Global numbers of infection and disease burden of soil transmitted helminth infections in 2010

Stunting as a Risk Factor of Soil-Transmitted Helminthiasis in Children: A Literature Review

As a high-burden neglected tropical disease, soil-transmitted helminth (STH) infections remain a major problem in the world, especially among children under five years of age. Since young children are at high risk of being infected, STH infection can have a long-term negative impact on their life, including impaired growth and development. Stunting, a form of malnutrition in young children, has been long assumed as one of the risk factors in acquiring the STH infections. However, the studies on STH infection in children under five with stunting have been lacking, resulting in poor identification of the risk. Accordingly, we collected and reviewed existing related research articles to provide an overview of STH infection in a susceptible population of stunted children under five years of age in terms of prevalence and risk factors. There were 17 studies included in this review related to infection with Ascaris lumbricoides, Trichuris trichiura, hookworm, and Strongyloides stercoralis from various countries. The prevalence of STH infection in stunted children ranged from 12.5% to 56.5%. Increased inflammatory markers and intestinal microbiota dysbiosis might have increased the intensity of STH infection in stunted children that caused impairment in the immune system. While the age from 2 to 5 years along with poor hygiene and sanitation has shown to be the most common risk factors of STH infections in stunted children; currently there are no studies that show direct results of stunting as a risk factor for STH infection. While stunting itself may affect the pathogenesis of STH infection, further research on stunting as a risk factor for STH infection is encouraged.

Anti-Trichuris mucosal responses are maintained during H. bakeri co-infection despite impaired parasite expulsion

In endemic regions concurrent infection with multiple gastrointestinal (GI) helminth species is more common than single species infection. However, the majority of model helminth infections focus on single species infections leading to a lack of understanding of how co-infection influences anti-parasite immune responses. Here, we use a model co-infection of Trichuris muris (Tm) and Heligmosomoides bakeri (Hb) to investigate the effect of Hb on anti-Tm immune responses. We observed a complete impairment of Tm expulsion in immune competent C57BL/6 mice when co-infected with Hb. This was coupled with reduced cellularity in the colonic mesenteric lymph node (cMLN) proximal to the caecum, however, cMLN cytokine responses and caecal mucosal immune responses in co-infected mice were not significantly different from mice infected with Tm alone. Interestingly, in immune-compromised mice, we found co-infection resulted in enhanced growth and fecundity of female Tm parasites. These data suggest that during helminth-helminth co-infection, immune-independent signals between species may promote survival and growth.

Risk of acquiring Ascaris lumbricoides infection in an endemically infected rural community in Venezuela

Soil-transmitted helminths, such as Ascaris lumbricoides, are the most prevalent parasites globally. Optimal anthelmintic treatment for A. lumbricoides in endemically infected communities is challenged by several host-related and environmental factors influencing infection acquisition. We assessed the risk of A. lumbricoides (re)infection after treatment in a Venezuelan rural community. Individual merthiolate-iodine-formaldehyde-fixed faecal samples were collected from 224 persons before a single-dose pyrantel treatment and at 1, 3, 6, 9 and 15 months after treatment. Effects of age, sex and socioeconomic status (SES) on A. lumbricoides prevalence, eggs/gram faeces (EPG) and infection (re)acquisition were assessed using both generalised linear mixed-effects models and survival analysis. Pre-treatment A. lumbricoides prevalence was 39.7%. Higher prevalence was associated with younger age and lower SES. Higher EPG values were observed among young children. Median time to A. lumbricoides infection was six months after treatment: at 1, 3, 6, 9 and 15 months post-treatment, cumulative incidence was 6.7%, 18.9%, 34.6%, 42.2%, and 52.6%, respectively. Younger age, lower SES, and pre-treatment A. lumbricoides infection status showed significantly elevated hazard ratios. Mass drug administration protocols would benefit from considering these factors in selective treatment strategies and possibly more than just annual or biannual treatments in the target population.

Eukaryotic expression and immunogenicity of Ancylostoma ceylanicum calreticulin

Ancylostoma ceylanicum is a zoonotic soil-derived nematode that parasitizes human and animal intestines, causing malnutrition and iron-deficiency anemia. Calreticulin is a multifunctional protein involved in all stages of parasitic infection. Studies have found that parasites can secret calreticulin to regulate the host's immune response. To explore the immunogenicity of the eukaryotic expression plasmid of Ancylostoma ceylanicum calreticulin (Ace-CRT), we constructed a recombinant Ace-CRT eukaryotic expression plasmid (pEGFP-N3-Ace-CRT). Successful expression of the target protein in Human Embryonic Kidney (HEK) 293 T cells was confirmed by indirect immunofluorescence and Western blot analysis. BALB/c mice were immunized with pEGFP-N3-Ace-CRT plasmid. Measuring IgG antibody levels in immunized mice sera by ELISA showed that the recombinant plasmid stimulated IgG antibody production in mice. Spleen lymphocytes were collected from vaccinated mice to determine the proportion of T cell subsets and the expression levels of cytokines. Flow cytometry revealed that the percentage of CD3 + CD4+ and CD3 + CD8+ T cells in mice spleen in the immunization group was significantly higher than that in the control group. Recombinant plasmid immunization increased IL-4, IL-10, IL-12, and IL-13 expression while decreasing IL-5, IL-6, and INF-γ in mice spleens. These results indicate that the eukaryotic plasmid constructed in this study had good immunogenicity and mainly induced a T helper 2 response in the host, laying a foundation for screening candidate molecules for anti-hookworm vaccines.

Costs of community-wide mass drug administration and school-based deworming for soil-transmitted helminths: evidence from a randomised controlled trial in Benin, India and Malawi

OBJECTIVES

Current guidelines for the control of soil-transmitted helminths (STH) recommend deworming children and other high-risk groups, primarily using school-based deworming (SBD) programmes. However, targeting individuals of all ages through community-wide mass drug administration (cMDA) may interrupt STH transmission in some settings. We compared the costs of cMDA to SBD to inform decision-making about future updates to STH policy.

DESIGN

We conducted activity-based microcosting of cMDA and SBD for 2 years in Benin, India and Malawi within an ongoing cMDA trial.

SETTING

Field sites and collaborating research institutions.

PRIMARY AND SECONDARY OUTCOMES

We calculated total financial and opportunity costs and costs per treatment administered (unit costs in 2019 USD ($)) from the service provider perspective, including costs related to community drug distributors and other volunteers.

RESULTS

On average, cMDA unit costs were more expensive than SBD in India ($1.17 vs $0.72) and Malawi ($2.26 vs $1.69), and comparable in Benin ($2.45 vs $2.47). cMDA was more expensive than SBD in part because most costs (~60%) were 'supportive costs' needed to deliver treatment with high coverage, such as additional supervision and electronic data capture. A smaller fraction of cMDA costs (~30%) was routine expenditures (eg, drug distributor allowances). The remaining cMDA costs (~10%) were opportunity costs of staff and volunteer time. A larger percentage of SBD costs was opportunity costs for teachers and other government staff (between ~25% and 75%). Unit costs varied over time and were sensitive to the number of treatments administered.

CONCLUSIONS

cMDA was generally more expensive than SBD. Accounting for local staff time (volunteers, teachers, health workers) in community programmes is important and drives higher cost estimates than commonly recognised in the literature. Costs may be lower outside of a trial setting, given a reduction in supportive costs used to drive higher treatment coverage and economies of scale.

TRIAL REGISTRATION NUMBER

NCT03014167.

Population genomics of ancient and modern Trichuris trichiura

The neglected tropical disease trichuriasis is caused by the whipworm Trichuris trichiura, a soil-transmitted helminth that has infected humans for millennia. Today, T. trichiura infects as many as 500 million people, predominantly in communities with poor sanitary infrastructure enabling sustained faecal-oral transmission. Using whole-genome sequencing of geographically distributed worms collected from human and other primate hosts, together with ancient samples preserved in archaeologically-defined latrines and deposits dated up to one thousand years old, we present the first population genomics study of T. trichiura. We describe the continent-scale genetic structure between whipworms infecting humans and baboons relative to those infecting other primates. Admixture and population demographic analyses support a stepwise distribution of genetic variation that is highest in Uganda, consistent with an African origin and subsequent translocation with human migration. Finally, genome-wide analyses between human samples and between human and non-human primate samples reveal local regions of genetic differentiation between geographically distinct populations. These data provide insight into zoonotic reservoirs of human-infective T. trichiura and will support future efforts toward the implementation of genomic epidemiology of this globally important helminth.

The spatial-temporal distribution of soil-transmitted helminth infections in Guangdong Province, China: A geostatistical analysis of data derived from the three national parasitic surveys

BACKGROUND

The results of the latest national survey on important human parasitic diseases in 2015-2016 showed Guangdong Province is still a moderately endemic area, with the weighted prevalence of soil-transmitted helminths (STHs) higher than the national average. High-resolution age- and gender-specific spatial-temporal risk maps can support the prevention and control of STHs, but not yet available in Guangdong.

