The Millennium
Development Goals
The evidence is in: deworming helps meet theMillennium Development Goals Schistosomes and soil-transmitted helminths have Today, control of these infections can be achieved through few rivals in terms of prevalence. They occur regular treatment with inexpensive, single-dose and throughout the developing world, but are most highly effective drugs so safe they can be given to all commonly seen in the poorest communities. WHO groups at risk. Deworming drugs are almost irresistibly Preschool child receiving a deworming tablet in the Lao People’s Democratic Republic and impaired cognitive function. They do so at a critical settings is now feasible. Few other conditions, associated time in life: infection reaches maximum intensity in the with poverty and perpetuating poverty, can be so easily alleviated, for a fistful of pennies per person.1 Goal 1: Eradicate extreme poverty and hunger
Deworming boosts the prospects of school-age children to earn their way out of poverty.2,3 The improvements in
intellectual development and cognition that follow deworming have been shown to have a substantial impact on
professional income later in life. Studies conducted in the USA estimated the benefits of a hookworm-free
childhood at around 45% of adult wages.4 When these estimates are applied to a developing country like Kenya,
studies show that deworming could raise per capita income from the present US$ 337 per person to approxi-
mately US$ 490 per person.4,5 In Japan, successful deworming programmes in the 1950s are considered one
reason for the country’s subsequent economic boom.6
The impact of inadequate nutrient intake is amplified by worm infections, which interfere with nutrient uptake
and are a major cause of anaemia.7,8 Malnourished children become more malnourished when infected with
worms. The effects of deworming are dramatic, as illustrated by a large study conducted in India. Six-monthly
deworming was able – within two years – to prevent 82% of the stunting that occurs without intervention;
dewormed children showed a 35% greater weight gain.9
Goal 2: Achieve universal primary education
In 2003, a report to the United States Congress on the world economic situation concluded that in developing
countries treatment of schoolchildren with deworming drugs can reduce primary school absenteeism by 25%,
leading ultimately to higher wages.10 This finding agrees with data on United States schoolchildren, which
showed a 23% drop in school attendance in children infected with hookworm.4 Moreover, when compared with
other measures for improving school attendance, deworming was ranked as by far the most cost effective.2,3
The evidence is most compelling when viewed at the global level. Of the estimated 562 million school-aged
Deworming children in the developing world, worm infections are estimated to cause around 16 million cases of mental
retardation in primary school children and 200 million years of lost primary schooling.11 Goal 3: Promote gender equality and empower women
A girl’s best head-start in life is a good education. It is also her best chance of finding employment outside the
agricultural sector. Although the gender gap in education is slowly closing in the developing world, the percent-
age of boys in schools still outnumbers that of girls. Deworming programmes, especially when associated with
other simple measures such as school meals and take-home rations, have been shown to contribute to school The evidence is in: deworming helps meet the Millennium Development Goals 1 Savioli L et al. Schistosomiasis and soil-transmitted helminth enrolment by girls and to improve their drop-out and retention rates. In 2000 a infections: forging control efforts. Transactions of the Royal pilot project in Nepali schools, involving deworming tablets, a hot noon meal and Society of Tropical Medicine and Hygiene, 2002, 96:577–579.
2 Miguel E, Kremer M. Worms: identifying impacts on education food gifts for girls to take home, resulted in a 43% growth in school enrolment and health in the presence of treatment externalities (National by girls. In addition, anaemia vanished.12 Bureau of Economic Research Working Paper, 8481, 2001).
Econometrica (forthcoming).
