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Summary Background Few studies have been done of patterns of treatment during mass drug administration (MDA) to control neglected tropical diseases. We used routinely collected individual-level treatment records that had been collated for the Tuangamize Minyoo Kenya Imarisha Afya (Swahili for Eradicate Worms in Kenya for Better Health [TUMIKIA]) trial, done in coastal Kenya from 2015 to 2017. In this analysis we estimate the extent of and factors associated with the same individuals not being treated over multiple rounds of MDA, which we term systematic non-treatment. Methods We linked the baseline population of the TUMIKIA trial randomly assigned to receive biannual community-wide MDA for soil-transmitted helminthiasis to longitudinal records on receipt of treatment in any of the four treatment rounds of the study. We fitted logistic regression models to estimate the association of non-treatment in a given round with non-treatment in the previous round, controlling for identified predictors of non-treatment. We also used multinomial logistic regression to identify factors associated with part or no treatment versus complete treatment. Findings 36 327 participants were included in our analysis: 16 236 children aged 2–14 years and 20 091 adults aged 15 years or older. The odds of having no treatment recorded was higher if a participant was not treated during the previous round of MDA (adjusted odds ratio [OR] 3·60, 95% CI 3·08–4·20 for children and 5·58, 5·01–6·21 for adults). For children, school attendance and rural residence reduced the odds of receiving part or no treatment, whereas odds were increased by least poor socioeconomic status and living in an urban or periurban household. Women had higher odds than men of receiving part or no treatment. However, when those with pregnancy or childbirth in the previous 2 weeks were excluded, women became more likely to receive complete treatment. Adults aged 20–25 years were the age group with the highest odds of receiving part (OR 1·41, 95% CI 1·22–1·63) or no treatment (OR 1·81, 95% CI 1·53–2·14). Interpretation Non-treatment was associated with specific sociodemographic groups and characteristics and did not occcur at random. This finding has important implications for MDA programme effectiveness, the relevance of which will intensify as disease prevalence decreases and infections become increasingly clustered. Funding Bill & Melinda Gates Foundation, Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, Wellcome Trust, Children's Investment Fund Foundation, and London Centre for Neglected Tropical Diseases.

Countries have seen substantial disruptions to usual health services related to coronavirus disease 2019 and these are likely to have immediate and long-term indirect effects on many disease control programmes, including neglected tropical diseases (NTDs). The pandemic has highlighted the usefulness of mathematical modelling to understand the impacts of these disruptions and future control measures on progress towards 2030 NTD goals. The pandemic also provides an opportunity, and a practical necessity, to transform NTD programmes through innovation.

Background Soil-transmitted helminth (STH) and schistosome infections are among the most prevalent neglected tropical diseases (NTDs) in the world. School-aged children are particularly vulnerable to these chronic infections that can impair growth, nutritional status and cognitive ability. Mass drug administration (MDA) delivered either once or twice annually is a safe and effective approach recommended by the World Health Organization (WHO) to reduce worm burden. In 2012, Kenya began a national school-based deworming programme (NSBDP) aimed at reducing infection and associated morbidity. The change in prevalence and intensity of these infections was monitored over five years (2012–2017). Here, we present the changes in STH and schistosome infections between baseline and endline assessments, as well as explore the yearly patterns of infection reductions. Methods We used series of pre- and post-MDA intervention, repeat cross-sectional surveys in a representative, stratified, two-stage sample of schools in 16 counties of Kenya. The programme consisted of two tiers of monitoring; a national baseline, midterm and endline surveys consisting of 200 schools, and pre- and post-MDA surveys conducted yearly consisting of 60 schools. Stool and urine samples were collected from randomly selected school children and examined for STH and schistosome infections using Kato-Katz and urine filtration techniques respectively. Results Overall, 32.3%, 16.4% and 13.5% of the children were infected with any STH species during baseline, midterm and endline assessment, respectively, with a relative reduction of 58.2% over the five-year period. The overall prevalence of S. mansoni was 2.1%, 1.5% and 1.7% and of S. haematobium was 14.8%, 6.8% and 2.4%, respectively, for baseline, midterm and endline surveys. We observed inter-region and inter-county heterogeneity variation in the infection levels. Conclusions The analysis provided robust assessment of the programme and outlined the current prevalence, mean intensity and re-infection pattern of these infections. Our findings will allow the Government of Kenya to make informed decisions on the strategy to control and eliminate these NTDs. Our results suggest that complimentary interventions may have to be introduced to sustain the chemotherapeutic gains of MDA and accelerate attainment of elimination of these NTDs as a public health problem in Kenya. Electronic supplementary material The online version of this article (10.1186/s13071-019-3322-1) contains supplementary material, which is available to authorized users.

