Efficacy and safety of co-administered ivermectin plus albendazole for treating soil-transmitted helminths: A systematic review, meta-analysis and individual patient data analysis.

BACKGROUND: The soil-transmitted helminths (STH), Ascaris lumbricoides, Trichuris trichiura and hookworms, infect 1.5 billion people worldwide and cause an estimated burden of 3.3 million disability-adjusted life years (DALYs). Current control strategies focus on morbidity reduction through preventive chemotherapy (PC) but the most commonly used recommended drugs (albendazole and mebendazole) are particularly inefficacious against T. trichiura. This, together with the threat of emerging drug resistance, calls for new control strategies, including co-administration with other anthelminthics. Ivermectin plus albendazole is widely used against lymphatic filariasis, but its efficacy and safety against STH infections has not yet been fully understood. METHODS AND FINDINGS: We conducted a systematic literature review and meta-analysis on the efficacy and safety of ivermectin-albendazole co-administration in five different databases (i.e. PubMed, ISI Web of Science, ScienceDirect, CENTRAL and clinicaltrials.gov) from 1960 to January 2018. Four studies reporting efficacy of ivermectin-albendazole against STH infections and five studies on its safety met the selection criteria and were included for quantitative analysis. Ivermectin-albendazole was significantly associated with lower risk (risk ratio (RR) = 0.44, 95% confidence interval (CI) = 0.31-0.62) for T. trichiura infection after treatment compared to albendazole alone. The co-administration revealed no or only a marginal benefit on cure and egg reduction rates over albendazole alone for A. lumbricoides and hookworm infections. Adverse events (AEs) occurring after ivermectin-albendazole co-administration were mostly mild and transient. Overall, the number of individuals reporting any AE was not different (RR = 1.09, 95% CI = 0.87-1.36) in co-treated and albendazole-treated patients. However, although not statistically significant, sub-group analysis showed a tendency for slightly more AEs in patients with filariasis treated with ivermectin-albendazole compared to those treated with albendazole alone (RR = 1.29, 95% CI = 0.81-2.05). CONCLUSIONS: Our findings suggest a good tolerability and higher efficacy of ivermectin-albendazole against T. trichiura compared to the current standard single-dose albendazole treatment, which supports the use of this co-administration in PC programs. Large-scale definitive randomized controlled trials are required to confirm our results.

Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa.

OBJECTIVE: To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. DESIGN: We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004-2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4 cell count). METHODS: We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. RESULTS: We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2-5.7). Among all cohort members who were linked to care, the median CD4 cell count at linkage was 350 cells/µl (95% confidence interval: 330-380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. CONCLUSION: Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.

Preventive chemotherapy in one year reduces by over 80% the number of individuals with soil-transmitted helminthiases causing morbidity: results from meta-analysis.

The morbidity due to Ascaris lumbricoides and Trichuris trichiura is caused by infections of moderate and heavy intensity while hookworm infections of all intensities are recognized to cause morbidity. This study aims to evaluate the effect of repeated rounds of preventive chemotherapy on the proportion of soil-transmitted helminth (STH) infections causing morbidity. We identified studies from 17 countries, reporting changes in the proportion of STH infection causing morbidity between baseline and follow-up. In the studies identified, the average proportion of individuals with STH infections of moderate and heavy intensity was of 14% at baseline and was on average reduced to 2% by the intervention (i.e., 85% reduction). There was an average reduction of 73% after the first year of treatment, which reached almost 80% after 5 years and over 95% in 10 years of deworming interventions. The reduction in hookworm prevalence was 57% after 12 months reaching 78% after 5 years. We consider the results presented in this study especially useful for decision makers as it demonstrates the effectiveness of preventive chemotherapy in reducing STH prevalence and morbidity. We encourage the implementation of deworming programs to achieve the goal, set by WHO for 2020, to eliminate STH morbidity in children.

Adverse Events from a Randomized, Multi-Arm, Placebo-Controlled Trial of Mebendazole in Children 12-24 Months of Age.

