Mass deworming

Nurse giving a deworming tablet to a child in Kakute, Uganda

Mass deworming (also called preventive chemotherapy)[1][2] is the process of treating large numbers of people for helminthiasis (for example soil-transmitted helminths or STH) and schistosomiasis infections in areas with high degree of worm infection in the general population, particularly for children.[3][4] It involves treating everyone – often all children who attend schools, using existing infrastructure to save money – rather than testing first and then only treating selectively. Serious side effects have not been reported when administering the medication to those without worms,[1][2] and testing for the infection is many times more expensive than treating it. So for the same amount of money, mass deworming can treat more people more cost-effectively than selective deworming.[5] Mass deworming is one example of mass drug administration.[3]

Mass deworming of children can be carried out by administering mebendazole and albendazole which are two types of anthelmintic drug.[6] The cost of providing one tablet every six to twelve months per child (typical doses) is relatively low.[7]

Over 870 million children are at risk of parasitic worm infection.[8] Worm infections interfere with nutrient uptake; can lead to anemia, malnourishment and impaired mental and physical development; and pose a serious threat to children’s health, education, and productivity. Infected children are often too sick or tired to concentrate at school, or to attend at all.[9] In 2001, the World Health Assembly set a target for the World Health Organization (WHO) to treat 75% of school-aged children by 2010.[6] There has been disagreement on the evidence regarding the extent of the long-term benefits for children who have been part of mass deworming programmes.[3] Proponents of mass deworming argue that the methodology of studies that discount the value of mass deworming is biased, sample sizes have been small, and studies did not evaluate more subtle long-term impacts. As a result, they argue that such studies should not be used alone in deciding mass deworming policy.[10][11]

Some non-governmental organizations specifically support mass deworming. The Deworm the World Initiative, a project of the non-governmental organization Evidence Action, is one of the highest-rated charities by the evaluator Givewell because of the low cost of deworming children, large-scale implementation, and wider benefits to society.[12]

Background

A nurse giving deworming medication to a child
Hand washing and twice annual deworming is part of the Essential Health Care Package in the Philippines ("Fit for School" program)

Intestinal parasitic worms (collectively called soil-transmitted helminths) affect approximately 2 billion people,[13] according to WHO estimates in 2015,[14] with 249 million being infected with Schistosoma-type worms.[15]

The World Health Organization recommends mass deworming of children living in endemic areas, in order to reduce morbidity by reducing the overall worm burden.[16] It asserts that worm infections adversely affect nutritional status, impair cognitive processes, and can cause conditions such as intestinal obstruction or lesions in the urinary tract and liver. Periodic drug treatment is expected to bring about health benefits such as reduced micronutrient loss, reduced environmental contamination, improved nutritional status and cognitive function, and better school performance in certain circumstances.[3][17]

In 2001, the World Health Assembly set a target for the World Health Organization (WHO) to treat 75% of school-aged children by 2010.[6] In 2014, over 396 million preschool- and school-aged children were treated, corresponding to 47% of all children at risk.[18]

Methods

Pills

Deworming programmes usually give children a pill of an of anthelmintic drug. The treatment of choice for soil-transmitted helminths is mebendazole or albendazole[3] and praziquantel for schistosomiasis.[6] Other drugs used, though not approved by the WHO, include pyrantel pamoate, piperazine, piperazine citrate, tetrachloroethylene, and levamisole.[3] In mass deworming programs, all children are given the medication, whether they are infected or not. In endemic areas, this usually needs to be repeated regularly.[3] The WHO advises deworming programme managers to make decisions on the frequency of treatment by considering the prevalence of helminth infection, measured through prevalence surveys conducted at various intervals.[6] The frequency of deworming rounds is determined by the prevalence and severity of infection, and in most endemic areas, is an annual round.

