WHO CDS CPE PVC 2005.14.pdf

Dewormingfor Health and Development

World Health Organization



Front cover: original painting by D.W.T. Crompton

Report of the third globalmeeting of the partnersfor parasite control

Deworming for Health and Development

Geneva, 29–30 November 2004

World Health OrganizationGeneva, 2005

Strategy Development and Monitoring for Parasitic Diseases and Vector ControlCommunicable Diseases Control, Prevention and EradicationCommunicable Diseases

http://www.who.int/wormcontrol

WHO/CDS/CPE/PVC/2005.14

© World Health Organization 2005

All rights reserved

The designations employed and the presentation of the material in this publicationdo not imply the expression of any opinion whatsoever on the part of the WorldHealth Organization concerning the legal status of any country, territory, city or areaor of its authorities, or concerning the delimitation of its frontiers or boundaries.Dotted lines on maps represent approximate border lines for which there may not yetbe full agreement.

The mention of specific companies or of certain manufacturers’ products does notimply that they are endorsed or recommended by the World Health Organization inpreference to others of a similar nature that are not mentioned. Errors and omissionsexcepted, the names of proprietary products are distinguished by initial capital letters.

The World Health Organization does not warrant that the information contained inthis publication is complete and correct and shall not be liable for any damagesincurred as a result of its use.

- Report of the third PPC meeting

The Partners for Parasite Control

Contents

Acknowledgements ------------------------------------------------------- ii

A tribute ------------------------------------------------------------------- iii

Message from the Director-General of WHO-------------------------- v

1. Letter from President Jimmy Carter ----------------------------------- 1

2. By way of explanation ---------------------------------------------------- 2

3. Resolution of the Third Global Meeting of the Partners forParasite Control, WHO, Geneva, 29-30 November 2004 ---------- 3

4. Deworming for health and development ------------------------------ 4

5. Hitching a lift -------------------------------------------------------------- 6

6. Deworming is building better lives ------------------------------------ 7

7. WHO and the partners at work ----------------------------------------- 8

8. Making it happen in Uganda -------------------------------------------11

9. Feed the kids, not the worms ------------------------------------------12

10. A world fit for children--------------------------------------------------13

11. Making it happen in Nepal ---------------------------------------------14

12. Deworming enhances education-------------------------------------- 15

13. Scaling-up deworming --------------------------------------------------16

14. NGOs facilitate deworming ---------------------------------------------17

15. Deworming as an investment for health and development -------18

16. Making it happen in Ecuador ------------------------------------------19

17. Deworming for healthier mothers and infants ----------------------20

18. Don’t forget the preschool children ---------------------------------- 21

19. Making it happen in Brazil ---------------------------------------------22

20. A pro-poor strategy ------------------------------------------------------23

21. Deworming helps meet the Millennium Development Goals -----25

22. New technology for sustaining deworming ------------------------- 27

23. Making it happen in Cambodia ----------------------------------------28

24. Questions needing answers --------------------------------------------29

25. WHO at the helm of the PPC -------------------------------------------30

26. Onwards and upwards --------------------------------------------------31

27. Action points --------------------------------------------------------------32

References-----------------------------------------------------------------34

List of participants -------------------------------------------------------37

List of acronyms ---------------------------------------------------------48

Annex: The Lancet editorial Thinking beyond deworming --------49

i

Report of the third PPC meeting -


Acknowledgements

The Organization thanks all those who contributed towards the successfuloutcome of the Third Global Meeting of the Partners for Parasite Control,and in particular to the Bill and Melinda Gates Foundation which iscontributing to the work of the Secretariat.

ii



A tribute

A tribute paid by Arlene MitchellWorld Food Programme, Romeduring the opening ceremony of the Meeting of the Partners forParasite ControlGeneva, 29 November 2004

"We would like to take this moment to reflect on the thousands of peopleinvolved in carrying out deworming campaigns, and the challenges anddangers they face. We ask you now to join us in honouring a fallen Afghancolleague, Mr Najibullah Zulfaqar.

Mr Zulfaqar was a teacher for the Department of Education in Uruzgan.On 24th June 2004 he was on a bus and was taking Ministry of Educationforms for a deworming campaign to 40 schools, two madrasas and onehome school when the bus was attacked by anti-government people.Another teacher with him managed to escape, but Mr Zulfaqar and15 others lost their lives in this incident.

Mr Zulfaqar leaves a family of 12. His oldest son has had to leave school toearn a living in an effort to support the family."

iii



Message from the Director-General of WHO

More than two billion people around the worldlive with unrelenting illness due to intestinalparasites. Parasitic infections deprive the poorestof the poor of health and well-being, slow theireconomic progress and contribute to socialmarginalization. However, this situation need notcontinue. The optimum use of safety-testedanthelminthic drugs that are now of low cost andhigh quality means that we can reduce and controlworm-induced illness. The 54th World HealthAssembly (WHA) recognized that tools areavailable so that health professionals can preventand treat these infections. New policies haveemerged since that resolution was adopted inMay 2001, recognizing that regular treatment of high risk groups is the bestmeans of saving lives, preventing illness and improving the health anddevelopment of infected communities. This strategy is now showing clearsigns of success. The health benefits of treating school-age children,preschool children as young as 12 months, and pregnant women withanthelminthic drugs greatly outweigh the risks of possible minor sideeffects.

The scale of the challenge posed by intestinal parasites is formidable. Thegovernments of low-income countries do not have the necessary resourcesto manage alone. Partnerships provide the best approach for applying theknowledge, skills and resources needed to achieve short-term success in theendeavour to reduce and control morbidity. Impoverished countries clearlyneed the support of partnerships.

On behalf of the World Health Organization, I thank the representatives ofthe Partners for Parasite Control for attending this meeting at ourheadquarters in Geneva. WHO is pleased to serve as the executivesecretariat to your contribution to the intensified control of tropicaldiseases. There can be no doubt that what you have set out to do willstrengthen our effort to achieve the Millennium Development Goals.

v

Dr LEE Jong-wookDirector-GeneralWorld Health Organization

1- Report of the third PPC meeting


Letter from President Jimmy Carter1

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2 Report of the third PPC meeting -


The PPC was formed in 2001. The partners include governments of MemberStates where worm infections are endemic, governments of Member Stateswith commitment to reduce poverty in low-income countries, United Nations(UN) agencies [United Nations Children's Fund (UNICEF), World HealthOrganization (WHO), World Food Programme (WFP), Office of the UnitedNations High Commissioner for Refugees (UNHCR), World Bank,nongovernmental organizations (NGOs)], universities, philanthropicfoundations and pharmaceutical companies. Organizations with concern fordisease due to worm infections are welcome to join the Partners for ParasitesControl (PPC). WHO serves as executive secretariat to the PPC.

The partners work towards delivering permanent relief from worm-induceddisease for millions of poor people. The principal effort has been madeagainst schistosomiasis and soil-transmitted helminthiasis but the PPC isready to promote control of other worm-induced diseases according tonational needs and priorities. Effective control measures have beendeveloped and tested. The major challenge is the scale of the problem. Howcan deworming be extended to embrace all the desperately poor people inneed of this health-giving endeavour? Deworming is defined as the deliveryof safety-tested, single dose, oral anthelminthic drugs for the reduction ofboth the subtle and the overt morbidity that accompanies worm infections.

This report from the third meeting of the PPC

• summarizes successes achieved in worm control• explains why deworming is such a highly cost-effective

investment for health• proposes that deworming become part of a wider multidisease

approach for improving the health and well-being of poorpeople

• shows how deworming will contribute to meeting theMillennium Development Goals (MDGs)

…... now read on

By way of explanation .....2

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Resolution3Resolution of the Third Global Meeting of the Partners forParasite Control, WHO, Geneva, 29-30 November 2004

The partners agree that while worm-induced disease may not have such anobvious impact on the well-being of people as Tuberculosis (TB), malaria andhuman immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS), it is nevertheless a relentless drain on the health, development,education and economy of socially-marginalized poor people in low-incomecountries.

The partners PROPOSE that the control of parasitic worminfections (cestodiasis, dracunculiasis, lymphatic filariasis,onchocerciasis, schistosomiasis, soil-transmitted helminthiasis,strongyloidiasis and trematodiasis) should be effectivelyincorporated into a multidisease control approach together withTB, malaria and HIV/AIDS.

This strategy will contribute significantly to the attainment of most of theeight MDGs. In fact, without action to control worm-induced disease,measures to bring relief from TB, malaria and HIV/AIDS are incomplete andmay be compromised.

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Hundreds of millions of people do not enjoy ahealthy, productive life because they aredebilitated and unable to achieve their fullpotential. Parasitic infections contributesignificantly to this widespread deprivation.This assemblage of heterogeneous infectionshas poverty as its common denominator.Control of communicable diseases has alwaysbeen a challenge for WHO. Although focus hasbeen on malaria, TB and HIV in the last twoyears the attention to other tropical diseaseshas been expanded. The PPC is aware thatthose suffering the most from parasitic diseaseslive in resource-poor communities: they havelittle political influence, and they often live in remote areas, in conflict zonesor urban slums where there is minimal or even no access to health care andother services. Parasitic infections are the hallmark of poverty andunderdevelopment.