Large-scale deworming interventions, using anthelminthic drugs, are recommended in areas where the prevalence of soil-transmitted helminth infection is high. Anthelminthic safety has been established primarily in school-age children. Our objective was to provide evidence on adverse events from anthelminthic use in early childhood. A randomized multi-arm, placebo-controlled trial of mebendazole, administered at different times and frequencies, was conducted in children 12 months of age living in Iquitos, Peru. Children were followed up to 24 months of age. The association between mebendazole administration and the occurrence of a serious or minor adverse event was determined using logistic regression. There was a total of 1,686 administrations of mebendazole and 1,676 administrations of placebo to 1,760 children. Eighteen serious adverse events (i.e., 11 deaths and seven hospitalizations) and 31 minor adverse events were reported. There was no association between mebendazole and the occurrence of a serious adverse event (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 0.47, 3.09) or a minor adverse event (OR = 0.84; 95% CI = 0.41, 1.72). Results from our trial support evidence of safety in administering mebendazole during early childhood. These results support World Health Organization deworming policy and the scaling up of interventions to reach children as of 12 months of age in endemic areas.

The Effect of Deworming on Growth in One-Year-Old Children Living in a Soil-Transmitted Helminth-Endemic Area of Peru: A Randomized Controlled Trial.

BACKGROUND: Appropriate health and nutrition interventions to prevent long-term adverse effects in children are necessary before two years of age. One such intervention may include population-based deworming, recommended as of 12 months of age by the World Health Organization in soil-transmitted helminth (STH)-endemic areas; however, the benefit of deworming has been understudied in early preschool-age children. METHODOLOGY/PRINCIPAL FINDINGS: A randomized, double-blind, placebo-controlled trial was conducted to determine the effect of deworming (500 mg single-dose crushed mebendazole tablet) on growth in one-year-old children in Iquitos, Peru. Children were enrolled during their routine 12-month growth and development clinic visit and followed up at their 18 and 24-month visits. Children were randomly allocated to: Group 1: deworming at 12 months and placebo at 18 months; Group 2: placebo at 12 months and deworming at 18 months; Group 3: deworming at both 12 and 18 months; or Group 4: placebo at both 12 and 18 months (i.e. control group). The primary outcome was weight gain at the 24-month visit. An intention-to-treat approach was used. A total of 1760 children were enrolled between September 2011 and June 2012. Follow-up of 1563 children (88.8%) was completed by July 2013. STH infection was of low prevalence and predominantly light intensity in the study population. All groups gained between 1.93 and 2.05 kg on average over 12 months; the average difference in weight gain (kg) compared to placebo was: 0.05 (95% CI: -0.05, 0.17) in Group 1; -0.07 (95%CI: -0.17, 0.04) in Group 2; and 0.04 (95%CI: -0.06, 0.14) in Group 3. There was no statistically significant difference in weight gain in any of the deworming intervention groups compared to the control group. CONCLUSIONS: Overall, with one year of follow-up, no effect of deworming on growth could be detected in this population of preschool-age children. Low baseline STH prevalence and intensity and/or access to deworming drugs outside of the trial may have diluted the potential effect of the intervention. Additional research is required to overcome these challenges and to contribute to strengthening the evidence base on deworming. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01314937).

The effect of deworming on early childhood development in Peru: A randomized controlled trial.

BACKGROUND: There is a knowledge gap on the effect of early childhood deworming on development in low- and middle-income countries. This evidence is important in the critical window of growth and development before two years of age. METHODS: A randomized controlled trial of the benefit, and optimal timing and frequency, of deworming on development was conducted in Iquitos, Peru. Children were enrolled during routine 12-month growth and development visits and randomly allocated to: (1) deworming at the 12-month visit and placebo at the 18-month visit; (2) placebo at the 12-month visit and deworming at the 18-month visit; (3) deworming at the 12 and 18-month visits; or (4) placebo at the 12 and 18-month visits. The Bayley Scales of Infant Development III was used to assess cognitive, language and motor skills at the 12 and 24-month visits. One-way ANOVA analyses used an intention-to-treat approach. RESULTS: Between September 2011 and June 2012, 1760 children were enrolled. Attendance at the 24-month visit was 88.8% (n=1563). Raw scores on all subtests increased over 12 months; however, cognitive and expressive language scaled scores decreased. There was no statistically significant benefit of deworming, or effect of timing or frequency, on any of the development scores. Baseline height and weight and maternal education were associated with development scores at 24 months. CONCLUSIONS: After 12 months of follow-up, an overall benefit of deworming on cognition, language or fine motor development was not detected. Additional integrated child and maternal interventions should be considered to prevent developmental deficits in this critical period.

