State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study.

BACKGROUND: Mass deworming against soil-transmitted helminthiasis, which affects 1 billion of the poorest people globally, is one of the largest public health programmes for neglected tropical diseases, and is intended to be equitable. However, the extent to which treatment programmes for deworming achieve equitable coverage across wealth class and sex is unclear and the public health metric of national deworming coverage does not include representation of equity. This study aims to measure both coverage and equity in global, national, and subnational deworming to guide future programmatic evaluation, investment, and metric design. METHODS: We used nationally representative, geospatial, household data from Demographic and Health Surveys that measured mother-reported deworming in children of preschool age (12-59 months). Deworming was defined as children having received drugs for intestinal parasites in the previous 6 months before the survey. We estimated deworming coverage disaggregated by geography, wealth quintile, and sex, and computed an equity index. We examined trends in coverage and equity index across countries, within countries, and over time. We used a regression model to compute the household correlates of deworming and ecological correlates of equitable deworming. FINDINGS: Our study included 820 883 children living in 50 countries from Africa, the Americas, Asia, and Europe that are endemic for soil-transmitted helminthiasis using 77 Demographic and Health Surveys from December, 2003, to October, 2017. In these countries, the mean deworming coverage in preschool children was estimated at 33·0% (95% CI 32·9-33·1). The subnational coverage ranged from 0·5% to 87·5%, and within-country variation was greater than between-country variation. Of the 31 countries reporting that they reached the WHO goal of more than 75% national coverage, 30 had inequity in deworming, with treatment concentrated in wealthier populations. We did not detect systematic differences in deworming equity by sex. INTERPRETATION: Substantial inequities in mass deworming programmes are common as wealthier populations have consistently higher coverage than that of the poor, including in countries reporting to have reached the WHO goal of more than 75% national coverage. These inequities seem to be geographically heterogeneous, modestly improving over time, with no evidence of sex differences in inequity. Future reporting of deworming coverage should consider disaggregation by geography, wealth, and sex with incorporation of an equity index to complement the conventional public health metric of national deworming coverage. FUNDING: Bill & Melinda Gates Foundation, Stanford University Medical Scientist Training Program.

Spiritual Themes and Challenges in Global Health.

Although the importance of spirituality is increasingly recognized in clinical medicine, spirituality is rarely mentioned in the practice, literature, or training programs of global health. To understand the role of spirituality in global health practice and identify factors that influence and limit its expression, I initiated conversations and informal interviews with more than 300 global health leaders, students, and practitioners during 2010-2014. Four spiritual themes or challenges emerged: compassion at a distance; dichotomous thinking; conspiracy of silence; and compulsion to save the world. Practitioners expressed strong interest in bringing spirituality more fully into global health discourse, which could help the field realize its potential.

A call to strengthen the global strategy against schistosomiasis and soil-transmitted helminthiasis: the time is now.

In 2001, the World Health Assembly (WHA) passed the landmark WHA 54.19 resolution for global scale-up of mass administration of anthelmintic drugs for morbidity control of schistosomiasis and soil-transmitted helminthiasis, which affect more than 1·5 billion of the world's poorest people. Since then, more than a decade of research and experience has yielded crucial knowledge on the control and elimination of these helminthiases. However, the global strategy has remained largely unchanged since the original 2001 WHA resolution and associated WHO guidelines on preventive chemotherapy. In this Personal View, we highlight recent advances that, taken together, support a call to revise the global strategy and guidelines for preventive chemotherapy and complementary interventions against schistosomiasis and soil-transmitted helminthiasis. These advances include the development of guidance that is specific to goals of morbidity control and elimination of transmission. We quantify the result of forgoing this opportunity by computing the yearly disease burden, mortality, and lost economic productivity associated with maintaining the status quo. Without change, we estimate that the population of sub-Saharan Africa will probably lose 2·3 million disability-adjusted life-years and US$3·5 billion of economic productivity every year, which is comparable to recent acute epidemics, including the 2014 Ebola and 2015 Zika epidemics. We propose that the time is now to strengthen the global strategy to address the substantial disease burden of schistosomiasis and soil-transmitted helminthiasis.

A survey of treatment practices and burden of lymphoedema in Togo.

Lymphatic filariasis, a mosquito-borne parasitic disease, can lead to lymphoedema and elephantiasis. This study describes the results of a baseline survey of a lymphoedema morbidity management programme in Togo. A convenience sample of 188 people with lymphoedema was asked about symptoms, treatment preferences and quality of life. Those with higher stage lymphoedema were more likely to have experienced an acute attack (odds ratio=1.9; P=0.002). Although only 28.2% of those surveyed reported currently using any lymphoedema treatment, 80.3% had used treatments in the past, primarily traditional products (68.1%) and scarification (38.8%). Medication was the preferred treatment for acute attacks, both currently (73.1%) and in the past (61.7%). Patients reported difficulties performing activities such as walking to the field (44%) and carrying a heavy load (63%) as a result of their lymphoedema. Patients felt avoided by their family (17%) and their community (36%). Using the Duke Anxiety-Depression scale, over 70% of patients were found to be at high risk of depression and this risk increased with lymphoedema stage (P=0.04). The survey results demonstrate the need for a morbidity management programme that will increase the use of morbidity management techniques and decrease the physical and emotional burden of this disease.