soil transmitted helminth.pdf

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TELIMINATING SOIL-TRANSMITTED HELMINTHIASES

AS A PUBLIC HEALTH PROBLEM IN CHILDREN

TSOIL-TRANSMITTED HELMINTHIASESPROGRESS REPORT 20012010 AND STRATEGIC PLAN 20112020


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TTSOIL-TRANSMITTED HELMINTH


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World Health Organization 2012

All rights reserved. Publications of the World Health Organization are available on the WHO web site (wwwint) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 GeneSwitzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requepermission to reproduce or translate WHO publications whether for sale or for noncommercial distr should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensingright_form/en/index.html).

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WHO Library Cataloguing-in-Publication Data

Soil-transmitted helminthiases: eliminating soil-transmitted helminthiases as a public health problem in ch

progress report 2001-2010 and strategic plan 2011-2020

1.Helminthiasis - transmission. 2.Helminths. 3.Soil - parasitology. 4.Child. I.World Health Organization

ISBN 978 92 4 150312 9 (NLM classificat ion: WC 800)


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Contents

Acknowledgements and dedication vGlossary viiExecutive summary ix

1. INTRODUCTION 1 1.1 Soil-transmitted helminthiases (SH) 1

1.2 Evolution o the global strategy to control SH 2

1.3 Setting the global strategy 3

1.3.1 Eliminating morbidity 3 1.3.2 Integrating control activities 5

1.4 SH and neglected tropical diseases 6

1.5 Purpose o the strategic plan 20112020 7

2. PROGRESS REPORT 20012011 9 2.1 Achievements 9

2.1.1 Expanding coverage 9

2.1.2 Developing tools 12 2.2 Opportunities 14

2.2.1 Drug donations 14

2.2.2 Working in partnership 14

2.3 Challenges 15

2 3 1 Commitment and coordination 15


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3.3.1 Strengthening political commitment 21 3.3.2 Harmonizing coordination 22

3.3.3 Building technical capacity and providing guidance 23

3.3.4 Improving sustainability and acilitate ullgovernmental responsibility 24

3.3.5 Rening monitoring capacities 25

3.4 Expected increase in the number o countries implementing

preventive chemotherapy or SH and reaching75% coverage 20112025 28

3.5 Milestones 29

4. FORECAST OF REQUIREMENTS FOR ANTHELMINTHICMEDICINES 20112020 30

5. REGIONAL HIGHLIGHTS AND PRIORITIES 34

5.1. Arican Region 36 5.2 Region o the Americas 42

5.3 South-East Asia Region 48

5.4 European Region 53

5.5 Eastern Mediterranean Region 58

5.6 Western Pacic Region 63

Reerences 68

Annexes 71

Annex I Country prole or Ghana 72

Annex II Partners 74


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ACKNOEliminating soil-transmitted helminthiases as a public healt

Acknowledgemen

and dedicationEliminating soil-transmitted helminthiasis as a public health problem in

children: progress report 20012010 and strategic plan 20112020is the result o aseries o meetings convened by the World Health Organization (WHO) in GenevaSwitzerland, in April and July 2011, with the participation o national controlprogramme managers, independent experts, partners rom donor agencies, andrepresentatives o pharmaceutical companies, nongovernmental organizations anacademic and research institutions, as well as staff rom the WHO Department oControl o Neglected ropical Diseases, and regional and country offi ces.

WHO acknowledges all those who contributed to the publication o thisdocument. Special thanks are due to the ollowing individuals:

Dr Marco Albonico (Ivo de Carneri Foundation, Italy), Dr Riadh Ben-Ism

(WHO Regional Offi ce or the Eastern Mediterranean, Egypt), Proessor MosesJ. Bockarie (Centre or Neglected ropical Diseases, Liverpool School o ropicalMedicine,UK), Dr Mark Bradley (GlaxoSmithKline, UK), Dr Molly A. Brady (WHRegional Offi ce or the Western Pacic, Philippines), Dr Simon Brooker (LondonSchool o Hygiene & ropical Medicine, UK), Mr Colin H. Buckley (ChildrensInvestment Fund Foundation, UK), Dr Eva-Maria Christophel (WHO Regional


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vi ACKNOWLEDGEMENSEliminating soil-transmitted helminthiases as a public health problem in children

USA), Dr Narcis Kabatereine (Ministry o Health o Uganda), Ms Kim Koporc(Children Without Worms, USA), Dr Patrick Lammie (United States Centers orDisease Control and Prevention, US), Dr uan Le Anh (WHO Regional Offi ce orthe Western Pacic, Philippines), Dr William Lin (Johnson & Johnson, USA), DrJaouad Mahjour (WHO Regional Offi ce or the Eastern Mediterranean, Egypt), DAdiele Onyeze (WHO Regional Offi ce or Arica, Congo), Dr Eric A. Ottesen (aForce or Global Health, USA), Dr Anna Philipps (Schistosomiasis Control InitiaImperial College London, UK), Dr Maria Rebollo,(Centre or Neglected ropical

Diseases, Liverpool School o ropical Medicine, UK), Dr Jutta Reinhard-Rupp(Merck Serono, S.A., Germany), Dr C.R. Revankar (WHO Regional Offi ce or SouEast Asia, India), Dr Frank Richards (Te Carter Center, USA), Dr Martha Saboy(WHO Regional Offi ce or the Americas, USA), Dr Alexander Scheer (Merck SeroS.A., Germany), Dr Marcia de Souza Lima (Global Network or Neglected ropicDiseases, USA), Proessor Russell Stothard (Liverpool School o ropical MedicinUK), Dr Richard Tompson (National Institute o Health, Mozambique), Dr JrgUtzinger (Swiss ropical and Public Health Institute, Switzerland), Dr Marci Van

Dyke (United States Agency or International Development, USA), Dr Andy Wrig(GlaxoSmithKline, UK), Dr Willemijn Zaadnoordijk (Merck Serono, S.A., GermaDr Alexandra Zoueva (Childrens Investment Fund Foundation, UK).

Tis document is dedicated to the memory o Dr Likezo Mubila (WHORegional Offi ce or Arica) or her signicant contribution to overcoming neglecttropical diseases in Arica.


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EXECUEliminating soil-transmitted helminthiases as a public healt

Glossary of terms

Te denitions given below apply to the terms as used in this document. Tmay have different meanings in other contexts.

anthelminthicA medicine used to expel helminths (worms) in humans. Te action o the

medicine kills the worms and acilitates their explusion rom the human body. Tanthelminthics most commonly used to treat intestinal worm inections in childrare the benzimidazoles (albendazole and mebendazole).

coverageTe proportion o the target population reached by an intervention (or

example, the percentage o preschool-age children and school-age children receivpreventive chemotherapy on a treatment day).

elimination as a public-health problemFor operational purposes, WHO denes SH as a public-health problem

when more than 1% o the at-risk population has inection o moderate orhigh intensity and its control requires the delivery o one or more public healthinterventions. Elimination o SH as a public-health problem reers to eliminatio


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viii EXECUIVE SUMMARYEliminating soil-transmitted helminthiases as a public health problem in children

Tree classes o intensity (light, moderate and heavy) o inection are dened or eSH; the thresholds or each class are shown below.1

Organism Light-intensity Moderate-intensity He infections infections

Ascarsis lumbricoides 1 4 999 epg 5 000 49 999 epg >

richuris trichiura 1 999 epg 1 000 9 999 epg >

Hookworms (Necator americanus 1 1 999 epg 2 000 3 999 epg >orAncylostoma duodenale)

epg = eggs per gram o aeces.

morbidity

Te clinical consequences o inections and diseases that adversely affecthuman health. Morbidity rom SH is usually subtle (or example, malabsorptionstunted growth) and proportional to the number o worms inecting an individua

neglected tropical diseases (NTDs)A group o diseases that historically has been overlooked. WHO is workin

overcome 17 neglected tropical diseases.

preschool-age children (pre-SAC)Children aged between 1 and 4 years.

prevalence o any STH inectionTe percentage o individuals in a population inected with at least one spe

o soil-transmitted helminth.

preventive chemotherapyUse o anthelminthic as a public health tool to target simultaneously the

prevalent helminth inections in the area.

school-age children (SAC)Children aged between 5 and 14 years who may or may not be enrolled in

school. Te exact ages o school enrolment may vary slightly between differentcountries Because peak prevalence and intensity o SH inection occur primaril


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EXECUEliminating soil-transmitted helminthiases as a public healt

Executive summa

Soil-transmitted helminthiases (SH) affect more than 2 billion peopleworldwide. In 2001, the World Health Assembly resolved to attain by 2010 aminimum target o regular administration o chemotherapy to at least 75% and u100% o all school-age children at risk o morbidity rom the disease.

o achieve the target set by World Health Assembly Resolution WHA54.19,efforts must be intensied to eliminate SH as a public-health problem. In 2010, oabout a third o children requiring treatment had access to anthelminthic medicinand two thirds had not been reached.

