A Qualitative Study on the Implementation of the Workplace TB Program in the Philippines: Challenges and Way Forward.

Tuberculosis (TB) is a chronic infectious disease that remains to be a primary health concern globally. The Philippines is among the top TB-burdened countries. Workplace TB prevention and control programs are essential to ensure the health and safety of workers and economic security. There remains a knowledge gap regarding the Philippine workplace TB prevention and control program implementation. This qualitative study involving key informant interviews reviewed the implementation of the workplace TB program in selected companies in a high TB burden region in Eastern Philippines. Results were presented under four themes in accordance with the components of the workplace TB policy: preventive strategies, medical management, data recording and reporting, and social policy. Various good practices, opportunities, and challenges in the implementation of the workplace TB program were identified. There is a need to strengthen the enforcement of policy across different components. Compliance with guidelines on preventive strategies and recording and reporting schemes needs to be intensified. Coordination across different levels and agencies may also be enhanced to allow more efficient implementation. Increased awareness of corporate decision-makers may improve company ownership of the program leading to improved implementation while increased awareness of employees on their rights and entitlements may likewise enhance compliance.

Critical medical ecology and intersectionality perspectives in schistosomiasis prevention and control in selected communities in Mindanao, the Philippines.

Schistosomiasis japonica remains a public health concern in many areas of the Philippines. Periodic Mass Drug Administration (MDA) to at-risk populations is the main strategy for morbidity control of schistosomiasis. Attaining MDA coverage targets is important for the reduction of morbidity and prevention of complications due to the disease, and towards achieving Universal Health Care. The study employed a qualitative case study design. Key informant interviews and focus group discussions were conducted to provide in-depth and situated descriptions of the contexts surrounding the implementation of MDA in two selected villages in known schistosomiasis-endemic provinces in Mindanao in the Philippines. Data analysis was done using the Critical Ecology for Medical Anthropology (CEMA) model coupled with the intersectionality approach. It was found that within various areas in the CEMA model, enabling as well as constraining factors have been encountered in MDA in the study settings. The interplay of income class, geographical location, gender norms and faith-based beliefs may have led to key populations being missed during the conduct of MDA in the study sites. The constraints faced by the target beneficiaries of MDA, as well as programme implementers, must be addressed to enhance service delivery and to control morbidity due to schistosomiasis. Improving compliance with MDA also requires a holistic, integrated approach to addressing barriers to participation, which are shaped by wider socio-political and power structures.

Co-infection of intestinal helminths in humans and animals in the Philippines.

BACKGROUND: A large number of studies have assessed risk factors for infection with soil-transmitted helminths (STH), but few have investigated the interactions between the different parasites or compared these between host species across hosts. Here, we assessed the associations between Ascaris, Trichuris, hookworm, strongyle and Toxocara infections in the Philippines in human and animal hosts. METHODS: Faecal samples were collected from humans and animals (dogs, cats and pigs) in 252 households from four villages in southern Philippines and intestinal helminth infections were assessed by microscopy. Associations between worm species were assessed using multiple logistic regression. RESULTS: Ascaris infections showed a similar prevalence in humans (13.9%) and pigs (13.7%). Hookworm was the most prevalent infection in dogs (48%); the most prevalent infection in pigs was strongyles (42%). The prevalences of hookworm and Toxocara in cats were similar (41%). Statistically significant associations were observed between Ascaris and Trichuris and between Ascaris and hookworm infections in humans, and also between Ascaris and Trichuris infections in pigs. Dual and triple infections were observed, which were more common in dogs, cats and pigs than in humans. CONCLUSIONS: Associations are likely to exist between STH species in humans and animals, possibly due to shared exposures and transmission routes. Individual factors and behaviours will play a key role in the occurrence of co-infections, which will have effects on disease severity. Moreover, the implications of co-infection for the emergence of zoonoses need to be explored further.

Evaluation of loop-mediated isothermal amplification assay and enzyme-linked immunosorbent assay in detecting Schistosoma japonicum in Siargao Island, Surigao del Norte, the Philippines.

