Challenges for national deworming policy in Indonesia: experience from Bandung district West Java province

The strategy of regular deworming has been the main STH control strategy recommended by the WHO for over a decade. In 2017, the Indonesian government also adapted this strategy by launching the Ministry of Health (MoH) Regulation No. 15 year 2017 regarding helminthiasis control. However, deworming effort is often hindered by various factors, including poor hygiene, habits, and irregular mass drug administration in developing countries. To obtain a picture of how the deworming regulation is carried out and key challenges in Indonesia, this study investigated deworming conducted in Bandung District—one of the densest areas in Indonesia. The main methodology was qualitative using published documents, interview and focus group discussion with related agencies such as MoH, Bandung District Health Office, primary health care and cadres (community participants). From this study, we discovered incompleteness and inconsistency of conduct—even within a relatively small area such as Bandung District. Moreover, this study also found that deworming is combined with stunting programs in some areas without proper study directly correlating the improvement of nutritional status with reduced incidence of STH. This study has demonstrated the challenges sustaining a consistent nationwide campaign over a wide area such as in Indonesia. In conclusion, we recommended that further nationwide evaluation is required—placing emphasis on dissemination of policy to ensure more standardized conduct.


Introduction
Soil-transmitted helminthiasis (STH) is the most common neglected tropical disease worldwide. It is a type of helminth infection caused by various species of roundworm. Three major helminths underlying STH are Ascaris lumbricoides, Hookworm, and Trichuris trichiura, which are prevalently found in endemic areas (Clarke et al. 2019). STH causes considerable health and economic burden-high to moderate STH infections are associated with increased risk of malnutrition, iron-deficiency anemia, and other adverse physical and cognitive morbidities, particularly in children (Freeman et al. 2019).
To tackle this problem, The World Health Organization (WHO) has set a global target to eradicate STH-caused morbidity by 2020 (Becker et al. 2018). This can be achieved through conducting STH control by regular deworming in 75% of preschool-and school-age children (aged 2-4 years and 5-12 years, respectively) in endemic areas. Subsequently, the current WHO strategy for controlling STH relies on mass drug administration (MDA) of albendazole or mebendazole to pre-school and school-age children (PSAC and SAC), women of childbearing age (including pregnant women in the second-third trimesters and breastfeeding women), and adults in certain high-risk occupations such as agricultural laborers or miners (Freeman et al. 2019;Lo et al. 2018).
In recent decades, Southeast Asia has been recognized as a region with the highest prevalence of STH infection. Many countries in Southeast Asia have a moist climate that provides an ideal environment for STH embryonation, survival of eggs, and larvae maturation (Pasaribu et al. 2019). Among these countries is Indonesia, where STH infection is one of the main public health concerns with prevalence ranging from 45% to 65%. In areas with poor sanitation, the prevalence can reach as high as 80% (Nasution et al. 2019).
Aiming to mitigate STH prevalence in Indonesia, the government through the Ministry of Health (MoH) has launched the MoH Regulation No. 15 year 2017 regarding helminthiasis control. This regulation adopts the WHO recommendation for annual treatment in areas where the prevalence of STH is between 20% and 50% and biannually where the prevalence is over 50% (Pasaribu et al. 2019). However, effective application of deworming regulation in developing countries is often hampered by lack of adequate water resources and poor sanitation infrastructure in many areas. Despite efforts to improve water resources availability and latrine utilization in these areas, complete eradication is also hindered by poor human sanitation habits and irregular mass drug administration (Pasaribu et al. 2019;Sungkar et al. 2017). Now in 2020, we have reached the end year for the global target set by WHO (Becker et al. 2018). It also has been three years since Indonesia launched the newest deworming regulation. However, evaluation regarding the execution of this policy has not been carried out yet. In order to obtain a picture of how the deworming regulation is carried out in Indonesia, we studied the execution of the deworming policy in Bandung District, West Java. West Java is one of the densest areas in Indonesia, with a population of 46,497,175 peopleapproximately 44% among them living in Bandung City and Bandung District. Bandung District is administratively divided into 31 sub districts and 270 villages. Most residents work in factories. Geographically, Bandung District lies between 6 0 41′ -7 0 19' SL and 107 0 22′ -108 0 5′ EL. The area is mountainous and is passed by the Citarum River. Because of poor drainage and sedimentation of the river, Bandung District is frequently flooded during the rainy season (Kementerian Kesehatan RI 2017). Through this study, we expect to identify key challenges in application of an effective deworming policy in Indonesia that could guide policymakers to design a more definitive control strategy for STH in the upcoming years.

