Malaria, other vectorborne and parasitic diseases programme

Communities drive elimination of schistosomiasis through improving water, sanitation and hygiene in Cambodia and the Lao People's Democratic Republic

Schistosomiasis is a parasitic disease caused by schistosoma parasites and can cause bloody diarrhoea, nausea, anaemia, stunting, development retardation and even death in severe cases.

Caused by Schistosoma mekongi, the disease is endemic in approximately 200 villages of Champassak province in the Lao People's Democratic Republic, and 200 villages of Kratie and Stung Treng provinces in Cambodia, along a 250 kilometre stretch of the Mekong River with about 178,000 people at risk.

Transmission occurs when infected people contaminate freshwater sources with excreta containing parasite eggs. These hatch in the water, develop into infective larva in snail hosts and penetrate the skin of new human hosts.

The disease was once highly endemic in these areas, with a prevalence of infection above 70% in many villages. Ongoing annual mass drug administration (MDA) campaigns for over 20 years has brought a significant reduction of prevalence of infection in all endemic villages. However, MDA alone cannot interrupt transmission of schistosomiasis. If this debilitating disease is to be banished, it is essential to also prevent contamination of river water by improving sanitation and eliminating open defecation.

With support from WHO, government authorities responsible for neglected tropical diseases (NTDs), water, sanitation and hygiene (WASH), and education and nutrition, joined forces in early 2016 to empower communities to become the drivers of elimination of schistosomiasis by voluntarily making decisions and taking actions in building latrines and improving their hygiene behaviours through the Community Led initiative to eliminate Schistosomiasis with Water, Sanitation and Hygiene (CL-SWASH).

A CL-SWASH taskforce was created at the national, provincial and district levels in both countries. After a series of field visits and consultations at all levels, CL-SWASH training materials were developed by the CL-SWASH taskforce in the Lao People's Democratic Republic and piloted in November 2016. Taskforce members in Cambodia participated in the first CL-SWASH training of facilitators and communities to learn from their experience. This enabled them to organize their own training between January and February 2017.

Training of facilitators – developing skills as facilitators rather than teachers

To truly empower communities, skilled facilitators are essential and a 3-day training of CL-SWASH facilitators was held in Kratie province, Cambodia. Participants included district and provincial officers from the Ministry of Health, the Ministry of Rural Development and the Ministry of Education, Youth and Sport, all responsible for or involved in NTD control or WASH. Leaders of selected communes also participated. With support from WHO, national officers responsible for NTDs and WASH from the Ministry of Health and the Ministry of Rural Development were facilitators of the training.

On the first day of training, participants conducted discussions on the transmission and prevention of schistosomiasis and carried out role playing for government officers and commune leaders to enable them to understand the various points of view of others and find ways to convince people to help improve sanitation.

On the second and third day of training, participants learnt the process of CL-SWASH planning at the community level. This included a CL-SWASH village team selection, a survey of WASH facilities and practices and mapping of the village with the survey results, identification and prioritization of risks, establishment of risk control measures and finalizing the CL-SWASH plan. Monitoring progress of the CL-SWASH plan and practice with various tools and games were conducted to let community members carry out experiential learning activities which helped them discover and understand the root causes of ill health and propose solutions.

Community training – empowering communities as the drivers of change

The 3-day community training was held in two villages in Sambo commune, Sambo district, Kratie province in Cambodia. The 25 facilitators were divided into two groups in each village.

During community training, focus was on empowerment of community members, who learnt the basics of the transmission cycle of schistosomiasis and its linkage with their sanitation and hygiene behaviours and malnutrition. Community members self-selected the village CL-SWASH team composed of eight volunteer community members each which went house to house with checklists, water quality test kits and malnutrition check kits to assess their WASH situation.

The survey found that in one village 67% of households had no latrines and 60% of households still practice open defecation and in another 60% of households had no latrines and 45% of households still practice open defecation. Lack of latrines and the common practice of open defecation were identified as the major factors contributing to transmission of schistosomiasis in the area.

The village CL-SWASH team mapped the results of the household survey and presented it to community members who could clearly see the linkage between their behaviour and the sustained transmission of schistosomiasis and other health problems including outbreaks of diarrhoea leading to significant health consequences. They then discussed the findings and possible solutions they themselves could enact. Throughout the training, community members, with the help of WASH facilitators, participated in interactive demonstrations to understand how schistosomiasis is transmitted via water infected with faecal matter and learnt how to prioritize and deal with problems related to schistosomiasis transmission. Community members developed their own CL-SWASH plan and pledged to abide by the plan, which includes building and using latrines at their own expenses with the support of the village CL-SWASH team. The Government will also support this through negotiation with suppliers of construction materials for preferential pricing.

The way forward

Even though the programme in Cambodia was launched in just two villages, marked enthusiasm has been seen among the community members, which has encouraged the provincial and district CL-WASH taskforce to continue their joint efforts further. The CL-SWASH taskforce members in the Lao People's Democratic Republic also joined activities in Cambodia to share experiences and learn from each other. Encouraged by the enthusiasm of community members, the national and provincial CL-SWASH taskforce in Cambodia is developing the provincial roll-out plan to expand the community CL-SWASH training in all endemic villages in the near future. The delegation from the Lao People's Democratic Republic also renewed their commitment to continue efforts to scale up CL-SWASH planning in all endemic villages in close coordination and collaboration with Cambodia, with the goal of eliminating schistosomiasis by 2020.