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Impact Evaluation on Health-outcome of theEssential Health Care Package (EHCP) in Public

Elementary Schools in the Philippines

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Impact Evaluation on Health-outcome of the Essential Health Care Package(EHCP) in Public Elementary Schools in the Philippines

Study Protocol

I !esearch ob"ective#

The objective of this research is to evaluate the efficacy of combined generalhealth and oral health interventions on the health status, academic performanceand school attendance of public elementary school children in the Philippines. II $ackground%Introduction The health status of the public elementary school population in the Philippines isalarmingly poor. A recent report of the Department of ducation revealed that 2!" of #2$year old children had a %ody &ass Inde' (%&I) belo* normal (Dep d 2++ ).A nation$*ide study on pre$school children sho*ed that " of the pre$schoolchildren *ere infected *ith common intestinal helminths (de -eon and -umampao,2++ ). Another study on school age children in selected sites in -u/on, 0isayas and&indanao sho*ed that the cumulative prevalence of soil transmitted helminth(1T ) infections *as 3" and *as noted to be greater than +" in all selectedareas (%eli/ario et al., 2++ ).

According to the recent 4ational 5ral ealth 1urvey 63 " of first graders areaffected by dental caries (Dep d, 2++!). The average year old student *as

sho*n to suffer from nine decayed teeth *ith three of the teeth having cariesreaching the pulp. In the #2 year olds the mean number of permanent teethaffected by dental caries *as 7, one *ith pulp involvement already. 4o teeth *erefilled in both age groups. 2+" of the $year old and # " of the #2$year old childrenreported to have actual pain in the moment they *ere 8uestioned. Toothache isthe main reason for absenteeism from school in the Philippines.

All these diseases are not life$ threatening but they are neglected and have a hugeimpact on the physical and mental development of children, their schoolattendance, productivity and 8uality of life. 9orm infections cause anaemia,reduced physical gro*th, delay motor activity and result in poor mental

development. &alnourished children become even more malnourished. :hildren*ho suffer from toothache cannot eat, sleep or concentrate.

All these findings are strongly associated *ith poverty. :ro*ded living conditions,overcro*ded classrooms, lac; of *ater, lac; of sanitation facilities at home as *ellas in the schools, lac; of healthy and sufficient food are the root causes. Thesocial and the physical environment lead to diseases, *hich *ill ;eep the childrenin the cycle of poverty. And even more important, all these diseases can becontrolled through relatively simple cost$effective interventions.

:urrent approaches by government agencies mandated *ith health of the childpopulation, focus on preventive health education and service delivery<implementation ho*ever is noted to be generally poorly coordinated among

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implementing agencies li;e the Department of ealth, the Department of ducation, and the -ocal =overnment >nits.

The ealth and 4utrition :entre ( 4:) of the Dep d :entral 5ffice &anila hasta;en these concerns into account and has developed in close cooperation *ith

:I&?=T@ and the 9 5 :ollaborative :entre in 4jimegen, 4etherlands anssential ealth :are Pac;age for ilipino :hildren ( :P) This program is beingimplemented in pilot schools in all # # provinces of the Philippines, covering#++ +++ students.

:ornerstone of the :P program is an intersectoral strategy that uses theschools and day care centers as venues to reach the *hole child population *ithsimple and proven evidence based preventive interventions. Implementation of daily soap hand *ashing, daily fluoride toothbrushing and bi$annual de$*ormingare the core interventions to improve health of the child population.