Background Podoconiosis is a type of elephantiasis characterised by swelling of the lower legs. It is often confused with other causes of tropical lymphedema and its global distribution is uncertain. Here we synthesise the available information on the presence of podoconiosis to produce evidence consensus maps of its global geographical distribution. Methods and findings We systematically searched available data on podoconiosis in SCOPUS and MEDLINE from inception, updated to 10 May, 2019, and identified observational and population-based studies reporting podoconiosis. To establish existence of podoconiosis, we used the number of cases reported in studies and prevalence data with geographical locations. We then developed an index to assess evidence quality and reliability, assigning each country an evidence consensus score. Using these summary scores, we then developed a contemporary global map of national-level podoconiosis status. There is evidence of podoconiosis in 17 countries (12 in Africa, three in Latin America, and two in Asia) and consensus on presence in six countries (all in Africa). We have identified countries where surveillance is required to further define the presence or absence of podoconiosis. We have highlighted areas where evidence is currently insufficient or conflicting, and from which more evidence is needed. Conclusion The global distribution of podoconiosis is not clearly known; the disease extent and limits provided here inform the best contemporary map of the distribution of podoconiosis globally from available data. These results help identify surveillance needs, direct future mapping activities, and inform prevention plans and burden estimation of podoconiosis., Author summary The global distribution of podoconiosis is uncertain. With our current understanding of its distribution still incomplete, many of the countries suspected to be endemic for podoconiosis are based on expert opinion and lack published evidence of confirmed cases. In this study, we used multiple data sources and health metrics to identify countries with presence and absence of podoconiosis with appropriate uncertainties. After assembling a database of different evidence types we constructed a weighted score for each country called ‘evidence consensus scores’. We used these scores to measure the certainty of the presence and absence of podoconiosis. The maps produced help to identify evidence gaps and uncertainties in the current global distribution of podoconiosis. Countries with evidence of podoconiosis are mostly clustered in Africa, and a few in Asia and Latin America. We have also identified countries with indeterminate status on the presence and absences of podoconiosis. These countries are characterised by weak health systems and multiple co-endemic diseases causing lower leg swelling, potentially leading to misdiagnosis of podoconiosis. Given these challenges, we recommend intensified disease surveillance and active case searching be implemented in areas where evidence is lacking.

BACKGROUND: The burden of malaria infection in sub-Saharan Africa among school-aged children aged 5-15 years is underappreciated and represents an important source of human-to-mosquito transmission of Plasmodium falciparum. Additional interventions are needed to control and eliminate malaria. We aimed to assess whether preventive treatment of malaria might be an effective means of reducing P falciparum infection and anaemia in school-aged children and lowering parasite transmission. METHODS: In this systematic review and two meta-analyses, we searched the online databases PubMed, Embase, Cochrane CENTRAL, and Clinicaltrials.gov for intervention studies published between Jan 1, 1990, and Dec 14, 2018. We included randomised studies that assessed the effect of antimalarial treatment among asymptomatic school-aged children aged 5-15 years in sub-Saharan Africa on prevalence of P falciparum infection and anaemia, clinical malaria, and cognitive function. We first extracted data for a study-level meta-analysis, then contacted research groups to request data for an individual participant data meta-analysis. Outcomes of interest included prevalence of P falciparum infection detected by microscopy, anaemia (study defined values or haemoglobin less than age-adjusted and sex-adjusted values), clinical malaria (infection and symptoms on the basis of study-specific definitions) during follow-up, and code transmission test scores. We assessed effects by treatment type and duration of time protected, and explored effect modification by transmission setting. For study-level meta-analysis, we calculated risk ratios for binary outcomes and standardised mean differences for continuous outcomes and pooled outcomes using fixed-effect and random-effects models. We used a hierarchical generalised linear model for meta-analysis of individual participant data. This study is registered with PROSPERO, CRD42016030197. FINDINGS: Of 628 studies identified, 13 were eligible for the study-level meta-analysis (n=16 309). Researchers from 11 studies contributed data on at least one outcome (n=15 658) for an individual participant data meta-analysis. Interventions and study designs were highly heterogeneous; overall risk of bias was low. In the study-level meta-analysis, treatment was associated with reductions in P falciparum prevalence (risk ratio [RR] 0·27, 95% CI 0·17-0·44), anaemia (0·77, 0·65-0·91), and clinical malaria (0·40, 0·28-0·56); results for cognitive outcomes are not presented because data were only available for three trials. In our individual participant data meta-analysis, we found treatment significantly decreased P falciparum prevalence (adjusted RR [ARR] 0·46, 95% CI 0·40-0·53; p