Eliminating soil-transmitted helminthiasis as a public health problem in childprogress report 20012010 and strategic plan 20112020 reports the progress madeduring the rst 10 years o implementing control programmes, and identies new

opportunities and challenges or scaling up control activities. A timeline is proposor achieving the 75% coverage target by 2020. Te strategic plan sets out a dynamapproach to achieve the elements o Resolution WHA54.19 based on an evaluatioo progress and an analysis o why the target has not been universally achieved.Identication o the problems that impede greater access to anthelminthic mediciis the key to proposing practical solutions that can be implemented within the


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x EXECUIVE SUMMARYEliminating soil-transmitted helminthiases as a public health problem in children

Strategic plan 20112020

Strategic approaches have been proposed or each o the challenges identieand milestones have been set or eliminating morbidity rom SH in children by2020. Te situation in each WHO region has been analysed and priority countriehave been identied.

Te strategic plan suggests uture directions or strengthening political

commitment and coordination, building technical capacity, acilitating sustainabiand improving monitoring capacities.

Signicant donations o anthelminthic medicines by GlaxoSmithKline andJohnson & Johnson and increased interest in neglected tropical diseases by manypartners offer a unique opportunity to control SH in the next 10 years.

Te partners and experts who met in April and July 2011 to discuss the draf

strategic plans or SH and schistosomiasis agreed with WHOs recommendationthat control o SH, schistosomiasis and lymphatic lariasis should be integratedbut that a global strategy or each o these three neglected tropical diseases betterresponds to their particular challenges and geographical distribution.

WHO will thereore publish three strategic plans: one or lymphatic lariasi(published in 2010), one or SH (the present document) and one or schistosom(due or publication in 2012) with an introduction that will present the concept oND and the characteristic o preventive chemotherapy. Te introduction will alshighlight the common eatures and the synergies o the strategies or the controlo ND eligible or preventive chemotherapy (lymphatic lariasis, schistosomiasisoil-transmitted helminthiasis, onchocerciasis and trachoma) reinorcing the call integration o the three control activities among themselves and within other exisinrastructures in health or education eld.


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IEliminating soil-transmitted helminthiases as a public healt

Section 1

1.1 Soil-transmitted helminthiases

Soil-transmitted helminthiases (SH) is a term reerring to a group o paradiseases caused by nematode worms that are transmitted to humans by aecally-contaminated soil. Te soil-transmitted helminths o major concern to humansareAscaris lumbricoides, Trichuris trichiura, Necator americanusandAncylostomaduodenale. Te latest estimates indicate that more than 2 billion people are inectewith these parasites. Te highest prevalence occurs in areas where sanitation isinadequate and water supplies are unsae. Figure 1 shows the proportion o childreaged 114 years requiring preventive chemotherapy in each endemic country.

Introduction

Figure 1. Proportion o children aged 114 years requiring preventive chemotherapy (PC) or soil-transmitted helminthiases (SH), by country, 2009


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2 INRODUCIONEliminating soil-transmitted helminthiases as a public health problem in children

Te burden o disease rom SH is mainly attributed to their chronic andinsidious impact on the health and quality o lie o those inected rather than tothe mortality they cause. Inections o heavy intensity impair physical growth andcognitive development and are a cause o micronutrient deciencies including irodeciency anaemia leading to poor school perormance and absenteeism in childreduced work productivity in adults and adverse pregnancy outcomes (1).

1.2 Evolution of the global strategy to control STH

Te global strategy to control SH has evolved with advances in modernchemotherapy. Te rst major historical effort to control worm diseases was theRockeeller Foundations hookworm eradication campaign in the United Statesin the early 1900s. Te rst broad-spectrum anthelminthic (phenothiazine) wasdeveloped or veterinary use in 1938. Since then, broad-spectrum anthelminthicshave been discovered and developed. Te rst benzimidazole developed or huma

use (thiabendazole) was licensed in 1962; WHO reviewed the easibility o large-schemotherapy in 1967, learning rom successes in Japan and Mexico. By the 1980mebendazole, a more effi cacious and sae medicine, became widely available andmathematical models were developed to identiy the most cost-effective requenctreatment to reduce worm burdens (2, 3).

Accumulated scientic knowledge and the availability o sae anthelminthisuch as mebendazole and albendazole laid the oundation or a global strategyto control SH that was widely advocated during the 1990s. In its 1993 WorldDevelopment Report, the World Bank ranked the control o morbidity attributablto SH as the most cost-effective intervention or school-age children (4). Teapplication o regular chemotherapy to control SH was discussed at a WHOInormal Consultation in 1996 (5). In 1998, Prime Minister Hashimoto o Japan

Box 1. Schistosomiasis and soil-transmitted helminth infections (resolution WHA54.19)

In 2001, the Fifty-fourth World Health Assembly expressed concern that the high prevalence and morbidity of STH an

occurring among the poorest populations in the least-developed countries of the world.

Recognizing that repeated chemotherapy with safe, single-dose, affordable medicines at regular intervals reduces le

those associated with morbidity, resolution WHA54.19 urged Member States:

to give high priority to implementing or intensifying control of STH and schistosomiasis in areas of high transm

th lit d ffi f di i


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proposed a parasite control initiative at the G8 summit in Denver, USA, whichsecured a commitment or international cooperation. Around the same time,concurrent administration o albendazole and praziquantel to simultaneously treaSH and schistosomiasis was shown to be sae (6). In 2001, the Fify-ourth WorlHealth Assembly adopted resolution WHA54.19, urging Member States to ensureaccess to essential medicines or SH and schistosomiasis in endemic areas or thtreatment o both clinical cases and groups at high risk or morbidity (Box 1). Teresolution specied a minimum target or global coverage: that by 2010 at least

75% o all school-age children at risk o morbidity rom SH and schistosomiasisshould be regularly treated in order to eliminate these two diseases as a public-heproblem (7).

In 2001, WHO recommended the integration o SH control into existingprimary health-care and school-based systems (8). Te second meeting o Partneor Parasite Control (Rome, Italy, 2002) urged endemic countries to develop natioplans o action or SH and schistosomiasis control, supported by ministrieso health and education, and suggested that SH and schistosomiasis controlprogrammes be integrated with national lymphatic lariasis elimination programin order to reduce costs and increase effi ciencies.

In 2005, this concept culminated in the development o a strategy or theintegrated control o a group o diseases (SH, schistosomiasis, lymphatic lariasonchocerciasis and, in some instances, trachoma) using preventive chemotherapyTe strategy was advocated by WHO and several partners including the GlobalNetwork or Neglected ropical Diseases, the Schistosomiasis Control Initiative a

the Global Alliance or the Elimination o Lymphatic Filariasis (see also section 1.

1.3 Setting the global strategy

1.3.1 Controlling morbidity

Te strategy recommended by WHO (9) to control morbidity rom SH (dene

as the elimination o inections o moderate and high intensity) involves the periodicadministration o anthelminthic medicines (mainly single-dose albendazole (400 mg) an

mebendazole (500 mg)) to the ollowing populations at risk o the disease (10):

preschool-age children (aged 14 years);1

school-age children (aged 514 years);1


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trichiuraor hookworms (Necator americanusandAncylostoma duodenale) in schoage children. Te aim is to reduce and maintain low levels o inection and thusprotect individuals at risk rom morbidity caused by SH (Box 2). Figure 2 showssteps that each country should take to eliminate morbidity rom SH.

Box 2. Why eliminate morbidity not parasites?

Ideally, an effective and efficient sanitation infrastructure would interrupt transmission of STH and impede the dev

In reality, the resources required in endemic countries to sustain such infrastructure are rarely available (3). Elimina

feasible; demonstrated progress will strengthen efforts to improve sanitation infrastructure.

