Mixed progress on preventive chemotherapy coverage among all children at risk of STH
Posted: March 2018
The World Health Organization (WHO) recommends countries with ≥20% prevalence of soil-transmitted helminthiasis (STH) at baseline administer preventive chemotherapy (PC) to preschool-age (PSAC: ages 1-4) and school-age children (SAC: ages 5-14). The related WHO target is ≥75% treatment coverage of PSAC and SAC in all countries requiring preventive chemotherapy (PC) by 2020. Ministries of health annually report PC coverage by risk group[i] to monitor progress toward the indicated target. Using publicly available WHO data, we analyzed progress in PC coverage among all children in countries requiring PC. The analysis considers any country reporting zero treatments or lacking reported data as not having conducted PC.
From 2006 to 2016, countries requiring PC for STH decreased from 130 to 103 (-21%),[i] while global treatment coverage[ii] for all children increased from 15% to 60% (Figure 1). In 2016, over 500 million children requiring PC received PC, an 18% increase from 2015. Of countries requiring PC in 2016, 50 (49%) treated PSAC and SAC (Table 1). Of countries requiring PC in 2016, 50 (49%) treated PSAC and SAC (Table 1). This is the highest proportion of countries treating both risk groups in a given year. However, the number of countries treating both risk groups has largely remained the same from 2006 (47) to 2016 (50). Data from the last three years bear this out; of 53 countries not providing PC to both risk groups in 2016, 38 (72%) also did not provide PC to both risk groups in 2014 or 2015.
Figure 1. Countries treating/not treating all children 1-14 years old and global PC coverage, 2006-2016. Coverage is calculated by dividing the number of children requiring PC and treated by the total number of children in need of PC.
In 2016, 20 (19%) countries treated only SAC and five (5%) only treated PSAC. Of these 25 countries, only 9 (36%) reached 75% PC coverage among all children. More than half of the countries treating both risk groups reached the 75% coverage target for all children in 2016. Considering all countries (N=103), regardless of which risk group(s) they treated, 35 (34%) reached the ≥75% PC coverage target for all children in 2016 (Figure 2). With the 2020 target quickly approaching, the failure to meet the coverage target in the majority of countries is obviously concerning. And while most countries (73%) conducted PC for at least one risk group in 2016, a marked 165 million (20%) children requiring PC live in countries not conducting any PC or in countries where their risk group did not receive PC.
Globally, PC coverage rates have increased substantially as have the number of children treated. The WHO strategy of focusing on countries with large numbers of at-risk children [iv] has been a key contributing factor to increased coverage. However, achievement of the WHO coverage target by 2020 is uncertain given, among other factors, the lack of treatment of both risk groups in most countries. It would be difficult to argue that a country unable to cover both risk groups – which share similar levels of risk – implements effective STH control programming. Partners should prioritize technical and financial support toward those countries that have been consistently unable to treat PSAC and SAC. Quantifying the exact impact of inconsistent PSAC and SAC treatment across years is not possible, given available data, but it is reasonable to assume that inconsistent targeting undermines progress. Failure to treat both risk groups leaves a large reservoir of infection negatively impacting the entire community. Finally, missing the target will mean millions of at-risk children go unreached, undermining achievement of the WHO goal of eliminating moderate-to-high intensity infections in all children.
*Inclusion of information in STH by the Numbers does not constitute “publication” of that information.
How many children needing deworming attend school?
Posted: January 2017
The WHO strategy for control of soil-transmitted helminthiasis (STH) focuses on routine preventive chemotherapy (PC) of all children (ages 1-14) in endemic areas. Schools offer a cost-effective platform to deliver PC to school-age children (SAC: ages 5-14), as they allow for ready access to much of the target population (i.e. school-enrolled children) and leverage existing infrastructure by enabling teachers to act as distributors. In 2015, 63% of the SAC requiring PC received treatment. While school-based PC has demonstrated its success in reaching large numbers of children, assuring treatment to out-of-school children remains a key challenge. In this article, we seek to estimate the number of SAC requiring PC not enrolled in school and thus, potentially unreached or difficult to reach through a school-based PC platform.