Soil-transmitted helminths and schistosomes are the most common infectionsworldwide. Some two billion people are chronically infected with soil-transmitted helminths and schistosomes, many suffer from severe morbidity,and others from more hidden manifestations of disease. Almost all casesoccur in areas of poverty in low-income countries in the tropics andsubtropics.

The control of morbidity due to soil-transmitted helminthiasis andschistosomiasis in poor communities is now a realistic possibility becauselow-cost, safety-tested drugs are widely available. Importantly, these drugsshould be given regularly and can be given concomitantly in integratedcontrol programmes. In 2001 this innovative strategic approach wasendorsed by the WHA at its 54th Session and it is now being implemented inmany endemic countries.

At the same time, WHO was requested to promote a new partnership to steerand implement this control strategy. The PPC, launched in June 2001, is aplanning and management forum that retains an informal structure. Butinformal does not stand for uncommitted. The PPC has already demonstratedthat different institutions can work together with the common aim of parasitecontrol. Public health issues such as parasite control will not succeed withoutmultifaceted collaboration.

Deworming for health and development4

Dr Anarfi Asamoa-BaahAssistant Director-GeneralCommunicable Diseases

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The key intervention adopted by the PPC is morbidity control based on thedelivery of regular anthelminthic treatment to high-risk groups.Periodic administration of anthelminthic tablets to school-age children isnow part of the policy of many well-designed school health programmes inendemic countries. This intervention is expanding all over the worldtowards the 75% global coverage target.

There is evidence that anthelminthic treatment of women during pregnancyimproves maternal health, increases birth weight and reduces infantmortality. Anthelminthic treatment is also recommended for children asyoung as 12 months because this improves their health. These healthbenefits should significantly change the way people at risk of parasiticinfections are treated and enable an even wider coverage.

The WHA in 2001 encouraged the organizations of the UN system, bilateralagencies and NGOs to take advantage of a combined action linked to existinginitiatives for the prevention, control and elimination of other communicablediseases when combating schistosomiasis and soil-transmitted helminthiasis.

Massive progress has been witnessed in the drive to eradicatedracunculiasis. Progress is taking place towards the elimination of lymphaticfilariasis as a public health problem by the year 2020. The WHO, NGOs,governments, and pharmaceutical industries are collaborating closely toensure the success of these and similar initiatives.

The PPC now has to investigate how this wealth of experience, skill,knowledge and resource can be harnessed to work at country level to reducedelivery costs and ensure sustainability. The PPC must promote theintensified control of tropical disease, including all forms of helminthiasis, asa most worthwhile contribution to development and to the reduction ofpoverty.

Regular treatment of at least75% of all school-age childrenat risk of morbidity for schisto-somiasis and soil-transmittedhelminth infections by 2010

WHO’s target

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Implementation of any helminth control programme at country levelrequires strong links with existing interventions that are already in place toreach women and children.

A most striking example is the simultaneous delivery of deworming tabletswith vitamin A supplements. One of its unmistakable advantages is thecoverage opportunity: over 167 million children are reached yearly byvitamin A supplementation programmes worldwide and more than50 countries report more than 70% coverage. Worms and vitamin Adeficiency thrive in poor communities and the two problems often coexist.Delivering deworming by using the vitamin A distribution infrastructure (1)reduces delivery costs and (2) enables remote communities to be included.Deworming drugs are safe and can be delivered by non-health staff such ascommunity volunteers after simple training.

In addition, deworming is popular and increases vitamin A supplementationcoverage. Nepal is successfully pioneering this approach and is makingdeworming happen in children under five by using existing resources andboosting the success of the vitamin A distribution campaign (see section 11).

Deworming may also hitch a lift from the National Child Health Days, a wayof giving children a health package including immunization, vitamin Asupplements and deworming. This intervention is successful in theDemocratic People's Republic of Korea and in several other countries.

In Cambodia the Ministry of Health uses monthly outreach services to delivereffectively a minimum package of activities through health centres(immunization, antenatal care, health education, family planning,tuberculosis and leprosy care), and has effectively included vitamin Adistribution and deworming.

5 Hitching a lift

Deworming can beeffectively added to ongoingpublic health programmes

Deworming can be addedto Integrated Managementof Childhood Illness (IMCI)including community IMCI;school health programmes;maternal and child health;Roll Back Malaria,reproductive health -including Making PregnancySafer; distribution of bednetsand/or micronutrients; andvaccination programmes

Worm-free children havea better vitamin A status

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Deworming has made remarkable advances in the realm of public health.Millions of people, especially school-age children, have gained access toaffordable, effective anthelminthic drugs; health and well-being haveimproved. Such has been the progress that in May 2001 the 54th Session ofthe WHA adopted Resolution WHA54.19. The prevailing deworming strategywas endorsed, Member States were urged to intensify control activities, andUN organizations and bilateral agencies were encouraged to intensifysupport for control activities. The Resolution also asked the Director-Generalof WHO to expedite the formation and work of partnerships for the control ofschistosomiasis and soil-transmitted helminthiasis.

Deworming success rests on knowledge and experience from controlledoperational research, extensive trials and powerful advocacy. The resultshave laid the following foundation:

• Concurrent use of anthelminthic drugs for schistosomiasis andsoil-transmitted helminthiasis

• Considerable coverage of primary school-age children throughschools

• Extension of deworming to pregnant and lactating women• Inclusion of preschool children as young as 12 months in

deworming activities• Deworming can be combined with other health interventions• Deworming can increase community health awareness and

compliance• Deworming serves as an entry point into health care systems• Deworming represents a high return for low investment• Benefits for participating communities include increases in

growth rates of children, better school attendance andperformance, improved iron status, decline in anaemia rates,healthier pregnancies and birth outcomes, greater adultproductivity

6 Deworming is building better lives

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Resolution WHA54.19 in May 2001 endorsed a strategy for the control ofschistosomiasis and soil-transmitted helminths in high transmission areas.

In the short-term, morbidity will be reduced by• access to drugs (PZQ + broad-spectrum anthelminthics) and

good case management in all health services• regular treatment of at least 75% of school-age children by 2010• targeting other high risk groups (young children, women of

childbearing age, occupational groups) through existing publichealth programmes and channels

For long-term sustainability, environmental health aspects will be required,including

• improving access to safe water and sanitation• improved hygiene behaviour through health education

Following the 2001 WHA resolution, WHO was requested to set up a systemto monitor each endemic country's progress towards the 2010 target. Theglobal PPC databank has been established and tracks the number of childrenwho are treated each year for soil-transmitted helminths andschistosomiasis.

Epidemiological maps are being created; these describe the soil-transmittedhelminths and/or schistosomiasis situation according to the latest dataavailable for district level.

7 WHO and the partners at work

For further information,please refer to web site:http://www.who.int/wormcontrolEnquiries to Email:[email protected]

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Country profiles, including information on coverage data, plans of action,and anthelminthic drugs on the Model List of Essential Medicines and theircost are collected through questionnaires and extensive liaison with otherpartners, regional colleagues, and national programme managers.

Global progress in coverage of school-age children from 1999 to 2004 isreported from 73 out of 104 endemic countries. Although data are awaitedfrom 26 countries in the Americas, India and China, there has been a steadyincrease in coverage over time. Thirty of the 73 countries are known to beexpanding control activities.

Preschool children are also being treated and coverage is building up.UNICEF is planning to use the momentum generated by NationalImmunization Days (NIDs) and vitamin A supplementation programmes todeliver deworming to preschool children in some countries.

The progress of WHOand other partners isillustrated in issues ofthe PPC Newsletter whichare available online atwww.who.int/wormcontroland are widely distributed

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Progress in deworming these groups of children depends on the work of thepartners, each of whom brings a unique skill to the partnership: some excelat training, others are better positioned to produce advocacy materials. Theprovision of drugs falls under the remit of some agencies and outreach is oneof the most valuable resources of the NGOs.

Each partner has contributed in their own individual way to the globalactivities during the period 1999-2004. For example, UNICEF often buysand delivers drugs for treating preschool-age children. However theprogramme remains under the jurisdiction of the Ministries of Health (MOH).Similarly, WHO and the Programme to Eliminate Lymphatic Filariasis (PELF)have bought drugs for MOH activities.

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In a keynote address The Hon. Jim K. Muhwezi, MP,Maj. Gen.(rtd), Minister of Health of Uganda,explained how the Ugandan government hadestablished and implemented a national programmefor the control of schistosomiasis and soil-transmitted helminthiasis in addition to its efforts tocontrol malaria, TB and HIV/AIDs. Six factors hadcombined to facilitate the deworming programme.

• The availability of highly efficaciouslow-cost drugs which have been givento millions of individuals. The healthbenefits for these people far outweighany role of minor side effects.

• Political commitment to redirect existing services towardsprimary health care with the involvement of both the public andprivate sectors.

• Decentralization allowing districts to make decisions to suit localneeds.

• The government’s PEAP (poverty eradication action plan) whichaims to eradicate absolute poverty in Uganda by 2017.

• Health care reforms based on a sector-wide approach forfunding health care development.

• The readiness of willing partners to provide financial andtechnical resources.