Given that

morbidity from STH becomes prominent only when worm burdens are relatively high;

eliminating moderate and heavy intensity infections is achievable (2);

preventive chemotherapy is feasible in countries with limited resources(11);

anthelminthic medicines used for preventive chemotherapy are available at low cost or are donated

Preventive chemotherapy represents a cost-effective and easy-to-implement short-to-medium term strategy for

associated with STH, while improved access to sanitation is a long-term strategy towards the same goal.

Figure 2. Steps that should each country should conduct to eliminate the morbidity dueto SH

Situation analysis

Situation Classiication*analysis

* Classiication is done by implementation area

Large Scale PC

High-risk

Moderate-risk

Low-risk No PC intervention

Mid-termevaluation

1

1

2

2

3 4 5 6 7 8 9

4 5

10

3

Legend:


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able 1presents the WHO recommended schedule o treatment accordingthe baseline prevalence o SH inection.

1.3.2 Integrating control activities

Within the public health sector, at international, national and community levels,

there are competing demands or unds. Limited nancial resources need to be investedthose areas o greatest public-health need and where cost effectiveness is demonstrated.

recommended strategy or SH control (ensuring regular treatment o all populations a

risk o developing morbidity) includes its integration within existing public-health activ

in order to reduce costs and increase effectiveness.

Deworming school-age children in schools. Te school system offers an idealsetting or deworming and the provision o health education messages to children:

school enrolmenthas increased in recent years: in 2008, the net enrolment rwas 94% in Latin America and the Caribbean, 76% in sub-Saharan Arica an

88% in South and West Asia (12);

teachers can administer the medicines: anthelminthic medicines are sae,administration is simple and only minimal training is required;

Category of risk Prevalence of any STH among Re-treatm school-age children

High-risk areas 50%

Moderate-risk areas 20% and


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Deworming preschool-age children during vaccination campaigns. Vaccinatioand supplementary campaigns (or example, vitamin A distribution) offer convenient

opportunities to deworm preschool-age children:

deworming usually increases the coverage o vaccination and supplementary

campaigns (14);

health personnel are skilled in providing medicines to children.

Adding deworming to vaccination and supplementary campaigns can be doneat extremely low cost because the inrastructure and the personnel in place to distribute

vitamins or vaccines can also easily administer the deworming tablets.

Deworming women of childbearing age in maternal and child health services.SH are strongly associated with iron-deciency anaemia during pregnancy (15). Data

have shown that deworming during pregnancy (afer the rst trimester) associated with

iron supplementation reduces maternal anemia, increases the weight o the newborn an

also reduces inant mortality (16). Furthermore, provision o deworming or women o

childbearing age is easible even in resource-poor settings (17).

1.4 STH and neglected tropical diseases

In 2003, a historical paradigm shif occurred or a number o chronicallyendemic tropical diseases, now known collectively as neglected tropical diseases(NDs). Many o these diseases, while preventable and/or treatable, had been

neglected in the global public-health agenda because o their relatively low mortacompared with the big three (HIV/AIDS, malaria and tuberculosis). Realizingthat many o these diseases affect similar populations (poor or marginalized peopliving in settings where poverty is widespread, resources are limited, and access tosanitation is poor), a collective response to overcome these diseases emerged as anew concept in light o economics, public health and human rights. Te internatiocommunity recognized that such diseases required more attention. In 2005 in BerGermany, WHO convened a meeting o partners and experts to secure strategic

and technical guidance and take this agenda orward. A ND control strategy wadened by WHO in 2006 (18).

Integrated preventive chemotherapy is dened as a rational approach tocontrol SH, lymphatic lariasis (LF), onchocerciasis, schistosomiasis and blindintrachoma (8). Control or elimination o these diseases is based on providing


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distributed simultaneously with anthelminthic medicines because o its saety prointegrating activities or deworming and trachoma will mainly involve trainingdistributors and providing health education or children.

Tis approach is being implemented globally, and more than hal a billionindividuals are estimated to be treated every year or NDs. Te success o theapproach is boosted by a number o actors: clear demonstration o the associatiothese inections with poverty and economic burden (20); their geographical overl

(21); the impact o preventive chemotherapy not only in reducing morbidity but ain sustaining decreases in transmission (22); and the possibility o expansion to tavirtually any helminth inection, as shown in the case o ascioliasis and oodborntrematode inections (23). In addition, mechanisms or delivering medicines areestablished or helminth control and can be used as a platorm to target othercommunicable diseases such as trachoma (24).

In 2007, WHO convened the rst Global Partners Meeting on NDs attenby some 200 participants, including representatives o WHO Member States,United Nations agencies, the World Bank, philanthropic oundations, universitiespharmaceutical companies, international nongovernmental organizations and othinstitutions dedicated to contributing their time, efforts and resources to overcomNDs (25). Since then, donors have made signicant commitments, medicinedonation programmes have been set up, and national governments in endemiccountries are engaged in efforts to implement and scale-up activities to control aneliminate NDs.

1.5 Purpose of the strategic plan 20112020

Te target date o 2010 or attaining 75% coverage o regular administratioo preventive chemotherapy to school-age children at risk o morbidity rom SHand schistosomiasis (7) was not reached. Only a third o all children in need havereceived appropriate treatment or SH (26).

Te purpose o the strategic plan is to propose a revitalized global strategyor eliminating SH as public health problem in childhood by 2020, in line withelimination o LF and that o morbidity rom schistosomiasis by 2020.

Te plan is intended to guide governments in countries where SH areendemic, as well as all the relevant donors and partners, towards a world ree rom


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Section 2

2.1. Achievements

Progress has been achieved during 20012010 in expanding coverage o prevent

chemotherapy to school-age children and preschool-age children and developing tools t

acilitate this expansion.

2.1.1 Expanding coverage

School-age children. School-age children are usually the greatest beneciaries o

deworming programmes because, o the three high-risk groups (preschool-age children

school-age children and women o childbearing age), they bear the highest burden o S

attributable disease.

Beore 2000, a limited number o national SH control programmes had beenimplemented (or example, in Guinea and Mexico). Te World Food Programme (WFP

was a major implementation agency, providing deworming to more than 1.5 million

children in 23 countries (27).

By 2001, other countries had initiated national or subnational SH control activ

Progress report 20012010

PREliminating soil-transmitted helminthiases as a public healt


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10

Te majority (73%) o SH-endemic countries now have specic deworming

programmes or school-age children (Table 2). Most countries in WHOs Arican Regio

and the Region o the Americas have implemented deworming programmes targeting

school-age children. All eight endemic countries in the South-East Asia Region have

deworming programmes, reaching approximately 40% o this target age group.

By 2010, the rst countries to have reached the target o 75% national coverage

were Mexico (by 2000), Cambodia and Nicaragua (in 2004), and Aghanistan, Burkina

Faso, Burundi, Bhutan, Ecuador, the Lao Peoples Democratic Republic, Mali, Myanmar

Swaziland and Viet Nam (between 2005 and 2006). Many o these countries continue to

maintain high coverage rates despite ongoing challenges. WHO will continue to publish

regular updates o the progress o programmes in the PC (preventive chemotherapy an

transmission control) databank.

WHO region Number Estimated number Number of countries Number o of countries of SAC that reported PC that repo

i i PC i i PC f SAC b f 2009 75%

able 2. Countries requiring preventive chemotherapy (PC) or soil-transmitted helminthiases in school-agWHO region, 2009

PROGRESS REPOREliminating soil-transmitted helminthiases as a public health problem in children

Figure 3. Number o school-age children (SAC) treated* by tthe Global Programme to EliminateLymphatic Filariasis (GPELF) and deworming programmes, by year, 20032009

a he number o children treated may include those who were not considered in nee d o preventive chemotherapy.However, estimated coverage uses the number o children requiring preventive chemotherapy as the denominator.

600

500

400

300

200

100

0 2003 2004 2005 2006 2007 2008 2009

Millions

30.0%

13.3%10.2%9.6%10.7%9.0%7.6%

Year

SAC treated by GPELF SAC treated by deworming programme

75% target


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Preschool-age children. Te United Nations Childrens Fund (UNICEF) has beethe lead implementation agency or deworming preschool-age children since WHO and

UNICEF published the joint statement on treatment o preschool children or SH cont

in 2004 (28). In addition, some preschool-age children, as with school-age children, rec

deworming within GPELF. It is estimated that the number o preschool-age children

beneting rom deworming increased seven-old between 2003 and 2009 (Figure 4).