To quantify the out-of-school population, we compared WHO estimates of the number of SAC requiring PC by country to UNICEF estimates of the proportion of primary SAC not enrolled in school[1]. In addition to slight differences in age profiles used by the two databases, our ability to quantify the number of out-of-school children requiring PC is limited by uncertainty about the extent to which SAC requiring PC are represented in the national household surveys compiled by UNICEF (e.g. UNICEF data may represent the entire country while PC may only be required in parts of a country). However, notably nearly 63% of SAC requiring PC (excluding India) are from 44 (43%) countries where more than 85% of the total SAC population is considered at-risk of STH. Therefore, we expect a reasonable level of representation of SAC requiring PC using nationally representative UNICEF data.
Out-of-school data were available for 91% (93/102) of countries requiring PC – representing over 99% of the global SAC population at-risk of STH (Table 1). The proportion of out-of-school children ranged from under 1% (in four countries) to 75% (Somalia and South Sudan) (Figure 1). Based on these data, the number of out-of-school children requiring PC is substantial. An estimated 107 million (19%) SAC requiring PC are out-of-school worldwide; the majority of which are in Africa (51 million), South-East Asia (32 million) and the Eastern Mediterranean (19 million) (Table 1).
Out-of-school children are typically economically disadvantaged and have limited access to proper hygiene and sanitation. They exemplify STH advocacy messaging which frequently emphasizes the ‘pro-poor’ potential of PC, with the aim of assisting ‘the bottom billion.’ A platform – and global campaign – that excludes these children could fail to reach those with higher prevalence rates and intensity of infection relative to their school-attending peers.[2] Furthermore, the systematic under-treatment of out-of-school children could potentially ignore an important transmission reservoir, and thus, undermine global control efforts.
While ‘outreach activities’ (e.g. school-children accompanying their non-enrolled siblings and friends to school on a “treatment day”) can serve out-of-school children,[3],[4] improved PC program monitoring, such as coverage surveys and treatment reporting by enrollment status, are needed to monitor coverage and thus help ensure that those at greatest risk receive PC. Where programs consistently fail to reach out-of-school children, implementers and donors will need to consider other methods and platforms to cover this important population.
[1] UNICEF. http://data.unicef.org/topic/education/primary-education/
[2] Montresor et. al. 2001. School enrolment in Zanzibar linked to children’s age and helminth infection.
[3] WHO. 2012. Soil-transmitted helminthiases: progress report 2001-2020 and strategic plan 2011-2020. Page 17.
[4] WHO. 2011. Helminth control in school-age children: a guide for managers of control programmes. Page 34-35.
Timeliness of Treatment Reporting
Posted: August 2016
Timely, complete, and accurate monitoring of process indicators enables effective program management and provides evidence of programmatic progress. In STH control, preventive chemotherapy (PC) is the primary intervention for achieving the World Health Organization (WHO) goal of less than 1% of the world’s at-risk population with moderate-to-high intensity infection. To measure progress toward the WHO goal at the national and global levels, PC treatment reports should be accurate, timely, and include all target populations.[1]
Challenges to accurate and timely PC reporting include lack of coordination among PC delivery ‘platforms’ targeting different risk groups, inadequate data-sharing between sectors (e.g., education and health ministries, non-governmental organizations and government ministries), and health emergencies. Assembling reliable and timely treatment figures at the global level is a complex undertaking. This article briefly reviews timeliness of global reporting on PC coverage for STH. 
The WHO Weekly Epidemiological Record (WER) aims to provide rapid and accurate dissemination of programmatic and epidemiologic data. Annually, the WER summarizes the number of children reached with PC for STH. Treatment reports for 2009 to 2014 were, on average, published 15 months after the end of the calendar year (Table 1). A steady improvement in reporting timeliness occurred during the period. Nonetheless, because 2015 treatment data are still unreported, as of the publication of this newsletter, the most recent available PC data are over 20 months old. Of the 102 countries in need of PC for STH in 2014, 61 (61/102, 60%) and 56 (56/102, 55%) reported data in the WER report for SAC and PSAC, respectively (Table 2). (Note: WER also includes treatment reported from countries where PC for STH was not needed).