The programme began in 2003 in a phased manner and is muchappreciated by the people in the 18 districts that are now involved. Thegovernment is convinced that better coverage and greater impact will beachieved if a plan to incorporate deworming into a multidisease controlapproach is adopted. The government also expects that deworming must beseen as a priority if MDGs are to be achieved.

8 Making it happen in Uganda

The Hon. Jim K. Muhwezi, MP, Maj. Gen.(rtd)Minister of Health of Uganda

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School feeding helps to break the interrelated cycles of hunger, illiteracy,poverty and disease, and serves as a platform for deworming and otherinterventions. In 2003, the WFP reached 15.2 million children in69 countries. The goal is to reach 50 million children by 2008.

WFP works with communities, governments, NGOs and other agencies -especially UNICEF, WHO and FAO - in schools to train food preparers, carryout deworming, provide clean water and latrine facilities for girls and boys,promote HIV prevention, and more.

The deworming component has evolved, and by the 1990s various effortswere under way. An evaluation of a WHO-WFP programme in Nepal in 2000showed very positive results within two years. WHO and WFP then began amajor effort in Africa in 2001, training country teams of officials from WFPand from the Ministries of Health and Education to organize dewormingcampaigns for primary schools. Since 2001, WFP and WHO have held fiveworkshops in Africa with support from the Canadian InternationalDevelopment Agency (CIDA) and World Bank; and 36 country teams (over100 officials) were trained. In turn, over 10,000 African teachers weretrained in 2002, almost 12,000 in 2003, and over 22,000 in 2004.

These programmes reached almost 2 million children in 2002, nearly3 million in 2003 and 7 million in 2004.

Why would one want to feed worms as well as kids? Nobody would want tofill a leaking bucket with water. Feeding children and combating worms is asuccessful recipe for improving their nutrition, achieving better educationand developing them into fully healthy adults.

9 Feed the kids, not the worms

The average cost per childper year is 59 cents:4 cents for mebendazole,25 cents for praziquantel,and 30 cents for all othercosts (training, monitoring,educational materials)

Thirty countries worldwidenow report activedeworming and schoolfeeding programmes

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Carol Bellamy, UNICEF’s Executive Director, wrote that it is incredible thatin an age of technology and medical marvels, child survival, growth anddevelopment is still so tenuous in so many places, especially for the poor andmarginalized. In the report of a UN special session held in May 2002 entitled“A World Fit for Children”, world leaders committed themselves to reduceinfection with intestinal parasites by 2010.

UNICEF advocates that this urgently needed control of worm infections canbe achieved by scaling-up deworming, particularly by including the processin programmes for the IMCI and in Child Health Days. The success ofdeworming needs to be sustained. Interventions should be encouraged tobuild a culture of good hygiene practice at school. Equally important is tomake sure that all schools have latrines and that these are used properly andare maintained in good condition.

The inclusion of sanitation and hygiene in the curricula for teacher trainingcolleges and schools represents an investment for home and communityenvironments as well as for schools. The PPC must recognize that resourcesearmarked for sanitation and health education are as important as thosedirected at deworming. The pledge to reduce infection with intestinalparasites by 2010 is more likely to be achieved if the effort includes theestablishment of appropriate sanitation and health education in every school.

10 A world fit for children

Sou

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UN

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F, 2

000

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The mountainous, landlocked country of Nepal is home to 25 millionpeople, most of whom live in the countryside. Nepal has been designated asa least developed country; the gross national income in 2003 was US$ 230per capita and 38% of the population live on less than US$ 1 per day(adjusted for purchasing power parity). Nevertheless Nepal has made ithappen. The achievements of three projects show how successfuldeworming improves the health and well-being of school-age children,pregnant women and infants.

Between 1998 and 2001, the Nepalese Ministries of Health and Education,in partnership with WHO and WFP, and with financial support from theCanadian Women’s Health and Micronutrient Facility, embarked on a schemeof integrated nutrition and deworming. Some 250,000 primary schoolchildren were given a nutritious meal during the school day and were alsooffered two doses of albendazole (manufactured in Nepal) during the schoolyear. Significant nutritional improvements were found in the children andthere were significant falls in the prevalences and intensities of soil-transmitted helminth infections. The success of this initiative triggered thepolitical will which is now urging that the deworming programme inschoolchildren be extended to national scale.

A second example of improving child health and involving dewormingintegration is the experience with vitamin A supplementation in pre-schoolchildren. In Nepal vitamin A distribution is made twice yearly and in 2004was scaled up to all 75 districts, reaching up to 2 million children under5 years of age. The programme is funded by UNICEF but the system used isa capillary distribution at village level with the aid of community healthvolunteers. Since 2001 deworming has been added with no additionaldistribution cost, the albendazole being purchased by the MOH. Extremelyhigh coverage (over 95%) led to the outstanding result of reduction inanaemia by 77% in one year, in addition to a reduction in soil-transmittedhelminth infections.

A recent research study undertaken in an area of rural Nepal hasdemonstrated in a most convincing and controlled fashion that deworminggreatly improves the health of pregnant women and the birth weight andsurvival of their babies (see section 17). This work in Nepal confirms thatantenatal deworming surely deserves more attention and implementationwhen appropriate circumstances prevail.

11 Making it happen in Nepal

Nutritional improvementand deworming go handin hand

Regular deworming inNepal has reducedanaemia by 77 %

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Deworming undoubtedly makes a significant contribution to the educationof children, and in so doing to a nation’s development. Not surprisingly,children experiencing the debilitating effects of worm infections spend fewerdays in school compared with those who are free from infection. Forexample, children enduring intense infections with whipworm miss twice asmany school days as their infection-free peers. This result has beendemonstrated convincingly in Jamaica and in Kenya.

That deworming increases attendance at school is to be welcomed. What ismore important and encouraging is that children who have been treated gainmuch more from their increased time at school, not only because they arefree from illness but also because their cognitive performance improves andthey learn significantly better. Tests have shown that a child’s short-termmemory, long-term memory, executive function, language, problem solvingand attention respond positively to deworming. Interestingly, girls displaygreater improvements than boys.

Estimates have been made of the quantitative costs of worm infections tocognition and education. The total lost years of schooling due to worm-associated absenteeism amounts to over 200 million years; almost all thisloss occurs in low- and middle-income countries. The average IQ loss perworm infection is 3.75 points, amounting to a total IQ loss of 633 millionpoints for the world’s low-income countries.

12 Deworming enhances education

A nation’s children arethat nation’s future

Deworming enhances andenriches education

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The 3 key issues for scaling-up deworming are: (1) assist endemic countriesto implement national control programmes; (2) develop a demand fortreatment and monitor and evaluate the programmes; and (3) encourageoperational research.

These are the objectives of the Schistosomiasis Control Initiative (SCI),Imperial College, London, UK, which is working with Burkina Faso, Mali,Niger, Tanzania (including Zanzibar), Uganda and Zambia. By the end of2004 approximately 5.25 million treatments with praziquantel andalbendazole were dispensed in these countries.

In Uganda, 1.4 million school-age children and adults in highly endemicareas have been treated and a reduction in the prevalence and intensity ofschistosomiasis and soil-transmitted helminthiasis has been demonstrated.In addition, an increase in knowledge of schistosomiasis and reduction inpathology have been achieved.

Mainland Tanzania is also decreeing a National Schistosomiasis Day in 2005,targeting over 4 million school-age children.

One of the merits of SCI is to facilitate integration of other dewormingprogrammes at the national level, the synergistic deworming in collaborationwith PELF being an example.

SCI has worked to develop partnerships at international and country levelsbetween the Ministries of Health and Education in the 6 countries, WHO,WFP, the United States Agency for International Development (USAID), theUnited Kingdom Department for International Development (DFID), theDanish Bilharziasis Laboratory (DBL), and the Wellcome Trust. SCI hasallocated funds given by the Bill and Melinda Gates Foundation(US$ 30 million) and will approach other donors for funding to meet newrequests. An initial success has been achieved with a pharmaceuticalcompany, MedPharm, which donated over 14 million tablets of praziquanteland one million tablets of albendazole in 2004.

SCI has met the big challenge of drug procurement by facilitating registrationof drug products in each country, promoting local production by nationalpharmaceutical companies, and assisting and strengthening procurementagencies at country level according to local needs.

13 Scaling-up deworming

Boosting local capacity fordrug procurement

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NGOs play a crucial role in advancing and improving the effectiveness ofdeworming in the context of School Health and Nutrition (SHN) programmes.With experienced staff, technical expertise and strong local and nationallinks, NGOs are able to pilot and scale-up model SHN programmes(including deworming) and carry out operational research. NGOs alsoinfluence national policy and advocate for and support the development andimplementation of national SHN programmes.

In Burkina Faso, Save the Children/USA piloted and evaluated an SHNprogramme in Bazega Province, and used the results to raise funds, scale-upthe programme and advocate for a national SHN programme. Six years later,the national SHN programme has been developed and Save the Children/USA is one of three NGOs (along with Catholic Relief Services and HelenKeller International) to be contracted by the Ministry of Education toimplement the programme.

