The global progress of soil-transmitted helminthiases control in 2020 and World Health Organization targets for 2030.

Soil-transmitted helminth (STH) infections are the most widespread of the neglected tropical diseases, primarily affecting marginalized populations in low- and middle-income countries. More than one billion people are currently infected with STHs. For the control of these infections, the World Health Organization (WHO) recommends an integrated approach, which includes access to appropriate sanitation, hygiene education, and preventive chemotherapy (i.e., large-scale, periodic distribution of anthelmintic drugs). Since 2010, WHO has coordinated two large donations of benzimidazoles to endemic countries. Thus far, more than 3.3 billion benzimidazole tablets have been distributed in schools for the control of STH infections, resulting in an important reduction in STH-attributable morbidity in children, while additional tablets have been distributed for the control of lymphatic filariasis. This paper (i) summarizes the progress of global STH control between 2008 to 2018 (based on over 690 reports submitted by endemic countries to WHO); (ii) provides regional and country details on preventive chemotherapy coverage; and (iii) indicates the targets identified by WHO for the next decade and the tools that should be developed to attain these targets. The main message is that STH-attributable morbidity can be averted with evidence-informed program planning, implementation, and monitoring. Caution will still need to be exercised in stopping control programs to avoid any rebound of prevalence and loss of accrued morbidity gains. Over the next decade, with increased country leadership and multi-sector engagement, the goal of eliminating STH infections as a public health problem can be achieved.

Bayesian Methods for Exposure Misclassification Adjustment in a Mediation Analysis: Hemoglobin and Malnutrition in the Association Between Ascaris and IQ.

BACKGROUND: Soil-transmitted helminth infections have been found to be associated with child development. The objective was to investigate hemoglobin levels and malnutrition as mediators of the association between Ascaris infection and intelligence quotient (IQ) scores in children. METHODS: We conducted a longitudinal cohort study in Iquitos, Peru, between September 2011 and July 2016. A total of 1760 children were recruited at 1 year of age and followed up annually to 5 years. We measured Ascaris infection and malnutrition at each study visit, and hemoglobin levels were measured as of age 3. The exposure was defined as the number of detected Ascaris infections between age 1 and 5. We measured IQ scores at age 5 and used Bayesian models to correct exposure misclassification. RESULTS: We included a sample of 781 children in the analysis. In results adjusted for Ascaris misclassification, mean hemoglobin levels mediated the association between Ascaris infection and IQ scores. The natural direct effects (not mediated by hemoglobin) (95% CrI) and natural indirect effects (mediated by hemoglobin) (95% CrI) were compared with no or one infection: -0.9 (-4.6, 2.8) and -4.3 (-6.9, -1.6) for the effect of two infections; -1.4 (-3.8, 1.0) and -1.2 (-2.0, -0.4) for three infections; and -0.4 (-3.2, 2.4) and -2.7 (-4.3, -1.0) for four or five infections. CONCLUSION: Our results are consistent with the hypothesis that hemoglobin levels mediate the association between Ascaris infection and IQ scores. Additional research investigating the effect of including iron supplements in STH control programs is warranted.

Infant and young child feeding practices and stunting in two highland provinces in Ecuador.

The first two years of life are critical for growth and development. Little is known about infant and young child feeding (IYCF) practices in the Ecuadorian highlands and how they contribute to stunting. With the objective of understanding nutritional status and the influencing factors to design an intervention, we assessed the nutritional status of 293 infants and children between 0 and 24 months of age, living in 14 communities in the provinces of Tungurahua and Chimborazo using a cross-sectional study design. We used the WHO IYCF indicators to assess feeding practices; estimated dietary intake with 24-h recalls; and identified nutritious local foods by food frequency questionnaires. Multiple regression modelling was performed to identify correlates of nutritional status. Stunting was found in 56.2% of children. Mean protein, vitamin A and vitamin C intakes were above recommendations for all ages. Only infants 6.0 to 8.9 months of age and non-breastfed children 12-23.9 months of age consumed energy intakes below recommendations. Younger age groups had below recommended intakes for iron and calcium. While mean complementary food densities met recommendations for protein, vitamin A, vitamin C and energy, those for zinc, iron and calcium were lower than recommended. Older age, respiratory infections and being male were predictors of lower HAZ, whereas early initiation of breastfeeding, higher socioeconomic status, consumption of iron-rich foods and higher dietary protein density were protective. Interventions that promote and support optimal breastfeeding practices and enable increased consumption of nutritious local foods have potential to contribute to reducing stunting in this vulnerable population. © 2016 John Wiley & Sons Ltd.

