Effects of long-term indiscriminate use of macrocyclic lactones in cattle: Parasite resistance, clinical helminthosis, and production losses.

Our aims were to describe a case of clinical helminthosis caused by parasite resistance to macrocyclic lactones (MLs) after the long-term frequent use of these drugs in a cattle herd, and to evaluate the production losses prevented by the use of an effective anthelmintic treatment to control these resistant gastrointestinal nematodes (GINs). A case of clinical helminthosis culminating in the death of steers was investigated, the history of the antiparasitic treatments used during an 11-year period in the herd was assessed, and an efficacy test involving seven different drugs was performed. Thereafter, two groups of heifers naturally infected by ML-resistant GINs were formed and strategically treated with either a highly effective (levamisole) or less effective drug (doramectin) over a 9-month period. The heifers were evaluated monthly based on eggs per gram of feces (EPG) counts and liveweights. An evaluation of the history of parasite control in the farm revealed that MLs were used in 96.5% of the treatments aimed at controlling GINs, ticks, and myiasis in the herd. The efficacy test showed the presence of GINs resistance to all the MLs tested. However, levamisole and albendazole sulphoxide were highly effective against these parasites. Heifers treated with levamisole gained 12.1 kg more liveweight on average, compared to those treated with doramectin. Thus, we conclude that indiscriminate and long-term use of MLs in the studied herd led to the failure of GINs control, a critical situation resulting in significant production losses, and a surge of clinical helminthosis in young cattle. In addition, we showed increase in liveweight gain due to using a highly effective drug, in comparison to an ML, during a 9-month period, in heifers naturally infected by ML-resistant GINs.

Economic losses caused by the use of low-efficacy anthelmintic drugs in growing heifers.

The aim of this study was to compare the economic revenue related to the use of low- or high-efficacy anthelmintic drugs within suppressive or strategic schemes of treatment in growing heifers. Heifers raised in a semi-intensive grazing system in southern Brazil were used. Levamisole and ivermectin were selected as the high- and the low-efficacy drugs, respectively, based on a previous efficacy test. Subsequently, these drugs were used within strategic (Strat; four times per year) or suppressive (Supp; once a month) treatment regimens in the heifers, and their liveweight and eggs per gram of feces counts were monthly evaluated during a 13-month period. The total costs of the treatments and their cost-benefit ratio in regard to liveweight gain were calculated. Final mean liveweight gains (kg) observed were 126.7 (Strat-Low), 133.6 (Supp-Low), 141.3 (Strat-High), 142.9 (Supp-High), and 125.8 (Control). Treatments with a high-efficacy drug resulted in monetary gains of US$ 19.56 (Strat-High) and US$ 14.98 (Supp-High), but Supp-Low and Strat-Low treatments caused economic losses. Total cost of the efficacy test (US$ 374.79) could be paid by the additional liveweight gain of 20 heifers from the Strat-High group. These results showed that it would be preferable not to treat the heifers against GIN if compared with treating them with a low-efficacy drug. In addition, we showed that the use of four treatments per year with a high-efficacy drug-selected by efficacy test-resulted in a profitable management to control GIN in growing heifers raised in a semi-intensive gazing system in southern Brazil.

Prevalence, economic assessment, and risk factors of gastrointestinal nematodes infecting herds in tropical, dry and temperate climate regions in Mexico.

This study investigated exposure to gastrointestinal (GI) nematodes on dairy cattle farms by antibody level determination in bulk tank milk (BTM) samples and its influence on production to detect the risk factors for infection in different climate regions in three states of Mexico. From January to April 2017, BTM samples were collected from 1058 dairy cattle herds and used to establish three Köppen climate classes (tropical, dry and temperate) and states of Mexico. A questionnaire on farm management was applied. The overall herd prevalence of parasites was 67.20%. The highest percentage of positive herds was detected in Veracruz state (78.45%). In addition, the highest prevalence among the climate regions was found in the tropical climate (78.59%). In general, production losses were approximately 1.37-1.78 kg of milk/cow per day. The annual costs of milk production losses per farm were estimated for three different climate regions, ranging between $5541.49 and 6982.50 US$, and those in the three states varied between 5974.10 and 8660.06 US$. The costs for anthelmintic treatments for young stock and adult cows ranged between 57.51 and 192.75 US$, respectively, among the three climate regions and between 46.02 and 189.49 US$, respectively, among the three states. The overall annual costs of milk yield loss per cow were estimated to be 150.74 US$ for the climate regions and 190.54 US$ for the three states of Mexico, followed by the treatment costs for young stock (4.02 US$) and adult cows (3.99 US$). The results suggest that the economic losses due to GI nematodes in Mexican dairy herds are approximately 248 million US$ per annum. Four final models were built based on multivariate logistic regression for potential statistical association from the ELISA results using climatic/environmental and management factors so that each model used different risk factors that were significantly associated with helminth infections in dairy herds.

