Winning the war on worms

Last year, the World Health Organisation said approximately 1.5 billion people globally were at risk of contracting soil-transmitted helminth (STH) infections — or roundworms. That is, 270 million pre-school children and 600 million children of school-age live in areas where these parasites are intensively transmitted. India accounts for a quarter of the world’s STH-infected children; 64% of them are younger than 14 years. Because of the pronounced impact on child growth and development, the 54th World Health Assembly, in 2011, committed itself to reducing the prevalence and the intensity of soil-transmitted helminth infections in all countries by 50%. Recognising this challenge, India’s Ministry of Health and Family Welfare, in 2015, launched the National Deworming Programme under the National Health Mission, one of the largest fixed-day, mass drug administration public health programmes in the world, to reach out to over 230 million children by 2020. Primarily a school and Anganwadi-based initiative, this involves teachers and frontline health workers administering deworming tablets (Albendazole). This initiative has garnered many accolades globally, especially from public health advocates of neglected tropical diseases. Open defecation, contaminated soil and water, uncooked food, and not following basic hygiene are the main reasons for transmission (worm larvae and eggs). If undiagnosed, worms persist in the body and lay thousands of eggs every day. Worms cause a decline in iron, protein and vitamin A levels, leading to anaemia, a lower appetite, malnutrition, and diarrhoea. Though there have been impressive gains as far as the national deworming programme is concerned, there are some ways in which it can be improved. First, teachers and frontline workers are overburdened and under-incentivised to participate in the programme. Thus, the engagement of community volunteers, youth and the village health and sanitation committees needs to be planned. Second, there needs to be special focus on out-of-school children and adolescents through intensified outreach and also using peer-group and youth-group networks to administer the drug. Third, private schools need to raise awareness among parents and increase participation. Finally, the State departments (of health, women and child development, and education) must coordinate better and improve drug procurement and the timely delivery of drugs. The reach of mass drug administration is commendable, but what India needs to do on a war footing is to focus on preventive chemotherapy, improved sanitation facilities, enable access to clean/safe drinking water, and enable hygiene awareness. Since eradication of STH infections is difficult, given its faeco-oral and penetration-via-skin transmission patterns, the chances of re-infection are very high in population living in endemic areas. This is particularly a concern in regions with tropical climate with high humidity and warm temperatures such as Tamil Nadu, Andhra Pradesh, Bihar, Assam, and West Bengal and in cities that have seen unplanned urbanisation. In February 2018, India reached out to more than 266 million children through the National Deworming Day programme. State governments are also leveraging this programme to tackle health challenges such as anaemia and malnutrition by complementing it with other health programmes, for example, the Government of India’s Vitamin A as well as the Iron and Folic Acid Programme. The Swachh Bharat Mission has to a large extent addressed the issue of open defecation in many States, but we need to ensure that this rigour is maintained. Issues of clean drinking water, safe faecal sludge management, and safe waste disposal and recycling need to be prioritised. Alternatively, the problem of STH infections should also be considered as a part of India’s urbanisation and city-planning mandates.

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