Evidence for daily soap hand-washing:urtis 0 , :airncross 1 (2++7)

A systematic revie* *ith random effects meta$analysis on the impact of *ashinghands *ith soap on the ris; of diarrhoeal diseases in the community *as carriedout. 1even intervention studies, si' case$control, t*o cross$sectional, and t*ocohort studies *ere located from electronic databases, hand searching, and theauthorsB collections. 5n current evidence, *ashing hands *ith soap can reduce theris; of diarrhoeal diseases by C2$C3" and interventions to promote hand*ashingmight save a million lives caused by diarrhoea and acute respiratory infections in

developing countries.Evidence of daily fluoride toothbrushing:

The decline in caries in the past 2 years seen *ith the *idespread use of fluoride toothpaste in many high income countries in spite of the high levels of sugar consumption (%ratthall et al., #66 ) *arrants the promotion of daily toothbrushing *ith fluoride toothpaste. According to 9 5?IAD daily fluoridetoothbrushing is the only realistic measure to reduce the burden of dental cariesin populations. 1chool based fluoride toothbrushing programs have sho*nreduction in caries increment up to !" in high ris; population in 1cotland

(:urno* et al, 2++2, Pine et al 2++3) and up to C+ " in a high caries ris; publicelementary population in Indonesia( Adyatma;a A et al., #66!). In thePhilippines, daily school based fluoride tooth brushing in pilot schools hasresulted in C+" reduction of caries increment *hich is in line *ith internationalliterature and even more important a +" reduction of caries progressionmeasured as reduction in caries *ith pulp involvement *as observed after #!month of program. (&onse, unpublished data).

Evidence of self applied fluoride gel

luoride gels are available for professional application and for self applied use ona toothbrush under supervision. Different fluoride concentration (+. " $ #.2 "ppm luoride) and different formulation as Acidulated Phosphate luoride (AP ),1odium fluoride and Amin fluoride are being used. The variety of fre8uency of

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application is varying from *ee;ly to bi$annual depending on the ris; of thepatient, the formulation of the gel and the intervention concept. &ost common isthe Acidulate Phosphate luoride (AP ) *here the effectiveness has been firmlyestablished by research for more than 7+ years.

vidence of the effectiveness of fluoride gel has been provided by :ochranerevie*. (&arinho 0 et al., 2++7)

• 2!" pooled preventive fraction in caries increment *as sho*n for alldifferent application forms, different fre8uency and different baselinecaries data.

• 1ignificantly greater treatment effect *as observed *ith increasedfre8uency and intensity (fre8uency ' concentration) of gel application *ithself$applied compared *ith operator$applied gel treatment

• ncouraging results from school based programs in Argentina sho*edresults of to !#" reduction in caries increment after 2 years of *ee;ly self

application +. " AP (%ardoni et al #66 )

Evidence for Oral Urgent Treatment (OUT)

9 5 recommends a %asic Pac;age of 5ral :are (%P5:) that includes 5ral >rgentTreatment (5>T) as an Eon demand treatmentF for the relief of oral pain andtrauma. ( renc;en et al., 2++2).

According to the 45 1 in the Philippines, the child population is suffering fromhigh prevalence and e'perience of odontogenic infection. evie* of possible

effects of caries on failure to thrive ( TT) found, in other*ise healthy children.( lice : et ields 9. ,#66+) that severe dental caries (caries *ith pulpinvolvement) contributed to TT. In 4orth American 7.2 year$olds *ith severedental caries *eighed #;g less than controls< !.3" *ith caries *eighed less than!+" of ideal *eight compared to #.3" of comparison group (Acs = et al., #662).Tur;ish children *ith caries *eighed bet*een 2 th and + th percentiles *hereascontrols *eighed bet*een + th and 3 th percentiles< 3" of cases and +.3" controls*eighed less than 2+ th percentile (Ayhan . et al., #66 ). In the Philippines theaverage year$old has C caries teeth *ith pulp involvement. That is much higherthan in >1A and Tur;ey. 1o treatment may be even more beneficial.

Plausible mechanisms for severe caries and toothache being associated *ithunder*eight and poor gro*th areG

#. Altered eating because of pain and discomfort.

2. Pain during night, irritability and disturbed sleeping habits that may affectglucosteroid production and gro*th.

7. Dental sepsis and inflammation can affect gro*th through chronicinflammation via a metabolic path*ay *here cyto;ines affects

erythropoiesis. Interleu;in$# (I-$#), *hich has a *ide variety of actions ininflammation, can induce inhibition of erythropoiesis. This suppression of

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haemoglobin can lead to anaemia of chronic disease from depressederythrocyte production (&eans T et Hrant/ 1%, #662).

