Appropriateness of the current parasitological control target for hookworm morbidity: a statistical analysis of individual-level data
Authors: Malizia Veronica , Giardina Federica , de Vlas Sake J. , Coffeng Luc E. 
Published: March 2022

AbstractBackgroundSoil-transmitted helminths affect almost 2 billion people globally. Hookworm species contribute to most of the related morbidity. Hookworms mainly cause anaemia, due to blood loss at the site of the attachment of the adult worms to the human intestinal mucosa. The World Health Organization (WHO) aims to eliminate hookworm morbidity by 2030 through achieving a prevalence of moderate and heavy intensity (M&HI) infections below 2%. In this paper, we aim to assess the suitability of this threshold to reflect hookworm-attributable morbidity.Methodology/Principal FindingsWe developed a hierarchical statistical model to simulate individual haemoglobin concentrations in association with hookworm burdens, accounting for low haemoglobin values attributable to other causes. The model was fitted to individual-level data within a Bayesian framework. Then, we generated different endemicity settings corresponding to infection prevalence ranging from 10% to 90% (0% to 55% M&HI prevalence), using 1, 2 or 4 Kato-Katz slides. For each scenario, we estimated the prevalence of anaemia due to hookworm. Our results showed that on average, haemoglobin falls below the WHO threshold for anaemia when intensities are above 2000 eggs per gram of faeces. For the different simulated scenarios, the estimated prevalence of anaemia attributable to hookworm ranges from 0% to 30% (95%-PI: 24% - 36%) being mainly associated to the prevalence of M&HI infections. Simulations show that a 2% prevalence of M&HI infections in adults corresponds to a prevalence of hookworm-attributable anaemia lower than 1%.Conclusions/SignificanceOur results support the use of the current WHO thresholds of 2% prevalence of M&HI as a proxy for hookworm morbidity. A single Kato-Katz slide may be sufficient to assess the achievement of the morbidity target. Further studies are needed to elucidate haemoglobin dynamics pre- and post-control, ideally using longitudinal data in adults and children.Author summarySoil-transmitted helminths affect almost 2 billion people globally. About 65% of the related morbidity is attributable to hookworm infection, especially anaemia, which is caused by adult worms attaching to the intestinal mucosa of the human host to feed on blood. The World Health Organization (WHO) defines the target for the elimination of morbidity as reaching moderate-to-heavy intensity infections prevalence < 2%. In this paper, we aim to assess the suitability of the current WHO threshold to reflect hookworm-attributable anaemia. To this end, we developed a statistical model to simulate individual haemoglobin concentrations in association with hookworm burdens in adults, accounting for low haemoglobin values attributable to other causes, such as malnutrition and malaria. We used model outcomes to estimate the prevalence of hookworm-attributable anaemia in different endemicity scenarios. Our predictions suggested that anaemia is mainly associated to moderate-to-heavy intensity infection and that the 2% threshold corresponds to a prevalence of hookworm-attributable anaemia <1%. These results support the use of the current WHO threshold as a proxy for hookworm morbidity. Our predictions represent a first step towards better quantifying the prevalence of anaemia due to hookworm infection.