METHODOLOGY

Georeferenced age- and gender-specific disease data of STH infections in Guangdong Province was derived from three national surveys on important human parasitic diseases, conducted in 1988-1992, 2002-2003, and 2015-2016, respectively. Potential influencing factors (e.g., environmental and socioeconomic factors) were collected from open-access databases. Bayesian geostatistical models were developed to analyze the above data, based on which, high-resolution maps depicting the STH infection risk were produced in the three survey years in Guangdong Province.

PRINCIPAL FINDINGS

There were 120, 31, 71 survey locations in the first, second, and third national survey in Guangdong, respectively. The overall population-weighted prevalence of STH infections decreased significantly over time, from 68.66% (95% Bayesian credible interval, BCI: 64.51-73.06%) in 1988-1992 to 0.97% (95% BCI: 0.69-1.49%) in 2015-2016. In 2015-2016, only low to moderate infection risk were found across Guangdong, with hookworm becoming the dominant species. Areas with relatively higher risk (>5%) were mostly distributed in the western region. Females had higher infection risk of STHs than males. The infection risk of A. lumbricoides and T. trichiura were higher in children, while middle-aged and elderly people had higher infection risk of hookworm. Precipitation, elevation, land cover, and human influence index (HII) were significantly related with STH infection risk.

CONCLUSIONS/SIGNIFICANCE

We produced the high-resolution, age- and gender-specific risk maps of STH infections in the three national survey periods across nearly 30 years in Guangdong Province, which can provide important information assisting the control and prevention strategies.

Plasmodium falciparum coinfection is associated with improved IgE and IgG3 response against hookworm antigens

Background

Plasmodium falciparum and Hookworm infections are prevalent in West Africa and they cause iron deficiency anemia and protein malnutrition in Children. Immune response of these parasites interact and their interactions could have repercussions on vaccine development and efficacy. The current goal of hookworm eradication lies on vaccination. We evaluated the effect of P. falciparum coinfection and albendazole treatment on naturally acquired antibody profile against hookworm L3 stage larvae antigen.

Methods

In a longitudinal study, 40 individuals infected with Necator americanus only, 63 participants infected with N. americanus and P. falciparum, and 36 nonendemic controls (NECs) were recruited. The study was done in the Kintampo North Metropolis of Ghana. Stool and blood samples were taken for laboratory analyses. Serum samples were obtained before hookworm treatment and 3 weeks after treatment.

Results

The malaria-hookworm (N. americanus and P. falciparum) coinfected subjects had significantly higher levels of IgE (β = 0.30, 95% CI = [0.12, 0.48], p = 0.023) and IgG3 (β = 0.15, 95% CI = [0.02, 0.52], p = 0.004) compared to those infected with hookworm only (N. americanus). The N. americanus groups had significantly higher levels of IgG3 (β = 0.39, 95% CI = [0.14-0.62], p = 0.002) compared to the control group. Similarly, N. americanus and P. falciparum coinfected participants had significantly higher levels of IgE (β = 0.35, 95% CI = [0.70-0.39], p = 0.002) and IgG3 (β = 0.54, 95% CI = [0.22-0.76], p = 0.002). Moreover, albendazole treatment led to a significant reduction in IgE, IgA, IgM, and IgG3 antibodies against hookworm L3 stage larvae (p < 0.05).

Conclusion

P. falciparum is associated with improved IgE and IgG response against hookworm L3 stage larvae. Treatment with single dose of albendazole led to reduction in naturally acquired immune response against hookworm infection. Thus, P. falciparum infection may have a boosting effect on hookworm vaccine effectiveness.

Burden and factors associated with schistosomiasis and soil-transmitted helminth infections among school-age children in Huambo, Uige and Zaire provinces, Angola

BACKGROUND

Schistosomiasis and soil-transmitted helminths (STHs) contribute high disease burdens amongst the neglected tropical diseases (NTDs) and are public health problems in Angola. This study reports the prevalence, intensity and risk factors for schistosomiasis and STH infection in Huambo, Uige and Zaire provinces, Angola, to inform a school-based preventive chemotherapy program.

METHODS

A two-stage cluster design was used to select schools and schoolchildren to participate in parasitological and water, sanitation and hygiene (WASH) surveys across Huambo, Uige, and Zaire provinces. Point-of-care circulating cathodic antigen and urinalysis rapid diagnostic tests (RDTs) were used to determine the prevalence of Schistosoma mansoni and S. haematobium, respectively. Kato-Katz was used to identify and quantify STH species and quantify and compare with RDTs for S. mansoni. Urine filtration was used to quantify and compare with RDTs for S. haematobium. Descriptive statistics were used for prevalence and infection intensity of schistosomiasis and STH infection. Performance of RDTs was assessed through specificity and Cohen's Kappa agreement with microscopy. A multivariate regression analysis was used to determine demographic and WASH factors associated with schistosomiasis and STH infection.

RESULTS

A total 575 schools and 17,093 schoolchildren participated in the schistosomiasis survey, of which 121 schools and 3649 schoolchildren participated in the STH survey. Overall prevalence of S. mansoni was 21.2% (municipality range 0.9-74.8%) and S. haematobium 13.6% (range 0-31.2%), with an overall prevalence of schistosomiasis of 31.4% (range 5.9-77.3%). Overall prevalence of Ascaris lumbricoides was 25.1% (range 0-89.7%), hookworm 5.2% (range 0-42.6%), and Trichuris trichiura 3.6% (range 0-24.2%), with an overall prevalence of STH infection of 29.5% (range 0.8-89.7%). Ecological zone and ethnicity were factors associated with schistosomiasis and STH infection, with older age and female sex additional risk factors for S. haematobium.

CONCLUSIONS

Most municipalities met World Health Organization defined prevalence thresholds for a schistosomiasis preventive chemotherapy program. A STH preventive chemotherapy program is indicated for nearly all municipalities in Uige and select municipalities in Huambo and Zaire. The association between ecological zone and ethnicity with schistosomiasis and STH infection necessitates further evaluation of home and school environmental, sociodemographic and behavioural factors to inform targeted control strategies to complement preventive chemotherapy programs.

Interventions to improve water, sanitation, and hygiene for preventing soil-transmitted helminth infection

BACKGROUND

It is estimated that 1.5 billion people are infected with soil-transmitted helminths (STHs) worldwide. Re-infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours.

OBJECTIVES

To assess the effectiveness of WASH interventions to prevent STH infection.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 19 October 2021.

SELECTION CRITERIA

We included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non-random method (non-RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles and abstracts and full-text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non-RCTs. We used a random-effects meta-analysis to pool study estimates. We used Moran's I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 32 studies (16 RCTs and 16 non-RCTs) involving a total of 52,944 participants in the review. Twenty-two studies (14 RCTs (16 estimates) and eight non-RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty-one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non-RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non-RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non-RCTs); and one on the prevalence of S stercoralis (1 non-RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non-RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non-RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non-RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis. The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate-certainty evidence) and an OR of 0.71 amongst non-RCTs (95% CI 0.54 to 0.94; low-certainty evidence). All six of the meta-analyses assessing individual worm infection amongst both RCTs and non-RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome. We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA).

AUTHORS' CONCLUSIONS

Whilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.

Evaluation of Commercial Concentration Methods for Microscopic Diagnosis of Protozoa and Helminths in Human Stool Samples in a Non-Endemic Area

The diagnosis of intestinal parasitic infections still widely relies on microscopic examination of stools and requires reliable reagents and staff expertise. The ParaFlo® assays (Eurobio Ingen) are ready-to-use concentration methods for parasite egg detection, and they could improve reagent traceability and ease of manipulation. Ninety-three stool samples were analyzed with the ParaFlo® concentration methods and then compared with routine microscopic methods for protozoa and helminth detection: seventy-eight were analyzed with ParaFlo® Bailenger and in-house Thebault or Bailenger concentrations, and fifty-five were analyzed with ParaFlo®DC and the in-house merthiolate-formalin diphasic concentration (DC) method. Fully concordant results were obtained for 75%, 70%, and 69% of samples when comparing ParaFlo® DC and in-house DC, ParaFlo® Bailenger and in-house Bailenger, and ParaFlo® Bailenger and Thebault, respectively. The performances of the ParaFlo® assays did not differ statistically from that obtained with their in-house counterparts (Bailenger and DC) for the detection of protozoa, but ParaFlo® Bailenger performed significantly poorer than the Thebault method (p < 0.001). No statistical differences were observed between the commercial and in-house methods for helminth detection. These marketed concentration methods could be used in routine if combined with other techniques for protozoa detection.