5ral >rgent Treatment (5>T) may reverse these processes by eliminating pain andinflammation.

According to research significant improvements in o- can be e'pected afterprovision of oral urgent treatment.

Evidence of Mass rug !dministration for e-worming

Ample evidence clearly demonstrates that regular treatment of soil transmittedhelminth (1T ) infections produces immediate as *ell as long term benefits thatsignificantly contribute to the development of infected individuals J particularlyschoolchildren (9 5G =eneva< 2++ )

Anti helminthic drugs due to its safety and straightfor*ard administration can beincluded in large scale public interventions. (>rbani c. et. al, 2++7)

1chool based approach is the best *ay to reach en masse, the infected childpopulation in the most cost effective and systematic manner. In such manner,substantial return in terms of reduced morbidity, improved gro*th, and improvededucational outcomes can be achieved. (9 5 =eneva, 2++ )

4umerous researches clearly demonstrate ho* 1T infections impair healthy

nutrition (1tephenson, -1 et. al< 2+++). =ro*th is affected through severalmechanisms, including reduced food inta;e due to malabsorption and poorappetite, (:rompton, D9T, et. al., 2++2) As a result, infected children, if not givenappropriate and timely intervention *ill sho* higher levels of stunting. (1tolt/fus,. et. al., #663). ven light levels of infection may cause deleterious effects inprotein metabolism, appetite, and red blood cell production and development(erythropoises). 1uch effects may be mediated by cyto;ines (I-#, I- ) that areproduced by the childKs body immune response to the ne* helminth infection.(1tolt/fus L, 2++C)

1T also negatively impacts on the motor and language development of a child.

There is negative association bet*een 1T infection and cognitive performance.( /eamama, A et. al 2++ ) 1T infections early in life may therefore affect thecognitive indicators *hich are measured later in life.(H*alsvig, L., 2++2) Thenegative correlation can be due to a variety of reasons, both direct and indirect,including induced sleeplessness, micronutrient losses, and reduced absorption.(1tolt/fus L et. al 2++C) A possible cause may also be due to inflammatory andcyto;ine responses triggered by the parasitic infection. (Dant/er ., 2++#)

To date, t*o primary drugs most commonly used in the Philippines for soiltransmitted helminthiasis treatment are albenda/ole and mebenda/ole.

Albenda/ole, at the recommended dosage generally has lo* incidence of posttreatment side effect, as reported by literature, comprising of migration of A.lumbricoides through the mouth, mild gastrointestinal symptoms, head ache,

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di//iness, and rare allergic reactions. All these are minor and transient andgenerally recede *ithin C! hours. ( orton L.,2+++)

&ebenda/ole treatment generally also has fe* instances of erratic migration, mildgastro intestinal disturbances, and transient abdominal pain. Diarrhea has also

been reported post treatment. (Albonico, &. et.al., #66C)

It is substantial to recogni/e that in endemic areas *here 1T re infection isdefinite, the objective of regular de*orming is not to cure, but to reduce and;eep the *orm burden of infected individuals belo* the threshold that causemorbidity. ( 1avioli, -., et. al., #662)

Evidence of efficacy of biannual deworming

Provision of levamisole every si' months to pre school age and school age childreninfected *ith A. lumbricoides in &yanmar have been sho*n to drastically reducedfre8uency of morbidity symptoms. (Thein$ laing, et. Al, #66+)

In >ganda, a randomi/ed control study sho*ed that *eight of children receivingalbenda/ole every si' months *as #+" greater than in untreated control. ( "greater *hen treatment *as given annually) (Alderman, ., et< al.,2++ )

In the slums of urban India, a series of studies has been conducted on the effect of bi annual (every si' months) de*orming using albenda/ole. vidence sho* thatinfants and pre school age children had reduced stunting by 6.C" and improved

*eight by 7 " *ithin t*o years. ( A*asthi, 1. et.al, 2++#)

III &b"ectives#

The objectives of this study are to determine the efficacy of different school basedhealth promotion interventions on health, school attendance and performance of ilipino public elementary students. The study *ill loo; into the impact of thedifferent interventions onG

#. 4utritional status

2. Parasitologic status7. 5ral health statusC. 1elf reported oral pain?problems. 1chool attendance. 1chool performance

3. %ehavior change

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I' aterials and ethods#

Study esign

The research is a controlled clinical study *ith a longitudinal design to be

conducted in Philippine Public lementary 1chools of the Province of :amiguin andthe :ity of =ingeoog, in 4orthern &indanao, Philippines.