Goals 4, 5: Reduce child mortality, improve maternal health
3 Kremer M. Randomized evaluations of educational programs in Worm infection weakens very young children in ways that increase their developing countries: some lessons. American Economic Re- view Papers and Proceedings (forthcoming).
vulnerability to infectious diseases. Recent studies conducted in areas where 4 Bleakley H. Disease and development: evidence from the Ameri- malaria is a major childhood killer show that deworming and the resulting can South. Journal of the European Economic Association, 2003, reductions in anaemia improve the chances of surviving severe malaria. The large 5 http://www.nationmaster.com/red/graph-B eco_gro_nat_ reductions in wasting malnutrition and anaemia that followed deworming contributed to the survival as well as development of these children.13–15 6 Hashimoto R, Former Prime Minister, Senior Foreign Policy Advi- Poor nutrition in general and anaemia in particular are the main underlying sor to the Prime Minister, Japan. Keynote speech – G8 Follow-UpInternational Symposium: Hashimoto Initiative – Global parasite causes of poor pregnancy outcomes in the developing world. By reducing control for the 21st century meeting report 27 March 2000.
anaemia, deworming drugs – which can be safely administered during pregnancy – contribute directly to 7 Stephenson L et al. Malnutrition and parasitic helminth infec- maternal survival.16,17 In anaemic women, the risk of dying during pregnancy or childbirth is up to 3.5 times tions. Parasitology, 2000, 121:S23–38.
8 Crompton DWT, Nesheim MC. Nutritional impact of intestinal higher than in non-anaemic women.18 Abundant evidence shows that regular deworming reduces anaemia in helminthiasis during the human life cycle. Annual Review of adolescent girls and women of childbearing age, thus preparing them for a healthier pregnancy.19 A large study of pregnant women in Nepal has shown that women given a deworming drug (albendazole, for Awasthi S et al. Effectiveness and cost-effectiveness of albendazolein improving nutritional status of pre-school children in urban treatment of soil-transmitted helminths) in the second trimester of pregnancy had a lower rate of severe slums. Indian Pediatrics, 2000, 37:19–29.
10 Annual report of the council of economic advisers. Economic Deworming also improves birth outcome. In 1989, a large study in Guatemala involving some 15 000 report of the President. Transmitted to the Congress February2003. Washington, United States Government Printing Office, pregnant women found a clear link between worm infection and retarded fetal growth.21 In the Nepal study, birth weight of infants born to women receiving two doses of albendazole rose by 59 g. More important, 11 Bundy DAP et al. School health and nutrition programs. In: infant mortality at 6 months fell by 41%.20 In Sri Lanka, a study showed that deworming during pregnancy Disease control priorities in developing countries, 2nd ed. WorldBank and Oxford University Press, in press:chapter 61.
resulted in a 42% reduction in the proportions of stillbirths and perinatal deaths and a 52% reduction in 12 Khanal P, Walgate R. Nepal deworming programme ready to go worldwide. Bulletin of the World Health Organization, 2002,80:423–424.
The evidence is even more compelling for schistosomiasis, which affects an estimated 10 million pregnant 13 Stoltzfus RJ et al. Effects of the Zanzibar school-based deworming women in Africa alone. Recent studies show that half of these women suffer from anaemia.23 These figures program on iron status of children. American Journal of Clinical demonstrate the enormous scale of the impact that deworming can have on the survival of both pregnant women and their babies. Fortunately, praziquantel, the drug of choice for schistosomiasis, can be safely Stoltzfus RJ et al. Malaria, hookworms and recent fever are re-lated to anaemia and iron status indicators in 0- to 5-y old Zanzibari given to women at any time during their pregnancy.24,25 children and these relationships change with age. Journal ofNutrition, 2000, 130:1724–1733.
Goal 6: Combat HIV/AIDS, malaria and other diseases
15 Stoltzfus RJ et al. Low dose daily iron supplementation improves While worm infections do not cause the same high mortality as that of AIDS and malaria, they do number iron status and appetite but not anemia, whereas quarterly anthelmin-thic treatment improves growth, appetite and anemia in Zanzibari among the “other diseases” that impair the health, physical and mental development, and productivity of huge preschool children. Journal of Nutrition, 2004, 134:348–356.
numbers of the poor. In so doing, they anchor large populations in poverty. Reducing worm infections and other 16 Reduction of maternal mortality (a joint WHO/UNFPA/UNICEF/ ancient companions of poverty builds the very foundation for good health and – in the spirit of the Millennium World Bank statement). Geneva, World Health Organization, 1999.