Mapping the global distribution of Strongyloides stercoralis and hookworms by ecological niche modeling

Background

The WHO has established a control strategy for Strongyloides stercoralis in school-aged children as well as targets and to maintain control programs for Ascaris lumbricoides, Trichuris trichiura and hookworms. For an efficient development of control programs, it is necessary to know the target countries around the world, as well as the areas within each country where efforts should be focused. Therefore, maps that provide information on the areas at risk for soil-transmitted helminth (STH) infections on a national and sub-national scale would allow for a better allocation of resources.

Methods

We used the ecological niche models MaxEnt and Kuenm R library to estimate the global distribution of S. stercoralis and hookworms. We used occurrence points of both species extracted from surveys of two literature reviews and from the Global Atlas of Helminth Infection database, together with 14 raster maps of environmental variables.

Results

We obtained two raster maps with the presence probability of S. stercoralis and hookworm infections at a global level and then estimated the global population at risk to be 2.6 and 3.4 billion, respectively. The population at risk was also estimated at the country level using estimations for areas as small as 25 km². A relationship was found between the probability of the presence of S. stercoralis and its prevalence, and a raster map was generated. Annual precipitation, annual temperature, soil carbon content and land cover were the main associated environmental variables. The ecological niches of Strongyloides stercoralis and hookworms had an overlap of 68%.

Conclusions

Here we provide information that can be used for developing more efficient and integrated control strategies for S. stercoralis and hookworm infections. This information can be annexed to the study of other risk factors or even other diseases to assess the health status of a community.

Graphical Abstarct

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05284-w.

Higher helminth ova counts and incomplete decomposition in sand-enveloped latrine pits in a coastal sub-district of Bangladesh

Pit latrines are the most common latrine technology in rural Bangladesh, and untreated effluent from pits can directly contaminate surrounding aquifers. Sand barriers installed around the latrine pit can help reduce contamination but can also alter the decomposition of the fecal sludge and accelerate pit fill-up, which can counteract their benefits. We aimed to evaluate whether there was a difference in decomposition of fecal sludge and survival of soil-transmitted helminth (STH) ova among latrines where a 50-cm sand barrier was installed surrounding and at the bottom of the pit, compared to latrines without a sand barrier, in coastal Bangladesh. We assessed decomposition in latrine pits by measuring the carbon-nitrogen (C/N) ratio of fecal sludge. We enumerated Ascaris lumbricoides and Trichuris trichiura ova in the pit following 18 and 24 months of latrine use. We compared these outcomes between latrines with and without sand barriers using generalized linear models with robust standard errors to adjust for clustering at the village level. The C/N ratio in latrines with and without a sand barrier was 13.47 vs. 22.64 (mean difference: 9.16, 95% CI: 0.15, 18.18). Pits with sand barriers filled more quickly and were reportedly emptied three times more frequently than pits without; 27/34 latrines with sand barriers vs. 9/34 latrines without barriers were emptied in the previous six months. Most reported disposal methods were unsafe. Compared to latrines without sand barriers, latrines with sand barriers had significantly higher log10 mean counts of non-larvated A. lumbricoides ova (log10 mean difference: 0.35, 95% CI: 0.12, 0.58) and T. trichiura ova (log10 mean difference: 0.47, 95% CI: 0.20, 0.73). Larvated ova counts were similar for the two types of latrines for both A. lumbricoides and T. trichiura. Our findings suggest that sand barriers help contain helminth ova within the pits but pits with barriers fill up more quickly, leading to more frequent emptying of insufficiently decomposed fecal sludge. Further research is required on latrine technologies that can both isolate pathogens from the environment and achieve rapid decomposition.

Appropriateness of the current parasitological control target for hookworm morbidity: A statistical analysis of individual-level data

BACKGROUND

Soil-transmitted helminths affect almost 2 billion people globally. Hookworm species contribute to most of the related morbidity. Hookworms mainly cause anaemia, due to blood loss at the site of the attachment of the adult worms to the human intestinal mucosa. The World Health Organization (WHO) aims to eliminate hookworm morbidity by 2030 through achieving a prevalence of moderate and heavy intensity (M&HI) infections below 2%. In this paper, we aim to assess the suitability of this threshold to reflect hookworm-attributable morbidity.

METHODOLOGY/PRINCIPAL FINDINGS

We developed a hierarchical statistical model to simulate individual haemoglobin concentrations in association with hookworm burdens, accounting for low haemoglobin values attributable to other causes. The model was fitted to individual-level data within a Bayesian framework. Then, we generated different endemicity settings corresponding to infection prevalence ranging from 10% to 90% (0% to 55% M&HI prevalence), using 1, 2 or 4 Kato-Katz slides. For each scenario, we estimated the prevalence of anaemia due to hookworm. Our results showed that on average, haemoglobin falls below the WHO threshold for anaemia when intensities are above 2000 eggs per gram of faeces. For the different simulated scenarios, the estimated prevalence of anaemia attributable to hookworm ranges from 0% to 30% (95%-PI: 24% - 36%) being mainly associated to the prevalence of M&HI infections. Simulations show that a 2% prevalence of M&HI infections in adults corresponds to a prevalence of hookworm-attributable anaemia lower than 1%.

CONCLUSIONS/SIGNIFICANCE

Our results support the use of the current WHO thresholds of 2% prevalence of M&HI as a proxy for hookworm morbidity. A single Kato-Katz slide may be sufficient to assess the achievement of the morbidity target. Further studies are needed to elucidate haemoglobin dynamics pre- and post- control, ideally using longitudinal data in adults and children.

Status of Helminthic Infections in Residents around River Basins in the Republic of Korea for 10 Years (2011-2020)

The positive rate of Clonorchis sinensis is the highest among intestinal parasites in the Republic of Korea (Korea). More than 1.2 million people were at risk of C. sinensis infection in Korea in 2012. An intensive control program is being implemented for residents of the 5 major river basins to reduce helminthic infections, including C. sinensis infection. This study evaluated the continuous intensive control program for parasitic diseases including clonorchiasis in areas near the 5 major river basins in Korea over the past 10 years (2011-2020). A total of 335,020 fecal samples (one sample per resident) prepared by the modified sedimentation technic were microscopically examined. Those who expelled helminth eggs were treated with anthelmintics through local health centers and re-examined 3 months later. The overall positive rate of helminths egg was 7.1%. The annual positive rates were dramatically decreased from 14.4% (2011) to 5.9% (2020). The egg positive rate was highest in C. sinensis (5.3%), followed by heterophyid flukes (1.5%) and Trichuris trichiura (0.2%). The prevalence of C. sinensis was significantly higher in males (7.6%) than in females (3.7%), and the highest in the 50-59 years (7.0%) age group. Our results are beneficial to establish prevention and control policies against helminthiases including clonorchiasis in endemic areas in this country.

Detangling the Crosstalk Between Ascaris, Trichuris and Gut Microbiota: What´s Next?

Helminth infections remain a global public health issue, particularly in low- and middle-income countries, where roundworms from theTrichuris and Ascaris genera are most prevalent. These geohelminths not only impact human health but most importantly also affect animal well-being, in particular the swine industry. Host-helminth parasite interactions are complex and at the same time essential to understand the biology, dynamics and pathophysiology of these infections. Within these interactions, the immunomodulatory capacity of these helminths in the host has been extensively studied. Moreover, in recent years a growing interest on how helminths interact with the intestinal microbiota of the host has sparked, highlighting how this relationship plays an essential role in the establishment of initial infection, survival and persistence of the parasite, as well as in the development of chronic infections. Identifying the changes generated by these helminths on the composition and structure of the host intestinal microbiota constitutes a field of great scientific interest, since this can provide essential and actionable information for designing effective control and therapeutic strategies. Helminths like Trichuris and Ascaris are a focus of special importance due to their high prevalence, higher reinfection rates, resistance to anthelmintic therapy and unavailability of vaccines. Therefore, characterizing interactions between these helminths and the host intestinal microbiota represents an important approach to better understand the nature of this dynamic interface and explore novel therapeutic alternatives based on management of host microbiota. Given the extraordinary impact this may have from a biological, clinical, and epidemiological public health standpoint, this review aims to provide a comprehensive overview of current knowledge and future perspectives examining the parasite-microbiota interplay and its impact on host immunity.

Visualizing the Knowledge Domain in Health Education: A Scientometric Analysis Based on CiteSpace

OBJECTIVES

This study aimed to visualize the evidence in the global research on health education to better improve the nation's health literacy and to guide future research.

METHOD

We searched the Web of Science (Core Collection) electronic databases. The search strategies: topic: ("Health Education" OR "Education, Health" OR "Community Health Education" OR "Education, Community Health" OR "Health Education, Community") AND document: (Article) AND language:(English). Articles of evidence from January 2011 to December 2021 with those words in the title or abstract or keywords will be included in this review. We used the Citespace 5.6.R5 (64-bit) to investigate and determine the thematic patterns, and emerging trends of the knowledge domain, and presented a narrative account of the findings.