Anthelmintic Drugs: Their Efficacy and Cost-Effectiveness in Different Parity Cattle.

Gastrointestinal nematodes are responsible for economic losses in bovines and are characterized by reduced milk production, decreased working efficiency, and even death. In our study, the effect of different anthelmintic treatments on nematode control in different parity cattle (Friesian crossbreds) at calving and their effect on milk yield were evaluated. The economics of anthelmintics and farm benefits in terms of increased milk production after deworming was also calculated. We screened cattle of first and second parity for nematodes. Animals were randomly selected in each group. In first parity animals, there were 23 positive cattle found, which were divided into 3 different groups, while in second parity animals there were 20 positive cattle which were also divided into 3 groups. For treatment of gastrointestinal nematodes, we used albendazole (velbazine) at 10 mg/kg body weight and levamisole (Nilverm®) at 7.5 mg/kg. In this study, both drugs were found effective in controlling nematode infections in cattle. Percentage reduction of eggs per gram (EPG) by albendazole was 48.20, 85.34, and 93.90% and 51.54, 81.43, 91.74% on day 7, 14, and 21 in first and second parity animals, respectively. Percentage reduction of EPG by levamisole was 44.45, 76.92, and 88.03% and 46.60, 73.78, 85.43% on day 7, 14, and 21 in first and second parity animals, respectively. The average increase in milk production in albendazole-treated groups was 0.39 and 0.92 L per day while increases in levamisole treated groups were 0.27 and 0.55 L per day in first and second parity cattle, respectively. After treatment, albendazole increased the milk fat by 0.07 and 0.1% while levamisole decreased by 0.02 and 0.05% in first and second parity cattle, respectively. It is concluded that anthelmintic treatments of recently calved cattle have a significant effect on milk production due to the nematode control. Milk production increased significantly in second parity cattle following anthelmintic treatment as compared to first parity animals. Levamisole had a negative effect on fat concentration in cattle while albendazole-treated cattle showed a positive effect. Albendazole has been found more efficient in reducing EPG of helminths in both parity animals as compared to levamisole-treated animals while the cost-benefit ratio of levamisole was greater than albendazole.

The relation between input-output transformation and gastrointestinal nematode infections on dairy farms.

Efficiency analysis is used for assessing links between technical efficiency (TE) of livestock farms and animal diseases. However, previous studies often do not make the link with the allocation of inputs and mainly present average effects that ignore the often huge differences among farms. In this paper, we studied the relationship between exposure to gastrointestinal (GI) nematode infections, the TE and the input allocation on dairy farms. Although the traditional cost allocative efficiency (CAE) indicator adequately measures how a given input allocation differs from the cost-minimising input allocation, they do not represent the unique input allocation of farms. Similar CAE scores may be obtained for farms with different input allocations. Therefore, we propose an adjusted allocative efficiency index (AAEI) to measure the unique input allocation of farms. Combining this AAEI with the TE score allows determining the unique input-output position of each farm. The method is illustrated by estimating efficiency scores using data envelopment analysis (DEA) on a sample of 152 dairy farms in Flanders for which both accountancy and parasitic monitoring data were available. Three groups of farms with a different input-output position can be distinguished based on cluster analysis: (1) technically inefficient farms, with a relatively low use of concentrates per 100 l milk and a high exposure to infection, (2) farms with an intermediate TE, relatively high use of concentrates per 100 l milk and a low exposure to infection, (3) farms with the highest TE, relatively low roughage use per 100 l milk and a relatively high exposure to infection. Correlation analysis indicates for each group how the level of exposure to GI nematodes is associated or not with improved economic performance. The results suggest that improving both the economic performance and exposure to infection seems only of interest for highly TE farms. The findings indicate that current farm recommendations regarding GI nematode infections could be improved by also accounting for the allocation of inputs on the farm.