The intestinal nematodes Enterobius vermicularis, Trichuris trichiura, Capillaria philippinensis, and Trichostrongylus spp. are endemic worldwide, although the true prevalence is not known, as many infections are undiagnosed and some are difficult to diagnose. T. trichiura is estimated to infect as many as 500 million people worldwide. Each of these nematodes has distinctive life cycles, varying degrees of pathology, and different epidemiologic features. However, they all infect the gut as larvae and adults, producing eggs that are excreted in the stool. Most of the intestinal nematodes are susceptible to anti-helminthic drugs, with trichuriasis requiring additional rounds of treatment for maximum efficacy. Prevention is through handwashing, sanitary disposal of human excreta, prevention of fecal contamination of topsoil, and improved food hygiene.

Ascariasis is the most prevalent human helminth infection, with an estimated 819 million infections worldwide. Transmission primarily occurs in warm, tropical climates that lack water and sanitation facilities and have poor hygiene. Worms inhabit the small intestine, and morbidity is related to worm burden. A small proportion of the infected population harbors the majority of worms, with intense infection most common in school-age children, and intensity and prevalence declining to a low level throughout adulthood. School-age children are therefore the targets for school-based community control efforts in large-scale treatment campaigns. Light infections can affect growth and development, whereas, due to the size of the worms, heavier worm burdens can result in intestinal obstruction, particularly in young children. Treatment with mebendazole or albendazole is efficacious, with cure rates of >90% commonly achieved.

IntroductionEvidence indicates children who suffer from ill-health are less likely to attend or complete schooling. Malaria is an important cause of morbidity and mortality in school-age children. However, they are less likely to receive malaria treatment at health facilities and evidence for how to improve schoolchildren’s access to care is limited. This study aimed to evaluate the impact of a programme of school-based malaria case management on schoolchildren’s attendance, health and education.MethodsA cluster randomised controlled trial was conducted in 58 primary schools in Zomba District, Malawi, 2011–2015. The intervention, implemented in 29 randomly selected schools, provided malaria rapid diagnostic tests and artemisinin-based combination therapy to diagnose and treat uncomplicated malaria as part of basic first aid kits known as ‘Learner Treatment Kits’ (LTK). The primary outcome was school attendance, assessed through teacher-recorded daily attendance registers and independent periodic attendance spot checks. Secondary outcomes included prevalence of Plasmodium spp infection, anaemia, educational performance, self-reported child well-being and health-seeking behaviour. A total of 9571 children from standards 1–7 were randomly selected for assessment of school attendance, with subsamples assessed for the secondary outcomes.ResultsBetween November 2013 and March 2015, 97 trained teachers in 29 schools provided 32 685 unique consultations. Female schoolchildren were significantly more likely than male to seek a consultation (unadjusted OR=1.78 (95% CI 1.58 to 2.00). No significant intervention effect was observed on the proportion of child-days recorded as absent in teacher registers (n=9017 OR=0.90 (95% CI 0.77 to 1.05), p=0.173) or of children absent during random school visits—spot checks (n=5791 OR=1.09 (95% CI 0.87 to 1.36), p=0.474). There was no significant impact on child-reported well-being, prevalence of Plasmodium spp, anaemia or education scores.ConclusionDespite high community demand, the LTK programme did not reduce schoolchildren’s absenteeism or improve health or education outcomes in this study setting.Trial registration numberClinicalTrials.gov NCT02213211.