RESULT

We analyzed 10,273 eligible articles. It showed that BMC Public Health displays the most prolific journals. Author MARCO PAHOR is highlighted in health education. The University of Sydney has published the most studies about health education. The USA plays an important role in these studies. Specifically, the visualization shows several hotspots: disease prevalence surveys and a specific population of knowledge, attitude and practice surveys, health intervention, chronic and non-communicable management, youth-health action, sexual and reproductive health, and physical activity promotion. Furthermore, document co-citation analysis indicated that there are 10 main clusters, which means the research front in health education. Meanwhile, by the citation detected, COVID-19, has achieved universal health coverage in related studies, however, public health education and the health workforce might be more popular in the coming years.

CONCLUSION

Health education is an effective measure to shift the concept of public health and improve healthy living standards. The present study facilitates an extensive understanding of the basic knowledge and research frontiers that are pivotal for the developmental process of health education and allows scholars to visualize the identification modes and tendencies.

Urude R, Kadimbo J, Danboyi J, Miri E, Nute AW, Rakers L, Nebe O, Anyaike C, Weiss P, S. Noland G, Richards F. Impact of Three to Five Rounds of Mass Drug Administration on Schistosomiasis and Soil-Transmitted Helminths in School-Aged Children in North-Central Nigeria

Nasarawa and Plateau states of north-central Nigeria have implemented programs to control schistosomiasis (SCH) and soil-transmitted helminths (STH) in children since the 1990s. Statewide mapping surveys were conducted in 2013, when 11,332 school-aged children were sampled from 226 schools. The local government areas (LGAs) then received varying combinations of mass drug administration (MDA) for the next 5 years. We revisited 196 (87%) schools in 2018 plus an additional six (202 schools in total), sampling 9,660 children. We calculated overall prevalence and intensity of infection and evaluated associations with gender; age; behaviors; water, sanitation, and hygiene (WASH); and treatment regimen. Urine heme detection dipsticks were used for Schistosoma hematobium in both surveys, with egg counts added in 2018. Stool samples were examined by Kato-Katz for Ascaris lumbricoides, Trichuris trichiura, Schistosoma mansoni, and hookworm. Schistosomiasis prevalence among sampled students dropped from 12.9% (95% confidence interval [CI]: 11.1-14.9%) to 9.0% (95% CI: 7.5-10.9%), a statistically significant change (P < 0.05). In 2018, eight LGAs still had > 1% of children with heavy-intensity schistosome infections. Prevalence of STH infection did not significantly change, with 10.8% (95% CI: 9.36-12.5%) of children positive in 2013 and 9.4% (95% CI: 8.0-10.9%) in 2018 (P = 0.182). Heavy-intensity STH infections were found in < 1% of children with hookworm, and none in children with A. lumbricoides or T. trichiura in either study. The WASH data were collected in 2018, indicating 43.6% of schools had a latrine and 14.4% had handwashing facilities. Although progress is evident, SCH remains a public health problem in Nasarawa and Plateau states.

The first report on the prevalence of soil-transmitted helminth infections and associated risk factors among traditional pig farmers in Bali Province, Indonesia

Background and Aim:

Pigs are the main livestock commodity in Bali Province, Indonesia, where traditional farming practices are widely used. Traditional pig farmers are often closely associated with poverty and a perceived lack of knowledge regarding health and hygiene. Data on soil-transmitted helminthiasis (STH) and risk factors associated with STH worm infection among traditional pig farmers in Bali were previously unavailable. This study aimed to analyze the prevalence and risk factors for STH infections among traditional pig farmers in Bali Province, Indonesia.

Materials and Methods:

This study involved the fecal examination of 238 traditional pig farmers from all areas of Bali Province in Indonesia. In addition, several pig feces samples were combined into one pooled sample belonging to each farm. All fresh fecal samples were stored in a 5% formaldehyde solution before being analyzed using concentration flotation techniques. Subsequently, risk factors were determined through an interview and a questionnaire. The odds ratio (OR) and Chi-square tests were used to determine the risk factors associated with STH infections.

Results:

The result showed that there was a high prevalence of STH infections among traditional pig farmers and pig farms in Bali, with rates of 21.8% and 76.5%, respectively. This could be due to risk factors, such as personal hygiene (OR: 5.756; confidence interval [CI]: 2.96-11.193; p=0.00), sanitation (OR: 1.914; CI: 1.024-3.576; p=0.042), education level (OR: 7.579; CI: 2.621-21.915; p=0.00), household income (OR: 2.447; CI: 1.122-5.338; p=0.025), and occupation (OR: 2.95; CI: 1.356-6.415; p=0.006).

Conclusion:

The infections seen in farmers were distributed among hookworm, Ascaris spp., and Trichuris spp., at 15.1%, 9.2%, and 4.2%, respectively. The risk factors associated with infections of STH and Ascaris spp. were personal hygiene, home sanitation, education level, household income, and having a primary occupation as a traditional pig farmer. In contrast, personal hygiene, education level, and primary occupation were the only risk factors for hookworm infection, while personal hygiene and home sanitation were the risk factors associated with Trichuris spp. infection. The limitation of this study was that the number of samples was relatively small due to the difficulty of obtaining stool samples from traditional pig farmers, with many individuals refusing to provide their stool for inspection. We suggest that future research focus on identifying the species of worms that infect traditional pig farmers and to better identify the zoonotic link of STH transmission from pigs to humans.

Serum cytokine profile of pregnant women with malaria, intestinal helminths and HIV infections in Ibadan, Nigeria

Malaria, helminthiasis and HIV are widespread in developing countries taking a heavy toll on pregnant women. Due to similar environmental and human factors of transmission, they co-exist. The epidemiology and pathology of these diseases have been extensively studied but data on serum cytokine profile changes which is crucial in pregnancy is limited. The aim of this study was to evaluate the co-infections and their impact on peripheral blood cytokines. Blood and stool samples were collected from recruited 18-45-year-old pregnant women in different trimesters who were apparently healthy with no obvious complications in pregnancy. Pretested questionnaires were administered for personal and socio-demographic details. Malaria parasitemia in Giemsa-stained thick blood films was examined microscopically. Stool samples were screened for helminths using Kato-Katz method. Cytokine levels of TNF-α, IFN-γ, IL-1α, IL-2, IL-4, IL-6, IL-10, IL-12p70, IL-13 and IL-17 in 121 serum samples were determined using ELISA. Data were analysed using descriptive statistics and Mann-Whitney U test at α_0.05. Relative to the single infections, there were significant reductions in IFN-γ and IL-13 in second and third trimesters respectively in those with Plasmodium and helminth co-infection. IFN-γ and IL-17 were elevated while IL-1α and IL-12p70 were reduced in co-infection of helminths and HIV. Co-infection of Plasmodium and HIV in second and third trimesters showed significant elevations in IL-1α, IL-10 and IL-17 while TNF-α, IL-4 and IL-12p70 were significantly reduced. HIV in pregnancy and its co-infection with Plasmodium resulted in significant distortions in the cytokine profile. However, helminth and its co-infection with Plasmodium or HIV produced less changes in the cytokine profile.

Convergent evolution of a parasite-encoded complement control protein-scaffold to mimic binding of mammalian TGF-β to its receptors, TβRI and TβRII

The mouse intestinal helminth Heligmosomoides polygyrus modulates host immune responses by secreting a transforming growth factor (TGF)-β mimic (TGM), to expand the population of Foxp3⁺ T_regs. TGM comprises five complement control protein (CCP)-like domains, designated D1-D5. Though lacking homology to TGF-β, TGM binds directly to the TGF-β receptors TβRI and TβRII and stimulates the differentiation of naïve T-cells into T_regs. However, the molecular determinants of binding are unclear. Here, we used surface plasmon resonance, isothermal calorimetry, NMR spectroscopy, and mutagenesis to investigate how TGM binds the TGF-β receptors. We demonstrate that binding is modular, with D1-D2 binding to TβRI and D3 binding to TβRII. D1-D2 and D3 were further shown to compete with TGF-β(TβRII)₂ and TGF-β for binding to TβRI and TβRII, respectively. The solution structure of TGM-D3 revealed that TGM adopts a CCP-like fold but is also modified to allow the C-terminal strand to diverge, leading to an expansion of the domain and opening potential interaction surfaces. TGM-D3 also incorporates a long structurally ordered hypervariable loop, adding further potential interaction sites. Through NMR shift perturbations and binding studies of TGM-D3 and TβRII variants, TGM-D3 was shown to occupy the same site of TβRII as bound by TGF-β using both a novel interaction surface and the hypervariable loop. These results, together with the identification of other secreted CCP-like proteins with immunomodulatory activity in H. polygyrus, suggest that TGM is part of a larger family of evolutionarily plastic parasite effector molecules that mediate novel interactions with their host.

