Commentary: Replication of influential trial helps international policy Evidence for spending millions on deworming schoolchildren is inadequate, report says Results of a national school-based deworming programme on soil-transmitted helminths infections and schistosomiasis in Kenya: 2012–2017 The impact of mass deworming programmes on schooling and economic development: an appraisal of long-term studies Effects of a Post-Deworming Health Hygiene Education Intervention on Absenteeism in School-Age Children of the Peruvian Amazon The Effect of Deworming on Growth in One-Year-Old Children Living in a Soil-Transmitted Helminth-Endemic Area of Peru: A Randomized Controlled Trial Effect of Deworming on Indices of Health, Cognition, and Education Among Schoolchildren in Rural China: A Cluster-Randomized Controlled Trial. A controlled evaluation of two school-based anthelminthic chemotherapy regimens on intensity of intestinal helminth infections. Fortified Snack Reduced Anemia in Rural School-Aged Children of Haiti: A Cluster-Randomized, Controlled Trial Lack of Risk of Adverse Birth Outcomes After Deworming in Pregnant Women A Double-Blind Randomized Controlled Trial of Maternal Postpartum Deworming to Improve Infant Weight Gain in the Peruvian Amazon Impact of Health Education on Soil-Transmitted Helminth Infections in Schoolchildren of the Peruvian Amazon: A Cluster-Randomized Controlled Trial Effects of the Zanzibar school-based deworming program on iron status of children. ‘Fit for school’ – a school-based water, sanitation and hygiene programme to improve child health: Results from a longitudinal study in Cambodia, Indonesia and Lao PDR Adverse Events from a Randomized, Multi-Arm, Placebo-Controlled Trial of Mebendazole in Children 12-24 Months of Age. Population deworming every 6 months with albendazole in 1 million pre-school children in north India: DEVTA, a cluster-randomised trial School-based deworming program yields small improvement in growth of Zanzibari school children after one year. Effects of Vitamin A Supplementation on Iron Status Indices and Iron Deficiency Anaemia: A Randomized Controlled Trial (S)WASH-D for Worms: A pilot study investigating the differential impact of school- versus community-based integrated control programs for soil-transmitted helminths Design of a Prospective, Randomized Evaluation of an Integrated Nutrition Program in Rural Viet Nam Effects of Deworming on Malnourished Preschool Children in India: An Open-Labelled, Cluster-Randomized Trial Maternal Deworming Research Study (MADRES) protocol: a double-blind, placebo-controlled randomised trial to determine the effectiveness of deworming in the immediate postpartum period Mini Nutritional Assessment of rural elderly people in Bangladesh: the impact of demographic, socio-economic and health factors.
The World Bank , the Gates Foundation and the World Health Organization promote national child deworming programmes in developing countries.1 They assert these programmes will improve nutritional status , health and school performance , and hence contribute to economic growth . Indeed , the World Health Organization states that deworming contributed to Japan ’s economic boom in the 1950s,2 and Nobel Laureates meeting in Copenhagen ranked deworming as the fourth most important intervention to solve the health problems of the whole world.3 Surprisingly , the evidence base for these cl aims from controlled studies is limited . Critically , according to the Cochrane review which two of us author , there is quite good evidence of no effect for the main biomedical outcomes in deworming , making the broader societal benefits on economic development barely credible ( Figure 1).4 Nevertheless , the advocates increasingly rely on a single large quasi-r and omized trial carried out in Kenya , published in 2004 in Econometrica,5 which reports school attendance . Figure 1 . Conceptual framework used to underpin the effects of deworming programmes on economic growth  in developing countries . Contemporary evidence questions this model , as there is now quite good contemporary evidence , summarized in the Cochrane review , that ... This study has been highly influential . The International Initiative for Impact Evaluation commissioned the London School of Hygiene and Tropical Medicine ( LSHTM ) to replicate the analysis , as the original analysis is ‘ based on econometric approaches and used a language and format that would be unfamiliar to many health care research ers’.6 The replication aim ed to provide detail of the methods and reporting in line with the CONSORT statement . The team are internationally recognized , independent and meticulous in their approach . They agreed a protocol , carefully checked and corrected the raw data , and then re-ran their prespecified analysis .6 Their first paper is a pure replication,7 exactly repeating the authors ’ original analysis . This paper clarifies some method ological details not provided in the original paper , but it also uncovers a series of important coding and analysis errors . Some of the corrected results are consistent with the original findings , but others are quite different . Most notably , the much quoted ‘ positive externalities’—where the benefits of treating children in one school ‘ spill over ’ to benefit children in adjacent schools — vanish in their corrected analysis . Their second paper uses approaches more familiar to epidemiologists , and allows a more thorough exploration of the data .8 There are substantial amounts of missing information , and some unexpected patterns that are difficult to explain . For example , there is a correlation between the number of observations in each school and the reported attendance , with more observations associated with lower attendance reported — except in some of the intervention groups , where more frequent observation is associated with better attendance . This raises the possibility that the process of observation influenced outcome reporting and this was different in control and intervention groups . The second paper confirms an association with higher attendance in the deworming schools when stratified by year , but found the combined estimate across years was much larger , and the authors caution the validity of the combined year estimate : this may be due to the stepped-wedge design where the combined year estimate includes a before and after comparison ; or it may be due to the problems with secular and group effects of the number of observations of school attendance varying . To further complicate matters , there was also a concurrent ‘ School Assistance Program ’ ( SAP ) evaluating five other interventions in 27/75 of the study schools , which was not part of the r and omized intervention . Attendance patterns differed on the basis of involvement in the SAP , which the authors suggest could well lead to bias.8 One of the