Save the Children/USA supports SHN programmes in 11 countries in Africa,Asia, the Middle East and Latin America. The programmes aim to achieveeducation for all by addressing children’s health and nutrition problems,using the four main strategies supported by the FRESH initiative (FocusingResources on Effective School Health): 1) school-based health and nutritionservices (including deworming); 2) safe water and sanitation; 3) promotion ofhealthy behaviours; and 4) school health-related policies.

NGOs (international and national) have resources and expertise for parasitecontrol. Governments should be encouraged to liaise more with internationalNGOs that play a major role in advocacy and with local NGOs which mayhave a deep knowledge and trust within the community and could effectivelyassist in the implementation of deworming programmes.

14 NGOs facilitate deworming

School health andnutrition programmes needa deworming component

Governments liaisewith nongovernmentalorganizations

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The World Development Report for 1993 entitled Investing in Healthrevealed that common soil-transmitted helminth infections caused thegreatest burden of infectious disease in children aged between 5 and14 years in countries with developing economies. Now that safety-tested,effective anthelminthic drugs cost no more than a few cents per dose, thismeans that deworming school-age children is probably the mosteconomically efficient public health activity that can be implemented in anylow-income country where such infections are endemic.

An often-overlooked aspect in public health expenditure is the cost ofinfrastructure and institutional capacity to implement the desiredinterventions. Deworming is a particularly effective intervention because thecapacity costs are negligible.

High death rates are not obviously associated with disease due toschistosomiasis and soil-transmitted helminthiasis. Recent re-analysis hasfound, however, that the costs of subtle morbidity are far higher than waspreviously thought. For example, seemingly uncomplicated schistosomiasisis far from benign and is linked to anaemia, body weight and energy deficits,chronic pain, fatigue and exercise intolerance. On average, schistosomiasiscauses a haemoglobin reduction of 4g/l that relates to reduced work outputand to as much as a 60% reduction in peak workload capacity. It is nowpossible to predict that the average disease burden for a schistosomiasis-infected person ranges from 2-15% chronic disability. Programmes thatsucceed in controlling disease due to worm infections contribute not only tothe health and well-being of individuals but also to the economicdevelopment and progress of the nation.

15 Deworming as an investmentfor health and development

The contribution of subtlemorbidity to chronicdisability should not beoverlooked

Chronic disability costsmore in development termsthan death

Source: Dean Jamison, University of California, Los Angeles, USA, 2004

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The National Institute of the Child and theFamily (INNFA) is a private organizationdedicated to social development in Ecuador.One area of health intervention to whichINNFA gives high priority is deworming ofchildren. INNFA has formed a successfulalliance with the MOH in Ecuador, MedPharmand volunteers who assist with theprogramme. Dr Ximena Bohorquez deGutierrez, the First Lady of the Republic ofEcuador, is the Chair and President of INNFA.

There can be no doubt that the dailycommitment of such a high profile person todeworming has manifestly increased the compliance with and support fordeworming in Ecuador.

Between 1999 and 2003 over 500,000 people were treated annually withthe appropriate dose of albendazole. During the first part of 2004, coveragewith this treatment rose to 1.2 million people. Albendazole tablets (400mg)were made available at 1046 locations such as schools, INNFA’s communitycentres and shopping markets. This degree of coverage depends on the workof both paid and volunteer agents trained by INNFA. It is planned that thenext round of treatment will reach 2 million people.

Without a robust and secure supply of quality albendazole this ambitiousdeworming programme would falter. MedPharm has generously helped tocover the cost of the drug and arranged additional donor support for thesame purpose.

16 Making it happen in Ecuador

High coverage wasobtained thanks to thecontribution of numerousvolunteers working forINNFA

The alliance betweenINFFA, MedPharm and itsphilanthropic partners andthe Government of Ecuadoris making deworminghappen in Ecuador

Dr Ximena Bohorquez de GutierrezFirst Lady of the Republic of Ecuador

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Hookworm and other helminth infections have long been known to haveadverse effects on maternal health and pregnancy outcomes. When widely-used, safety-tested anthelminthic drugs became available, a significant policychange was implemented. In areas endemic for hookworm infection,deworming after the first trimester of pregnancy has been demonstrated tobe safe and results in improvements in maternal health, in birth weight andin infant survival.

A randomized trial in Sierra Leone demonstrated the additive effect of ironand albendazole treatment in the improvement of haemoglobinconcentration in the third trimester of pregnancy. This was followed by amajor study in rural Nepal that demonstrated in a most convincing andcontrolled fashion that deworming greatly improves the health of allpregnant women and the birth weight and survival of their infants. Thestudy was carried out in the district of Sarlahi where three quarters of allpregnant women were infected with hookworm. Several thousand expectantmothers were registered in the study; most received micronutrientsupplements and were given a dose of albendazole in the second trimesterand another dose in the third trimester. The researchers demonstrated thatreceipt of albendazole in the second trimester was associated with asignificant decrease in the prevalence of severe anaemia in treated mothers,that the birth weight of babies from mothers given two doses of albendazolerose on average by 59g, and that the infant mortality rate at 6 months hadfallen by 41%.

A recent review also suggests that pregnant women and their newbornfetuses can suffer from the adverse effects of schistosomiasis. Praziquantelcan be safely given during pregnancy and should therefore be included inroutine deworming during antenatal care.

This work confirms that deworming as part of routine antenatal care is acost-effective strategy for reducing maternal anaemia that in turn hasbroader health benefits related to birth outcomes. Where anthelminthics areused in pregnancy, efforts should be made to set up a system ofpharmacovigilance for reporting any possible side effect on pregnancyoutcome.

17 Deworming for healthier mothers and infants

Anthelminthic treatmentafter the first trimesterof pregnancy benefitsmothers and infants

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Morbidity is directly related to worm burden. School-age children with thegreatest number of worms are assumed to be at greatest risk and areexpected to benefit most from deworming. Preschool children, whose wormburdens are housed in smaller bodies, are just as much at risk of diseaseand more at risk of death.

In young rural African children with prevalent helminth infections andmalnutrition, a placebo-randomized trial was conducted to measure theeffects of low-dose daily iron and/or 3-monthly deworming on growth, ironstatus and anemia, and development. Results showed that periodicdeworming after 12 months

• reduced mild wasting malnutrition by 62%• reduced the prevalence of small arm circumference by 71% in

children < 30 months• reduced moderate anaemia (Hb < 9 g/dl) by 59% in children

< 24 months• improved appetite by 48% in all children

In addition, periodic mebendazole had a positive effect on children’s motorand language development.

Young children are at higher risk of anaemia and wasting malnutrition andthus might be most vulnerable to the detrimental effects of worms. Thisunexpected significant reduction in wasting malnutrition and anaemia inchildren with light infections suggests that incident helminth infections in anon-immune population may stimulate immune responses that havedeleterious effects on protein metabolism, appetite and erythropoiesis. Theseeffects are large and potentially important to the development and survival ofyoung children and are presently being confirmed in a larger trial.

The benefits of deworming on malnutrition and anaemia in preschoolchildren have been demonstrated in recent studies from India and Nepal.The evidence calls for including young children also in control programmeswhere helminth infections are endemic. It is worth noting that these trialshave further confirmed the safety of deworming treatment in this age group.

18 Don’t forget the preschool children

Preschool childrendeserve to be dewormed

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Recife is the capital city of Pernambuco State and is a port located on thenorth-eastern coast of Brazil. About 1.5 million people live in the city and afurther 1.5 million in the metropolitan area. Many waterways divide the city,which has become known as the Venice of the Americas, into distinctdistricts. Some of these districts have become pockets of severe urbanpoverty where households have to endure frequent episodes of flooding.Despite the abundance of water around Recife many people have restrictedaccess to drinking water that may be available on only one day in three.

The Brazilian constitution declares that health is a right for all its citizens.Health is a government priority and the national health budget has beenincreased significantly in recent years. In Recife, the municipal authoritieshave concluded that improving the quality of the urban environment isessential if public health problems are to be resolved. A holistic approachhas been adopted for dealing with environmental issues and for providinghealth care to reduce poverty-related diseases such as lymphatic filariasisand leptospirosis. Deworming features prominently in this integrated driveto control disease and improve the environment for poor people in Recife.

The family health programme must go hand in hand with the environmentalhealth programme if benefits are to be gained and sustained. The zerohunger programme has proved to be a good entry point for delivering ahealth care package for the poorest families suffering from parasitic diseases.

19 Making it happen in Brazil

Source: Dr Tereza Maciel Lyra, Diretoria de Epidemiologia e Vigilância a Saúde,Secretaria Municipal de Saúdes, Recife, Brasil, 2004.

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Development is an optimistic word that evokes progress towards thepermanent release of poor people from poverty. The MDGs have beendevised to stimulate and guide efforts to reduce the never-ending dailyreality of poverty. The response of institutions established to eradicatepoverty involves planning and implementing a diverse set of programmes,including those for improving the health of the poor. Excellent advocacy hasraised awareness of malaria, TB and HIV/AIDS and ensured that thesedevastating diseases have attracted a major share of health resources.