Background: Success of mass drug administration (MDA) for control of neglected tropical diseases depends on treatment coverage and patterns across rounds. There has been limited opportunity to explore these features within programmes at scale. Here we use routinely-collected individual-level treatment records collated for the TUMIKIA trial, conducted in coastal Kenya from 2015-2017, to estimate the extent of -- and factors associated with -- systematic non-treatment in the targeted population. Methods: The trial baseline population (N=36327) was linked with treatment records from four rounds of biannual community-wide MDA for soil-transmitted helminthiasis. We fit logistic regression models to estimate the association of non-treatment with treatment status during the previous round, controlling for identified predictors of non-treatment, and used multinomial logistic regression to identify factors associated with partial or no treatment versus complete treatment. Findings: Children aged 2-14 years and individuals aged 15+ years were more likely to remain untreated if they were not treated during the previous MDA. For children, school attendance and rural residence were protective against receiving partial and no treatment. Women were more likely than men to receive partial and no treatment, unless periods of pregnancy and recent childbirth were excluded; then, women more likely received complete treatment. Adults aged 20-25 years were most likely to receive partial or no treatment. Interpretation: We identified eligible populations who received incomplete treatment across multiple MDA rounds and found that this non-treatment did not occur at random. This finding has important implications for MDA programme effectiveness and will be increasingly important as prevalence reaches low levels. Funding Statement: Funding for TUMIKIA was received from the Bill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children’s Investment Fund Foundation. This analysis was supported by the London Centre for Neglected Tropical Diseases. SK is supported by THRiVE-2, a DELTAS Africa grant # DEL-15-011 from Wellcome Trust grant # 107742/Z/15/Z and the UK government. Declaration of Interests: RMA was a non-executive director of GlaxoSmithKline during the TUMIKIA trial. GlaxoSmithKline had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. SJB is currently employed by the Bill & Melinda Gates Foundation (BMGF) but was employed by the London School of Hygiene & Tropical Medicine when TUMIKIA was designed and commenced. GlaxoSmithKline and BMGF played no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. All other authors declare no competing interests. Ethics Approval Statement: The TUMIKIA trial protocol, including measurement of treatment coverage and adherence using routine and household survey data, was approved by the Kenya Medical Research Institute and National Ethics Review Committee (SSC Number 2826) and the London School of Hygiene & Tropical Medicine (LSHTM) Ethics Committee (7177). Written informed consent was sought from the household head or adult answering the household-level questionnaire. All information and consent procedures were conducted in Kiswahili.

Background: The achievement of neglected tropical diseases (NTDs) program goals depends on numerous factors, including the ability of national programs to use high-quality, timely data to inform their decision-making and program delivery. This paper presents a use case analysis of the routine data used by national NTD programs targeting lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma. Methods: The use cases were developed through a combination of secondary and primary research focused on both global trends and deep dives into Burkina Faso, Ethiopia, and Tanzania. Results were refined through a stakeholder convening and the final eight use cases were determined through iteration and prioritization with stakeholders. Results: Eight use cases were developed: improve treatment register data quality, strengthen supervision of drug distributors during mass drug administration (MDA), generate accurate community-level population data for MDAs, create and manage an accurate inventory of drugs, meet district coverage targets during MDA campaigns, feedback and performance to sub-district teams, feedback on performance to sub-national teams, and national-level program use of data for evaluation and decision making. Each use case identifies key actors and their data-related needs and critical challenges, defines the current and desired state, and articulates the profile of a solution (digital and non-digital) needed to complete the use case. Conclusion: The systematic strengthening of data use for decision-making in NTD programs is key for reaching the 2030 Roadmap goals. Integrated together, the presented use cases, when translated into action using appropriate and innovative solutions, can help to ensure that accurate and timely data are present at every step of a program and empower countries to use these data to make program decisions.