Risk factors associated with malnutrition in one-year-old children living in the Peruvian Amazon.

BACKGROUND: Children under two years of age are in the most critical window for growth and development. As mobility increases, this time period also coincides with first exposure to soil-transmitted helminth (STH) infections in tropical and sub-tropical environments. The association between malnutrition and STH infection, however, has been understudied in this vulnerable age group. METHODOLOGY/PRINCIPAL FINDINGS: A nested cross-sectional survey was conducted in 12 and 13-month old children participating in a deworming trial in Iquitos, an STH-endemic area of the Peruvian Amazon. An extensive socio-demo-epi questionnaire was administered to the child's parent. Length and weight were measured, and the Bayley Scales of Infant and Toddler Development were administered to measure cognition, language, and fine motor development. Stool specimens were collected to determine the presence of STH. The association between malnutrition (i.e. stunting and underweight) and STH infection, and other child, maternal, and household characteristics, was analyzed using multivariable Poisson regression. A total of 1760 children were recruited between September 2011 and June 2012. Baseline data showed a prevalence of stunting and underweight of 24.2% and 8.6%, respectively. In a subgroup of 880 randomly-allocated children whose specimens were analyzed by the Kato-Katz method, the prevalence of any STH infection was 14.5%. Risk factors for stunting in these 880 children included infection with at least one STH species (aRR = 1.37; 95% CI 1.01, 1.86) and a lower development score (aRR = 0.97; 95% CI: 0.95, 0.99). A lower development score was also a significant risk factor for underweight (aRR = 0.92; 95% CI: 0.89, 0.95). CONCLUSIONS: The high prevalence of malnutrition, particularly stunting, and its association with STH infection and lower developmental attainment in early preschool-age children is of concern. Emphasis should be placed on determining the most cost-effective, integrated interventions to reduce disease and malnutrition burdens in this vulnerable age group.

Timing of umbilical cord-clamping and infant anaemia: the role of maternal anaemia.

BACKGROUND: Evidence from randomized controlled trials has shown that delayed cord-clamping is beneficial to infant iron status. The role of maternal anaemia in this relationship, however, has not been established. OBJECTIVE: To determine the effect of maternal anaemia at delivery on the association between timing of umbilical cord-clamping and infant anaemia at 4 and 8 months of age. METHODS: A cohort of pregnant women admitted to the labour room of Hospital Iquitos (Iquitos, Peru) and their newborns were recruited into the study during two time periods (18 May to 3 June and 6-20 July 2009). Between the two recruitment periods, the hospital's policy changed from early to delayed umbilical cord-clamping. Maternal haemoglobin levels were measured before delivery, and the time between delivery and cord-clamping was recorded at delivery for the entire cohort. Mother-infant pairs were followed-up at 4 (n = 207) and 8 months (n = 184) post partum. Infant haemoglobin levels were measured at follow-up visits. Data were analysed using logistic regression models. RESULTS: The prevalence of maternal anaemia (Hb <11.0 g/dl) at delivery was 22%. Infant haemoglobin levels at 4 and 8 months of age were 10.4 g/dl and 10.3 g/dl, respectively. Infant haemoglobin levels did not differ significantly between infants born to anaemic mothers and those born to non-anaemic mothers at either 4 or 8 months of age. However, the association between the timing of cord-clamping and infant anaemia was modified by the mother's anaemia status. Significant benefits of delayed cord-clamping in preventing anaemia were found in infants born to anaemic mothers at both 4 months (aOR = 0.59, 95% CI 0.36-0.99) and 8 months (aOR = 0.38, 95% CI 0.19-0.76) of age. CONCLUSION: The study contributes additional evidence in support of delayed cord-clamping. This intervention is likely to have most public health impact in areas with a high prevalence of anaemia during pregnancy.