Each child is given a single tablet of albendazole or mebendazole for a single dose. However, praziquantel doses depend on body weight.[6] The WHO has developed a "tablet pole" to calculate correct doses of praziquantel for children when weighing scales are not available.[6]

Accompanying measures

To increase the benefits of mass deworming and to lower the rate of reinfection, accompanying measures of mass deworming programmes should include water, sanitation and hygiene (WASH) interventions.[19] A good example for such a combined intervention is the Essential Health Care Program implemented by the Department of Education in the Philippines: This national programme combines twice annual deworming of school children with group handwashing with soap at set times of the day at the school premises.[20][21] This so-called "Fit for School" approach has also been implemented in Indonesia in 2014.[20]

Health aspects

Evidence

A 2015 review in a World Bank journal concluded that evidence supports a benefit with respect to school attendance and long term income.[22]

The 2015 the Cochrane review, however, found that high quality medical evidence on mass deworming of children did not support beneficial effect on school performance, body weight, cognition, and rates of anemia.[3] However, the Cochrane review excluded a number of studies which showed positive long-term results as they did not meet the inclusion criteria of a pure control (for studies using the method of randomized controlled trials (RCT)). Supporters of mass deworming argue that these studies make a case for long-term benefits.[23][24]

Reinfection and resistance

Reinfection with worms may begin shortly after the pill has killed the intestinal worm population.[25] Regular re-treatment together with an increased focus on other aspects of water, sanitation and hygiene (WASH) reduces the rates of infection in areas where parasitic worms are endemic.[19][25]

Resistance of worms to anthelmintic drugs over time is a possibility.[26]

Costs

Mass deworming has been determined to be cheap when calculated on a 'per child/per year'[7] or $/DALY[27] basis. Screening test to detect if a child is actually infected would be up to 12 times more expensive.[28]

The cost of treating a child for infection of soil transmitted helminths and schistosomes costs different amounts in different countries when administered as part of mass school-based deworming, but Evidence Action states that their recent programmes cost $0.56 or less per child per dose.[29] This programme is recommended by Giving What We Can and the Copenhagen Consensus Centre as one of the most efficient and cost-effective solutions. Modelling studies also suggest that deworming programmes are highly cost effective.[30]

National deworming programmes

National deworming programmes target children of school age, which the WHO defines as being between 5 and 14.[6] By 2015, the total global number estimated to be in deworming programmes was 495 million[31] and national deworming programs had been started in a number of countries. The world's largest deworming programme was started in 2015 in India, with an aim to target 240 million children at risk for parasitic worms.[32]

National deworming programmes listed by country in alphabetical order:

Acceptance

Deworming programmes are widely accepted, although there have been some reports of parents refusing to allow their children to receive medication due to fears of illness, such as those reported in the media in the Philippines.[46] One study in the Philippines reported that some parents will not allow their children to receive deworming tablets, while the majority would.[47] Another in rural China found that scepticism and local myths about the deworming programme could affect the uptake of medication.[48]

Other actors

UN agencies and NGOs

The UN is involved in mass deworming programmes via the World Food Programme,[49] UNICEF[39] and World Health Organisation.[39]

NGOs involved in deworming advocacy or delivery include: the Deworm the World Initiative from Evidence Action, Goods For Good, Save the Children, Counterpart International, Helen Keller International, the Carter Center, Inmed Partnerships for Children, Operation Blessing International, and Children Without Worms.[49]

Pharmaceutical companies

Biotechnology companies in the developing world have targeted neglected tropical diseases - which many helminth infections are classified as - and mass drug administration due to a need to improve global health.[50][51]

For example, Johnson & Johnson has in 2012 pledged 200 million deworming tablets per year.[52]

Examples

Nicaragua

The national deworming programme was established as a partnership between the Pan American Health Organization - which serves as the Regional Office of the WHO, the Global Network for Neglected Tropical Diseases, the Inter-American Development Bank, Nicaraguan Government ministries, International NGOs and the main donor Children Without Worms.[53]

Children Without Worms is a public-private partnership between The Task Force for Global Health and Johnson & Johnson, who donated the mebendazole medication.[53] Intestinal helminths are a major problem in Nicaragua with 73% of rural households lacking clean drinking water and 73% lacking sanitation.[53]