OBJECTIVES: This study aimed to describe the prevalence and seroprevalence of schistosomiasis in Siargao Island, Surigao del Norte and to compare the performance of enzyme-linked immunosorbent assay antibody test (ELISA Ab) and loop-mediated isothermal amplification assay (LAMP) for diagnosis of schistosomiasis. METHODS: The study was conducted in selected barangays (villages) in five municipalities in Siargao Island, Surigao del Norte and included school-age children (SAC) who submitted stool and blood samples. Stool samples were examined using the Kato-Katz technique. Blood samples were collected through venipuncture. The stool samples and the blood samples collected were tested using LAMP assay and polymerase chain reaction (PCR). The blood samples were examined using ELISA Ab. Diagnostic performance of LAMP assay using stool specimen was evaluated using Kato-Katz technique and PCR assay as the composite reference standard, while PCR assay was used as the reference standard to evaluate LAMP assay and ELISA Ab using blood specimens. RESULTS: A total of 417 stool samples from SAC were examined. The prevalence of schistosomiasis and moderate-heavy intensity (MHI) schistosomiasis were 3.8% and 1.4%, respectively. Schistosomiasis and soil-transmitted helminthiases (STH) coinfection prevalence were 2.6%. A total of 425 blood samples were examined using ELISA Ab. Seroprevalence was 61.6%. The municipality of San Isidro had the highest seroprevalence at 84.8%, while Burgos had the lowest seroprevalence at 48.5%.LAMP assay had higher sensitivity and positive predictive value but lower specificity when using stool than when using blood samples. Its negative predictive value was similar regardless of the specimen used. ELISA Ab has higher sensitivity and negative predictive value than LAMP assay although it has lower specificity and positive predictive value. This may be due to ELISA Ab measuring Schistosoma exposure and is thus unable to distinguish past from active infection. CONCLUSIONS: Schistosomiasis remains a public health concern in Siargao Island, Surigao del Norte. The locally developed LAMP assay offers a simpler diagnostic test for schistosomiasis compared with PCR, while minimizing the risk of misdiagnosis compared with Kato-Katz technique. It could serve as a point of care diagnostics for schistosomiasis. ELISA Ab is more useful in surveillance particularly in low-endemicity areas where determination of exposure is more important than differentiating past from active infection. ELISA Ab may be helpful in the clinical setting when coupled with the expertise of a physician who is familiar with schistosomiasis.

Prevalence of soil-transmitted helminth infections, schistosomiasis, and lymphatic filariasis before and after preventive chemotherapy initiation in the Philippines: A systematic review and meta-analysis.

OBJECTIVE: To estimate the impact of preventive chemotherapy on the prevalence and intensity of soil-transmitted helminth (STH) infections, schistosomiasis, and lymphatic filariasis in the Philippines, using systematic review and meta-analysis. METHODS: We included reports reporting prevalence of STH infections, schistosomiasis, or lymphatic filariasis in the Philippines published until 31 March 2021. Peer-reviewed studies were identified in electronic databases. Grey literature reports by the University of the Philippines and the Department of Health were also included. Pooled infection prevalence, before and after the initiation of preventive chemotherapy, stratified by age group, was calculated using the inverse variance heterogeneity model. FINDINGS: A total of 109 reports were included in the review and meta-analysis. Overall prevalence of moderate-heavy intensity Ascaris lumbricoides (6.6%) and Trichuris trichiura (2.7%) infection after initiation of preventive chemotherapy were significantly lower than the prevalence prior to initiation (23.6% for A. lumbricoides and 12.2% for T. trichiura). Prevalence reductions were also found in school and preschool-age children for A. lumbricoides and T. trichiura. Studies conducted after preventive chemotherapy initiation had significantly lower overall prevalence of moderate-heavy intensity schistosomiasis (3.1% vs 0.2%) and of schistosomiasis in school-age children (30.5% vs 1%). Pooled prevalence of lymphatic filariasis prior to preventive chemotherapy initiation was 3.2% across 12 provinces, while currently only two provinces still have prevalence of more than 1%. There were no published studies reporting prevalence of lymphatic filariasis after initiation of preventive chemotherapy. Heterogeneity was high with I2 mostly above 90%. CONCLUSION: The burden of STH infections and schistosomiasis in children were significantly lower in studies conducted following the initiation of preventive chemotherapy. Eliminating morbidity and interrupting transmission, however, may require expanded control initiatives including community-wide treatment, and improved water, sanitation, and hygiene. Lymphatic filariasis burden has decreased since the implementation of preventive chemotherapy, with all but two provinces having reached the elimination of lymphatic filariasis as a public health problem.

