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Untapped Potential: How schools play a critical role in fighting NTDs
- 1. Untapped Potential: How Schools Play A Critical Role In Fighting NTDs Dr. Neeraj Mistry – April 16, 2012
- 2. What Are NTDs? 2 17 major chronic parasitic and related infectious diseases They cause high morbidity and disability but low mortality NTDs affect one in six people worldwide, primarily those in developing countries Subsistence farmers, their families and urban slum dwellers are commonly affected
- 3. 7 NTDs Cause Most of the Burden 3 7 of the 17 diseases cause 90 percent of the global health burden Lymphatic Ascariasis Trichuriasis Hookworm Schistosomiasis Filariasis Trachoma Onchocerciasis (Roundworm) (Whipworm) (Snail Fever/ (Elephantiasis) (River Blindness) Bilharzia) 1.2 billion 795 million 740 million 240 million 120 million 41 million 26 million Soil-transmitted helminthes (STH, Intestinal Worms)
- 4. NTDs and their Impact 4 Health—Can cause blindness, horrible swelling of the limbs, and even death. Education—Children with NTDs are often too sick to attend or perform well in school. Economic Development—NTDs are debilitating and prevent adults from working and caring for their families. Hunger and Nutrition—Anemia and malnutrition are common side effects of several NTDs. Women’s Empowerment—Most NTDs have more severe effects on women and girls.
- 5. Then: NTDs Addressed in Silos 5
- 6. Now: Integrated NTD Community 6 The NTD community is now moving towards integrated control because the diseases: Frequently overlap Are concentrated in under-served communities Share many features that make integrated technical guidance both feasible and cost-effective Integration is an opportunity for more efficient use of financial resources, staff, delivery systems, and opportunities for contact with populations
- 7. Current Methods for NTD Control Fight All 7 Diseases 7 DONATED DRUGS Mass Drug + Delivery Administration + Training + Community mobilization + Monitoring and evaluation USD $0.50 / per person per year
- 8. Pharmaceutical partners have donated billions of pills 8 Company Commitment Target(s) 2.2 billion tablets of Diethylcarbamazine Eisai Co. Ltd. Lymphatic filariasis (DEC) for 2014-2020 Sanofi/Eisai/BMGF 120 million DEC tablets 2012-2013 Lymphatic filariasis Over 2 billion tablets of Albendazole since Lymphatic filariasis and GlaxoSmithKline 1998; 1 billion tablets annually Soil-transmitted helminthes 50 million tablets of Mebendazole yearly Johnson & Johnson since 2007; now increased to 200 million Soil-transmitted helminthes annually Unlimited supply of Mectizan; Over 2.9 Onchocerciasis and lymphatic Merck & Co., Inc. billion tablets donated since 1987 filariasis 200 million tablets of praziquantel for Merck KGaA Schistosomiasis 2008-2020 Unlimited supply of azithromycin; Over 145 Pfizer, Inc. Trachoma million tablets of azithromycin since 1998
- 9. The Challenge: Bringing NTD Control to Scale 9 Many endemic countries do not have strong health infrastructure at the community level Geographic and socio-economic challenges make reaching the most marginalized and at-risk communities difficult How do we scale up this solution to NTD control?
- 10. Schools are Already Playing a Critical Role in Fighting NTDs 10
- 11. Schools are Already Playing a Critical Role in Fighting NTDs 11 “Children cannot go to school when they have worm infections, even if they do come to school, they cannot follow the lessons and leave early.” - Teacher at the Musekera Primary School , Rwanda
- 12. Deworming Programs Improve Physical Growth 12 Percentiles 17 17 PERCENTILES 97 16 16 90 15 75 15 14 50 14 13 25 10 13 12 12 3 Weight (kg) 11 11 Weight (kg) 10 10 9 9 8 8 7 7 6 6 5 5 4 4 Treatment for 2 days Thiabenazole for 2 days 3 3 2 2 0 0 33 6 6 99 1212 15 18 18 21 24 15 21 24 27 27 AgeAge (months) (months)
- 13. Deworming Programs Improve School Attendance 13 Controlling intestinal worms is estimated will help prevent 200 million years of lost primary schooling A study in Malaysia found that school absenteeism went down by 16% among Aboriginal children after a deworming campaign Controlling intestinal worms will also help children perform better in school A study in India among school children found hookworm infection was linked to lower cognitive function, even when controlling for socio-eco factors A study in Jamaica found that children who were treated against worms improved their scores on cognitive functions test to the level of children who were not infected within nine weeks.