A Community-Based Positive Deviance/Hearth Infant and Young Child Nutrition Intervention in Ecuador Improved Diet and Reduced Underweight.

OBJECTIVE: Underweight and stunting are serious problems in Ecuador that require interventions in the first 2 years of life. The researchers assessed the effectiveness of a Positive Deviance (PD)/Hearth community-based intervention using local foods to improve infant and young children's nutrition. DESIGN: A quasi-experimental nonrandomized study was conducted between March and October, 2009. SETTING: The intervention and study were implemented in the Ecuadorian highlands provinces of Chimborazo and Tungurahua. PARTICIPANTS: Eighty mother-child pairs in 6 intervention communities and 184 mother-child pairs in 9 comparison communities. INTERVENTION: Mothers met in participatory peer-led PD/Hearth cooking and nutrition education sessions for 12 days. MAIN OUTCOME MEASURES: Dietary intake and nutritional status were collected at baseline and 6-month follow-up. ANALYSIS: Multiple linear and logistic regression were used for growth outcomes, and ANCOVA for mean dietary intakes. RESULTS: Mothers in the intervention were 1.3-5.7 times more likely to feed their children the promoted foods (P < .05). Children in the intervention consumed a higher percentage of recommended intakes for iron, zinc, vitamin A, protein, and energy (P < .05) at follow-up and had improvements in weight-for-age z-score (ß = .17; 95% confidence interval, 0.01-0.31). Likelihood of underweight was reduced for children in the intervention (odds ratio = 0.36; 95% confidence interval, 0.13-0.96) CONCLUSIONS AND IMPLICATIONS: The PD/Hearth interventions support mothers to improve infant and young children's nutrition practices and reduce underweight.

School hygiene and deworming are key protective factors for reduced transmission of soil-transmitted helminths among schoolchildren in Honduras.

BACKGROUND: Among many neglected tropical diseases endemic in Honduras, soil-transmitted helminth (STH) infections are of particular importance. However, knowledge gaps remain in terms of risk factors involved in infection transmission. The aim of this study was to investigate risk factors associated with STH infections in schoolchildren living in rural Honduras. METHODS: A cross-sectional study was conducted among Honduran rural schoolchildren in 2011. Demographic, socio-economic, and epidemiological data were obtained through a standardized questionnaire and STH infections were determined by the Kato-Katz method. Logistic regression models accounting for school clustering were used to assess putative risk factors for infection. RESULTS: A total of 320 children completed the study. Prevalences for any STH and for Ascaris lumbricoides, Trichuris trichiura and hookworms were: 72.5%, 30.3%, 66.9% and 15.9%, respectively. A number of risk factors were identified at the individual, household, and school level. Boys were at increased odds of infection with hookworms (OR 2.33, 95% CI = 1.23-4.42). Higher socio-economic status in the family had a protective effect against infections by A. lumbricoides (OR 0.80, 95% CI = 0.65-0.99) and T. trichiura (OR 0.77, 95% CI = 0.63-0.94).Low school hygiene conditions significantly increased the odds for ascariasis (OR 14.85, 95% CI = 7.29-30.24), trichuriasis (OR 7.32, 95% CI = 3.71-14.45), mixed infections (OR 9.02, 95% CI = 4.66-17.46), and ascariasis intensity of infection (OR 3.32, 95% CI = 1.05 -10.52).Children attending schools not providing deworming treatment or that had provided it only once a year were at increased odds of ascariasis (OR 10.40, 95% CI = 4.39-24.65), hookworm (OR 2.92, 95% CI = 1.09-7.85) and mixed infections (OR 10.57, 95% CI = 4.53-24.66). CONCLUSIONS: Poverty-reduction strategies will ultimately lead to sustainable control of STH infections in Honduras, but as shorter-term measures, uninterrupted bi-annual deworming treatment paired with improvements in school sanitary conditions may result in significant reductions of STH prevalence among Honduran schoolchildren.

