The challenge of ensuring equity in mass deworming programmes
Authors: Peter Mark Jourdan, Fabrizio Tediosi
Journal: The Lancet Global Health (2019)

Preventing neglected tropical diseases (NTDs) through mass treatment of at-risk populations provides a cost-effective way of improving health equity in endemic countries.1WHOInvesting to overcome the global impact of neglected tropical diseases. World Health Organization, Geneva2015Google Scholar Considerable funds and human resources are invested in mass deworming of children and women of childbearing age in areas endemic of soil-transmitted helminthiasis; that is, infections with parasites, such as roundworms, whipworms, and hookworms.2Jourdan PM Lamberton PHL Fenwick A Addiss DG Soil-transmitted helminth infections.Lancet. 2018; 391: 252-265Summary Full Text Full Text PDF PubMed Scopus (311) Google Scholar Ministries of Health have together with UN agencies, philanthropic foundations, pharmaceutical companies, and non-governmental organisations, put in place large-scale programmes for dispatching deworming medication across vast areas of the world, with inherent challenges related to logistics, infrastructure, human resources, sociocultural issues, and even armed conflict and unrest. Tremendous advances have been made, and in 2017, close to 750 million people were reached yearly.3WHOSchistosomiasis and soil transmitted helminthiases: numbers of people treated in 2017. Weekly epidemiological record. World Health Organization, Geneva2018Google Scholar Nathan Lo and colleagues4Lo NC Heft-Neal S Coulibaly JT Leonard L Bendavid E Addiss DG State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study.Lancet Glob Health. 2019; (published online Sept 23)https://doi.org/10.1016/S2214-109X(19)30413-9Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar have estimated the equity of access to such deworming by analysing Demographic and Health Surveys data for over 820 000 children aged 1–4 years across 50 low-income and middle-income countries. The study includes analyses of data collected between 2004 and 2017, on the basis of mother-reported access to deworming for preschool age children. The findings suggest that deworming programmes did not consistently provide deworming equitably across geographical locations and wealth classes, indicating that children of wealthier families were more likely to be treated than others. The results also apply to countries that, in line with the WHO goal, have reported more than 75% national coverage. The study draws attention to the need to assess the equity of access to deworming, in order to further strengthen and improve the efficacy and cost-effectiveness of such programmes. Although it has been argued that an average NTD service coverage indicator might serve as a measure of equity in the progress towards universal health coverage,5Fitzpatrick C Bangert M Mbabazi PS et al.Monitoring equity in universal health coverage with essential services for neglected tropical diseases: an analysis of data reported for five diseases in 123 countries over 9 years.Lancet Glob Health. 2018; 6: e980-e988Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar NTD specific equity metrics have yet to be included in regular NTD programme monitoring and evaluation. As such, Lo and colleagues' article is an important addition to the literature on global health equity. The success of large public health programmes depends on a complex interdependency between the many stakeholders involved in programme funding and organisation, including on-the-ground staff, and the many intermediaries involved in programme logistics. Such interdependency, as well as the relatively limited financial and human resources typically available for such programmes, has the potential to affect the way in which deworming is provided, and subsequently reported, evaluated and monitored. Various other factors associated with both supply and demand sides of deworming programmes, could also explain the findings by Lo and colleagues, including the motivation of health-care workers and community volunteers at the end of the supply chain. However, although some reports suggest that mismatches can occur between reported programme activities and actual treatments,6Worrell C Mathieu E Drug coverage surveys for neglected tropical diseases: 10 years of field experience.Am J Trop Med Hyg. 2012; 87: 216-222Crossref PubMed Scopus (34) Google Scholar other data suggest that sufficiently funded and well-organised programmes can be successful in providing equitable preventive chemotherapy.7Pullan RL Halliday KE Oswald WE et al.Effects, equity, and cost of school-based and community-wide treatment strategies for soil-transmitted helminths in Kenya: a cluster-randomised controlled trial.Lancet. 2019; 393: 2039-2050Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar Importantly, the study by Lo and colleagues found a correlation between deworming and vitamin A supplementation and three doses of the diphtheria-tetanus-pertussis vaccine. This finding indicates that key to addressing the challenge of equitable deworming will lie in strengthening integrated public health services, in line with the Sustainable Development Goal of universal health coverage by 2030. Further research is needed to determine whether the findings by Lo and colleagues might be supported by other studies, and whether the results are representative also for other age groups. Also, it remains unclear how simple and pragmatic the use of the suggested equity index might be in a programmatic context, and therefore how to accurately measure, assess, and address equitable access to mass deworming and, potentially, other NTD programmes.8Dean L Page S Hawkins K et al.Tailoring mass drug administration to context: implementation research is critical in achieving equitable progress in the control and elimination of helminth neglected tropical diseases in sub-Saharan Africa.Int Health. 2016; 8: 233-234Crossref PubMed Scopus (12) Google Scholar If the authors' findings do hold up, the question is whether there is room for readjusting NTD programmes to further improve access to deworming of those most in need. We declare no competing interests. State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional studySubstantial 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. Full-Text PDF Open Access