17 Savioli L et al. Use of anthelminthic drugs during pregnancy.
Development Goals – contributes to human progress.
American Journal of Obstetrics and Gynecology, 2003, 17:29–31.
Evidence that worm infections may influence the clinical burden of AIDS and malaria is just beginning to emerge.
18 Brabin B et al. Anaemia prevention for reduction of mortality in One recent study indicates that worm infections disrupt the immune response in ways that could hasten the mothers and children. Transactions of the Royal Society of Tropi-cal Medicine and Hygiene, 2003, 97:36–38.
progression from HIV infection to AIDS.26 The impact of deworming on improved educational outcome also 19 Report of the WHO informal consultation on hookworm infection contributes to the “social vaccination” against HIV infection.27 Another recent study found that malaria attacks and anaemia in girls and women, 5–7 December 1994. Geneva, were more frequent in persons infected with intestinal worms.28 While these studies need to be confirmed, the role World Health Organization, 1996 (WHO/CTD/SIP/96.1).
20 Christian P et al. Antenatal anthelminthic treatment, birthweight, of deworming in building good health during a critical period of life has been amply demonstrated.
and infant survival in rural Nepal. Lancet, 2004, 364:981–983.
21 Villar J et al. The effect on fetal growth of protozoan and helmin- Goal 8: Develop a global partnership for development
thic infection during pregnancy. Obstetrics and Gynecology, 1989, This goal includes a target, to be achieved in cooperation with pharmaceutical companies, of access to affordable, essential drugs in De Silva NR et al. Effect of mebendazole therapy during pregnancyon birth outcome. Lancet, 1999, 353:1145–1149.
developing countries. For worm infections, many studies have clearly 23 King C et al. Re-gauging the cost of chronic helminthic infec- shown that morbidity can be significantly reduced through repeated tion: meta-analysis of disability-related outcomes in endemic and regular treatment with single-dose drugs delivered through school 24 Report of the WHO informal consultation on the use of praziquantel health programmes. The drugs are safe, inexpensive and simple to during pregnancy/lactation and albendazole/mebendazole in administer, and thus ideally suited for mass administration.
children under 24 months, 8–9 April 2002. Geneva, World HealthOrganization, 2002 (WHO/CDS/CPE/PVC/2002.4).
Because such huge numbers are affected, the benefits of bringing Olds GR. Administration of praziquantel to pregnant and lactating these drugs to the masses in need is likewise huge. Systematic women. Acta Tropica, 2003, 86:185–195.
delivery of deworming drugs in sustainable ways is a pro-poor Healthy worm-free schoolchildren in Uganda 26 Fincham JE et al. Could control of soil-transmitted helminthic strategy with great potential for development. That potential is infections influence the HIV/AIDS pandemic. Acta Tropica, 2003,86:315–333.
further amplified by its suitability for integration with other mass-treatment programmes for diseases of the 27 De Walque D. How does the impact of an HIV/AIDS information poor – onchocerciasis, lymphatic filariasis, blinding trachoma, and the foodborne trematode infections.29 campaign vary with educational attainment? Evidence from rural As these are diseases of the poor, they frequently overlap, thriving under the conditions of poor hygiene and Uganda. World Bank, Development Research Group, WorkingPaper No. 3289, April 2004.
sanitation seen throughout the developing world. The challenge now is to rationalize existing control 28 Spiegel A et al. Increased frequency of malaria attacks in subjects programmes through integrated approaches that streamline delivery and bring down costs, thus allowing co-infected by intestinal worms and Plasmodium falciparum more of the world’s poor to benefit from essential drugs for ancient diseases.
malaria. Transactions of the Royal Society of Tropical Medicineand Hygiene, 2003, 97:198–199.
We would like to thank The Bill & Melinda Gates 29 Molyneux DH, Nantulya VM. Linking disease control programmes Foundation for their generous financial assistance in rural Africa: a pro-poor strategy to reach Abuja targets and which has made this publication possible.
millennium development goals. BMJ, 2004, 328:1129–1132.
World Health Organization 2005
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