Since 2009, drug donations from Johnson & Johnson have enabled annual deworming of school-aged children and medication supplied by other NGOs has enabled deworming of pre-school children, although questions were raised as to whether the frequency should have been increased.[53]

Philippines

Soil Transmitted Helminth Control Program run by the Department of Health

The Philippines Soil Transmitted Helminth Control Program is run by the Department of Health and implemented by the Department of Education in the Philippines.[54] It is a partnership with the WHO, University of the Philippines Manila, UNICEF, World Vision International, Feed the Children, Helen Keller International, Plan International and Save the Children.[54] It involves giving all children doses of Albendazole or Mebendazole.[54]

However, in 2013 the Director of the National Institute of Health in the Philippines questioned the effectiveness of the programme because it only covered only 20% of affected children with an infection rate of 44%.[55] By 2015, 16 million children were targeted in the deworming programme.[56] with some media claims that some of the medication was found to be expired.[57] Government officials later denied this.[58] Other national press reports in July 2015 stated that a small number of children had been admitted to hospital due to an "adverse effect" of the deworming medication.[46]

Essential Health Care Program implemented by the Philippine Department of Education

Successful deworming and positive health outcomes were also achieved by the Essential Health Care Program implemented by the Department of Education in the Philippines. This national programme includes giving school children deworming drugs twice a year, as well as group handwashing with soap and brushing teeth daily with fluoride toothpaste as a group activity at set times of the day at the school premises.[20] In 2012 UNICEF described it as an "outstanding example of at scale action to promote children’s health and education".[21]

History

United States

Public health campaigns to reduce helminth infections in the US may be traced as far back as 1910, when the Rockefeller Foundation began the fight against hookworm – the so-called "germ of laziness" – which was found to infect 40% of children in the American South.[59][60] Records of the programme suggest that it led to increased school enrollment and attendance for children, and improved literacy and income for adults who were treated as children.[59][61]

This campaign was enthusiastically received by educators throughout the region; as one Virginian school observed: "children who were listless and dull are now active and alert; children who could not study a year ago are not only studying now, but are finding joy in learning... for the first time in their lives their cheeks show the glow of health."[62] From Louisiana, a grateful school board added: "As a result of your treatment...their lessons are not so hard for them, they pay better attention in class and they have more energy...In short, we have here in our school-rooms today about 120 bright, rosy-faced children, whereas had you not been sent here to treat them we would have had that many pale-faced, stupid children."[62]

Military personnel returning from the Second World War were found to be bringing intestinal worms back to the United States, so in 1947 the American Society of Parasitologists called for increased attention on deworming.[59]