Mixed methods evaluation of targeted selective anthelmintic treatment by resource-poor smallholder goat farmers in Botswana.

Due to the threat of anthelmintic resistance, livestock farmers worldwide are encouraged to selectively apply treatments against gastrointestinal nematodes (GINs). Targeted selective treatment (TST) of individual animals would be especially useful for smallholder farmers in low-income economies, where cost-effective and sustainable intervention strategies will improve livestock productivity and food security. Supporting research has focused mainly on refining technical indicators for treatment, and much less on factors influencing uptake and effectiveness. We used a mixed method approach, whereby qualitative and quantitative approaches are combined, to develop, implement and validate a TST system for GINs in small ruminants, most commonly goats, among smallholder farmers in the Makgadikgadi Pans region of Botswana, and to seek better understanding of system performance within a cultural context. After the first six months of the study, 42 out of 47 enrolled farmers were followed up; 52% had monitored their animals using the taught inspection criteria and 26% applied TST during this phase. Uptake level showed little correlation with farmer characteristics, such as literacy and size of farm. Herd health significantly improved in those herds where anthelmintic treatment was applied: anaemia, as assessed using the five-point FAMACHA(©) scale, was 0.44-0.69 points better (95% confidence interval) and body condition score was 0.18-0.36 points better (95% C.I., five-point scale) in treated compared with untreated herds. Only targeting individuals in greatest need led to similar health improvements compared to treating the entire herd, leading to dose savings ranging from 36% to 97%. This study demonstrates that TST against nematodes can be implemented effectively by resource-poor farmers using a community-led approach. The use of mixed methods provides a promising system to integrate technical and social aspects of TST programmes for maximum uptake and effect.

[Effect of control interventions for intestinal nematodiasis in areas with low prevalence in Changzhou City].

OBJECTIVE: To evaluate the effect of control interventions for intestinal nematodiasis in areas with low prevalence, so as to explorethe effective measures for the control of intestinal nematode infections in Changzhou City, Jiangsu Province, China. METHODS: The residents in Wujin, Jintan, Tianning districts were selected as monitor subjects and the infections of intestinal nematodes were investigated with Kato-Katz technique or the transparent tape anal swab method. The results were analyzed statistically and the cost-effectiveness was also analyzed. RESULTS: A total of 26 966 people were investigated and the total infection rate of intestinal nematodes was 0.37% (99/26 966). The infection rates of the local residents and floating population were 0.31% (63/20 267) and 0.55% (37/6 699), respectively, and the former was lower the latter (P < 0.01); the infection rates of urban residents and rural residents were 0.29% (44/15 328) and 0.47% (55/11 638),respectively, and the former was lower than the latter (P < 0.05). The 3 jurisdictions used different interventions, and the costs of 1% infection rate drop were 15.9 yuan/thousand people in Wujin District, 1.9 yuan/thousand people in Jintan District, and 1.7 yuan/thousand people in Tianning District. The cost in Jintan was lower than that in Wujin, but the infection rate drop in Jintan was more than that in Wujin. CONCLUSION: The floating population as well as the rural residents is still the focus and difficulty of the intestinal nematodiasis control. The deworming and health education are the main interventions in the key population.

The economic effects of whole-herd versus selective anthelmintic treatment strategies in dairy cows.

Current control practices against gastrointestinal nematodes in dairy cows rely strongly on anthelmintic use. To reduce the development of anthelmintic resistance or disposition of drug residues in the environment, novel control approaches are currently proposed that target anthelmintic treatment to individual animals instead of the whole herd. However, such selective treatment strategies come with additional costs for labor and diagnostics and, so far, no studies have addressed whether they could be economically sustainable. The objectives of this study were to (1) investigate the economic effects at farm level of whole-herd versus more selective anthelmintic treatment strategies in adult dairy cows, and (2) determine how these economic effects depend on level of infection and herd size. A Monte Carlo simulation, fed by current epidemiological and economical knowledge, was used to estimate the expected economic effects and possible variation of different control strategies under Belgian conditions. Four treatment strategies were compared with a baseline situation in which no treatments were applied: whole herd at calving (S1), selective at calving with (S2) or without (S3) treatment of the first-calf cows, and whole-herd when animals are moved from grazing to the barn in the fall (housing treatment, S4). The benefit per lactation for an average dairy herd varied between -$2 and $131 (average $64) for S1, between -$2 and $127 (average $62) for S2, between -$17 and $104 (average $43) for S3, and between -$41 and $72 (average $15) for S4. The farmer's risk associated with any treatment strategy, as indicated by the width of the 95% credible intervals of economic benefit of anthelmintic treatment, decreased with increasing level of exposure, as assessed by bulk tank milk ELISA. The order of the different strategies when sorted by expected benefit was robust to changes in economic input parameters. We conclude that, on average, strategies applying anthelmintic treatment at calving outperform a strategy applying treatment at housing. Within the strategies that applied treatment at calving, more selective treatment strategies can be economically sustainable. However, given the large variation in possible benefits within each treatment strategy, decision support systems are needed to account for the multitude of cow, epidemiological, and economic factors that determine the economics of nematode control and select the optimal treatment strategy for a specific farm.

