The Interaction of Deworming, Improved Sanitation, and Household Flooring with Soil-Transmitted Helminth Infection in Rural Bangladesh.

BACKGROUND: The combination of deworming and improved sanitation or hygiene may result in greater reductions in soil-transmitted helminth (STH) infection than any single intervention on its own. We measured STH prevalence in rural Bangladesh and assessed potential interactions among deworming, hygienic latrines, and household finished floors. METHODOLOGY: We conducted a cross-sectional survey (n = 1,630) in 100 villages in rural Bangladesh to measure three exposures: self-reported deworming consumption in the past 6 months, access to a hygienic latrine, and household flooring material. We collected stool samples from children 1-4 years, 5-12 years, and women 15-49 years. We performed mini-FLOTAC on preserved stool samples to detect Ascaris lumbricoides, Enterobius vermicularis, hookworm, and Trichuris trichiura ova. Approximately one-third (32%) of all individuals and 40% of school-aged children had an STH infection. Less than 2% of the sample had moderate/heavy intensity infections. Deworming was associated with lower Ascaris prevalence (adjusted prevalence ratio (PR) = 0.53; 95% CI 0.40, 0.71), but there was no significant association with hookworm (PR = 0.93, 95% CI 0.60, 1.44) or Trichuris (PR = 0.90, 95% CI 0.74, 1.08). PRs for hygienic latrine access were 0.91 (95% CI 0.67,1.24), 0.73 (95% CI 0.43,1.24), and 1.03 (95% CI 0.84,1.27) for Ascaris, hookworm, and Trichuris, respectively. Finished floors were associated with lower Ascaris prevalence (PR = 0.56, 95% CI 0.32, 0.97) but not associated with hookworm (PR = 0.48 95% CI 0.16,1.45) or Trichuris (PR = 0.98, 95% CI 0.72,1.33). Across helminths and combinations of exposures, adjusted prevalence ratios for joint exposures were consistently more protective than those for individual exposures. CONCLUSIONS: We found moderate STH prevalence in rural Bangladesh among children and women of childbearing age. This study is one of the first to examine independent and combined associations with deworming, sanitation, and hygiene. Our results suggest that coupling deworming with sanitation and flooring interventions may yield more sustained reductions in STH prevalence.

School-based mass distributions of mebendazole to control soil-transmitted helminthiasis in the Munshiganj and Lakshmipur districts of Bangladesh: an evaluation of the treatment monitoring process and knowledge, attitudes, and practices of the population.

Bangladesh's national deworming program targets school-age children (SAC) through bi-annual school-based distributions of mebendazole. Qualitative and quantitative methods were applied to identify challenges related to treatment monitoring within the Munshiganj and Lakshmipur Districts of Bangladesh. Key stakeholder interviews identified several obstacles for successful treatment monitoring within these districts; ambiguity in defining the target population, variances in the methods used for compiling and reporting treatment data, and a general lack of financial and human resources. A treatment coverage cluster survey revealed that bi-annual primary school-based distributions proved to be an effective strategy in reaching school-attending SAC, with rates between 63.0% and 73.3%. However, the WHO target of regular treatment of at least 75% of SAC has yet to be reached. Particularly low coverage was seen amongst non-school attending children (11.4-14.3%), most likely due to the lack of national policy to effectively target this vulnerable group. Survey findings on water and sanitation coverage were impressive with the majority of households and schools having access to latrines (98.6-99.3%) and safe drinking water (98.2-100%). The challenge now for the Bangladesh control program is to achieve the WHO target of regular treatment of at least 75% of SAC at risk, irrespective of school-enrollment status.

Contributions of non-governmental organizations to WHO targets for control of soil-transmitted helminthiases.

Soil-transmitted helminthiases (STH) may affect up to 1 billion children globally. The World Health Organization (WHO) recommends regular preventive chemotherapy for at-risk individuals. The WHO Preventive Chemotherapy (PCT) Databank tracks annual treatments reported by national Ministries of Health (MOHs) to evaluate progress to coverage goals. Non-governmental organizations (NGOs) deliver STH treatments; the extent to which they are included in MOH reports to the WHO is unclear. The Global NGO Deworming Inventory solicited treatment reports from NGOs to compare with the PCT Databank. In 2010, NGOs delivered 65.4 million STH treatments, which is an estimated 25.1% of the total delivered. Of these treatments, 23.3 million (35.6%) were not reported to the WHO; 22.3 million (95.7%) were from countries that had not submitted STH treatment reports to the WHO. Reporting from NGOs to MOHs and from MOHs to the WHO should be strengthened to ensure that progress to WHO treatment goals is monitored with better completeness and assessed accurately.

Treatment coverage survey after a school-based mass distribution of mebendazole: Kampot Province, Cambodia.

In efforts to reduce the global burden of soil transmitted helminth (STH) infections in school age children (SAC, 6-14 years old), Children Without Worms donates mebendazole to 8 countries with high prevalence of STH infections. Cambodia's national deworming program currently targets SAC through bi-annual school-based distributions of a single dose of mebendazole. A 30-cluster household survey was conducted in the rural province Kampot, to validate mebendazole treatment coverage in SAC and to assess the level of improved water supply and sanitation. Bi-annual primary school-based distributions proved to be an effective strategy in reaching school attending SAC, with treatment coverage rates between 84.1% and 88.8%. However, significantly lower rates (23.3-48.8%) were seen among SAC not enrolled in primary schools. Often members of the most marginalized families of the community, they are particularly at risk of STH infection. Methods to reach these children need to be explored to avoid treatment inequities.

A public-private partnership for malaria control: lessons from the Malarone Donation Programme.

In 1996, Glaxo Wellcome offered to donate up to a million treatment courses annually of Malarone, a new antimalarial, with a view to reducing the global burden of malaria. The Malarone Donation Programme (MDP) was established the following year. Eight pilot sites were selected in Kenya and Uganda to develop and evaluate an effective, locally sustainable donation strategy that ensured controlled and appropriate use of Malarone. The pilot programme targeted individuals who had acute uncomplicated Plasmodium falciparum malaria that had not responded to first-line treatments with chloroquine or sulfadoxine-pyrimethamine. Of the 161 079 patients clinically diagnosed at the pilot sites as having malaria, 1101 (0.68%) met all the conditions for participation and received directly observed treatment with Malarone. MDP had a positive effect at the pilot sites by improving the diagnosis and management of malaria. However, the provision of Malarone as a second-line drug at the district hospital level was not an efficient and effective use of resources. The number of deaths among children and adults ineligible for MDP at the pilot sites suggested that high priority should be given to meeting the challenges of malaria treatment at the community level.