IL-27 Enhances γδ T Cell–Mediated Innate Resistance to Primary Hookworm Infection in the Lungs

IL-27 is a heterodimeric IL-12 family cytokine formed by noncovalent association of the promiscuous EBI3 subunit and selective p28 subunit. IL-27 is produced by mononuclear phagocytes and unfolds pleiotropic immune-modulatory functions through ligation to IL-27 receptor α (IL-27RA). Although IL-27 is known to contribute to immunity and to limit inflammation after various infections, its relevance for host defense against multicellular parasites is still poorly defined. Here, we investigated the role of IL-27 during infection with the soil-transmitted hookworm, Nippostrongylus brasiliensis, in its early host intrapulmonary life cycle. IL-27(p28) was detectable in bronchoalveolar lavage fluid of C57BL/6J wild-type mice on day 1 after s.c. inoculation. IL-27RA expression was most abundant on lung-invading γδ T cells. Il27ra^-/- mice showed increased lung parasite burden together with aggravated pulmonary hemorrhage and higher alveolar total protein leakage as a surrogate for epithelial-vascular barrier disruption. Conversely, injections of recombinant mouse (rm)IL-27 into wild-type mice reduced lung injury and parasite burden. In multiplex screens, higher airway accumulations of IL-6, TNF-α, and MCP-3 (CCL7) were observed in Il27ra^-/- mice, whereas rmIL-27 treatment showed a reciprocal effect. Importantly, γδ T cell numbers in airways were enhanced by endogenous or administered IL-27. Further analysis revealed a direct antihelminthic function of IL-27 on γδ T cells as adoptive intratracheal transfer of rmIL-27-treated γδ T cells during primary N. brasiliensis lung infection conferred protection in mice. In summary, this report demonstrates protective functions of IL-27 to control the early lung larval stage of hookworm infection.

Prevalence, intensity of infection and associated risk factors of soil-transmitted helminth infections among school children at Tachgayint woreda, Northcentral Ethiopia

BACKGROUND

Soil-transmitted helminths (STH) are one of the most common infections affecting underprivileged populations in low- and middle-income countries. Ascaris lumbricoides, Trichuris trichiura, and hookworm are the three main species that infect people. School children are the most vulnerable groups for STH infections due to their practice of walking and playing barefoot, poor personal hygiene, and environmental sanitation. However, evidence is limited in the study area. So, this study aimed to assess the current prevalence, infection intensity, and associated risk factors of STHs among school children in Tachgayint woreda, Northcentral Ethiopia.

METHODS

A cross-sectional study was conducted among school children of Tachgayint woreda from February to May 2021. The study participants were chosen via systematic random sampling. Stool samples were collected from 325 children and examined using the Kato-Katz technique. The data was analyzed using SPSS version 23. Binary and multivariable logistic regression analyses were used to identify the potential associated factors for STHs. An adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to measure the magnitude of the association. A P-value <0.05 was considered statistically significant.

RESULTS

The overall prevalence of STHs in this study was 36.0% (95% CI: 30.5-41.2%). Ascaris lumbricoides are the most prevalent species 89 (27.4%) followed by hookworm 14 (4.3%) and Trichuris trichiura 10 (3.1%). All of the infected school children had light-intensity of infections with the mean of eggs per gram (EPG) being 464.53. Lack of shoe wearing habit (AOR = 4.08, 95% CI: 1.29-12.88) and having untrimmed fingernail (AOR = 1.85, 95% CI: 1.06-3.22) were identified as risk factors for STH infections.

CONCLUSIONS

More than one-third of the school children were infected with at least one STH species and this indicates that STHs are still a health problem among school children in the study area. Therefore, periodic deworming, implementation of different prevention strategies, and health education programs should be regularly applied in the area.

The FAR protein family of parasitic nematodes

Fatty acid–and retinol-binding proteins (FARs) belong to a unique family of excreted/secreted proteins (ESPs) found exclusively in nematodes. Much of our understanding of these proteins, however, is limited to their in vitro binding characteristics toward various fatty acids and retinol and has provided little insight into their in vivo functions or mechanisms. Recent research, however, has shown that FARs elicit an immunomodulatory role in plant and animal model systems, likely by sequestering lipids involved in immune signaling. This alludes to the intricate relationship between parasitic nematode effectors and their hosts.

Reconstructing the history of helminth prevalence in the UK

Intestinal helminth parasites (worms) have afflicted humans throughout history and their eggs are readily detected in archaeological deposits including at locations where intestinal parasites are no longer considered endemic (e.g. the UK). Parasites provide valuable archaeological insights into historical health, sanitation, hygiene, dietary and culinary practices, as well as other factors. Differences in the prevalence of helminths over time may help us understand factors that affected the rate of infection of these parasites in past populations. While communal deposits often contain relatively high numbers of parasite eggs, these cannot be used to calculate prevalence rates, which are a key epidemiological measure of infection. The prevalence of intestinal helminths was investigated through time in England, based on analysis of 464 human burials from 17 sites, dating from the Prehistoric to Industrial periods. Eggs from two faecal-oral transmitted nematodes (Ascaris sp. and Trichuris sp.) and the food-derived cestodes (Taenia spp. and Diphyllobothrium latum syn Dibothriocephalus latus) were identified, although only Ascaris was detected at a high frequency. The changing prevalence of nematode infections can be attributed to changes in effective sanitation or other factors that affect these faecal-oral transmitted parasites and the presence of cestode infections reflect dietary and culinary preferences. These results indicate that the impact of helminth infections on past populations varied over time, and that some locations witnessed a dramatic reduction in parasite prevalence during the industrial era (18^th-19^th century), whereas other locations continued to experience high prevalence levels. The factors underlying these reductions and the variation in prevalence provide a key historical context for modern anthelmintic programs.

Parasitic worms (helminths) cause many health problems in poorer countries, particularly those in tropical and sub-tropical regions. In modern Europe these infections are very rare and mostly found in those travelling from endemic areas but this wasn’t always the case. Archaeological studies have detected eggs of parasitic helminths in numerous European sites. Key questions include how prevalent these infections were in past communities and whether (or when) these patterns changed over time? This paper addresses both of these questions using a large number of single grave samples from archaeological sites in England dating between Prehistoric and Industrial periods. Helminth infections were detected across all periods but the overall prevalence rates changed over time, being highest in the Roman and Late-Medieval periods. The Industrial period was interesting in that two of the three sites contained very few (or no) parasites whereas the third, London, contained high levels of infection. We discuss factors that may have contributed to the changing parasite landscape and how understanding these factors may influence efforts to control helminth infections in modern endemic areas.

Worms and bugs of the gut: the search for diagnostic signatures using barcoding, and metagenomics-metabolomics

Gastrointestinal (GI) helminth infections cause significant morbidity in both humans and animals worldwide. Specific and sensitive diagnosis is central to the surveillance of such infections and to determine the effectiveness of treatment strategies used to control them. In this article, we: (i) assess the strengths and limitations of existing methods applied to the diagnosis of GI helminth infections of humans and livestock; (ii) examine high-throughput sequencing approaches, such as targeted molecular barcoding and shotgun sequencing, as tools to define the taxonomic composition of helminth infections; and (iii) discuss the current understanding of the interactions between helminths and microbiota in the host gut. Stool-based diagnostics are likely to serve as an important tool well into the future; improved diagnostics of helminths and their environment in the gut may assist the identification of biomarkers with the potential to define the health/disease status of individuals and populations, and to identify existing or emerging anthelmintic resistance.

Mucosal Vaccination With Recombinant Tm-WAP49 Protein Induces Protective Humoral and Cellular Immunity Against Experimental Trichuriasis in AKR Mice

Trichuriasis is one of the most common neglected tropical diseases of the world's poorest people. A recombinant vaccine composed of Tm-WAP49, an immunodominant antigen secreted by adult Trichuris stichocytes into the mucosa of the cecum to which the parasite attaches, is under development. The prototype is being evaluated in a mouse model of Trichuris muris infection, with the ultimate goal of producing a mucosal vaccine through intranasal delivery. Intranasal immunization of mice with Tm-WAP49 formulated with the adjuvant OCH, a truncated analog of alpha-GalCer with adjuvanticity to stimulate natural killer T cells (NKT) and mucosal immunity, induced significantly high levels of IgG and its subclasses (IgG1 and IgG2a) in immunized mice. This also resulted in a significant reduction of worm burden after challenge with T. muris-infective eggs. The addition of QS-21 adjuvant to this vaccine formulation further reduced worm counts. The improved protection from the dual-adjuvanted vaccine correlated with higher serum antibody responses (IgG, IgG1, IgG2a, IgA) as well as with the induction of antigen-specific IgA in the nasal mucosa. It was also associated with the robust cellular responses including functional subsets of CD4 T cells producing IL-4, and cytotoxic CD8 T cells expressing granzyme B. The worm reduction achieved by mucosal immunization was higher than that induced by subcutaneous immunization. Intranasal immunization also induced a significantly higher nasal mucosa-secreted antigen-specific IgA response, as well as higher functional cellular responses including CD4⁺IL4⁺ (Th1) and CD8⁺GnzB⁺ (Th2) T cells, and antigen-specific INFγ-producing T cells in both spleen and MLNs and antibody-producing B cells (CD19⁺B220⁺/B220⁺GL7⁺). Mucosal immunization further induced long-term T lymphocyte memory with increased central (CD62L⁺CD44⁺) and effector (CD62L^-CD44⁺) memory subsets of both CD4 and CD8 T cells at 60 days after the last immunization. In summary, intranasal immunization with recombinant Tm-WAP49 protein induced strong protection versus murine trichuriasis. It represents a promising vaccination approach against intestinal nematodes.