Figure 4. Number o preschool-age children (pre-SAC) treated* by the Global Programme toEliminate Lymphatic Filariasis (GPELF) and deworming programmes, by year, 20032009

a he number o children treated may include those who were not considered in nee d o preventive chemotherapy.However, estimated coverage uses the number o children requiring preventive chemotherapy as the denominator.

300

250

200

150

100

50

0 2003 2004 2005 2006 2007 2008 2009

Millions

33.7%27.8%24.3%

21.1%

14.2%11.4%

3.9%

Year

SAC treated by GPELF SAC treated by deworming programme

75% target

All WHO regions report deworming activity targeting preschool-age children. TArican Region leads the way, with the highest number o implementing countrieand the highest number o preschool-age children treated (able 3).

WHO region Number Estimated number Number of countries Number o of countries of pre-SAC that reported PC that repo

i i PC i i PC f SAC 75%

able 3. Countries requiring preventive chemotherapy (PC) or soil-transmitted helminthiases in preschoolWHO region, 2009



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12

2.1.2 Developing tools

In order to scale-up national programmes or integrated ND control(including deworming), WHO has collaborated with technical partners to develonew tools.

Tally sheets and joint reporting orm. Collection o reliable inormationon selected epidemiological indicators and treatment coverage is essential to

dene those areas where deworming interventions are needed, to select the mostappropriate interventions, to orecast the quantity o anthelminthic medicinesrequired or each distribution cycle, and to provide baseline data or monitoringthe impact o programmes and adjusting their implementation, as necessary. Inorder to improve data collection and reporting rom the peripheral level to districand national levels and on to WHO, reporting orms have been developed or eacadministrative level and made available online (peripheral level: tally sheets; distrlevel: tabulated summary orm; national level: joint reporting orm).1

PCT databank. Te inormation collected through the Joint Reporting Formwhich collates treatment data at the national level, is stored in the PC databank.2

For each endemic country the databank records the numbers o school-age childrand preschool-age children in need o deworming and the number o these childrtreated every year. According to the databank, the estimated number o people o ages at risk or SH inection, and or whom deworming is considered benecial,2009, is over 880 million globally, in 112 countries (able 4).

WHO region Number of countries where PC Number of countries wis required for STH control integrated control of N

finalized or are bein

Arican 42 26

Americas 30 6

South-East Asia 8 2

European 11 2

able 4. Countries requiring preventive chemotherapy (PC) or soil-transmitted helminthiases (SH)o action (PoA) or integrated control o neglected tropical diseases in countries where SH are enderegion, 2010



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National plans o action or integrated control o neglected tropical diseasIntegration o disease control programmes targeting the same geographical areas,same populations and using similar interventions towards the same goal o reducpoverty into one national ND control programme is becoming a necessity rathethan an option in order to increase cost-effi ciency, maximize benets and ensureaccess to treatment.

As a rst step in the expansion o national programmes or integrated

ND control, ministries o health in countries where SH are endemic havebeen encouraged to prepare multi-year national plans o action that dene theepidemiological situation o each disease, the scale o co-endemicity, national goaand objectives and actions or achieving them, and a budget. Tese integrated conactivities are usually done in collaboration with national partners (ministries oeducation, ministries responsible or sae water and sanitation) and internationalpartners (donors, NGOs and academic institutions providing technical support).

By April 2011, 44 o the 112 SH-endemic countries that required deworm

programmes had drafed, revised or nalized national plans o action (able 4).Te development process or these plans has proven benecial in orging strongcommitment rom ND programme managers and in-country stakeholders; theprocess has also driven the donation o medicines into countries with action planand the inrastructure to deliver the intervention.

Country proles. Conducting parasitological surveys can be costly and timeconsuming. In order to minimize diversion o limited nancial and human resour

available or SH control rom actual implementation o administering medicinesattempts have been made to utilize all existing epidemiological data to map SHdistribution and to estimate the population requiring deworming or each endemicountry. Where no epidemiological data were available, other parameters (orexample, prevalence o SH in ecologically similar neighbouring areas, and sanitacoverage) were taken into consideration to identiy the areas where preventivechemotherapy should be implemented and to estimate the population at risk.

Country proles summarize the inormation needed by public-healthproessionals involved in implementing and monitoring the annual progress odeworming programmes. Te proles include the most recent epidemiologicalinormation, maps o the geographical distribution o SH, recommended integrainterventions by district and a progress chart o treatment coverage. Country proare regularly updated on line.1Annex Iprovides an example o a country prole (



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14

the newsletterAction Against Worms(20032009); the joint statement or school deworming by WHO and the World Bank ( the joint statement or worm control by WHO and UNICEF (28); the document stressing the evidence that deworming helps meet the

Millennium Development Goals (30); the report Deworming for Health and Development(31).

A second group o documents was produced to acilitate the work o

programme managers in endemic countries:

the guidelines Helminth control in school-age children(32) and its secondedition (published in 2012);

the manual or teachers How to deworm school children(33); the manual How to add deworming to vitamin A distribution (34). the manual Preventive chemotherapy in human helminthiasis(9) or healt

proessionals and programme managers; the manualMonitoring drug coverage for preventive chemotherapy(35).

A third group o technical documents addresses specic issues in SH cont

the manualAssuring the safety of preventive chemotherapy interventions fthe control of neglected tropical diseases(36).

2.2 Opportunities

Te concept o using an integrated approach to control several NDs (seesection 1.5) has increased the cost effectiveness o control activities (37), generatininterest rom manuacturers, decision-makers in endemic countries, donor agencNGOs and academic institutions (18).

Scaling up deworming during the 10-year period o the strategic plan willensure that the opportunities provided by a myriad o dedicated and committed

partners are not be lost. Never beore has such a ocused effort been undertaken tovercome the burden o disease caused by NDs in general and SH in particular

2.2.1 Drug donations

GlaxoSmithKline is increasing its donation o albendazole through WHO



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2.2.2 Working in partnership

In addition to government ministries o health and education, the mainpartners in the area o SH control and their roles are summarized inAnnex II.

Te combined effort o partners has stimulated decision-makers in manySH-endemic countries, resulting in the development o national plans o action integrated control o NDs in more countries. Comprehensive national plans havcontributed to the clarication o needs or SH control, providing a better ideao the expected progression o programmes at national, regional and global levelsFurthermore, the process o developing national plans by ND coordinators, diseprogramme managers and collaborating partners as a team has helped increasepolitical commitment, attracting nancial resources to start deworming programin many countries (Annex III).

Operational experience is accumulating through the implementation o larscale deworming programmes in an increasing number o countries. Tis experie

provides valuable evidence and knowledge o programme implementation, helps rene the orecast or deworming medicines, inorms the development o new tooand training materials, and establishes an expert pool o managers with rst-handexperience in programme management and implementation.

Academia has contributed signicantly to the global effort to control NDFrom 2006 (the year in which WHO established the Department o Control oNeglected ropical Diseases), the number o scientic publications with ND in

their keywords has increased 40-old, leading to a widening resource o robustscientic evidence on different aspects o ND prevention and control.

Tere has also been an increasing number o bilateral and multilateral dondevelopment banks and philanthropic oundations whose interest and investmentND control (and in some cases specically in SH control) has been vital in scalup ND control programmes.

Tis effort culminated in 2010 when WHO launched Working to overcomethe global impact of neglected tropical diseases(18). Tis rst report on NDsacknowledges all the partners committed to ND control and serves as a cornerstin ostering ongoing and uture donations and active involvement in prevention acontrol activities worldwide.



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inadequate in many endemic countries, partly due to the lack o a clear global goaand targets, and partly due to neglect o the magnitude o the disease burdencaused by SH and the resultant disproportionate unding or other diseases withhigher proles.

In-country coordination. Decision-makers and control managers requenview control o NDs as a group o vertical programmes competing amongthemselves or resources and organized within a specialized hierarchy. Programmmanagers may not be aware o similar activities conducted by colleagues not onlyin the ministry o health but also in ministries o education and by NGOs. Severaopportunities or integration are lost because coordination is lacking. Tis includnot only activities related to distribution o medicines but also to improvements inaccessing sae water, sanitation and health education. SH are strongly linked to psanitation; however, coordination among personnel working in SH control andthose working in sanitation is woeully unexplored.

International coordination. At the global level, donor agencies,

manuacturers, bilateral agencies, private oundations and NGOs, despite their gowill to contribute to SH control, sometimes overlap in their efforts to providedeworming interventions.