- 14. Deworming Programs Lead to Positive Economic Outcomes 14 A study found that down the road the economic performance of children who received treatment is significantly greater At ages 20-26, children who had received deworming treatment worked 5.2 more hours per week, missed less work days do to sickness, had three more meals per month, and held higher wage professions.
- 15. Partners Buy into Deworming 15 International stakeholders have established programs and policies to include deworming FRESH Framework—WHO, World Bank, UNICEF, UNESCO, PCD, Save the Children Global Partnership for Education (GPE) World Food Programme (WFP) Small NGOs and Faith-based Groups Ministries of Education
- 16. Deworming Programs: Nepal’s Story of Success 16 The Ministry’s “Vitamin A Plus Programme” coupled deworming and vitamin A with remarkable results: Anemia fell 77% Moderate/severe anemia fell 90%
- 17. What’s Next? 17 Opportunity to leverage school infrastructure to control more diseases Using the school system for NTD treatment campaigns means reaching more children and entire communities with needed interventions Existing collaboration between MOH and MOE could become a platform for broader school health programs
Editor's Notes
- - Imagine how you feel after having given blood. If that was how you felt every day, it would have a major impact on your productivity, and well-being.- These diseases disproportionately affect the world’s poorest people/the “Bottom Billion”.
- -In some countries only one or two NTDs are endemic. - But in many countries, as many as 5, 6, or all 7 of the most common NTDs are present at the same.
- HEALTH—Blindness, swelling, genital lesions, even death in the case of schisto. Increased susceptibility to malaria, tuberculousis, and HIV/AIDS as well as hinder the treatment of these diseases.EDUCATION—Will talk more about this when we get to school-based deworming.ECONOMIC DEVELOPMENT—NTDs are debilitating and prevent adults from working and caring for their families. Evidence suggests that treating hookworm alone can increase future wage earnings by up to 43%.Lymphatic filariasis caused the loss of 3.8% of the potential labor inputs of men and 0.77% of the inputs of women in India.A study of workers in Egypt found those with schistosomiasis had lower quality of life and lower additional work hours.A study of female tea pickers in Bangladesh found helminth infection was associated with lower labor productivity and more sick daysHUNGER AND NUTRITION—Anemia and malnutrition are common effects of NTDs. Even when people have enough food to eat, parasitic worms rob them of these nutrients. This also comes into play significantly in the push for school-based deworming.WOMEN’S EMPOWERMENT—Pregnant women have a greater risk for infection, miscarriage, and death. Presence of gemale genital schisto makes women three times more likely to contract HIV/AIDS.- The impact of NTDs on so many aspects of life means that NTD control is really crucial to achieving the millennium development goals as well.
- - Each NTD basically had its own champion organization(s).- Ministries of Health worked on the various diseases individually.- Lots of good work was done but there wasn’t enough communication between the groups.- There was a realization that more could be accomplished by working together to fight these diseases.
- Mass Drug Administration (MDA)- A combination of pills – called a rapid impact package – can treat and prevent someone against all seven diseases.- This treatment can be delivered to the entire community in an endemic area once or twice a year until transmission is interrupted.
- Pharmaceutical industry partners have donated billion sof pills, enough o meet global treatment requirements for the most common NTDs.
- -Already many schools are fighting NTDs by providing deworming treatments- The health and education sectors recognize the burden of infection, and the incredible impact of treatment programs- These photos are from a deworming campaign in Bihar, India that was run across the state through the school system.
- - Teachers recognize the impact of worm burden.
- Soil-transmitted helminthes cause poor nutrition (and compound existing micronutrient deficiencies) - The vast endemicity –about 33% prevalence rate worldwide—of parasitic helminthes in impoverished areas amounts to a crippling burden on rural villages throughout the developing world where chronic infection and regular re-infection become the norm. - Soil-transmitted helminthes (STH) infections are among the greatest contributors to childhood diseases. - Infection with intestinal worms leads to micronutrient deficiency and iron-deficiency anemia, resulting in poor nutritional status and impaired growth (Hotez et al 2008). - STH infection takes a significant toll on vitamin A status as well, cutting liver stores in half, and depleting them to a negligible level within two years (Miller et al 2002). -In addition, ascariasis, the most common intestinal worm infections, is closely associated with vitamin A deficiency; it lives in the gut and interferes with proper absorption, which can trigger clinical malnutrition, particularly in children whose dietary intake of vitamin A is already very low (Albonico et al 2008).- There is also evidence that deworming treatment can reduce the likelihood of malaria infection in African children (Kirwan et al 2010).PRESCHOOL CHILDREN- Preschool children account for as many as 20% of the 2 billion people infected with STHs (Albonico et al 2008), leading to nearly 230 million cases in children less than 5 years old (Hotez 2008). - The most critical period for physical development, and the time when growth faltering is most likely to present, is between 6 and 24 months. This stage gravely overlaps with the time when STH infections begin to occur. - Nearly 200 million preschool age children are stunted; helminthes infections are a leading contributor to malnutrition among children of this age (Albonico et al 2008). - A cohort study in Brazil of children 2-7 years old, found that early infection was associated with a 4.6 cm height reduction by the age of 7 (Albonico et al 2008).