Prevalence of soil-transmitted helminths infections among preschool and school-age children in Ethiopia: a systematic review and meta-analysis

BACKGROUND

There is a lack of comprehensive national data on prevalence, geographical distribution of different species, and temporal trends in soil-helminthiasis (STHs). Therefore, this study aimed to provide a summary and location of the available data on STHs infection among preschool and school-age children in Ethiopia.

METHODS

The search was carried out in Medline via PubMed, Scopus, Science Direct, Web of Science, and Google Scholar on data published between 1997 to February 2020 for studies describing the rate of STHs infection among preschool and school-age in Ethiopian. We followed the Patient, Intervention, Comparison, and Outcome (PICO) approach to identify the studies. Meta-regression was performed to understand the trends and to summarize the prevalence using the "metaprop" command using STATA software version 14.0 RESULTS: A total of 29,311 of the 61,690 children examined during the period under review were infected with one or more species of intestinal parasites yielding an overall prevalence of 48% (95% CI: 43-53%). The overall pooled estimate of STHs was 33% (95% CI: 28-38%). The prevalence was 44% (95% CI: 31-58%) in SNNPR, 34% (95% CI: 28-41%) in Amhara region, 31% (95% CI: 19-43%) in Oromia region and 10% (95% CI: 7-12%) in Tigray region. Soil-transmitted helminths infection rate has been decreasing from 44% (95% CI: 30-57%) pre-Mass Drug Administration (MDA) era (1997-2012) to 30% (95% CI: 25-34%) post-MDA (2013-2020), although statistically not significant (p = 0.45). A lumbricoides was the predominant species with a prevalence of 17%.

CONCLUSION

Southern Nations Nationalities and Peoples Region, Amhara, and Oromia regions carry the highest-burden and are categorized to Moderate Risk Zones (MRZ) and therefore, requiring MDA once annually with Albendazole or Mebendazole. The prevalence of STHs decreased after MDA compared to before MDA, but the decline was not statistically significant. A. lumbricoides was the predominant species of STHs among preschool and school-age children in Ethiopia. The high prevalence of STHs observed in this review, underscores the need for better control and prevention strategies in Ethiopia.

Anthelmintic Effect of Leucaena leucocephala Extract and Its Active Compound, Mimosine, on Vital Behavioral Activities in Caenorhabditis elegans

Helminth infections continue to be a neglected global threat in tropical regions, and there have been growing cases of anthelmintic resistance reported towards the existing anthelmintic drugs. Thus, the search for a novel anthelmintic agent has been increasing, especially those derived from plants. Leucaena leucocephala (LL) is a leguminous plant that is known to have several pharmacological activities, including anthelmintic activity. It is widely known to contain a toxic compound called mimosine, which we believed could be a potential lead candidate that could exert a potent anthelmintic effect. Hence, this study aimed to validate the presence of mimosine in LL extract and to investigate the anthelmintic effect of LL extract and mimosine on head thrashing, egg-laying, and pharyngeal pumping activities using the animal model Caenorhabditis elegans (C. elegans). Mimosine content in LL extract was confirmed through an HPLC analysis of spiking LL extract with different mimosine concentrations, whereby an increasing trend in peak heights was observed at a retention time of 0.9 min. LL extract and mimosine caused a significant dose-dependent increase in the percentage of worm mortality, which produced LC50s of 73 mg/mL and 6.39 mg/mL, respectively. Exposure of C. elegans to different concentrations of LL extract and mimosine significantly decreased the head thrashing, egg-laying, and mean pump amplitude of pharyngeal pumping activity. We speculated that these behavioral changes are due to the inhibitory effect of LL extract and mimosine on an L-type calcium channel called EGL-19. Our findings provide evidential support for the potential of LL extract and its active compound, mimosine, as novel anthelmintic candidates. However, the underlying mechanism of the anthelmintic action has yet to be elucidated.

Prevalence of Intestinal Protozoa and Soil Transmitted Helminths Infections among School Children in Jaragedo Town, South Gondar Zone of Ethiopia

Background

Parasitism is a relationship where one, the parasite, harms the host or lives at the expense of the host. Intestinal parasites (protozoa and STHs-soil-transmitted helminths) cause gastrointestinal tract infection in humans and animals. Intestinal parasitic infections (IPIs) predominate the tropics and subtropics and affect poor countries, where school children suffer the most. To prevent and control these infections, local risk factors must first be identified. The aim of the study was to determine the prevalence of intestinal parasitic infections and associated risk factors among school children in Jaragedo town schools, South Gondar Zone of Ethiopia.

Methods

A cross-sectional study was conducted from October 2018 to April 30, 2019, involving 396 students from one elementary and one secondary school. Stratified simple random sampling method was used. A questionnaire was prepared to collect sociodemographic and socioeconomic data of the study subjects. Stool samples were collected and examined using formalin-ether concentration technique. Data were analyzed using SAS software version 9.4. Descriptive statistics were used to give a clear picture of population characteristics. Logistic regression was also used to determine the relationship between dependent variables (primary infection) with independent (explanatory) variables using SAS software.

Results

Results showed that the overall prevalence of intestinal parasitic infections was 65.4%. E. histolytica was the most prevalent intestinal parasite (12–14%) followed by G. lamblia (8–9%); other parasites could not infect more than 5% of the study subjects. Generally, parasitism did not vary between the sexes. The logistic regression analysis showed that grade, level of students, water source, habit of consuming raw meat, and level of income had a strong effect on intestinal parasitic infection (P < 0.05). Other explanatory variables were not significant (P > 0.05). High prevalence of parasites indicates improper disposal of waste, low socioeconomic level, low living standard, and poor water quality.

Conclusion

Therefore, short-term and long-term intervention strategies are required to minimize rates of infection.

Evaluation of School-Based Health Education Intervention on the Incidence of Soil-Transmitted Helminths in Pupils of Rural Communities of Eastern Kogi State, North Central Nigeria

The negative impact of soil-transmitted helminths (STHs) in Nigeria is enormous, and it poses serious public health issues and concerns. This study was undertaken to investigate the impact of health education intervention on reinfection of STHs in pupils of rural schools of Kogi East, North Central Nigeria. A total of 10 schools with the highest prevalence of STHs at baseline were selected from the 45 schools assessed during the baseline survey. These 10 schools were randomly paired into two groups of 5 schools per group. Five schools were dewormed and given health education (DHE) intervention while the other 5 schools were dewormed only (DO) without health education. Reassessment of schools for reinfection was carried out for a period of 12 months. Data obtained were analyzed using descriptive statistics. Student's t-test was used to make comparison between interventions in the incidence of infections. Analysis was carried out at p < 0.05. Reinfection with STHs was observed from the 28th week (7th month) of both interventions with incidence of 0.29 (2 pupils) and 1.00 (7 pupils) in DO and DHE schools, respectively. In the 36th week (9th month), incidence observed in schools given DHE was 0.56 (5 pupils) while incidence of 0.89 (8 pupils) was observed in DO schools, and there was no significant difference (t = -1.000, p = 0.347) between the interventions. At 48th week (12th month), there was no significant difference (t = -0.547, p = 0.599) in incidence between the DHE and DO schools with incidence of 1.00 (12 pupils) and 0.83 (10 pupils), respectively. Hookworms had an incidence of 0.78 (7 pupils) at DHE schools and 0.56 (5 pupils) at DO schools in the 36th week while an incidence of 0.92 (11 pupils) and 0.83 (10 pupils) at DHE and DO schools, respectively, in the 48th week. Ascaris lumbricoides was only observed in DHE schools in a pupil with an incidence of 0.11 (1 pupil) and 0.08 (1 pupil) at 36th and 48th weeks. There was no significant difference in the prevalence of the parasites between DO and DHE intervention groups (p > 0.05). School-based health education intervention had no significant impact on STH incidence in pupils of rural schools in Kogi East. Community-based deworming should be encouraged alongside improvement in the water, sanitation, and hygiene infrastructures and practices at both school and home.