See also

References

  1. 1 2 WHO (2006). Preventive chemotherapy in human helminthiasis: coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers (PDF). WHO Press, World Health Organization, Geneva, Switzerland. pp. 1–61. ISBN 9241547103.
  2. 1 2 Albonico, Marco; Allen, Henrietta; Chitsulo, Lester; Engels, Dirk; Gabrielli, Albis-Francesco; Savioli, Lorenzo; Brooker, Simon (2008). "Controlling Soil-Transmitted Helminthiasis in Pre-School-Age Children through Preventive Chemotherapy". PLoS Neglected Tropical Diseases 2 (3): e126. doi:10.1371/journal.pntd.0000126. PMC 2274864. PMID 18365031.
  3. 1 2 3 4 5 6 7 8 Taylor-Robinson, DC; Maayan, N; Soares-Weiser, K; Donegan, S; Garner, P (23 July 2015). "Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin, and school performance.". The Cochrane database of systematic reviews 7: CD000371. doi:10.1002/14651858.CD000371.pub6. PMID 26202783.
  4. ↑ Gabrielli, A.-F.; Montresor, A.; Chitsulo, L.; Engels, D.; Savioli, L. (December 2011). "Preventive chemotherapy in human helminthiasis: theoretical and operational aspects". Transactions of the Royal Society of Tropical Medicine and Hygiene 105 (12): 683–693. doi:10.1016/j.trstmh.2011.08.013.
  5. ↑ Helminth Control in school-age children: a guide for managers of control programmes - 2nd edition. World Health Organization. 2011. pp. vii. ISBN 9789241548267.
  6. 1 2 3 4 5 6 7 8 "Helminth control in school-age children" (PDF). World Health Organisation. 2011. Retrieved 28 July 2015.
  7. 1 2 "How Do We Calculate the Cost of Deworming?". Evidence Action. 2015. Retrieved 30 July 2015.
  8. ↑ "Soil Transmitted Helminths". WHO. Retrieved 28 July 2015.
  9. ↑ Miguel, Edward; et al. (May 2015). "Worms at work: Long-run impacts of a child health investment" (PDF). Working Paper. Retrieved 28 July 2015.
  10. ↑ Montresor, A; Addiss, D; Albonico, M; Ali, SM; Ault, SK; Gabrielli, AF; Garba, A; Gasimov, E; Gyorkos, T; Jamsheed, MA; Levecke, B; Mbabazi, P; Mupfasoni, D; Savioli, L; Vercruysse, J; Yajima, A (October 2015). "Methodological Bias Can Lead the Cochrane Collaboration to Irrelevance in Public Health Decision-Making.". PLoS neglected tropical diseases 9 (10): e0004165. doi:10.1371/journal.pntd.0004165. PMID 26492178.
  11. ↑ Montresor, A; Gabrielli, AF; Engels, D; Daumerie, D; Savioli, L (2013). "Has the NTD community neglected evidence-based policy? PLOS NTDs 2013 expert commentary of the viewpoint by Nagpal S, Sinclair D, Garner P.". PLoS neglected tropical diseases 7 (7): e2299. doi:10.1371/journal.pntd.0002299. PMID 23875037.
  12. ↑ "Deworm the World Initiative (DtWI), led by Evidence Action". Givewell. 2014. Retrieved 28 July 2015.
  13. ↑ "WHO | Soil-transmitted helminth infections". www.who.int. Retrieved 2016-01-25.
  14. ↑ "Soil-transmitted helminth infections". WHO. 2015. Retrieved 29 July 2015.
  15. ↑ "WHO". Schistosomiasis fact sheet. 2015. Retrieved 29 July 2015.
  16. ↑ "WHO | Strategy". www.who.int. Retrieved 2016-01-26.
  17. ↑ The World Health Organization (2011). "Helminth Control in School-age Children: A guide for managers of control programmes" (PDF). WHO. Second edition. Retrieved 26 January 2016.
  18. ↑ World Health Organization (18 December 2015). "Weekly Epidemiological Record, Nos. 51/52, 2015, 90, 701–712" (PDF). Retrieved 25 January 2016.
  19. 1 2 Hales,S; Ziegelbauer,K; Speich,B; et al. (2012). "Effect of Sanitation on Soil-Transmitted Helminth Infection: Systematic Review and Meta-Analysis". PLoS Medicine 9 (1): e1001162. doi:10.1371/journal.pmed.1001162. ISSN 1549-1676. PMC 3265535. PMID 22291577.
  20. 1 2 3 School Community Manual - Indonesia (formerly Manual for teachers), Fit for School. GIZ Fit for School, Philippines. 2014. ISBN 978-3-95645-250-5.