critical points the LSHTM papers make is that the administration of the deworming drugs was part of a ‘ complex health education and drug treatment intervention’.8 The intervention schools also received regular public health lectures , wall charts and teacher training on worm prevention . Interestingly , the pure replication shows very similar impacts of the intervention on children in the intervention schools irrespective of whether they took the deworming medicine or not.7 For Miguel and colleagues , they term this as ‘ indirect within-school effects ’ of deworming , but equally the effects could be due to the non-specific effects of the health promotion interventions in the intervention schools . So where does this take us ? There is a small effect on school attendance for sure , but this should not be over-interpreted , as the LSHTM authors say , given the concerns raised regarding the risk of bias , and the independent effects on school attendance of the programme of health promotion . In addition , the study shows that allocation to the deworming group does not influence student progress , as the re- analysis shows clearly no evidence of a difference in examination performance between deworming and control groups.7,8 In the context of the global evidence base , there is only one other study that has examined school attendance with no obvious effect shown.4 Given all these uncertainties , we simply do n’t know if there is truly an effect on school attendance from the data , in taking all these factors into account formally in a GRADE analysis .4 But what weakens the case of deworming still further is that there is now quite good evidence of no effect for most of the main outcomes ( Figure 1 ) , including nutritional status , haemoglobin , cognition and school performance . This is important because without these effects it seems implausible that deworming itself would have an independent effect on school attendance or economic development . Obviously children infected with worms should be treated . Trials from over 20 years ago in an area of Kenya where all the children were heavily infected showed benefit . Another trial in India showed benefit , but subsequent trials in the same area failed to show an effect.4,9 So deworming may have helped in these exceptional , heavily infected , untreated population s from another decade , but this is scarcely a solid base for contemporary policy : public health nutrition has changed , worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies .10 We have been perplexed by the un question ing belief behind deworming in the advocates , and have found it is deep rooted in American history . The Rockefeller Sanitary Commission in 1909 sought to eradicate hookworm in the Southern USA population , where it was seen as a cause of ‘ some of the proverbial laziness of the poorer classes ’ and to improve worker productivity ; these were extended with the Rockefeller International Health Commission established in 1913.11 The beliefs and assumptions appear to continue , with ‘ Deworm the World ’ aim ing to deworm 220 million children in India during 2015.12 What have we learned from this ? Certainly that replication is a valuable process , not least for errors that have the potential to mislead , but also to provide a much better interpretation of the potential biases in studies . In terms of policies in deworming , it suggests donors and Nobel Prize winners need to be aware of their prior assumptions , and base decisions on the all the evidence from reliable studies within a systematic review , not just select a single study . They need to look at all relevant outcomes , not just one . They need to consider bias and confounding . Our view is that current promotion of community deworming is certainly a panacea : a single solution to multiple problems in low- and middle-income countries , and that the belief that deworming will impact substantially on economic development seems delusional when you look at the results of reliable controlled trials . This is a view , based on over 15 years of engagement with critically appraising the literature in this field.13 We recommend anyone responsible for public or philanthropic money going to large scale deworming to read these replication studies , the original publication , the authors ’ responses to the replication and the 2015 version of the Cochrane review that includes corrections from these replications plus data from five further studies , including the recently published DEVTA study of 2 million children.4,14 Then make up your own mind . Conflict of interest : PG and DTR are authors of a Cochrane review of community deworming programmes . PG is funded by the Department for International Development to provide reliable independent systematic review s for the benefit of developing countries ; PG receives salary support from Countdown , a DFID-supported research grant in programmatic implementation of neglected tropical disease programmes New analysis of a l and mark paper on the health and economic benefits of eliminating worm infections in children has found little evidence that it does any good . Deworming programmes have been heavily promoted by the World Bank , the World Health Organization , and international charities as a key to improving health , school performance , and , by inference , economic development in poor and middle income countries . India has recently launched the world ’s largest deworming programme , with the aim of treating 240 million children once or twice a year with albendazole , a drug that can eliminate worm infections.1 The policy relies on a limited evidence base , with a single r and omised trial carried out in 75 Kenyan schools regularly cited by its proponents . In this 2004 study Edward Miguel of the University of California at Berkeley and Michael Kramer of Harvard University found that the treated children had a lower prevalence of worm infestation , improved nutritional status , and higher school attendance.2 Importantly , they also found that these benefits extended to untreated children in the treated schools and to Background Soil-transmitted helminth ( STH ) and schistosome infections are among the most prevalent neglected tropical diseases ( NTDs ) in the world . School-aged children are particularly vulnerable to these chronic infections that can impair growth , nutritional status and cognitive ability . Mass drug administration ( MDA ) delivered either once or twice annually is a safe and effective approach recommended by the World Health Organization ( WHO ) to reduce worm burden . In 2012 , Kenya began a national school-based deworming programme  ( NSBDP ) aim ed at reducing infection and associated morbidity . The change in prevalence and intensity of these infections was monitored over five years ( 2012–2017 ) . Here , we present the changes in STH and schistosome infections