Abstract
SummaryBackgroundSchool-based deworming programmes can reduce morbidity attributable to soil-transmitted helminths in children but do not interrupt transmission in the wider community. We assessed the effects of alternative mass treatment strategies on community soil-transmitted helminth infection.MethodsIn this cluster-randomised controlled trial, 120 community units (clusters) serving 150 000 households in Kenya were randomly assigned (1:1:1) to receive albendazole through annual school-based treatment targeting 2–14 year olds or annual or biannual community-wide treatment targeting all ages. The primary outcome was community hookworm prevalence, assessed at 12 and 24 months through repeat cross-sectional surveys. Secondary outcomes were Ascaris lumbricoides and Trichuris trichiura prevalence, infection intensity of each soil-transmitted helminth species, and treatment coverage and costs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02397772.FindingsAfter 24 months, prevalence of hookworm changed from 18·6% (95% CI 13·9–23·2) to 13·8% (10·5–17·0) in the annual school-based treatment group, 17·9% (13·7–22·1) to 8·0% (6·0–10·1) in the annual community-wide treatment group, and 20·6% (15·8–25·5) to 6·2% (4·9–7·5) in the biannual community-wide treatment group. Relative to annual school-based treatment, the risk ratio for annual community-wide treatment was 0·59 (95% CI 0·42–0·83; p<0·001) and for biannual community-wide treatment was 0·46 (0·33–0·63; p<0·001). More modest reductions in risk were observed after 12 months. Risk ratios were similar across demographic and socioeconomic subgroups after 24 months. No adverse events related to albendazole were reported.InterpretationCommunity-wide treatment was more effective in reducing hookworm prevalence and intensity than school-based treatment, with little additional benefit of treating every 6 months, and was shown to be remarkably equitable in coverage and effects.FundingBill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children's Investment Fund Foundation.
Highlights
In 2012, the London Declaration on neglected tropical diseases announced a cross-sectoral commitment to control or eliminate ten neglected tropical diseases by 2020, on the basis of WHO roadmap targets.[1]
For soil-transmitted helminths, the target is to provide regular anthelmintic treatment to at least 75% of children aged 1–14 years in districts where prevalence of any soil-transmitted helminth infection exceeds 20% in schoolchildren, with a view to controlling the morbidity associated with infection.[2]
We originally planned to do the trial in two contrasting settings, but financial and practical considerations meant we prioritised work in Kwale, which had benefited from previous mass drug administration for lymphatic filariasis
Summary
In 2012, the London Declaration on neglected tropical diseases announced a cross-sectoral commitment to control or eliminate ten neglected tropical diseases by 2020, on the basis of WHO roadmap targets.[1]. Mathe matical models suggest that community-wide treatment can interrupt soil-transmitted helminth transmission[4,5] and a meta-analysis suggests it would be more effective than school-based treatment in reducing infection among school-age children.[6]. Other neglected tropical disease programmes, including those against onchocerciasis, trachoma, and lymphatic filariasis, have achieved treatment of entire comm unities with community health workers or volunteers, using central point or house-to-house delivery models. In addition to providing a platform for reducing community infection levels, these programmes might provide an important gateway to universal health coverage, through
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