Integrated parasite management: products for adoption by the Australian sheep industry.

The increasing cost of production loss caused by gastrointestinal nematodes (GIN) highlights the importance of good control programs. However, the endemic nature of anthelmintic resistance also reminds of the need for nonchemical options. Both chemical and nonchemical control options need to be integrated into regional parasite management programs (IPM) with the emphasis on component options determined by factors such as major GIN species, regional climate, property size and enterprise structure. The Integrated Parasite Management of Sheep project was established to develop and demonstrate regional parasite control programs, that integrated chemical and nonchemical options, for the main sheep-producing regions of Australia. The project included research about the ecology of the main endo and ecto-parasites of sheep and a national survey of parasite control practices by sheep producers. IPM approaches developed for two contrasting regions of Australia are discussed. Barriers for the adoption of IPM programs include perceived complexity associated with a multi-component approach, time requirements and difficulty. Facilitating the industry adoption of IPM programs is discussed with relevance to the use of small group extension and involvement of the commercial sector. Perceptions of complexity of IPM may be managed by facilitating adoption of components in a step-wise process such that learning outcomes accumulate over time. Extension efforts must address the needs of industry sectors other than sheep producers and explore user pay approaches. The success of these approaches will depend on the relation of the extra profit to producers, through adoption of IPM programs, with remuneration sufficient to attract a commercial service.

The costs and cost-effectiveness of mass treatment for intestinal nematode worm infections using different treatment thresholds.

BACKGROUND: It is estimated that almost a half of all of people living in developing countries today are infected with roundworms, hookworms, or whipworms or combinations of these types of intestinal nematode worms. They can all be treated using safe, effective, and inexpensive single-dose generic drugs costing as little as USD 0.03 per person treated when bought in bulk. The disease caused by intestinal nematodes is strongly related to the number of worms in the gut, and it is typical to find that worms tend to be aggregated or clumped in their distribution so that <20% of people may harbour >80% of all worms. This clumping of worms is greatest when the prevalence is low. When the prevalence rises above 50%, the mean worm burden increases exponentially, worms are less clumped, and more people are likely to have moderate to heavy infections and may be diseased. Children are most at risk. For these reasons, the World Health Organization (WHO) currently recommends mass treatment of children > or =1 year old without prior diagnosis when the prevalence is > or =20% and treatment twice a year when the prevalence is > or =50%. METHODS AND FINDINGS: The risk of moderate to heavy infections with intestinal nematodes was estimated by applying the negative binomial probability distribution, then the drug cost of treating diseased individuals was calculated based on different threshold numbers of worms. Based on this cost analysis, a new three-tier treatment regime is proposed: if the combined prevalence is >40%, treat all children once a year; >60% treat twice a year; and >80% treat three times a year. Using average data on drug and delivery costs of USD 0.15 to treat a school-age child and USD 0.25 to treat a pre-school child (with provisos) the cost of treating children aged 2-14 years was calculated for 105 low- and low-middle-income countries and for constituent regions of India and China based on estimates of the combined prevalence of intestinal nematode worms therein. The annual cost of the three-tier threshold was estimated to be USD 224 million compared with USD 276 million when the current WHO recommendations for mass treatment were applied. CONCLUSION: The three-tier treatment thresholds were less expensive and more effective as they allocated a greater proportion of expenditures to treating infected individuals when compared with the WHO thresholds (73% compared with 61%) and treated a larger proportion of individuals with moderate to heavy worm burdens, arbitrarily defined as more than 10 worms per person (31% compared with 21%).

