Abstract
Recent debates about deworming school-aged children in East Africa have been described as the 'Worm Wars'. The stakes are high. Deworming has become one of the top priorities in the fight against infectious diseases. Staff at the World Health Organization, the Gates Foundation and the World Bank (among other institutions) have endorsed the approach, and school-based treatments are a key component of large-scale mass drug administration programmes. Drawing on field research in Uganda and Tanzania, and engaging with both biological and social evidence, this article shows that assertions about the effects of school-based deworming are over-optimistic. The results of a much-cited study on deworming Kenyan school children, which has been used to promote the intervention, are flawed, and a systematic review of randomized controlled trials demonstrates that deworming is unlikely to improve overall public health. Also, confusions arise by applying the term deworming to a variety of very different helminth infections and to different treatment regimes, while local-level research in schools reveals that drug coverage usually falls below target levels. In most places where data exist, infection levels remain disappointingly high. Without indefinite free deworming, any declines in endemicity are likely to be reversed. Moreover, there are social problems arising from mass drug administration that have generally been ignored. Notably, there are serious ethical and practical issues arising from the widespread practice of giving tablets to children without actively consulting parents. There is no doubt that curative therapy for children infected with debilitating parasitic infections is appropriate, but overly positive evaluations of indiscriminate deworming are counter-productive.
Highlights
Analysing data collected from primary schools in Kenya’s Busia County during 1998 and 1999, their results indicated a reduction in absenteeism of 25%, following deworming with albendazole at 6-month intervals for soil-transmitted helminths and with praziquantel once a year for intestinal schistosomiasis (S. mansoni)
Once again, citing Miguel and Kremer’s work in Kenyan schools, and highlighting on-going deworming programmes in East Africa, the report explained that the key intervention adopted by the Partners for Parasite Control (PPC) is morbidity control based on the delivery of regular anthelminthic treatment to high-risk groups, including school-aged children, in endemic countries
Almost any organism will respond to a selective drug pressure by developing resistance over time, and it hard to see how a decline in helminth infections as a result of mass treatments with albendazole and ivermictin could be maintained without indefinite distributions, unless there is a reduction in the risks of re-infection
Summary
Given the emphasis that has been placed on deworming in African schools, the evidence that it is an effective public health strategy is surprisingly weak. Analysing data collected from primary schools in Kenya’s Busia County during 1998 and 1999, their results indicated a reduction in absenteeism of 25%, following deworming with albendazole at 6-month intervals for soil-transmitted helminths and with praziquantel once a year for intestinal schistosomiasis (S. mansoni). They did not find an improvement in academic attainment, but they did find that deworming ‘substantially improved health and school participation among untreated children in both treatment schools and neighbouring schools’
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