(S)WASH-D for Worms: A pilot study investigating the differential impact of school- versus community-based integrated control programs for soil-transmitted helminths.

Naomi E Clarke,Archie C A Clements,James S Mccarthy,John Mcgown,Salvador Amaral,Susana V Nery,Darren J Gray,Alice Richardson,Stuart Bryan

doi:10.1371/journal.pntd.0006389

Abstract

BackgroundSoil-transmitted helminths (STH) infect nearly 1.5 billion individuals globally, and contribute to poor physical and cognitive development in children. STH control programs typically consist of regular delivery of anthelminthic drugs, targeting school-aged children. Expanding STH control programs community-wide may improve STH control among school-aged children, and combining deworming with improvements to water, sanitation and hygiene (WASH) may further reduce transmission. The (S)WASH-D for Worms pilot study aims to compare the differential impact of integrated WASH and deworming programs when implemented at primary schools only versus when additionally implemented community-wide.Methodology/Principal findingsA two-arm, non-randomized cluster intervention study was conducted. Six communities were identified by partner WASH agencies and enrolled in the study. All communities received a school-based WASH and deworming program, while three additionally received a community-based WASH and deworming program. STH infections were measured in school-aged children at baseline and six months after deworming. Over 90% of eligible children were recruited for the study, of whom 92.3% provided stool samples at baseline and 88.9% at follow-up. The school WASH intervention improved school sanitation, while the community WASH intervention reduced open defecation from 50.4% (95% CI 41.8–59.0) to 23.5% (95% CI 16.7–32.0). There was a trend towards reduced odds of N. americanus infection among children who received the community-wide intervention (OR 0.42, 95% CI 0.07–2.36, p = 0.32).ConclusionsThis pilot study provides proof of principle for testing the hypothesis that community-wide STH control programs have a greater impact on STH infections among children than school-based programs, and supports the rationale for conducting a full-scale cluster randomized controlled trial. High recruitment and participation rates and successful implementation of school WASH programs demonstrate study feasibility and acceptability. However, eliminating open defecation remains a challenge; ongoing work is required to develop community sanitation programs that achieve high and sustainable latrine coverage.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12615001012561

Highlights

Soil-transmitted helminthiases–caused by roundworm (Ascaris lumbricoides), hookworm (Necator americanus, Ancylostoma duodenale, and Ancylostoma ceylanicum) and whipworm (Trichuris trichiura)–constitute the world’s most common parasitic diseases of humans, with an estimated 1.45 billion people affected globally [1]
The (S)WASH-D for Worms pilot study aims to compare the differential impact of integrated WASH and deworming programs when implemented at primary schools only versus when implemented community-wide
There was a trend towards reduced odds of N. americanus infection among children who received the community-wide intervention

Summary

Introduction

Soil-transmitted helminthiases–caused by roundworm (Ascaris lumbricoides), hookworm (Necator americanus, Ancylostoma duodenale, and Ancylostoma ceylanicum) and whipworm (Trichuris trichiura)–constitute the world’s most common parasitic diseases of humans, with an estimated 1.45 billion people affected globally [1]. Heavy STH infections are associated with iron-deficiency anaemia, poor growth, and impaired cognitive development [2], despite recent controversy over the benefits of treatment in terms of morbidity reversal [3]. Children are believed to suffer the majority of STH-associated morbidity, partly due to a peak in A. lumbricoides and T. trichiura prevalence and infection intensity among school-aged children [2]. Regular distribution of anthelminthic drugs, aiming to reduce morbidity, is the cornerstone of STH control programs, as advocated by the World Health Organization (WHO) [5]. STH control programs typically consist of regular delivery of anthelminthic drugs, targeting school-aged children. Expanding STH control programs community-wide may improve STH control among school-aged children, and combining deworming with improvements to water, sanitation and hygiene (WASH) may further reduce transmission. The (S)WASH-D for Worms pilot study aims to compare the differential impact of integrated WASH and deworming programs when implemented at primary schools only versus when implemented community-wide

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