In addition, two anthelminthic medicines (albendazole and mebendazole)are donated by two different manuacturers. Albendazole is donated both or theelimination o LF and or SH control, and specication o the programme orwhich the medicine is needed is required beore dispatch to endemic countries. N

donations o medicines are expected to provide additional impetus towards scalinup SH control activities but might also pose some coordination challenges.

2.3.2 Technical issues

Technical capacity. In some countries where SH control is needed,national staff, teachers and community distributors might not have the necessarytechnical capacity to plan and implement comprehensive SH control activities o

example, social mobilization, health education, medicine logistics, anthelminthicadministration, monitoring and evaluation, and managing severe adverse events.

Insuffi cient provision o technical support to countries. Given thesimultaneous start-up o control activities in several countries, the capacity ointernational and academic organizations to provide technical support may be



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programme managers have experienced diffi culties in applying recommendationsan integrated approach at national and district levels.

Reaching non-enrolled school-age children. Rates o school enrolment andschool attendance vary by country. Reaching those who are not enrolled (or notattending schools) through school-based control programmes in countries or areawhere school attendance is low remains a challenge.

Monitoring and reporting. National programme managers are required tocomplete multiple types o orms and annual progress reports or different diseaseand or different anthelminthic manuacturers. Tis reporting requirement posesa considerable burden on health staff and programme managers. In addition,lack o resources and appropriately trained health staff have hindered practicalimplementation in countries o WHOs monitoring and evaluation manual (34).

Lack o strategy and coordination or health education. Health educationis an essential component o the SH control programme; however, the provision

o effective health education messages is requently not optimally incorporated inschool curricula, relying on the good will o individual teachers.

2.3.3 Operational capacity

Sustainability. One o the potential challenges to expanding SH controlis the perception by local decision-makers and potential donors that controlprogrammes are too heavily dependent on external support and thus cannot be

maintained with local resources. Clear evidence is also lacking to demonstratethat the requency o deworming activities can be reduced without transmissionreturning to its original levels and, that even in some cases, transmission caneventually be interrupted through regular drug administration coupled withimproved sanitation, sae water and appropriate health education.

Lack o nancial resources. Competing priorities have prevented manyendemic countries rom securing suffi cient local nancial resources to either scale

up or maintain SH control activities, despite the proven cost-effectiveness o thisintervention.

Nevertheless, even countries with very limited resources and minimalexternal support have been able to successully conduct control activities.



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Cost-containment strategies. Insuffi cient attention is given to strategies thcontain the costs o many aspects o the control programme that are not relatedto medicines (or example, mapping, teacher training, reducing the requency odistribution afer 56 years o implementation, and monitoring).

Guidance on sustaining STH control activities afer successul LF controafer years o successul implementation o school-based deworming programmIn the many areas where PELF ends afer 5 or 6 rounds o mass drug administrati(MDA), it is essential to ensure that, where needed, administration o albendazoleand mebendazole continues in the context o SH control in order to sustain thereduced morbidity rom SH achieved through MDA in PELF. Managers o schoodeworming programmes conront a similar situation afer years o successulimplementation; guidance is needed to help managers decide whether to maintainreduce the same requency o the intervention.

2.3.4 Monitoring and evaluation

Insuffi cient capacity within the programme. Monitoring the progress odeworming programmes and evaluating their impact on public health are essentiaor programme managers and policy-makers to assess whether objectives are beinmet and, i necessary, to correct the implementation strategy. However, nationalprogrammes ofen lack capacity to conduct such activities effi ciently.

Need or standard indicators or monitoring and or evaluation withinthe programme. Conusion has arisen regarding which indicators should be

collected annually by national deworming programmes and which should becollected periodically or monitoring purposes. Furthermore, there is no consensuon the types o impact indicators or standard operating procedures required toregularly collect these indicators, such as nutritional status including absorption omicronutrients, and school attendance and perormance.

Reporting o adverse events. Adverse events afer administration oanthelminthic medicines are rarely reported. Te reasons or this should be clari

to determine whether such events are rare or underreported. A standard method investigate and report adverse events should be adopted.

Possible development o resistance to anthelminthics. o date, no cases oresistance to the anthelminthic medicines used or SH control have been reporteHowever, as activities to administer medicines are progressively scaled up in man



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SEliminating soil-transmitted helminthiases as a public healt

Section 3

3.1 Background

Te past decade has seen a signicant accumulation o scientic evidenceand operational experience on effective SH control rom many countries. Inaddition, unds and donations o anthelminthic medicines have become available

global SH control on an unprecedented scale. In response to these opportunitiespolicy-makers and decision-makers in many endemic countries are developingcomprehensive action plans at various levels o government. Te time is opportunconsolidate the actions o relevant stakeholders and accelerate the process o scaliup preventive chemotherapy interventions.

Tis strategic plan outlines the ramework or achieving the global goal oeliminating SH as a public health problem in children, based on an analysis o

the current situation and the challenges to the scaling-up process. Tis chapter alsoillustrates how different stakeholders can contribute to achieving the global goal (Box

Strategic plan 20112020

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20 SRAEGIC PLANEliminating soil-transmitted helminthiases as a public health problem in children

3.2 Vision, goal, objectives and target

Box 3. Global STH control programme

Vision

A world free of childhood morbidity due to STH.

Goal

To reduce morbidity from STH in preschool-age children (aged 14 years) and school-age children (aged 514

which it would not be considered a public health problem.

STH is considered as a public health problem when:

the prevalence of STH infection of moderate and high intensity among school-age children is over 1%

Objectives

All the countries where STH is considered as a public health problem startsnational STH control programmes by

All the countries where STH is considered as a public health problem reach 75% national coverage and 100% by 2020.

Conduct situation analysis

Classify country

Conduct pilot intervention

Scale up progressively

Maintain high coverage 4-6 years

Adjust treatment schedule if necessary

Institutionalize deworming

Mai

Sus

comheal

DEWORMING

NOT STARTED

75% COVERAGE

NOT REACHED

COUNTRY FREE OF CHILD

MORBIDITY DUE TO ST

75% COVERAGE

REACHED

COUNTRY STATUS STRATEGIC APPROACH

Not started deworming Strengthen political commitment

Harmonize coordination

Not reached 75% coverage Build technical capacity and provide guidance

Reached 75% coverage Improve sustainability and facilitate governemntal responsibility

S


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duration o a large-scale deworming programme and or containing costs during maintenance phase.

Tis section o the strategic plan presents the strategic approaches and actior each o the global challenges identied (see section 2.3); the organization or gro organizations responsible or implementation and a timerame are proposed.

3.3.1 Strengthening political commitment

Weak political commitment is one o the major impediments to starting an

scaling up national SH control programmes. Tis may reect a lack o knowledgabout the cost effectiveness o the interventions in reducing SH-attributablemorbidity. o address this limitation, WHO has accepted responsibility or ensuria more active role in the development o an effective communication strategytargeting decision-makers in national governments (or example, in the Ministry Health and the Ministry o Education) the donor community and other partners

Strategic approach Strategic action Responsible party

Strengthening political Develop a communication strategy to address WHO headquarters acommitment each o the key audiences (e.g. intersectoral,

United Nations agencies, nongovernmentalorganizations, ministries o health, ministrieso education, private sector and others)

Develop a national policy on SH control, Ministries o health, eincluding health education and improved supply, sanitation andwater and sanitation as key complementary WHO support)

interventions to preventive chemotherapyinterventions

Assure that control o SH is included in the Ministry o Education and water

development sector plans

Document the benets to health and the Academic andeconomy o SH control (knowledge research institutionstranslation and dissemination)

Advocate improvements to water and WHO and partners sanitation

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Harmonizing Coordinate among in-country stakeholders Ministry o healthcoordination (governments, nongovernmental

organizations) through, or example, anational ND steering committee

Develop a national plan o action or Ministry o health integrated ND control

Review annually national programmes WHO through regional programme review groups

Conduct intersectoral coordination through WHO, ministries o heducation and water and sanitation networks water supply, sanitatioat regional and country levels development, NGOs

Coordinate the global SH control programme WHO

Coordinate medicine supplies WHO, donors, nation

3.3.2 Harmonizing coordination

In order to guide effi cient concerted efforts rom a variety o partners orstarting and scaling up deworming interventions, coordination at all levels is criti

At country level, implementation o SH control activities should beintegrated with other activities to control or eliminate NDs as well as other existinitiatives or health, education, and water and sanitation. Tis integration requirintersectoral coordination among not only ND control programmes but also all stakeholders. Intersectoral coordination can be best acilitated by the establishmeo an ND Steering Committee responsible or developing national plans o actioor integrated ND control and coordinating the different partners. Tis committ

should include all in-country partners, at all stages o planning and implementatito clariy their roles and responsibilities and identiy any opportunities orintegration.

