Including women in deworming the world

Abstract

“Every girl and every woman of a reproductive age who is infected with soil-transmitted helminths has the right to be treated.” That is the opening line of The Bellagio Declaration, a commitment made in 2017 by a WHO Advisory Group that aimed to promote the inclusion of women and girls in deworming programmes. According to the 2020 WHO Progress Report, an estimated 108 million adolescent girls and 138·8 million pregnant women require treatment for at least one of the soil-transmitted helminths—Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm), and Necator americanus and Ancylostoma duodenale (hookworms). However, only 23% of pregnant women at-risk of these infections received deworming treatment in 2019. The global effort to control helminth infections over the past two decades has relied on school-based mass drug administration (MDA) campaigns using donated anthelmintics. In India, the first of the biannual National Deworming Day takes place each year on Feb 10, and involves administering a single oral dose of albendazole to approximately 250 million children aged 1–19 years, which has substantially reduced the prevalence and intensity of soil-transmitted helminth infections in the country. African countries with MDA programmes have seen similar progress: soil-transmitted helminth prevalence decreased from 44% in 2000 to 13% in 2018, and prevalence of childhood schistosomiasis reduced by 58·3% over the past decade across the continent. These deworming efforts have set a solid foundation to control helminth infections, but the 2030 target of eliminating soil-transmitted helminths among children will not be met if women and girls continue to be underserved. Part of the problem is that girls and women are a difficult to reach population. In 2016, 69·5% of school children (aged 5–14 years) received deworming treatment for soil-transmitted helminths, whereas only 18·5% of women of a reproductive age were reached. On Feb 1, WHO launched a policy paper outlining recommendations to expand deworming programmes to adolescent girls and women of reproductive age. The report calls for deworming interventions to be integrated into general health-related consultations that these groups attend, such as receiving the human papillomavirus vaccination for adolescent girls and attending antenatal and postnatal appointments for pregnant and lactating women. Deworming of pregnant women in endemic countries is particularly important because of the health risks that helminth infections pose during pregnancy—notably, anaemia and impairment of nutrient uptake. However, many countries do not have a policy for deworming pregnant women, despite the donated anthelmintics—albendazole, mebendazole, and praziquantel—being safe to use after the first trimester. Integrating deworming practices into health care for pregnant women has been successful in Cambodia, where the prevalence of helminth-associated anaemia during pregnancy reduced from more than 20% in 2004 (when deworming coverage was 11%) to 3% in 2014 (when coverage had increased to 72%). By contrast, only 2·8% of pregnant women received deworming treatment during their last pregnancy in 2013 in Peru, despite helminth-associated anaemia being identified as a public health problem by PAHO. Current and consistent data reporting the deworming of women and girls are scarce for many countries. A systematic review and meta-analysis of 128 schistosomiasis studies found that girls were under-represented in the research. This under-representation could be due to the widespread practice of prevalence surveys being school based, which can miss important groups such as adolescent girls and adults in high-risk occupations. This issue of The Lancet Microbe features a study of an outbreak of dracunculiasis in Chad where women accounted for 59% of the confirmed cases. Control of Dracunculus medinensis is not done through MDA, however, this example highlights how gender-aggregated data can inform targeted helminth control. Establishing a deworming programme for girls and women is difficult. However, targeting these groups through existing health-care services can substantially improve helminth-associated morbidity and newborn mortality. Ministries of health should promote the message that deworming is safe during pregnancy, and existing school-based deworming programmes should consider integrating women into their strategy. Failure to do so will facilitate the life cycles of helminths and damage the right that women and girls have to deworming treatment. Sustainable access to deworming drugs in a changing landscapeThe global effort to control and eliminate soil-transmitted helminthiasis (STH) currently depends on donations of albendazole and mebendazole, which reached more than 530 million children in 2016. As we approach 2020, the WHO goal of eliminating STH as a public health problem will not be met in most endemic countries, and ongoing treatment will be necessary. Additionally, the volume of drugs required might increase because global strategies for STH aim to interrupt transmission. Under the 2012 London Declaration on Neglected Tropical Diseases, pharmaceutical company commitments to donate drugs to control or eliminate neglected tropical diseases extend to 2020. Full-Text PDF