How much evidence do we have that mass deworming of children really has much of an impact?

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  • joeturner
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

I have found a series of interesting articles which are arguing about whether randomised control trials (RCTs) - which are the only ones accepted by the Cochrane review - are really relevant in public health.

The first, by James Shelton, is an editorial in Global Health: Science and Practice.

Shelton concludes:

To achieve ambitious global health goals, such as ending preventable child and maternal mortality, we need evidence on the “how and when” of implementation at scale, in the face of vast real-world complexity and situational variability. Evidence arising within a specific program can help with better implementation in that setting. But beyond locally relevant learning, a major objective is identifying systematic patterns for wider application. Triangulating and otherwise bringing together evidence arising from different methodologies with sufficient detail to illuminate causal relationships is essential to applying such knowledge to real-world public health problems across diverse situations. When assessing public health evidence, WHO and others should move beyond predominant reliance on RCT evidence.


Evidence-based public health: not only whether it works, but how it can be made to work practicably at scale by Shelton in Global Health Science and Practice

The next is a response by Laurel Hatt and others:

RCTs do have well-documented limitations, some of which are outlined in Shelton's editorial, and conducting a randomized experiment may not always be possible even when it might be ideal. But one commonly made assertion is important to counter here—that RCTs have particularly burdensome cost requirements. Based on our experience, RCTs can be conducted for the same budget (or less) than pre-post or quasi-experimental design studies. In many instances, a baseline survey is not needed when interventions are allocated by random assignment


A False Dichotomy: RCTs and Their Contributions to Evidence-Based Public Health by Hatt et al in Global Health Science and Practice

Finally a response by James Shelton:

While I really do appreciate randomized studies, perhaps my biggest concern is the “hierarchy” whereby some colleagues place controlled trials at the top of a pyramid as manifestly the best evidence. For understanding public health programming, I see that as quite misguided. Randomized studies help us to understand some things, but they are only one piece of the picture in “triangulating” evidence for programming. And evidence from real-world programming is especially key.

Response to “A False Dichotomy: RCTs and Their Contributions to Evidence-Based Public Health” by Shelton in Global Health Science and Practice
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  • Bellamonse
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Re: FW: Children Without Worms Quarterly Dose Newsletter July 2015

Dear SUSANA colleagues,
I would like to forward this newsletter of the NGO ‘Children Without Worms', where the current discussion on mass deworming is addressed.
Best regards
Bella

Bella Monse
GIZ Philippines

Link to the newsletter:
www.childrenwithoutworms.org/quarterly-dose

or:
www.childrenwithoutworms.org/news?page=1

Begin forwarded message: (note by moderator: the newsletter forwarded below is not including the hyperlinks and images; please use the link to the newsletter given above to read the newsletter in its proper format.)

++++++++++++++++++++++++++

From: Children Without Worms <This email address is being protected from spambots. You need JavaScript enabled to view it.>
Subject: Children Without Worms Quarterly Dose Newsletter July 2015
Date: 30 Jul 2015 22:23:58 GMT+2
Reply-To: Children Without Worms <This email address is being protected from spambots. You need JavaScript enabled to view it.>

CWW Quarterly Dose Newsletter July 2015
View this email in your browser

Letter from the Director

The first half of 2015 has been a time of great productivity and action in the fight against soil-transmitted helminthiasis (STH) and other neglected tropical diseases (NTDs). This issue of the Quarterly Dose highlights major events and meetings during this period as well as the launch of the new Global NGO Deworming Inventory.

During the past week, though, in the midst of such positive momentum, STH has also received a great deal of mixed attention in the media. This attention was stimulated by the publication of a Cochrane Collaboration review on the benefits of mass deworming and a series of articles in the International Journal of Epidemiology that featured reanalyses of Miguel and Kremer’s 2004 article on the educational benefits of deworming. These articles were followed by a flurry of blogs, tweets, and op-eds, many with a sensational angle; some even claiming that deworming has been “debunked.” What are we to make of all of this? I offer a few words here and share further thoughts within this newsletter.

Read more.


What’s the deal here? Worms in the News
During the last few days, intestinal worms have received a great deal of attention in the media. This attention was stimulated by the publication of a Cochrane Collaboration review on the benefits of mass deworming and a series of articles in the International Journal of Epidemiology that featured reanalysis of Miguel and Kremer’s 2004 article on the educational benefits of deworming. These articles were followed by a flurry of blogs, tweets, and op-eds in the public media, many with a sensational angle. What are we to make of all of this?

Read more.


Summit Session Produces Roadmap for School-age Children Deworming
On June 26, 2015, in a meeting room at the Royal Institution of Great Britain in London, 23 major players in school-age deworming came together to identify barriers and create a roadmap for scaling up deworming using the school platform. A Summit Session on School-Age Deworming was organized by the World Health Organization, the Children’s Investment Fund Foundation, the School-Age Children Workstream of the STH Coalition, and Children Without Worms (CWW).

Read more.