A hospital policy change toward delayed cord clamping is effective in improving hemoglobin levels and anemia status of 8-month-old Peruvian infants.

OBJECTIVE: To assess the effectiveness of a hospital policy change toward delayed cord clamping on infant hemoglobin (Hb) levels and anemia status at 4 and 8 months of age. METHODS: A cohort of Peruvian mothers and infants, originating from a pre/post study investigating a change in hospital policy from early to delayed cord clamping, was followed until 8 months postpartum. Infant hemoglobin levels and anemia status were measured at 4 and 8 months postpartum. RESULTS: Following the hospital policy change, adjusted mean infant Hb levels improved by 0.89 gdl(-1) [95% confidence interval (95% CI) 0.57-1.22] and anemia was significantly reduced (aOR = 0.38; 95% CI 0.19-0.78) at 8 months postpartum. CONCLUSIONS: A hospital policy change toward delayed cord clamping is effective in improving Hb levels and the anemia status of 8-month-old infants. Prior to scaling-up this intervention, issues related to training, monitoring, safety, additional long-term benefits and specific local conditions should be investigated.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon.

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95% confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95% CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (ß adjusted = 113.2 seconds, 95% CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon / Efecto de una intervención de dos componentes para modificar la práctica hospitalaria de pinzamiento del cordón umbilical de precoz a tardío en la Amazonia peruana

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95 percent confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95 percent CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (βadjusted = 113.2 seconds, 95 percent CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

OBJETIVO: Investigar el efecto de una intervención de dos componentes para modificar la práctica hospitalaria respecto del momento en que se practica el pinzamiento del cordón umbilical. MÉTODOS: Se empleó un estudio con diseño antes-después para medir el efecto de una intervención de dos componentes sobre el tiempo medio de pinzamiento del cordón umbilical. El estudio se llevó a cabo en el Hospital Iquitos "César Garayar Gar-cía" en Iquitos (Perú). Se incluyeron en total 224 mujeres atendidas en la sala de trabajo de parto del hospital: 112 antes de la intervención, entre el 18 de mayo y el 3 de junio del 2009, y 112 después de la intervención, entre el 6 y el 20 de julio del 2009. La intervención consistió en: 1) un taller de capacitación sobre las "mejores prácticas" en la atención del parto, de 3 días de duración y 2) una directiva del hospital. Se observaron todos los partos y se midió el tiempo entre la salida del hombro anterior y el pinzamiento del cordón umbilical con un cronómetro digital. RESULTADOS: El tiempo medio entre el parto y el pinzamiento del cordón antes de la intervención fue de 56,8 segundos (intervalo de confianza [IC] de 95 por cento: 51,0-62,7), y aumentó a 169,8 segundos (IC 95 por cento: 153,8-185,8) después de la intervención. La diferencia en el tiempo medio hasta el pinzamiento siguió siendo significativa en los análisis multivariados (βajustado = 113,2 segundos, IC 95 por cento: 96,6-129,9). CONCLUSIONES: Es posible cambiar las normas y las prácticas hospitalarias de pinzamiento del cordón umbilical de precoz a tardío mediante una intervención sencilla de dos componentes.

Stunting and helminth infection in early preschool-age children in a resource-poor community in the Amazon lowlands of Peru.

The World Health Organization recommends deworming of children aged 12-24 months in highly endemic areas. Our research objectives were to: 1) examine prevalence patterns of helminth infection in early childhood; 2) assess the association between helminth infection and socio-demographic characteristics; and 3) examine the effect of the intensity of helminth infection on stunting and anemia. A survey of children (7-9 and 12-14 months) living in Belén (Peru) was undertaken between July 2007 and February 2008. A questionnaire was administered to obtain socio-demographic characteristics, blood and stool samples were collected, and length-for-age Z scores were calculated. The Kato-Katz method was used to determine the prevalence and intensity of Ascaris, Trichuris, and hookworm infections. Of 370 participating children, 349 had parasitological results. Infections first appeared in children at 8 months of age. The prevalence of any helminth infection increased linearly to approximately 37.0% (95%CI: 24.3-51.3%) by 14 months of age. Multivariate analysis showed that age, female sex, and residing in the floodplain were significant determinants of helminth infection. Among infected children, moderate-to-heavy infection of any helminth was associated with stunting (ßadjusted=-0.84; 95%CI: -1.48, -0.20). These results support the implementation of deworming programs aimed at young children in highly endemic areas.