between baseline and endline assessment s , as well as explore the yearly patterns of infection reductions . Methods We used series of pre- and post-MDA intervention , repeat cross-sectional surveys in a representative , stratified , two-stage sample of schools in 16 counties of Kenya . The programme consisted of two tiers of monitoring ; a national baseline , midterm and endline surveys consisting of 200 schools , and pre- and post-MDA surveys conducted yearly consisting of 60 schools . Stool and urine sample s were collected from r and omly selected school children and examined for STH and schistosome infections using Kato-Katz and urine filtration techniques respectively . Results Overall , 32.3 % , 16.4 % and 13.5 % of the children were infected with any STH species during baseline , midterm and endline assessment , respectively , with a relative reduction of 58.2 % over the five-year period . The overall prevalence of S. mansoni was 2.1 % , 1.5 % and 1.7 % and of S. haematobium was 14.8 % , 6.8 % and 2.4 % , respectively , for baseline , midterm and endline surveys . We observed inter-region and inter-county heterogeneity variation in the infection levels . Conclusions The analysis provided robust assessment of the programme and outlined the current prevalence , mean intensity and re-infection pattern of these infections . Our findings will allow the Government of Kenya to make informed decisions on the strategy to control and eliminate these NTDs . Our results suggest that complimentary interventions may have to be introduced to sustain the chemotherapeutic gains of MDA and accelerate attainment of elimination of these NTDs as a public health problem in Kenya Abstract Background : Documents from advocacy and fund-raising organizations for child mass deworming programmes in low- and middle-income countries cite unpublished economic studies cl aim ing long-term effects on health , schooling and economic development . Methods : To summarize and appraise these studies , we search ed for and included all long-term follow-up studies based on cluster-r and omized trials included in a 2015 Cochrane review on deworming . We used Cochrane methods to assess risk of bias , and appraised the credibility of the main findings . Where necessary we contacted study authors for clarifications . Results : We identified three studies ( Baird 2016 , Ozier 2016 and Croke 2014 ) evaluating effects more than 9 years after cluster-r and omized trials in Kenya and Ug and a. Baird and Croke evaluate short additional exposures to deworming programmes in setting s where all children were dewormed multiple times . Ozier evaluates potential spin-off effects to infants living in areas with school-based deworming . None of the studies used pre-planned protocol s nor blinded the analysis to treatment allocation . Baird 2016 has been presented online in six iterations . The work is at high risk of reporting bias and selective reporting , and there are substantive changes between versions . The main cited effects on secondary school attendance and job sector allocation are from post hoc subgroup analyses , which the study was not powered to assess . The study did not find any evidence of effect on nutritional status , cognitive tests or school grade s achieved , but these are not reported in the abstract s. Ozier 2016 has been presented online in four iterations , without substantive differences between versions . Higher cognitive test scores were associated with deworming , but the appropriate analysis was underpowered to reliably detect these effects . The size of the stated effect seems inconsistent with the short and indirect nature of the exposure to deworming , and a causal pathway for this effect is unclear . Croke 2014 uses a data set unrelated to the base trial , to report improvements in English and maths test scores . The analysis is at high risk of attrition bias , due to loss of clusters , and is substantially underpowered to assess these effects . Conclusions : In the context of reliable epidemiological methods , all three studies are at risk of substantial method ological bias . They therefore help in generating hypotheses , but should not be considered to provide reliable evidence of effects Soil-transmitted helminth ( STH ) infections are a leading cause of disability and disease burden in school-age children of worm-endemic regions . Their effect on school absenteeism , however , remains unclear . The World Health Organization currently recommends delivering mass deworming and health hygiene education through school-based programs , in an effort to control STH-related morbidity . In this cluster- RCT , the impact of a health hygiene education intervention on absenteeism was measured . From April to June 2010 , all Grade 5 students at 18 schools in a worm-endemic region of the Peruvian Amazon were dewormed . Immediately following deworming , nine schools were r and omly assigned to the intervention arm of the trial using a matched-pair design . The Grade 5 students attending intervention schools ( N = 517 ) received four months of health hygiene education aim ed at increasing knowledge of STH prevention .  Grade 5 students from the other nine schools ( N = 571 ) served as controls . Absenteeism was measured daily through teachers ' attendance logs . After four months of follow-up , overall absenteeism rates at intervention and control schools were not statistically significantly different . However , post-trial non-r and omized analyses have shown that students with moderate-to-heavy Ascaris infections and light hookworm infections four months after deworming had , respectively , missed 2.4 % ( 95 % CI : 0.1 % , 4.7 % ) and 4.6 % ( 95 % CI : 1.9 % , 7.4 % ) more schooldays during the follow-up period than their uninfected counterparts . These results provide empirical evidence of a direct effect of STH infections on absenteeism in school-age children Background Appropriate health and nutrition interventions to prevent long-term adverse effects in children are necessary before two years of age . One such intervention may include population -based deworming , recommended as of 12 months of age by the World Health Organization in soil-transmitted helminth (STH)-endemic areas ; however , the benefit of deworming has been understudied in early preschool-age children . Methodology /Principal Findings A r and omized , double-blind , placebo-controlled trial was conducted to determine the effect of  deworming ( 500 mg single-dose crushed mebendazole tablet ) on growth in one-year-old children in Iquitos , Peru . Children were enrolled during their routine 12-month growth and development clinic visit and followed up at their 18 and 24-month visits . Children were r and omly allocated to : Group 1 : deworming at 12 months and placebo at 18 months ; Group 2 : placebo at 12 months and deworming at 18 months ; Group 3 : deworming