Evidence-based policy and practice
Using national health weeks to deliver deworming to
1
Departamento de Microbiologı́a
y Parasitologı́a, Facultad de
Medicina, Universidad Nacional
Autonoma de México, Ciudad
Universitaria, San Ángel,
México; 2 Laboratorios de
Biológicos y Reactivos de
Mexico, Secretarı́a de Salud,
Mexico DF, Mexico; 3 Instituto
Nacional de Salud Pública,
Cuernavaca, Morelos, Mexico;
4
Instituto de Diagnóstico y
Referencia Epidemiológicos
(INDRE), México DF, México;
5 of millions of school-age and preschool children between
Division of Clinical
Epidemiology, McGill University
Health Centre, McGill University,
Montreal, Québec, Canada
Correspondence to:
Dr Ana Flisser, Departamento de
Microbiologı́a y Parasitologı́a,
Facultad de Medicina, UNAM,
Ciudad Universitaria, San Ángel,
México 04510 DF, Mexico;
flisser@servidor.unam.mx
Accepted 23 September 2007
314
children: lessons from Mexico
A Flisser,1 J L Valdespino,2 L Garcı́a-Garcı́a,3 C Guzman,4 M T Aguirre,4 M L Manon,4
G González-González,4 T W Gyorkos5
ABSTRACT
Mexico established national health weeks (NHWs) in the
early 1980s to promote childhood vaccinations. Because
of the cumulative worldwide peer-reviewed scientific
evidence, the recommendations of the World Health
Organization and other international organisations, the
political will of the Mexican government and the
infrastructure provided by the NHWs, deworming was
added to the NHWs in 1993. In addition to the Ministry of
Health, several other government organisations partici-
pated in administering the deworming component. Tens
the ages of 2 years and 14 years now receive deworming
(a single 400 mg dose of albendazole) approximately
every 8 months. Between 1993 and 1998 evaluations
were carried out in over 90 000 children to determine the
effect of NHWs on the prevalence of geohelminth
infections. In 1993, the overall prevalence of Ascaris was
20% and that of Trichuris was 15%. Prevalences
decreased significantly over time (p ,0.001). Treatment
efficacy for Ascaris ranged from 91.6% to 85.3%, and for
Trichuris, from 97.9% to 42.6%. In 1998, after conducting
12 NHWs with deworming, the respective prevalences
were Ascaris 8% and Trichuris 11%. The experience of
Mexico in integrating albendazole into its NHWs shows
how deworming can be delivered to large numbers of at-
risk children using an existing infrastructure. The NHW
approach may be generalisable in other countries with
successful national vaccination campaigns. The challenge
remaining is to sustain the deworming programme until
other longer-term behavioural, environmental and socio-
economic changes can be implemented.
In geohelminth-endemic areas, deworming is con-
sidered to be a highly cost-effective intervention,
with health benefits in both preschool and school-
age children.1–6 One of the most important benefits
relates to improved cognitive performance.7 8 In
addition, it became clear, after the first estimates of
disability-adjusted life years lost (DALYs) were
published, that in developing countries intestinal
parasites ranked first among all causes of disease
burden in girls and boys of school age (5–14 years).9
These advances, among others, spurred the World
Health Organization and other international orga-
nisations to recommend that deworming be
included in large-scale programmes targeting at-risk
child groups. Indeed, at the World Health Assembly
in 2001, a deworming policy was ratified.10 The goal
is to provide periodic deworming treatment to at
least 75% of at-risk school-age children by the year
2010. Many of the deworming programmes are
school-based, as large numbers of children can be
reached via the school infrastructure and non-health
J Epidemiol Community Health 2008;62:314–317. doi:10.1136/jech.2007.066423
personnel can administer the deworming drugs.11–13
However, other delivery vehicles have also been
used (for example, child health days in Uganda) and
the infrastructure provided by national health
services may also be effective.14 15
All of Mexico’s 32 states are endemic for
geohelminths. Ascaris and Trichuris prevalences
exceeding 70% have been reported in child age
groups of many community-based surveys.16
Therefore, for these and other reasons (box 1),
Mexico decided to add a deworming component to
its highly visible and widely recognised national
health weeks (NHWs).
The NHWs were initially established and orga-
nised by the National Vaccination Council
(CONAVA) in the early 1980s to promote child-
hood vaccination and were conducted three times
per year. Local health and civil authorities, and a
large cadre of health volunteers (promotores),
participated in delivering vaccinations and other
selected health interventions (for example, vitamin
A supplements and oral hydration packages,
among others). Interventions targeted to children
were delivered in schools, parks and health units.
Starting in October 1993, Mexico integrated
deworming into the NHWs of municipalities
considered to be at higher risk for geohelminth-
attributable disease burden. Between 1993 and
1995, the Instituto Nacional de Diagnóstico y
Referencia Epidemiológicos (INDRE) coordinated
and evaluated the deworming component of the
NHWs, which were organised three times per
year.17 18 From 1995 onwards, CONAVA, which
coordinated the NHWs, integrated deworming
every 8 months, INDRE conducted the evaluations
(until 1998).19 This study describes how the
deworming component of the NHWs was orga-
nised and evaluated.
METHODS
Selection of municipalities adding deworming to the
NHWs
In 1993, municipalities were selected on the basis
of being above the 50th percentile for the following
indicators: illiteracy among persons older than 10
years of age, all-cause mortality in children under
4 years of age and diarrhoea-attributable mortality
in children under 4 years of age. In this way, a total
of 887 municipalities from all 32 states were
selected.
Selection of the deworming drug
Of the four WHO-recommended deworming
drugs,20 Mexico chose to use albendazole because
 Evidence-based policy and practice