1chool sites from the Divisions *ere selected for accessibility (*ithin ;ilometerradius from the 4ational igh*ay), security and safety of the project proponentsand strong administrative support from the local chief e'ecutives and the Dep d1chool administrators.

1elected schools *ill be randomly assigned to any of the four study groups. ealthinterventions *ill be implemented in the entire school.

Criteria for Inclusion of Schools into the Intervention *roup

The selection of public elementary schools *ill be based onG

o #st level selectionG• Accessibility and safety• 1chool si/e• Administrative 1upport

o 2nd -evel 1electionG• Prevalence of %elo* 4ormal %ody &ass Inde' (Dep d Data)

o 7rd -evel 1election• Pulp involvement, ulceration, fistula and abscess (P> A) inde'

Intervention *roups

*roup +

Philippine public elementary schools that *ill fully implement the ssentialealth :are Pac;age including daily fluoride tooth brushing using +.7 ml. (pea

si/ed) fluoride toothpaste (#,C + fluoride ppm free available fluoride), dailyhand *ashing *ith soap done as a group activity prior to recess in the morningin school and albenda/ole (C++ mg tablet) or mebenda/ole ( ++ mg tablet)single dose as mass drug administration (&DA) given every months for soiltransmitted helminthiasis as per 9orld ealth 5rgani/ation (9 5)recommendations, starting Luly 2++6.

*roup ,

Philippine public elementary schools that *ill implement the 9ar on 9ormsProgram consisting of either mebenda/ole ++ mg or albenda/ole (C++ mgtablet) mass drug administration (&DA) given every months plus healtheducation, and distribution of one piece #+ ml commercial toothpaste sachet

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and tooth brush at the beginning of the school year as a preventive oral healthadvocacy, starting Luly 2++6.

*roup

Philippine public elementary schools that *ill implement :P according to the:P guidelines (anne' #) plus access to oral urgent treatment t*ice a year,

starting Luly 2++6. 5ral >rgent Treatment is defined as on demand treatmentfor children suffering oral pain, mostly caused by advanced dental caries. ( ef.=uidelines for 5>T in public elementary schools in the Philippines, Anne' 2)The treatment includes tooth e'tractions, drainage of abscesses and drugadministration in selected cases.

*roup .

Philippine public elementary schools that *ill implement :P plus once*ee;ly use of +.7 ml high fluoride concentration gel used as alternate to thedaily regular :P toothpaste. The high fluoride concentration gel contains#2,+++ ppm fluoride.

Study population

The study population *ill be $3 years old school children attending grade one in1chool Mear 2++6J2+#+. 1tudents from this group *ill be follo*ed up for the ne't 7years. valuation *ill be carried out after #2 and 7 months, using the health and

child development indicators?parameters follo*ed belo*.Selection Criteria for inclusion of children#

1. InclusionGa. AgeG J 3 years old at baseline e'amination time.

2. 'clusion criteriaGa. :hildren *ith systemic medical conditions, and other chronic infectious

diseases

Control *roup

Due to ethical considerations, the study has no true control group. A semi controlgroup therefore *ill be composed of randomly selected students from grades 2and C *ithin the intervention schools at baseline e'amination time (in Luly 2++6).These older students *ill come from the same communities as the interventionchildren ensuring similar socioeconomic bac;ground.