The cost of treatments per patient for these three killer diseases contrastsdramatically with the cost of treatments per patient for worm-induceddisease. Calculations indicate that a bundle of diseases, includingschistosomiasis, soil-transmitted helminthiasis, onchocerciasis, lymphaticfilariasis, trachoma and vitamin A deficiency, can be controlled at costsranging from about US$ 1 to US$ 2.50 per patient. The infrastructure for thedelivery of such a package of health care to millions of poor people alreadyexists in many endemic areas through primary health care provision, publicand private schools, faith-based organizations and social institutions such asthe scout movement.

20 A pro-poor strategy

Source: D. Molyneux, Liverpool School of Tropical Medicine, 2004

Source: Molyneux, DH, Liverpool School of Tropical Medicine, 2004

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Adopting a multidisease control approach on the scale that is neededrequires good partners to emerge and work together. In addition to securingresources for disease control, partners should attend to five key features ofthis pro-poor strategy:

• networking needs to be strengthened between compatiblepartners

• proposals should be developed for integrated action wheregeographically and technically appropriate

• evidence for the cost-benefits of infectious disease control needsto be increased and circulated

• interaction between programmes at the country level should beencouraged

• the contribution that controlling infectious disease can make tothe attainment of MDGs should be promoted

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21 Deworming helps meet the MillenniumDevelopment Goals

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Page two of flyer

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Periodic chemotherapy with single dose anthelminthic drugs will be themainstay for helminth control in developing countries for some time. Untilnew drugs have been developed, tested and registered, it is essential tomake the best use of existing products. This is particularly important in lightof the increasing drug resistance of nematodes of livestock to anthelminthicproducts. Recent evidence suggests reduced efficacy of benzimidazolesagainst hookworm infections in humans after 13 rounds of treatments.

Assessment and monitoring of efficacy of anthelminthic drugs in areas wherethey are commonly used should be performed in a standard way so as towarn of possible treatment failures. In addition to the availablemeasurement of reduction in faecal egg count following treatment, tests suchas the Egg Hatch Assay have been developed to monitor benzimidazoleefficacy against human hookworms. A far more sensitive technique for drugefficacy monitoring would be the development of molecular probes withpolymerase chain reaction (PCR) techniques. Desirable research studies toidentify sensitive and resistant genes in worm populations are at an earlystage.

The creation of a global network for monitoring anthelminthic drug efficacy/resistance is a much needed response to this emerging threat. Such anetwork will depend on action by different partners with dedicated funding.A successful example is the concerted action on the use of praziquantel forthe treatment of schistosomiasis that is funded by the European Union andinvolves a forum of scientists and public health planners. In the praziquantelinitiative, the operational research component is tailored to health policyissues in endemic countries.

A human hookworm vaccine is being developed and tested by the HumanHookworm Vaccine Initiative. This public partnership consists of The GeorgeWashington University (Washington, DC), London School of Hygiene andTropical Medicine, and Oswaldo Cruz Foundation (Brazil) with programmemanagement sponsored by the Sabin Vaccine Institute (Washington, DC). Thelead candidate for the vaccine is ASP-2, an antigen from infective larvae thathas been selected for product development and clinical testing. It is expectedthat Phase 1 clinical trials for safety and immunogenicity will begin in thefirst quarter of 2005. Ultimately, proof-of-concept for the efficacy of theNa-ASP-2 Hookworm Vaccine to reduce hookworm burden and intestinalblood loss will be evaluated in a Phase 2b clinical trial in Minas Gerais State,Brazil.

22 New technology for sustaining deworming

Provision of tools to detectand monitor drugresistance

Preparation to safeguardanthelminthic efficacy

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Cambodia is one of the least developedcountries and has an under-five mortalityrate of 138/1000. Five years ago more than70% of Cambodian children were infectedwith intestinal worms. In July 2004Cambodia became the first country toprotect three out of four school-age children(nearly three million) with regularanthelminthic treatment against intestinalworms and reach WHO’s 2010 target sixyears ahead of schedule. Cambodia hasmade it happen.

Drugs are distributed across 24 Provinces bythousands of teachers. The campaigns wereconducted by the Cambodian Ministry ofHealth, Education and Sport, with thesupport of WHO, together with UNICEF, theJapanese Government and the Sasakawa Memorial Health Foundation. Thesuccess demonstrates what can be achieved when the political will is theretogether with financial support from donors and partners.

Deworming in Cambodian schools is promoted by the production anddistribution of a school kit, a package that includes deworming pills, healtheducation posters and pamphlets for teachers, games and attractivepictures for children giving simple messages on how to prevent infection.All this is possible at a cost of US$ 0.07 per child treated.

23 Making it happen in Cambodia

Political will drivesdeworming

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• Advocacy for sustaining the effort to control helminthiasis willrequire the latest and best information: the disease burdenregularly revised and expressed in terms of the most reliableDALYs available. In this exercise the incorporation of chronicdisabilities and coinfections should be considered.

• There is emerging evidence that concurrent worm infectionsmay have synergistic effects on the severity of malaria, theprogression of HIV/AIDS, and the development and effects ofanaemia. These interactions and potentially importantconsequences merit more extensive investigation.

• Impressive benefits of deworming on education, povertyreduction and contribution towards the MDGs have been putforward, though they need further quantification and widerdissemination.

• Further research on the possible use of 'packaging' dewormingwith other programmes is needed to sustain science-basedsynergy and integration with other programmes such as: PELF,vitamin A distribution campaigns, Child Health Days, malaria,Expanded Programme on Immunization.

• There is inconsistency between WHO recommendations and thedrug producers’ prescribing information. The WHOrecommendations are based on toxicological evidence presentedto experts at two informal consultations. The cost of undertakingthe extensive process required by regulatory bodies is beyondthe resources of WHO at present. Nevertheless, the full-scaletoxicological review expected of the pharmaceutical industryshould be undertaken. A pressing issue to be addressed is theneed to set up a reliable system for pharmacovigilance incommunity deworming campaigns.

• Sensitive molecular tools to monitor drug efficacy need to bedeveloped. To wait for drug resistance to occur before seekingfunds for research on drug efficacy monitoring might be too latean answer if this potential problem emerges.

• The possibility of development of new anthelminthic drugs andthe efficacy and safety of available drugs administered incombination should be evaluated.

• Availability of efficient vaccines would make a difference inhelminth control. Trials for the development of vaccines againstschistosomiasis and hookworms should be supported andcollaboration between research and control should beencouraged.

24 Questions needing answers

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Within the PPC, WHO has the role of technical agency and secretariat. Astechnical agency, WHO is developing strategies, tools and guidelines forparasite control and gives technical guidance and support for theimplementation of these strategies to the partners and countries wheneverthis is required. WHO is committed to partnership building, with particularemphasis on implementation at country level and in advocacy at all levels.As the secretariat of the PPC, WHO’s primary responsibility is to keep trackof the global epidemiological situation for parasite control and to monitorprogress towards the 2010 goals.

The PPC Newsletter is widely distributed and a website is available fromwhich guidelines and tools can be downloaded. WHO is also buildingregional and country capacity to strengthen implementation.

A PPC global data bank has been established to track progress towards the2010 target, and should be sustained with regular reporting of data from theendemic countries. Global data management requires a routine system totransmit the data from the country to regional and global levels. WHO hasprovided evidence as to how deworming helps to meet the MDGs, andprogress towards achieving them should be further documented. WHO, withthe help of its Collaborating Centres, is fostering global networking amongpartners to assist in their varied contributions to promote control, includingmonitoring anthelminthic drug efficacy and pharmacoviligance for adverseevents. Resources are needed from international agencies and public-privatedonors to make this happen.

At the end of 2004, deworming had reached close to 5-10% of globalcoverage and PPC partners have been indispensable in this good beginning.The initial burst of activity must be sustained. Expanding and maintaining ahigh yearly coverage is the major challenge for the future. In order to meetthe target of reaching at least 650 million children by 2010, dewormingshould become part of a multidisease control approach, with sustainedpolitical commitment on the part of national authorities.

25 WHO at the helm of the PPC

Web site:www.who.int/wormcontrol

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A letter from President Jimmy Carter was readat the opening of the meeting with a message ofinspirational exhortation to build and strengthenpartnerships for advancing the control of worm-induced disease. The resolution passed at the54th WHA has proved to be a landmark inmaking it happen.

Progress towards protecting at least three out ofevery four school-age children fromschistosomiasis and soil-transmittedhelminthiasis in countries where these diseasesare endemic has exceeded the most optimisticexpectations. Cambodia has reached its target sixyears early. Bhutan, Burkina Faso, Mali,Philippines, Sri Lanka, Uganda and Viet Nam are some of the manycountries that are firmly set on the path to reach the WHA’s target by 2010.

Worm control is succeeding where governments have established legislativeand structural support, where intersectoral collaboration is strong andwhere partners strive to provide and use resources to best effect. There is nouniversal paradigm or all-embracing plan. The PPC recognize that eachcountry must set its own health priorities and implement its own plansaccording to prevailing conditions. It accepts that partners must be flexible intheir responses to requests for support.

Control of these diseases is certainly moving onwards, but how may it moveupwards? How may deworming coverage be expanded and sustained?Perhaps the answer lies in a proposal to adopt a multidisease controlapproach that includes worms, malaria, TB and HIV/AIDS. Evidence isbeginning to suggest that the control and management of malaria, TB andHIV/AIDS may be less effective unless the insidious impact of concurrentworm infections is reduced.