used for vitamin A supplementation and consequently afforded

Box 1 Rationale for including deworming in national
health weeks (NHWs) in Mexico
c Overwhelming cumulative peer-reviewed scientific evidence
on efficacy/effectiveness
c WHO, World Bank policy recommendation
c Important impact in improving cognitive performance in
school-age children
c Top-ranked burden of disease (in terms of DALYs) in girls and
boys 5–14 years of age in developing countries
c Local surveys in different parts of Mexico with geohelminth
prevalences over 50%
c Strong national, state and institutional political will in Mexico
c Manufacturing facility for albendazole on site in Mexico
c Successful track record of NHWs since the early 1980s in
Mexico
of its single dose format (400 mg), overall high efficacy, little or
no side effects, low cost ($0.04 per tablet for NHWs in 1993–5
provided by SmithKlineBeecham Mexico; thereafter, generic
formulations were used) and the presence of albendazole
(originator and generic) manufacturing facilities in the country.
Between 1993 and 1995 SmithKlineBeecham Mexico provided
the albendazole to each state capital for distribution to the local
administering institutions. From 1996 on, each state purchased
generic albendazole for municipalities in their jurisdiction. A
suspension was used for children between 2 years and 4 years of
age, while tablets were used for the older children. The quality
of the generic albendazole used after 1995 was ensured by the
manufacturing facilities. No additional testing was done by the
Ministry of Health.
Selection of the frequency of deworming
The frequency of deworming was initially planned to be two to
three times per year. This frequency is recommended by WHO
for areas where the prevalence of geohelminths exceeds 50%, as
some of the selected regions did.2 16 This same frequency was
economies of scale. The frequency was changed after June 1995
to every eight months although, owing to other factors (for
example, change in directorship, change in health ministers,
change in lead organisation, among others), some NHWs did
not include deworming.
The programme involved all public institutions of the Mexican
health sector that cover 90% of the Mexican population. The
public Mexican health sector includes the Ministry of Health,
which services the greatest majority of the underprivileged non-
insured groups representing 40% of the total population and the
social security institutions that provide service to approximately
50% of the population and that include the Mexican Institute of
Social Security (Instituto Mexicano del Seguro Social, IMSS)
servicing workers in the formal sector (obligatory) or in the
informal sector (solidarity); the Institute of Social Security for
State Workers (Instituto de Seguridad y Servicios Sociales de los
Trabajadores del Estado, ISSSTE) that covers government work-
ers, and smaller institutions that cover specific groups such as the
army (Secretarı́a de la Defensa Nacional, SEDENA), the navy
(Secretarı́a de Marina, SEMAR), workers of the national oil
company (Petróleos Mexicanos, PEMEX), autochthonous groups
(Instituto Nacional Indigenista, INI) or have specific purposes
such as family development (Sistema Nacional para el Desarrollo
Integral de la Familia (SNDIF). Organisation and training for the
deworming programme involved all institutions and were headed
by the Ministry of Health. Activities were cascaded from the
federal to the state and to the municipal levels. For the inaugural
NHW in October 1993, the state level was charged with
contacting the municipal level that would distribute and
administer the albendazole together with any other intervention
included in the NHW.
Children received the albendazole, together with a bottle of
water (to ensure that the water was safe), donated by the
participating municipalities.
Selection of the study population for the evaluation study
A target sample size of 500 children was planned to be recruited
from one or two participating municipalities in each state. This

Table 1 Coverage of albendazole during the national health weeks (NHWs), by administering institution, 1993–8*
Institutions in Mexico{
NHW dates SSA IMSS (Oblig) IMSS (Solid) ISSSTE Others Total coverage

