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Greetings!
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 We present you with a fairly content-rich newsletter compared to the typical
newsletter, but it is important to me to provide a true sense of what
our program is
doing and some of the technical barriers we face.
In this issue, we show you how the work of Children Without Worms has improved the health and quality of life for millions of
children in Cameroon. In addition, we introduce you to Dr. Israt Hafiz, with the
Filariasis Elimination and STH Control Program in Bangledesh. The
dedication and hard work of Dr. Hafiz and our other program partners is
what really makes
this program succeed.
For
the more technically-minded, we highlight the main points of an article
presented at the recent Mebendazole Advisory Committee (MAC) meetings.
The article provides valuable information for ensuring the continued
efficacy
of Benzamidizoles (BZ) in treating hookworm and other Soil-transmitted
Helminthes (STH).
I
hope you enjoy getting to know our program partners, learning more
about the challenges we face, and hearing about the successes that
continue to inspire us in this important work.
Thank you for your interest in Children Without Worms.
Sincerely,
Kim Koporc
Acting Director
Children Without Worms
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| Scaling Cameroon's Deworming Program to the National Level
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 Just 10 years ago, Cameroon's Ministry of Public Health had no intestinal worm control program in place, with approximately 10,000,000 Cameroonians infected with soil-transmitted helminthiasis (STH). That all changed in 1999, when Pr. Louis-Albert Tchuem Tchuenté returned to Cameroon from his studies and research abroad.
Pr. Tchuem Tchuenté immediately recognized the need to address the high levels of infection of Schistosomiasis and Intestinal Helminthiasis. He first founded the Center for Schistosomiasis and Parasitology, a national research center, and then worked through Cameroon's Ministry of Public Health to establish the National Programme for the Control of Schistosomiasis and Intestinal Helminthiasis in 2003.
Early on, the program was very limited in scope due to resource constraints, so efforts were focused on establishing the necessary infrastructure for the program. They developed an action plan, built strategic relationships with partners and stakeholders, and set up pilot studies for the plan. Working closely with the Ministry of Basic Education, the local health district medical officers, and the community, the Programme was able to deworm 200,000 children, mostly in the Adamawa region in the northern part of the country. But Pr. Tchuem Tchuenté knew that with more support, the program could do so much more.
Late in 2006, Cameroon was selected to participate as one of the first sites for Children Without Worms (CWW), a program that resulted from a partnership between Johnson & Johnson and The Task Force for Global Health. Their selection was due in part to Cameroon's existing infrastructure for distributing the drugs to school children and the country's high political commitment to the program. In Pr. Tchuem Tchuenté's words, "The first donation of drugs from CWW allowed the National Programme for the Control of Schistosomiasis and Intestinal Helminthiasis to scale its efforts to a national level." Within the first year of the drug donations from Johnson & Johnson, Cameroon's Programme was able to deworm over 4,000,000 children.
In the communities where they've done their work, the evidence of the programme's success is overwhelming. According to Pr. Tchuem Tchuenté, parents once reticent to give their children the deworming medication now eagerly request more. They have seen, as Pr. Tchuem Tchuenté says, their children go from "anemic, in constant pain, weak and fatigued, to healthy and energetic." In fact, the children themselves ask for the deworming drugs, having felt the health benefits the drugs offer.
Statistics based on surveys that assessed the prevalence of STH in Loum, one of the pilot studies located in the Littoral region of Cameroon, show evidence of further success. The prevalance of whipworms has decreased from a 66 percent infection rate in 2000 to a 17 percent rate in 2007, after repeated deworming with medication that included the donated Mebendazole from CWW. Similarly, the prevalence of roundworm infection dropped from 48 percent in 2000 to 15 percent in 2007.
Although Pr. Tchuem Tchuenté says Cameroon's programme still faces many challenges, including the continued need for resources to implement and sustain the program and to educate the community about good health and hygiene practices, he recognizes and is extremely grateful for the incredible difference the drug donations from the CWW program have made for the health of millions of Cameroon's children. As he said, "The drugs have tremendously boosted the Cameroonian government's efforts to fight against the worms."
For more information about Cameroon's National Programme for the Control of Schistosomiasis and Intestinal Helminthiasis or the Children Without Worms program, you may contact Pr. Tchuem Tchuenté by email at tchuemtchuente@schisto.com.
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The People Behind CWW: Dr. Israt Hafiz of Bangladesh
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 When the Technical Consultant position with Bangladesh's Filariasis
Elimination and STH Control Program opened up a year ago, Dr. Israt
Hafiz immediately applied. As a medical doctor with an MPH specializing
in managing communicable disease and prevention programs, Dr. Hafiz was
well suited for the job. She also had vast experience with Bangladesh's
Ministries of Health and Education on policy development, planning and
monitoring developing programs, and in-school health programs.
Long
before she accepted the position, Dr. Hafiz was interested in STH
control, as she had great concern over the "very high level of worm
infestation in her country." Although Dr. Hafiz was concerned over the
infection prevalence, she believed the problem was "very easy and cheap
to control and prevent by giving deworming medication and hygiene
education."