Such infections thrive amongst the poorest of the poor and are a proxy forpoverty. WHO must be enabled to build and service partnerships for wormcontrol. Such an effort, particularly if it includes a multidisease approach,will support the drive to achieve the MDGs. This approach deserves highpriority because the poorest of the poor deserve it.

26 Onwards and upwards

Dr Kazem BehbehaniAssistant Director-GeneralExternal Relations and Governing Bodies

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Control

1. The partners are convinced that the control of worm-induced diseaseis a highly effective investment in terms of health, education, povertyreduction and development.

The partners RECOMMEND that this important message shouldbe vigorously promoted to governments, employers and labourorganizations.

2. The partners recognized that the significant benefits of deworming forwomen during the second and third trimesters of pregnancy and theirinfants merit wide promotion.

The partners RECOMMEND that an informal consultation shouldbe held to review use of anthelminthic drugs throughoutpregnancy and to advise on setting-up a system ofpharmacovigilance for reporting side effects.

3. The partners acknowledge that while funds for parasite control areavailable from the World Bank, utilization of these funds at country level isperceived to be complicated and difficult.

The partners RECOMMEND that guidance about how toapproach the World Bank for funding for school healthprogrammes should be compiled and distributed and that afocal person be identified to liaise with the World Bank andcountries to facilitate utilization of funds for parasite control.

4. The partners recognized that NGOs (international and national) haveresources and expertise for parasite control, and that governments couldengage more with NGOs in control enterprises.

The partners RECOMMEND that an NGO data file should becompiled to provide governments with information aboutsources of support for parasite control.

5. The partners accepted that approaches for the control of disease due tocestode and trematode infections and to infection with Strongyloidesstercoralis are essentially the same as for schistosomiasis and soil-transmitted helminthiasis.

The partners RECOMMEND that measures for the control ofcestodiasis, trematodiasis and strongyloidiasis should beincluded in health packages in places where these diseases areendemic.

27 Action points

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3 3 Report of the third PPC meeting -


Research

1. The partners were concerned with the urgent need to monitoraccurately and promptly all aspects of anthelminthic drug efficacy becausecontrol of worm-induced disease currently depends on the use of few drugs.

The partners RECOMMEND that every parasite control measureshould include systems for

(a) measuring drug efficacy;(b) monitoring for signs of possible drug resistance; and(c) reporting results.

Networks for sharing information and experience should beestablished, and methods for the early detection of drugresistance should be developed.

2. The partners agreed that current DALY values for the health impact ofschistosomiasis and soil-transmitted helminthiasis require regular revision toinclude new information.

The partners RECOMMEND that DALYs for these diseasesshould be recalculated and the results should be widelycirculated.

3. The partners are concerned that concurrent worm infections may havesynergistic effects on the development and effects of anaemia, and on theseverity and progression of malaria, TB and HIV/AIDS.

The partners RECOMMEND that these potentially importantconsequences be more extensively investigated.

4. The partners accept that the control of worm-induced disease wouldbenefit from research and development of new control tools.

The partners RECOMMEND that research for the developmentof anti-worm vaccines and combination therapy includingpyrantel and levamisole should be supported and carried out.

33� Report of the third PPC meeting


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Albonico M et al.2004. Monitoring drug efficacy and early detection of drugresistance in human soil-transmitted nematodes: a pressingpublic health agenda for helminth control. International Journalfor Parasitology, 34:1205-1210.

Awasthi S et al.2000. Effectiveness and cost-effectiveness of albendazole inimproving nutritional status of preschool children in urbanslums. Indian Pediatrics, 37:19-29.

Bleakley H2003. Disease and Development: Evidence from the AmericanSouth. Journal of the European Economic Association,1:376-386.

Bundy DAP et al.2005. School Health and Nutrition Programs. In: Disease ControlPriorities in Developing Countries. 2nd ed. World Bank andOxford University Press, in press.

Christian P et al.2004. Antenatal anthelminthic treatment, birthweight, andinfant survival in rural Nepal. The Lancet, 364:981-983.

Crompton DWT and Nesheim MC2002. Nutritional impact of intestinal helminthiasis during thehuman life cycle. Annual Review of Nutrition, 22:35-59.

De Silva NR et al.1999. Effect of mebendazole therapy during pregnancy on birthoutcome. The Lancet, 353:1145-1149.

Engels D and Savioli I2005. Public Health Strategies for Schistosomiasis Control. In:Secor & Colley, eds. World Class Parasites: Vol. 10:Schistosomiasis, New York.

Fincham JE et al.2003. Could control of soil-transmitted helminthic infectionsinfluence the HIV/AIDS pandemic. Acta Tropica, 86:315-333.

Hotez P et al.2005. Helminth infections. In: Disease Control Priorities inDeveloping Countries. 2nd ed. World Bank and OxfordUniversity Press, in press.

References

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Hotez P et al.2004. Hookworm infection. New England Journal of Medicine,351(8):799-807.

Khanal P and Walgate R2002. Nepal deworming programme ready to go worldwide.Bulletin of the World Health Organization, 80:423-424.

King C et al.2005. Re-gauging the cost of chronic helminthic infection: Metaanalysis of disability-related outcomes in endemicschistosomiasis. The Lancet, 365:1561-...

Kremer M2003. Randomized Evaluations of Educational Programs inDeveloping Countries: Some Lessons. American EconomicReview, 93:102-106

Miguel E and Kremer M2001. Worms: Identifying Impacts on Education and Health inthe Presence of Treatment Externalities. Forthcoming in:Econometrica, (NBER Working Paper 8481, 2001)

Molyneux DH2004. “Neglected” diseases but unrecognized successes –challenges and opportunities for infectious disease control.The Lancet, 364:380-383.

Molyneux DH and Nantulya VM2004. Linking disease control programmes in rural Africa:a pro-poor strategy to reach Abuja targets and millenniumdevelopment goals. British Medical Journal, 328:1129-1132.

Montresor A, Awasthi S, Crompton DWT2003. Use of benzimidazoles on children younger than24 months for the treatment of soil-transmitted helminthiasis.Acta Tropica, 86:223-232.

Olds GR2003. Administration of praziquantel to pregnant and lactatingwomen. Acta Tropica. 86:185-195.

Savioli L et al.2002. Schistosomiasis and soil-transmitted helminth infections:forging control efforts. Transactions of the Royal Society ofTropical Medicine and Hygiene, 96: 577-579.

Savioli L et al.2003. Use of anthelminthic drugs during pregnancy. AmericanJournal of Obstetrics and Gynecology,17:29-31.

Sinuon M et al.Financial costs of the national deworming programme inCambodia. Transactions of the Royal Society of TropicalMedicine and Hygiene, in press.

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Spiegel A et al.2003. Increased frequency of malaria attacks in subjectsco-infected by intestinal worms and Plasmodium falciparummalaria. Transactions of the Royal Society of Tropical Medicineand Hygiene, 97:198-199.

Stoltzfus RJ et al.2004. Low dose daily iron supplementation improves iron statusand appetite but not anemia, whereas quarterly anthelminthictreatment improves growth, appetite and anemia in Zanzibaripreschool children. Journal of Nutrition, 134:348-356.

World Health OrganizationReport of the WHO Informal Consultation on Hookworm Infectionand Anaemia in Girls and Women. Geneva 5-7 December 1994,Geneva, World HealthOrganization, 1996.Ref: WHO/CTD/SIP/96.1.http://www.who.int/wormcontrol/documents/publications/en/96-1.pdf

Document A54/10. Communicable diseases. Control ofSchistosomiasis and soil-transmitted helminth infections. Reportby the Secretariat to the Fifty-fourth World Health Assembly,Geneva, World Health Organization, 2001.

Resolution WHA54.19. Schistosomiasis and soil-transmittedhelminth infections. Geneva, World Health Organization, 2001.

Report of the WHO Informal Consultation on the use ofpraziquantel during pregnancy/lactation and albendazole/mebendazole in children under 24 months. Geneva 8-9 April2002, Geneva, World Health Organization, 2003Ref: WHO/CDS/CPE/PVC/2002.4.

How to add deworming to vitamin A distribution. Geneva,World Health Organization, 2004Ref: WHO/CDS/CPE/PVC/2004.11.