  21. 1 2 UNICEF (2012) Raising Even More Clehran Hands: Advancing Health, Learning and Equity through WASH in Schools, Joint Call to Action
  22. ↑ Ahuja, Amrita; Baird, Sarah; Hicks, Joan Hamory; Kremer, Michael; Miguel, Edward; Powers, Shawn (2015). "When Should Governments Subsidize Health? The Case of Mass Deworming". The World Bank Economic Review 29 (suppl 1): S9–S24. doi:10.1093/wber/lhv008.
  23. ↑ Ozier, Owen (Oct 2014). "Exploiting Externalities to Estimate the Long-Term Effects of Early Childhood Deworming" (PDF). World Bank Group.
  24. ↑ "New deworming reanalyses and Cochrane review". The GiveWell Blog. July 24, 2015. Retrieved 12 August 2015.
  25. 1 2 Cooper, PJ; Jia,T; Melville,S; et al. (2012). "Soil-Transmitted Helminth Reinfection after Drug Treatment: A Systematic Review and Meta-Analysis". PLoS Neglected Tropical Diseases 6 (5): e1621. doi:10.1371/journal.pntd.0001621. ISSN 1935-2735. PMC 3348161. PMID 22590656.
  26. ↑ Levecke,B; Montresor,A; Albonico,M; et al. (9 October 2014). "Assessment of Anthelmintic Efficacy of Mebendazole in School Children in Six Countries Where Soil-Transmitted Helminths Are Endemic". PLoS Neglected Tropical Diseases 8 (10): e3204. doi:10.1371/journal.pntd.0003204.
  27. ↑ "Cost-Effectiveness in $/DALY for Deworming Interventions". Givewell. Retrieved 30 July 2015.
  28. ↑ Ahuja, A; Baird, S; Hicks, JH (2015). When Should Governments Subsidize Health? The Case of Mass Deworming (PDF) (NBER Working Paper No. 21148 ed.). National Bureau of Economic Research. Retrieved 30 July 2015.
  29. ↑ Williams, Katherine (16 January 2015). "How Do We Calculate the Cost of Deworming?". Evidence Action. Retrieved 6 October 2015.
  30. ↑ Lo, Nathan C; Bogoch, Isaac I; Blackburn, Brian G; Raso, Giovanna; N'Goran, Eliézer K; Coulibaly, Jean T; Becker, Sören L; Abrams, Howard B; Utzinger, Jürg; Andrews, Jason R (2015). "Comparison of community-wide, integrated mass drug administration strategies for schistosomiasis and soil-transmitted helminthiasis: a cost-effectiveness modelling study". The Lancet Global Health 3 (10): e629–e638. doi:10.1016/S2214-109X(15)00047-9. ISSN 2214-109X.
  31. ↑ "Deworming campaign improves child health, school attendance in Rwanda". WHO. 2015.
  32. 1 2 "World's Largest Deworming Program in India To Start". Evidence Action. 2015. Retrieved 28 July 2015.
  33. 1 2 3 4 5 6 7 8 9 10 11 12 "SCI Summary sheet of treatments instigated and overseen by SC". Givewell. 2014. Retrieved 30 July 2015.
  34. ↑ "Scaling Cameroon's Deworming Program to the National Level". Children Without Worms. 2012. Retrieved 29 July 2015.
  35. ↑ "The Central African Republic: Going Beyond Providing Food As Part Of Our School Meal Programme". World Food Programme. 2015. Retrieved 29 July 2015.
  36. ↑ "DRC: National deworming campaign under way". IRIN. 2009. Retrieved 29 July 2015.
  37. ↑ "Ethiopia launches school program to treat parasitic worms". Reuters. Retrieved 29 July 2015.
  38. ↑ "Gambia SHN Success Story". Schools and Health. Retrieved 29 July 2015.
  39. 1 2 3 Kabaka, S; Kisia, CW (2011). "National deworming program - Kenya's experience" (PDF). World Conference on the Social Determinants of Health.
  40. ↑ "Kenya National Deworming Programme". Children's Investment Fund Foundation. Retrieved 29 July 2015.
  41. ↑ "Deworming in Madagascar: The Power of Partnerships". Children Without Worms. 2012. Retrieved 29 July 2015.
  42. ↑ "Child Health Week reaches more than two million children in Malawi". UNICEF Malawi. 2011. Retrieved 29 July 2015.
  43. ↑ "Schistosomasis Control Initiative - Mozambique". Imperial College. Retrieved 29 July 2015.
