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

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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?

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
Regional Technical Advisor South Asia
WaterAid

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

Dear Joe,

Thanks for your clarification. What had/has me confused in the Cohrane review is the following conclusion:

Treating children known to have worm infection may have some nutritional benefits for the individual. However, in mass treatment of all children in endemic areas, there is now substantial evidence that this does not improve average nutritional status, haemoglobin, cognition, school performance, or survival.

(my emphasis).

While in the table that summarizes their findings:
onlinelibrary.wiley.com/doi/10.1002/14651858.CD000371.pub6/full
They say the quality of the data is low or moderate. So how do they get to such a strong conclusion, from the data that they consider low/moderate in quality? As I said, this is probably somewhere in the report, but I don't have the time to dig it up.

In general the "worm wars" look pretty nasty to me. I don't really have anything to do with de-worming at the moment so I will leave it for what it is.

For me the conclusion is that de-worming alone is not going to solve the problem. So we need safe toilets as a first crucial step. Further, I still wonder how big transmission rates from animals (walking freely in villages) to humans are.

Regards

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

hajo wrote: Joe wrote:

That may explain why it is not enough to treat once but good enough to treat every 6 months (in living environments where worm infections are endemic).

ciao Hajo


I have no idea whether the size of the worms is related to medical complications, but can also imagine that it does. But if this is the case, one would think that a single dose that removed large worms would have a big effect, no?

Also, according to Cochrane, there is either not enough information or little evidence of a positive effect of multiple doses of medication when given on a widespread basis to children in areas where the worms are endemic.

Their rather startling point is that the medication does not seem to have any effect on the individual or the community, although they do not seem to have considered multiple doses on infected individuals.

Elsewhere I read that targeting deworming medication to infected children would cost 6-10 times more than treating all children.

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

Joe wrote:
‘Which isn't a great surprise if children are rapidly getting reinfected after they have received the medication.’

If I look at the pictures on Wikipedia (en.wikipedia.org/wiki/Helminthiasis) provided by Elisabeth, I can imagine that these worms have grown over quite some time and have affected the patients’ condition in multiple ways.

My assumption is that treating children every six months ensures that worms never reach numbers and sizes which can affect their wellbeing. I assume developers of the treatment have looked into the growth and multiplication rates of worms.

That may explain why it is not enough to treat once but good enough to treat every 6 months (in living environments where worm infections are endemic).

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

Marijn Zandee wrote: Dear colleagues,

That the review comes to the conclusion that the research into the effect of de-worming does not proof that mass de-worming is useful, I can understand. As mentioned above, I can quite easily accept that many of the trials were flawed in some way. What I do find harder to understand is that the reviewers come to a fairly firm conclusion that mass de-worming in not effective based on the same data. I wonder if this is just because they follow the convention that if you cannot prove that something has an effect you have to accept that it does not, or have they done more testing with the available research data which proves that mass de-worming in not effective?

Regards

Marijn


Hi Marijn, they have looked at published results they have decided are suitable for inclusion in the Cochrane review and have collated the overall message.

If anyone wants to check what I've said below, the article is open-access: onlinelibrary.wiley.com/doi/10.1002/14651858.CD000371.pub6/full

Finding 2 says that the data is too poor to know what the effect on infected children is of a single course of deworming medication in terms of weight, haemoglobin, cognition and physical wellbeing.

Finding 3 says that there is better quality information about the effects of giving a single dose of deworming medication to all children in an area where the helminths are endemic. They say there is "probably" no effect on weight gain or haemoglobin and "may be" little or no effect on cognition. And not enough information to make a judgement about well-being and school attendance.

Which isn't a great surprise if children are rapidly getting reinfected after they have received the medication.

In terms of their main finding, they say that the data is mixed in terms of the effects of multiple doses of medication on all children in endemic areas. They say there may be little or no effect on weight gain (low quality data), probably little effect on height (moderate data), little or no effect on haemoglobin (low quality), probably little effect on cognition (moderate), don't know about cognition or school attendance (v low quality data), probably little effect on school performance (moderate data), little or no effect on death (low quality).

It is hard to see these conclusions and see them saying anything other than that single doses of deworming tablets have little effect both on the individual and on a mass basis. They also seem to be suggesting even multiple doses on a mass basis have little measurable effect over not giving any treatment.

edit: in fact the main conclusion is "Current evidence does not support large public health programmes of deworming in developing countries."

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

Dear colleagues,

I am not a statistician, so I can also not judge the pure technicalities of the arguments. But here is my take:

First off all, this is not happening in a vacuum, there is a lot of debate within (medical) science about research standards. For example:

www.thelancet.com/pdfs/journals/lancet/P...40-67361560696-1.pdf

Despite the comments made in the article above, doing research at the level of medical science is very hard. This is especially true if you are doing the fieldwork in a developing country. Also, research at this level (controlled randomized trials, double blinding, etc.) is relatively new in development. That there are many studies from the last 10 years which do not meet the quality criteria of a Cochrane review is in my opinion not surprising.

One thing which I do find interesting is that there seems to be a strong disagreement between the medical and economical sciences. This disagreement suggests that in the economic sciences (which I think is the corner from which the introduction of randomized trials in development originated) the standards are less strict than in medical science.

I have no time to read the full Cochrane review article, but would be very happy if someone could help me with the following:

That the review comes to the conclusion that the research into the effect of de-worming does not proof that mass de-worming is useful, I can understand. As mentioned above, I can quite easily accept that many of the trials were flawed in some way. What I do find harder to understand is that the reviewers come to a fairly firm conclusion that mass de-worming in not effective based on the same data. I wonder if this is just because they follow the convention that if you cannot prove that something has an effect you have to accept that it does not, or have they done more testing with the available research data which proves that mass de-worming in not effective?

Regards

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

Thanks Hajo, that is very well explained.

I guess part of a debate might be about whether to treat sick children rather than to treat every child twice a year (or whatever it is). If, as you say, giving the medication to healthy children has no adverse effect, then I can believe there are economies of scale.

On the other hand, if this just becomes a box to tick, then the actual provision per child might be inadequate - for example if there are limited amounts of the medication and this only allows sick children to be treated once, when on average they need to be treated twice - meaning that treating healthy children is affecting the healthcare for the sickest.

It feels like handwashing must be similar. A recent trial found handwashing with soap and nail clipping had a dramatic effect on child illness. However it also found that there needed to be a lot invested (in terms of worker time etc) in regularly visiting children's homes to get the effect. So it is more than just about providing free soap and hygiene tuition to people.

Of course, we know this - I just wonder whether the costs calculated and the benefits accrued consider all of these extra costs. Maybe those who want to give the "greatest benefit" for the least cost look at information put out about handwashing and deworming and just end up delivering a single dose of medication or a limited supply of soap to every child. I am uncomfortable about programmes which try to provide a large number of people with a benefit, because the benefit offered is usually inadequate. I would rather supply a smaller number of people with something which is worth having.

I don't really see how handwashing can be considered without addressing drinking/washing water quality or deworming without considering sanitation.

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