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Country representatives

BrazilDr Tereza Maciel Lyra, Diretoria de Epidemiologia e Vigilância aSaúde, Secretaria Municipal de Saúdes, rua Major Codeceira,194, Edificio Julião Paulo da Silva, Bairro Santo Amaro,50.100-070, Recife, PE, Brasil.Email: [email protected]

Burkina FasoDr Seydou Touré, Coordinator, National Schistosomiasis ControlProgramme, PNLSC, 06 BP 9103 Ouagadougou 06, Burkina Faso.Email: [email protected]

EcuadorThe First Lady of Ecuador, Dr Ximena Bohórquez de Gutiérrez,National President of the Instituto Nacional de la Niñez y laFamilia (INNFA), Venezuela 131 OE-4 y Sucre, Quito, Ecuador.Email: [email protected]

HondurasDr Concepción Zuniga Valeriano, Coordinador Programa deChagas y Leishmaniasis, Ministerio de Salud de Honduras,5to piso del edificio BANMA, Tegucigalpa, Honduras.Email: [email protected]

MyanmarDr Thet Thet Zin, Deputy Director (School Health), Department ofHealth, Ministry of Health, 27 Pyidaungsu Yeiktha Road, DagonPO 11191 Yangon, Myanmar.Email: [email protected]

NepalDr Sharada Pandey, Chief of Nutrition Section, Child HealthDivision, DHS/MoH, GPO No. 13458, Kathmandu, NepalEmail: [email protected]

PhilippinesDr Yvonne Lumampao, National Programme Manager forHelminth Control, Infectious Disease Office, Building 13,Department of Health, Sta Cruz, Manila, Philippines.Email: [email protected]

SomaliaDr Mohamed M. Ali-Fuje, Emerging Diseases Coordinator,c/o WHO Mogadishu sub-office, Somalia.Email: [email protected]; [email protected]

List of participants

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UgandaThe Hon. Jim Muhwezi, MP, Maj. Gen.(rtd), Minister of Health ofUganda

Dr Narcis Kabatereine, Vector Control Division, Ministry ofHealth, PO Box 7272, Kampala, Uganda.(generously supported by the SCI, London)

Dr Sam Zaramba, Director Health Services, Ministry of Health,PO Box 7272, Kampala, Uganda.Email: [email protected]

Viet NamDr Le Khanh Thuan, Director, National Institute of Malariology,Parasitology and Entomology, Ministry of Health, BC 10200Tulium, Hanoi, Viet Nam.Email: [email protected]

Government representatives

GermanyDr Assia Brandrup-Lukanow, Director of the Division, Health,Education and Social Protection, Deutsche Gesellschaft fürTechnische Zusammenarbeit (GTZ) GmbH, Dag-Hammarskjöld-Weg 1-5, Postfach 51 80, 65726 Eschborn, Germany.E-mail: [email protected]

ItalyMs Lucia Fiori, Counselor, Italian Mission to the United NationsOffice and other International Organizations at Geneva, cheminde l'Imperatrice 10, 1292 Chambésy, Switzerland.

Dr Giancarlo Majori, Istituto Superiore di Sanità, Laboratorio diParassitologia, Viale Regina Elena 299, 10016, Rome, Italy.Email: [email protected]

JapanMr Shinjiro Nozaki, Director, International Programme Division,Japan International Corporation of Welfare Services (JICWELS),Shinjuku Takasago Building 10F,16-5 Tomihisa-cho,Shinjuku-ku, Tokyo 162-0067, Japan.Email: [email protected]

Professor Tsutomu Takeuchi, School of Medicine, HashimotoInitiative, Department of Tropical Medicine and Parasitology,Keio University, 35 Shinanomachi Shinjuku,Tokyo, Japan.Email: [email protected]

United KingdomDr Rebecca Affolder, Human Development Policy Analyst,Secretariat to the Commission for Africa, 20 Victoria Street,London SW1 0NF, U.K.Email: [email protected]

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USADr James H. Maguire, Centers for Disease Control &Prevention, MS F-36, 4770 Buford Highway NE,Chamblee, GA 30341, USA.Email: [email protected]

Nongovernmental and other organizations

Fondation Project HOPEDr Bettina Schwethelm, Director, route des Coudres 60,1298 Céligny, Switzerland.Email: [email protected]

Dr Francisca Merino, Medical Adviser to Fondation Project HOPE.

Helen Keller InternationalDr Regina Moench-Pfanner, Regional Coordinator, Asia Pacific RegionalOffice, 20 Cross St., N°02-13, China Court, 048422 Singapore.Email: [email protected]

INMED Partnerships for ChildrenDr Thad M. Jackson, Executive Vice President, 45449 SevernWay, Suite 161, Sterling, VA 20166, USA.Email: [email protected]

International Federation of the Red Cross and Red Crescent SocietiesDr Elizabeth Mbizvo, Chemin des Crêts, P.O. Box 372,1211 Geneva 19, Switzerland.Email: [email protected]

Ivo de Carneri FoundationDr Alessandra Carozzi, V.le Monza 44, 20127 Milan, Italy.Email: [email protected]

Ms Deborah Cocorullo,Project Coordinator, V.le Monza 44, 20127 Milan, Italy.

Micronutrient InitiativeDr Erick Boy, Coordinator, Global Programs Unit,P.O. Box 56127, 250 Albert Street, Ottawa, Ontario,Canada K1R 7Z1.Email: [email protected]

Partnership for Child DevelopmentDr Celia Maier, Imperial College School of Medicine, University ofLondon, St Mary's Campus, Norfolk Place, London W2 1PG, UK.Email: [email protected]

PanAmerican Health and Education FoundationMs J. Gersky, PanAmerican Health & Education Foundation,525 23rd Street N.M., Washington, DC 200037-2895,USA.Email: [email protected]

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RISEALDr Bertrand Sellin, Saint Mathurin, 56270 Ploemeur, France.Email: [email protected][RISEAL: Réseau International Schistosomoses, Environnement,Aménagement et Lutte]

Save the Children USADr Karin Lapping, School Health and Nutrition Advisor,54 Wilton Road, Westport, CT 06880, USA.Email: [email protected]

Dr Natalie Roschnik, 191 Coldhams Lane,Cambridge CB1 3HY, UK.Email: [email protected]

Schistosomiasis Control InitiativeDr Alan Fenwick, Executive Director, Department of InfectiousDisease Epidemiology, Faculty of Medicine, Imperial CollegeLondon, St Mary’s Campus, Norfolk Place, London W21PG, UK.Email: [email protected]

Dr James Hammersley, Department of Infectious DiseaseEpidemiology, Imperial College London, St Mary's Campus,Norfolk Place, London W2 1PG, UK.Email: [email protected]

Mr James Howard Thompson, Department of Infectious DiseaseEpidemiology, Faculty of Medicine, Imperial College London,St Mary’s Campus, Norfolk Place, London W21PG, UK.Email: [email protected]

World Scout BureauMr David Wanstall, U.N. Representative in Geneva to theOrganization of the World Scout Movement, c/o World ScoutBureau, Rue du Pré-Jérôme 5, PO Box No. 241, 1211 Geneva 4,Switzerland.Email: [email protected]

UN specialized agencies

UNICEFDr Kopano Mukelabai, Senior Health Advisor, Health Section,Programme Division, Three United Nations Plaza, New York,NY 10017, USA.Email: [email protected]

UNICEF - EASRODr Saba Mebrahtu, Regional Nutrition Advisor, Eastern andSouthern Africa Regional Office, Box 44145, Nairobi 00100, Kenya.Email: [email protected]

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UNICEF - NepalDr Pragya Mathema, Project Officer, Nutrition and Care Section,UN House, Pulchowk, Nepal.Email: [email protected]

United Nations System Standing Committee on NutritionDr Roger Shrimpton, Secretary, c/o World Health Organization,20 Avenue Appia, 1211 Geneva 27, Switzerland.Email: [email protected]

WFPMs Rita Bhatia, Public Health Nutrition, Via Cesare Giulio Viola,68/70 Parco de’Medici, 00148, Rome, Italy.Email: [email protected]

Dr Nandiguim Kamnadji, 10 Avenue Pasteur, X Rue Galliéne, BP6288, Dakar Etoile, Dakar, Senegal.Email: [email protected]

Ms Arlene Mitchell, School Feeding Programme, Via CesareGiulio Viola, 68/70 Parco de’Medici, 00148, Rome, Italy.Email: [email protected]

Universities/Institutes

Dr Parul ChristianJohns Hopkins Bloomberg School of Health, Department ofInternational Health, 615 N Wolfe Street, Room 2041, Baltimore,MD 21205, USA.Email: [email protected][Temporary WHO Adviser]

Dr Theresa GyorkosMcGill University, Associate Professor, Department ofEpidemiology and Biostatistics, Division of ClinicalEpidemiology, The Montreal General Hospital, McGill University,1650 Cedar Avenue, Montreal, Quebec, Canada H3G 1A4.Email: [email protected]

Dr Paul HaganUniversity of Glasgow, Institute of Biomedical and Life Sciences,Glasgow G12 8QQ, UK.Email: [email protected]

Dr Peter HotezThe George Washington University, Department of Microbiologyand Tropical Medicine, Ross Hall, Suite 736, 2300 I St. NW,Washington, DC 20037, USA.Email: [email protected]

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Dr Dean JamisonDepartments of Education and Community Health Sciences,UCLA, 405 Hilgard Avenue, Los Angeles, CA 90024-1487, USA.Email: [email protected]

Dr Charles KingCase Western Reserve University, Center for Global Health andDisease, School of Medicine, Wolstein 4126, 19000 EuclidAvenue, Cleveland, Ohio 44106-1286, USA.Email: [email protected][Temporary WHO Adviser]

Dr Pascal MagnussenDanish Bilharziasis Laboratory, Department of Public Health,Jaegersborg Allé 1 D, 2920 Charlottenlund, Denmark.Email: [email protected]

Dr Santiago Mas-ComaPresident of the European Federation of Parasitologists (EFP),University of Valencia, Director, Department of Parasitology,Faculty of Pharmacy, Av. Vicente Andrés Estellés s/n Burjassot,46100 Valencia, Spain.Email: [email protected]

Dr David MolyneuxLiverpool School of Tropical Medicine, Lymphatic FilariasisSupport Centre, Pembroke Place, Liverpool L3 5QA, UK.Email: [email protected].