A comparison of low birth weight among newborns of early adolescents, late adolescents, and adult mothers in the Peruvian Amazon.

To compare low birth weight (LBW: <2,500 g) between infants born to adolescent and adult mothers in Iquitos, Peru. A random sample of 4,467 records of women who delivered at the Hospital Apoyo Iquitos between 2005 and 2007 was collected from hospital birth registries. Multivariate logistic and linear regression analyses were performed to compare LBW in newborns of adolescents (10-14, 15-19 years) and adults (≥20 years) and then for primiparous mothers with a normal gestational age, adjusting for newborn sex, antenatal care, and location of the mother's residence. A total of 4,384 mothers had had a singleton live birth and 1,501 were primiparous with a normal gestational age. Early and late adolescents had significantly greater odds of having a LBW infant than adults (OR = 2.28, 95%CI: 1.09, 4.78; OR = 1.67, 95%CI: 1.30, 2.14, respectively). For primiparous mothers with a normal gestational age, the same was true only for early adolescents (OR = 3.07, 95%CI: 1.09, 8.61). There were significant differences in mean birth weight between adults (3178.7 g) and both adolescent age groups overall (10-14 years: 2848.9 g; 15-19 years: 2998.3 g) and for primiparous mothers with a normal gestational age (10-14 years: 2900.8 g; 15-19 years: 3059.2 g; ≥20 years: 3151.8 g). Results suggest there is an important difference between adolescent and adult mothers in terms of newborn birth weight, especially among early adolescents. Future research on LBW and possibly other adverse birth outcomes should consider early adolescents as a separate sub-group of higher risk.

Comparison of prenatal care coverage in early adolescents, late adolescents, and adult pregnant women in the Peruvian Amazon.

OBJECTIVE: To compare prenatal care coverage between adolescent (early and late) and adult pregnant women in Iquitos, Peru. METHODS: A random sample of 4467 birth records was collected. Multivariate analyses were performed to compare prenatal care coverage in all adolescent (10-14 years, 15-19 years) and adult (>or=20 years) age groups and then for primiparous women only. RESULTS: The mean number of visits was 5.0 for adolescents aged 10-14 years, 6.1 for adolescents aged 15-19 years, and 6.2 for women aged 20 years or older. For primiparous women, the means were 5.1, 6.2, and 6.8, for the respective age groups. Both the proportion attending and the number of prenatal visits were significantly lower in primiparous adolescents aged 10-14 years than in primiparous women aged 20 years or older (aOR 0.25; 95% CI, 0.10-0.62 and aRR 0.83; 95% CI, 0.74-0.94, respectively). CONCLUSION: All women attended prenatal care more frequently than the WHO's recommended 4 visits; however, early adolescents attended significantly less often than late adolescents or adult women. Further study of this inequality is warranted to adequately inform local health services.

Progress towards the Millennium Development Goals in a community of extreme poverty: local vs. national disparities in Peru.

OBJECTIVES: Standard indicators are being used worldwide to track progress towards achieving the Millennium Development Goals (MDGs). These are usually at country level and do not accurately reflect within-country variability of progress towards the targets. This may lead to lack of attention and under-resourcing of the most vulnerable populations. Therefore, the objective of this study was to compare selected standard MDG indicators at country level and community level in Peru. METHODS: As MDG indicators we selected: (i) moderate to severe and severe underweight in children under 5 years old; (ii) immunization against measles in 1-year olds; (iii) births attended by skilled health professionals and (iv) youth unemployment. Country-level data for Peru were obtained from United Nations published sources. Community-level data were obtained from a household survey conducted in 2005-2006 in Belén, a community of extreme poverty in the Amazon region. RESULTS: Belén indicators were consistently less favourable than country-level indicators, and indicators even differed between zones of high and low socioeconomic status within Belén itself. CONCLUSIONS: Compared to MDG indicators at the national level in Peru, the population of Belén experiences intra-country regional disparities in important health and social outcomes. Improving the coverage and quality of interventions and services in this community is essential. Other vulnerable populations in Peru should also be identified and targeted so that they can benefit from, and ultimately contribute to, progress in achieving the MDGs.