Oct 93 4 583 878 2 803 765 1 743 615 582 784 0 9 714 042
Feb 94 4 362 635 2 769 967 1 464 248 585 252 0 9 182 102
Jul 94 5 463 474 3 329 832 1 732 191 788 914 22 381 11 336 792
Oct 94 5 271 054 3 458 226 1 751 259 714 174 213 510 11 408 223
Mar 95 5 051 865 2 902 174 1 953 435 928 442 208 442 11 044 358
Jun 95 6 440 650 3 061 555 1 963 778 1 021 786 263 487 12 751 256
Oct 95 No albendazole administered in this NHW
Feb 96 No albendazole administered in this NHW
May 96 5 609 536 3 025 279 2 049 734 843 964 191 090 11 719 603
Oct 96 6 138 975 2 741 345 1 941 988 760 808 230 976 11 814 092
Feb 97 No albendazole administered in this NHW
May 97 6 295 746 2 730 745 1 550 729 892 812 209 056 11 679 088
Nov 97{ 11 767 417
Feb 98 No albendazole administered in this NHW
May 98 6 581 190 3 531 629 1 806 160 962 332 236 448 13 117 759
Oct 98 7 038 559 4 770 573 1 929 473 980 421 230 695 14 949 721
*Data from the Consejos Estatales de Vacunacion (members of CONAVA).
{SSA, Secretaria de Salud; IMSS (Oblig), Instituto Mexicano del Seguro Social (Obligatorio); IMSS (Solid), Instituto Mexicano del Seguro Social (Solidaridad); ISSSTE, Instituto de
Seguridad y Servicios Sociales de los Trabajadores del Estado; Others, PEMEX, SEMAR, SNDIF, SEDENA, INI and other non-specified groups.
{Breakdown by institutions not available for this NHW.

J Epidemiol Community Health 2008;62:314–317. doi:10.1136/jech.2007.066423 315

 Evidence-based policy and practice

Table 2 Evaluation of the deworming component of Mexico’s national health weeks (NHW) between 1993 and 1998: prevalences for Ascaris and
Trichuris infections
Date of NHW following initiation No of states participating in the No of children participating in % positive for Ascaris pre- % positive for Trichuris pre-
of deworming evaluation the evaluation treatment treatment

Oct 93 30 13 804 20.25 15.42

Feb 94 27 11 844 11.74 13.95
Jul 94 27 8515 11.06 11.39
Oct 94 28 10 381 9.00 11.77
Mar 95 29 9996 13.69 13.17
Jun 95 15 4797 10.35 9.27
May 96 21 6561 10.24 8.38
Oct 96 25 9166 9.83 9.69
May 97 Not done Not done
Nov 97 18 5131 6.06 5.85
May 98 Not done Not done
Oct 98 26 10 134 8.40 11.01
Total 90 329

sample size is sufficient to determine the deworming RESULTS

treatment strategy for a community and exceeds the one
that is recommended by WHO for school-based surveys for
this purpose.2 Plastic stool containers were distributed by
nurses and health promoters to children in the selected
municipalities the day before albendazole administration. A
similar process was followed two weeks later to determine
treatment efficacy.
Data collection
Standardised forms were used to record each child’s age, sex and
parasite results. All questionnaires were sent to INDRE for data
entry into Excel databases, data cleaning and data management.
Parasite measurement
One laboratory technologist and one epidemiologist from each
of the participating state public health laboratories (SPHLs)
were trained in Mexico City at INDRE for a period of five days
in the standard performance of the Kato-Katz technique and in
the conduct of the deworming component of the NHW.
Evaluation was based on the prevalences of Ascaris and
Trichuris infections, as there were laboratory problems in
accurately estimating hookworm prevalence and intensity
measures. INDRE provided all necessary laboratory supplies to
the SPHLs. In 1997, an additional quality control assessment
was carried out by INDRE in each of the participating SPHLs.
This consisted of confirming all positive specimens and 10% of
all negative specimens.
Statistical analysis
Descriptive statistics included means and proportions.
Univariate statistical testing included the x2 test. Age was
categorised into three groups: 2–4 years, 5–9 years and 10–
14 years. For comparisons among the age groups, the 10–
14 year age group was used as the reference group. The x2 test
for trend was used to evaluate trends in prevalence and in
treatment efficacy over time. Statistical significance was
attributed to p values ,0.05. The calculation of efficacy was
limited to those children who were positive pretreatment and
combined results from participating states for each NHW.
Because of the variable participation of individual states and
the variable sample sizes of children participating in each
evaluation, it was not possible to accurately compare states in
terms of better or worse results.
Deworming in NHWs
A total of 887 municipalities from all states met the eligibility
criteria based on illiteracy and child mortality rates. There were
12 NHWs between October 1993 and October 1998 that
administered albendazole to over 100 million children, with an
average coverage of 11 707 038 children per NHW (table 1).
Several health and social institutions participated in the
distribution and administration of the albendazole, with the
Ministry of Health accounting for approximately half of each
distribution. As of the June 1995 NHW, a steady state of
approximately 12 million doses had been distributed per NHW.
Evaluation of deworming in NHWs
A total of 90 329 children participated in the 10 evaluations
(table 2), with a mean of 9033 children per NHW. Not all states
participated in the evaluations at every NHW; participation
ranged from 15 states to 30 states for any one evaluation.
In October 1993, the prevalence of Ascaris infection was
20.25% and that of Trichuris, was 15.42%. Prevalences of both
infections decreased steadily over time (x2 trend: p,0.001).
After 12 NHWs with deworming, the prevalence of Ascaris was
8.40% and that of Trichuris was 11.01%.
The efficacy of albendazole was higher for Ascaris (range
91.64% to 85.30%) than for Trichuris (range 97.86% to 42.56%)
(fig 1). Overall, there were no statistically significant differences
between boys and girls at any evaluation in terms of Ascaris
prevalence or efficacies of albendazole for either Ascaris or
Trichuris infection. Boys, however, tended to have a higher
prevalence of Trichuris infection pretreatment than girls
(p,0.001). The 5–9 year age group had a statistically signifi-
cantly higher prevalence of Ascaris than did the other age groups
(p,0.001). Both the 2–4 year and the 5–9 year age groups had
statistically higher prevalences of Trichuris than did the 10–
14 year group (p,0.001).
DISCUSSION
Building on the routine infrastructure provided by the national
health weeks conducted periodically in all states of Mexico, the
inclusion of deworming has benefited millions of preschool and
school-age children. Deworming continues to be administered
within the NHWs in Mexico benefiting approximately 13
million pre-school and school-age children per NHW. Its impact
is being observed in recent surveys.21 This impact should