at both 12 and 18 months ; or Group 4 : placebo at both 12 and 18 months ( i.e. control group ) . The primary outcome was weight gain at the 24-month visit . An intention-to-treat approach was used . A total of 1760 children were enrolled between September 2011 and June 2012 . Follow-up of 1563 children ( 88.8 % ) was completed by July 2013 . STH infection was of low prevalence and predominantly light intensity in the study population . All groups gained between 1.93 and 2.05 kg on average over 12 months ; the average difference in weight gain ( kg ) compared to placebo was : 0.05 ( 95 % CI : -0.05 , 0.17 ) in Group 1 ; -0.07 ( 95%CI : -0.17 , 0.04 ) in Group 2 ; and 0.04 ( 95%CI : -0.06 , 0.14 ) in Group 3 . There was no statistically significant difference in weight gain in any of the deworming intervention groups compared to the control group . Conclusions Overall , with one year of follow-up , no effect of deworming on growth could be detected in this population of preschool-age children . Low baseline STH prevalence and intensity and /or access to deworming drugs outside of the trial may have diluted the potential effect of the intervention . Additional research is required to overcome these challenges and to contribute to strengthening the evidence base on deworming . Trial Registration Clinical Trials.gov ( NCT01314937 Abstract Soil-transmitted helminths ( STHs ) infect over one billion people worldwide . There is concern that chronic infection with STHs among school-aged children may detrimentally affect their development , including their health , cognition , and education . However , two recent Cochrane review s examining the impact of deworming drugs for STH on nutrition , hemoglobin , and school performance found that r and omized controlled trials ( RCTs ) in the literature provide an insufficient evidence base to draw reliable conclusions . This study uses a cluster- RCT to add to existing evidence by assessing the impact of a deworming intervention on nutrition , cognition , and school performance among schoolchildren in rural China . The intervention , implemented by local health practitioners in a setting with a baseline infection prevalence of 41.9 % ( 95 % confidence interval [ CI ] = 39.8 % , 43.9 % ) and infection intensity of 599.5 eggs per gram of feces among positive-tested schoolchildren ( 95 % CI = 473.2 , 725.8 ) , consisted of distributing a 400-mg dose of albendazole accompanied with educational training about STH infection , treatment , and prevention . The intervention was conducted twice over the course of the study -at baseline in May 2013 and later in November 2013 . We found that the deworming intervention reduced both infection prevalence and infection intensity , but these declines in infection were not accompanied by an impact on outcomes of nutrition , cognition , or school performance . Our interpretation is that the impact of deworming was attenuated by the light infection intensity in our sample population . Evidence from future RCTs is needed to assess the effect of deworming on key outcomes in areas with moderate and severe worm infections BACKGROUND School-based deworming programmes have been promoted as a cost-effective strategy for control of nematode infection in developing countries . While numerous efficacy studies have been conducted , there is little information on actual programme effectiveness in areas of intense transmission . METHODS A r and omized trial of a  school-based deworming programme  was conducted in 12 primary schools on Pemba Isl and , Zanzibar . Four schools each were r and omized to control , twice a year deworming with single dose mebendazole or three times a year deworming . Baseline and 12-month follow-up data on helminth infection using the Kato-Katz technique , demographic information and nutritional status were collected on 3028 children from March 1994 to May 1995 . RESULTS Intensity of infection measured as eggs per gram of faeces ( epg ) declined significantly for Ascaris lumbricoides , Trichuris trichiura and hookworm infections in both treatment groups . A. lumbricoides infection intensity declined 63.1 % and 96.7 % in the twice and three times per year treatment groups compared to the controls . T. trichiura infection intensity declined 40.4 % and 75.9 % respectively and hookworm intensity declined 35.3 % and 57.2 % respectively compared to control schools . CONCLUSIONS These results suggest that school-based programmes can be a cost-effective approach for controlling the intensity of intestinal helminth infection even in environments where transmission is high Background Nutrition in the school-aged child matters for brain development and public policy investments globally . Our group previously conducted a trial in urban schools of Haiti to examine the effects of a fortified peanut butter snack , Vita Mamba , with limited findings for anemia . Objective We aim ed to test the hypothesis that Vita Mamba , with systematic deworming in both study arms , would significantly reduce anemia  among rural , school-aged children . Methods A cluster , r and omized longitudinal study was conducted in two rural communities of the North-East Department of Haiti , 2014–2015 . Healthy children ages 3–16 years were enrolled ( n = 321 ) and assigned by school to intervention ( Vita Mamba and deworming ) and control ( deworming ) . Vita Mamba contains 260 kcal and meets > 75 % of the Recommended Dietary Allowance for critical micronutrients . Multivariate regression analyses including propensity score matching techniques to correct for potential group imbalance ( Kernel-based Matching and Propensity Score Weighting ) were applied to examine difference-in-difference intervention effects . Results At baseline , 51 % of the children were anemic  with no significant differences between study groups . Vita Mamba supplementation showed a consistent , positive effect across regression models on increasing Hb concentration and reducing the odds of anemia compared to the control group after adjusting for child age , vitamin A supplementation , milk consumption , and height-for-age z score . The average treatment effect for the treated in the Propensity Score Weighting models was 0.62±0.27 grams per 100 milliliters ( g/dL ) for Hb concentration ( F = 4.64 , P = 0.001 ) , and the odds of anemia were reduced by 88 % ( Wald χ² = 9.77 , P = 0.02 ) . No differences in change in anthropometric markers were evident . Conclusions School feeding programs that integrate fortified foods with deworming could reduce anemia burden with important implication s for learning , health , and well-being . The rural-urban differences in anemia require further study 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 r and omized , 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 χ2 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 r and omized , controlled trial