Share Data for the Global NGO Deworming Inventory
At the request of the World Health Organization (WHO) and with the endorsement of the STH Coalition and the Global Schistosomiasis Alliance, CWW will be collecting data for the Global NGO Deworming Inventory. If your organization participates in deworming activities, please share your data with us, starting on Aug.4, atwww.deworminginventory.org.

The Global NGO Deworming Inventory complements WHO’s Preventive Chemotherapy (PCT) Databank by collecting district-level data on NGO deworming activities that treat soil-transmitted helminthiasis (STH) and schistosomiasis.

Read more.


Uniting to Combat NTDs Launches Third Progress Report
On June 25, 2015, the Uniting to Combat Neglected Tropical Diseases coalition held a launch event in London celebrating the release of its third progress report, Country Leadership and Collaboration on Neglected Tropical Diseases. CWW staff and members of the STH Coalition attended the event, which featured a variety of speakers from the NTD community.

Read more.


STH Coalition Contributes to ‘Green’ Rating in London Declaration Scorecard
The Uniting to Combat Neglected Tropical Diseases third progress report included a revised scorecard showing indicators and milestones for 10 NTDs. STH moved from yellow to green – meaning that we are now on target to meet the World Health Organization (WHO)’s roadmap targets for STH control.

Read more.


Progress Report Presents Focused Messages
The third progress report since the London Declaration, released on June 25, highlights the health and economic benefits of investing in NTDs and provides a snapshot of where each of the 10 NTDs of focus are in meeting WHO NTD roadmap targets.

Read more.


G7 Declares Commitment to Research, Control, and Treatment of NTDs
June 2015 may go on record as a pivotal time for building upon and creating additional momentum in the STH control community and in the larger NTD world. In addition to the third update to the London Declaration progress report and the summit session on school-age deworming, the Group of 7 (G7) committed to tackling NTDs by investing in research and development.

Read more.


Aug. 15 Deadline to Apply to WHO for PC Medicines
There’s an important deadline on the horizon in the NTD world: August 15 is the deadline for Ministries of Health (MoH) to apply to the World Health Organization (WHO) for preventive chemotherapy (PC) medicines.

Read more.


Upcoming Events

September 13-16, 2015
NTD NGDO Network (NNN) Annual Meeting
Abu Dhabi, UAE

October 22-23, 2015
Coalition for Operational Research on NTDs (COR-NTD) Annual Meeting
Philadelphia, PA

October 24-25, 2015
STH Advisory Committee Meeting
Philadelphia, PA

October 25-29, 2015
American Society of Tropical Medicine and Hygiene (ASTMH) Annual Meeting
Philadelphia, PA


Copyright © 2015 Children Without Worms, All rights reserved.

Our mailing address is:
325 Swanton Way, Decatur, GA 30030
www.childrenwithoutworms.org
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  • Marijn Zandee
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Dear Bella,

I clicked the link in your comment above, but somehow the most recent news letter I can access on the site is from May 2014 :( .

Kind regards

Marijn
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  • joeturner
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

I am not sure if it is accurate to describe Children Without Worms as an NGO - it is a collaboration between drug companies - primarily Johnson and Johnson - and the Taskforce for Global Health to enable the donation and use of deworming medication.

So I am not sure they are in a position to give much more than a loud endorsement of deworming programmes.
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  • Arjen
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Interesting topic!

This triggers a question from my side, if somebody has experience in linking a deworming campaign to an ODF declaration. In principle, ODF and proper hygiene ensures that contamination is no longer possible, but if people already have worms, they will not get better, and still be a possible source of contamination. This could be one of the reasons that various studies trying to link ODF with diminished stunting have not been very convincing.

As deworming is regarded as one of the most cost-effective interventions, it would make sense to deworm (for free?) a community as a first follow-up of an ODF declaration. Obviously, this needs to be well communicated and presented as a logical follow-up on being ODF and needs to be coordinated with the health departments.

Any thoughts or publications?
Arjen Naafs
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  • joeturner
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Hi Arjen - I'm not sure what you mean here, deworming involves medication which costs money to deliver. Typically the cost of delivery is around $1 per child per year for two courses of medication, including the donated medication.

So, I don't really see how it can be done "for free".

But I do see your point that tackling OD without also offering deworming might be ineffective.
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  • Arjen
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Sorry, for not explaining my thoughts further. First of all, doing deworming campaigns without attaining ODF and better hygiene behaviour is in a way set to fail - and ineffective.

Therefore, I am trying to link it to the many, large scale programmes for ODF that are present world wide - but very few have a clear strategy what should happen once a community/region is Open Defecation Free. The post-ODF discussion talks about cleaner environment and solid waste - but I have yet to hear that it has been linked to a deworming campaign. The "free" was indicative as many deworming campaigns are provided for free to the people. I take your point and appreciate the remark that it obviously still has a cost.

Many programmes are looking how to "reward"/"incentivise communities to become ODF. Providing deworming may be one of the ways (though deworming itself needs good messaging!)
Arjen Naafs
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  • joeturner
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Ah I see what you mean. Deworming as a reward for OD. I'm not sure what to think about that!
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  • Arjen
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

More as a natural follow-up of ODF. It seems a bit silly that we expect better health outcomes from ODF declarations - if people had worms before, they will have them after, unless we treat it / the whole community.