[An insight into the epidemiology and economic impact of gastro-intestinal nematodes in small ruminants]. / Nematodi gastrointestinali dei piccoli ruminanti: note di epidemiologia ed impatto economico.

Milk production has been a distinguishing characteristic of sheep breeding since antiquity in the Mediterranean area, including Italy, where prehistoric findings confirm this particular husbandry activity. In Homer's Odyssey, the description of Polifemo's sheep flock organization is remarkably similar to current production systems. The ancient roots of this tradition have grown into an important economic reality, with excellent levels of milk production and apporoximately 65 typical cheeses. It is interesting to note that the Italian word "pecora" (sheep) is believed to have originated from the Latin "pecunia" (money). Although heavy production losses are due to parasitic infections, only 250 papers have been published in the last 50 years in Italy on sheep parasites. Differences in climate, environmental factors and production tecniques may influence infection prevalence, load and pathogenesis. For this reason, prevention must be aimed at the particular epidemiological situation and not simply adapted from current schemes used abroad. The aim of this paper is to illustrate the epidemiology of ovine gastrointestinal nematodes in Italy and to evaluate the economic importance of their control.

Gastrointestinal nematode control programs with an emphasis on cattle.

Control strategies for nematode parasites rely on knowledge of the relationships between the parasites and their hosts. Specifically, these programs are based on identifying crucial points of interaction in the environment provided by the host, including genetics and the immune response, and critical periods in the physical environment in which the eggs and larval stages must develop. When these targets are identified and the interactions understood, cost-effective sustainable programs can be developed using currently available antiparasitic compounds. Resistance to the major classes of anthelmintic compounds requires consideration of new approaches, such as immunity or genetics of the host. Additionally, the efficacy of these compounds can be expanded with combined or concomitant use. Increased study of the use of novel approaches, including fungi, elements such as copper, and plant products, has also occurred. This article explores each of these areas to allow readers to appreciate how various approaches may be developed and incorporated into an effective parasite control program.

Current research and future prospects in the development of vaccines against gastrointestinal nematodes in cattle.

Vaccination is being considered as the most feasible alternative for anthelmintic drugs to control gastrointestinal nematode infections in cattle. However, despite the identification of several candidate protective antigens, no vaccines against gastrointestinal nematode parasites are currently available. The main problems that hamper the development of nematode vaccines in ruminants are that vaccination with recombinant nematode proteins produced in bacterial or eukaryotic expression systems did not induce a protective immune response and no suitable antigen delivery system is available for presentation of protective worm antigens to the bovine mucosal immune system. The present review will focus on recent advances and remaining obstacles in vaccine development against gastrointestinal nematodes in cattle, in particular against the abomasal parasite Ostertagia ostertagi.

Gastrointestinal nematodes of cattle in the northeastern US: results of a producer survey.

A questionnaire covering management practices and producer perception of the effects of gastrointestinal nematode infections was sent to dairy and beef producers in the northeastern US. The mailing list was derived from membership in grazing groups and attendance at grazing events. A final total of 474 responses were suitable for analyses. These responses covered 14 states, but for the purpose of analysis were broken into five groups: New England (NE), Vermont (VT), New York (NY), Pennsylvania (PA), and south and west (S and W) of Pennsylvania. Two-thirds of the responses were from dairy producers. The average number of animals for the farms was 50 cows, 27 heifers, and 20 calves. The average acreage used for grazing was 70 acres, and about two-thirds of the responses used rotational grazing for at least the cows. About one-half of the rotational grazers had been practicing rotational grazing for more than 5 years. Most rotational programs for cows involved a daily rotation, but the rotational interval for other age groups was longer. There was a difference of about 2 months (5.25-7.27) in the length of the grazing season as one moved from New England to south and west of Pennsylvania. Parasite control practices varied greatly by location and animal class. Most producers used anthelmintics one to two times per year, but 10-30% of responses said they did not deworm their cattle. The most common time to deworm was in the spring, and the second most common time was the fall. Between 10 and 20% of respondents reported deworming as a response to decreased productivity or body condition. The use of anthelmintics increased as the location moved from New England to south and west of Pennsylvania. Producer perception of parasite effects was closely related to their anthelmintic use, and also increased as the location moved to the south, and is most likely the result of the increased length of the grazing season. Of producers who ascribed estimated a cost of the parasite, the majority estimated this cost to be between US$ 5 and 20 per animal per year.