of mebendazole administered during pregnancy indicates that deworming with mebendazole can be safely included in antenatal care programs in hookworm-endemic areas Background Nutritional interventions targeting the critical growth and development period before two years of age can have the greatest impact on health trajectories over the life course . Compelling evidence has demonstrated that interventions investing in maternal health in the first 1000 days of life are beneficial for both mothers and their children . One such potential intervention is deworming integrated into maternal postpartum care in areas where soil-transmitted helminth ( STH ) infections are endemic . Methodology /Principal Findings From February to August 2014 , 1010 mother-infant pairs were recruited into a trial aim ed at assessing the effectiveness of maternal postpartum deworming on infant and maternal health outcomes . Following delivery , mothers were r and omly assigned to receive either single-dose 400 mg albendazole or placebo . Participants were followed-up at 1 and 6 months postpartum . There was no statistically significant difference in mean weight gain between infants in the experimental and control groups ( mean difference : -0.02 ; 95 % CI : -0.1 , 0.08 ) at 6 months of age . Further , deworming had no effect on measured infant morbidity indicators . However , ad hoc analyses restricted to mothers who tested positive for STHs at baseline suggest that infants of mothers in the experimental group had greater mean length gain in cm ( mean difference : 0.8 ; 95 % CI : 0.1 , 1.4 ) and length-for-age z-score ( mean difference : 0.5 ; 95 % CI : 0.2 , 0.8 ) at 6 months of age . Conclusions / Significance In a study population composed of both STH-infected and uninfected mothers , maternal postpartum deworming was insufficient to impact infant growth and morbidity indicators up to 6 months postpartum . Among STH-infected mothers , however , important improvements in infant length gain and length-for-age were observed . The benefits of maternal postpartum deworming should be further investigated in study population s having higher overall prevalences and intensities of STH infections and , in particular , where whipworm and hookworm infections are of public health concern . Trial registration Clinical Trials.gov ( NCT01748929 ) Background To control soil-transmitted helminth ( STH ) infections , the World Health Organization recommends school-based deworming programs with a health hygiene education component . The effect of such health hygiene interventions , however , has not been adequately studied . The objective of the present study was to determine the effectiveness of a health hygiene education intervention on the occurrence of STH re-infection four months post-de-worming . Methodology /Principal Findings An open-label pair-matched cluster-r and omized trial was conducted in Grade 5 schoolchildren of 18 primary schools ( 9 intervention and 9 control ) in the Peruvian Amazon . Baseline assessment included interview with a pre-tested question naire and collection of single stool specimens that were examined using the single Kato-Katz thick smear . All schoolchildren were then treated with single-dose albendazole ( 400 mg ) . Schoolchildren in intervention schools then received 1 ) an initial one hour in-class activity on health hygiene and sanitation and 30-minute refresher activities every two weeks over four months ; and 2 ) a half-day workshop for teachers and principals , while children in control schools did not . Four months later , STH infection was re-assessed in all schools by laboratory technologists blinded to intervention status . From April 21–October 20 , 2010 , a total of 1,089 schoolchildren ( 518 and 571 from intervention and control schools , respectively ) participated in this study . Intervention children scored significantly higher on all aspects of a test of STH-related knowledge compared with control children ( aOR = 18·4 ; 95 % CI : 12·7 to 26·6 ) . The intensity of Ascaris lumbricoides infection at follow-up was statistically significantly lower ( by 58 % ) in children in intervention schools compared with children in control schools ( aIRR = 0·42 ; 95 % CI = 0·21 to 0·85 ) . No significant changes in hookworm or Trichuris trichiura intensity were observed . Conclusions / Significance A school-based health hygiene education intervention was effective in increasing STH knowledge and in reducing Ascaris lumbricoides infection . The benefits of school-based periodic deworming programs are likely to be enhanced when a sustained health hygiene education intervention is integrated into school curricula We evaluated the effects of the  Zanzibar school-based deworming program  on the iron status of primary school children . Parasitologic and nutritional assessment s were carried out at baseline , 6 mo , and 12 mo in 4 nonprogram schools ( n = 1002 ) , 4 schools in which students received twice-yearly deworming ( n = 952 ) , and 4 schools in which students received thrice-yearly deworming ( n = 970 ) with 500 mg generic mebendazole .  Schools were r and omly selected for evaluation and allocated to program groups . Relative to no treatment , thrice-yearly deworming caused significant decreases in protoporphyrin concentrations and both deworming regimens caused marginally significant increases in serum ferritin concentrations . The average annual changes in protoporphyrin concentrations were -5.9 and -23.5 micromol/mol heme in the control and thrice-yearly deworming groups , respectively ( P < 0.001 ) . The average changes in ferritin concentration were 2.8 and 4.5 microg/L , respectively ( P = 0.07 ) . Deworming had no effect on annual hemoglobin change or prevalence of anemia . However , the relative risk of severe anemia ( hemoglobin < 70 g/L ) was 0.77 ( 95 % confidence limits : 0.39 , 1.51 ) in the twice-yearly deworming group and 0.45 ( 0.19 , 1.08 ) in the thrice-yearly deworming group . The effects on prevalence of high protoporphyrin values and incidence of moderate-to-severe anemia ( hemoglobin < 90 g/L ) were significantly greater in children with > 2000 hookworm eggs/g feces at baseline . We estimate that this deworming program prevented 1260 cases of moderate-to-severe anemia and 276 cases of severe anemia in a population of 30,000 schoolchildren in 1 y. Where hookworm is heavily endemic , deworming programs can improve iron status and prevent moderate and severe anemia , but deworming may be needed at least twice yearly Background The Fit for School ( FIT ) programme integrates school health and Water , Sanitation and Hygiene interventions , which are implemented by the Ministries of Education in four Southeast Asian countries . This paper describes the findings of a Health Outcome Study , which aim ed to assess the two-year effect of the FIT programme on the parasitological , weight , and