Ethical declaration
This study was part of a main study, "The Relation of vitamin D, confounding and comorbid factor of stunting in an infant in Bandung District" which is approved by the Health Research Ethical Committee, Medical Faculty of Universitas Padjadjaran (No.1170/UN6.KEP/EC/2019).

Study area
The study was conducted in Bandung District, West Java Province, Indonesia. This district covers an area of 1762.39 km 2 with a population of 4,069,872 people (density of 2309.29 people/km 2 ).

Data collection and analysis
This study employed a qualitative approach, combining analysis of published documents, interviews, and focus group discussions (FGD) involving related agencies such as MoH, Bandung District Health Office, primary health care and cadres (community participants) to obtain information regarding how this deworming program is conducted, the prevalence of STH in that area, MDA program for STH and determine the obstacles.
For the interview, we purposely selected several key informants (n = 15) among those agencies. Meanwhile, FGD was done involving primary health center workers and cadres (n = 80) across Bandung District. Both resource groups have educational backgrounds with a major degree from bachelor to university graduate from public health or medical studies background and an age range between 20 and 40 years old. All of these were audiotaped and transcribed.

Analysis of published documents: Deworming as a national issue
The timeline of Indonesian deworming policy can be summarized in Fig. 1. In 2009 to 2013, the Indonesian nationwide program for deworming was conducted through an integrated MDA for filariasis; therefore, all data obtained then was measured in terms of filariasis incidence. Prior to commencement of the program, surveillance has shown that incidence of microfilaria was >1% across various municipalities and regencies in Indonesia. In order to reduce this incidence to less than 1%, the MDA filariasis program in 2009-2013 was done by administering diethylcarbamazine citrate (DEC) 6 mg/kg of body weight in combination with albendazole 400 mg. Following a national report in 2017, this program has shown success in which 78 provinces in Indonesia demonstrated a decrease to <1% microfilaria incidence (target = 55 provinces) (Kementerian Kesehatan RI 2017 Under the condition where the laboratory resource is very limited or geographically challenging for stool examination, the area will be considered as having >20% prevalence and the local MDA will be carried out for 4 to 6 years (Kementerian Kesehatan RI 2017).
This new regulation also requires evaluation through a prevalence study for roundworm, hookworm, and human whipworm for every five years of administration of MDA of STH. The study shall use a clustering survey method and the result of the study will decide the appropriate follow-up interventions in the surveyed area ( Furthermore, the regulation also mandates the local government to conduct the program. This includes supporting resources, mobilizing society to control the risk factor of STH, and administering MDA under supervision (Kementerian Kesehatan RI 2017).

Real-life condition of deworming program at the national level
Through interviews and FGD with health agencies in various levels of authority, the study obtained a visual summary of how the deworming program is carried out in Indonesia (Fig. 2).
At the national level, an interview with the subdirectory of prevention and control of direct infection in the Ministry of Health Indonesia revealed that the deworming program is carried out differently in STH-endemic, stunting-prevalent, and other areas. In areas endemic to STH, deworming is focused on administration of MDA annually for residents aging 2-70 years old. Meanwhile, in areas where cases of stunting are prevalent, MDA is only given to the younger population (1-12 years old) and pregnant women twice a year. In other areas, deworming is done by annual supplementation of Fe