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1election criteria for inclusion of children to the semi control groupG

#. InclusionGa. AgeG

i. 3$! year old school children (grade 2) in 1M 2++6J2#+, forcomparison *ith the intervention group one year after the start ofthe intervention.

ii. +6 J #+ year old school children (grade C) in 1M 2++6J2+#+ forcomparison *ith the intervention group three years after the startof intervention.

Sample Si/e

o An overall total of !++ schoolchildren *ill be the target group sample si/e*ith 2++ children assigned to each of the four intervention groups to allo*for drop outs, loss to follo* up, and other issues that may confoundresearch health outcomes from baseline to final evaluation. ( 7years)

o %asis for computation for sample si/e

0ength and 1ime of Study#

The study *ill be started *ith the beginning of the 1M 2++6$2+#+. It *ill beconducted over 7year period.

:hildren *ill be assessed at baseline, after # and 7years follo*ing introduction of the interventions.

*roup +

This is the group *ill receive :P. %aseline e'aminations of =rades 2 and C pupils*ill serve as this groupKs control for respective outcome effects

$aseline *rade + *rade , *rade . &21C& E

4umber 2++ #2+ #++

%aseline Test Test Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1choolAttendance, 4AT

Performance

#2 months Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1chool

Attendance, 4ATPerformance

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7 months Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1chool

Attendance,4AT Performance

The 2++ children at baseline in grade # are follo*ed over the years. Due to dropouts, the number is e'pected to decrease.

*roup ,

Participants receive de*orming, health education and one toothbrush *ith a sachetof commercial toothpaste).%aseline e'aminations of =rades 2 and C pupils *illserve as this groupKs control for respective outcome effects.

$aseline *rade + *rade , *rade . &21C& E

4umber 2++ #2+ #++

%aseline Test Test Test

elminth infection,Type of *orms,

uantity, %&I,:aries, P> A, pain1chool Attendance4AT Performance

#2 months Test

elminth infection,Type of *orms,uantity, %&I,

:aries, P> A, pain1chool Attendance4AT Performance

7 months Test

elminth infectionType of *orms

uantity%&I

:aries, P> A, pain1chool Attendance4AT Performance

The 2++ children at baseline in grade # are follo*ed over the years. Due to dropouts, the number is e'pected to decrease

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*roup

This is the group *ho receives :P N 5>T. %aseline e'aminations of =rades 2 andC pupils *ill serve as this groupKs control for respective outcome effects .

$aseline *rade + *rade , *rade . &21C& E

4umber 2++ #2+ #++

%aseline Test Test Test

elminth infection,Type of *orms,

uantity, %&I,:aries,P> A, pain

#2 months Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1choolAttendance, 4AT

Performance

7 months Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1choolAttendance, 4AT

Performance

The 2++ children at baseline in grade # are follo*ed over the years. Due to dropouts, the number is e'pected to decrease.

*roup .

This is the group *ho receives :P N once a *ee; tooth brushing *ith highfluoride gel. %aseline e'aminations of =rades 2 and C pupils *ill serve as thisgroupKs control for respective outcome effects.

$aseline *rade + *rade , *rade . &21C& E

4umber 2++ #2+ #++

%aseline Test Test Test

elminth infection,Type of *orms,

uantity, %&I, :aries,P> A, pain, 1choolAttendance, 4AT

Performance#2 months Test elminth infection,

Type of *orms,uantity, %&I, :aries,P> A, pain, 1chool

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Attendance, 4ATPerformance

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+.# cm and #++ grams respectively using height and *eight measurement of thedetecto *eighing scale.

@$scores of height for age and *eight for age *ill be calculated using the 4: 1reference standards on pi Info soft*are (4ut1tat module) i.

eight *ill be measured using in the stadiometer *ithout shoes. :hildren *ill bemeasured *ith ran;furt plane hori/ontal.

9eight *ill be measured using the detecto calibrated *eighing scale on a firm flatsurface. T*o sets of calibrated scales *ill be available to the research team. Thescales need to be chec;ed every after measurements for calibration purposes.

%&I *ill be calculated by *eight (in ;gs) for height (in meters) s8uaredO*(;g)?h(m) 2 . The mean height for age @ score, the *eight for age @ scores andthe %&I of groups *ill be e'pressed as arithmetic means and standard deviations.