Let's see what others think of it! :-)
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  • Elisabeth
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Dear Marijn,
It took me a little while but here is now the link to the newsletter of "Children Without Worms":
us9.campaign-archive2.com/?u=69cf8aa7d0d...4aa944b&e=2de8f51cd1

Dear Joe,
Thanks for pointing out this potential conflict of interest... On their website, they don't really state that link clearly, do they? I checked on About Us and only found:

Children Without Worms was Created as a Partnership

Partnership and collaboration have been key tenets for Children Without Worms (CWW) since our inception in 2006. Those tenets are best personified by our team of compassionate, committed staff members.


Good old Wikipedia however tells me that:

Childred Without Worms (CWW) is a global collaborative health programme among two pharmaceutical giants, Johnson & Johnson and GlaxoSmithKline, and a nonprofit organisation, the Task Force for Global Health.


Dear Arjen and Joe,

I like the idea of combining mass deworming treatment with CLTS. I think you (Arjen) are right that if people have worms before then they will still have them after the latrines are built and used because once infected the worms stay in your body, don't they? Therefore, to start with a clean bill of health after triggering and after latrine use has started, by deworming all the children (and adults, too?) once or twice, would surely make some sense?

I am actually frustrated because it seems to me that the "deworming community" and the "sanitation community" are not yet talking to each other sufficiently. We both think we are doing good things for health but perhaps the real, measurable impacts only occur when we combine forces? Toilets AND deworming and not toilets without deworming, or deworming without toilets... (and toilets AND nutrition, too...)

Arjen, would you like to fill in your forum profile a bit more so that we know more about you and your work? Thanks.

Regards,
Elisabeth
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  • Marijn Zandee
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Dear Elisabeth,

Thank you for this link to CWW's news letter. They seem to have revamped their website, so maybe that is why it was hard to find things. The link between CWW and J&J and GS is still on the site under "partnerships and Advocacy"

Forging strong and productive partnerships and advocating for STH control are vital parts of the work of Children Without Worms (CWW). We started in 2006 as a partnership between Johnson & Johnson and The Task Force for Global Health. Since then, we have forged partnerships with others in the STH control community, including GSK, the Children’s Investment Fund Foundation, and more, through our work managing the STH Coalition and the STH Advisory Committee.


I get the impression that CWW is one of the driving forces behind the soil Transmitted Helminths (STH) coalition, which now also includes a number of WASH organizations.

The actual content of the CWW newsletter is a bit underwhelming, to say the least. I think one of the better worked out responses as to why deworming makes sense is given here:
blog.givewell.org/2015/07/24/new-dewormi...and-cochrane-review/

As far as I can make out, the people from Givewell agree with the Cochrane review that the evidence for short term health impact is weak. They also agree that there is currently no good explanation as to why people who were dewormed in these studies do better later in life, and that this lack of obvious cause-effect is problematic. However, they claim that the evidence that the people who were dewormed as children do better later in life is strong. This, combined with the relative cheapness of the programs is reason for Givewell.org to keep supporting deworming programs. ( I hope I summarized that correct :P)

Further, I also think that combining WASH interventions with deworming makes sense. As I have mentioned a few times before, I also wonder how many of these helminth infections are caused by a lack of animal manure management.

Regards

Marijn Zandee
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  • Elisabeth
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Re: How much evidence do we have that mass deworming of children really has much of an impact?

Dear Marijn,

You wrote:

As I have mentioned a few times before, I also wonder how many of these helminth infections are caused by a lack of animal manure management.


I think animal manure is only part of the life cycle of a few of the helminths but not of Ascaris for example whose eggs are in the human feces (not the animal feces, I think).
The number of all the different helminth types and their complicated life cycles is mind boggling...

With some helminths, humans get infected by eating raw or undercooked pork or beef if the animal was infected. For example Taeniasis is spread like this:
en.wikipedia.org/wiki/Taeniasis

Taeniasis is contracted after eating undercooked or raw pork and beef that contain the larvae. Cysticercosis occurs after ingestion of contaminated food, water, or soil that contain T. solium eggs.[14][15]


My general impression from reading about helminths is that as far as feces go, human feces are more dangerous for re-infection with helminths than animal faeces.
But I might be wrong.

More information here:
en.wikipedia.org/wiki/Helminths
and here:
en.wikipedia.org/wiki/Helminthiasis


By the way, with regards to that dispute about randomized controlled trials proving or not proving the evidence for health benefits of mass deworming, if anyone is interested in that, please read the discussion of Joe, James and others here:
en.wikipedia.org/wiki/Talk:Mass_deworming

Right now, this has come to a temporary halt. Nicole Siegmund told me that we are waiting for a WHO statement that should come out in 'PLoS Neglected Tropical Diseases' soon which would proably explain the shortcomings of RCT for this kind of public health issue. Once that's out, we can cite that in the Wikipedia article on mass deworming:
en.wikipedia.org/wiki/Mass_deworming#Evidence

Regards,
Elisabeth
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