Real-life condition of deworming program in Bandung District
Interview with the person-in-charge of the deworming program in the Bandung District Public Health Office revealed further information regarding the implementation, surveillance study, and the follow-up interventions done in this area. In Bandung District, the deworming program has been conducted annually since 2009. The program focuses on the population aging 1-65 years old. For the first five years of the study (2009)(2010)(2011)(2012)(2013), evaluation was carried out in September to October 2016, targeting the population of children in primary school grade 3 to 5. The study involves 2 cluster targets and a total of 664 stool samples. These samples are collected through a sequence of directions: program holders educate teachers, who then teach their students. These students will relay the directions to their parents at home; the next morning, these students will bring the stool samples to school. These samples were then collected by officials and sent to the district laboratory. There, these samples were examined using the Kato-Katz technique. The results showed prevalence of STH 1.95%; with roundworm 1.2%, human whipworm 0.85%, while there is no hookworm found. Following this result, the follow-up intervention for deworming should only be conducted in children with positive STH. However, based on a letter from the Ministry of Health Indonesia number PV/04.02/Menkes/528/2017, the Bandung District should conduct MDA for STH twice a year in April and October in order to ensure reduction of STH infection to 10%. In further development, a new policy regarding stunting in 2018 has altered the execution of the deworming program-deworming is only carried out in areas with a high number of stunting.
These changes of directions in the deworming program is reflected in information obtained from the person-in-charge of the deworming program in primary health care regarding what they know of the program. One of the noticeable findings in this level is the inconsistency of application of deworming programs. We also found that in several areas, further interventions after 2017 have not been done yet; presumably  (2009)(2010)(2011)(2012)(2013) and following change of policy to focus deworming only in areas with high stunting prevalence. Among the results of the interviews with person-in-charge, there were common answers, as shown in Table 3, from three different primary health care workers within Bandung District that might represent the general answer of the whole sample.

Discussion
Sustaining a huge national campaign over a long period and wide area is a challenge in any society. Even though the prevalence of STH in Bandung District is very low, we found several aspects that could be improved. First, we identified an incomplete and inconsistent implementation of the program-as seen in the difference between information in national and regional levels of the health agency (Fig. 1). This inconsistency is also found in surveillance of program status, as demonstrated in the case of Bandung District. There, evaluation of the 2009-2013 program was conducted in 2016-three years after conclusion of the program. While indeed at that time, the MoH Regulation No. 15 year 2017 that dictates evaluation every five years had not been launched yet, evaluation of the deworming program should have been done immediately (Mwandawiro et al. 2013) in order to determine the next step for the deworming program. Fortunately, the prevalence of STH infection in Bandung District was rather low in 2016 (1.95%). However, a significant decline in prevalence does not mean that the deworming program should stop immediately. Continuous monitoring should be carried out as part of disease control, as experience from Togo on STH program has demonstrated that abrupt stopping of MDA in areas with high baseline prevalence may result in significant rebound of infection (Bronzan et al. 2018;Dunn et al. 2019). Therefore, in the areas where prevalence of STH is high, repeated mass treatment for at least five consecutive years to prevent reinfection is needed (Sungkar et al. 2017).
Another area of improvement is the use of the Kato-Katz technique in examining stool samples. Indeed, it has several advantages: it is inexpensive, widely used, and sensitive in detecting moderate or heavy infection (MHI) of STH. However, it has limitations regarding predictive values in low-prevalence settings and the effect of stool preparation (consistency, amount, part of stool sampled) on the result. The latter concern is also exacerbated due to the complex sequence of directions from program holders to students and their parents, increasing likelihood of obtaining inappropriate stool samples. In addition, some preliminary analysis from microscopy and PCR has suggested that hookworm infection may be misidentified (Freeman et al. 2019).
The importance of STH to global child health is associated with their ability to cause chronic disability that often lasts throughout childhood and adolescence. Over this period, worms might stunt growth and cause intellectual and cognitive deficits (Weatherhead and Hotez 2019). This led to the decision of the Ministry of Health Indonesia in 2018 to conduct a deworming program only in areas with a high prevalence of stunting. Indeed, a previous study in several areas of Indonesia demonstrated that deworming effectively improved the nutritional status in children. Before the deworming program, 33% of study participants were in good nutritional status, 47.7% of them were underweight, and 19.3% were severely underweight. After the deworming program, the percentage of participants with good nutritional status rose up to 75%, while the percentage of underweight participants reduced to 25%, and none of them were severely underweight (Clarke et al. 2016;Sungkar et al. 2017;Thayer et al. 2017). However, there has not been any study that directly correlates the improvement of nutritional status with reduced incidence of STH. Through this study, we revealed that the deworming program in Bandung District has included areas with a high prevalence of stunting. Nevertheless, further study to find the correlation between STH and stunting in the Indonesian community would support the benefit of MDA for STH in the stunting population.
In this study, we highlighted the necessity of timely evaluation of the deworming program to determine its efficacy. We also suggest that consistency and implementation of this nationwide policy continues to be monitored and evaluated.