316 J Epidemiol Community Health 2008;62:314–317. doi:10.1136/jech.2007.066423


Figure 1 Efficacy of originator albendazole (1993–5) and generic
albendazole (1996–8) in each of the deworming national health weeks
(NHWs), in terms of Ascaris and Trichuris prevalence in Mexico. The
calculation of efficacy was limited to those children who were positive
pretreatment and combined results from participating states for each
NHW.
continue to be felt and will influence indicators of the
millennium development goals.5
Although the evaluation was limited in its scope, being
restricted to a comparison of prevalences of Ascaris and Trichuris
infections over time, and to albendazole efficacy, the results
demonstrate a positive impact. In addition, it is likely that
significant parasite egg reductions occurred and contributed to
subsequent reductions in prevalence over time. Of note also is
the observation that treatment efficacy remained high even
after 1995 when the albendazole used changed from an
originator drug to a generic equivalent.
Future evaluations would benefit from an assessment of egg
reduction rates (in addition to prevalences) and of school effects
(absenteeism, retention rates, gender effects, etc) as this type of
evidence would contribute to programme review in Mexico and
to advocacy of these programmes in other countries.22 The
results of the univariate analysis considering age groups and sex
are suggestive but remain to be confirmed in surveys using
representative sampling methodology and multivariate ana-
lyses.
Mexico’s nationwide deworming programme is among the
longest running in the world (14 years to date) and its coverage
has extended to well over 400 million children. The question
that needs to be asked now is: how long should it run? As no
evaluation has been carried out since 1998, it would be
important to plan for an evaluation in 2008 in order to review
the strategy. Care must be taken in conducting a rigorous
analysis as modifying the programme in any significant way or
exiting from it altogether will be of monumental consequence.23
A review is not only needed of the deworming programme itself,
but complementary non-drug interventions to reduce geohel-
minth infections also require assessment so that their use may
be appropriately gauged. It may be that a prospective
randomised evaluation type of design is required to ensure the
methodological rigour of any new evaluation data.24 Together
with other considerations (political, logistic, etc), these data can
contribute to the development of a decision algorithm regarding
the continuation of the programme. Such a process would also
be instructive for other countries.
J Epidemiol Community Health 2008;62:314–317. doi:10.1136/jech.2007.066423
Evidence-based policy and practice
Acknowledgements: The vision and dedication of those officials in the Ministry of
Health of Mexico who initiated the deworming component of the NHWs is recognised.
The work of all SPHL and all other health personnel is greatly appreciated. We thank
Ms Serene Joseph for conducting the statistical analyses. Lastly, and most
importantly, the children who provided their stool specimens so evaluations of this
programme could be carried out, are especially recognised.
Funding: TWG’s contribution was within the context of a Canadian Institutes of Health
Research (CIHR) Interdisciplinary Capacity Enhancement (ICE) grant HOA80064.
Competing interests: None.
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