Background Training teachers to diagnose uncomplicated malaria using malaria rapid diagnostic tests and treat with artemisinin-based combination therapy has the potential to improve the access of primary school children (6–14 years) to prompt and efficient treatment for malaria, but little is known about the acceptability of such an intervention. This qualitative study explored experiences and perceptions of users and implementers of a programme of school-based malaria case management via a first-aid kit—the Learner Treatment Kit (LTK)—implemented as part of a cluster-randomized controlled trial in Zomba district, Malawi. Methods From 29 primary schools where teachers were trained to test and treat school children for malaria using the LTK, six schools were purposively selected on the basis of relative intervention usage (low, medium or high); school size and geographical location. In total eight focus group discussions were held with school children, parents and guardians, and teachers; and 20 in-depth interviews were conducted with key stakeholders at the school, district and national levels. Interviews were recorded, transcribed, and analysed using a thematic analysis approach. Results The LTK was widely perceived by respondents to be a worthwhile intervention, with the opinion that trained teachers were trusted providers of malaria testing and treatment to school children. Benefits of the programme included a perception of improved access to malaria treatment for school children; decreased school absenteeism; and that the programme supported broader national health and education policies. Potential barriers to successful implementation expressed included increased teacher workloads, a feeling of inadequate supervision from health workers, lack of incentives and concerns for the sustainability of the programme regarding the supply of drugs and commodities. Conclusion Training teachers to test for and treat uncomplicated malaria in schools was well received by both users and implementers alike, and was perceived by the majority of stakeholders to be a valuable programme. Factors raised as critical to the success of such a programme included ensuring an effective supervisory system, a reliable supply chain, and the training of greater numbers of teachers per school to manage high consultation numbers, especially during the peak malaria transmission season.

Introduction Few studies have simultaneously examined the role of sanitation conditions at the home, school, and community on soil-transmitted helminth (STH) infection. We examined the contribution of each domain that children inhabit (home, village, and school) to STH infection and estimated the association of STH infection with sanitation in each domain. Methods Using data from 4,104 children from Kwale County, Kenya, who reported attending school, we used logistic regression models with cross-classified random effects to calculate measures of general contextual effects and estimate associations of village sanitation coverage (percentage of households with reported access to sanitation), school sanitation coverage (number of usable toilets per enrolled pupil), and sanitation access at home with STH infection. Findings We found reported use of a sanitation facility by households was associated with reduced prevalence of hookworm infection but not with reduced prevalence of T. trichiura infection. School sanitation coverage > 3 toilets per 100 pupils was associated with lower prevalence of hookworm infection. School sanitation was not associated with T. trichiura infection. Village sanitation coverage > 81% was associated with reduced prevalence of T. trichiura infection, but no protective association was detected for hookworm infection. General contextual effects represented by residual heterogeneity between village and school domains had comparable impact upon likelihood of hookworm and T. trichiura infection as sanitation coverage in either of these domains. Conclusion Findings support the importance of providing good sanitation facilities to support mass drug administration in reducing the burden of STH infection in children., Author summary Infection by the soil-transmitted helminths (STH) whipworm and hookworm results from either ingestion of eggs or larvae or through skin exposure to larvae. These eggs and larvae develop in suitable soils contaminated with openly-deposited human faeces. Safe disposal of faeces should reduce transmission of STH, yet evidence of the impact of sanitation on STH transmission remains limited. A large, community-wide survey was conducted in 2015 to measure prevalence of STH infections in Kwale County, Kenya. Here, we used this data and observations made in schools to examine the relationship between sanitation conditions at home, school, and village and the presence of STH infection among 4,104 children who attend school. We found that sanitation access at home and school sanitation coverage (number of usable toilets per enrolled pupil), but not the overall level of village sanitation coverage (percentage of households with reported access to sanitation), was protective against hookworm infection. In contrast, only high village sanitation coverage, but not home or school sanitation, was protective against whipworm infection. Current STH control strategies emphasise periodic deworming of at-risk populations, including school-age children. Our findings highlight the need for continued efforts, alongside deworming, to extend access to good sanitation facilities at homes, schools, and across communities.