Sensitive and semiquantitative detection of soil-transmitted helminth infection in stool using a recombinase polymerase amplification-based assay.

BACKGROUND: Soil-transmitted helminths (STHs) are parasitic nematodes that inhabit the human intestine. They affect more than 1.5 billion people worldwide, causing physical and cognitive impairment in children. The global strategy to control STH infection includes periodic mass drug administration (MDA) based on the results of diagnostic testing among populations at risk, but the current microscopy method for detecting infection has diminished sensitivity as the intensity of infection decreases. Thus, improved diagnostic tools are needed to support decision-making for STH control programs. METHODOLOGY: We developed a nucleic acid amplification test based on recombinase polymerase amplification (RPA) technology to detect STH in stool. We designed primers and probes for each of the four STH species, optimized the assay, and then verified its performance using clinical stool samples. PRINCIPAL FINDINGS: Each RPA assay was as sensitive as a real-time polymerase chain reaction (PCR) assay in detecting copies of cloned target DNA sequences. The RPA assay amplified the target in DNA extracted from human stool samples that were positive for STH based on the Kato-Katz method, with no cross-reactivity of the non-target genomic DNA. When tested with clinical stool samples from patients with infections of light, moderate, and heavy intensity, the RPA assays demonstrated performance comparable to that of real-time PCR, with better results than Kato-Katz. This new rapid, sensitive and field-deployable method for detecting STH infections can help STH control programs achieve their goals. CONCLUSIONS: Semi-quantitation of target by RPA assay is possible and is comparable to real-time PCR. With proper instrumentation, RPA assays can provide robust, semi-quantification of STH DNA targets as an alternative field-deployable indicator to counts of helminth eggs for assessing infection intensity.

A mathematical model of the dynamics of lymphatic filariasis in Caraga Region, the Philippines.

Despite being one of the first countries to implement mass drug administration (MDA) for elimination of lymphatic filariasis (LF) in 2001 after a pilot study in 2000, the Philippines is yet to eliminate the disease as a public health problem with 6 out of the 46 endemic provinces still implementing MDA for LF as of 2018. In this work, we propose a mathematical model of the transmission dynamics of LF in the Philippines and a control strategy for its elimination using MDA. Sensitivity analysis using the Latin hypercube sampling and partial rank correlation coefficient methods suggests that the infected human population is most sensitive to the treatment parameters. Using the available LF data in Caraga Region from the Philippine Department of Health, we estimate the treatment rates r 1 and r 2 using the least-squares parameter estimation technique. Parameter bootstrapping showed small variability in the parameter estimates. Finally, we apply optimal control theory with the objective of minimizing the infected human population and the corresponding implementation cost of MDA, using the treatment coverage γ as the control parameter. Simulation results highlight the importance of maintaining a high MDA coverage per year to effectively minimize the infected population by the year 2030.

Use of geographic information system as a tool for schistosomiasis surveillance in an endemic Municipality in Eastern Samar, The Philippines.