A comparison of 2014 PC coverage data in the WER and WHO PCT Databank suggests that five (5%) countries reported data on school-age children (SAC) after publication of the WER (Table 2). Furthermore, 2014 data on STH drug coverage were adjusted as late as March 2016 to accommodate newly available reports.
As noted above, timeliness of STH drug coverage reports has improved significantly since 2009. Continued improvement is needed, given the increased attention, resources, and scrutiny being given to STH control since the London Declaration in 2012. Partners rely on both WER and the PCT Databank for timely, accurate data on PC coverage. These data enable tracking of global and national PC coverage. Ongoing improvement in data timeliness and quality is our collective responsibility.
The reporting status of treatments for all children at-risk of infection
Posted: May 2016
The World Health Organization (WHO) aims to achieve 75% national treatment coverage of preschool-age children (PSAC: ages 1-4) and school-age children (SAC: ages 5-14) in all countries requiring preventive chemotherapy (PC; i.e. mass treatment) for STH by 2020. The WHO PCT Databank tracks annual treatments reported by national ministries of health; coverage data are reported annually in the WHO Weekly Epidemiological Record.  
From 2006 to 2014, the number of countries requiring PC for STH decreased from 130 to 102 (-22%), while treatment coverage for all children (ages 1-14) requiring PC increased from 13% to 47%. According to the Databank, 49 (48%) countries requiring PC for STH reported treatments for both age groups (i.e. complete reporting) in 2014. To date, this is the highest proportion of countries with complete reporting in a given year. Yet, non-reporting and incomplete reporting remain substantial barriers to reaching 75% global coverage. Slightly more than half of the countries did not report or had incomplete reporting. Of these, 12 (12/53, 23%) countries reported SAC treatments (5 countries with ≥75% SAC coverage) but did not report treatments for PSAC. Similarly, 12 countries reported PSAC treatments (9 countries with ≥75% PSAC coverage) but did not report SAC treatments.
To better understand recent trends in STH treatment coverage, CWW analyzed 2014 data to categorize the 49 countries with complete reporting as: a) “scaled up” – reached ≥75% coverage for both SAC and PSAC; or b) “scaling up” – did not reach ≥75% coverage for both SAC and PSAC. Only 12 (12%) countries reached the WHO target of at least 75% coverage for both age groups in 2014. These countries represented 6% (53 million) of the global target population of 851 million children. While the majority (52%) of countries requiring PC did not report or incompletely reported in 2014, 78% (658 million) of the children requiring PC reside in “scaling up” or “scaled up” countries.
The relatively high proportion of children in scaling-up and scaled-up countries supports the WHO strategy of focusing efforts to scale-up treatment on countries with the highest number of children at-risk of STH infection. The 10 countries with the highest burden represent nearly a third (547 million) of all children globally requiring PC in 2014. Surprisingly, in that year, reporting was incomplete for two of these countries.
While political will, resources, and effective coordination are essential for scaling-up deworming, improved reporting is also needed to track progress and guide program decision-making.
NTD Plans of Action
January 2016
A key World Health Organization (WHO)-defined STH milestone is that 100% of countries requiring preventive chemotherapy (PC) for STH have NTD plans of action (POA) by 2015. To measure this indicator, between December 2014 and August 2015 CWW collected national NTD POAs from WHO, national programs, and implementing partners. CWW was able to confirm POAs for 41 (39%) countries requiring PC for STH in 2014 (N=106) (Figure 1) of which 11 expired before December 31, 2014.
All confirmed NTD POAs included STH control, but a substantial proportion did not address important aspects of control efforts. For example, many plans failed to indicate a role for key sectors including WASH, nutrition, and education (Figure 2). In addition, only 16 (39%) NTD POAs had monitoring and evaluation plans. Given the growing global consensus that STH control should target both preschool (1-4 years old) and school age children (5-14 years old), it is notable that 16 (39%) POAs focused exclusively on school age children.
All countries requiring PC need POAs and many such countries need to strengthen existing plans. Children Without Worms is ready to work with any country, who so requests, to ensure such planning takes place in 2016.