The effect of strategic anthelmintic treatment on internal parasites in communally grazed sheep in a semi-arid area as reflected in the faecal nematode egg count.

Communally grazed sheep were dosed at 4-, 12-, 24- or 48-week intervals for 1 year. Dosing every 4 weeks proved to be the most effective (p < 0.05), as reflected in a lower worm egg count compared to the 12-, 24- or 48-week intervals. Since most nematode life cycles lie between 3 and 6 weeks, the treatment has to be given during this critical period if maximum economic advantage is to be gained from deworming. However, treating communally grazed sheep every 12 weeks was found to keep worm egg numbers relatively low and may be advantageous in providing seasonal control, especially in semi-arid environments. Dosing communally grazed sheep once or twice a year under the same conditions is not recommended because reinfection appeared to result in similar faecal egg counts to those from the untreated animals (p > 0.05).

Do intestinal nematodes affect productivity in adulthood?

Intestinal nematode infections have been associated with many physical and mental developmental insults. These include anaemia, wasting, stunting, cognitive impairment and lowered educational achievement, all of which have in turn been shown to interfere with productivity and wage-earning capacity in adults. Although there is no direct evidence for an effect of intestinal nematodes on productivity, circumstantial evidence suggests such an effect. Here, Helen Guyatt reviews the indirect evidence for an effect of intestinal nematodes on productivity in adults through current infection and associated morbidity, and on early ill-health in children, which might affect productivity later in life.

Economic evaluation of three anthelmintic strategies for lamb flocks affected by benzimidazole-resistant nematodes.

OBJECTIVE: To compare the profitability of three anthelmintic strategies in growing lambs in flocks with nematodes resistant to benzimidazole anthelmintics. METHOD: A partial-budgeting analysis was carried out by means of a stochastic simulation model, which allows inputs to be described as distributions rather than as fixed values, and hence permits variation between farms to be considered in the analysis. RESULTS: The results show that control of nematode parasites by use of an effective anthelmintic provides the highest net returns, yielding a margin over ineffectively treated lambs of A$114 per 100 lambs on average. Suppressive treatment based on the administration of two controlled-release capsules and monthly with moxidectin resulted in an average loss of A$131 per 100 lambs in comparison with animals treated with an ineffective anthelmintic. Analysis of the results from capsule-treated lambs did not take into account the unmeasured benefits associated with less contamination of pastures. Sensitivity analysis using a stochastic model indicates that apart from the effect of treatment on weight gain variation in carcase price greatly influences the profitability of all the parasite control programs examined. CONCLUSION: The results suggest that it is economically important for farmers to adjust their strategy in the presence of anthelmintic resistance. But as a result of uncertainty in the factors influencing economic return, the expected economic benefit is likely to vary substantially.

The cost of large-scale school health programmes which deliver anthelmintics to children in Ghana and Tanzania. The Partnership for Child Development.

It has been argued that the delivery of anthelmintics to school-children through existing education infrastructure can be one of the most cost-effective approaches to controlling parasitic worm infection. This paper examines the actual costs of a combination of mass and selective treatment for schistosomiasis using praziquantel and mass treatment for intestinal nematodes using albendazole, as an integral part of school health programmes reaching 80442 pupils in 577 schools in Volta Region, Ghana, and reaching 109099 pupils in 350 schools in Tanga Region, Tanzania. The analysis shows that financial delivery costs per child treated using praziquantel, which involved a dose related to body mass and a prior screening at the school level, were US$ 0.67 in Ghana and US$ 0.21 in Tanzania, while the delivery costs for albendazole, which was given as a fixed dose to all children, were US$ 0.04 in Ghana and US$ 0.03 in Tanzania. The higher unit costs in Ghana reflect the epidemiology of infection; overall, fixed costs were similar in both countries, but fewer children required treatment in Ghana. Analysis of economic costs-which includes the cost of unpaid days of labour--indicates that the financial costs are increased in Ghana by 78% and in Tanzania by 44%. It is these additional costs which are avoided by integration into an existing infrastructure. It is concluded that: the base cost of delivering a universal, standard, school-based health intervention can be as low as US$ 0.03 per child treated; that even a slight increase in the complexity of delivery can have a significant impact on the cost of intervention; and that the use of the education infrastructure does indeed offer significant savings in delivery costs.