This study aimed to demonstrate the use of geographic information systems (GIS) in identifying factors contributing to schistosomiasis endemicity and identifying high-risk areas in a schistosomiasis- endemic municipality in the Philippines, which was devastated by Typhoon Haiyan in 2013. Data on schistosomiasis determinants, obtained through literature review, the Philippine Department of Health, and concerned local government units, were standardized and incorporated into a GIS map using ArcGIS. Data gathered included modifiable [agriculture, poverty, sanitation, presence of intermediate and reservoir hosts, disease prevalence and mass drug administration (MDA) coverage] and nonmodifiable (geography and climate) determinants for schistosomiasis. Results showed that most barangays (villages) are characterized by favourable conditions for schistosomiasis transmission which include being located in flood-prone areas, presence of vegetation, low sanitary toilet coverage, presence of snail intermediate host, high carabao (water buffalo) population density, previously reported ≥1% prevalence using Kato-Katz technique, and low MDA coverage. Similarly, barangays not known to be endemic for schistosomiasis but also characterized by the same favourable conditions for schistosomiasis as listed above and may therefore be considered as potentially endemic, even if not being high-risk areas. This study demonstrated the importance of GIS technology in characterizing schistosomiasis transmission. Maps generated through application of GIS technology are useful in guiding program policy and planning at the local level for an effective and sustainable schistosomiasis control and prevention.

High burden of soil-transmitted helminth infections, schistosomiasis, undernutrition, and poor sanitation in two Typhoon Haiyan-stricken provinces in Eastern Philippines.

This study aimed to describe: 1) soil-transmitted helminthiasis (STH) and schistosomiasis prevalence and intensity in preschool-age children (PSAC) and school-age children (SAC), 2) schistosomiasis seroprevalence in SAC, 3) undernutrition prevalence in SAC, 4) sanitary toilet coverage in households, and 5) association between STH, Schistosoma japonicum exposure, nutritional status, and sanitation. PSAC and SAC in two Haiyan-stricken provinces were examined using Kato-Katz technique and ELISA Antibody test. Anthropometric and hemoglobin measurements were also obtained. The reported sanitary toilet coverage was validated in a survey. The prevalence of any STH in PSAC and SAC was 50.2% and 41.3%, respectively. Moderate-heavy intensity (MHI) STH prevalence in PSAC and SAC was 20.8% and 5.9%, respectively. The prevalence of any STH, MHI STH, ascariasis, MHI ascariasis, and MHI trichuriasis was significantly higher in PSAC. Stunting, underweight, wasting, overweight/obesity, and anemia prevalence was 38.4%, 24.5%, 4.8%, 2.7%, and 34.7% in PSAC, while the prevalence was 34.3%, 21.6%, 8.7%, 3.0%, and 19.2% in SAC, respectively. Anemia and wasting prevalence were significantly higher in PSAC and SAC, respectively. There were five schistosomiasis cases found (0.8% prevalence), while schistosomiasis seroprevalence was 60.1%. Validated and reported sanitary toilet coverage was significantly different in eight out of 13 barangays. Stunting and anemia were associated with STH. STH and anemia prevalence were significantly higher in non-ZOD barangays. High STH burden in PSAC and SAC persists. A more coordinated response addressing STH, undernutrition, and WASH in disaster-stricken areas will require strengthening local health systems and promoting intersectoral collaboration.

Health and Education Officials' Perspectives on the Impact of Typhoon Haiyan on Mass Drug Administration for Soil-Transmitted Helminth Infections in the Philippines.