oral health status of children attending schools implementing the programme in Cambodia , Indonesia and Lao PDR . Methods The study was a non-r and omized clustered controlled trial with a follow-up period of two years . The intervention group consisted of children attending public elementary schools implementing the FIT programme  , including daily group h and washing with soap and toothbrushing with fluoride toothpaste , biannual school-based deworming ; as well as construction of group h and washing facilities . Control schools implemented the regular government health education curriculum and biannual deworming . Per school , a r and om selection of six to seven-year-old grade -one students was drawn . Data on parasitological infections , anthropometric measurements , dental caries , odontogenic infections and sociodemographic characteristics were collected at baseline and at follow-up ( 24 months later ) . Data were analysed using the χ2-test , Mann Whitney U-test and multilevel logistic and linear regression . Results A total of 1847 children ( mean age = 6.7 years , range 6.0–8.0 years ) participated in the baseline survey . Of these , 1499 children were available for follow-up examination – 478 , 486 and 535 children in Cambodia , Indonesia and Lao PDR , respectively . In all three countries , children in intervention schools had a lower increment in the number of decayed , missing and filled permanent teeth between baseline and follow-up , in comparison to children in controls schools . The preventive fraction was 24 % at average . The prevalence of soil-transmitted helminth infection ( which was unexpectedly low at baseline ) , the prevalence of thinness and the prevalence of odontogenic infections did not significantly differ between baseline and follow-up , nor between intervention and control schools . Conclusions The study found that the FIT programme significantly contributed to the prevention of dental caries in children . This study describes the challenges , learnings and , moreover , the importance of conducting real-life implementation research to evaluate health programmes to transform school setting s into healthy learning environments for children . The study is retrospectively registered with the German Clinical Trials Register , University of Freiburg ( Trial registration number : DRKS00004485 , date of registration : 26th of February , 2013 ) Large-scale deworming interventions , using anthelminthic drugs , are recommended in areas where the prevalence of soil-transmitted helminth infection is high . Anthelminthic safety has been established primarily in school-age children . Our objective was to provide evidence on adverse events from anthelminthic use in early childhood . A r and omized multi-arm , placebo-controlled trial of mebendazole , administered at different times and frequencies , was conducted in children 12 months of age living in Iquitos , Peru . Children were followed up to 24 months of age . The association between mebendazole administration and the occurrence of a serious or minor adverse event was determined using logistic regression . There was a total of 1,686 administrations of mebendazole and 1,676 administrations of placebo  to 1,760 children . Eighteen serious adverse events ( i.e. , 11 deaths and seven hospitalizations ) and 31 minor adverse events were reported . There was no association between mebendazole and the occurrence of a serious adverse event ( odds ratio [ OR ] = 1.21 ; 95 % confidence interval [ CI ] = 0.47 , 3.09 ) or a minor adverse event ( OR = 0.84 ; 95 % CI = 0.41 , 1.72 ) . Results from our trial support evidence of safety in administering mebendazole during early childhood . These results support World Health Organization deworming policy and the scaling up of interventions to reach children as of 12 months of age in endemic areas Summary Background In north India many pre-school children are underweight , many have intestinal worms , and 2–3 % die at ages 1·0–6·0 years . We used the state-wide Integrated Child Development Service ( ICDS ) infrastructure to help to assess any effects of regular deworming on mortality . Methods Participants in this cluster-r and omised study were children in catchment areas of 8338 ICDS-staffed village child-care centres ( under-5 population 1 million ) in 72 administrative blocks . Groups of four neighbouring blocks were cluster-r and omly allocated in Oxford between 6-monthly vitamin A ( retinol capsule of 200 000 IU retinyl acetate in oil , to be cut and dripped into the child 's mouth every 6 months ) , albendazole ( 400 mg tablet every 6 months ) , both , or neither ( open control ) . Analyses of albendazole  effects are by block ( 36 vs 36 clusters ) . The study spanned 5 calendar years , with 11 6-monthly mass-treatment days for all children then aged 6–72 months . Annually , one centre per block was r and omly selected and visited by a study team 1–5 months after any trial deworming to sample faeces ( for presence of worm eggs , reliably assessed only after mid- study ) , weigh children , and interview caregivers . Separately , all 8338 centres were visited every 6 months to monitor pre-school deaths ( 100 000 visits , 25 000 deaths at age 1·0–6·0 years [ the primary outcome ] ) . This trial is registered at Clinical Trials.gov , NCT00222547 . Findings Estimated compliance with 6-monthly albendazole was 86 % . Among 2589 versus 2576 children surveyed during the second half of the study , nematode egg prevalence was 16 % versus 36 % , and most infection was light . After at least 2 years of treatment , weight at ages 3·0–6·0 years ( st and ardised to age 4·0 years , 50 % male ) was 12·72 kg albendazole versus 12·68 kg control ( difference 0·04 kg , 95 % CI −0·14 to 0·21 , p=0·66 ) . Comparing the 36 albendazole-allocated versus 36 control blocks in analyses of the primary outcome , deaths per child-care centre at ages 1·0–6·0 years during the 5-year study were 3·00 ( SE 0·07 ) albendazole versus 3·16 ( SE 0·09 ) control , difference 0·16 ( SE 0·11 , mortality ratio 0·95 , 95 % CI 0·89 to 1·02 , p=0·16 ) , suggesting absolute risks of dying between ages 1·0 and 6·0 years of roughly 2·5 % albendazole versus 2·6 % control . No specific cause of death was significantly affected . Interpretation Existing ICDS village staff can be organised to deliver simple pre-school interventions sustainably for many years at low cost , but regular deworming had little effect on mortality in this lightly infected pre-school population . Funding UK Medical Research Council , USAID , World Bank ( albendazole donated by GlaxoSmithKline ) Efficacy trials of antihelminthic therapies conducted in Africa have reported improvements in children 's growth , but nutritional evaluations of large-scale deworming programs are lacking . We evaluated the first-year effect on growth of a school-based deworming program in Zanzibar , where growth retardation occurs in school children . Children in four primary schools were given thrice-yearly mebendazole ( 500 mg ) and compared with children in four schools that received twice-yearly mebendazole and children in four non-program schools . Evaluation schools were r and omly selected and allocated to control , twice-yearly or thrice-yearly deworming .  