  44. ↑ Brooker,S; Leslie,J; Garba,A; et al. (2011). "Schistosomiais and Soil-Transmitted Helminth Control in Niger: Cost Effectiveness of School Based and Community Distributed Mass Drug Administration". PLoS Neglected Tropical Diseases 5 (10): e1326. doi:10.1371/journal.pntd.0001326. ISSN 1935-2735.
  45. ↑ "Sierra Leone". Helen Keller International. Retrieved 29 July 2015.
  46. 1 2 Garcia, Bong (July 2015). "Deworming tablet downs hundreds of schoolchildren". Sun Star. Retrieved 31 July 2015.
  47. ↑ Parikh, DS; Totañes, FI; Tuliao, AH; et al. (2013). "Knowledge, attitudes and practices among parents and teachers about soil-transmitted helminthiasis control programs for school children in Guimaras, Philippines.". The Southeast Asian journal of tropical medicine and public health 44 (5): 744–52. PMID 24437309.
  48. ↑ Lu, Louise; Liu, Chengfang; Zhang, Linxiu; et al. (2015). "Gut Instincts: Knowledge, Attitudes, and Practices regarding Soil-Transmitted Helminths in Rural China". PLOS Neglected Tropical Diseases 9 (3): e0003643. doi:10.1371/journal.pntd.0003643.
  49. 1 2 Global NGO Deworming Inventory 2010 (2011). "2010 Global NGO Deworming Inventory Summary Report: Deworming Programs by Country" (PDF). http://www.deworminginventory.org. External link in |website= (help)
  50. ↑ Frew SE, Liu VY, Singer PA (2009). "A business plan to help the 'global South' in its fight against neglected diseases" (PDF). Health Aff (Millwood) 28 (6): 1760–73. doi:10.1377/hlthaff.28.6.1760. PMID 19887417.
  51. ↑ Keenan JD, Hotez PJ, Amza A, et al. (2013). "Elimination and eradication of neglected tropical diseases with mass drug administrations: a survey of experts". PLoS Negl Trop Dis 7 (12): e2562. doi:10.1371/journal.pntd.0002562. PMC 3855072. PMID 24340111.
  52. ↑ Fenwick A (March 2012). "The global burden of neglected tropical diseases". Public Health 126 (3): 233–6. doi:10.1016/j.puhe.2011.11.015. PMID 22325616.
  53. 1 2 3 4 Lucien, F; Janus, CB (2011). "Worms and WASH(ED) Nicaragua" (PDF). The George Washington University. Retrieved 30 July 2015.
  54. 1 2 3 "Soil Transmitted Helminth Control Program". Republic of the Philippines Department of Health. Retrieved 31 July 2015.
  55. ↑ Tubeza, Philip (2013). "Gov deworming programme in public schools not very effective". Philippine Daily Inquirer. Retrieved 31 July 2015.
  56. ↑ Crisostomo, Sheila (July 2015). "DOH targets deworming of 16M students". philststar. Retrieved 31 July 2015.
  57. ↑ Geronimo, Jee (2015). "DOH looks into 'expired' deworming medicine claim". Rappler. Retrieved 31 July 2015.
  58. ↑ Jocson, Liza (2015). "DOH confirms deworming medicine not expired". CNN Philippines. Retrieved 31 July 2015.
  59. 1 2 3 Bundy, DAP; Walson, JL; Watkins, KL (2013). "Worms, wisdom, and wealth: why deworming can make economic sense". Trends in Parasitology 29 (3): 142–148. doi:10.1016/j.pt.2012.12.003. ISSN 1471-4922. PMID 23332661.
  60. ↑ Watkins WE & Pollitt E (1997). "'Stupidity or Worms': Do Intestinal Worms Impair Mental Performance?" (PDF). Psychological Bulletin 121 (2): 171–91. doi:10.1037/0033-2909.121.2.171. PMID 9100486.
  61. ↑ Hoyt, Bleakley (2007). "Disease and Development: Evidence from Hookworm Eradication in the American South*". The Quarterly Journal of Economics 122 (1): 73–117. doi:10.1162/qjec.121.1.73. PMID 24146438. Retrieved 28 July 2015.
  62. 1 2 Bleakley, Hoyt (2007). "Disease and Development: Evidence From Hookworm Eradication in the American South". The Quarterly Journal of Economics 122: 73–117. doi:10.1162/qjec.121.1.73. PMC 3800113. PMID 24146438.
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