Hookworm re-infection rate and efficacy of single-dose albendazole among pregnant women in Debre Elias District, Northwest Ethiopia: A single-arm trial

Hookworm is one of the soil-transmitted nematodes causing anaemia and low birth weight in pregnant women. This study aimed to assess albendazole efficacy and re-infection rate among pregnant women. A community-based cross-sectional study was conducted from February to September 2021 in Debre Elias District. Albendazole (400mg) was administered to assess efficacy and hookworm re-infection rate. Though the cure rate of single-dose albendazole was 81.7%, with an overall egg reduction rate of 92.5%, the re-infection rate of hookworm 18–24 weeks post-treatment was substantial at 21.4%. More effective intervention measures are thus needed.

Impact of ivermectin mass drug administration on burden of soil-transmitted helminths in onchocerciasis control and elimination programs, Yeki district, southwest Ethiopia

Community-directed treatment with ivermectin (CDTi) is the primary strategy employed to control and eliminate human onchocerciasis in Ethiopia. After long-term mass distribution for onchocerciasis, ivermectin is expected to have additional benefits beyond the envisioned targets by reducing the burden of other co-endemic parasitic infections as to STHs. To date, studies focused on the collateral impact of CDTi on STH in Ethiopia are scanty. Two community-based cross-sectional surveys (baseline in 1997 and post-CDTi in 2017) were conducted to evaluate the impact of long-term CDTi employed to control and eliminate onchocerciasis on the burden of STH infections in Yeki district of southwest Ethiopia. Stool samples were collected and examined using Ritchie`s concentration and Kato-Katz techniques in the baseline and current study, respectively. Overall, 188(38.3%, 95% Confidence interval (CI) 34.1–42.7%) individuals were positive at least for any of the STH species from 491 study participants in the post-CDTi. The prevalence of A. lumbricoides, hookworms, and T. trichiura was 11.2% (95% CI 8.7–14.3%), 16.3% (95% CI 13.3–19.8%), and 29.9% (95% CI 26.1–34.1%), respectively. Individuals aged 5–9 years had a significantly higher prevalence of A. lumbricoides (Adjusted odds ratio (AOR) 6.5, 95% CI 1.7–25.4), T. trichuria (AOR 8, 95% CI 2.6–25.1), and any STH infection (AOR 5, 95% CI 1.7–14.7) than those of ≥ 51 years. Also, significantly higher prevalences of T. trichuria infection were observed in individuals aged 10–14 years (AOR 4.1, 95% CI 1.7–9.9), 15–20 years (AOR 3.1, 95% CI 1.2–8.1), 21–30 years (AOR 2.4, 95% CI 1.1–5.5), and 31–40 years (AOR 3.2, 95% CI 1.3–7.5) compared with those of ≥ 51 years. The prevalence of A. lumbricoides was significantly higher in males (AOR 0.5, 95% CI 0.3–0.9). Of the 491 study participants, only data from 400 individuals who had not been involved in a mass drug administration (MDA) with other STH anthelmintics were considered in the comparative analysis. Before CDTi, the prevalence of A. lumbricoides, T. trichiura, hookworm, and any STH infection was 47.1% (95% CI 41.6–52.7%), 3.3% (95% CI 1.8–5.9%), 37.9% (95% CI 32.7–43.5%), and 58.8% (95% CI 53.2–64.1%), respectively. Long-term CDTi considerably reduced the prevalences of A. lumbricoides and hookworm by 76.2% and 56.9%, respectively (p < 0.001). Nonetheless, CDTi did not affect the prevalence of T. trichiura infection and, in contrast, it was significantly higher in the current study (P < 0.001). Overall post-CDTi prevalence of any STH infection was considerably lower than reported in the baseline (p < 0.001). It is evidenced that long-term CDTi for onchocerciasis control and elimination had additional benefits by reducing the prevalence of STH infections specifically of A. lumbricoides and hookworm, but had no impact on infections with T. trichuria. Our finding of additional health benefits of large-scale ivermectin administration taking it will aid to increase positive engagement and sustain participation of communities during MDA campaigns, and strengthen governmental and non-governmental organizations (NGOs) support for the undergoing national onchocerciasis elimination program.

Hatching of parasitic nematode eggs: a crucial step determining infection

Although hatching from eggs is fundamental for nematode biology it remains poorly understood. For animal-parasitic nematodes in particular, advancement has been slow since the 1980s. Understanding such a crucial life-cycle process would greatly improve the tractability of parasitic nematodes as experimental systems, advance fundamental knowledge, and enable translational research. Here, we review the role of eggs in the nematode life cycle and the current knowledge on the hatching cascade, including the different inducing and contributing factors, and highlight specific areas of the field that remain unknown. We examine how these knowledge gaps could be addressed and discuss their potential impact and application in nematode parasite research, treatment, and control.

Important Nematodes in Children

Intestinal nematode infections caused by soil-transmitted helminths (STH), such as the roundworm Ascaris lumbricoides, the whipworm Trichuris trichiura, and the hookworms Ancylostoma duodenale, and Necator americanus, infect more than 1 billion people throughout the world. School-aged children tend to harbor the greatest numbers of intestinal worms, and as a result, experience more adverse health consequences, such as poor growth, anemia, and cognitive decline. Clinicians should maintain a high degree of suspicion in endemic areas when patients present with surgical abdomens, particularly children. Current antihelminthic drugs are moderately effective, but reinfection is possible. Global efforts are needed to eradicate STH infections.

Association between allergic sensitization and intestinal parasite infection in schoolchildren in Gqeberha, South Africa

Background

Inconsistent data exist regarding the influence of parasitic infection on the prevalence of allergic sensitization and disorders.

Objective

To investigate the impact of geohelminth and protozoan infections on sensitization patterns and allergic symptoms of children living in low‐income communities in Gqeberha, South Africa.

Methods

In a cross‐sectional study, 587 schoolchildren aged 8–12 years were recruited in June 2016 and screened for reactivity to common allergens by skin prick tests (SPTs) and for parasitic infections by stool examination. Additionally, questionnaires were completed to record allergic symptoms the children may have experienced.

Results

Positive SPTs were found in 237/587 children (40.4%), and about one‐third of whom were polysensitized. Sensitizations were most frequently detected against the house dust mites (HDM) Dermatophagoides spp. (31.9%) and Blomia tropicalis (21.0%). Infections with geohelminths (Ascaris lumbricoides, Trichuris trichiura) were found in 26.8% and protozoan infections (Giardia intestinalis, Cryptosporidia spp.) in 13.9% of study participants. Mixed logistic regression analyses revealed negative associations between parasite infection and sensitization to Blomia tropicalis (OR: 0.54, 95% CI 0.33–0.89) and to Dermatophagoides spp. (OR 0.65, 95% CI 0.43–0.96), and between protozoan infection and allergic sensitization to any aeroallergen, although these associations were not significant when adjusted for false discovery. Geohelminth infection and intensity of geohelminth infection were both associated with reduced risk of polysensitization (OR 0.41, 95% CI 0.21–0.86), and this association remained significant with adjustment for false discovery. Reported respiratory symptoms were associated with HDM sensitization (ORs from 1.54 to 2.48), but not with parasite infection.

Conclusions and clinical relevance

Our data suggest that geohelminth infection and high geohelminth infection intensity are associated with a reduced risk of polysensitization.

Disease Surveillance Among U.S.-Bound Immigrants and Refugees — Electronic Disease Notification System, United States, 2014–2019

Problem/Condition

Period Covered

Description of System

Results

Interpretation

Public Health Action

Helminth-virus interactions: determinants of coinfection outcomes

Viral infections are often studied in model mammalian organisms under specific pathogen-free conditions. However, in nature, coinfections are common, and infection with one organism can alter host susceptibility to infection with another. Helminth parasites share a long coevolutionary history with mammalian hosts and have shaped host physiology, metabolism, immunity, and the composition of the microbiome. Published studies suggest that helminth infection can either be beneficial or detrimental during viral infection. Here, we discuss coinfection studies in mouse models and use them to define key determinants that impact outcomes, including the type of antiviral immunity, the tissue tropism of both the helminth and the virus, and the timing of viral infection in relation to the helminth lifecycle. We also explore the current mechanistic understanding of how helminth-virus coinfection impacts host immunity and viral pathogenesis. While much attention has been placed on the impact of the gut bacterial microbiome on immunity to infection, we suggest that enteric helminths, as a part of the eukaryotic macrobiome, also represent an important modulator of disease pathogenesis and severity following virus infection.