OBJECTIVES: In the Philippines, morbidity control of soil-transmitted helminth (STH) infections is done through mass drug administration (MDA) of anthelmintics to school-age children (SAC). In 2013, the Philippines was devastated by the deadliest cyclone ever recorded, Typhoon Haiyan. The study aimed to understand the impact of Typhoon Haiyan on the MDA of anthelmintics to SAC in the provinces of Capiz and Iloilo in the Philippines from the perspectives of local health and education officials. METHODS: The study was conducted in the municipalities of Panay and Pilar in Capiz and the municipalities of Estancia and Sara in Iloilo, areas that were devastated by Typhoon Haiyan. Qualitative, semi-structured key informant interviews were conducted with 16 total participants, which included officials of the Department of Health, Department of Education, and concerned local government units. All interviews were transcribed verbatim and coded in an open, iterative manner. Codes were reviewed to identify patterns and themes. RESULTS: Participants described the following themes: (1) their perception that the typhoon had no effect on the MDA program or on resources necessary to complete the program; (2) the program's simple design allowed for 1-time administration to a pre-assembled population; (3) the program allowed a sense of community cohesiveness; (4) the program served as a vehicle for altruism, particularly regarding helping needy children, in this time of calamity. CONCLUSIONS: Our informants perceived that the MDA program in Region VI was not affected by Typhoon Haiyan. They attributed the resilience to the program's simple procedure, attitudes of altruism, program importance, and community cohesiveness. Despite Typhoon Haiyan's mass destruction of infrastructure and livelihood leading to incredible challenges, mobilization of the community allowed for the continuation and successful implementation of the MDA program. The experience of Region VI may serve as a model for other low- and middle-income countries prone to natural disasters.

Zoonotic transmission of intestinal helminths in southeast Asia: Implications for control and elimination.

Intestinal helminths are extremely widespread and highly prevalent infections of humans, particularly in rural and poor urban areas of low and middle-income countries. These parasites have chronic and often insidious effects on human health and child development including abdominal problems, anaemia, stunting and wasting. Certain animals play a fundamental role in the transmission of many intestinal helminths to humans. However, the contribution of zoonotic transmission to the overall burden of human intestinal helminth infection and the relative importance of different animal reservoirs remains incomplete. Moreover, control programmes and transmission models for intestinal helminths often do not consider the role of zoonotic reservoirs of infection. Such reservoirs will become increasingly important as control is scaled up and there is a move towards interruption and even elimination of parasite transmission. With a focus on southeast Asia, and the Philippines in particular, this review summarises the major zoonotic intestinal helminths, risk factors for infection and highlights knowledge gaps related to their epidemiology and transmission. Various methodologies are discussed, including parasite genomics, mathematical modelling and socio-economic analysis, that could be employed to improve understanding of intestinal helminth spread, reservoir attribution and the burden associated with infection, as well as assess effectiveness of interventions. For sustainable control and ultimately elimination of intestinal helminths, there is a need to move beyond scheduled mass deworming and to consider animal and environmental reservoirs. A One Health approach to control of intestinal helminths is proposed, integrating interventions targeting humans, animals and the environment, including improved access to water, hygiene and sanitation. This will require coordination and collaboration across different sectors to achieve best health outcomes for all.

Identification of suspected paragonimiasis-endemic foci using a questionnaire and detection of Paragonimus ova using the Ziehl-Neelsen technique in Zamboanga Region, the Philippines.

Improving paragonimiasis surveillance, which is crucial for disease control, requires adopting new tools and techniques useful in mapping endemic areas. This study aimed to (1) develop a questionnaire to identify suspected paragonimiasis-endemic foci, (2) describe the epidemiology of paragonimiasis, and (3) evaluate Ziehl-Nielsen Staining technique (ZNS) in detecting Paragonimus ova. The questionnaire, which municipal health officers filled out, was based on proposed site inclusion criteria utilized in the integrated tuberculosis (TB)-paragonimiasis surveillance and control project. Newly deployed medical technologists in Zamboanga Region underwent training, which included laboratory diagnosis of paragonimiasis using preserved and fresh specimens and an integrated tuberculosis-paragonimiasis survey in nine selected barangays (villages). Paragonimiasis cases were found in seven out of the nine barangays identified by the questionnaire. Of the 373 patients, three (0.80%) were TB-positive, and 29 (7.77%) were paragonimiasis-positive. The highest paragonimiasis prevalence (27%) was found in Barangay Libato. Ziehl-Neelsen Staining technique (ZNS) correctly detected 8 out of the 29 samples positive (sensitivity - 27.59%; 95% CI: 12.73-47.24%) and all the 334 samples negative (specificity - 100%; 95% CI: 98.90-100%) for Paragonimus ova. The questionnaire may be improved by refining the inclusion criteria. In paragonimiasis-endemic areas, the ZNS and the NaOH concentration technique may be used for detecting Paragonimus ova. Modifying the ZNS, for instance by including a concentration step, may improve its sensitivity. The model for the integrated capacity building of health workers and surveillance and research demonstrated in this project may contribute to improving surveillance and control of paragonimiasis and other neglected tropical diseases.