Multidisciplinary and participatory workshops with stakeholders in a community of extreme poverty in the Peruvian Amazon: development of priority concerns and potential health, nutrition and education interventions.

BACKGROUND: Communities of extreme poverty suffer disproportionately from a wide range of adverse outcomes, but are often neglected or underserved by organized services and research attention. In order to target the first Millennium Development Goal of eradicating extreme poverty, thereby reducing health inequalities, participatory research in these communities is needed. Therefore, the purpose of this study was to determine the priority problems and respective potential cost-effective interventions in Belen, a community of extreme poverty in the Peruvian Amazon, using a multidisciplinary and participatory focus. METHODS: Two multidisciplinary and participatory workshops were conducted with important stakeholders from government, non-government and community organizations, national institutes and academic institutions. In Workshop 1, participants prioritized the main health and health-related problems in the community of Belen. Problem trees were developed to show perceived causes and effects for the top six problems. In Workshop 2, following presentations describing data from recently completed field research in school and household populations of Belen, participants listed potential interventions for the priority problems, including associated barriers, enabling factors, costs and benefits. RESULTS: The top ten priority problems in Belen were identified as: 1) infant malnutrition; 2) adolescent pregnancy; 3) diarrhoea; 4) anaemia; 5) parasites; 6) lack of basic sanitation; 7) low level of education; 8) sexually transmitted diseases; 9) domestic violence; and 10) delayed school entry. Causes and effects for the top six problems, proposed interventions, and factors relating to the implementation of interventions were multidisciplinary in nature and included health, nutrition, education, social and environmental issues. CONCLUSION: The two workshops provided valuable insight into the main health and health-related problems facing the community of Belen. The participatory focus of the workshops ensured the active involvement of important stakeholders from Belen. Based on the results of the workshops, effective and essential interventions are now being planned which will contribute to reducing health inequalities in the community.

Parasite and maternal risk factors for malnutrition in preschool-age children in Belen, Peru using the new WHO Child Growth Standards.

Child malnutrition, including wasting, underweight and stunting, is associated with infections, poor nutrient intake, and environmental and socio-demographic factors. Preschool-age children are especially vulnerable due to their high growth requirements. To target interventions for preschool-age children in a community of extreme poverty in Peru, we conducted a household survey between October 2005 and January 2006 to determine the prevalence of malnutrition and its risk factors. Of 252 children < 5 years old, the prevalence of wasting, underweight and stunting was 26.6, 28.6 and 32.1 %, respectively, based on the new WHO Child Growth Standards. Risk factors for wasting were: (1) moderate-high intensity Trichuris infection (OR 2.50; 95 % CI 1.06, 5.93); (2) hookworm infection (OR 6.67; 95 % CI 1.08, 41.05); (3) age (OR6-month 1.27; 95 % CI 1.11, 1.46); (4) maternal education (secondary incomplete) (OR 5.77; 95 % CI 2.38, 13.99); and (5) decreasing maternal BMI (OR1 kg/m2 1.12; 95 % CI 1.02, 1.23). Risk factors for underweight were: (1) moderate-high intensity Trichuris infection (OR 4.74; 95 % CI 1.99, 11.32); (2) age (OR6-month 1.22; 95 % CI 1.07, 1.38); (3) maternal education (secondary incomplete) (OR 2.92; 95 % CI 1.40, 6.12); and (4) decreasing maternal BMI (OR1 kg/m2 1.11; 95 % CI 1.02, 1.21). Risk factors for stunting were: (1) age (OR6-month 1.14; 95 % CI 1.02, 1.27) and (2) decreasing maternal height (OR1 cm 1.12; 95 % CI 1.06, 1.20). Overall, risk factors for malnutrition included both child and maternal determinants. Based on these data, locally appropriate and cost-effective dietary, de-worming and educational programmes should be targeted to mothers and preschool-age children.