The prevalence of human trichuriasis in Asia: a systematic review and meta-analysis

Trichuriasis is one of the most common soil-transmitted helminth (STH) infections, affecting populations globally. The condition is particularly prevalent in tropical and subtropical areas with low levels of sanitation and poor living conditions. The objective of this systematic review and meta-analysis was to evaluate the prevalence of Trichuris trichiura infection in Asia at the country and region level. Multiple databases/academic search engines (Web of Science, PubMed, ProQuest, Scopus, and Google Scholar) were searched for literature on T. trichiura prevalence in Asia published through January 2021. Pooled prevalence was determined using the meta-package in R (version 3.6.1). Out of 13,836 articles, 226 studies (5,439,500 individuals) from 26 countries met the inclusion criteria. Of the 226 studies, 151 were community-based studies that included individuals across the age spectrum, while 75 studies focused on school children (typically in the 5-16 years age range). The overall T. trichiura pooled prevalence was 15.3% (95% CI: 12.4-19.1%), with a pooled prevalence of 13.3% (95% CI: 10.0-17.1%) for the community studies and 20.9% (95% CI: 14.7-27.9%) for the studies only including school children. For studies including all age groups, individuals in the 1-15 years age group had the highest pooled prevalence at 23.4% (95% CI: 1.7-49.4%). There was a significant difference found in overall pooled prevalence by sex (p < 0.001) and community type (rural versus urban) (p < 0.001). Although prevalence appears to be decreasing, study findings suggest that T. trichiura infection continues to be a public health problem in Asia. Therefore, control programs focused on at-risk individuals in endemic areas are needed.

Anemia and undernutrition in intestinally parasitized schoolchildren from Gakenke district, Northern Province of Rwanda

Background

Rwanda is a sub-Saharan country, where intestinal parasite infections, anemia and undernutrition coexist. The purpose of this research is to study the relationship between intestinal parasite infections and undernutrition/anemia to clarify the priorities of intervention in the rural area of Gakenke district in the Northern Province of Rwanda.

Materials and methods

A total of 674 students from Nemba I School, participated in a cross-sectional study, in which their parasitological and nutritional status were analysed. Statistical analysis was performed by χ2 test, univariate analysis and Odds ratios (OR).

Results

A total of 95.3% of children presented intestinal parasitism, most of whom (94.5%) infected by protozoa and 36.1% infected by soil-transmitted helminths (STH), with Trichuris trichiura (27.3%) being the most prevalent. Multiple infections were found to be high (83.8%), with protozoa and STH co-infections in 30.6%. STH infections were mainly of low/moderate intensity. Neither infection nor STH infection of any intensity profile, was significantly related to anemia. In addition, STH infection, regardless of the intensity profile, was not associated with stunting, underweight or thinness. There was no difference between genders nor among ages in odds of anemia and nutritional status in STH-infected schoolchildren.

Conclusion

Multiparasitism remains high among Rwandan schoolchildren and is likely to cause nutritional problems. This work emphasizes the importance of keeping up health programs to reduce the prevalence of infection.

Prevalence and Intensity of Soil-Transmitted Helminths and Associated Factors among Adolescents and Adults in Bibugn Woreda, Northwest Ethiopia: A Community-Based Cross-Sectional Study

Background

Soil-transmitted helminths are a common public health problem in Ethiopia, affecting all age groups. However, epidemiological studies and interventions primarily target school-age children, despite the fact that 44.6 million adults live in endemic areas. Hence, data on the prevalence and intensity of soil-transmitted helminths infections and associated factors among adolescents and adults helps to expand interventions.

Objective

The aim of the study was to assess the prevalence and intensity of soil-transmitted helminths and associated factors among adolescents and adults in Bibugn Woreda, East Gojjam, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted in Bibugn Woreda from February to September 2021. Using multistage proportionate sampling technique, 641 adolescents and adults were enrolled in this study. Data on sociodemographic characteristics and factors associated with helminthic infections was collected using structured questionnaire prepared in Amharic and administered through face-to-face interview. Parasite detection in stool samples was performed using modified formol-ether concentration and Kato-Katz techniques following standard protocols. Data was entered and analyzed using Statistical Package for the Social Sciences software version 25. Multivariable logistic regression was used to assess factors associated with soil-transmitted helminths infections. P value <0.05 was considered as statistically significant.

Results

The overall prevalence of soil-transmitted helminths infection was 20.9% (134/641). The most detected parasite was Ascaris lumbricoides (12.5%), followed by hookworm species (7.5%) and Trichuris trichiura (1.1%). Fecal egg counts revealed that 96.5% (112/116) of the infections were with light parasite intensity, while 3.5% (4/116) were with moderate parasite intensity. Family size >5 (AOR = 1.866; 95% CI: 1.221–2.853; P=0.004), absence of latrine (AOR = 3.675; 95% CI: 1.599–8.449; P=0.002), and no habit of hand washing before meal (AOR = 2.622; 95% CI: 1.073–6.405; P=0.034) were significantly associated with soil-transmitted helminths infections.

Conclusion

There was moderate prevalence of soil-transmitted helminths among adolescents and adults with predominance of A. lumbricoides. Family size greater than five, absence of latrine, and no hand washing habit before meal predisposed adolescents and adults for soil-transmitted helminths. The existing school-based interventions should expand to address adolescents and adults.

Intestinal epithelial tuft cell induction is negated by a murine helminth and its secreted products

Helminth parasites are adept manipulators of the immune system, using multiple strategies to evade the host type 2 response. In the intestinal niche, the epithelium is crucial for initiating type 2 immunity via tuft cells, which together with goblet cells expand dramatically in response to the type 2 cytokines IL-4 and IL-13. However, it is not known whether helminths modulate these epithelial cell populations. In vitro, using small intestinal organoids, we found that excretory/secretory products (HpES) from Heligmosomoides polygyrus blocked the effects of IL-4/13, inhibiting tuft and goblet cell gene expression and expansion, and inducing spheroid growth characteristic of fetal epithelium and homeostatic repair. Similar outcomes were seen in organoids exposed to parasite larvae. In vivo, H. polygyrus infection inhibited tuft cell responses to heterologous Nippostrongylus brasiliensis infection or succinate, and HpES also reduced succinate-stimulated tuft cell expansion. Our results demonstrate that helminth parasites reshape their intestinal environment in a novel strategy for undermining the host protective response.

Prevalence of intestinal nematodes infection in school children of urban areas of district Lower Dir, Pakistan

Abstract Intestinal parasitism is the main cause of disease all over the world and described as a significant community health problem. The current study intended to find out the occurrence and identification of hazard factors linked with IPIs among 4-12 years aged shool-age children residing in Lower Dir district, Pakistan during 2019 - 2020. A cross-sectional school-based study was conducted using a pre-arranged pre-tested survey. Anthropometric data and stool collection were done to obtain the findings. The direct wet mount preparation in saline/iodine/methods was used for stool examination. Data were investigated using the GraphPad Prism 5. A total of 400 children studied (mean age of 8.6±3.6 years) the total incidence rate for the intestinal parasitic disease was established to be 71.75%. Of the 400 children studied, the overall prevalence rate for intestinal parasitic infections was found to 71.75% Ascaris lumbricoides (33.1%), Trichuris trichiura (1.04%), E. vermicularis (1.39%), Hookworm (19.86%) were identified in children living in the study area. We concluded that there is a mass scale campaigns were required to generate alertness about health and sanitation in children and the need for the development of effective poverty control programs because deworming (killing of worm with drugs) alone is not adequate to control parasitic infections.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Prevalence of malnutrition, anemia, and soil-transmitted helminthiasis in preschool-age children living in peri-urban populations in the Peruvian Amazon

Stunting, anemia, and soil-transmitted helminth (STH) infections are major health concerns for children in extremely poor regions of the world, especially rural and periurban ones. This study aimed to determine the prevalence of these three cooccurring conditions in preschool-age children in an extremely poor district on the outskirts of Iquitos, in the Peruvian Amazon, to inform public health actions. Malnutrition was assessed by standard World Health Organization-recommended metrics; anemia, by hemoglobin levels; and STH, by the Kato-Katz technique. Logistic regression analyses were performed to identify the risk factors for our three outcomes of interest. A total of 572 children aged 6-59 months were recruited in March 2019. We found a 31.3% stunting, 47.2% anemia, and 34.1% STH prevalence. Stunting and anemia figures exceeded both regional and national estimates for 2019. Having more children was a risk factor for stunting, whereas married mothers were associated with a lower risk. Risk factors for anemia included younger age and the male sex, whereas those for STH, older age, incomplete vaccination, and a lower socioeconomic status. Mothers’ employment outside the home was also associated with a lower STH risk. This recent evidence highlights the need for prompt and integrated clinical attention and public health actions to address both short- and long-term health consequences in this vulnerable child age group. The integration of a monitoring and evaluation framework is important to effectively manage these conditions, optimize resources and accountability, and show their impact.