Formative research to inform development of a new diagnostic for soil-transmitted helminths: Going beyond the laboratory to ensure access to a needed product.

Soil-transmitted helminths (STHs) affect more than 1.5 billion people. The global strategy to control STH infections requires periodic mass drug administration (MDA) based on prevalence among populations at risk determined by diagnostic testing. Widely used copromicroscopy methods to detect infection, however, have low sensitivity as the prevalence and intensity of STH infections decline with repeated MDA. More sensitive diagnostic tools are needed to inform program decision-making. Using an integrated product development process, PATH conducted qualitative and quantitative formative research to inform the design and development of a more sensitive test for STH infections. The research, grounded in a conceptual framework for ensuring access to health products, involved stakeholder analysis, key opinion leader interviews, observational site visits of ongoing STH surveillance programs, and market research including market sizing, costing and willingness-to-pay analyses. Stakeholder analysis identified key groups and proposed strategic engagement of stakeholders during product development. Interviews highlighted features, motivations and concerns that are important for guiding design and implementation of new STH diagnostics. Process mapping outlined current STH surveillance workflows in Kenya and the Philippines. Market sizing in 2016 was estimated around half a million tests for lower STH burden countries, and 1-2 million tests for higher STH burden countries. The cost of commodities per patient for a molecular STH diagnostic may be around $10, 3-4 times higher than copromicroscopy methods, though savings may be possible in time and staffing requirements. The market is highly price sensitive as even at $5 per test, only 27% of respondents thought the test would be used by surveillance programs. A largely subsidized STH control strategy and a semi-functional Kato-Katz test may have created few incentives for manufacturers to innovate in STH diagnostics. Diverse partnerships, as well as balancing needs and expectations for new STH diagnostics are necessary to ensure access to needed products.

Child development center-based sentinel surveillance of soil-transmitted helminthiases in preschool-age children in selected local government units in the Philippines.

Soil-transmitted helminthiasis (STH) remains a public health concern in developing countries, such as the Philippines. Preschool-age children (PSAC) are among the high-risk groups for STH. Data on the status of STH in PSAC are needed to help guide policy formulation and program implementation; however, in the usual setting, such data may remain limited. This study aimed to describe the parasitologic status of PSAC in selected local government units (LGUs) in the Philippines through sentinel surveillance methodology in a child-development center (CDC)-based setting. This cross-sectional study, which included 1732 PSAC in selected barangays (a village or the smallest administrative unit in the country) in the provinces of Cavite, Guimaras, Iloilo, Negros Occidental, and Davao del Norte and cities of Iloilo and Lapu-Lapu in the Philippines, utilized Kato-Katz technique to determine parasitologic status. A single Kato-Katz smear was prepared from the adult-thumb sized stool sample submitted by each participant. Ten percent of Kato-Katz slides examined by field microscopists were re-examined by a reference microscopist as part of quality control. Results showed a prevalence of any STH infection and a moderate-heavy ((M-H)) intensity prevalence of 24.9% and 10.3%, respectively. Five cases of schistosomiasis were found in Lapu-Lapu City and Davao del Norte. While the Philippines' Department of Health (DOH) - Integrated Helminth Control Program (IHCP) target for prevalence of any STH of less than 50% was attained, none of the barangays or villages met the World Health Organization (WHO) target for (M-H) intensity STH prevalence of less than 1%, despite the program being implemented for almost a decade. Sentinel surveillance in PSAC, possibly adopting a CDC-based approach, may be implemented biannually in the Philippines and other countries where a similar early child care development system exist to generate data needed to guide policy formulation and program implementation. Preventive chemotherapy through facility-based mass drug administration (MDA), such as CDC-based MDA, may be explored to improve the mode of MDA delivery and coverage in PSAC.