- Deworming leads to:Improved nutritional status, and les anemiaImproved cognitive abilitiesImproved school attendanceImproved school performance- A study in Malaysia among Aboriginal children in rural areas found that deworming reduced school absenteeism.- They study looked at 289 children and found that 94% of there were infected with at least one worm species (mostly low intensity). The children had never been a part of a deworming program before.- After treatment, school absenteeism was reduced by 16% on average. The impact was even greater on children with high intensity infections—before tx they were missing more days of school than the average.- A study in Indonesia looked at cognitive function and infection with hookworm among 432 children in 42 schools ages 8-13.- They found that hookworm infection explained significantly lower scores on tests of cognitive function (primarily working memory). They controlled for school, age, schio-economic status, parental education, sex, stunting, body mass index, haemoglobin concentration, ascariasis, and trichuriasis.- Additionally, they found that the interactions between hookworm and scores increased with age.- The study suggests that these effects on working memory can have consequences for a child’s reasoning ability and reading comprehension.- A study in Jamaica found that children who were infected with worms performed significantly lower than uninfected children on eight tests of cognitive function. - This study used a double blind placebo methodology.- Nine weeks after treatment there was no significant difference between the groups.
- Down the road, economic performance of children who receive treatment is significantly greaterMichael Kremer and Edward Miguel conducted a longitudinal study from 1998-2001, with a follow up in 2009.- The study was conducted in Kenya at 75 primary schools with 30,000 children.- Deworming was done 1 or 2x per year depending on prevalence.- Initial study results demonstrated that:- 52% of untreated children tested positive for worms vs only 25% in treated children. (reinfection possible explanation why treated still presented)- 25% reduction in school absences.Also decreases in school absences in siblings and neighboring schools (spill over effect).A follow up study in 2009 found 7,530 adults (20-25) from original child cohort.- A self reported result survey was done and found:- No significant change in BMI or height- School attendance increased 0.129 years- Years enrolled in school increased 0.279 years- Test scores increased 0.1 standard deviations- 3 extra meals/ month resulting from:- 12% increase in working hours (5.2 more hours per week)- 0.5 fewer work days missed to sickness- Higher wage profession
- Many international stakeholders are recognizing the incredible impact of worms on children’s educational potential and physical development and are responding through programmatic and policy changes.FRESH (Focusing Resources on Effective School Health) names deworming as one of the basic pillars of school health programs in the framework. FRESH is a framework for developing an effective school health component. This FRESH approach was launched at the same World Education Forum in Senegal, in 2000 where partners reaffirmed their commitment to EFA. It is backed by the World Bank, UNICEF, UNESCO, WHO, PCD, Save the Children, and many others.WFP includes deworming as part of their ‘essential package’. Their policy is to implement deworming campaigns along with their school feeding and other nutrition interventions wherever it is logistically feasible.GPE (Global Partnership for Education) puts deworming explicitly in their TA strategy, so all countries developing a plan to be funded by FTI must decide whether to include deworming or not.GPE is an actual multi-lateral, grant-making partnership. It was launched in 2002 to help low-income countries meet the education MDGs and the EFA goals. It is a platform for collaboration at the global and country levels. Developing countries commit to design and implement sound education plans while donor partners commit to align and harmonize additional support around these plans. Today there are 45 counties that participate in GPE.The World Bank is interested in incorporating heath programs in the FTI because it sees health as an education component.
- In Nepal the Ministry of Health coupled deworming with vitamin A supplementation in preschool age children with remarkable results.Post-campaign surveys reported coverage rates of 85 to 95 percent in different regions. AND results from survey revealed that the addition of deworming had not affected the vitamin A supplementation campaign, which maintained more than 95 percent coverage.-The prevalence of worm infections fell from 39% to 22% - a 43% reduction- The percentage of anemic children fell from 47% to 11% - a 77% reduction- The percentage of children with moderate or severe anemia fell from 21% to 2% - a 90% reduction
- - Successful school-based deworming programs have laid the groundwork for integrated NTD control activities.- There is an opportunity to leverage school infrastructure to control more diseases—using schools means reaching more children and entire communities.- It’s not only possible, it’s probable that we can eliminate/control all 7 NTDs by 2020.