At regional level, the progress o national SH control programmes shoulbe reviewed annually within the context o an overall ND control plan to ensure

S


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Strategic approach Strategic action Responsible partyBuilding technical Build capacity or programme managers on WHO headquarters acapacity implementation (including resource ministries o health an

identication, undraising, monitoring and NGOs, academic andevaluation, and quality assurance) institutions

Develop operational tools, guides and WHO, ministries o hmanuals up to peripheral level to acilitate education, NGOs, aca

programme implementation (including those institutions targeting the educational sector)

Providing technical Develop, disseminate and maintain up-to-date WHO, ministries o hsupport to endemic WHO manuals up to the peripheral level academic and researc

countries - on surveys- mapping

- reaching non-enrolled school-age children - scaling down strategy

Establish a technical expert group on WHO SH control at global level

Establish regional pools o experts to provide WHO, NGOs, academcountry support institutions

Appoint national programme officers based WHO headquarters a

At global level, the progress o the global SH control programme shouldbe monitored and evaluated in order to identiy any discrepancies rom an expectprogression and to coordinate with the WHO regional offi ces. Also, the dispatch oalbendazole and mebendazole or SH should be coordinated as much as possiblewith that o albendazole or LF and that o praziquantel or schistosomiasis controo this end, WHO plays a pivotal role in acilitating and coordinating medicinedonations and serves as a liaison between the beneciary endemic countries andthe donors. Tis acilitating and coordinating activity will help to ensure thatanthelminthic medicines reach national programmes on time and in suffi cientamounts, particularly in areas where multiple NDs are concurrently endemic anthus where preventive chemotherapy interventions would normally be integrated

3.3.3 Building technical capacity and providing guidance

24 SRAEGIC PLAN


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implementation and monitoring and evaluation o activities in integrated NDcontrol programmes, including SH control components, should conveneperiodically to build capacity. Operational tools, guidelines and manuals to supponational staff (rom the health and education sectors) and acilitate implementatioo national programmes should be made available at every level in all countrieswhere SH are a public-health problem. In particular, guidance is needed on howreach non-enrolled school-age children, how to map and re-map, and how to scaldown interventions afer successul implementation.

A pool o experts on SH control who can provide technical support tocountries should be established in each region. In addition, a technical expert groon SH should be established at the global level to address technical issues raised national and regional programmes. Te establishment o national programme offican help to progress programmes at the local level.

3.3.4 Improving sustainability and facilitating full governmental responsib

Strategic approach Strategic action Responsible partyImproving Create local partnerships Ministry o health, Wsustainability offi ces

Facilitating ull Improve access to external nancial support Ministry o health, Wgovernmental

Make the deworming programme a standard Ministry o education

responsibility or component o school activitiesSTH control asIncrease cost-effi ciency o preventive Ministry o healthdonor support

chemotherapy interventions or SH controlphases out

Te creation o a local partnership or ND control can benet sustainabil

by allowing effi cient use o available resources and avoiding duplication.Sustainability can also be increased by improving cost effi ciency (or example, byprogressively reducing training costs and the requency o drug administration). Tinclusion o preventive chemotherapy interventions within routine school-based ohealth-care activities will urther reduce operational costs.

Sl l d h l h bl h l


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Eliminating soil-transmitted helminthiases as a public healt


Dening standard Increase accuracy o collection o: WHO, NGOs, academindicators or - process indicators institutionsmonitoring - perormance indicators (including coverageperormance o and its validation)programmes - impact indicators (health, nutritional

and education outcomes)

Provide technical guidance or integrated WHO academic and

3.3.5 Rening monitoring capacities

Partner RoleWHO - Develop and disseminate guidelines and manuals - Establish roadmap, global strategies and policies - Provide technical assistance or developing and implementi

and or monitoring and evaluating programmes - Procure and supply medicines

Ministries o Health and - Advocate or political commitment in countriesMinistries o Education - Develop national plans and annual work plans - Provide operational management - Coordinate national and subnational activities

- Coordinate logistics- Ensure continuous commitment to monitoring and evaluati

programmes

NGOs - Assist ministries o health and ministries o education in imadvocacy, resource mobilization, monitoring and evaluation

Academic and - Assist ministries o health and ministries o education in maresearch institutions monitoring and evaluation - Conduct operational research to acilitate implementation a

o the programmes

Bilateral & multilateral donors, - Provide nancial support or procurement, implementationPhilanthropic oundations evaluation, and operational research

26 SRAEGIC PLANEli i ti il t itt d h l i thi bli h lth bl i hild


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Eliminating soil-transmitted helminthiases as a public health problem in children


Integrating orms Consolidate integrated tools and their WHO

and tools or dissemination (including drug applicationdifferent diseases orms, annual reporting orms, the unding gapand donors analysis tool and adverse event report orms)

implementing SH control. Te accuracy o all reported data should be improvedby devising an appropriate mechanism to validate coverage. For example, in a recesurvey conducted by Children Without Worms among NGOs, the use o morethan 80 million tablets o anthelminthic medicines (procured independently by thNGOs) was not properly recorded (unpublished data, 2010).

In addition to coverage data, managers o SH control programmes need aset o additional process indicators to be able to manage the different aspects o thcontrol programme (such as training, medicine procurement, and development o

health education material).

A more precise estimation o the impact o deworming programmes, in ternot only o health and nutrition but also o educational achievements, is requiredTis impact assessment is especially important or donors in order to justiy andeventually expand investments in SH control. It is recognized that the collectiono these indicators may be diffi cult and expensive and may not be required or allcontrol programmes; however, standardizing impact assessment would be import

or comparing results in different settings and setting up specic surveys in sentinidentied countries, possibly through WHO collaborating centres working withnational and international research institutions.

National programme managers are overburdened with multiple reportingrequirements (drug application orms, annual reporting orms and adverse eventreport orms) or different NDs or multiple donation programmes and with

orwarding them to donors and partners at different times o the year. Wherepossible, such orms should be consolidated not only to reduce the administrativeburden but also to acilitate the reviews by regional programme review groups oapplications and progress. Similarly, a single template o a standardized nationalplan o action or integrated ND control should be developed and disseminated guide national programmes and acilitate review o the plans by donors and regio

SEliminating soil transmitted helminthiases as a public healt


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Eliminating soil-transmitted helminthiases as a public healt

As more national programmes implement routine large-scale preventivechemotherapy interventions, the risk o emerging resistance to these medicines shoube considered (although no resistance has yet been conrmed in human dewormingprogrammes). In order to detect such an occurrence as early as possible, and implemcorrective measures promptly, a standard operating procedure to periodically assessanthelminthic effi cacy within national programmes should be developed.

3.4 Expected increase in the number of countries implementipreventive chemotherapy for STH and reaching 75% coverage 201120

Figure 5 shows the 10 countries with larger number o children (pre schoolschool-age children) in need o deworming. Tese 10 countries alone contain mothan two thirds o the total number o children.

Figure 5. en countries with larger numbers o children (school-age and preschool-age)in need o deworming

Indonesia

7%

India27%

Nigeria7%

Bangladesh5%

China6%

Pakistan4%

Ethiopia4%

Philippines3%

Democratic Republico the Congo 3%

United Republico anzania 2%

Other countries32%



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Eliminating soil transmitted helminthiases as a public health problem in children

Figure 6. Expected increase in the proportion o countries implementing preventivechemotherapy or the control o SH in preschool-age and school-age children, by year

100

80

60

40

20

0

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Figure 7. Expected increase in the proportion o countries reaching 75% coverageor preventive chemotherapy or the control o SH in preschool-age and school-agechildren, by year

100

80

60

40

20

0

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Figures 6 and 7 show the expected progression in the proportion o endemi

countries that start the implementation and reach 75% coverage o PC or the cono SH or pre-SAC and SAC.