Efficacy and safety of co-administered ivermectin plus albendazole for treating soil-transmitted helminths: A systematic review, meta-analysis and individual patient data analysis.

BACKGROUND: The soil-transmitted helminths (STH), Ascaris lumbricoides, Trichuris trichiura and hookworms, infect 1.5 billion people worldwide and cause an estimated burden of 3.3 million disability-adjusted life years (DALYs). Current control strategies focus on morbidity reduction through preventive chemotherapy (PC) but the most commonly used recommended drugs (albendazole and mebendazole) are particularly inefficacious against T. trichiura. This, together with the threat of emerging drug resistance, calls for new control strategies, including co-administration with other anthelminthics. Ivermectin plus albendazole is widely used against lymphatic filariasis, but its efficacy and safety against STH infections has not yet been fully understood. METHODS AND FINDINGS: We conducted a systematic literature review and meta-analysis on the efficacy and safety of ivermectin-albendazole co-administration in five different databases (i.e. PubMed, ISI Web of Science, ScienceDirect, CENTRAL and clinicaltrials.gov) from 1960 to January 2018. Four studies reporting efficacy of ivermectin-albendazole against STH infections and five studies on its safety met the selection criteria and were included for quantitative analysis. Ivermectin-albendazole was significantly associated with lower risk (risk ratio (RR) = 0.44, 95% confidence interval (CI) = 0.31-0.62) for T. trichiura infection after treatment compared to albendazole alone. The co-administration revealed no or only a marginal benefit on cure and egg reduction rates over albendazole alone for A. lumbricoides and hookworm infections. Adverse events (AEs) occurring after ivermectin-albendazole co-administration were mostly mild and transient. Overall, the number of individuals reporting any AE was not different (RR = 1.09, 95% CI = 0.87-1.36) in co-treated and albendazole-treated patients. However, although not statistically significant, sub-group analysis showed a tendency for slightly more AEs in patients with filariasis treated with ivermectin-albendazole compared to those treated with albendazole alone (RR = 1.29, 95% CI = 0.81-2.05). CONCLUSIONS: Our findings suggest a good tolerability and higher efficacy of ivermectin-albendazole against T. trichiura compared to the current standard single-dose albendazole treatment, which supports the use of this co-administration in PC programs. Large-scale definitive randomized controlled trials are required to confirm our results.

Epidemic hysteria following the National School Deworming Day, Zamboanga Peninsula, Philippines, 2015.

INTRODUCTION: In July 2015, the Philippines conducted a school-based mass drug administration using albendazole for soil-transmitted helminths infection. Reports of adverse events were subsequently made through the event-based surveillance system, mostly from the Zamboanga Peninsula on the island of Mindanao. A team from the Epidemiology Bureau investigated the reports of adverse events following mass drug administration (AEFMDA). METHODS: Five schools were identified for the investigation which comprised an unmatched case-control study, key informant interviews and laboratory examinations. AEFMDA cases were students who had sudden onset of abdominal pain, vomiting, diarrhoea, loss of consciousness, headache or dizziness within 24 hours after intake of deworming tablet; controls were healthy students who did not develop signs and symptoms after deworming. RESULTS: Most (85%) of the 7313 AEFMDA cases reported nationwide were from Zamboanga Peninsula. Most reports were made after rumours of deaths following deworming and of the use of expired drug were spread through the region. Many parents sent their children to hospital, even if asymptomatic. The case-control study found that being an AEFMDA case was associated with no history of previous deworming (odds ratio = 4.08, 95% confidence interval: 1.77-9.42). DISCUSSION: The investigation concluded that epidemic hysteria was the cause of the increased number of AEFMDA cases in the Zamboanga Peninsula. The false information, aggravated by social media, caused panic and an increase in reporting. Some cases had no history of deworming, and they may not have been aware that albendazole is safe and that side-effects are expected. Risk communication before, during and after future national deworming programmes are recommended to prevent unnecessary reporting of AEFMDA.