Monthly Archives: August 2017

Essential ingredients: a framework for STH control programming

By Grace Hollister, Evidence Action (STH Coalition partner)

Parasitic worm infection, or soil-transmitted helminthiasis (STH), is one of the most prevalent causes of illness among the world’s poorest and most vulnerable populations, especially children. Close to a quarter of the world’s population is infected with at least one STH species, and globally an estimated 870 million children are at risk of infection[1].

Intestinal worm infections cause a range of symptoms, including intestinal blood loss resulting in anemia, and impaired cognitive and physical development. Indeed, by interfering with nutrient uptake, worm infections undermine children’s health and ability to learn, preventing them from reaching their full potential.

Mass drug administration, long the cornerstone of STH control efforts, is the use of deworming drugs to treat an entire population in a given geographic area, regardless of each individual’s infection status. Deworming drugs are safe, efficacious, and available free of charge for school-age children through generous pharmaceutical donations coordinated by the World Health Organization (WHO). Treatment reduces morbidity, particularly in heavily-infected children, and is strongly associated with improved health, learning potential, and long-term productivity. However, to ensure these positive effects, treatment coverage must be sufficient and occur regularly.

The good news is that increased investments in STH control are paying off. Between 2011 and 2015 (the most recent year for which data is available), treatment coverage doubled among school-age children, reaching 63%.[2][3]And that progress has put within reach the target set by the World Health Organization: 75% treatment coverage for school-age children globally by the year 2020.

STH Coalition partners are contributing to this work in a variety of ways. In collaboration with country governments, they’re supporting school-based treatment programs, integrating deworming with other NTD treatments, and, in the case of preschool-age children, combining deworming with the provision of nutritional supplementation.

Still, lest this good news lead to complacency, consider that measures of progress at a global level mask variability among and within countries. Some countries have yet to scale their treatment programs to all at-risk areas, while others have fallen short of their coverage targets. In addition, many deworming treatments are effectively provided through the administration of albendazole as part of treatment for lymphatic filariasis (LF), given the overlap in drugs between the two diseases. Many countries are successfully reaching their LF elimination goals, meaning that as LF efforts stop, treatment gaps may emerge.

It’s imperative that these gaps are immediately addressed, and three key objectives can help us, as a community, maintain focus on the outcome of interest: reduced morbidity from worms for those who stand to lose the most when infected.

  • Ensure consistent drug treatment coverage and compliance within countries by strengthening and maintaining scaled programs.
  • Increase understanding of the impact of programs on morbidity control through regular parasitologic monitoring.
  • Develop a comprehensive framework for sustained control efforts, containing the essential ingredients to enable quality programming in all at-risk areas.

We propose that a framework for quality programming should include:

  • Evidence of what works: Findings from further operational and implementation-focused research must feed back into program strategy and decision-making to ensure an evidence-based approach is widely implemented.
  • A supportive policy environment: Programs backed by solid policies can maintain political support over time. Policies should extend beyond the health sector alone to engage education and environmental issues such as access to safe water and sanitation.
  • Standard practices and tools: Key tools for specific programmatic aspects including training, program monitoring, and evaluation support for program scale up. Standard processes and procedures can support replication of promising practices across many countries.
  • Tailored modalities: There is not a one-size-fits-all approach; multiple models from which countries can choose and adapt to the local context should be developed.
  • Common metrics and measurement methodologies: Key indicators and agreed methodologies will facilitate collection of high quality coverage and epidemiological data and encourage data sharing to monitor progress.
  • Technical capacity: Effective morbidity control efforts require the use of mathematical modelling and epidemiologic assessment to track the intensity of infection. Building this technical capacity may require training within countries that have achieved some success with mass drug administration.
  • Financial and human resources: A lack of financial resources can impede scale up, hence the need for continued support to sustain long-term treatment strategies. Domestic resources alone are insufficient.
  • Partnerships: Strong relationships within and between all stakeholders are needed to leverage resources and expertise for maximum impact.

Aligning partners on the framework their potential related roles can help to keep STH control on track to meet the 2020 goals – and most importantly to ensure that at-risk children receive the treatment they deserve to lead healthy, productive lives.