As Technical Consultant, Dr. Hafiz promotes the
program, organizes its stakeholders, develops work plans for local
health officers, manages the budget, and negotiates with partners for the program's
success. However, Dr. Hafiz always strives to improve the program and
overcome challenges to its success, which include low confidence in
drugs distributed by the government, bureaucratic delays in receiving
funds and little administrative support.
In spite of these
challenges, Dr. Hafiz sees the program as highly successful. In
particular, the Mebendazole donations from Johnson & Johnson
through the Children Without Worms (CWW) program have enabled the
Bangladesh STH Control Program to deworm about 25 percent of Bangladesh's
children aged 6 - 12 years. By combining the Johnson & Johnson donations with additional sources for deworming
drugs, the program has dewormed a significant percent of Bangladesh's
school-aged population. A recent survey of 792 students from three
schools indicates further success, with a reduction in hookworm
infections from 79 percent to 23 percent over a period of two years. And
parents even come to the schools requesting drugs for themselves and
siblings of the treated school-age children.
She attributes the
program's success to its school-based approach, which provides a
reliable focal point for distributing the drugs and for monitoring the
outcomes. She also explained what makes her most proud about the
program, "Bangladesh has 147 million people--a huge population--so it
is very difficult to cover the whole country for any program. But the
deworming program does cover the whole country."
Dr. Hafiz is
thankful for the CWW program, which supports the twice-a-year deworming
of a significant percent of Bangladesh's school-age children
through its Mebendazole donations. She is equally appreciative of CWW's recent technical assistant workshop in Phnom Penh that supported building capacity for the program and allowed her to connect with other CWW recipient countries in Asia.
In closing Dr. Hafiz noted, "The worm
infestation due to the high [population] density [in Bangladesh] is a
real problem. Is important to integrate deworming with water and
sanitation. If we integrate these programs and make a common platform
for health and education, we can be more effective."
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| Mitigating Benzimidazole (BZ) Resistance |
 Although no conclusive data demonstrates that Benzimidazole (BZ)
resistance is widespread in human STH, the risk for such resistance to emerge is
a potential threat. Therefore, monitoring the efficacy of existing BZ is
of paramount importance. Fortunately, by
taking advantage of the lessons learned by veterinary researchers and
developing more sensitive techniques for resistance detection, public
health practitioners and healthcare providers can proactively address
and mitigate drug resistance. The Molecular Genetics Behind ResistanceTo
be effective, BZ must bind to the helminth cytoskeleton
protein, tubulin. A variety of research and experiments have been conducted
to identify the molecular genetics related to potential Benzimidazole
resistance. For example, a 1990 study by H. M. Roos of nematode
parasites in livestock detected that a mutant resistance-inducing gene
already exists in the population. This gene reduces the ability of
Benzimidazole to bind to the β-tubulin molecule, and frequent exposure to Benzimidazole
treatment enhances the frequency of this gene. Low Concern About Resistance in Human NematodesOver
the last 30 to 40 years the problem of drug resistance, especially to
BZ, has become fairly serious with animal nematodes. But current
evidence of drug resistance of human nematodes is inconclusive. Perhaps a lack of data in this area is more the issue. The few
studies that have been conducted have relied on small sample sizes or non-standardized methods, leading to difficulties drawing conclusions about
drug efficacy. Current Detection Tools Not Sensitive EnoughResearchers
predominantly use two methods to monitor drug efficacy with Human
Nematodes: the Egg Reduction Rate (ERR) and the Egg Hatch Assay (EHA).
ERR makes the assumption that following a drug treatment, egg counts
should be lower. A standard fecal egg count reduction test (FECRT), however, is lacking. EHA, a technique adapted from techniques
developed to study resistance in animals, measures the effect of a drug
at a given concentration to inhibit the embryonation and hatching of
nematode eggs. The EHA has proved feasible for use with human hookworm, but needs to be further tested and validated to determine the appropriate "resistance" threshhold. Though the sensitivity of both methods are too
low to detect drug-resistant worms, a push is occurring toward
developing molecular biology techniques that detect lower proportions
of resistant worms. These methods show great promise. A Need for Improved Tools and Standardized Protocols To
prevent drug-resistance to BZ from developing in human nematodes,
managers of helminth control programs need new tools and standardized
approaches for monitoring drug efficacy in the field. These tools
include developement of a standardized FECRT, mathematical models that use real data to detect possible
resistance, use of EHA tests that detect resistant nematodes at much
lower levels, and use of polymerase chain reaction (PCR) methods to
identify the earliest genetic changes that indicate BZ resistance. At
the World Bank and WHO joint meeting in late 2007, a working group was
established to develop standard operating procedures for STH
surveillance tools and guidelines for systems monitoring STH. The
product of their work will be the FECRT research protocol, which will be tested in Brazil, India,
Cameroon, Zanzibar, Ethiopia and Vietnam. The final report on the
standard operating procedure is anticipated in mid-2009. Learn MoreLearn
more about this topic by reading Monitoring Benzimidazole Efficacy and the Development of Resistance, the research paper on
which this article was based that Dr. Marco Albonico presented to the Mebendazole Advisory Committee (MAC). Dr. Albonico is a member of the MAC.
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If you are interested in learning more, please visit the Children Without Worms web site or fill out the contact form on our site.
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