Approximately 1000 children in each program group completed the 1-y follow-up . Children < 10 y old gained 0.27 kg more weight ( P < 0.05 ) and 0.13 cm more height ( P = 0.20 ) in the twice-yearly group , and 0 . 20 kg more weight ( P = 0.07 ) and 0.30 cm more height ( P < 0.01 ) in the thrice-yearly group , compared with the control group . Children < 10 y old with higher heights-for-age at baseline had higher weight and height gains in response to deworming . In children > /=10 y old , overall program effects on height or weight gains were not significant . But in this age range , younger boys had significant improvements in height gain with thrice-yearly deworming , and children with higher heights-for-age had greater improvements in weight gain with deworming . We conclude that the deworming program improved the growth  of school children , especially children who were younger and less stunted , but the improvements were small . More effective antihelminthic regimens or additional dietary or disease control interventions may be needed to substantially improve the growth of school children in areas such as Zanzibar Iron deficiency anaemia ( IDA ) is the most common nutritional deficiency in the world including developed and developing countries . Despite intensive efforts to improve the quality of life of rural and aboriginal communities in Malaysia , anaemia and IDA are still major public health problems in these communities particularly among children . A r and omized , double-blind , placebo-controlled trial was conducted on 250 Orang Asli ( aboriginal ) schoolchildren in Malaysia to investigate the effects of a single high-dose of vitamin A supplementation ( 200,000 IU ) on iron status indices , anaemia and IDA status . The effect of the supplement was assessed after 3 months of receiving the supplements ; after a complete 3-day deworming course of 400 mg/day of albendazole tablets . The prevalence of anaemia was found to be high : 48.5 % ( 95 % CI = 42.3 , 54.8 ) . Moreover , 34 % ( 95 % CI = 28.3 , 40.2 ) of the children had IDA , which accounted for 70.1 % of the anaemic cases . The findings showed that the reduction in serum ferritin level and the increments in haemoglobin , serum iron and transferrin saturation were found to be significant among children allocated to the vitamin A group compared to those allocated to the placebo group ( p < 0.01 ) . Moreover , a significant reduction in the prevalence of IDA by almost 22 % than prevalence at baseline was reported among children in the vitamin A group compared with only 2.3 % reduction among children in the placebo group . In conclusion , vitamin A supplementation showed a significant impact on iron status indices and IDA among Orang Asli children . Hence , providing vitamin A supplementation and imparting the knowledge related to nutritious food should be considered in the efforts to improve the nutritional and health status of these children as a part of efforts to improve the quality of life in rural and aboriginal communities Background Soil-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 . Exp and ing 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 findings A two-arm , non-r and omized 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 sample s 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 ) . Conclusions This 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 r and omized 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 registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) Few prospect i ve studies of child growth and its determinants take place in programmatic context s. We evaluated the effect of Save the  Children 's ( SC ) community empowerment and nutrition program ( CENP ) on child growth , care , morbidity , empowerment , and behavioral determinants . This paper describes the research methods of this community-based study . We used a longitudinal , prospect i ve , r and omized design . We selected 12 impoverished communes with documented child malnutrition , three comparison , and three intervention communes in each of two districts in Phu Tho Province , west of Hanoi . SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP , including situation analysis , positive deviance ( PD ) inquiry , growth monitoring and promotion , nutrition education and rehabilitation program ( NERP ) , deworming , and monitoring . PD inquiries aim to discover successful care practice s in poor households that likely promote well-nourished children . NERPs are neighborhood-based , facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors . We dewormed all intervention and comparison children . We weighed all children less than 24 months of age living in the intervention and comparison communes and r and omly selected 240 children ( 120 intervention and 120 comparison ) . We gathered information on nutritional status , diet , illness , care , behavioral determinants , empowerment , and program quality , monthly for six months with a re-survey at 12 months . We collected most information through maternal interview but also observed hygiene and program quality , and videotaped feedings at home . Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness Background More than a third of the world 's children are infected with intestinal nematodes . Current control approaches emphasise treatment of school age children , and there is a lack of information on the effects of deworming preschool children . Methodology We studied the effects on the heights and weights of 3,935 children , initially 1 to 5 years of age , of five rounds of anthelmintic treatment ( 400 mg albendazole ) administered every 6 months over 2 years . The children lived in 50 areas , each defined by precise government boundaries as urban slums , in Lucknow , North India . All children were offered vitamin A every 6 months , and children in 25 r and omly assigned slum areas also received 6-monthly albendazole . Treatments were delivered by the State Integrated Child Development Scheme ( ICDS ) , and height and weight were monitored at baseline and every 6 months for 24 months ( trial registration number NCT00396500 ) . p Value calculations are based only on the 50 area-specific mean values , as r and omization was by area . Findings The ICDS infrastructure proved able to deliver the interventions . 