Evaluation of Strategies for Improved Uptake of Preventive Treatment for Intestinal Schistosomiasis Among School Children in Jinja District, Uganda: a Stratified Cluster Randomized Controlled Trial

Schistosomiasis is one of the most important parasitic infections in children particularly in Sub-Saharan Africa and the age related patterns of water contact explain the high prevalence and intensity of S. mansoni infection in children. If left untreated, schistosomiasis results in retarded growth and impairment of cognitive function especially among school children. Repeated treatment in the early stages of life has a long-lasting effect on morbidity at a later age. Focusing on the delivery of regular chemotherapy to the younger age groups produces maximum benefits and prevents chronic sequelae in adulthood.

In 2001, the World Health Organization (WHO) recommended treatment programs for schistosomiasis to target school-age children who could be reached through the primary school system, in collaboration with the education sector. This method was considered affordable and cost-effective and the goal was to provide regular treatment to at least 75% of school-age children at risk of morbidity by the year 2010.

The Ugandan national program for the control of schistosomiasis adopted the WHO recommendations in 2003 and has since supported Mass Drug Administration (MDA) with praziquantel, a single dose drug known for its efficacy and safety, in high burden communities including primary schools. The current national Health Sector Strategic and Investment Plan (HSSIP) underscores schistosomiasis as one of the diseases targeted for elimination by the year 2015. In Jinja, implementation of the control program for schistosomiasis started in August 2003 and has been scaled up to most of the endemic areas in the district. Annual mass treatment using praziquantel and albendazole for schistosomiasis and soil transmitted helminths (STH), respectively, targets all school-age children and adults at risk of infection. Preventive measures focusing on raising awareness on schistosomiasis include distribution of information, education and communication materials and health education especially in the primary schools but also in the wider communities. These are provided prior to MDA. In the primary schools, the teachers are trained to distribute the drugs to the children and to fill the treatment registers. These activities are supported through a parallel structure within the Ministry of Health with external funding from the United States Agency for International Development (USAID) channeled through Research Triangle Institute (RTI) International

Previous research undertaken among adults in high endemic districts of Busia, Adjumani, Moyo and Nebbi reported unwillingness to take preventive treatment. A particular study conducted in primary schools of Jinja district showed that only 30% of school children took praziquantel during the 2011 MDA. Fear of side effects of praziquantel, lack of knowledge about schistosomiasis transmission and prevention and lack of teacher support were some of the major factors associated with the low uptake. Similar reasons for non-uptake have been reported elsewhere.

Thus, measures are needed to increase uptake of MDA in Uganda. There is no doubt that health education facilitates a better understanding of the obvious risks to health, including the knowledge of preventing parasitic infections among primary school children. Better compliance to treatment for schistosomiasis among school children can be achieved through implementing carefully designed programs involving face to face education methods. Increasing knowledge about schistosomiasis transmission and prevention and implementing measures to mitigate the side effects attributable to praziquantel, such as providing a snack prior to drug administration may improve uptake of the drug among school children.