Dr Niels ØrnbjergDanish Bilharziasis Laboratory, Jaegersborg Allé 1D, 2920Charlottenlund, Denmark.Email: [email protected]

Dr Eric OttesenEmory Lymphatic Filariasis Support Center, Department ofInternational Health,1518 Clifton Road, Atlanta, GA 30322, USA.Email: [email protected]

Dr Richard SpeareJames Cook University, School Of Public Health and TropicalMedicine, Townsville 4811, Australia.Email: [email protected]

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Observers Day 1 only

GlaxoSmithKlineDr Mark Bradley, CS12-126, GSK House, 980 Great West Road,Brentford, Middlesex TW8 9GS, UK.Email: [email protected]

Dr Mark Felton, Director, Diseases of the Developing World,Anti-infectives MDS, Greenford Road, Greenford, MiddlesexUB6 0HE, UK.Email: [email protected]

Dr Didier Lapierre, Infectious Diseases, MDC Europe, GreenfordRoad, Greenford, Middlesex UB6 0HE, UK.Email: [email protected]

International Dispensary AssociationMs Connie van Marrewijk, Marketing Manager, PO Box 37098,1030 AB Amsterdam, Netherlands.Email: c/o [email protected]

Johnson & JohnsonDr Anu Gupta, Director, Corporate Contributions, One Johnson &Johnson Plaza, New Brunswick, NJ 08933, USA.Email: [email protected]

MedPharmDr Andrew Koval, President & CEO, 1101 King Street,Suite No. 360, Alexandria, VA 22314, USA.Email: [email protected]; [email protected]

Novartis PharmaDr Chantal Laburte, Drug Regulatory Affairs, Postfach,4001 Basel, Switzerland.Email: [email protected]

Pfizer IncDr Charles Knirsch, Therapeutic Head, Anti-infectives, WorldWide Medical, 235 East 42nd Street, New York,NY 10017-5755, USA.Email: [email protected]

Shinpoong Pharm Co LtdDr Won-June Chang, Director, Planning Department,772 Yoksam-dong, Kangnam-ku, Seoul, Korea.Email: [email protected]

Dr Byung Yong Kim, 772 Yoksam-dong, Kangnam-ku, Seoul, Korea.

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Invited but unable to attend

Asian Centre for International Parasite ControlProf Somei Kojima, 5th floor, Hospital Building (T Building),Faculty of Tropical Medicine, Mahidol University,420/6 Rachawithi Road, Bangkok 10400, Thailand.Email: [email protected]

Asian Development BankDr Vincent de Wit, Regional and Sustainable DevelopmentDepartment, 6ADB Avenue, Mandaluyong City, 0401 Metro Manila,Philippines. Postal Address PO Box 789, 0980 Manila, Philippines.Email: [email protected]

BelgiumDr Jacques Laruelle, Public Health -BADC/AGCD, Direction of theMultilateral Cooperation, Office of the U.N., Belgian Administration forDevelopment Cooperation, 6 rue Brederode, 1000 Brussels, Belgium.Email: [email protected]

Dr Simon BrookerLondon School of Hygiene & Tropical Medicine, Department ofInfectious and Tropical Diseases, Keppel Street,London WC1E 7HT, UK.Email: [email protected]

Dr Yankum DadzieChair, Lymphatic Filariasis Technical Advisory Group and GlobalAlliance for the Elimination of Lymphatic Filariasis,P.O. Box 0S 1905, Osu, Accra, Ghana.Email: [email protected]

International Committee of the Red CrossDr Eric Burnier, Specialist in Tropical Medicine, Health ServicesUnit, 19 Avenue de la Paix, 1202 Geneva, Switzerland.Email: [email protected]

Thrasher Research FundDr A. Dean Byrd, President, Gateway Tower West, 15 WestSouth Temple Street, Suite 1650, Salt Lake City, UT 84101, USA.Email: [email protected]

WHO Regional Office for the Eastern MediterraneanDr Nikolai Neouimine, STP/CEE, WHO Post Office, Abdul RazzakAl Sanhouri Street, Naser City, Cairo, Egypt.Email: [email protected]

World BankDr Donald Bundy, Lead Specialist, School Health and Nutrition,1818 H Street NW, Washington, DC 20433, USA.Email: [email protected]

YemenDr Saeed Mohammed Al-Sheibani, Director of the Central HealthLaboratory, Sana'a, Yemen.

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WHO Regional offices

AfricaDr Jean-Baptiste Roungou, Other Tropical Diseases, Division ofPrevention and Control of Communicable Diseases,Parirenyatwa Hospital, P.O. Box BE 773, Harare, Zimbabwe.Email: [email protected]

AmericasDr Steven Ault, Regional Ecologist, Communicable Diseases Unit,Area of Disease Prevention and Control, PAHO/WHO Programfor the Elimination of Lymphatic Filariasis in the Americas,OPAS/OMS, SEN Lote 19, Brasilia, DF, Brasil CEP 70800-400.Email: [email protected])[representing AMRO, Communicable Diseases Unit, 525, 23rdStreet, NW, Washington, DC 20037, USA]

South-East AsiaDr E.A. Padmasiri, STP, Communicable Disease Surveillance andResponse, World Health House, Indraprastha Estate, MahatmaGandhi Road, New Delhi 110002, India.Email: [email protected]

Western PacificDr Antonio Montresor, Public Health Specialist, Vector-borne andother Parasitic Diseases, WHO, 63 Tran Hung Dao Street, PO Box52, Ha Noi, Viet Nam.Email: [email protected][representing WPRO, Malaria, other Vectorborne and ParasiticDiseases Programme, PO Box 2932, 1099 Manila, Philippines]

WHO Secretariat

Dr A. Asamoa-BaahAssistant Director-General, Communicable Diseases

Dr M. Albonico, Co-RapporteurTemporary Adviser

Ms H. AllenStrategy Development and Monitoring for Parasitic Diseases andVector Control

Dr K. BehbehaniAssistant Director-General, External Relations and Governing Bodies

Dr B. de BenoistNutrition for Health and Development

Dr J. BilousExpanded Programme on Immunization

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Dr R. BosWater, Sanitation and Health

Dr V. Chandra-MouliChild and Adolescent Health and Development

Dr R. CarrWater, Sanitation and Health

Dr L. ChitsuloUNDP/WB/WHO Special Programme for Research and Trainingin Tropical Diseases

Dr D.W.T. Crompton, Co-RapporteurTemporary Adviser

Dr H. EndoDirector, Communicable Diseases Control, Preventionand Eradication

Dr D. EngelsStrategy Development and Monitoring for Parasitic Diseasesand Vector Control

Dr R. GrayEssential Drugs and Medicines Policy

Dr H. HogerzeilEssential Drugs and Medicines Policy

Dr J. Y. KimDirector, HIV/AIDS

Dr J. Lazdins-HeldsUNDP/WB/WHO Special Programme for Research and Trainingin Tropical Diseases

Dr S. MariottiBlindness and Deafness

Dr C. MathersAssessing Health Needs, Epidemiology and Burden of Disease

Dr V. NantulyaThe Global Fund

Dr J. PhumaphiAssistant Director-General, Family and Community Health

Dr J. RemmeUNDP/WB/WHO Special Programme for Research and Trainingin Tropical Diseases

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Dr L. Savioli, SecretaryStrategy Development and Monitoring for ParasiticDiseases and Vector Control

Dr J. SommerfeldUNDP/WB/WHO Special Programme for Research and Trainingin Tropical Diseases

Dr T. UketyBlindness and Deafness

Dr J. VandelaerImmunization, Vaccines and Biologicals

Dr J. YarteyMaking Pregnancy Safer

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CIDA Canadian International Development AgencyDALY Disability-Adjusted Life YearDBL Danish Bilharziasis LaboratoryDFID United Kingdom Department for International DevelopmentFRESH Focusing Resources on Effective School HealthHIV/AIDS Human immunodeficiency virus/Acquired immunodeficiency

syndromeIMCI Integrated Management of Childhood IllnessINNFA Insituto Nacional de la Ninez y la FamiliaMDGs Millennium Development GoalsMOH Ministry of HealthNGOs Nongovernmental organizationsNIDs National immunization daysPCR Polymerase chain reactionPEAP Poverty eradication action planPELF Programme to Eliminate Lymphatic FilariasisPPC Partners for Parasite ControlSCI Schistosomiasis Control InitiativeSHN School Health and NutritionTB TuberculosisUN United NationsUNHCR Office of the United Nations High Commissioner for RefugeesUNICEF United Nations Children's FundUSAID United States Agency for International DevelopmentWFP Word Food ProgrammeWHA World Health AssemblyWHO World Health Organization

List of acronyms

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Annex: Thinking beyond deworming

Lancet cover page and article

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WHO CDS CPE PVC 2005.14.pdf

Documents

Transcript of WHO CDS CPE PVC 2005.14.pdf