Background As many countries with endemic soil-transmitted helminth (STH) burdens achieve high coverage levels of mass drug administration (MDA) to treat school-aged and pre-school-aged children, understanding the detailed effects of MDA on the epidemiology of STH infections is desirable in formulating future policies for morbidity and/or transmission control. Prevalence and mean intensity of infection are characterized by heterogeneity across a region, leading to uncertainty in the impact of MDA strategies. In this paper, we analyze this heterogeneity in terms of factors that govern the transmission dynamics of the parasite in the host population. Results Using data from the TUMIKIA study in Kenya (cluster STH prevalence range at baseline: 0–63%), we estimated these parameters and their variability across 120 population clusters in the study region, using a simple parasite transmission model and Gibbs-sampling Monte Carlo Markov chain techniques. We observed great heterogeneity in R0 values, with estimates ranging from 1.23 to 3.27, while k-values (which vary inversely with the degree of parasite aggregation within the human host population) range from 0.007 to 0.29 in a positive association with increasing prevalence. The main finding of this study is the increasing trend for greater parasite aggregation as prevalence declines to low levels, reflected in the low values of the negative binomial parameter k in clusters with low hookworm prevalence. Localized climatic and socioeconomic factors are investigated as potential drivers of these observed epidemiological patterns. Conclusions Our results show that lower prevalence is associated with higher degrees of aggregation and hence prevalence alone is not a good indicator of transmission intensity. As a consequence, approaches to MDA and monitoring and evaluation of community infection status may need to be adapted as transmission elimination is aimed for by targeted treatment approaches.

Most epidemiological studies of soil-transmitted helminth (STH) infections focus on school-going children. The majority of large-scale cross-sectional and longitudinal community-based studies have been conducted prior to the implementation of wide-scale mass drug administration (MDA). This study investigates age-related patterns in prevalence and intensity of STH infection, and associated risk factors, in a region of south coastal Kenya that had previously received three consecutive years of school-based deworming (2012–14) and four rounds of community-based MDA for lymphatic filariasis between 2003 and 2014. Between March and May 2015, a cross-sectional survey was conducted in 120 community clusters as a baseline for a cluster randomised trial. Individuals aged two years and above were randomly selected during household surveys and requested to provide stool samples, which were assessed for presence and intensity of STH using the duplicate Kato-Katz thick smear method. Species-specific predictors of presence and intensity were investigated through multilevel logistic regression and zero-inflated negative binomial regression models. Of the 19,684 individuals who provided a stool sample, 21.5% were infected with at least one STH. Hookworm was the predominant species, with an overall prevalence of 19.1%; Trichuris trichiura prevalence was 3.6% and Ascaris lumbricoides was negligible (0.4% prevalence). The vast majority were light intensity infections. Prevalence and intensity of hookworm infection were significantly higher in adults and males, and were associated with environmental conditions, low socio-economic status, household flooring, individual and household water, sanitation and hygiene (WASH) characteristics and behaviours, previous treatment, lack of shoe-wearing and not attending school. In contrast, T. trichiura was more commonly found in school-aged boys and those living in communities close to the coast, with reduced infection in the least poor individuals with private latrine access. Overall, results show that despite several years of school-based deworming, hookworm infection remains common among untreated adults in this population, suggesting that this strategy alone is insufficient to reduce community-wide hookworm infection and in the longer term to eliminate transmission. Trial registration ClinicalTrials.gov NCT02397772, Author summary Soil-transmitted helminth (STH) infections, including Trichuris trichiura, Ascaris lumbricoides and the hookworms Ancylostoma duodenale and Necator americanus, remain endemic in many regions of sub-Saharan Africa (SSA), including parts of Kenya. The current WHO-recommended treatment strategy focuses on morbidity control, and comprises periodic deworming of population groups at particular risk, including pre-school and school–age children. Consequently, the majority of epidemiological descriptions of STH have focused on infection in this age group, and are conducted using a school platform. There is therefore a notable lack of age-stratified data (that includes adults) from communities. We present data from a community-wide, cross-sectional survey of STH infection across 19,684 individuals and investigate associated risk factors at the household and individual level. We demonstrate highest prevalence and intensity of hookworm (the predominant species in this setting) in adults and males—a group not routinely included in deworming activities. There was marked geographic variation in infection risk across the study area, and an enduring relationship between infection risk and factors associated with poor access to sanitation and hygiene. Conducted after three years of ongoing, annual school-based deworming, the findings presented here are likely to be representative of many regions of SSA, with similar epidemiological and demographic profiles, implementing the current WHO-recommended STH control strategy.