[1] World Health Organization. Soil-transmitted helminthiases: Situation and trends. Global Health Observatory data. 2015.
[2]Weekly Epidemiological Record Nos. 49/50, 2016, 91, 585-600
[3]Weekly Epidemiological Record No. 14, 2013, 88, 145-152

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Progress, Partners and Promise: Mapping the Way Forward

It’s an oft-quoted adage that “if you can’t measure it, you can’t manage it.”

Nowhere is that maxim more firmly embraced than among the constellation of STH Coalition as they collectively advance the global goal of “elimination of STH as a public health problem.”

The WHO defines elimination of STH as a public health problem as achieving a prevalence of moderate-to-heavy STH infection of less than 1% among pre-school age children (1-4 years) and school-age children (5-14 years), key at-risk populations. Adoption of the goal of eliminating STH as a public health problem has in turn prompted changes in the way STH programs operate. Indeed, while STH programs have traditionally relied on the coverage of preventive chemotherapy as the measure of programmatic achievement, it’s clear that this intervention indicator does not measure the impact on STH. Going forward, and following years of deworming, countries are urged to implement regular parasitologic monitoring – a measure of the prevalence of infection intensity in a given area and population.

Last year, CWW partnered with the Government of Bangladesh to conduct parasitologic monitoring at the community level. The effort marks a major step forward for STH control in the country, allowing the government to address gaps in programmatic data and to strengthen decision-making around a range of interventions.

“Previously, we measured the prevalence of STH among the school-age children,” says Dr. Mohammed Jahirul Karim, Deputy Program Manager of the Filariasis Elimination and STH Control program in the Bangladesh Ministry of Health. “The WHO recommendation is still to survey this group. But we are taking a new approach – we are measuring the burden of disease in the population.”

That’s important, he says, because “if you do not assess the parasitologic burden in the community, in the entire population, then you will not be able to understand whether the reservoir is there.” If there is a transmission reservoir within the community – a continuous source of infection – “deworming will not be effective,” says Karim. “So we have to measure this, because we cannot do deworming indefinitely.”

One possible source of infection could be the use of open latrines in a community. That was the case in one upzilla in Bandarban district, one of two districts where community-wide parasitologic monitoring has already been implemented. “We found a 50% infection rate, so we took immediate action there. We instructed civil servant to close the latrines and improve sanitation.” Parasitologic surveys, supported by STH Coalition member Nutrition International, are planned for four additional districts in 2017.

For Bangladesh, eliminating STH remains a top priority, says Karim. “If a child is infected, she could have many complications, and the child is the future of the nation. We must be successful.”

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STH Coalition to Provide Opportunities for Strengthening National STH Programs

STH Coalition partners, and increasingly ministry of health-led national STH programs it supports, aim to achieve the WHO-defined goal of eliminating STH as a public health problem by 2020. To achieve this important goal, the Coalition advocates for a comprehensive approach to STH control. Such an approach relies, in part, on clear governmental policies. These policies may be directly related to STH control; for example, a policy on child health clearly states the government’s goal for STH control. While other necessary policies may address important contributing factors such as the provision of sanitation facilities in schools and homes.

To assist endemic country governments, and partners supporting them, to establish an enabling policy environment, CWW as the STH Coalition secretariat, drafted a tool to assess the existing national policy environment and identify clear gaps to address.

The Coalition will present a draft of the instrument during a session of the Neglected Tropical Disease NGO Network (NNN) annual meeting in September 2017.  We encourage interested national STH program managers and STH Coalition partners to attend the session.  In addition, we seek to identify national programs that are interested in providing input or piloting the assessment. For additional information please contact the STH Coalition secretariat at

A second NNN workshop will explore specific opportunities for improving data collection, analysis, and use. National STH programs increasingly recognize the essentiality of appropriate program monitoring to guide decision making and demonstrate progress toward the goal of elimination of STH as public health problem. STH Coalition partners, including national STH programs, will discuss their experiences in shifting from school-based to community-based program monitoring surveys. Additionally, they will describe data issues related to unprogrammed or private sector deworming – particularly for the preschool-age population.

We look forward to the participation of a wide range of STH Coalition partners at these workshops.

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