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Eliminating soil transmitted helminthiases as a public healt

3.5. Milestones

Milestones have been set to monitor and evaluate the global progress o SHcontrol to ensure that programmes are on the right track (able 5).

able 5. Milestones or global control o soil-transmitted helminthiases

Year Milestone

2012 Communication strategy or control o SH (and other NDs) developed

Regional programme review groups expanded

National plans o action or ND control developed by 50% o countries requiring chemotherapy or SH

National policies or SH control involving intersectoral collaboration (or exampleand water and sanitation sectors) exist in 50% o countries requiring preventive che

Standard operating procedures to evaluate drug resistance developed

2013 National plans o action or ND control developed by 75% o countries requiring chemotherapy or SH

National policies or SH control involving intersectoral collaboration (or exampleand water and sanitation sectors) exist in 75% o countries requiring preventive che

Manuals or control o SH in all at-risk groups produced and disseminated

Mapping to identiy areas requiring preventive chemotherapy completed in all counSH are endemic

2015 National plans o action or ND control developed by 100% o countries requiringchemotherapy or SH

National policies or SH control involving intersectoral collaboration (or examplewater and sanitation sectors) available in 100% o countries requiring preventive che

50% o countries requiring preventive chemotherapy or SH have achieved 75% no SAC and pre-SAC, and 50% o SAC and pre-SAC needing treatment worldwide h

2020 100% o countries requiring preventive chemotherapy or SH have achieved 75% n

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g p p

Section 4Forecast of requirements for anthelminthi

medicines, 20112020

Te aim o orecasting the number o individuals requiring preventivechemotherapy or SH and the corresponding amount o anthelminthic medicineis to guide national programme managers and partners through the various stepsrequired to achieve the milestones and global target set out in this strategic plan o20112020.

Tis section elucidates the method used to orecast the number o children(school-age and preschool-age, separately) in need o preventive chemotherapy oSH and their associated needs or anthelminthic medicines during the 10-year pperiod.

Te orecast does not take into consideration the unding available toimplement or scale-up deworming activities. Rather, it indicates (particularly inscenario 2) the minimum requirements or achieving the global target, startingwith the existing institutional capacity (assumed to be based on reported progressin deworming activities). Tese requirements should be used as (i) a reerence toevaluate whether the SH programme is making progress towards achieving theregional and global target, and to adjust the pace o activities as necessary; and (iiguidance or resource mobilization, and regional and national planning.

FORECAS OF Eliminating soil-transmitted helminthiases as a public healt


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Data source

Data were collected rom a variety o sources (able 6).

Population requiring preventive chemotherapy through STH priorityprogrammes

School-age and preschool-age children requiring preventive chemotherapySH or a particular year (say, Year 1) comprising:

1. those living in LF-endemic areas who would be treated in Year 1 byGPELF;

2. those living in LF-endemic areas who would not be treated in Year 1 byGPELF (and who would thus need to receive albendazole or mebendaz

able 6. Data sources used to orecast requirements or anthelminthic medicinesa

Type of data Data source

Estimated number o school-age and preschool-age children Weekly Epidemiologic requiring preventive chemotherapy or SH 2011 (26)

Implementation data on deworming or SH between 2003 and 2009, PC databank by country

Proportion (%) o school-age and preschool-age children inpopulation, by country

Population living in LF-endemic areas Global Programme to

Albendazole need orecast or LF Lymphatic Filariasis

Number o school-age and preschool-age children requiring second National plans o actio rounds o drug administration (that is, those living in high-risk areas) Country proiles

Communication with

aFrom 2012, national plans o action and annual progress reports will be analysed to adjust the orecast annually.

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Setting scenarios

Based on the strategic target that all countries requiring preventivechemotherapy or SH would achieve national coverage rates o at least 75% and to 100% by 2020, three scenarios were ormulated:

Scenario 1: all the countries will reach 100% national coverage, by 2020;Scenario 2 : all the countries requiring PC or SH will reach 75% nationacoverage by 2020;

Extrapolating the number of children targeted and the number of tablerequired

Forecasting the scale up o deworming activities between 2011 and 2020 wextrapolated rom the three scenarios by analysing the reported progress o SHdeworming activities between 2003 and 2009 and the number o children requirintreatment via SH deworming programmes. Tese orecasts were multiplied by th

proportion o school-age children and preschool-age children requiring two rouno preventive chemotherapy (that is, those living in areas where the prevalence oSH exceeds 50%) in order to orecast the number o albendazole or mebendazoltablets required every year up to 2020.

Validation

Te results o the orecasts were validated in consultation with WHOs regio

offi ces.

Notes

Te Region o the Americas is undertaking a detailed orecasting exercise the requirements or anthelminthic medicines to treat SH and other NDs, counby country, in accordance with the objectives o its regional plan; when the resultsavailable, the current preliminary estimates may change.

Population growth is not incorporated into this preliminary orecast, nor ithe increase in the intervals between treatments that may be required afer 5 or 6years o intervention.

Te ollowing graphs present the number o tablets that should be distribu

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Figure 8. Global

Estimated number o albendazole (ALB) and mebendazole (MBD) tablets required toachieve the global target or coverage o school-age children by 2020

Scenario 1

Scenario 2

Scenario Number o ALB/MBD tablets required (million)

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

159 277 392 509 646 751 850 932 978 1,054 1,041 1,016 996 958 902

119 208 294 382 485 563 637 699 733 791 781 762 747 718 676

Scenario 1: All countries reach 100% national coverage by 2020Scenario 2: All countries reach 75% national coverage by 2020

1200

1000

800

600

400

200

-

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Millions

Figure 9. GlobalEstimated number o albendazole (ALB) and mebendazole (MBD) tablets required toachieve the global target or coverage o preschool-age children by 2020

Scenario 1

Scenario 2


500

450

400

350

300

250

200

150

100

50

-

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Millions

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Section 5

Soil-transmitted helminthiases are endemic in all the six WHO regions. Othe total number o children requiring treatment, three quarters are in countrieso the South-East Asia and Arican regions, and approximately one quarter inthe Western Pacic Region, the Eastern Mediterranean Region and the Region othe Americas. Only 4 million children (or less than


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Rates o deworming coverage exceeded 46% in the countries in the Regiono the Americas, ollowed by countries in the South-East Asia Region (39%) and t

Arican Region (32%) (able 7).

WHO region Estimated No. of SAC and pre-SAC Region requiring PC for STH

Arican 283 784 317

Americas 45 453 923

South-East Asia 371 953 171

European 4 277 721

Eastern Mediterranean 77 952 920

Western Pacic 99 122 402

Total 882 544 454

able 7. Coverage o preventive chemotherapy (PC) or soil-transmitted helminthiases (SH) in pre(pre-SAC) and school-age children (SAC), by WHO region, 2009



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Te burden o disease rom SH in WHOs Arican Region is shown in FigureA summary o the main regional indicators is presented inTable 8.

African Region

Indicators pre-SA

able 8. Status o preventive chemotherapy (PC) or soil-transmitted helminthiases (SH) in presc(pre-SAC) and school-age children (SAC), WHO Arican Region, 2009

Figure 11. Burden o soil-transmitted helminthiases, by country, WHO Arican Region, 2009

Estimated number o people r

pre-SAC SAC

93 834 170 189 950 147

High burden

Country where the proportio

SAC population requiring PC

Moderate burden Country where the proportio


Low burden



No PC required

No data available

Not applicable

Countries not in AFR

REGIONEliminating soil-transmitted helminthiases as a public healt


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5.1. African Region

5.1.1 Background

More than 280 million children in need o deworming (30% o the globaltotal) live in the 42 countries o the Arican Region. More than 40% are rom threpopulous countries (the Democratic Republic o the Congo, Ethiopia and Nigeria(Figure 12).

Coverage o preventive chemotherapy has been progressively scaling up in

this region, reaching 32% in 2009. In the three populous countries, the coveragein school-age children has been consistently below 5% while that in preschool-agechildren is relatively high.

Figure 13 Coverage o preventive chemotherapy in preschool-age children (pre-SAC)

Figure 12. Proportion o children requiring preventive chemotherapy orsoil-transmitted helminthiases, by country, WHO Arican Region, 2009

Ethiopia12%

Nigeria21%

Democratic Republico the Congo 10%

United Republico anzania 6% Kenya

5%

M

Uganda5%

WPR11%

AFR32%

SEAR42%

EMR9%

AMR5%

EUR1%

Other co16%

Legend:

AFR: Arican Region

AMR: Region o the Americas

EMR: Eastern Mediterranean Region

EUR: European Region

SEAR: South-East Asia Region

WPR: Western Pacic Region



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For pre-school children, the Democratic Republic o the Congo achieved

national coverage exceeding 75% in 2005 and 2008 (coverage was lower in 2009, a22%). Since 2005, Ethiopia has been implementing deworming to a large numbero preschool-age children, with coverage o 78% in 2009. Nigeria achieved nationcoverage o 22% in 2006 and 13% in 2008.