The transmission soil transmitted helminths (STH) occurs via ingestion of or contact with infective stages present in soil contaminated with human faeces. It follows therefore that efforts to reduce faecal contamination of the environment should help to reduce risk of parasite exposure and improvements in water, sanitation and hygiene (WASH) are seen as essential for the long-term, sustainable control of STH. However, the link between WASH and STH is not always supported by the available evidence from randomised controlled trials, which report mixed effects of WASH intervention on infection risk. This review critically summarises the available trial evidence and offers an interpretation of the observed heterogeneity in findings. The review also discusses the implications of findings for control programmes and highlights three main issues which merit further consideration: intervention design, exposure assessment, and intervention fidelity assessment.

More than half of the world’s population lives in places endemic for soil-transmitted helminths (STHs), and an estimated 1.45 billion people are infected. In 2017, the global burden of STH infection (Ascaris lumbricoides, hookworm, and Trichuris trichiura) was estimated at 1.9 million disability-adjusted life years (DALYs). Moderate and heavy infection intensity and chronic STH infection are associated with anemia, malnutrition, educational loss, and cognitive deficits, but recent systematic reviews and meta-analyses produced conflicting results on the impact of preventive chemotherapy (PC). The Soil-Transmitted Helminthiasis Advisory Committee (hereafter called “the Committee”) is a group of independent experts with a broad range of expertise. It is convened annually by Children Without Worms (CWW), an organization whose purpose is to utilize available evidence to identify best practices and opportunities for the prevention and control of STH infection. On November 1 and 2, 2017, the Committee met in Baltimore, Maryland, United States of America, in order to discuss the critical need to develop a data-driven guide to the STH endgame on late-stage program functioning, processes, and surveillance. The focus was on research and field experiences from countries approaching the “elimination of STH infection as a public health problem” after consecutive years of PC and countries that are now considering scaling down their PC frequency but may be concerned about infection rebound. Emphasis was placed on interim recommendations for monitoring and decision-making for national program managers desiring to achieve the World Health Organization (WHO) goal of eliminating STH infection as a public health problem by 2020, particularly related to STH infections in risk groups other than school-age children (SAC), namely preschool-age children (PSAC) and women of reproductive age (WRA) [8]. The following is the Committee’s recommendations stemming from the Baltimore meeting in November 2017. It complements and updates the publication derived by the Committee’s meeting a year earlier in Basel, Switzerland, and was instrumental in shaping the agenda for the October 2018 meeting, convened jointly by CWW and WHO, with recommendations to be reported elsewhere. Fil: Freeman, Matthew C.. University of Emory; Estados Unidos Fil: Akogun, Oladele. Modibbo Adama University of Technology; Nigeria Fil: Belizario, Vicente. University of The Philippines Manila; Filipinas Fil: Brooker, Simon J.. Bill And Melinda Gates Foundation; Estados Unidos Fil: Gyorkos, Theresa W.. McGill University; Canadá Fil: Imtiaz, Rubina. The Task Force for Global Health; Estados Unidos Fil: Krolewiecki, Alejandro Javier. Universidad Nacional de Salta. Sede Regional Orán. Instituto de Investigación de Enfermedades Tropicales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Salta; Argentina Fil: Lee, Seung Hwa. Save the Children; Estados Unidos Fil: Matendechero, Sultani H.. Ministry of Health; Kenia Fil: Pullan, Rachel L.. London School of Hygiene & Tropical Medicine; Reino Unido Fil: Utzinger, Jürg. Swiss Tropical and Public Health Institute; Suiza. University of Basel; Suiza

We evaluated a program to improve literacy instruction on the Kenyan Coast using training workshops, semi-scripted lesson plans and weekly text message support for teachers to understand its impact on students' literacy outcomes and on the classroom practices leading to those outcomes. The evaluation ran from the beginning of Grade 1 to the end of Grade 2 in 51 government primary schools chosen at random, with 50 schools acting as controls. The intervention had an impact on classroom practices with effect sizes from 0.57 to 1.15. There was more instruction with written text and more focus on letters and sounds. There was a positive impact on 3 of 4 primary measures of children's literacy after 2 years, with effect sizes up to 0.64, and school dropout reduced from 5.3% to 2.1%. This approach to literacy instruction is sustainable and affordable and a similar approach has subsequently been adopted nationally in Kenya.

