-Based Deworming Program can be seen by its coverage: 1,954,888 children enrolled in schools and a total of 2,060,016 school-age Gustavo J. Bobonis, Edward Miguel, Charu Puri children were dewormed through the program. All Sharma: “Iron Deficiency Anemia and School six districts were reached through this program and Participation.” Journal of Human Resources, 2006, In addition to the programmatic roll out of “Mass Deworming: A Best Buy for Education and deworming, the AP program has been accompanied Health.” J-PAL Policy Briefcase # 4. by a rigorous randomized evaluation of the impact of school-based health programs comprising Michael Kremer, Edward Miguel: “Worms: deworming, iron, and Vitamin A supplements. In Identifying Impacts on Education and Health in the partnership with the Azim Premji Foundation and the World Bank, the Government of Andhra Econometrica, Vol.72, No.1, 2004, 159-217.

Source: https://www.povertyactionlab.org/sites/default/files/Session_2_Deworming.pdf

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