The success of the Community-Directed Treatment (ComDT) approach in the control of onchocerciasis and filariasis has caught the attention of other disease control programmes. In this study the ComDT approach was implemented and compared with the school-based approach for control of schistosomiasis and soil-transmitted helminthiasis among school-age children in Lushoto District, Tanzania. This was a qualitative study, consisting of in-depth interviews with village leaders, community drug distributors (CDDs) and schoolteachers, as well as focus group discussions with separate groups of mothers and fathers to assess the perceptions and experiences of the villagers on the implementation of the two approaches. It was found that the villagers accepted the ComDT approach and took the responsibility of selecting the CDDs, organizing and implementing their own method of distributing drugs to the school-age children in their villages. The ComDT approach was well received and was successfully implemented in the villages. Although the villagers pointed out the limitation in reaching the non-enrolled children in the school-based approach, they also expressed satisfaction with this approach. This study suggests that the ComDT approach is well accepted and can be implemented effectively to ensure better coverage of especially non-enrolled school-age children.

The prevalence of urinary schistosomiasis among schoolchildren in Pangani District (Tanzania) was assessed rapidly by a questionnaire approach. Based on the results, a strategy of selective treatment with praziquantel was adopted. Eleven primary schools in Mwera Division, Pangani District, with about 2500 schoolchildren were included in a control programme for urinary schistosomiasis. Macro- and microscopic haematuria diagnosed visually and with urine reagent strips was used as an indirect indicator of Schistosoma haematobium infection. Intensity of infection among children was monitored in class 5 (median age 14 years, range 11-17) by urine filtration techniques. Treatment was administered as 40 mg/kg praziquantel in a single dose at the beginning of the school year. The programme was implemented by schoolteachers and coordinated by the District Health Management Team in collaboration with the District Education Office. Teachers were responsible for carrying out all programme activities. Community participation was through collaboration with Teachers-Parents Associations and Village Health Committees. Coverage at yearly (1995-99) examination varied from 67.7% to 80.3%. Prevalence of haematuria decreased from 51.2% (range 22.2-89.5%) at baseline to 23.4% (range 5.8-56.7%) in 1999, a reduction of 54.3%. Macrohaematuria was 21.2% at baseline and 7.2% in 1999, a reduction of 66.0%. Prevalence of infection in class 5 was reduced by 71.4% and geometric mean intensity of positives reduced from 71 eggs/10 mL (95% confidence interval [CI] 52.5-97.7) to 28 eggs/10 mL (95% CI 25.7-55.0), a reduction of 60.6%. Teachers were highly committed, and secured community participation and a smooth implementation of the programme. The community accepted the introduction of a cost-recovery system, whereby parents pay for the treatment of children with episodes of visible haematuria during the school year. Communities also participated in the improvement of sanitary installations at the schools.

This study compared the effect of the community-directed treatment (ComDT) approach and the school-based treatment approach on the prevalence and intensity of schistosomiasis and soil-transmitted helminthiasis (STH) among schoolchildren. Following a parasitological survey in a randomly selected sample of 1140 schoolchildren, school-age children in 10 study villages received one dose of praziquantel (40 mg/kg body weight) against schistosomiasis and one dose of albendazole (400mg) against STH. Five of these villages implemented the ComDT approach and received treatment by community drug distributors, while school teachers administered treatment in five other villages using the school-based approach. At 12 months follow-up, the prevalence of Schistosoma mansoni and Trichuris trichiura infections were similar between the ComDT and the school-based approaches when examined in randomly selected schoolchildren (10.1 vs. 9.4%, P=0.66 and 0.8 vs. 1.4%, P=0.37). However, the prevalence of S. haematobium and hookworm infections were significantly lower in the ComDT approach villages compared to the school-based approach villages (10.6 vs. 16.3%, P=0.005 and 2.9 vs. 5.8%, P=0.01, respectively). The results showed that the ComDT approach is at least as effective as the school-based approach in reducing prevalence and intensity of schistosomiasis and STH among schoolchildren.

Control programmes generally use a school-based strategy of mass drug administration to reduce morbidity of schistosomiasis and soil-transmitted helminthiasis (STH) in school-aged populations. The success of school-based programmes depends on treatment coverage. The community-directed treatment (ComDT) approach has been implemented in the control of onchocerciasis and lymphatic filariasis in Africa and improves treatment coverage. This study compared the treatment coverage between the ComDT approach and the school-based treatment approach, where non-enrolled school-aged children were invited for treatment, in the control of schistosomiasis and STH among enrolled and non-enrolled school-aged children. Coverage during the first treatment round among enrolled children was similar for the two approaches (ComDT: 80.3% versus school: 82.1%, P=0.072). However, for the non-enrolled children the ComDT approach achieved a significantly higher coverage than the school-based approach (80.0 versus 59.2%, P<0.001). Similar treatment coverage levels were attained at the second treatment round. Again, equal levels of treatment coverage were found between the two approaches for the enrolled school-aged children, while the ComDT approach achieved a significantly higher coverage in the non-enrolled children. The results of this study showed that the ComDT approach can obtain significantly higher treatment coverage among the non-enrolled school-aged children compared to the school-based treatment approach for the control of schistosomiasis and STH.

SummaryA school health programme in Mwera Division, Pangani District included treatment of malaria attacks occurring in children during school time. A combination of symptoms (headache, muscle/joint pains, feeling feverish) and oral temperature ³ 37.5°C was used for the diagnosis of malaria. Chloroquine (25 mg/kg given over 3 days) was used for treatment. Malariometric surveys on children aged 7±15 years (mean 10 years) were conducted once a year (1995±1997). Plasmodium falciparum accounted for 100% of infections and the parasite prevalence varied between 32.7 and 35.3% from 1995 to 1997. The number of malaria cases (cases/1000 registered school children) diagnosed and treated by school teachers was 159 (67) in 1995, 324 (124) in 1996, 348 (128) in 1997 and 339 (108) in 1998. Children in grades 1±4 (age 7±13) accounted for 64.6% of cases. Symptoms and oral temperature were recorded for 1258 children. Of those, 992 (78.9%) complained of fever and at least one other symptom when presenting to teachers, 98 (7.8%) had fever as their only complaint and 168 (13.5%) presented without a perception of fever, but with other symptoms. Of these children, 36 (21.4%) had a temperature ³37.5°C. The sensitivity of`feeling feverish' was 96.5% with a speci®city of 54.5%. The positive predictive value of feeling feverish was 89.9% and the negative predictive value 78.6%. Blood slides were prepared from 55.3 and 37.2% of children diagnosed by teachers during 1995 and 1996, respectively, and 71.4% were found positive. Among children who ful®lled the algorithm criteria 75.0% had a positive blood slide. With little training and regular supervision it was feasible for school teachers to make a presumptive diagnosis of malaria. We conclude that teachers can play a major role in school health programmes and are willing to be involved in health matters as long as they are supported by health and educational authorities.keywords malaria control, malaria, school children, school-health, Tanzania correspondence Pascal Magnussen,