Water, sanitation, and hygiene (WaSH) technologies and behaviors can prevent infection by soil-transmitted helminth species independently, but may also interact in complex ways. However, these interactions are poorly understood. The purpose of this study was to characterize how school and home WaSH exposures were associated with Ascaris lumbricoides infection and to identify relevant interactions between separate WaSH technologies and behaviors. A study was conducted among 4,404 children attending 51 primary schools in western Kenya. We used multivariable mixed effects logistic regression to characterize how various WaSH exposures were associated with A. lumbricoides infection after annual school-based deworming. Few WaSH behaviors and technologies were independently associated with A. lumbricoides infection. However, by considering relevant interdependencies between variables, important associations were elucidated. The association between handwashing and A. lumbricoides depended largely upon the pupils' access to an improved water source. Among pupils who had access to improved water sources, A. lumbricoides prevalence was lower for those who handwashed both at school and home compared with neither place (odds ratio: 0.38, 95% confidence interval: 0.18–0.83; P = 0.01). This study contributes to a further understanding of the impact of WaSH on A. lumbricoides infection and shows the importance of accounting for interactions between WaSH technologies and behaviors.

BackgroundTrichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can cause blindness. Accurate estimates of numbers affected, and their geographical distribution, help guide resource allocation.MethodsWe obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used (1) the most recent data for a district, if more than one estimate was available; (2) age- and sex-standardized corrections of historic estimates, where raw data were available; (3) historic estimates adjusted using a mean adjustment factor for districts where raw data were unavailable; and (4) expert assessment of available data for districts for which no prevalence estimates were available.FindingsInternally age- and sex-standardized data represented 1,355 districts and contributed 662 thousand cases (95% confidence interval [CI] 324 thousand-1.1 million) to the global total. age- and sex-standardized district-level prevalence estimates differed from raw estimates by a mean factor of 0.45 (range 0.03-2.28). Previously non-standardized estimates for 398 districts, adjusted by ×0.45, contributed a further 411 thousand cases (95% CI 283-557 thousand). Eight countries retained previous estimates, contributing 848 thousand cases (95% CI 225 thousand-1.7 million). New expert assessments in 14 countries contributed 862 thousand cases (95% CI 228 thousand-1.7 million). The global trichiasis burden in 2016 was 2.8 million cases (95% CI 1.1-5.2 million).InterpretationThe 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.Author SummaryAs an individual with trichiasis blinks, the eyelashes abrade the cornea, which can lead to corneal opacity and blindness. Through high quality surgery, which involves correcting the position of the in-turned eyelid, it is possible to reduce the number of people with trichiasis. An accurate estimate of the number of persons with trichiasis and their geographical distribution are needed in order to effectively align resources for surgery and other necessary services. We obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used the most recently available data and expert assessments to estimate the global burden of trichiasis. We estimated that in 2016 the global burden was 2.8 million cases (95% CI 1.1-5.2 million).The 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and malnutrition constrain growth, and mortality is higher than previously recognised; the adolescent growth spurt (10-14 years), when substantial changes place commensurate demands on good diet and health; and the adolescent phase of growth and consolidation (15-19 years), when new responses are needed to support brain maturation, intense social engagement, and emotional control. Two cost-efficient packages, one delivered through schools and one focusing on later adolescence, would provide phase-specific support across the life cycle, securing the gains of investment in the first 1000 days, enabling substantial catch-up from early growth failure, and leveraging improved learning from concomitant education investments. Refereed/Peer-reviewed

Schistosomiasis affects over 200 million people worldwide [1] and accounts for an estimated 1.9 million disability-adjusted life years (DALYs) annually [2], with 90% of the burden currently concentrated in Africa. The last decade has witnessed an extraordinary surge of advocacy and funding for neglected tropical diseases (NTDs), including schistosomiasis. Large-scale schistosomiasis control is now implemented in 30 countries in Africa [1], funded primarily through support from the United States Agency for International Development (USAID) and the Department for International Development (DFID), private philanthropic funds from the END Fund and through GiveWell recommendations, and leveraging praziquantel donations from Merck KGaA. However, the number of people still requiring treatment remains daunting [1]. The aim of current public health strategies for schistosomiasis is to decrease morbidity through preventive chemotherapy (PC) (Fig 1) [3]. Periodic large-scale administration of the drug praziquantel focusing on the school-aged population and high-risk adults aims to reduce the prevalence and intensity of infection [4].