Re-visiting Trichuris trichiura intensity thresholds based on anemia during pregnancy.

BACKGROUND: The intensity categories, or thresholds, currently used for Trichuris trichiura (ie. epg intensities of 1-999 (light); 1,000-9,999 epg (moderate), and ≥ 10,000 epg (heavy)) were developed in the 1980s, when there were little epidemiological data available on dose-response relationships. This study was undertaken to determine a threshold for T. trichiura-associated anemia in pregnant women and to describe the implications of this threshold in terms of the need for primary prevention and chemotherapeutic interventions. METHODOLOGY/PRINCIPAL FINDINGS: In Iquitos, Peru, 935 pregnant women were tested for T. trichiura infection in their second trimester of pregnancy; were given daily iron supplements throughout their pregnancy; and had their blood hemoglobin levels measured in their third trimester of pregnancy. Women in the highest two T. trichiura intensity quintiles (601-1632 epg and ≥ 1633 epg) had significantly lower mean hemoglobin concentrations than the lowest quintile (0-24 epg). They also had a statistically significantly higher risk of anemia, with adjusted odds ratios of 1.67 (95% CI: 1.02, 2.62) and 1.73 (95% CI: 1.09, 2.74), respectively. CONCLUSIONS/SIGNIFICANCE: This analysis provides support for categorizing a T. trichiura infection ≥ 1,000 epg as 'moderate', as currently defined by the World Health Organization. Because this 'moderate' level of T. trichiura infection was found to be a significant risk factor for anemia in pregnant women, the intensity of Trichuris infection deemed to cause or aggravate anemia should no longer be restricted to the 'heavy' intensity category. It should now include both 'heavy' and 'moderate' intensities of Trichuris infection. Evidence-based deworming strategies targeting pregnant women or populations where anemia is of concern should be updated accordingly.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon.

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95% confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95% CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (ß adjusted = 113.2 seconds, 95% CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon / Efecto de una intervención de dos componentes para modificar la práctica hospitalaria de pinzamiento del cordón umbilical de precoz a tardío en la Amazonia peruana

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95 percent confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95 percent CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (βadjusted = 113.2 seconds, 95 percent CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

OBJETIVO: Investigar el efecto de una intervención de dos componentes para modificar la práctica hospitalaria respecto del momento en que se practica el pinzamiento del cordón umbilical. MÉTODOS: Se empleó un estudio con diseño antes-después para medir el efecto de una intervención de dos componentes sobre el tiempo medio de pinzamiento del cordón umbilical. El estudio se llevó a cabo en el Hospital Iquitos "César Garayar Gar-cía" en Iquitos (Perú). Se incluyeron en total 224 mujeres atendidas en la sala de trabajo de parto del hospital: 112 antes de la intervención, entre el 18 de mayo y el 3 de junio del 2009, y 112 después de la intervención, entre el 6 y el 20 de julio del 2009. La intervención consistió en: 1) un taller de capacitación sobre las "mejores prácticas" en la atención del parto, de 3 días de duración y 2) una directiva del hospital. Se observaron todos los partos y se midió el tiempo entre la salida del hombro anterior y el pinzamiento del cordón umbilical con un cronómetro digital. RESULTADOS: El tiempo medio entre el parto y el pinzamiento del cordón antes de la intervención fue de 56,8 segundos (intervalo de confianza [IC] de 95 por cento: 51,0-62,7), y aumentó a 169,8 segundos (IC 95 por cento: 153,8-185,8) después de la intervención. La diferencia en el tiempo medio hasta el pinzamiento siguió siendo significativa en los análisis multivariados (βajustado = 113,2 segundos, IC 95 por cento: 96,6-129,9). CONCLUSIONES: Es posible cambiar las normas y las prácticas hospitalarias de pinzamiento del cordón umbilical de precoz a tardío mediante una intervención sencilla de dos componentes.

Trichuris and hookworm infections associated with anaemia during pregnancy.