In the other countries also, once deworming programmes are initiated,relatively high national coverage has been achieved in preschool-age children(average 80%), while that in school-age children varies by country (able 9).

5.1.2 Regional priorities for 20112020

One o the main priorities in the Arican Region would be to implement arapidly scale up control activities or school-age children in the Democratic Repuo the Congo, Ethiopia and Nigeria beore 2015. o enable this expansion to takeplace, the actions suggested in section 3.3.1(developing a specic communicationstrategy) should be essential. A similar approach should be taken in countries

that have not yet started activities in preschool-age children and/or in school-agechildren.

A second priority would be to scale up deworming in areas where small-sccontrol activities (with coverage below 20%) have been initiated and where the LFelimination programme is present. Achieving scale-up in this group o countrieswould be presumably easier than in the rst group since technical capacity andpolitical commitment to a certain extent already exist.

A third priority would be to maintain high coverage in the countries that hexceeded the 75% national coverage. Tis group o countries would need to startplanning to reduce the requency o interventions and institute deworming in theschool system.

Table 9presents or all the endemic countries o the Arican Region in 2009the number o preschool-age children and school-age children requiring preventivechemotherapy, their coverage with the intervention and the status o endemicity or

Tables 10and 11present the regional situation or starting and scaling uppreventive chemotherapy deworming in school-age children and preschool-agechildren respectively.



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Country pre-SAC requiring National coverage SAC requiring PC National coverage PC or STH pre-SAC or STH SAC

Angola 2 532 354 100% 5 115 727

Benin 1 168 747 100% 2 357 012 10%

Botswana 70 506 170 124 Burkina Faso 2 355 883 4 224 893 82%

Burundi 925 228 37% 2 002 967 100%

Cameroon 2 415 723 100% 4 917 317 65%

Cape Verde 47 352 124 206 98%

Central Arican Republic 521 971 1 138 031

Chad 1 585 877 84% 3 098 286

Comoros 49 904 100% 101 663

Congo 440 113 935 094

Cte dIvoire 2 519 139 100% 5 387 511 100%

Democratic Republic 9 432 837 22% 18 830 830

o the Congo

Equatorial Guinea 40 518 100% 83 909 1%

Ethiopia 10 659 252 78% 22 461 523 2%

Gabon 145 518 349 386

Gambia 70 678 148 548

Ghana 104 675 100% 357 203 100%

Guinea 1 307 839 100% 2 642 076 13%

Guinea-Bissau 210 898 89% 417 401

Kenya 5 269 125 10 316 559 36%

Lesotho 153 388 377 239 Liberia 504 387 75% 1 049 976

Madagascar 2 451 597 21% 5 316 067 70%

Malawi 2 081 975 91% 4 414 660 71%

M li 1 761 949 3 486 783 81%

able 9. National coverage o preschool-age children (pre-SAC) and school-age children (SAC) requiring

chemotherapy (PC) or soil-transmitted helminthiases (SH) and status o lymphatic ilariasis (LF) endeadministration (MDA), by country, WHO Arican Region, 2009



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Country Pre-SAC requiring National coverage SAC requiring PC National coverage PC or STH pre-SAC or STH SAC

South Arica 955 872 2 326 653

Swaziland 126 830 63% 306 139 66%

ogo 760 842 100% 1 682 182 5%

Uganda 4 980 321 37% 9 615 007 71%

United Republic

6 104 447 91% 11 759 867 18% o anzania

Zambia 1 827 250 100% 3 654 251 9%

Zimbabwe 759 360 1 835 847

WHO Number of populous Number of additional Number of countries Num Region countries in which PC countries in which PC in which PC has been in w has not started has not started started but not scaled up is g

AFR 3 3 23

Action Start PC Start PC Scale up PC

able 10. School-age children

WHO Number of populous Number of additional Number of countries Num Region countries in which PC countries in which PC in which PC has been in w has not started has not started started but not scaled up is g

AFR 1 6 3

Action Start PC Start PC Scale up PC

able 11. Preschool-age children



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Figure 14. Arican Region

Estimated number o albendazole (ALB) and mebendazole (MBD) tablets required toachieve the global target or coverage o school-age children by 2020

300

250

200

150

100

50

0

Scenario 1

Scenario 2


2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Scenario 1 66 100 134 168 196 229 249 258 254 261

Scenario 2 50 75 100 126 147 171 187 193 191 196

Scenario 1: All countries reach 100% national coverage by 2020

Scenario 2: All countries reach 75% national coverage by 2020

Millions

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Figure 15. Arican Region

Estimated number o albendazole (ALB) and mebendazole (MBD) tablets required toachieve the global target or coverage o preschool-age children by 2020

160

140

120

100

80

60

40

20

0

Scenario 1

Scenario 2

Millions

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020



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Te burden o disease rom SH in WHOs Region o the Americas is showinFigure 16. A summary o the main regional indicators is presented in able 12.

Region of the Americas

Indicators pre- S

able 12. Status o preventive chemotherapy (PC) or soil-transmitted helminthiases (SH) in pres(pre-SAC) and school-age children (SAC), WHO Region o the Americas, 2009

Figure 16. Burden o soil-transmitted helminthiases, by country, WHO Region o the Americas, 2009

Estimated number o people r

pre-SAC SAC

14 048 625 31 405 298

High burden



Moderate burden Country where the proportio


Low burden



No PC required

No data available

Not applicable

Countries not in AMR



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5.2. Region of the Americas

5.2.1 Background

Approximately 45 million children in need o deworming (corresponding 5% o the global total) are rom countries in the Region o the Americas. Tis regiachieved the highest coverage among all o WHOs regions in 2009 (that is, 46% opreschool-age children and school-age children dewormed). More than 50% o thtotal number o children in need o treatment are rom three populous countries

(Brazil, Colombia and Mexico) (Figure 17).

Te PAHO/WHO Directing Council Resolution CD49.R19, signed by MemStates in October 2009, ocuses on elimination o neglected diseases and otherpoverty-related inections (12 diseases) o which ve are NDs targeted or prevenchemotherapy. An analysis o the progress, priorities and lines o action or LF,

Figure 17. Proportion o children requiring preventive chemotherapy, by country, WHORegion o the Americas, 2009

Argentina2%

VeRe

Mexico20%

Paraguay2%

Brazil20%

Colombia11%

Peru8%

H7%

WPR11%

AFR32%

SEAR42%

EMR9%

AMR5%

EUR1%

Other countries3%

Legend:

AFR: Arican Region

AMR: Region o the Americas

EMR: Eastern Mediterranean Region

EUR: European Region

SEAR: South-East Asia Region

WPR: Western Pacic Region



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Year

Coverage(%)

Year

Coverage(%)

Figure 18. Coverage o preventive chemotherapy in preschool-age children (pre-SAC)

and school-age children (SAC), WHO Region o the Americas, by year, 20032009

pre-SAC

100

80

60

40

20

0

2003 2004 2005 2006 2007 2008 2009

100

80

60

40

20

0

2003 2004 2005 2006 2007 2008 2009

SAC

5.1.2 Regional priorities for 20112020

o address NDs in a rational way, in 2010, the Region o the Americasdivided its countries into our groups (35) (Figure 19).

Figure 19. Groups o countries targeted or technical cooperation to achieve goals orcontrol and elimination o neglected tropical diseases, WHO Region o the Americas

GROUP 1

Most o the oci or ONCHO, RA, SCH and LF in LAC

67% of the children of LAC Region at risk of STH

GROUP 2

Some oci o ONCHO, RA and SCH

27% of the children of LAC Region at risk of STH

GROUP 3

No evidence o ONCHO, RA, LF and SCH

5.4% of the children of LAC Region at risk of STH

Fully developped integrated, inter-progrinter-sectoral plans to combat NIDs*

11 countries

Improve inter-programmatic and inter-coordination and includes SH into NIactions

6 countries

Focus activities or NIDs* at local level a

3 countries



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Groups 1 and 2 are where ND control will be

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