95 % ( 3,712/3,912 ) of those alive at the end of the study had received all five interventions and had been measured during all four follow-up surveys , and 99 % ( 3,855/3,912 ) were measured at the last of these surveys . At this final follow up , the albendazole-treated arm exhibited a similar height gain but a 35 ( SE 5 ) % greater weight gain , equivalent to an extra 1 ( SE 0.15 ) kg over 2 years ( 99 % CI 0.6–1.4 kg , p = 10−11 ) . Conclusions In such urban slums in the 1990s , five 6-monthly rounds of single dose anthelmintic treatment of malnourished , poor children initially aged 1–5 years results in substantial weight gain . The ICDS system could provide a sustainable , inexpensive approach to the delivery of anthelmintics or micronutrient supplements to such population s. As , however , we do not know the control parasite burden , these results are difficult to generalize . Trial Registration Clinical Trials.gov Introduction Soil-transmitted helminth infections are endemic in 114 countries worldwide , and cause the highest burden of disease among all neglected tropical diseases . The WHO includes women of reproductive age as a high-risk group for infection . The primary consequence of infection in this population is anaemia . During lactation , anaemia may contribute to reduced quality and quantity of milk , decreasing the duration of exclusive breastfeeding and lowering the age at weaning . To date , no study has investigated the effects of maternal postpartum deworming on infant or maternal health outcomes . Methods and analysis A single-centre , parallel , double-blind , r and omised , placebo-controlled trial will be carried out in Iquitos , Peru , to assess the effectiveness of integrating single-dose 400 mg albendazole into routine maternal postpartum care . A total of 1010 mother-infant pairs will be r and omised to either the intervention or control arm , following inhospital delivery and prior to discharge . Participants will be visited in their homes at 1 , 6 , 12 and 24 months following delivery for outcome ascertainment . The primary outcome is infant mean weight gain between birth and 6 months of age . Secondary outcomes include other infant growth indicators and morbidity , maternal soil-transmitted helminth infection and intensity , anaemia , fatigue , and breastfeeding practice s. All statistical analyses will be performed on an intention-to-treat basis . Ethics and dissemination Research ethics board approval has been obtained from the McGill University Health Centre ( Canada ) , the Asociación Civil Impacta Salud y Educación ( Peru ) and the Instituto Nacional de Salud ( Peru ) . A data safety and monitoring committee is in place to oversee study progression and evaluate adverse events . The results of the analyses will be published in peer- review ed journals , and presented at national and international conferences . Trial registration number Clinical trials.gov : NCT01748929 OBJECTIVE In stating the Millennium Development Goals , the United Nations aims to halve malnutrition around the world by 2015 . Nutritional status of the elderly population in low-income countries is seldom focused upon . The present study aim ed to evaluate the magnitude of malnutrition among an elderly population in rural Bangladesh . DESIGN AND SETTING Data collection for a multidimensional cross-sectional study of community-based elderly people aged 60 years and over was conducted in a rural area in Bangladesh . SUBJECTS Of 850 r and omly selected elderly individuals , 625 participated in home interviews .  Complete nutritional information was available for 457 individuals ( mean age 69+/-8 years , 55 % female ) .  Nutritional status was assessed using an adapted form of the  Mini Nutritional Assessment ( MNA ) including body mass index ( BMI ) . Age , sex , education , household expenditure on food and self-reported health problems were investigated as potential predictors of nutritional status . RESULTS BMI < 18.5 kg m(-2 ) , indicating chronic energy deficiency , was found in 50 % of the population . MNA revealed a prevalence of 26 % for protein-energy malnutrition and 62 % for risk of malnutrition . Health problems rather than age had a negative impact on nutritional status . Level of education and food expenditure were directly associated with nutritional status . CONCLUSION In order to reduce world hunger by half in the coming decade , it is important to recognise that a substantial proportion of the elderly population , particularly in low-income countries , is undernourished
Interestingly , the pure replication shows very similar impacts of the intervention on children in the intervention schools irrespective of whether they took the deworming medicine or not.7 For Miguel and colleagues , they term this as ‘ indirect within-school effects ’ of deworming , but equally the effects could be due to the non-specific effects of the health promotion interventions in the intervention schools .
In addition , the study shows that allocation to the deworming group does not influence student progress , as the re- analysis shows clearly no evidence of a difference in examination performance between deworming and control groups.7,8 In the context of the global evidence base , there is only one other study that has examined school attendance with no obvious effect shown.4 Given all these uncertainties , we simply do n’t know if there is truly an effect on school attendance from the data , in taking all these factors into account formally in a GRADE analysis .4 But what weakens the case of deworming still further is that there is now quite good evidence of no effect for most of the main outcomes ( Figure 1 ) , including nutritional status , haemoglobin , cognition and school performance .
This is important because without these effects it seems implausible that deworming itself would have an independent effect on school attendance or economic development .
The World Bank , the Gates Foundation and the World Health Organization promote national child deworming programmes in developing countries.1 They assert these programmes will improve nutritional status , health and school performance , and hence contribute to economic growth .
Indeed , the World Health Organization states that deworming contributed to Japan ’s economic boom in the 1950s,2 and Nobel Laureates meeting in Copenhagen ranked deworming as the fourth most important intervention to solve the health problems of the whole world.3 Surprisingly , the evidence base for these cl aims from controlled studies is limited .
Another trial in India showed benefit , but subsequent trials in the same area failed to show an effect.4,9 So deworming may have helped in these exceptional , heavily infected , untreated population s from another decade , but this is scarcely a solid base for contemporary policy : public health nutrition has changed , worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies .10 We have been perplexed by the un question ing belief behind deworming in the advocates , and have found it is deep rooted in American history .