2. Parasitologic 3ssessments

1tool cups *ill be given to the children targeted for monitoring *ith appropriatecollection instructions. 1tool samples *ill be sent to the field laboratory foranalysis using Hato Hat/ method by the project team as described in the 9orldealth 5rgani/ation %ench Aids for the Diagnosis of Intestinal Parasites (#66!).Data gathered *ill be used to derive the cumulative prevalence rates, prevalence

rates of individual elminth infections and intensities of 1T infections.Assessments *ill be done pre$treatment at baseline (day + ), Mears #, and 7.Provincial and :ity health office staff *ill be involved in parasitologic assessmentfor capability building purposes.

Quality Control

The accuracy and reliability of parasitological assessment *ill be maintainedthrough strict 8uality assurance measures. This *ill involve proper collection of specimens, availability of fresh reagents, appropriate laboratory techni8ue,meticulous e'amination of processed specimens and accurate reporting of

findings. 1lides positive for 1T *ill be referred to e'pert microscopists for cross$chec;ing and validation. Ten percent of all negative slides *ill be re$e'aminedblindly by a reference microscopist to ensure accuracy of microscopic readings.

3. &ral E5amination

All oral e'aminations of the schoolchildren *ill be carried out in the schoolcourtyard or in case there is rain under the covered court. Prior to e'amination,trained parents *ill brush the teeth of the children. 1tudents *ill be positionedsupine on a bench or table and e'amined by the gloved and mas;ed dentale'aminer using a battery po*ered headlamp to standardi/e e'aminationconditions. The teeth *ill be e'amined according to 9 5 basic methods (#663).&outh mirrors and cotton pellets held in t*ee/ers to dry the teeth and sharp eyes*ill be used. A :PI probe *ill be used gently to detect and confirm visual

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evidence of caries. All children *ill be e'amined on tooth level, only the firstmolar *ill be assessed on surface level.

Teeth, *ith pulp involvement *ill be recorded in primary as *ell as in permanentdentition according to P> A ?pufa inde'.(&onse et al. 2++!, submitted for

publication)

A trained assistant *ill record the data on a standardi/ed form.

Trained and calibrated dentists ;no*ledgeable *ith the diagnostic criteria *illperform the e'aminations. :alibration *ill be conducted by comparing the resultsof each e'aminer *ith the results of an e'perienced e'aminer. (gold standard)ee'amination of #+" of the schoolchildren *ill be conducted by the e'aminers inorder to assess intra$e'aminer consistency and calculate the Happa values. Toensure consistency at least half of the e'aminers of the baseline e'aminations *illparticipate in the follo* up evaluations.

4. Prevalence of oral pain % abdominal pain

:hildren *ill be 8uestioned concerning e'perience of pain and impact of pain inorder to assess if the program could improve their 8uality of life.The 8uestionnaire to be used in the intervie* *ill be pre$tested. :hildren *ill begiven at least #+ seconds to ans*er.

5. Prevalence of abdominal painChildren 6ill be 7uestioned concerning e5perience of pain or discomfort in

any part of the abdomen to assess if the program 6as able to improve the7uality of life of the school children 1he 7uestionnaire 6ill be in the localvernacular language and the 7uestion 6ill be pre tested Children 6ill begiven appropriate time to ans6er

6. Evaluation of school attendance

Information on school attendance of the students included in the e'amination *illbe ta;en from teachersK record boo;s from beginning of school year to an agreedcut off time (at the last day of the school year).

7. School performance

Information on school performance *ill be ta;en from the results of the ationalAchievement Test (4AT) for grades 7 and on all subject levels.

3. $ehaviour change

:hange in behaviour of the study children *ith respect to personal hygiene in thefamily environment *ill be researched by collection of dental pla8ue among studychildren on a &onday morning and determining the fluoride concentration in thedental pla8ue and measuring the bacterial coloni/ation of hands. This *ill giveinformation about hand*ahing and toothbrushing activities in the natural familyenvironment during the *ee; end.