OBJECTIVE: To assess the following associations between the second and third trimesters of pregnancy: (i) the intensity of soil-transmitted helminth (STH) infection and haemoglobin/anaemia, (ii) the effect of mebendazole treatment on the occurrence of STH infection, and (iii) the effect of mebendazole treatment on haemoglobin/anaemia. METHODS: Data originated from a trial of 1042 pregnant women recruited in their second trimester and followed to delivery. Baseline assessments included socio-demographic/health information from questionnaires, haemoglobin/anaemia from HemoCue ascertainment of fingerprick blood, and the presence and intensity of STH (Ascaris lumbricoides, hookworms and Trichuris trichiura) infections from Kato-Katz examination. All women were given iron supplements; half were randomly allocated to receive single dose 500 mg mebendazole, and half, placebo. Haemoglobin/anaemia and STH infection status were determined again in the third trimester of pregnancy. RESULTS: Complete information was available from 935 (89.7%) women. Mebendazole significantly reduced the prevalence and intensity of all three STH infections. Higher intensities of hookworm and Trichuris infections in the second trimester were associated with a higher risk of anaemia in the third trimester. Overall, women with moderate/heavy Trichuris infection were found to be at a higher risk of anaemia; the highest risk was observed among those with moderate/heavy hookworm co-infection (adjusted OR = 2.77; 95% CI: 1.26, 6.11). Mebendazole treatment did not reduce the risk of anaemia. CONCLUSION: Higher intensities of both Trichuris and hookworm infections are associated with anaemia in pregnancy. The importance of Trichuris infections during pregnancy requires renewed attention.

A double-blind randomized controlled trial of antenatal mebendazole to reduce low birthweight in a hookworm-endemic area of Peru.

OBJECTIVE: To assess the effect on birthweight of antenatal mebendazole plus iron vs. placebo plus iron in a highly hookworm-endemic area. METHODS: Double-blind, randomized controlled trial set in rural and peri-urban communities in the Peruvian Amazon region. A total of 1042 second trimester pregnant women between the ages of 18 and 44 years were recruited from April to November 2003, and followed to July 2004. Women were randomly assigned to receive either mebendazole (500 mg single dose) plus iron supplements (60 mg elemental iron daily) or placebo plus iron supplements. The primary outcome was mean infant birthweight and secondary measures included proportion of low birthweight babies and maternal anaemia. RESULTS: The prevalence of hookworm infection was 47.5%. There were no differences between intervention groups in mean birthweight (3104 g vs. 3090 g, P = 0.629), proportion of low birthweight (<2500 g; 8.1%vs. 8.7%, P = 0.755) or maternal anaemia in the third trimester [33.0% (158/479) vs. 32.3% (152/471), P = 0.815]. However, the proportion of very low birthweight (<1500 g) was significantly lower in the mebendazole group [0% (0/479) vs. 1.5% (7/471), P = 0.007]. CONCLUSIONS: This trial provides additional evidence for the use of anthelmintics, over and above iron supplementation, within antenatal care programmes in hookworm-endemic areas. Benefits of de-worming may be higher in countries not having an antenatal iron supplementation programme or where intensity of hookworm infections is higher.

Lack of risk of adverse birth outcomes after deworming in pregnant women.

BACKGROUND: Pregnant women who live in hookworm-endemic areas may benefit from deworming during their pregnancy. The benefit derives from reducing anemia, primarily iron-deficiency anemia caused by hookworm infection-attributable blood loss. Where the prevalence of hookworm is more than 20% to 30%, the World Health Organization recommends that pregnant women receive anthelminthic treatment (mebendazole, albendazole, levamisole or pyrantel) after their first trimester. The objective of this study is to report, describe and compare the occurrence of adverse birth outcomes in a large randomized, controlled trial of antenatal mebendazole (500 mg single dose) plus iron supplements versus placebo plus iron supplements conducted between April 2003 and June 2004 in the Amazon region of Peru. METHODS: Physician-recorded data on adverse birth outcomes occurring during the trial (N = 1042) were obtained. Proportions were compared using chi analysis. RESULTS: No statistically significant difference (P = 0.664) was found between the mebendazole group and the placebo group in terms of numbers of miscarriages, malformations, stillbirths, early neonatal deaths and premature babies (28 versus 31, respectively). CONCLUSIONS: The evidence provided by this large randomized, controlled trial of mebendazole administered during pregnancy indicates that deworming with mebendazole can be safely included in antenatal care programs in hookworm-endemic areas.