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8. Statistical 3nalysis

The follo*ing information *ill be described at baseline, at each follo* up

separately for each group.

#. Prevalence of 1T infections

2. 1everity of 1T infection (geometric mean egg counts)

7. Prevalence of dental caries

C. :aries e'perience (mean dmfs?t, D& 1?T)

. Prevalence of dentogenic infection

. Dentogenic infection e'perience (&ean pufa?P>A)

3. Distribution of children according to %&I classification (")

!. &ean %&I

6. Prevalence of children *ith self reported oral problem and?or abdominal

pain or discomfort

#+. Average time of being absent from school (mean number of days being

absent)

##. 1chool performance (mean " of 4ational Achievement Test? 4AT)

#2. %ehavior change (:ontact spotting for e coli coloni/ation on hands and

fluoride concentration in dental pla8ue to evaluate behavior change *ith

respect to hand*ashing and toothbrushing in school and family

environment)

'I !eports to the funding agency#

Implementation reports have to be submitted 1eptember # in every research

year, *hile the scientific report containing the data analysis have to be submitted

at the end of 5ctober 2++6, 2+#+ and 2+#2.

'I !E8E!E4CES

#. Acs =., -odolini =., Hamins;i 1., :isneros =L. (#662) ffect of nursing carieson body *eight in a pediatric population. Pediatr Dent #CG7+2$ .

2. Adyatma;a A, 1utopo >, :arlsson P, %ratthall D 1chool$%ased PrimaryPreventive Programme for :hildren Affordable toothpaste as a component in

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primary oral health care. 'periences from a field trial in Halimantan %arat,Indonesia.httpG??***.*hocollab.od.mah.se?searo?indonesia?afford?*hoafford.html

7. Albonico &, :rompton D9, 1avioli -. :ontrol strategies for human intestinal

nematode infections. Adv Parasitol. #666<C2G233J7C#. O Pub&ed

C. Alderman , Honde$-ule L, 1ebuliba I, %undy D, all A. ffect on *eight gainof routinely giving albenda/ole to pre$school children during child healthdays in >gandaG cluster randomised controlled trial. %r &ed L. 2++ <777G#22J#23. OPub&ed

. A*asthi 1, Pande 0H. 1i'$monthly de$*orming in infants to study effects ongro*th. Indian L Pediatr. 2++#< !G!27J!23. O Pub&ed

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!. %eli/ario 0M, de -eon 9>, 9ambangco &- and sparar D= (2++ ) %aselineassessment of intestinal parasitism in selected public elementary schools in-u/on, 0isayas and &indanao. Acta Medica Philippina , 76(2)G##$2#.

6. %ratthall, D< ansel$Petersson =< 1undbergh .< easons for the cariesdeclineG 9hat do the e'perts believeQ uropean journal of oral sciences,(#66 Aug) 0ol. #+C, 4o. C ( Pt 2), pp. C# $22< discussion C27$ , C7+$2. GLournal 0ol. 4o. 6 +C 7. I114G +6+6$!!7 .

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i

Principal Investigator#

Ella Cecilia 9 *amolo : 4aliponguit;

&edical 5fficer 0? ealth and 4utrition Division

Department of ducation egional 5ffice

Co- Investigators#

*ina 3 Itchon; ; Sc

Associate Professor, Preventive :ommunity &edicine Department

Dr. Lose P. i/al :ollege of &edicine,

avier >niversity Ateneo de :agayan

Preventive :ommunity &edicine Department

'icente $eli/ario; ; PH

Deputy Director

4ational Institutes of ealth&anila, Philippines

$ella onse; S; Ph

:I&$:onsultant on 1chool ealth Promotion

Dep d :ity Division of :agayan de 5ro,

:agayan de 5ro, Philippines

Prof <im van Palenstein -Heldermann

9 5 :ollaborative :enter E5ral ealth :are Planning and uture 1cenariosF,

adboudt >niversity, 4jimegen, The 4etherlands